All right, thank you. Our next speaker is Anish Kadakia from Northwestern University. He's going to review the foot. All right, good morning, everyone. I guess we're starting off your sports review with the foot so you can forget it as quickly as possible. So my job is the foot, and Cory did the ankle. I have no relevant financial disclosures for this presentation. Unfortunately, what I have to talk about is obviously pretty boring. I'm going to try to hit some of the highlights really related to sports, foot and ankle, and not bore you too much with the nuances of what foot and ankle really is, which is, I know for you guys, mostly diabetic foot care that you don't want to see. So for the gait cycle, stance phase and swing phase. Stance phase is when both feet, when one foot's on the ground. So just broken down in three parts, heel strike, foot flat, and toe off. You really don't have to know all of these in detail. The most important part's going to come when we start talking about pathology, and swing phase is when your foot is off the ground. So the gait cycle is relevant because when you have a issue with your tendons, such as the anterior tip tendon, if you have an anterior tip tendon rupture disease, they have problems with heel strike, because you'll get that foot drop or that foot slap if they have an anterior tip tendon rupture. At foot flat, that's when your gastrocsoleus is firing eccentrically to stop the body from propelling over the foot without any control. The hind foot's in valgus and eversion, accommodating the floor now. And the function of the hind foot is for ground accommodation. And as we talk about the different pathologies, whether it's flat foot, cavus, as Corey's talked about a little bit about flat foot, the position of the foot, its ability to deal with the ground, really starts making a lot of sense when people talk about their pathology. So for example, if you have a gastroc or Achilles rupture, one of the problems they have is not with walking, after two, three months they can walk, but they have a hard time going downstairs because they can't control themselves, or running becomes very difficult. If they have a cavus foot, and they have a rigid foot, and they come with a stress fracture of the fifth metatarsal, well the reason is because when you're at foot flat, if you have a cavus foot, your hind foot does not go into valgus, and you constantly load the lateral aspect of the foot, or for navicular stress fractures, they load that navicular. And so the position of the foot, its inability to accommodate the ground, starts making sense for all the injuries you see in sports. At toe-off, as we all know, the gastroc soleus complex is firing concentrically, launching you forward, allowing for that push-off, and running, and jumping that we all want, and the hind foot's in varus and inversion. Again, as Corey talked about, with a flat foot, you're unable to pull the foot back into a varus-locked position, so those pigeons have inability to run, jump, pound, and that's why a pathologic posterior tib is such a problem. They can walk, that's not a big deal, but for the high-level sports activities, or any even moderate sports activities, they have a hard time. So as boring as a gait cycle is, it actually starts to make sense over time. Walking versus running is somewhat relevant, especially if you are the Olympic doctors and you do speedwalking. I remember, I think it was the 84 Olympics, there was a speedwalker, she made it all the way to the end stadium, and right at the end, she was in the stadium, she was the only one, she got excited, and she had one period of time where both feet were off the ground, just for a split second. The judges caught her and they disqualified her, and so it does make a difference. So two feet off the ground, by definition, is running. Walking means one limb is always on the ground at any time. It's probably the only time it's actually that relevant, because the rest of life, I don't know why it matters. So the syndesmosis. Now, the syndesmosis, we all know what it is, it's the tibiofibular articulation. It is an articulation, it's not a static joint, and so why is that relevant? It's because you want to maintain that motion as much as possible, and you want to maintain the alignment. As a foot and ankle person, I spend a lot of time mentally thinking about the syndesmosis much more than most of you probably do, and that's because we have nothing else to think about that's interesting, probably. But that's why when you get to the controversy of trauma, which is not my job to talk about trauma today, but screw fixation versus flexible suture button fixation, if you look at the new data now, a lot of the flexible fixation is superior as long as you have a good reduction, and the reason is there is motion. You want to maintain it, statically locking it in an abnormal position, because we're not that great at getting the reduction, no matter who you think you are, that abnormally causes mechanical malalignment of the ankle joint and can cause pain. And that's why you should at least know that it is a real joint, and the fibula goes external rotation with slight proximal translation with dorsal flexion. The subtalar joint's quite a confusing joint, and I'm not sure I still fully understand it, but to keep it simple, it allows for your inversion, eversion, and the way it works is when I was a resident, I thought it would just book open one way or the other, which clearly is kind of stupid. It doesn't book open as you go varus or valgus, it rotates, and if you look at it, it's off axis in the sagittal plane, and it's pointing forward. And so when the joint moves side to side as it goes along the articular surface, the foot is actually swinging with it. And that's how it allows for that inversion, eversion position. You have more inversion than you do eversion. It's easy to remember because flat foot is easily accommodated, where we know that a cavus foot has a hard time accommodating, and it's not that simple, but it's an easy way to remember for the test and just for mechanics. So you have less eversion accommodation, which means if you have a cavus foot, you're going to have more problems, and that's why subtle cavus foot's a huge problem, where subtle flat