Foot Intro

    • Three regions:
      • 1. Hindfoot (talus and calcaneous)
      • 2. Midfoot (navicular, cuneiform, and cuboid)
      • 3. Forefoot (metatarsals and phalanges)
    • Foot Fractures result from:
      • 1. Direct Trauma
      • 2. Indirect Trauma
      • 3. Overuse
    • Foot Anatomy:
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    • Imaging
      • AP, (medial two TMT joints)
      • Oblique (lateral three TMT joints)
      • Lateral views (calcaneal)
    • Sessamoid bones - Bones within tendons over joints (such as the patella).  Help protect tendon from joint, and lifts the tendon from the joint space.
    • Secondary ossification centers - many in foot.



    • Most common tarsal injury (60% of tarsal injuries)
    • Anatomy:
      • Forms bottom of subtalar joint, which has three articular surfaces:
        • Anterior, middle, and posterior.
      • Sustentaculum talus is medial extension of calcaneus that supports anterior and middle articular facets.
      • Peroneal tubercle: on lateral surface provides a groove for peroneal tendons and groove where peroneal retinaculum attaches.
      • 75% of calcaneal fractures are intra-articular, 75% depressed.
    • Mechanism: Usually fall from height, often >8 feet.
    • Complciations:
      • Compartment Syndrome
      • Fracture blisters (clear or blood-filled), may delay surgery to avoid high rates of infection.
      • Sural nerve entrapment.
      • Based on mechanism:
        • Thoracolumbar Compression Fractures. (10%)
        • Compartment syndrome (10%)
    • Imaging:
      • Easy to see on AP/oblique/lateral views.
      • Bohler's Angle (20-40° normal)
        • Bohler's Angle (Normal: 20-40°)

          • Calculated by measuring angle between two lines
            • 1. From superior margin of posterior calcaneal tuberosity (back-top tip) to superior tip of posterior facet (back-top tip of ST joint).
            • 2. From superior tip of anterior facet (front-top of ST joint) to superior tip of posterior facet (back-top of ST joint).

