Good morning, everyone. My job is to do the stepchild, the foot and ankle, and I got the foot. So I'll try to keep it as interesting as I can for you. And obviously it's focused mostly towards sports medicine. I have no relevant disclosures for this talk. So the gait cycle, Corey obviously said I'm going to go through the gait cycle a little bit more. And the gait cycle is a very boring topic in general, but I think for everyone it does have relevance and I'll try to make it relevant to the injuries that we have. So we look at the gait cycle for heel strike. The anterior tip tendon is eccentrically contracting, slowing the foot down from hitting the floor. The hind foot's actually in varus and inversion. And when I first started foot and ankle, I always thought it was unlocked when you hit the ground, but it actually doesn't make any sense. And it's wrong. It's actually locked to give you stability when you strike the ground. When you go to foot flat, that's when your body's trying to accommodate over uneven ground, grass, gravel, or obviously the flat ground. And the gastroc soleus is now slowing you down, stopping the body from falling forward. The hind foot's in valgus and eversion, and you have unlocked and ground accommodation. That's relevant for patients who have a cavus foot, as Corey's talked about. They're the ones that will get a stress fracture of their fifth metatarsal navicular medial malleolus because they're unable to unlock their foot. And so then they'll have significant stress every time they hit the ground. At toe off, things change. You have to have the posterior tip tendon contract to invert the hind foot, and the gastroc soleus is now constantly contracting, giving you that push off, and the hind foot now should be in varus and inversion. That whole single limb heel rise that we ask patients to do for posterior tip is based off of this mechanics with the gait cycle. So if your posterior tip is dysfunctional or out, they're unable to lock the hind foot. And when the gastroc soleus fires, if your hind foot's not locked, you're just tearing through the midfoot and hind foot, and your heel never rises off the ground. It's different than a spring ligament rupture where the foot may be flat, which is an acute rupture, which I don't know you would ever be asked about that question. But you have a traumatic injury to the midfoot or the hind foot, and they get a collapsed acute flat foot, and maybe the spring ligament, and those patients can do a single limb heel rise because the posterior tip tendon's still working. The subtalar joint is a very confusing joint, and I don't know if I fully understand it yet, but it is designed for your inversion-eversion, and it works in congruity with the talonevicular joint. It's angled posterolateral to anteromedial, and the reason why that's relevant is if you're ever doing a talus fracture, you start your screw slightly lateral, and you're always angling medial, so you hit down the neck and head. It's angled off the floor about 41 degrees, so it's angled anteriorly, which again is for subtalar fusions, and that angle allows that swinging motion of the foot to give you that inversion-eversion. You invert more than you evert, and if you look at your own foot, that's pretty obvious unless your foot's really flat-footed, and things change, obviously. But normal inversion is more than eversion, and that should make sense when you think about the cavus versus the flat foot. Subtle cavus foot can cause lots of problems, and the simplistic thought process is that your foot is unable to accommodate as much, where you can have a flat foot that's pretty severe actually, and your foot will still accommodate because you have that inversion motion. The transverse tarsal joints are your talonovicular and calcaneocuboid joints, and they work in concert with the subtalar joint. At hindfoot eversion, the joints are parallel, and the reason why that's important is that unlocks the hindfoot, so it allows that slop in your foot. The tibia is internally rotated, and if you ever get this test question, because it's asked on the board sometimes in the OITE, if you take your own leg and plant it on the floor, and you internally rotate your tibia, you'll feel your hindfoot evert and unlock, and that's what the subtalar joint and transverse tarsal joints do. If you externally rotate your tibia, then you will invert, or you will lock the hindfoot, so the talonovicular and cc joints are oblique, and you get that rigidity to your foot. So sometimes the question is written such that what is the purpose of the subtalar joint, and it's a transfer rotation of the tibia to the foot. External rotation of the tibia locks the hindfoot, internal rotation unlocks it, and in pediatric cases, if you have severe internal or external tibial torsion, that can give you foot deformity as well. It's not as common in the adult, but definitely in pediatrics, you get these severe deformities. If you have a patient that has a malunion of a tibia fracture, obviously that can cause problems. So to think about it differently, the gastroxilius at foot flat is eccentrically contracting, decelerating the body as you walk, and at toe-off, the gastroxilius' main purpose is to accelerate you, give you that push-off. The tib end at heel strike is eccentrically contracting, preventing the foot slap, and in swing phase, it's constantly contracting, clearing the ground. That's where that steppage gait term comes from. So if your anterior tib isn't working, you'll flex your thigh, flex your knee to keep the foot from dragging off the ground. So if they're weak, if the gastroxilius is weak, such as Achilles rupture that's been neglected for a while, the patient will present sometimes with just heel pain and weak push-off. When you look at the test questions, it's always pretty straightforward. Weak push-off, painful heel strike, but what they may come in with is heel pain. I walk for two, three hours, my heel hurts for a while, and when I was in fellowship, one of my directors and me saw a patient, and we told him we had plantar fasciitis. We sent him for PT for gastroc stretching, and that obviously didn't work out so well. Then he saw my other mentor who told me and the junior guy, they were both morons. He had an Achilles rupture that was missed, and we'd failed to examine his other leg. So simple things like that, always examine the Achilles tendon, always examine the other leg, and you'll see this. And they may just come with heel pain, they may never remember the inciting rupture that they had. The anterior tib, the steppage gait and foot slap, and these patients, again, may not remember an injury. Because some of these are sometimes very painless, especially in the elderly. And they may tell you, I just have this slapping of my foot, or I have a mass in the front of my ankle, and I have an anterior tib tendon rupture. For plantar fasciitis, which is the bane of my existence, and I'm sure everyone here as well, since there's not much to do about it. But the one thing that they're going to ask you nowadays that is associated with a tight heel cord and a gastroc contracture, and this is very common in foot and ankle. I don't know how many of you here do a gastroc release, but it's very common for us to do it now for plantar fasciitis. The theory is that the tight gastroc is putting strain on the plantar fascia as you try to have your body come over your foot. If the ankle does not dorsal flex with the knee in extension, then the strain has to go somewhere. The strain either goes to the plantar fascia or the insertion of the Achilles tendon, as Corey's talked about. The treatment for this is focused on heel cord specific stretching and plantar fascia specific stretching. They like this type of a question a lot, so if you focus your PT on the plantar fascia, it has been shown to increase the effectiveness compared to just stretching the heel cord. The surgical treatment historically used to do a partial plantar fascia release, and the problem was if you do an excessive release, you get arch collapse. And the foot would hit this lateral border foot pain, for which there is really no known solution. Orthotripsy, excuse me. Orthotripsy is approved, the efficacy is questionable, but it's a reasonable non-operative intervention. But for the test, I wouldn't just shoot to that. Sorry, I've been out of the weather for the last week. The most effective operation for plantar fasciitis, if they have a gastrocnemius contracture, is a gastrocnemius recession. And that has definitely changed over the last five, six years. So if you see that type of a question, they will give you that the patient has a gastrocnemius contracture, as Corey has talked about. If they're giving you that information of a tight heel cord, they failed conservative therapy, please