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Ankle:

Sprain/Strain

  • Cause/Pathophysiology

    • Stretch injury to any of the ankle ligaments (ATF, PTF, CF, Deltoid, A&P Tib/fib, syndesmosis), which can cause ligament failure

    • Ligament to corresponding mechanism

      • inversion - ATF, CF, PTF possible syndesmosis

      • eversion/ER - deltoid, syndesmosis

    • Syndesmosis involvement = "high ankle sprain" and can take longer to resolve

  • History and symptoms

    • MOI

    • Pain

    • WB ability varies depending on severity

  • Exam Findings

    • +/- antalgic gait

    • TTP over injured ligament

    • Swelling

    • +/- ROM or strength deficits

    • Pain and/or instability with, drawer tests, talar tilt test, Kleiger test

  • Imaging

    • X-Ray 

      • AP, mortise view, lateral

      • should be done weight bearing

      • usually negative, but may see mortise widening or talar lateralization if significant syndesmotic and deltoid ligament injury

  • Treatment​

    • Conservative

      • RICE​

      • brace

      • PT

      • NSAIDs

      • Short period of immobilization, NWB with crutches if unable to WB

        • "high ankle sprain" may require longer 

    • Surgery

      • severe injuries with mortise widening on X-Ray​

      • severe chronic instability

  • Common ICD-10 codes​​

    • S93.499A

 

 

 

 

 

 

 

Posterior Tibial Tendonitis/Dysfunction

  • Cause/Pathophysiology

    • Tendonitis

      • Acute inflammation of the posterior tibial tendon​

      • Can occur after ankle injury

    • Dysfunction

      • Chronic failure of the posterior tibial tendon to maintain normal function​

      • Frequently associated with pet planus

  • History and symptoms

    • Complains of medial ankle pain

    • Worse with activity

  • Exam Findings

    • TTP over tendon proximal and posterior to medial malleolus

    • Frequently planus foot 

    • +/- medial swelling

    • Pain with toe raise

  • Imaging

    • X-Ray negative

    • MRI

      • Appropriate if conservative treatment fails, to evaluate for tearing​

  • Treatment​

    • Conservative​ options

      • NSAIDs​

      • Ice or contrast baths

      • Arch support (orthotics)

      • Ankle support

      • PT

    • Surgical referral if conservative options fail

  • Common ICD-10 codes

    • M76.829

Achilles Tendonitis/Tendonopathy

  • Cause/Pathophysiology

    • Tendonitis

      • Acute inflammation of the tendon​

    • Tendonopathy

      • Chronic microtrauma to the tendon​

  • History and symptoms

    • Atraumatic posterior ankle pain

    • Increased pain with push-off or stretch (stairs is a common complaint)

  • Exam Findings

    • TTP in tendon substance or insertion

    • +/- swelling

    • Painful passive dorsiflexion

    • Pain +/- weakness with toe raise

  • Imaging

    • X-Ray

      • generally not necessary initially​

      • lateral may show posterior calcaneal enthesopathy

  • Treatment​

    • Conservative

      • NSAIDs​ or steroid taper

      • Ice

      • Heel lift

      • PT

      • Boot or cast for up to 6 weeks, if refractory to other conservative treatment

    • Surgery

      • option for failed conservative measures​

  • Common ICD-10 codes​​

    • M76.60

Achilles Tendon Rupture

  • Cause/Pathophysiology

    • Usually an eccentric load that supersedes tendon strength, causing failure 

    • May be preceded by chronic tendonopathy

  • History and symptoms

    • Mechanism frequently involves trying to control a decent (coming down from a jump or stairs) or sudden forceful contraction (pushing off to sprint or jump)

    • Frequently described as "it felt like something hit the back of my leg"

    • Pain and difficulty WB or pushing off

  • Exam Findings

    • May/may not be able to ambulate, but limited push-off if able t

    • Swelling

    • Tendon defect palpable and usually visible

    • Weak plantarflexion

    • + Thompson test

  • Imaging

    • X-ray 

      • evaluate for bony avulsion if defect is close to insertion​

    • IF diagnosis suspected, but not confirmed with exam MRI or US indicated

  • Treatment​

    • Conservative​

      • Serial casting is traditional treatment​

      • Boot with serial wedges has recently shown to be effective

    • Surgical

      • Primary repair may be best choice for younger and active population​

  • Common ICD-10 codes​​

    • S86.019A

Osteoarthritis of the Ankle

  • Cause/Pathophysiology

    • Chronic or post-traumatic articular cartilage degeneration of the talocrural joint