          Screen shot 2013-08-14 at 8.50.35 PM.png

        • If angle is <20°:
          • 1. Depressed fracture present even if not seen on Xray
          • 2. Worse outcome regardless of intervention.
          • Bohler angle can be normal even with bad fractures, so it does not rule-out anything.
      • Can do Harris view to see extent of intra-articular involvement and degree of depression.
        • Shoot obliquely across plantar heel of dorsiflexed foot.
      • CT: Gold standard, can see extent of damage (xrays can't see extent in half cases)
        • Do CT if surgery needed.
    • Treatment:
      • ALL:
        • Ice, elevate (decreases soft-tissue injury, decrease blisters)
        • Immobilize: Bulky compression dressing + posterior splint.
        • Non-weight bearing: Give crutches to prevent further bone+soft tissue injury.
          • If intra-articular or displaced: non-wt bearing x6-8w.
          • If extra-articular: non-wt bearing x4-6w.
          • then gradual increase in activity.
        • Hydrothreapy
        • Surgery: Controversial.
          • Should consult ortho in all cases unless non-displaced, extra-articular
          • Surgery if compartment syndrome
          • Displaced intra-articular: controversial.  (can wait 7-10 days, especially if swelling)
          • If comminuted, displaced, depressed: need to re-establish joint congruity, so prob need surgery. (ORIF: often pins).
      • Admit if suspect compartment syndrome.
      • Anterior Process Fracture:  (15% of talar fractures)
        • Avulsion Fracture, secondary of abduction foot in plantarflexion.
        • Mechanism: Twisting foot.
        • Bifurcate ligament inserts into calcaneus and cuboid+navicular.
        • Tx:
          • ice, elevate, wt bear as tolerated.
          • Removal fracture boot 4-6wks.
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      • Sustentaculum Tali Fracture:
        • Uncommon.  
        • Mechanism: axial compression of heel with inverted ankle.
        • Pain worse with inversion of foot or hyperextension of great toe.  (Flexor hallucis longus passes beneath sustentaculum tali).
        • Tx:
          • Non-displaced:
            • Cast, and non-wt bearing for 8wks.
            • Ortho referral.
            • Chronic pain common
          • Displaced: Emergency ortho referral + ORIF.  (Sx in 10 days after swelling better).
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      • Lateral Calcaneal process and Peroneal Tubercle Fractures.
        • Tx symptomatic, soft support 4-6w.
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      • Medial Calcaneal process fracturs:  Uncommon, look up
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      • Calcaneal Tuberosity Fractures:
        • Avlusion by Achilles tendon.
        • Mechanism: Fall or jump landing on doris-flexed foot with knee extended.
        • ON Exam: weak plantarflexion, inability to walk, pain in this area.
        • Tx:
          • Non-displaced:
            • non-wt bearing cast in slight plantarflexion x6-8wks.
            • Ortho consult.
          • Displaced: Ortho ---> ORIF (especially if putting tension on soft-tissue).
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    • Uncommon <1% of all fractures.
    • Difficult to visualize
    • Anatomically three segments:
      • Head, neck body.
      • Held in place by ligaments, no muscle insertions.
      • Blood supply enters via deltoid ligament, talocalcaneal ligament, anterior capsul, and sinus tarsi.
    • Fractures: Major vs. Minor
      • Major Fractures:
        • Involve head, neck or central portion of body.
        • Neck fractures divided into Hawkins Types:
          • Type I - nondisplaced
          • Type II - displacement w subluxation or displacement of subtalar joint.
          • Type III - Process displacement + dislocation from subtalar and ankle joint.
          • Type IV - Displaced from subtalar joint and talar head dislocated.
      • Minor Fractures:
        • Fractures of body of talus (include lateral process, posterior process, and osteochondral talar dome).
        • "Snowboarder's ankle": lateral process fractures (axial loading, dorsiflexion, eversion, ext rotation.
        • Posterior process: uncommon, hyperextension.
    • Mechanism:
      • Neck Fractures: Acute dorsiflexion.
        • Called "Aviator's astragalus" b/c occured in WWII pilots after rudder forcibly dorsiflexed ankle when crashlanding planes after bombing missions.
      • Body Fractures: Acute hyperextension

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    • Treatment:
      • "Major" fractures:
        • Ice, elevate
        • Immobilize: crutches
        • Early consult.
        • Non-weight bearing cast for 6-8wks.
        • ORIF if talonavicular joint instability, displaced in articular step-off or later than 50% of articular surface.
        • Non-displaced: short-leg walking cast for 6wks followed by 3 weeks of partial wt bearing.
      • "Minor" fractures:
        • ice, elevation, immobilization in short-leg spint. (keep ankle in neural position).
        • Crutches + ortho referral.
        • OR if >2mm displaced.
    • Complications:
      • Talar Head: Talonavicular OA or chondromalacia.
      • Talar neck: AVN, peroneal tendon dislocations, delayed union.


    Midfoot (Navicular Cuboid and Cuneiforms)

    • Rare, non-mobile segments.
    • Sensitivy of xrays is 25-33% of detecting midfoot fractures


    • Four types:
      • 1. Dorsal avulsion # (most common)
      • 2. Tuberosity #
      • 3. Body fracture
      • 4. Compression fracture.

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    • Anatomy notes:
      • Tibialis posterior tendon attaches to navicular tuberosity.
    • Mechanism
      • Dorsal avulsion: Acute flexion with inversion of foot.  The talonavicular joint capsule is stressed and avulses the proximal dorsal aspect of navicular.
      • Tubercle avulsion: Eversion of foot increases tibialis post. tendon --> avulses tubercle.
    • Imaging:
      • Difficult to diagnose subtle fractures.
      • Often need CT or MRI. (especially stress fractures).
    • Treatment:
      • Dorsal avulsion & compression #'s:  ice, elevate, compressive dressing.
        • Weight bear w crutches x2 weeks until pain better.
        • Operate if >25% of articular surface (large fracturses) - use wires.
      • Tuberosity fracture: 
        • Compression dressing, short leg splint.
        • When swelling better: short-leg cast with foot in inversion x6weeks.
      • Body fractures:
        • Ice, elevation, post. splint.
        • Definitive management: well-molded walking cast x6-8weeks.



