1
Q
Heel pain differential (posterior or plantar os calcis)
A
- Achilles insertional tendinopathy
- Retrocalcaneal bursitis
- Haglund’s Syndrome
- Os trigonum syndrome
- FHL tendinopathy or tenosyvitis
2
Q
Achilles insertional tendinopathy often accompanied by
A
- Calcification (spur) at tendon attachment
3
Q
Haglund’s Syndrome
A
- Enlarged posterior superior margin of calcaneus
- Can impinge upon retrocalcaneal bursa and Achilles tendon
4
Q
Os trigonum syndrome
A
- Presence of os trigonum usually not painful
- Usually triggered by an ankle injury
- Repeated plantarflexion causes ossicle to become impinged
- Posterior ankle impingement
- The connective tissue connection between the ossicle and talus is damaged
5
Q
FHL tendinopathy or tenosynovitis
A
- Not common
- Seen in dancers
6
Q
Other possible heel pain diagnoses
A
- Plantar fasciitis (inferior heel)
- Calcaneal stress fracture
- Calcaneus fracture
- Tarsal tunnel syndrome
- Other arthropathies
- Infection
7
Q
Calcaneal apophysitis (Sever’s Disease)
A
- Overuse/overload injury to the posterior apophysis (posterior growth plate)
- Xrays can rule out other conditions
- Secondary center is usually fragmented (not always)
- Diagnosis is clinical
- Treated conservatively
8
Q
Calcaneal apophysitis (Sever’s Disease) causes
A
- Achilles tendon (traction apophysitis)
- Mechanical compression
9
Q
Calcaneal apophysis ossification
A
- Secondary center appears mostly btwn ages 6-9 (almost always appears by age 11)
- Fuses btwn 12-18 (most fused by 15)
10
Q
Calcaneal apophysitis (Sever’s Disease) symptoms
A
- Pain localized to posterior/plantar heel
- Elicited during weightbearing
11
Q
Calcaneal apophysitis (Sever’s Disease) most commonly seen in
A
- Children and adolescents during growth
- Especially ages 9-13 who are active in sports
- Boys > girls
- Both heels commonly affected
12
Q
Haglund’s deformity (pump bump, Mulholland deformity)
A
- Bony enlargement of the back of the heel (posterior superior calcaneus)
- Soft tissue surrounding (Achilles, bursa) can become irritated leading to Haglund’s syndrome
13
Q
Haglund’s Syndrome symptoms
A
- Retrocalcaneal pain
- Abnormal protuberance of the posterosuperior border
- Retrocalcaneal bursitis and swelling
- Achilles tendinosis
- Pumps or shoes with rigid shoe backs aggravate the enlargement (shoes with a hard back)
14
Q
Haglund’s Syndrome clinical appearance
A
- Can be difficult to distinguish Haglund’s syndrome from other causes of hindfoot pain
- Prominent calcaneal posterosuperior protuberance
- Usually on the lateral side
- Swelling and inflammation
15
Q
Haglund’s Syndrome predisposing factors
A
- Wearing tight, stiff shoes
- Pes cavus
- Forefoot varus
- Tight Achilles
- Walking on lateral side of foot
16
Q
Haglund’s Syndrome usually affects
A
- Middle-aged individuals
- F > M
- Often bilateral
17
Q
Conservative treatment of Haglund’s Syndrome
A
- Shoe modification
- Orthotics: heel pads and lifts
- PT: Achilles stretching, anti-inflammatories, ice
- Local injections (bursa)
18
Q
Surgical treatment of Haglund’s Syndrome
A
- Removal of bony enlargement (calcaneal osteotomy)
19
Q
AP view x-ray
A
- Foot positioned in dorsiflexion
- Toes toward ceiling
20
Q
Mortise view x-ray
A
- AP with foot internally rotated ~ 15-20ᵒ
- Brings malleoli parallel to each other
- Allow visualization of mortise (tibial plafond, malleoli, talar dome, clear space)
- Allows assessment of distal tib/fib syndesmosis
21
Q
Lateral view x-ray
A
- Calcaneus/talus profile
22
Q
Tibiofibular overlap
A
- Overlap of fibula and anterior tubercle of tibia (anterior aspect of fibular notch of tibia)
- Overlap should be at least ≥ 6mm on AP, ≥ 1mm on mortise view
23
Q
Tibiofibular clear space
A
- Distance between medial border of fibula and lateral border of posterior tubercle (posterior aspect of fibular notch of tibia)
- <6mm on both AP and Mortise view
24
Q
Medial clear space
A
- Between lateral border of medial malleolus and medial border of talus
<4mm on AP - Should be equal to superior clear space on mortise view
25
Stress x-rays
- Positioned for mortise view and then the foot is stressed into external rotation