  • History and symptoms

    • Usually gradual progressively worsening ankle pain

    • Worse with weight bearing

  • Exam Findings

    • TTP ankle joint space

    • +/- effusion

    • +/- deformity

    • +/- ROM deficit

  • Imaging

    • X-Ray​ (AP, Lateral, Mortise weight-bearing views)

      • joint space narrowing​

      • subchondral sclerosis

      • +/- osteophyosis

      • +/- loose bodies

  • Treatment​

    • Conservative options

      • NSAIDs

      • Compression

      • Bracing

      • Cortisone injection​

      • Rocker bottom shoes

    • Surgery

      • Historically fusion​

      • Total ankle replacement is becoming more common

  • Common ICD-10 codes​​

    • M19.079

 

FRACTURES

Lateral Malleolus

  • Cause/Pathophysiology

    • Usually an excessive inversion or rotational mechanism to the point of bone failure

    • Several classification systems

  • History and symptoms

    • Mechanism for injury

    • Pain 

    • May or may not be able to weight bear, depending on severity and individual pain tolerance

  • Exam Findings

    • +/- deformity

    • swelling

    • TTP over lateral malleolus

    • +/- palpable crepitus

    • +/- ROM and strength deficits

  • Imaging

    • X-Ray - AP, lateral, mortise, weight bearing views +/- stress view

      • evaluate for fracture, displacement, and mortise widening​

  • Treatment​

    • Conservative

      • indicated for non to minimally displaced stable injuries (NO MORTISE WIDENING)​

      • Posterior splint with or without U-splint for initial visit, if referring or using a cast for definitive management

      • Short leg cast - after initial swelling subsides

      • Fracture boot

      • Stirrup brace for small avulsion type injuries below the joint line

      • WB status depends on fracture location (Below level of mortise - WBAT; At or above - Partial WB for 4 weeks)

    • Surgery 

      • unstable fractures ​- mortise widening

      • significant displacement

  • Common ICD-10 codes​​

    • S82.66XA - ​non-displaced

    • S82.53XA - displd

Medial Malleolus

  • Cause/Pathophysiology

    • Usually rotational injury

    • Does not happen in isolation very often

    • Be sure to evaluate for proximal fibular tenderness as seemingly isolated medial malleolus fractures can also have associated proximal fibular fracture (Maisonneuve Fracture)

  • History and symptoms

    • Mechanism for injury

    • Pain 

    • May or may not be able to weight bear, depending on severity and individual pain tolerance

  • Exam Findings

    • +/- deformity

    • swelling

    • TTP over medial malleolus

    • +/- palpable crepitus

    • +/- ROM and strength deficits

  • Imaging

    • X-Ray - AP, lateral, mortise, weight bearing views +/- stress view

    • evaluate for fracture, displacement, and mortise widening​

  • Treatment​

    • Conservative ​

      • non-displaced injuries​

      • Posterior splint with or without U-splint for initial visit, if referring or using a cast for definitive management

      • Short leg cast - after initial swelling subsides

      • NWB

    • Surgical ORIF

      • any displacement ​

  • Common ICD-10 codes​​

    • S82.56XA - non-displaced

    • S82.53XA - displaced

Bimalleolar

  • Cause/Pathophysiology

    • Inversion or eversion with rotation injury

    • Unstable injury

  • History and symptoms

    • MOI

    • Complaint of pain

    • Inability to bear weight

  • Exam Findings

    • Swelling

    • TTP over malleoli

    • +/- deformity

  • Imaging

    • X-ray - AP, lateral, mortise

      • may not be able to bear weight​

    • CT

      • may be helpful for surgical planning if severely comminuted or involves the weight-bearing surface of the tibia​

  • Treatment​

    • Initially

      • SL posterior and stirrup splint​

      • NWB

    • Conservative treatment is not indicated, except in extenuating circumstances such as if patient at too for high risk surgery

    • Surgical ORIF​ 

  • Common ICD-10 codes

    • S82.846A - non displaced

    • S82.843A - displaced

Foot:

Plantar Fasciitis

  • Cause/Pathophysiology

    • Acute Inflammation or chronic tendonosis-type condition of the plantar fascia, typically, at the calcaneal attachment

  • History and symptoms

    • Complaints of pain on the bottom of the foot, particularly on the heel

    • Worse with first few steps after periods of rest

    • Generally pain improves at rest

  • Exam Findings

    • TTP at plantar fascia attachment on calcaneus

    • +/- antalgic gait

    • +/- Achilles tightness

  • Imaging

    • Not necessary initially, as diagnosis is clinical

    • X-Ray if refractory to conservative treatment

      • may have calcaneal enthesopathy (spur)​

  • Treatment​

    • Conservative​ options - 95% successful

      • Ice​

      • massage

      • NSAIDs

      • STRETCHING/PT

      • Heel cups

      • Orthotics

      • Compressive sleeves

      • Cortisone injection

  • Common ICD-10 codes​​

    • M72.2

Midfoot Sprain

  • Cause/Pathophysiology

    • Excessive stress on the foot that can be rotational (inversion or eversion) or hyper-dorsiflexion or plantar flexion​

    • Can involve any of the intertarsal or torso-metatarsal ligaments

    • LisFranc injury is a specific sprain injury that I have given its own section.  It is an important one not to miss.

  • History and symptoms

    • MOI​

    • Pain​ worse with weight bearing

  • Exam Findings

    • TTP over the midfoot​

    • +/- swelling

    • Pain with stress testing the mid foot

  • Imaging

    • X-Ray​ - AP, lateral, oblique weight bearing views

      • evaluate for fracture, displacement, alignment, joint space widening​

  • Treatment​

    • Conservative​

      • rigid soled shoe or fracture boot​

      • WBAT

      • RICE

      • NSAIDs

  • Common ICD-10 codes​​

    • S93.609A

Lis Franc Injury 

  • Cause/Pathophysiology

    • Direct trauma or significant rotational or hyperplantarflexion force to the foot​

    • Stretch or disruption of one or multiple tarso-metatarsal ligaments, causing dislocation, particularly the second metatarsal, middle cuneiform joint (Lis Franc joint)

    • Can be associated with fracture

  • History and symptoms

    • MOI​

    • Pain with weight bearing​

    • May be unable to weight bear

  • Exam Findings

    • Antalgic gait​, if able to weight bear

    • Midfoot swelling

    • Midfoot TTP, especially at Lis Franc joint

    • +/- ecchymosis

  • Imaging

    • X-Rays - AP, lateral, oblique weight bearing 

      • evaluate for fracture, Lis Franc joint widening (alignment of second metatarsal in relation to middle cuneiform), lateral dislocation of the forefoot ​

    • CT - standard for diagnosis and evaluation of suspected Lis Franc injury

    • MRI - better for evaluating the extent of ligament injury if no widening of the Lis Franc joint

  • Treatment​

    • Conservative​

      • Sprains with no Lis Franc joint widening​

      • Posterior splint with or without U-splint for initial visit, if referring or using a cast for definitive management

      • Short leg cast (after initial swelling subsides) or boot

      • NWB

    • Surgical

      • Any unstable injury with displacement​ (widening between 1st and 2nd metatarsal at base)

  • Common ICD-10 codes​​

    • S93.609A

Osteoarthritis

  • Cause/Pathophysiology

    • Chronic degeneration of the articular cartilage between any tarsal, metatarsal, or phalangeal joint​

  • History and symptoms

    • Gradually worsening foot/toe pain​

    • Worse with standing and/or motion​

  • Exam Findings

    • TTP of affected joint​

    • +/- stiffness

    • +/- swelling

    • +/- deformity, joint hypertrophy

  • Imaging

    • X-Ray - AP, Lateral, Oblique​

    • joint space narrowing

    • osteophytosis

  • Treatment​

    • Conservative options

      • NSAIDs

      • ice/heat modalities

      • orthotics

      • rocker-bottom shoe

      • Cortisone injection - may require image guidance if midfoot

    • Varying surgical options depending on joint location, if conservative options fail