    • Cuboid Fractures
    • Cuneiform Fractures
    • Usually fractures occur together from direct crush injury.
    • On Exam: midfoot motion will be painful.  Tender over the cuboid/cuneiform.
    • Cuboid/Cuneiform fractures are associated with tarsometatarsal dislocation (which may have spontaneously reduced).
      • Therefore: Assume dislocation until proven otherwise.
    • Tx
      • Ice, Elevation, Splint with crutches.
      • Non-weight bearing short-leg cast x6-8weeks.
        • After cast removal longitudinal arch support for 5-6mo
      • Surgery: if displaced or comminuted.

    Lisfranc Joint Fracture-Dislocation

    • Spectrum from stable sprain to unstable fracture dislocations.
    • Lisfranc fracture-dislocations are rare (0.2% of all fractures), but high incidence of chronic pain and functional disability.
    • 20% rate of misdiagnosis (one of the most common malpractice lawsuits against ER physicians).
    • If not properly managed --> HIGH POTENTIAL OF DISABILITY
    • Anatomy:
      • Lisfranc Joint: articulation of midfoot with metatarsals
        • Cuneiforms articulate with first three metatarsals
        • Cuboid articulates with last two metatarsals.
        • Ligaments:
          • TMT ligament (tarsometatarsal) binds each of the metatarsal bones to a bone of midfoot.
          • Transverse intermetatarsal ligament: binds proximal aspects of second through fifth metatarsals.  (strong ligament!)
          • Lisfranc ligament: Very strong ligament binding across from the 2nd metatarsal to medial cuneiform.
          • No ligament btwn 1st and 2nd metatarsals.
          • NOTE: 2nd metatarsal is bound by three ligaments, so usually fractures rather than dislocates.
          • NOTE: Fracture of base of 2nd metatarsal suggests a Lisfranc fracture-dislocation until proven otherwise!!!
        • photo.JPG
    • Classification (not prognostic!!!)
      • Classification based on whether or not all of the lisfranc joints disrupted (total/partial incongruity)
      • Direction of displacement is noted: Medial, lateral, dorsal, or plantar.
      • "Homolateral" dislocations are common (4 or 5 metatarsals moved to same direction)
      • "Divergent" dislocations occur usually between 1st and 2nd metatarsals (opposite directions) b/c weakest joint.
        • Direct force splits the groove btwn 1st and 2nd mt's. 
    • Mechanism:
      • Usually MVA..
      • Direct force - or indirect via axial loading on plantarflexed foot.
      • High risk of compartment syndrome!
    • Exam:
      • Tenderness over the joint.
      • Patient may be able to amulate!!  cannot exclude diagnosis.
      • Ecchymosis may be present on plantar aspect of foot.
      • Pain on passive dorsiflexion of toes suggest compartment syndrome.
    • Imaging:
      • AP, oblique, and lateral radiographs.
      • AP better 1st and 2nd metatarsal.
        • 1. 1st metatarsal aligns with medial cuneiform.
        • 2. Medial borders of 2nd metatarsal and middle cuneiform aligned.
        • 3. Distance btwn bases of 1st and 2nd mtls should be <3mm.
      • Oblique better for others.
        • 4. Lateral borders of 3rd mtsl  and lateral cuneiform aligned.
        • 5. Medial borders of 4th mtsl and cuboid aligned.
      • Lateral
        • Evalute dorsal and plantar dislocation
        • 6. Dorsal surface of metatarsals is in line with respective tarsal.  Never disrupted.
        • Medial aspect of middle cuneiform and 2nd metatarsal align.  Any disruption of this is indicative of dislocation, which may have spontaneously reduced.
      • Standing Stress Views:
        • May be required.  Up to 10% of Lisfranc injuries cannot be seen without stress views.
        • Poorly tolerated due to pain.
      • CT is best!  25% seen on CT and not on xray.
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    • Complications:
      • 1. Fracture of base of 2nd metatarsal
      • 2. Avulsion fractures of tarsals and metatarsals.
      • 3. Cuboid, cuneiform, navicular injuries.
      • 4. Compartment syndrome.
      • Degenerative arthritis, chronic pain, etc..
    • Tx:
      • Analgesics, ice, elevation, immobilization.
      • Even a mild sprain of the joint with normal radiographs should be kept non-wt bearing until further evaluation.
      • Fracture-dislocations ALMOST ALWAYS require ortho consult + operative repair.
        • If indicated, do surgery in 12-24hrs after injury, sometimes need to wait 7-10d for swelling to decr.
        • Closed reduction with cast will reduce, but not be stable enough. (need pins+screws).
      • Need Custom arch support for 12 months after. 
      • 90% success with good management.