26
Conservative treatment of ankle sprain
- Pressure, rest, ice, compression, stabilization
- Non-weight-bearing immobilization
- Progressed to functional brace and physiotherapy
27
Syndesmotic ankle sprains
- Less common than lateral ankle sprains (1-18% of all ankle sprains)
- Athletic population incidence increases up to 12-32%
- More difficult to diagnose and usually require longer recovery periods vs. lateral ankle sprain
28
Uncorrected unstable injuries can lead to
- Chronic instability
| - Degenerative OA
29
Common causes of syndesmotic ankle sprains
- External rotation of a planted foot (rotation of talus widens ankle mortise)
- Pivoting internally on an externally rotated foot
- Valgus load to the leg with planted foot
- Lateral blow to ankle in external rotation
30
Foot position (pronation vs supination) and deforming force (abduction,adduction, internal or external) rotation can influence other tissues that are damaged
- Deltoid ligament (syndesmosis injury + deltoid rupture usually causes instability)
- Malleoli and fibular fractures
- Very common to have frxs and other ligamentous injuries, need all 3 x-ray views
- Advanced imaging can be very helpful
31
Usually the 1st ligament to tear
- Anterior inferior tibiofibular ligament
32
Maisonneuve fracture
- Combination of proximal 1/3 of fibula and unstable ankle injury (widening of ankle mortise)
- Usually involves ligament injuries and/or frx
33
Ligament injuries and fractures often associated with Maisonneuve fracture
- Distal tib/fib syndesmosis
- Deltoid ligament
- Medial malleolus frx
34
Ankle stability depends on
- Congruency of bone: ankle mortise
- Joints and ligaments
- Joint capsule
35
Deltoid ligament resists
- Eversion, lateral translation, and external rotation of talus
36
Distal tib/fib syndesmosis
| prevents
- Separation of tibia and fibula
| - Talar wedging
37
Interosseous border of tibia (lateral border) ends as
- The fibular notch
38
Anterior tubercle of tibia (Chaput’s tubercle)
- Large tubercle that projects laterally
- Overlaps the fibula (supramalleolar shaft)
- Posterior tubercle of tibia (Volkmann’s tubercle) is smaller
39
Anterior inferior tibiofibular ligament
- Multiple bands that form a trapezoidal shaped ligament
40
Anterior inferior tibiofibular ligament attachments
- Medially to Chaput’s tubercle on distal anterolateral tibia (anterior fibular notch of tibia)
- Courses distolaterally to anterior border of fibula/lateral malleolus (Wagstaffe’s tubercle)
- Distal fascicle is known as Bassett ligament
41
Posterior inferior tibiofibular ligament attachments
- Trapezoidal shaped
- Distolateral margin of posterior fibular notch on tibia (Volkmann tubercle) and posterior malleolus of tibia
- Courses distolaterally to attach to posterior lateral malleolus
42
Chaput’s, Wagstaffe’s, and Volkmann’s tubercles
- Can be sites of avulsion fractures
43
Fibular notch is also known as
- Incisura fibularis tibiae (fibular incisure of tibia)
44
Inferior transverse tibiofibular ligament
- Deep inferior fibers of PIFL
| - Deepens posterior ankle mortise
45
Inferior transverse tibiofibular ligament attachments
- Posterior inferior fibular notch
| - Superior aspect of fibular fossa
46
Interosseous tibiofibular ligament
- Lower margin of interosseous membrane
| - Spring-like function allows slight separation during dorsiflexion
47
Interosseous membrane and deltoid ligament
- Also support the syndesmotic joint
48
Synovial recess
- Extends from from tibiotalar to interosseous ligament
49
Synovial lined plica
- Extends proximally from tibiotalar joint into distal tib/fib joint
50
Synovial recess and fold (fringe)
- Interposed between tibia and fibula
| - Contains adipose and fibrous tissue, nerves, vessels
51
Synovial recess and fold (fringe) movements
- Retracts between tib/fib during dorsiflexion
| - Descends during plantarflexion
52
Synovial recess and fold (fringe) function
- Believed to aid in synovial fluid distribution and protection of dital tib/fib edges
- Possible source of pain in ankle impingement
Lower Extremity Anatomy II
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