  • Common ICD-10 codes

    • M19.071

Hallux Valgus

  • Cause/Pathophysiology

    • Big toe deviates laterally​ and can lead to first metatarsal head prominence medially (bunion)

    • Can be associated with footwear that is too narrow or pointed 

  • History and symptoms

    • Gradually worsening deformity​

    • +/- pain​

    • Symptoms may be worse with narrower shoes

  • Exam Findings

    • Valgus deformity or big toe​ (points outward)

    • +/- Prominent metatarsal head

    • +/- TTP

    • +/- decreased ROM

  • Imaging

    • X-Ray - AP, lateral, oblique​

      • valgus deformity or big toe​

      • +/- degenerative changes of 1st MTPJ (joint space narrowing, flattening, osteophytosis)

  • Treatment​

    • Conservative options

      • Footwear change - wide toe-box shoes​

      • bracing

      • ice/heat modalities, if painful

      • NSAIDs if painful

    • Surgical correction if conservative efforts fail to resolve symptoms

  • Common ICD-10 codes

    • M20.10​

Hallux Rigidus (First MTPJ osteoarthritis)

  • Cause/Pathophysiology

    • Degeneration of first MTPJ articular cartilage​​

  • History and symptoms

    • Progressively worsening big toe pain and stiffness​

    • Worse with activity​

  • Exam Findings

    • +/- dorsal hypertrophic deformity of the MPTJ​

    • MTPJ TTP

    • MTPJ decreased ROM

  • Imaging

    • X-Ray - Big toe AP, lateral, oblique​

      • MTP joint space loss​

      • MTP osteophytosis

  • Treatment​

    • Conservative ​

      • Footwear modifications - wide toe box, stiff soles or insert​

      • NSAIDs

      • Ice/heat modalities

      • Cortisone injection

    • Surgical if conservative efforts fail

      • Cheilectomy or fusion​

  • Common ICD-10 codes​​

    • M20.20

Sever's Disease (Calcaneal Apophysitis)

  • Cause/Pathophysiology

    • Repetitive stress causes inflammation/microtrauma of the calcaneal apophysis​

    • Active pediatric population, M>F, average age 9-11

    • Resolves completely when ossification center closes

  • History and symptoms

    • Heel pain during or after activity​​

  • Exam Findings

    • TTP on back of the heel​

    • +/- antalgic gait

  • Imaging

    • X-Ray

      • not necessary in initial work-up but can show sclerosis and/or fragmentation​ at the secondary ossification center

  • Treatment​

    • Con​servative

      • ​Achilles stretching​​

      • Ice

      • NSAIDs

      • Heel cup/pad

      • Activity modification as needed

  • Common ICD-10 codes​​

    • M92.60

 

Pes Planus (Flat foot)

  • Cause/Pathophysiology

    • Congenital or acquired lack of medial longitudinal arch​

    • Arch can develop up until mid teens

    • Flexible Not a medical condition that needs to be corrected when bilateral or asymptomatic

  • History and symptoms​​

    • Frequently will see due to parent concern​

  • Exam Findings

    • Lack of medial longitudinal arch​

    • Check to see if arch develops when big toe is passively fully dorsiflexed (flexible flat foot), if not (rigid flat foot) there may be other pathology such as coalition

  • Imaging

    • Generally not necessary in work-up​

    • X-Ray - (AP, lateral, oblique) if foot is painful, unilateral, or rigid on exam

  • Treatment​

    • No treatment is indicated, necessary, or corrective for asymptomatic bilateral ​flexible pes planus

    • If other pathology is present, treat accordingly

  • Common ICD-10 codes

    • M21.40

 

Fractures:  

Metatarsal

  • Cause/Pathophysiology

    • Acute trauma​

    • Chronic repetitive stresses

    • Fifth is most common

      • Avulsion​

      • Jones

      • Shaft

  • History and symptoms

    • Acute pain after direct trauma or twist injury ​

    • Gradually worsening pain with activity​ - stress fractures

    • Pain worse with WB or activity

    • May not be able to weight bear, especially of acute

  • Exam Findings

    • TTP over affected metatarsal​

    • Swelling with acute fx, may not have swelling with stress fx

    • Painful metatarsal squeeze

    • Pain with active eversion and/or passive inversion for 5th metatarsal base fractures