    Metatarsal Fractures

    First Metatarsal

    • Usually direct crush.
    • Pain with axial loading.
    • Tx:
      • Ice, elevation, analgesics, immobilization.
      • Crutches, NON-weight bearing.
      • If Stable, non-displaced - cast x4-6 weeks. 
      • If displaced  or comminuted - require ORIF.
      • STABILITY is not definite until stress (weight-bearing) xrays show no displacement.

    Central Metatarsal

    • 2nd 3rd and 4rth metatarsals.
    • if fracture of base - check Lisfranc joint.
    • Usually direct crush injury.
    • Stress fractures common 2nd and 4rd mtls after repetitive trauma to forefoot.
    • Often stable fractures because lots of ligaments hold them in place (unlike 1st mtsl).
      • Often non-displaced.
    • Tx:
      • Elevate, Ice, analgesics.
      • Non-displaced generally heal well with hard-sole shoe. (distributes force and reduce stress on MTP joints).
      • May not be stable if multiple metatarsals fractured, less stabilizing effect of adjacent ones.
      • Closed reduction if:
        • Displaced >3mm or angulated >10°
        • Need to reduce - toes in finger traps, with weight, and counterraction on tibia.
        • Splint and non-wt bearing.

    Proximal 5th Metatarsal Fractures

    • Three types:
      • 1. Tuberosity avulsion fractures.
      • 2. Jones' Fractures
      • 3. Diaphyseal stress fractures.
    • Do not confuse os vesalianum (secondary ossification center) with fracture.
        • Secondary ossification centers are often smooth, rounded, bilateral and often sclerotic margins.
    • Tuberosity avulsion fractures often treated conservatively, unless complicated.
    • Jones and Diaphyseal stress fractures often require surgery due to high rates of non-union.
    • Tuberosity avulsion fractures (90% of base 5th mtl fractures)
      • Pseudo-Jones Fractures.
      • Defined as proximal to articulation btwn 4rth and 5th metatarsals. 
      • Transverse or oblique, often extra-articular but may extend into space btwn cuboid and 5th mtsl.
      • Mechanism:
        • Forced inversion of foot with ankle in plantarflexion
        • Avulses b/c both peroneus brevis tendon and lateral cord of plantar aponeurosis attaches there.
      • Tx:
        • Compression Dressing, hard-soled or cast shoe.
        • Wt-bearing as tolerated.
        • Heals for 4-6weeks.
        • If severe pain: can put in in post-splint with crutches or short-leg walking cast x2-3wks.
        • Refer to ortho and surgery if:
          • Comminuted or intra-articular involvement btwn metatarsal and cuboid >30% of joint space with significant step-off.
        • A transverse fracture of the base of 5th metatarsal should be confused with fracture that invovles the tuberosity.  Treatment and prognosis are entirely different.
    • Jones' Fracture
      • Fracture at junction of diaphysis and metaphysis.
      • Involve artcular facet btwn 4th and 5th mtsls.
      • Problematic b/c may disrupt blood supply to distal portion of proximal fragment.
      • Mechanism:
        • Laterally-directed force on forefoot that disrupts plantar-flexed foot.
      • Tx:
        • Ice, elevate, immobilize, non-wt bearing.
        • Short-leg non-wt bearing cast for 6-8wks.
        • Refer to Ortho b/c high incidence of non-union.
        • Surgery vs. Conservative:
          • Now often treat with ORIF.
          • Surgery especially if displaced
          • High incidence of delayed and non-union due to poor blood supply.
          • Often screw fixation to increase rate of primary union and decrease union time and earlier return to activity.
          • Up to 50% of #'s originally treated with immobilization later required surgery b/c of non-union or refracture.
    • Diaphyseal Stress Fracture.
      • Distal to ligamentous attachments of bone.  >1.5cm into diaphysis.
        • Often asymptomatic for several days before presentation (unlike Jones and avulsion #'s that acutely injured).
        • Often ppl enganaged in strenuous activities.
      • Tx:
        • Acute: immobilization and non-weight bearing x6-10wks similar to acute Jones' fractures.
        • Requires greater immobilization (up to 20wks sometimes with delayed union).
        • Often managed with screw fixation or bone grafting b/c high incidence of non-union.