answer gastrocnemius recession, not partial plantar fascia release. And you're trying to correct the contracture surgically that was unable to be contracted with physical therapy. So the rest of the anatomy with the superficial perineal nerve, it does have a motor branch proximal. So if you get a perineal nerve injury, such as a knee dislocation, which many of you may encounter, they'll get an injury to the superficial perineal nerve and they'll lose eversion. If it's a total injury to the nerve, there's a knee dislocation, the common perineal is completely injured, then you will get a complete foot drop and loss of eversion. But it's autogenic after it goes past the fibular head. Sometimes you can just get a perineal nerve injury for the SPN. The sensory branch is the dorsum of the foot, not the first web space. I think everybody does know that, but they do like that to ask you the question. The first web space is deep perineal nerve. The dorsum of the foot is superficial perineal nerve. And most commonly, it's at risk during an arthroscopy and the lateral portal. That's the question they like. If any of you do arthroscopy, you have to palpate the nerve, be very careful. And if they have dorsal numbness of the foot, that's the superficial perineal nerve. Lateral portion of the fibula, everybody does ankle fractures. The course is very variable. Typically, the common answer is 12 centimeters proximal to the tip of the fibula is where you'll encounter the nerve. The truth is we've done some anatomic dissections and others have too. It is literally anywhere you don't want it to be. So cutting down to the bone is dangerous. When I was a resident, we did that in the distal two centimeters. And there was this yellow stringy structure that we lacerated in half and we just kept going because we're orthopods and don't know how to sew things together. You just don't want to do that. So just be careful and it's anywhere. And then if you ever do an ankle fusion or ankle replacements in the anterior aspect of the incision, distally. For pilon fractures, you have to be careful if you have an anterolateral approach or an anterior approach for a pilon. The nerve will be there, especially with an anterolateral approach and you have to be careful that you don't lacerate it. The deep perineal nerve does the entire anterior leg and it does the foot. So the EHB and EDB are innervated by the deep perineal nerve and it does the first web space I've demonstrated here. It's always at risk really during a Lisfranc approach. So if anybody here does Lisfranc surgery, which we'll get into, oh, which Corey's got into, I'll talk about fusions. If you do that first web space approach, sorry, this is miserable, let me grab some water. That first web space approach, the deep perineal nerve and artery are right there. So you have to be careful if they have numbness after the surgery, it is the DPN. The serral nerve is a really annoying nerve. It's in the lateral aspect of the foot. Any posterior approach to the leg is at risk. So when you're doing an Achilles rupture, usually we're central or medial so you can avoid it. But if you happen to do a posterolateral approach, such as for an osteogonal removal, you will encounter the serral nerve and you may injure it. Posteromalleolus approach, posterolateral between the fibula and the Achilles tendon for a posterolateral approach for either bone grafting or a posteromalleolus fracture. The serral nerve is absolutely at risk and has a high rate of neuritis, so just be careful. And then for calcaneus fractures, especially with an extensile approach, it's at risk in the proximal and distal aspect of the incision, as you can see demonstrated here. So cavovarous foot, Corey's talked about, and the only reason I'm talking about is for orthotics because you will be asked this question, unfortunately. The pathology is a plantar flexed first metatarsal that's almost intrinsic in all cavovarous foot. And you can see there when you look at the lateral, it just has a high arch. You can measure the lateral talofirst metatarsal angle and it's pointing to the sky. It's positive. That's a cavous foot. If the angle is pointing down, it's a flat foot. When you look at them from the back, you can see the hind foot varies and it's relatively clear and these are bad x-rays, obviously. The mechanical effect, going back to biomechanics, and I keep going back to that biomechanical stuff, and I know you don't want to read it, but to understand, at least get the questions everything relates back to that first few slides. When you have a cavous foot, your foot is locked and that's going to cause all the stress fractures, ankle instability, Corey's talked about, because there's no give in the system, so all the stress goes to the ankle and the foot. The orthotic treatment for a cavous foot is the opposite, in some ways, of a flat foot. So you're trying to unwind the foot. So if the heel is inverted, the first ray is plantar flexed, you want to evert the hind foot, so that's a lateral post and you can see that demonstrated there, and you're trying to unwind the foot to evert it. The problem is the first metatarsal is plantar flexed, so you can put a post underneath the lateral hind foot, but if you don't put a well out for the first metatarsal, nothing happens and the patient actually hates the orthotic. So just putting a lateral wedge to somebody's foot who's cavous doesn't really help them because there's no potential space for the foot to drop into. And so when you write this orthotic and for the test, they want you to have a well out for the first metatarsal and a lateral post. There's only one over-the-counter orthotic, it's called the arch rival, I have nothing to do with it, but if you order the arch rival, there's a hole where the big toe is and it's a good cavus orthotic if you ever have any patients that have subtle cavus foot. And you want to lower the arch, you don't want to accommodate the arch, you don't want to support the arch, you actually want to lower the arch, you imagine like a cavus foot and you evert the hind foot, the arch has to be lower. If you don't do those three things, the cavus orthotics are extremely painful and sometimes actually counterproductive because you're locking the hind foot and making them now more rigid. The Coleman block test has been talked about, but the one thing I want you to remember is a positive test is if it corrects. I've never heard the positive except in the test questions, so just to be clear, a positive test is when the foot corrects. In that case, what they're getting at is a forefoot driven hind foot varus, that means it's the plantar flex first rate, that's the problem. You need to do a dorsiflexion osteotomy and that will solve all your problems. If the test is positive, just a dorsiflexion osteotomy. If it's negative, that means it doesn't correct, what they want you to focus on is that the hind foot is in varus, it's not just the forefoot and you need to do a calcaneal osteotomy. And I hope that's clear to everyone, they like that positive negative type of a question for this. So positive, it corrects, first rate is the problem, negative, the first rate is not contributing technically to the problem and you have to do a hind foot osteotomy. Really the best way to think about it is that if the test is negative, the hind foot is also a problem, not just the forefoot. Flat foot is the opposite in some ways, hind foot thalgus abduction and forefoot supination, you can see kind of the opposite x-ray, the foot is sloppy, unlocked and it does not become rigid for push off. So again, back to the biomechanics, if you can't make the foot rigid for push off, then you can no longer do a single limb heel rise propel yourself and you put more and more strain on the midfoot, giving you pain over the push or tip that gets worse over time. The orthotic treatment, this is a forefoot that is in quote unquote varus or supinated. In our world, they do like talking about this a lot because if you do not compensate for this, your orthotic or surgical reconstruction will fail because the foot will collapse back down. So to correct these patients, you need a medial post, a medial forefoot support if the foot is in varus as I've demonstrated here and increase the arch. You're trying to lift up the entire inside of the foot. Heel cart contracture has been talked about. I'm focusing on this a lot because it's relevant in a lot of pathology for foot and ankle now. So it's an equines contracture, that's the same with the knee extended and flexed as a true achilles contracture. That has to be treated with an achilles lengthening, not a gastroc recession. If you get more motion with the knee flexed and you have to hold the foot in neutral, so you don't have it in valgus or varus too much, just dead neutral, and