Foot and Ankle DDX
Content
Achilles Tendonitis • Athlete • Pain after jumping or running • Traumatic/Non-traumatic • Posterior Hindfoot pain Inspection Osseous Palpation Soft Tissue Palpation
ROM X-ray Special Test
- Gait may be affected - Tender calcaneus - Tender Achilles tendon ( cm pro!imal to calcaneal insertion" - Acti#e plantar fle!ion is painful - Passi#e dorsifle!ion is painful - $f it %ere ruptured there %ould be a disruption in &ager's triangle - (iagnostic )* - +,$ - Thompson Test - +uscle testing
Ankle Sprain Inversion • +ost common (plantar fle!ion/in#ersion" Inspection - *%elling/bruising Osseous Palpation - Tender lateral malleolus - Tender talus Soft Tissue Palpation - Tenderness lateral ligament ROM - Painful in#ersion- plantar and dorsi fle!ion X-ray - ,ule out a#ulsion of .th +T Special Test - (ra%er Test Ankle Sprain Eversion Inspection Osseous Palpation - *%elling/bruising - Tenderness at medial tubercle of talus - Tender na#icular - Tender medial malleolus - Tenderness medial ligaments - Painful e#ersion - Painful dorsi and plantar fle!ion - ,ule out a#ulsion - (ra%er Test
Soft Tissue Palpation ROM X-ray Special Test Co part ent Syndro e • Traumatic or o#eruse • Pain only felt %ith mo#ement • $nitially it is relie#ed by rest
• Hypertrophy and inflammation e!ceed the accommodations of the compartment • Aching and cramping at specific distance/time • Numbness/tingling into the foot may be associated • /!am %ill be normal bet%een e!acerbations Inspection - 0ocali1ed s%elling - Pallor in the foot of affected leg Osseous Palpation - None Soft Tissue Palpation - Tenderness o#er in#ol#ed compartment - +uscles of specific compartment may be tight ROM - Passi#e dorsifle!ion and acti#e plantar fle!ion causes se#ere posteromedial plain - Passi#e plantar fle!ion and acti#e dorsifle!ino causes anterior pain - Passi#e in#ersion and acti#e e#ersion causes lateral pain X-ray Special Test - 2racture (causing the compartment syndrome" - +easure compartment pressure - (iminished sensory in an3le/foot - ,esisted muscle testing e
!at Pad Syndro •
Pain in middle of heel o +uch %orse %ith %eight bearing • Non-traumatic • Aggra#ated by points of o#erpressure or irritation from shoes • Heel pain %ith land from jump • 4lder patient Inspection - 5hange in heel stri3e of affected foot (toe %al3" Osseous Palpation - Painful calcaneous Soft Tissue Palpation - Pain/tenderness at middle of heel ROM - Normal X-ray - None Special Test - *6uee1ing heel together %ill decrease pain %hen pressure is applied - +,$ !ifth Metatarsal !racture
• 0ateral foot after in#ersion an3le sprain • 0ateral foot pain during running/jumping Inspection - *%elling/bruising at .th +T - 7al3ing %ith e#erted foot Osseous Palpation - Pain/tenderness o#er fifth metatarsal Soft Tissue Palpation - 2ibularis muscles %ill be tender if it is an a#ulsion fracture ROM - Acti#e e#ersion is painful - Passi#e in#ersion is painful X-ray - 2racture Special Test - 5T - Tuning for3 - ,esisted "out • Affects big toe • +iddle-aged patient Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray
- Toe is s%ollen and red - Hallu! #algus - Tender first +TP joint - *%elling - (ecreased/stiff mo#ement of big toe - Acute phase8 normal - 0ater8 punched out area in bone (urate-tophi are radiolucent" - Hallu! #algus - 9lood %or3: high uric acid - ;oint aspiration identifies urate crystals
Special Test #allu$ %al&us
• Affects big toe • Aggra#ated by points of o#erpressure or irritation from shoes • Non-traumatic • +iddle-aged female Inspection - (eformity at first +TP joint (medial side" - 2irst toe de#iates laterally - 4#erlapping of toes - ,edness Osseous Palpation - Tender first +TP joint Soft Tissue Palpation - 9union ROM - (ecreased first toe abduction/adduction
X-ray Special Test
- $ncreased angular relationships at first +TP - Abduction/Adduction stress test (decreased motion"