    Toe Fractures

    • Phalanx Fractures are most common in forefoot.
    • Mechanism
      • Majority from direct blow. (heavy object dropped)
      • Some stubbing toe.
      • Abrupt abduction ("night walker's fracture").
    • Tx:
      • Most non-displaced or minimally displaced
      • Dynamic splinting (use cotton padding btween affected toe and neighbour
        • Change splint every few days for 2-3weeks.
        • Subungual hematomas can be drained with electrocautery or 18G needle.
      • 1st Metatarsal:
        • Important in weight bearing and balance... consider referring.
          • Especially refer if fracture intra-articular and >25% joint space involved.
        • Can buddy tape, hard-sole shoe.  If painful, can do posterior splint.
        • Comminuted:  Need walking cast (dynamic splinting not enough immobilization)
      • If Displaced:
        • Reduce in ER.
          • Digital block.
          • Traction + Manipulate (use nail for rotational guidance).
          • Postreduction film.
    • Sessamoids:
      • Two sessamoids (flexor hallucis brevis).
      • Often acute-on-chronic trauma.
      • Local pain on palpation.
      • Pain with phalanx extension.
      • Treat conservatively (orthotics, hard sole shoe... can do walking cast if extremely painful).
        • If all else fails surgically resect sessamoid.

    Plantar Fasciitis

    • 15% of foot problems.
    • Typically 40-60yo, but earlier in runners (10% of runners).
    • Presentation:
      • Pain on undersurface of heel on standing or walking, and relieved with rest.
      • Frequently patients note pain after a period of bed rest, lessens after some activity, then severe again after duration of weight bearing..
        • (can say worse in morning when gets up, then better w activity, then worse with more activity)
    • Mechanism:
      • Infalmmatory and Degenerative condition at site of origin of plantar fascia (medial tuberosity of calcaneus).
      • Irritation of periosteum can cause bone spur.
      • Risk Factors:
        • Excessive walking/standing/running.
        • Obseity
        • Poorly cushioned footwear.
    • Exam:
      • local tenderness at anteromedial surface of calcaneus where plantar fascia attaches.
      • Dorsiflexion of toes worsens pain.
      • Pain always anterior to heel, and may radiate to sole.
      • 1/3 bilateral:
        • If bilateral R/O rheumatoid arthritis, SLE, gout.
    • Imaging:
      • Clinical diagnosis, often no need imaging.
      • Radiographs or bone scans done sometimes to R/O spurs and stress fractures.
        • (15-25% of pop-n have spurs, most are asymptomatic)
    • Treatment:
      • Rest, ice for symptoms.
      • Physical therapy, stretching
        • Stretch Achilles tendon
          • Achilles Stretch

            • Lean against wall, one foot 1foot away, the other foot next to wall with forefoot extended up the wall).  Hold position x10secs and repeat 3x.  Perform stretch up to 5x/day initially and then couple of times per day for recurrence.
      • Foot-wear: new shoes, arch support, orthotics, night splits,
        • Use heel pad (1/2 inch) + arch support to reduce plantar fascia stretch.
        • Can also tape.
          •  (Apply 2-inch tape with tension on plantar aspect of foot.  Tape extends from base of 5th metatarsal to head of 5th metatarsal.  Tape should be bow-strung in arch area.)
        • DO NOT walk bearfoot, and replace worn-out shoes.
      • Anti-infammatories, i.e. NSAIDs
      • Injections (if all fails, effective, but cause fat pad atrophy --> pain!)
      • Surgery (Fasciotomy or release if all else fails)
    • 80% improve 12months, but early tx (within 6w) hastens recovery.