you get more motion with the knee flexed, that means the gastroc is tight. An isolated gastroc recession will help you and this is relevant in plantar fasciitis and achilles tendonitis most commonly for the sports population. So what is the most commonly injured structure during the creation of an anterolateral portal for ankle arthroscopy? All the two nerves are listed and two tendons are listed and the answer is B. For the medial portal at risk are two structures, the saphenous nerve and if you're too close to the anterior tip tendon, you can injure the anterior tip tendon. A 45-year-old woman has developed pain along the plantar aspect of the heel over the last month. She has pain with her first few steps in the morning, but the pain improves until the end of the day. The next treatment option is, the diagnosis is plantar fasciitis, they're asking what the next appropriate option is. A plantar fasciotomy is always incorrect because that's a complete fasciotomy, it should be partial plantar fascia release. Shockwave could be considered, steroids are inappropriate, but she hasn't tried any stretching and a cushioned heel insert, so conservative first, more aggressive second. If they said the patient has more pain throughout the day, that is more of a calcaneal stress fracture, hurts in the morning, then more and more it gets worse, they're on it, that's a stress fracture, may have a positive calcaneal squeeze test, that gets you with rest, vitamin D, etc. So for the hallux and bunions, and I'm sure none of you ever want to look at a bunion in your entire life, and honest to God, I don't even want to do that stuff, so you know, what are you going to do, huh? But they may ask you this stuff, and just to give you the numbers, just so you have it on, some idea. The hallux valgus angle is down the phalanx and the metatarsal, it's basically the deviation of the phalanx relative to the metatarsal. A bunion is not an outgrowth, it is the abnormal alignment of the metatarsal and the phalanx. Normal is less than 15. If you go to the inner metatarsal angle, which is the most relevant angle, if you had to remember one thing for the test, just remember this, it's the Spock sign, so a normal foot has a less than 9 degrees, so they're relatively parallel, but if you see that large Spock sign between the first and second, that is more of a bunion, that's going to determine what surgery you need to do. So if it looks really big, they want you to do something proximal, if it doesn't look that bad, they're going to ask you to do something distal. The number is 9 is normal, and I'll give you kind of some basic criteria. If it's less than 13 degrees for the IM angle, which is, honest to God, the only thing I think you should try to remember if you're going to remember anything for bunions, so a small bunion, that's a chevron or a distal osteotomy, and the reason is it's not that deformed, a distal correction, which is less biomechanically superior than a proximal correction, is appropriate, and you always want to do a soft tissue release when you do bunions. If the angles are bigger, either one, you have a really bad hallux valgus, really bad endometatarsal angle, you want to do something proximal. On the test, they should never ask you what type of osteotomy to do, they should keep it very general, such as a proximal osteotomy. If the word of the osteotomy is not chevron, just for example, then it's something proximal. There's 15,000 different names for proximal osteotomies that we do, and most of us only do one distal osteotomy called the chevron. So if it's confusing, they don't say proximal or distal, it just says, if it says chevron, that's distal and anything else is probably a proximal osteotomy. If there's instability, and they may, they should give you this on the test, they may say there's more motion at the first TMT joint than normal, the patient has severe flat foot deformity, what they're getting at is that the first TMT joint is unstable, and that is the root cause. So for those patients, you want to do what is called a lapidus, which is where you fuse the first TMT and realign the toe at the same time, and again, all of these have a soft tissue release. If there's arthritis, rigid deformity, or spasticity, and the way that will be phrased is the patient has pain in the great toe without shoe wear, pain with range of motion, or unable to be reduced. If the toe deformity is rigid or fixed, then you just have to fuse it, and that will correct everything. So pain is the indication, not cosmesis. Please keep that in mind. If they say the patient has a deformity, but it doesn't cause them any pain, it's shoe wear modification, that's it, not surgery. Soft tissue procedures alone are not indicated, so if you see capsule release and imbrication medially and no bony correction, that is always the wrong answer. If you see osteotomy alone, that's not indicated, unless all the answers are the same. So if all the answers are just talking about the bony, scarf, proximal osteotomy, distal osteotomy, lapidus, and none of them have a soft tissue correction, then they're just assuming that's part of the deal. But if there's four answers or five answers, and two do not have a soft tissue correction, and two do, the ones with soft tissue correction are universally going to be correct. Recurrence, which is what they like to talk about, is in juvenile how it's found. If you do a bad job, you don't correct the inner metatarsal angle, you don't do a bony correction, it will come back. This is my patient. She's a very kind old lady that didn't want to punch me in the face for doing this to her. So she had a bunion, and I did it, and then I did a bad job, and she tore through the inner cuneiform joint. I took her back, and I put that arm angle back where God didn't want it to go, and I overcorrected it, and she got hallux varus, and I never treated her after this. For her obvious reason, she didn't come back. I don't think she wanted me to touch her anymore. But this is the thing that you will see. This is iatrogenic is why you will get hallux varus. It's very rare to get this without a surgeon causing it. There's two reasons. One, if you are flip-flops, and you have to have rheumatoid. When I went to India to travel, they all have hallux varus, not hallux valgus for rheumatoid. So if your ligaments are loose, rheumatoids will get hallux varus. If you don't have anything stopping it from shooting over to the medial side, in America, rheumatoids get hallux valgus. It's just different. But in America, it's always surgically induced, and the key question is, is it flexible or rigid? And in foot and ankle, that's always kind of the thing that we think about. If the deformity is flexible, you can do soft tissue correction. And osteotomy, if it's rigid, it's fusion. And that principle can apply to almost everything. So the radiographs are always looking for arthritis, the intermetatarsal alignment, like I've done here. This would have to be corrected with an osteotomy to undercorrect that intermetatarsal angle to put it back where it belongs, and then a soft tissue correction. The surgical treatment, if it's flexible, really, you're going to do a tendon transfer with a split EHL or split EHB, and you can augment with a suture button type device if you choose. So the test is just going to be some sort of soft tissue correction if it's flexible. If it's rigid or arthritic, it's a toe fusion. Nothing else has to be done. Hallux rigidus, which is basically just arthritis of the great toe. This is a common finding for, I'm sure, in your practice as well. They have stiffness, pain with motion, swelling and redness, difficulty with shoe wear, and pain with push off. You can see in this picture here, the toe is plantar flexed, and that's why in podiatry they call this hallux flexus. Because of the arthritis and position of the metatarsal, the inability to dorsiflex the toe, the toe assumes a more plantar flexed position. There is nothing intrinsically elevated about the first metatarsal that's been proven, but it assumes this position because it cannot dorsiflex. The key radiographic findings that you want to look for when you're looking at the test are these dorsal osteophytes. If you see that, that's hallux rigidus. If you see loss of the joint space on the AP, that's obviously hallux rigidus, and what you're looking for is the amount of joint space. If there's less than 50% of the joint space that is missing relative to the second and third toe, then you want to do a chylectomy. You open it up, take off the offending osteophytes and the ebonated cartilage, mobilize the toe and we'll do okay. If there's erosive changes, it's gout, and you have to keep that in mind. It can be periarticular, not at the joint, but just at the medial or lateral aspect of the joint. You see