#allu$ Ri&idus • Affects big toe<pain on dorsal surface • Non-traumatic • /lderly patient • Athlete Inspection - Possibly dorsal bunion - 4bli6ue creases in forepart of shoe - Toe off on lateral side of foot Osseous Palpation - Tender first +TP joint Soft Tissue Palpation - bunion ROM - (ecreased and painful fle!ion/e!tension of great toe X-ray - (orsal ring of osteophytes at metatarsal head Special Test - *tress test Metatarsal&ia • Pain on bottom of foot (especially sole" - 5alluses or corns at metatarsals due to increased stress - Tender metatarsal heads on plantar surface - Tender distal metatarsal fat pad - Painful dorsifle!ion and plantarfle!ion of toes - Normal - 2 scan to measure pressure - +orton's Test
Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray Special Test Morton's (euro a
• Affects metatarsal • Pain on bottom of sole • $nsidious onset • 0ess pain %hen barefoot • Pain bet%een =rd and >th toes Inspection Osseous Palpation
- +ass - +etatarsal
Soft Tissue Palpation ROM
X-ray Special Test
- +ass bet%een =rd and >th toes - Passi#e e!tension of +TP or $P joints is painful and may cause numbness/tingling - Plantarfle!ion relie#es pain - None - +,$ -)* - +orton's Test
Osteochondrosis of (avicular • 5hild (? years old" • $nner foot pain Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray
Special Test Plantar !asciitis • Affects medial longitudinal arch • Non-traumatic • +edial pain at bottom of heel • Pain is %orse in the morning %hen the patient gets out of bed Inspection - Pes ca#us or pes planus - *%elling Osseous Palpation - Pain/tenderness o#er medial tubercle of calcaneus Soft Tissue Palpation - Tender plantar aponeurousis ROM - Passi#e dorsifle!ion of big toe is painful - Passi#e dorsifle!ion of an3le is painful X-ray - Normal Special Test - ,esisted plantar fle!ion Stress !racture of !orefoot • Pain initially only %ith acti#ity but no% also at rest • 5onstant pain %orse %ith %eight bearing • 2emales %ith menstrual irregularities • Affects metatarsal • Traumatic/Non-traumatic • History of prolonged %al3ing/runnning Inspection - *%elling o#er metatarsal
- 7al3s on outside of foot (in#erted" - Tenderness at na#icular - *%elling in surrounding soft tissue - Normal - Na#icular is more radiopa6ue and underde#eloped - 9one scan decreased ta3e up
Osse ous Palpation Soft Tissue Palpation ROM X-ray Special Test
- $n#ol#ed metatarsal is tender - s%elling - decreased at in#ol#ed joint - Normal - 9one scan<increased upta3e at fracture site - Pain increases %hen foot is s6uee1ed together
Tarsal Tunnel Syndro e • Numbness/tingling across bottom of foot • Posterior tibial ner#e is compressed • Not associated %ith lo% bac3 or leg pain Inspection - Pallor Osseous Palpation - +edial malleolus and calcaneus may be tender Soft Tissue Palpation - Tarsal tunnel ROM - Passi#e dorsifle!ion or toes and an3le coupled %ith e#ersion reproduces symptoms X-ray - None Special Test - Tinel tap behind medial malleolus - T%o-point discrimination on plantar surface is decreased - Hypoesthesia to pinpric3 on plantar surface - Ner#e conduction studies - Posterior tibial pulse Talar Osteophytes • 5an be anterior or posterior Inspection Osseous Palpation Soft Tissue Palpation ROM
X-ray Special Test Ti)ial Stress !racture
- 5lic3ing/popping - Talus - None - Anterior8 pain %ith dorsifle!ion - Posterior8 pain %ith plantar fle!ion - 5repitus - 4steophytes - None
• Acti#e patient • $nsidious onset/o#eruse • $nitially pain is better %ith rest but returns %hen loading o Pain %ith %eight bearing Inspection - /cchymosis
Osseous Palpation Soft Tissue Palpation ROM X-ray Special Test
- Tenderness at a discrete spot on tibial shaft - None - Normal - *mall radiolucent line - Tuning for3 - 9one scan
Turf Toe • Affects big toe • *udden dorsifle!ion hypere!tension of first toe<traumatic Inspection - *%elling - Gait abnormality Osseous Palpation - Tender first +TP joint Soft Tissue Palpation - *%elling in plantar capsule ROM - Painful dorsifle!ion X-ray - Normal Special Test - Passi#e dorsifle!ion - Traction "RO*PI("S @ @ &id8 osteochondrosis of na#icular Plantar surface o 2at pad syndrome o +etatarsalgia o +orton's Neuroma o Plantar fasciitis o Turf toe +edial o /#ersion sprain o Gout o Hallu! Aalgus/,igidus o 4steochondrosis of na#icular o Tarsal tunnel 0ateral o $n#ersion sprain o .th +T fracture o +etatarsalgia