    Heel Pad Atrophy

    • Usually older patients, obese, poor shoe cushion, hard floors.
    • Use NSAID
    • Use Dispersion pad.
    • Refer to chiropodist (heel dispersion padding, orthotics).

    Soft Tissue Injury and Dislocations

    Subtalar Dislocations

    • Rare
    • Fall from height, inversion, eversion
    • Treat: reduce to prevent skin necrosis.  
    • Refer to ortho for reduction, if ortho not available, can reduce in ER w/ analgesics, flexed knee to relax gastrocs.
      • Countertraction at leg (knee), and traction on forefoot + abduction/adduction depending on injury.


    Toe Diclocations

    • Rare
    • Simple vs complex (interposed soft tissue, sesamoid bones). 
    • Can be dorsal or volar (usually dorsal).
    • Usually big toe.
    • Reduction:
      • Dorsal MTP dislocation: hyperextension with distal traction.  (same as injuring force)
      • Stable reductions: hard-soled shoe and dynamic splinting.
      • Surgery if cannot reduce or if crepitus after reduction (soft tissue in joint)


    Compartment Syndrome of Foot

    • Three compartments:
      • Medial (Medial to first metatarsal)
        • Abductor hallucis brevis and flexor hallucis brevis
      • Lateral (Inferior and lateral to 5th metatarsal)
        • Abductor digiti minimi and flexor digiti minimi brevis.
      • Central
        • Flexor digitorum longus and brevis.



    • Soft-tissue infections: staph and strep.
    • Osteiomyelitis 90% pseudomonas, others include:
      • E.coli
      • Staph Aureus
      • mixed flora.


    Puncture Wounds

    • High risk of infection.
    • If only through soft-tissue, can irrigate, ask pt to clean twice daily, etc..
    • If deeper: must explore (either with sterile forceps, or by removing tissue around it).
      • High risk of becoming infected.
      • Prophylactic antibiotics do not help in studies.
    • Puncture wounds that are infected and have a foreign body require abx and surgery.
    • If infected: aggressive treatment: surgery, FB removal, debridgement. etc..


    Achilles Tendon Rupture

    • Commonly missed.
    • Achilles tendon: gastroc + soleus insertion.
    • forceful dorsiflexion when tendon is in relaxed state or direct trauma to back of ankle.
    • Exam:
      • Pt can still dorsiflex due to posterior tibial muscle, but weak.
      • May palpate empty space, but hard if swollen.
      • Calf-squeeze test: (Most common)
        • calves squeezed bilaterally and foot is observed in plantarflexion.  If no dorsiflexion then tendon ruptured.
      • Knee flexion test
        • Supine patient asked to flex knee to 90°.  Foot is observed: if tendon tear present, foot falls into neutral or dorsiflexion.
      • Sphygmomanometer test:
        • Wrap BP cuff around mid-calf, inflat to 100mmHg.  The foot is dorsiflexed, the manometer pressure will rise to ~140° if tendon is intact.
    • Tx:
      • Ice, analgesics, immobilization in "gravity equinus position" with ankle plantarflexed in comfortable position.
      • Give crutches, and NO weight bearing.
      • Treatment controversial:
        • Non-surgical:
          • 1. Splint immobilization in 20° plantarflexion x2 weeks to allow hematoma consolidation.
          • 2. Next, the lower extremity is immobilized in short-leg cast or removable boot with elevated heel x6-8weeks. 
          • 3. Next, gradual range of motion and 2cm heel lift is weaned over 2 months.
          • Disadvantage: decreased muscle strength (lengthened healed tendon and high rate of recurrent rupture 8-39%).
          • NOTE: If diagnosis delayed >1week, prefer surgical management.
        • Surgical:
          • Preferred in younger + athletic pts.
          • ROM in 3-7d after surgery, but walking boot worn x6weeks. 
          • Advantages: better strength, risk of recurrence less (5%)
          • Diadvantages: higher cost, post-surgical complications (infection, skin sloughing, nerve injury). 