that pencil and cup and nail pitting? If they give you that, they're talking about psoriatic arthritis, and both of those need a fusion actually. The conservative treatment is a Morse extension carbon fiber plate, and they will ask you this question. So for hallux rigidus or any problem with the great toe, if it's a pain, a carbon fiber plate or Morse extension limits the motion of the great toe and solves your problem for motion, and it's a very effective device to use. A high toe box shoe, because the toe is elevated, helps keep that toe from getting pressure from the dorsal aspect of the shoe, and a steel shank or stiff shoe can also help as well. The chylectomy and debridement is done like this. It's a small incision. You remove the osteophyte, and you can see on the lateral radiograph post-op, the bump is gone, and the patient now can theoretically dorsal flex to about, intraoperatively, you have to get 70 degrees, post-op they never get that. They may get 30, 40 degrees, and they're sometimes happy. Pain has to be at the extreme only, which means it's only from the mechanical abutment of the osteophyte. The grinding within the joint is not present. That's very important. If there's no pain with the grind test, which is where you have the central aspect of the joint, and you move it up and down and around and around, it doesn't hurt, that means the central portion of the articular surface is intact. They don't need a fusion. You can just take off the quote-unquote bump, and you'll be okay. For a fusion, if there's complete loss of the joint, pain with any motion, this joint is stiff or has no motion, they've had prior surgery, a rheumatoid or hallux valgus with arthritis, you want to do a toe fusion. So to simplify it again, if you have arthritis of the big toe, pain only at the extremes or over the bump, a colectomy is the best answer. If they have pain with a grind or throughout the range of motion, or it's very stiff, you want to fuse the toe because that will correct all your problems. There is a joint replacement center out there for the great toe. You probably have had patients or seen on TV this CARTIVA, although a lot of us do it, it is absolutely not the board answer. So please don't pick that for your exam questions at all. It's like $4,000 too. So turf toe, this is obviously very relevant for the sports. The top of the great toe has a lot of motion and on the bottom aspect of the great toe is a large thick ligament, the plantar plate that holds everything together. It's a complex of the ligament and the sesamoid, they function as one unit. So you get this with hyperdorsiflexion with tearing of the plantar plate, obviously artificial turf was the original description but can happen in any athlete that has a hyperdorsiflexion injury. They'll have pain, discomfort, ecchymosis in the great toe, that's the tip off. You always want to get bilateral x-rays to exclude proximal migration of the sesamoids. So if you see an x-ray with both feet and one set of sesamoids is proximal compared to the other side, that's a complete rupture of the plantar plate and the sesamoids migrate approximately, it's a grade three that needs surgery. Treatment is to get the swelling down, put them in a boot or graphite plate and surgeries for an unstable joint, that's your grade three if they have a proximal sesamoid migration or traumatic bunion. Those are indications for surgery, a sesamoid fracture, complete rupture of the plantar plate by MRI. Return to play, which is the most important for patients and for you. The key number is 60 degrees of painless range of motion. Grade one, it's tape and eat immediate return, so grade one means they can weight bear on their toe, no pain, no problem, let them go. They already have 60 degrees of painless range of motion. Grade two, they have a hard time weight bearing, they have pain with range of motion and therefore those are two weeks before you let them return to play. The MRI does not show a complete tear. For the grade three where they have a complete tear or sesamoid fracture or proximal migration as I've discussed, those really at this point based on the current literature which is limited do benefit from surgery and that probably is the best answer if they ask you that question. So sesamoid disorders without trauma, so sesamoiditis, chronic sesamoid fracture, AVN, if you do a sesamoidectomy, that's the only appropriate surgery that's available right now. You may have read about doing a bone grafting and screw fixation for a chronic sesamoid fracture but that's not the board answer. Sesamoidectomy works relatively well. The problem is you have to repair the flexor hallucis brevis, which is in the sesamoid or connects through the sesamoid. And so if you take out the tibial sesamoid, the common complication is hallux valgus as you would imagine and the medial plantar nerve is at risk. You take out the fibular sesamoid, it's hallux varus. So it's very straightforward. You take out the one on the right, the toe will go left. Take out the one on the left, the toe will go right. The key thing is for fibular sesamoidectomy, they may ask you what's the safer approach. You can go dorsal to avoid the plantar digital nerve. The problem is it's harder to see. I doubt that I'll ever ask you that. One thing they will ask you is what is the return to play after sesamoidectomy to full elite sports. It's only 80% return to the full activity. One out of five patients will not be able to return to the level activity after sesamoidectomy and that's a real problem. If you take out both sesamoids, the tibial and the fibular, what happens is you've lost the mechanical stability of the toe and you get a cock-up toe. And that's a devastating complication for which there is no great operation. So you can only take out one sesamoid, never both and keep that in mind if they have that kind of a weird question. 52-year-old presents with increasing pain, deformity and limitation of great toe motion. His exam demonstrates pain through the mid-range of motion of the joint. His x-rays show MTP arthritis. Treatment includes all the following except. So carbon fiber insert is reasonable because it will limit motion. Fuse is an acceptable surgical option. Anti-inflammatory is always an option but sesamoidectomy is not appropriate because that's not going to solve this problem. And number two will cause a cock-up deformity of the toe. So for the lesser toes, they may ask you these as well. I was obligated to talk about the foot stuff obviously. So it goes back to flexible and rigid. So hammer toes just deform the lesser toes which everyone will see. If it's a flexible deformity, you can either do a flexor tenotomy or FDL flexor to extensor tendon transfer. You take the long flexor, split it and put it to the top of the toe. I will tell you that tendon transfers, no one really does that anymore. It's a historical thing but we still have to answer it for the boards. If it's rigid, so the deformity is uncorrectable for the PIP joint, a tenotomy will not help you. So in that case, you have to do a PIP fusion or PIP arthroplasty which is a small dorsal approach to remove bone on both sides, put a screw, intermediate device or a K-wire and lock it together. If it's recurrent or spastic, then you want to do a PIP fusion. For a claw toe, this is really focusing on the MTP joints. When you look at a claw toe versus hammer toe, claw toe involves the MTP joint where a hammer toe really is isolated intrinsically to the PIP joint. So this is where you have to do an MTP capsulotomy because the toe is extended. You want to get the toe back down on the floor. You have to do an extensor lengthening sometimes. If it's dislocated or irreducible, they like this type of a question. So if you have a dislocated claw toe, subluxated claw toe that cannot reduce intraoperatively, what is the next most appropriate step? It's that in red. It's a shortening osteotomy, most commonly termed a while. The complication from that, the most common complication is a floating toe because the intrinsics are now relatively dorsal to the center of rotation and the toe slightly quote unquote floats up in the air and that's your problem. Crossover toe. This actually is an athletic problem, so a lot of your athletes who are running heavily, if you get into this barefoot running activity, you'll see this actually and they'll get swelling of the MTP joint and they may get slight varus deviation of the toe. So keep that in mind. If you see that, the etiology is overload. It's unloading of the first ray from maybe a short first metatarsal, prior surgery. Please don't put an injection into the joint. What happens is the pain will go away, but you attenuate the plantar plate and the toe will dislocate and pop. And the key physical exam finding, and see we're sportsy in foot and