  • Imaging

    • X-Ray - AP, lateral, oblique weight bearing​

      • evaluate for fracture, alignment, displacement, callous (stress fractures)​

      • Jones fracture is 1.5-3cm from the tip of the 5th metatarsal base tip

  • Treatment - depends on which metatarsal and location of fracture​​

    • Conservative​

      • Most metatarsal fractures, including stress fracture ​(EXCEPT Jones, First metatarsal, intra-articular)

        • fracture shoe, boot, or cast​

        • Can weight bear when symptoms allow

      • Jones

        • Non-displaced​

        • Cast

        • NWB 6-8 weeks

        • Higher incidence of non-union

      • First Metatarsal or intra-articular 

        • Non-displaced​

        • Cast

        • NWB

    • Surgery

      • Viable option for primary treatment of non-displaced Jones fracture, especially in younger, active population​

      • Indicated for displaced Jones, first metatarsal fractures, nonunions, significantly displaced or severely angulated fractures

  • Common ICD-10 code​​

    • S92.309A

 

 

Calcaneus

  • Cause/Pathophysiology

    • Trauma​

    • Frequently, landing on feet from a height

    • Stress fracture

  • History and symptoms

    • MOI​

    • Pain​

    • Usually unable to bear weight with traumatic injury

    • Stress fractures generally present as gradually worsening pain with weight-bearing

  • Exam Findings

    • Swelling​

    • TTP over calcaneus

    • +/- ecchymosis

  • Imaging

    • X-Ray - Axial and lateral calcaneus films

      • evaluate for fracture, displacement, articular surface congruency ​

    • CT

      • Frequently helpful in determining articular surface involvement and significance of displacement or step-off​

      • surgical planning

    • MRI

      • most sensitive in diagnosing stress fracture​

  • Treatment​

    • Conservative - non or minimally displaced​, no significant articular step-off

      • SL cast​

      • NWB 12 weeks

      • Stress fracture - boot or cast.  Weight bearing when symptoms allow.

    • Surgery - significant displacement, angulation or articular step-off

  • Common ICD-10 codes

    • S92.009 A - closed, B - open

 

Phalanx

  • Cause/Pathophysiology

    • Trauma​

  • History and symptoms

    • MOI​

    • Pain​

  • Exam Findings

    • +/- deformity​

    • Swelling

    • TTP

    • Decreased ROM secondary to pain

  • Imaging

    • X-Ray - AP, lateral, oblique​

  • Treatment​

    • Reduction after digital block, if significantly displaced or angulated​

    • Most toe fractures do well conservatively treating with buddy taping and fracture shoe 

    • Significantly displaced, angulated, or intra-articular big toe fractures may need surgical fixation 

  • Common ICD-10 codes

    • S92.919 A - closed, B - open

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Possible Location of Lateral Ankle Sprain Symptoms/Tenderness

Lateral Ankle Sprain

Possible Location of Posterior Tibial Tendonopathy Symptoms/Tenderness

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Possible Location of Achilles Tendonopathy Symptoms/Tenderness

Achilles Tendonitis

Possible Location of Achilles Tendon Rupture Defect and Tenderness

Achilles Tendon Rupture

Possible Location of Ankle Osteoarthritis Symptoms/Tenderness

Ankle OA

Possible Location of Lateral Malleolus Fracture Symptoms/Tenderness

Lateral Malleolus Fracture

Possible Location of Medial Malleolus Fracture Symptoms/Tenderness

Medial Malleolus Fx

Possible Location of Medial Malleolus Fracture Symptoms/Tenderness

Medial Malleolus Fx

Possible Location of Plantar Fasciitis Symptoms/Tenderness

Plantar fascitis

Possible Location of Midfoot Sprain Symptoms/Tenderness

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 Location of LisFranc Symptoms/Tenderness

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 Location of Foot Osteoarthritis Symptoms/Tenderness

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 Location of Hallux Valgus Symptoms/Tenderness

 Location of Hallux Rigid Symptoms/Tenderness

 Location of Sever's Disease Symptoms/Tenderness

 Location of Pes Planus Symptoms/Tenderness

 Location of Metatarsal Fracture Symptoms/Tenderness

 Location of Calcaneus Fracture Symptoms/Tenderness

 Location of Phalanx Fracture Symptoms/Tenderness