    Achilles Tendinopathy

    • Achilles tendon constitutes distal insertion of soleus and gastrocnemius. 
    • AKA: achilles tendonitis, tenosynovitis, peritendinitis, tendonitis, achillodynia...etc.
    • Mechanism:
      • Acute truma
      • Chronic overuse.
      • Overexertion
      • Often in long-distance runners and ballet dancers.  
      • Predisposing factors: improper muscle flexibility, increased foot pronation, leg-length discrepancy..etc..
    • Exam:
      • Swelling, tenderness around the tendon.
      • Fine crepitus on motion of foot due to presence of fibrin exucate with the paratendon. 
      • Pain with activity, relieved by rest.
      • Stiff in mornings.
      • Passive dorsiflexion aggravates pain.
    • Imaging: need MRI or U/S, but not necessary.
    • Tx:
      • Conservative:
        • decrease activity, Ice after activity. 
        • Elevate heel inside the shoe with small felt pad.
        • Runners: sustained stretching of Achilles complex.
        • Oral NSAIDs can be used.
        • NOTE: Steroid injections can cause tendon rupture, should be avoided!!!
        • If pain really bad: use short-leg walking cast or boot.
        • If pain still bad >6months: can surgically release tendon.


    Foot Strain

    • Many tendons can be strained.
    • Foot has longitudinal and transverse arch.  Function to spring-board forward motion.
    • When they are stretched by excessive weight, pressure, poor muscle tone, foot is strained.
    • Localize pain under navicular or under any point in arch: worse with activity, relieved by rest.
    • Tx:
      • Rest, hot soakes.
      • Support arch: sponge rubber pad under arch.
      • Simple rest, gradual return to activity.
      • Refer to podiatrist to rpevent complications (ligament elongation, joint inflammation, arthrosis, etc..)


    • Normally two sesamoids and first metatarsal head bear 1/3 of body weight.
      • In flattened foot, 2nd 3rd, 4rth metatarsal head bear greater weight.
      • Transverse arch becomes relaxed and subject to strain.
      • Often in high-heeled shoes.
    • Pain + tenderness over metatarsal heads during wt bearing, relieved with rest.
      • May be some edema on bottom of foot.
    • Often seen in pts with cavus deformity of foot and who wear high-heeled shoes.
    • Tx:
      • NSAIDs.
      • Use Low-heeled shoes.
      • Refer to podiatrist.


    Morton's Neuroma

    • Middle-aged women.
    • Sudden attacks of sharp pain that radiates to toes.
    • cutaneous branches of the digital nerves divide on plantar aspect of transverse metatarsal ligament and supply sides of toes.
    • Neuroma  occurs proximal to bifurcation. 
    • After sudden attacks tenderness stays for days.  
    • Can get tenderness in 3rd web space.
    • Severe pain by squeezing metatarsal heads together.


    Ingrown Toenail.

    • Distinguish from Subungual Exostosis.
    • Lateral margins of nail dig into surroudning nail fold. --> may lead to paronychial infection.
    • Causes:
      • Excessive external pressure (poorly fitted shoes).
      • Improperly trimmed nails.
      • Hyperhidrosis.
    • Commonly 20-30yolds. 
    • Tx:
      • Depends on stage.
      • Early stage: Only erythema, swelling.
        • Warm soaks, elevation of leading corner of nail with cotton pledget soaked in antiseptic solution.
        • Advised on proper nail trimming, do not wear narrow shoes. or with high heels.
      • Later Stages: acutely inflamed, or paronychial infection
        • Excission of lateral nail plate + lateral matricectomy.
          • Prep great toe with iodine/povidone soln, block with local anesthetic.  
          • Fine scissors or hemostat is used to carefully lift the lateral nail plate.  
          • Scissors is used to cut nail plate, and nail is removed.
          • The nail matrix is now exposed, and tissue can be ablated with cotton-tipped applicator soaked in phenol or electrocautery.  (must ablate, otherwise nail will come back). 


    Hallux Valgus

    • Large toe deviates laterally and bony prominence develops over the medeal aspect of first mtsl head.
    • MTP joint may become inflamed+thickened.
    • Can present to ER with bursitis.
    • Tx:
      • Warm moise soaks.
      • Pad placed over medial toe
      • Refer to podiatrist.
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