ankle now, we call it the vertical toe lockman. So you got your knee, we got the toe lockman. I swear to God, it's a real thing. And they've actually looked at this and they've looked at this with an MRI of the toe which you know you can't even make this stuff up. If you do a vertical toe Lachman where you actually dorsiflex and plantar flex the second toe and they have pain with that motion it's consistent with the rupture of the plantar plate. So you do not have to get an MRI on these patients if they have that it's it's consistent with the injury to the plantar plate and that's the diagnostic finding and so the surgery for this if it's dislocated irreducible so if you're too far gone it goes back to that osteotomy but the soft tissue correction these are historical that's why they're not I've not highlighted them in red the new thing is a plantar plate repair you actually open up the toe you can do a osteotomy at the same time actually repair that pair the empty plantar plate and that is the best answer. So swelling of the second toe with a vertical Lachman is a plantar plate injury and the treatment is a plantar plate repair and we utilize like a mini scorpion just like you guys and ladies all do so it's very sportsy and that's about as good as it gets in our world. So there you go sports and foot and ankle. So fibroids infection you will see this as well these are in your younger patients your teenagers your young athletes they may come with swelling pain discomfort in their second toe in distinction to a crossover toe there's no instability in this case there's there's limited range of motion they may have a hard thick swelling of that joint and you want to make sure you always get x-rays because you see this this is flattening of the second metatarsal head. The key etiologic factor in this is an elevated first ray if it's post-surgical but a long second ray can do and can this can occur in just children for no reason. The treatment for this and I'm relatively aggressive with fibroids because it usually doesn't get better but there is always stages in the early stages you do a synovectomy if they fail demobilization and that's just to clean out the synovitis theoretically that's now eating or injuring the articular cartilage that's very rare to see I've only seen it once and that's where I got that picture from if they have dorsal osteophytes which they will from the avascular necrosis you can just remove that if it's mild if you haven't had collapse yet most commonly this is where they present they already have joint collapse and the osteotomy is very unique it's a rotational osteotomy where you saw out all the avascular bone and you take that plantar cartilage and you rotate it back up it's actually an awesome operation if you ever have a patient with fibroids this works really well the extras look awesome and they do phenomenal it's one of my favorite things to do we don't get to see it that often if it's arthritic and it's too late you it's you waited or the patient waited years there's no cartilage left then the answer is a metatarsal head arthroplasty which is a fancy word for cutting the metatarsal head and throwing it in the garbage which I don't do there are other fancier ways we do we do interposition arthroplasty with cartilage fibro cartilage matrix just like it's kind of sportsy it's like you guys do for the shoulder and it kind of works but it's all a glorified resection of the med head so once it gets too far we don't have a good operation for these people the goal is to not let them get past flattening and condor collapse so it's a rotational osteotomy the metatarsal head if they ask you that most likely what they're going to ask you is to recognize this x-ray on the top right that is Freiburg's flattening you'll see the little loosens in the med head and that's what you're looking for nerve disorders this is the worst I think in foot and ankle you can take your pick as you finish this lecture if you want but tarsal tunnel is one of the hardest things to deal with one it's hard to diagnose their surgical treatment is difficult to do because of the neurologic structures and the artery then vein that's in the way and they don't do that well if you see this non-operative treatment for these patients so it's tarsal tunnel is obviously irritation of the tibial nerve pain discomfort shoots into the foot the non-operative treatment for it is orthotics for valgus so if they tell you the patient has a severe flat foot deformity with tarsal tunnel type symptoms you can put a orthotic in to decrease the strain theoretically off the nerve stockings if they're very swollen can decrease the pressure from their soft tissue but it has to be worn in the morning if you put a stocking on after the swelling has occurred obviously makes them worse and a cortisone injection can help if you're going to do surgical treatment for this the one in red there is actually the most important they like this question you have to do a complete release of the tarsal tunnel if you do a short segment release like you would for a carpal tunnel where you just released the main branch of the nerve it doesn't work in carpal tunnel and in tarsal tunnel you have to make a long incision get every single branch you have to divide both the deep and superficial abductor hallucis fascia so you have to really get every arborized branch of that tibial nerve in order to make this work so it's not a short incision it's a long incision the bottom of the foot and if you divide the fascia then you have a good chance of taking care of these patients if you get to them earlier than later their outcomes are better so they've looked at this if you somebody has tarsal tunnel and you surgically alleviate their symptoms or operate on them within the first year they do better than if you wait so as any nerve the longer you wait the worse it does Morton's neuroma is pain that radiates to the toes so in distinction to a crossover toe or MTP synovitis they have pain only in the joint if the test question says pain radiating to the second and third toes or the third and fourth toes and pain in the joint they're getting to a neuroma verse a MTP synovitis a crossover toe it's worse with shoes where Freiburg should be better with shoes where an MTP synovitis should be better with shoes Morton's is always worse with shoes because it crushes the foot and crushes the nerve and you get burning and numbness the Mulder sign is where you this is the Mulder sign you're trying to take put pressure I need to plant our aspect of the foot and push the nerve in between the second and third or third and fourth metatarsal heads then you compress the foot and they'll get pain and should shoot into their toes if they just have a click that just means they have a thickened nerve it's not an aroma but if the pain with the click it's consistent with the neuroma you can get a diagnostic test such as an x-ray which we always do to rule out all the other pathology we talked about but advanced imaging is not required you do not need to get an MRI you don't need to get ultrasound and for the test that is never the answer for neuroma now in reality a lot of us get MRIs and ultrasounds because it's hard to deal with these people and you don't want to operate unless you're a hundred percent sure and they're confident it's the right diagnosis but for the test you do not get any other imaging for these people if it sounds like a neuroma so radiating pain pain with compression and a positive Mulder sign is an aroma the treatment for it is conservatively you can do a steroid injection up to three is okay more than that is not okay you can get chronic damage and injure the plantar plate and then get secondary problems alcohol sclerosing which you may have read about I don't know if you do that at all I doubt it it's not recommended the OFS has a position statement now that says it's not appropriate so especially for the test alcohol sclerosing which may be an option is not the answer this the answer is pads wide shoes and steroid injection are three reasonable things to do surgical treatment is excision that's it 80 to 95 percent satisfaction ligament release is not appropriate that was an answer about 15 years ago the idea was that the inner metatarsal ligament was compressing the nerve and if you release that they do fine the problem is the pathology comes back with perineural fibrosis and if you don't take the nerve out you're not solving the problem they're not going to get better so for the test you just take it out they may ask you dorsal or plantar I doubt it but both have similar results if you go dorsal you can miss the nerve 5% of the time which is always depressing and if you go plantar 5% time they get a painful plantar scar most of us go dorsal center pathology hoping that we get the nerve I've