Lower Leg and Ankle/Foot Pain

What are the 5 types of a Salter-Harris fracture classification?

• Type I: fx through the physis (growth plate)

• Type II: fracture partway through the physis extending up into metaphysis

• Type III: fx partway through the physis extending down into the epiphysis

• Type IV: fx thorugh the metaphysis, physis, and epiphysis can lead to angulation deformities when healing

• Type V: crush injury to the physis

What is the healing time table for a fracture repair?

• Soft callus: 2 weeks

• Hard callus: 4-6 weeks

• Lamellar bone: 6-12 weeks

What are the methods of correcting a fracture?

• Closed reduction

  • Preferred method no hospital stay

  • Non surgical, manual reaglinment

• Open reduction

  • Correction of bone alignment through a surgical incision

  • Allows earlier mobilization of pt and the joints involved, decreased risk of contractures

• Arthroplasty

• Traction

  • Skin traction (short term)

  • Skeletal traction (longer periods)

What are complications to watch for after a fracture?

• Swelling, especially with casting

• Fat embolism, especially when pelvic fx and long bones

• Fixation devices (break or displacement)

• Skin issues

• Infections

• Delayed union, malunion, non-union, etc.

• Nerve or vascular compromise

Which has earlier mobility: post-operative or non-operative?

Post-operative.

Non-operative takes longer to mobilize due to callus formation

What are the symptoms of someone with tibialis posterior dysfunction?

• Impaired mobility and function

• Medial ankle pain with loss of strength in posterior tibialis

• Flat foot deformity, loss of medial arch height, swelling at medial ankle with forefoot valgus (too many toes sign)

Where is the pain located in a pt with tibialis posterior dysfunction?

Behind medial malleolus

What type of treatment is used for stage I and II tibialis posterior tendinopathy?

• Conservative treatment:

  • Focus on strengthening the posterior tibialis

  • Unload tendon with taping and/or orthotics

  • Balance and stretching/manual therapy for improving ankle DF

What are interventions used for tibial posterior tendinopathy?

• Talocreual mobilization for posterior glide, distraction prn

• Gastro-soleus stretching/mobility exercise for DF

• Foot intrinsic strengthening

• Closed chain for control of pronation (anti-pronation exercise)

• Hip strengthening

• Progress walking and functional exercises (squats, step downs)

Limited mobility of the hip causes shin splints.

Limited hip IR

What are the 4 grades of pain for medial tibial stress syndrome?

• Grade I: pain after activity

• Grade II: pain before and after activity and not affecting performance

• Grade III: pain before, during, and after activity, affecting performance

• Grade IV: pain so severe performance is impossible

What treatments can be done to help with medial tibial stress syndrome?

• Education (activity mod., footwear, modalities)

• Manual therapy to improve DF

• Exercise

  • Calf stretching

  • Strength for foot intrinsic muscles

  • Eccentric strengthening for ant tib

  • Hip strengthening

• Gait retraining: cadence

What are the symptoms of chronic exertional compartment syndrome (5 P’s)

• 5 P’s

  • Pain: ache, sharp dull

  • Pallor

  • Paresthesia

  • Pulselessness

  • Paralysis

• Tightness form to touch

• No symptoms at rest

S/S of tibial stress fractures?

• Focal, sharp palpable pain

• Progression of weight-bearing pain to pain at rest/night

• Location: ant tibia vs post tibia

• Tuning fork (Sp 19-83%) vs US (63-66%)

What is turf toe?

Tearing of ligament on bottom of great toe

What are the S/S of turf toe?

Decreased weight bearing, toe off

Pain/swelling @ first MTP

Pain w/ passive extension of 1st MTP

What is the treatment of turf toe?

Brace/taping

Exercise to promote motion/strength

Modalities

What is a Jones fracture?

5th metatarsal fracture. Due to overuse

What is a Lis Franc injury?

Tearing of ligament between 1st and 2nd metatarsals and ½ of cuneiforms

What is the WB status after a Lis Franc surgery?

• Arthrodesis: 6 weeks. NWB → 4 weeks in CAM boot

• ORIF: 6 weeks. NWB → 6 weeks WBAT in boot → hardware removal and wean from boot as tolerated

• Tight rope: 6 weeks. NWB → FWB

What is hallux valgus?

Angle on the 1 MTP (hallux moves laterally relative to metatarsals), >15 degrees = hallux valgus

What is the treatment of hallux valgus?

• Education (proper footwear, orthotic, rocker bottom shoe)

• Manual therapy

  • First MTP varus mob

  • Talocrural post glide

• Exercise

  • Stretching first MTP, calf

  • Balance activity

• Often go to surgery depending on angle

What are the symptoms of ankle osteoarthritis?

• Stiffness after prolonged inactivity and in early morning

• Pain eases after warm up

• Pain with WB, walking, and stairs

What will be found upon exam of ankle osteoarthritis?

• Joint line and peri-articular tenderness

• Limited ankle ROM w/ pain, possible crepitus

• Stiffness with passive and accessory motion

• Pain and limitation with squatting, STS, and aantalgic gait

Treatment of ankle osteoarthritis?

• Education (activity mod, bracing, shoes)

• Manual therapy

  • Joint mobs for talocrural joint, tib-fib glides

• Exercise

  • Stretching and mobility exercise

  • Strength training

  • Balance exercises

  • Functional exercise for gait, STS, step up/down

• Modalities

  • Heat, ESTIM

What is Mortons neuroma?

Irritation and swelling that surrounds the plantar nerve, most often between 3rd/4th digits

What are the S/S of Morton’s Neuroma?

• Insidious or post-traumatic onset of sharp, burning pain on the plantar surface near metatarsal heads

• Often pt will c/o of pebble in shoe

• Pain may radiate into toes and cause numbness

• Pain worse with WB activity/walking

• Pain relief upon remove of shoe and/or pressure

What would you find upon exam of Morton’s Neuroma?

• Point tenderness with palpation

• Positive “squeeze test” w possible click

  • Squeeze metatarsals. Will cause severe pain if positive.

What is the treatment of club foot (talipes equinovarus)?

Serial casting/surgery (go and cut achilles, reform foot and recast the foot into normals position)