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ROM X-ray Special Test
- Gait may be affected - Tender calcaneus - Tender Achilles tendon ( cm pro!imal to calcaneal insertion" - Acti#e plantar fle!ion is painful - Passi#e dorsifle!ion is painful - $f it %ere ruptured there %ould be a disruption in &ager's triangle - (iagnostic )* - +,$ - Thompson Test - +uscle testing
Ankle Sprain Inversion • +ost common (plantar fle!ion/in#ersion" Inspection - *%elling/bruising Osseous Palpation - Tender lateral malleolus - Tender talus Soft Tissue Palpation - Tenderness lateral ligament ROM - Painful in#ersion- plantar and dorsi fle!ion X-ray - ,ule out a#ulsion of .th +T Special Test - (ra%er Test Ankle Sprain Eversion Inspection Osseous Palpation - *%elling/bruising - Tenderness at medial tubercle of talus - Tender na#icular - Tender medial malleolus - Tenderness medial ligaments - Painful e#ersion - Painful dorsi and plantar fle!ion - ,ule out a#ulsion - (ra%er Test
Soft Tissue Palpation ROM X-ray Special Test Co part ent Syndro e • Traumatic or o#eruse • Pain only felt %ith mo#ement • $nitially it is relie#ed by rest
• Hypertrophy and inflammation e!ceed the accommodations of the compartment • Aching and cramping at specific distance/time • Numbness/tingling into the foot may be associated • /!am %ill be normal bet%een e!acerbations Inspection - 0ocali1ed s%elling - Pallor in the foot of affected leg Osseous Palpation - None Soft Tissue Palpation - Tenderness o#er in#ol#ed compartment - +uscles of specific compartment may be tight ROM - Passi#e dorsifle!ion and acti#e plantar fle!ion causes se#ere posteromedial plain - Passi#e plantar fle!ion and acti#e dorsifle!ino causes anterior pain - Passi#e in#ersion and acti#e e#ersion causes lateral pain X-ray Special Test - 2racture (causing the compartment syndrome" - +easure compartment pressure - (iminished sensory in an3le/foot - ,esisted muscle testing e
!at Pad Syndro •
Pain in middle of heel o +uch %orse %ith %eight bearing • Non-traumatic • Aggra#ated by points of o#erpressure or irritation from shoes • Heel pain %ith land from jump • 4lder patient Inspection - 5hange in heel stri3e of affected foot (toe %al3" Osseous Palpation - Painful calcaneous Soft Tissue Palpation - Pain/tenderness at middle of heel ROM - Normal X-ray - None Special Test - *6uee1ing heel together %ill decrease pain %hen pressure is applied - +,$ !ifth Metatarsal !racture
• 0ateral foot after in#ersion an3le sprain • 0ateral foot pain during running/jumping Inspection - *%elling/bruising at .th +T - 7al3ing %ith e#erted foot Osseous Palpation - Pain/tenderness o#er fifth metatarsal Soft Tissue Palpation - 2ibularis muscles %ill be tender if it is an a#ulsion fracture ROM - Acti#e e#ersion is painful - Passi#e in#ersion is painful X-ray - 2racture Special Test - 5T - Tuning for3 - ,esisted "out • Affects big toe • +iddle-aged patient Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray
- Toe is s%ollen and red - Hallu! #algus - Tender first +TP joint - *%elling - (ecreased/stiff mo#ement of big toe - Acute phase8 normal - 0ater8 punched out area in bone (urate-tophi are radiolucent" - Hallu! #algus - 9lood %or3: high uric acid - ;oint aspiration identifies urate crystals
Special Test #allu$ %al&us
• Affects big toe • Aggra#ated by points of o#erpressure or irritation from shoes • Non-traumatic • +iddle-aged female Inspection - (eformity at first +TP joint (medial side" - 2irst toe de#iates laterally - 4#erlapping of toes - ,edness Osseous Palpation - Tender first +TP joint Soft Tissue Palpation - 9union ROM - (ecreased first toe abduction/adduction
X-ray Special Test
- $ncreased angular relationships at first +TP - Abduction/Adduction stress test (decreased motion"