not taken the artery out yet but if you do enough of these you'll miss and that's a dangerous thing it's not dangerous but it's just frustrating obviously mostly for the patient so Baxter's neuritis is a is definitely a relevant sports concern so the two common diagnoses that get mixed up are Baxter's neuritis versus plantar fasciitis and there's I'll give you some answers to try to how to differentiate the two Baxter's neuritis is compression of the first branch of the lateral plantar nerve it's called the Baxter's nerve or joggers foot three different ways they describe this the key innervation is the abductor digiti minimi so it can be tested by a motor conduction test actually the key physical exam pain is inferior medial heel pain and pain with compression over the abductor so our plantar fascia is plantar heel pain for the test if they show you a diagram and I think I have a picture of it here as well at some point they have pain over the medial aspect of the hind foot and plantar not just plantar and they have pain with compression of the abductor hallucis it can absolutely mimic plantar fasciitis type pain it's more common in your marathon runners your joggers and that's what's called joggers foot the surgical treatment is release of the abductor so you can see that's the incision this is a patient a prior short tarsal tunnel release they fail to go inferiorly and I'm just finishing the job now so that's the incision that's the abductor superficial fascia that's been released you move that out of the way and you can see the deep abductor fascia and you release that that is the surgical treatment for Baxter's neuritis and if you do a partial plantar fascia release it doesn't work you have to release the abductor and then that's a complete release and there's a nerve in there somewhere which you hopefully don't see so to differentiate the two for the test plantar heel pain with plantar fasciitis pain directly over the plantar fascia and inferior not medial foot pain hind foot pain Baxter's neuritis or compression the first branch of the lateral plantar nerve is plantar heel pain so they're both the same but they have medial heel pain as well they have neurologic complaints and pain with compression over the abductor no pain over the plantar fascia on the test in reality they can have both but at least for the test they should have no pain over the plantar fascia and if they've had surgery to the foot which is more relevant for us is then that that lateral plantar nerve can get injured because it goes from medial and crosses right over the bottom of the foot to the lateral aspect diabetic feet I hope to God they don't ask you this only have a few slides the pathophysiology of ulcerations is neuropathic not ischemic you have loss of protective sensation the predictive sign for getting a foot complication is a history of a foot ulcer so if that question does come up was a sign of getting a complication or a risk of an amputation is it having a prior history of ulcer the risk for getting an ulcer is loss of protective sensation is not is have having neuropathy which is fairly to sense that 5.07 filament and I hope that distinction is clear I got it wrong when I first took my test but that's the clear answer so they had an ulcer they they're high risk for getting an amputation they've never had an ulcer the risk for getting an ulcer is not being able to sense that 5.07 filament if somebody does come with an ulcer and they want you to know what to do initially we always do a total contact cast and offload that foot it is not surgery if it's a great Wagner grade one or two which means there's no infection of the tendon or the bone distribute the pressure it decreases edema this is extremely effective it's very different than a regular cast because it minimizes all shear in motion and if put on incorrectly can cause amputations and ulcerations and then you're in trouble so you got to be a little careful with this thing the medical evaluations what they want to ask on these board exams and that you and your your test as well because they want you to be a doctor I know especially for sports you have to know a lot of primary care sports as well so for they give you an ulcer and maybe you have to check the vascular level so ABI should be greater than 0.45 absolute toe pressures should be greater than 45 and transcutaneous oxygen should be greater than 30 if you can't remember these numbers because I don't I swim or 45 is the kind of the magic number if it's above that they have a potential of healing that ulceration biologically if it's below that there's nothing you can do to get that to heal you have to revast them or cut it off nutrition they like this number a lot the absolute lymphocyte count should be greater than 1500 and your albumin should be greater than 3.5 and that's relevant because if somebody comes in with an in fact osteomyelitis and a plantar ulcer and they have a albumin of 2.5 and they're asking you what is the next most appropriate step it is actually nutritional optimization then surgery versus what we would do is operate on it and let God sort it out in the end that is not how you operate for the test unless they're septic that may be the only time that you're allowed to go and do something immediately if they ask you for the test they ask it for us on our tests they ask it for the OITE now so try to remember that albumin is the most important thing if it's low nutritional optimization then surgery if it's normal you can go ahead and do the surgery Charcot Corey talked about this a little bit but in general if you have a deformity and swelling of the foot without an ulceration it's probably Charcot in a diabetic if you have an ulcer then it's probably osteomyelitis and that's the simplest way at least for you to differentiate the two they have edema they have want they both sound like infection but if there's no ulcer in the foot or hole in the foot it's Charcot that treatment is elevation total contact casting non weight-bearing if there's an ulceration and it's all swollen then they're leading you down the road of infection hind foot arthritis loss of calcaneal height decreased to the declination angle is common after a calcaneus fracture what they want you to answer here if somebody has a prior calc fracture that was treated surgically or not treated surgically that has arthritis and they have anterior ankle pain they want you to a bone block arthrodesis which is a very hard operation to do to be honest it's a tested question a lot and all of us try to avoid it if you can so you put a block of bone between the toes and calcaneus to restore that natural tailor declination you can see here that the talus is flat or I should have about a 23 degree declination relative to the floor here it's about 10 they'll have pain they'll have ankle pain and subtalar pain so that's what they're gonna get out they may have limited motion if you do an in situ subtalar fusion you may eliminate their subtalar pain but they'll still have the ankle pain and that's what they want you to get at and patients that have lost a longitudinal arch and rheumatoid arthritis they can have hind foot arthritis and a triple arthrodesis is a great option for these people so the triple in general is for a rigid deformity of the foot and they'll give you that patient has pain discomfort arthritis it's uncorrectable you want to do a triple arthrodesis this is in distinction to what Corey talked about for like flat foot with posterior tip tendons function if the hind foot is supple and their tendon is deformed as is tendon is diseased and the foot is flat you can do osteotomy and a tendon transfer theoretically to correct the problem but if they have disease of the posterior tip tendon but the deformity is uncorrectable they cannot be reduced to neutral what they want you to answer is a triple arthrodesis if they have isolated tail and avicular arthritis you likely want to do a TN fusion or a triple and if there's any deformity that's not a calc fracture so any hind foot arthritis is not a calc fracture to keep it simple just pick a triple if it's after a calc fracture they may be leading you down the road of a bone block subtalar fusion if they have ankle pain if they don't have ankle pain it's an in situ subtalar fusion and then a lot of times we always add an Achilles length thing which the mayor might ask you about if they say they have an Aquinas contracture the union rate for subtalar fusions and isolation are okay but if they have two millimeter a vascular bone they don't do so well smokers obviously do worse the most important factor is that if they have a prior ankle fusion they have a higher non-union rate if they ever ask you that question and that's because of the mechanical stress if the ankle is fused the subtalar joint has a lot of stress to it and has a higher non-union rate midfoot arthritis is a common thing that we'll all see the way they will try to trip you up on the test is they'll give you a flat foot deformity and you have to look at the hind foot versus the midfoot so if you get an AP of the foot which I'll show you next and if the tail and a vascular joint looks reduced but the foot is collapsed look at the TMT joints and if that looks abducted and arthritic they're telling you it's a midfoot driven flat foot versus a hind foot driven flat foot and they'll put all the flat foot surgical correction on there for you osteotomy tendon transfer but the actual answer for midfoot driven is a realignment midfoot arthrodesis which I'll get into so that's the relevance flat foot is either hind foot or midfoot and for midfoot it's obvious they'll have dorsal exostosis they will universally say a progressive flat foot maybe after an injury or a fall getting you to a list frank that's been untreated they have a heel core contracture the key x-rays are this so this is patient that they'll tell you has a progressive flat foot deformity 40 years old and what is the next surgical what is the next most appropriate step and it's not a lace-up ankle brace or anything like that it's a midfoot arthritis and it's like a rigid shoe which I'll get into to stabilize the foot and surgically this person needs a midfoot arthrodesis with realignment versus a hind foot correction if you look at the lateral it becomes more obvious you can see the arthritis in the middle of the foot with the dorsal osteophytes so before you quickly answer the question for foot stuff just look at the extra real fast and if you see it's the hind foot it's all that flat foot stuff osteotomy tendon transfer if you see the midfoots collapse it's a midfoot realignment arthrodesis the conservative treatment is to limit the motion in the midfoot which is all we do in foot and ankle we just throw something stiff in there and most of our problems go away if you ever have a foot pain i'll just throw this out there there's a shoe called the hoka shoe i have nothing to do with it it solves half my pre-op and half my post-op problems the rocker bottom sole is what you need in a cushion heel and that's what that shoe has so the idea is when a patient walks with midfoot arthritis if the shoe takes the stress and you walk through the shoe and the foot doesn't have to take the stress their pain goes away so the prescription and for the test midfoot arthritis what's the most appropriate orthotic treatment is a rocker bottom sole with the cushioned heel you can use a steel shank but that in red is what the orthotic and the shoe modification should read it's not orthotic the shoe modification the surgical treatment is a midfoot fusion tarsal metatarsal arthrodesis that's what they look like you want to correct the deformity never fuse them in situ that's basic i think nowadays but you want to do a realignment midfoot arthrodesis and look for a heel core contracture and this is a good operation actually sorry subtalar dislocations which is not common but you'll see and they'll love to ask this question it's always distal relative to proximal and what they really want to know is the block to reduction so this is a medial subtalar dislocation you can see here on that top middle x-ray the foot is medial to the hind foot foot is medial to the hind foot here you can't tell much except it's dislocated but you can see the tailless head on so it's a medial dislocation the extension digitorum brevis or the perineal tendons is both one or the other can be there if they have both answers which they should not i would pick the edb but you're just throwing darts at a wall they should only have one of the two on there both can do it if it's a lateral dislocation again if you see here you see the tailor head but the foot's over laterally foot's over here tailor head is here these are a lateral dislocations the block to reduction is the poster tip tendon it's only one thing the one thing i would ask you to do is before you quickly answer closed reduction make sure there's no tailor neck fracture when i took my boards i missed this every time which is sad but i did it before i did fellowship but you can see here there's a tailor neck there's a tailor neck if you look at that x-ray quickly and there's no tailor neck and the head is with the navicular it's a tailor neck fracture dislocation treatment's obviously completely different so quick look at the x-ray before you answer the treatment is non-weight bearing short-legged cats for two three weeks if you're open reduction is only indicated if you cannot reduce this closed remove the interposed tissue reduce it do not do a primary rebellion menace repair there's no role for it post reduction they want you to get a ct so what's the next most appropriate step after reduction is ct scan to look for loose bodies they actually do really well you can actually wait for them in a boot at two three weeks and they'll stiffen up and they'll do fine calcaneal fractures you want to be aware of the wound so 24 wound complication with orif diabetics smokers open fractures are higher the most recent data suggests that non-operative management is exactly the same as operative management when you're comparing open approaches and extensile approach to non-operative treatment they may ask you that on the test and that's why i put it here so who should get an operation severe deformity if it's dislocated a tongue type fracture and that's what a sports type question would be this is a tongue type fracture this is an emergent problem this has to be operated on the same day within the first few hours if it comes in at two in the morning obviously you can do it in the morning but this is not something that can be treated closed because they'll get a massive wound problem and that's what they want you to know there's a percutaneous approach versus every other calc fracture with percutaneous is not a born answer and that's the wound so if you leave that alone for a while that wound will necrose because the calcaneus will erode that skin i've seen that happen it's really devastating complications so for the test if you see that fracture it's yes it's a calc fracture it's a tongue type they may show a picture of the skin it's emergent orif percutaneously two screws from the tuberosity towards the neck of the calcaneus so 40 year old female fell during a hike and sustained a lateral subtalar dislocation in the emergency room the doctors having difficulty reducing the joint the most common obstacle reduction of the dislocation is so if the foot is lateral it's the medial structure in this case that's going to be the posterior tibial tendon the lisfranc ligaments cannot be at the edbs for a medial dislocation the tibats not part of the equation the lisfranc anatomy we all have to know this is the mitochondria form to the second metatarsal there is no ligament connecting the first and second metatarsal unlike the rest of the lesser metatarsals so it has dorsal the interosseous ligament and the plantar ligament it's a huge huge amount of stability in there the diagnosis so indirect mechanism injury so for sports a football player soccer player struck from behind with a plantar flexed foot will get injury to the lisfranc ligaments happens in sports football rugby the radiographs this is you want to know the normal so you get an ap view they should be weight bearing that's always their favorite question so an athlete comes in with foot pain after an injury non-weight bearing radiographs are normal what is the next most appropriate step and it's a weight bearing x-ray looking for diastasis basically when you look at a foot x-ray you don't have to know everything in general but everything lines up that's just a simplistic way to think about a foot x-ray the medial aspect of the second lines up with the middle cuneiform every single time if there's ever in your mind that it's slightly off it is not a normal anatomic variant there's something wrong it's a lisfranc injury and it is always a nice contra between there you can see here it may look normal on quick glance but if you look that's a flex sign that's an avulsion of the lisfranc ligament by definition that's unstable that needs to be surgically treated is or if the treatment of choice is a very controversial topic and i'll try to give you my best estimation so this is a lisfranc injury you can see that does not line up perfectly there's no such thing as a subtle strain that has uh diastasis once it's off though everything is popped and that's a little aggressive i'll tell you that right now but it's what i used to do we fire a ton of screws in there and you lock it together we'll do things a little differently but the idea is to stabilize and reduce and the question is for