#allu$ Ri&idus • Affects big toe<pain on dorsal surface • Non-traumatic • /lderly patient • Athlete Inspection - Possibly dorsal bunion - 4bli6ue creases in forepart of shoe - Toe off on lateral side of foot Osseous Palpation - Tender first +TP joint Soft Tissue Palpation - bunion ROM - (ecreased and painful fle!ion/e!tension of great toe X-ray - (orsal ring of osteophytes at metatarsal head Special Test - *tress test Metatarsal&ia • Pain on bottom of foot (especially sole" - 5alluses or corns at metatarsals due to increased stress - Tender metatarsal heads on plantar surface - Tender distal metatarsal fat pad - Painful dorsifle!ion and plantarfle!ion of toes - Normal - 2 scan to measure pressure - +orton's Test
Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray Special Test Morton's (euro a
• Affects metatarsal • Pain on bottom of sole • $nsidious onset • 0ess pain %hen barefoot • Pain bet%een =rd and >th toes Inspection Osseous Palpation
- +ass - +etatarsal
Soft Tissue Palpation ROM
X-ray Special Test
- +ass bet%een =rd and >th toes - Passi#e e!tension of +TP or $P joints is painful and may cause numbness/tingling - Plantarfle!ion relie#es pain - None - +,$ -)* - +orton's Test
Osteochondrosis of (avicular • 5hild (? years old" • $nner foot pain Inspection Osseous Palpation Soft Tissue Palpation ROM X-ray
Special Test Plantar !asciitis • Affects medial longitudinal arch • Non-traumatic • +edial pain at bottom of heel • Pain is %orse in the morning %hen the patient gets out of bed Inspection - Pes ca#us or pes planus - *%elling Osseous Palpation - Pain/tenderness o#er medial tubercle of calcaneus Soft Tissue Palpation - Tender plantar aponeurousis ROM - Passi#e dorsifle!ion of big toe is painful - Passi#e dorsifle!ion of an3le is painful X-ray - Normal Special Test - ,esisted plantar fle!ion Stress !racture of !orefoot • Pain initially only %ith acti#ity but no% also at rest • 5onstant pain %orse %ith %eight bearing • 2emales %ith menstrual irregularities • Affects metatarsal • Traumatic/Non-traumatic • History of prolonged %al3ing/runnning Inspection - *%elling o#er metatarsal
- 7al3s on outside of foot (in#erted" - Tenderness at na#icular - *%elling in surrounding soft tissue - Normal - Na#icular is more radiopa6ue and underde#eloped - 9one scan decreased ta3e up
Osse ous Palpation Soft Tissue Palpation ROM X-ray Special Test
- $n#ol#ed metatarsal is tender - s%elling - decreased at in#ol#ed joint - Normal - 9one scan<increased upta3e at fracture site - Pain increases %hen foot is s6uee1ed together
Tarsal Tunnel Syndro e • Numbness/tingling across bottom of foot • Posterior tibial ner#e is compressed • Not associated %ith lo% bac3 or leg pain Inspection - Pallor Osseous Palpation - +edial malleolus and calcaneus may be tender Soft Tissue Palpation - Tarsal tunnel ROM - Passi#e dorsifle!ion or toes and an3le coupled %ith e#ersion reproduces symptoms X-ray - None Special Test - Tinel tap behind medial malleolus - T%o-point discrimination on plantar surface is decreased - Hypoesthesia to pinpric3 on plantar surface - Ner#e conduction studies - Posterior tibial pulse Talar Osteophytes • 5an be anterior or posterior Inspection Osseous Palpation Soft Tissue Palpation ROM
X-ray Special Test Ti)ial Stress !racture
- 5lic3ing/popping - Talus - None - Anterior8 pain %ith dorsifle!ion - Posterior8 pain %ith plantar fle!ion - 5repitus - 4steophytes - None
• Acti#e patient • $nsidious onset/o#eruse • $nitially pain is better %ith rest but returns %hen loading o Pain %ith %eight bearing Inspection - /cchymosis
Osseous Palpation Soft Tissue Palpation ROM X-ray Special Test
- Tenderness at a discrete spot on tibial shaft - None - Normal - *mall radiolucent line - Tuning for3 - 9one scan
Turf Toe • Affects big toe • *udden dorsifle!ion hypere!tension of first toe<traumatic Inspection - *%elling - Gait abnormality Osseous Palpation - Tender first +TP joint Soft Tissue Palpation - *%elling in plantar capsule ROM - Painful dorsifle!ion X-ray - Normal Special Test - Passi#e dorsifle!ion - Traction "RO*PI("S @ @ &id8 osteochondrosis of na#icular Plantar surface o 2at pad syndrome o +etatarsalgia o +orton's Neuroma o Plantar fasciitis o Turf toe +edial o /#ersion sprain o Gout o Hallu! Aalgus/,igidus o 4steochondrosis of na#icular o Tarsal tunnel 0ateral o $n#ersion sprain o .th +T fracture o +etatarsalgia
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