your subtle ligamentus is this still the right thing to do the other treatment options are non-optic cast that's wrong but at least for the test that's definitely not indicated i would tell you in real life that's not indicated either percutaneous fixation is wrong for the test there is no answer on the test where percutaneous lisfranc is the answer flexible fixation with a flexible suture button or any other device is the wrong answer for the test you may have seen this by your partners or yourself but you can't answer that it is a open reduction and then the only other option that's viable is a tarsal metatarsal arthrodesis however this is not for your ligamentous strains or sprains in your athletes these are for your purely purely ligamentous dislocations and high energy injuries such as motor vehicle accident with articular comminution and that's pretty now kind of set with the test questions so if they show you a dislocation dorsal subluxation it's a arthrodesis if they show you that x-rays that i showed you you're a 25 year old athlete with a subtle injury it's still orif it's not a midfoot fusion so pre-ligamentous dislocation is a fusion bony lisfranc is orif athletic unstable only is orif less revision surgery arthrodesis that's why that's the thought for the high energy injuries keep that in mind and again your athletic population does not get a fusion unless there's severe articular comminution the jones fractures corey's talked about this a little bit zone one zone two zone three zone three is your diaphyseal stress fractures that you'll see in your athletes chronic pain discomfort they come in with the fracture your zone one is proximal to the fourth fifth tarsal metatarsal joint these do not need any surgery it's a boot or post-op shoe for comfort after six weeks they can start doing activities there's very rarely surgery surgically indicated and for the test the answer is almost never zone two these are your acute jones i was running i never had pain i tripped i fell i have a jones fracture the fracture line goes into the four or five intermediate tarsal space that's where a jones fracture is 20 millimeters from the tip of the base of the fifth is how it was originally described by sir jones acutely you can actually non-weight-bearing cast and treat these patients so keep that in mind not every jones fracture technically by the test question and book need surgery so if they give you this patient low level athlete a 50 year old person tripped and fell with a jones fracture doesn't do any athletic activities the answer is not screw it is casting non-weight-bearing you can do vitamin d and the biology check but it is not surgery if it's an athlete collegiate high school professional obviously then an rf with a screw is the best answer but rf a screw is not the answer for every patient with the jones no matter what you may do in practice or what all of us do in practice it's really only relegated for the athletes you want to fix these early and the reason is they have a high refracture rate there is a couple articles now i don't know if i'll ask you on your test but i want to make sure you're aware for an elite athlete such as a high professional basketball player professional anything they may have the answer of bone marrow aspirate adjunct for a jones fracture if that's present in addition to putting a screw in you may want to put that as the answer it is a now a trend and almost advocated for your lead athletes it's not a hundred percent proven but i wanted to put that in there for you for a regular person it's just a screw but a professional player concentrated bone marrow aspirate is what your doctors are doing nowadays half the fractures don't heal with non-operative treatment and that's why we don't treat these non-operative and athletes your stress fractures are different they have repetitive distraction force look for metatarsus adductus capus foot like it's been talked about it's incorrect training these always get screws in every single person athlete non-athlete doesn't matter every stress fracture gets a screw because these by definition will not heal with non-surgical intervention metatarsal stress fractures these are very common to be talked about they're insidious onset they have swelling the treatment is non-surgical they get weight bearing in a boot evaluate for metabolic bone disease they want you to look at this so do not just treat the bony injury check their vitamin d the terrible the triad and women just to make sure there's nothing wrong with them they may ask you that as well navicular stress fraction we're almost done with this whole nonsense and get you going for your break this is a common missed injury so they have vague dorsal midfoot pain it's usually in a gymnast or high level athlete that has a lot of jumping and they'll tell you they're a lot of times it'll come as if their ankle is hurting them but if you ask them where they hurt they'll point to what is actually called the end spot i didn't make that up and they point from dorsal to plantar they point down versus ankle pain where they point posteriorly and it's very important because it's about the same anatomic location but where they point will clue you in it's runners gymnast repetitive impact and the best uh diagnostic tool is a ct and it's the coronal ct you'll see that stress fracture line that's the best test for it x-rays are typically negative until unless it's too late the next most appropriate step is a ct scan and you're looking for that particular coronal view the treatment this is controversial it used to be orif for your athletes but it's actually non-weight bearing in a boot or cast a metabolic bone workup and no surgery at all costs there's plenty of data now to show that orif for a navicular fracture does worse and they have chronic pain over that navicular if you operate on them i'll tell you that's my experience as well they do not do that well and it's non-operative non-operative non-operative they have this similar outcomes 10 osteonecrosis rate and surgical treated patients still had pain more often than non-surgical so these are terrible injuries think about it in your cavus feet that's what yaoming had um they're high level jumpers and shut them down metabolic bone workup and no surgery for these unlike most other foot stress fractures talus injuries lateral process fracture in your snowboarders any uh skateboarder it mimics lateral ankle pain the ct scan is the most sensitive way to identify it and i'm sorry about this x-ray i don't know why it looks so bad but you look at it on the ap of ankle x-ray not the mortise the ap ankle is a mortise the ap ankle is where you can see the lateral process most obvious if somebody comes back in with an ankle sprain it's been six seven weeks with continued pain discomfort what they're getting at is a missed lateral process fracture get a ct scan treatment's based on size if it's big it means if it's fixable more than one centimeter and it's displaced you can fix it if it's very small in this place you can take the pieces out if you catch it early the reason is um why this can be a litigiant problem if you see it at time zero the treatment is non-weight bearing in a cast or a boot versus verse an ankle sprain which is just weight bearing immediately so if you they give you a patient with a snowboarder skateboarder has ankle pain please look heavily for this on the on the x-ray that they give you and then the answer is non-weight bearing versus functional rehab an eight-year-old male has experienced lateral ankle pain after injury two weeks ago while snowboarding they usually give you something some sort of activity with it x-rays were negative for fracture the next most appropriate treatment would be so x-rays are negative could be a non-displaced lateral process of the talus you don't want to assure them that he's fine that's never the right answer prp you could do that but that's not appropriate in general for this stuff they want you to look a little farther ct scan to verify for lateral process fracture and you don't do any supplementation you want to look for that missed injury 21 year old female elite runner sudden pain along the lateral aspect of the foot soreness prior two weeks she has a fifth metatarsal jones fracture with sclerosis the next most appropriate step is so this is a stress fracture not a simple jones fracture so even if she was not an athlete the answer is repair the fifth metatarsal fracture with the im screw not a cast not therapy and not bone stimulation it's a stress injury that has to be fixed and look for a subtle cavus foot in that patient as well thank you very much

foot mechanics

ankle mechanics

gait cycle

common injuries

common conditions

surgical treatment

conservative treatment

athletes

plantar plate rupture

fibroids infection