foot's not really a big deal, and we can deal with that. The transverse trusser joints are your talonevicular and calcaneocuboid joints. These work in concert with the subtalar joint. Again, it goes back to the mechanics, so hind foot eversion is at foot flat and early stance. So the moment your foot hits the ground, early stance, the foot is in eversion to accommodate the ground. But at heel strike, it's slightly different. So the moment your foot hits the ground at heel strike, you actually have the foot inverted and locked, so that you have a stable platform to hit the ground. As your foot starts to hit the ground with early stance, the joints unlock, accommodating that uneven ground, grass, gravel, whatever you're standing on. And then as we launch ourselves forward in late stance, the posture tip contracts, locking the hind foot in. So it goes from inversion to eversion to inversion every time you take a step. Something that they like to ask about is, what is the purpose of the hind foot relative to the tibia? And what it does, it converts both tibial rotation into inversion, eversion. So as you are in hind foot eversion, your tibia is internally rotated. And as you propel yourself forward and the hind foot inverts, the tibia externally rotates. And the easiest way to remember that when you're taking the test is just throw your foot on the ground and internally rotate your tibia. You'll feel your foot go into eversion. If you externally rotate your tibia, you'll feel your foot go into inversion. It gets really goofy sometimes in some weird pathology that we actually will do tibial rotational osteotomy to correct the foot. None of this is going to be tested for you except that one question. Conversion of tibial rotation into inversion, eversion actually is a tested question. So muscle function during gait. So gastrocnemius at foot flat, we're eccentrically contracting to decelerate the body. And the best way I think about this is if you're going down the stairs, you don't fall down the stairs. It stops you from falling forward. And at toe off, it constantly contracts, accelerating. The tib and heel strike eccentrically contracts, preventing a foot slap gait. Keeps your foot slowly decelerating. But during swing phase, it keeps it off the ground. So you don't have to have what they call a steppage type gait. Otherwise, your foot would drag. So what happens when these are problems is the easiest way to remember it. So if you have a weak-ass rock sole, you actually have a dorsiflexed ankle and a painful heel strike. So in some situations, the chronic Achilles rupture, which they may ask you about, the patient comes in with a painful heel. Your first guess is going to be plantar fasciitis. But it's different because they'll have pain with prolonged walking. And they'll show you that they have decreased plantar flexion power and inability to a single limb heel rise compared to the contralateral side. And at toe off, they have a weak push off. A weak tibet. So a lot of patients, especially when they're older, for these anterior tip tendon ruptures, will not come in with a trauma. They'll just say, I'm unable to walk. And they may have a lump on the front of their ankle, which is a sports-related question. So they have a steppage gait. They flex their knee and they flex their hip to keep their foot from dragging on the ground. And they may notice a foot slap. As their heel strikes the ground, they're unable to decelerate the foot. You'll get that slapping of the foot. Now, I've seen a lot of this. And you don't really get that foot slap where you hear them walking down the hall. You have to kind of watch them. Because the other extensors will compensate over time. And they don't have that actual slap in reality. And if you talk to the patient, let's say they're just weak and they always have a lump on the front of their ankle. And that's a sports-type question for an anterior tip tendon rupture. So a 65-year-old male presents with a painless mass along the anterior aspect of the ankle. He notes difficulty navigating stairs. Exam is relevant for a steppage gait. The most likely etiology is common perineal nerve palsy. Could cause this. That typically doesn't come without some sort of a trauma. And they won't have a mass. EHL rupture does occur, but does not call a steppage-type gait. And doesn't cause real problems navigating stairs. Radiculopathy could cause it, too, for sure. But again, the mass is consistent with anterior tip tendon rupture, which is D. And there's no other neurologic symptoms. So D is the most likely answer in this case. Plantar fasciitis is a commonly asked sports injury. And a lot of us will see this. It's inflammation of the proximal plantar aponeurosis. The most important thing nowadays for the test is that it's associated with a tight heel cord and a gastroc contracture. This is a commonly hyped concept and is talked about a lot and may come up on your test if they're going to talk about plantar fasciitis. The treatment, what they want you to know is that you want to do non-operative first. We don't go for a gastrocnemius recession right away. It's heel cord stretching and plantar fascia-specific stretching. Those two words are critical for the test because there's a nice article, I believe it was by Kyoto, that showed plantar fascia-specific stretching significantly improves the non-op outcome compared to just stretching the Achilles. The cushioned heel inserts and night spins are not really as relevant. It's really the stretching, stretching, stretching. And if done correctly, most people do not need surgery. So those two things are important. The surgical treatment, which will be listed, so partial plantar fascia release, this is not an uncommon thing to do. The complication, which I'd like to ask, is if it's excessive release, you get arch collapse and lateral border foot pain. And that's because the secondary state of the arch is now completely compromised. The foot abducts. There's really no solution for this except a hindfoot fusion, which nobody wants to do. Orthotripsy may be asked. Don't answer it. The efficacy is questionable and not relevant for the test. The key thing that they want you to know is a gastric contracture. And they will harp on this for you. As a patient has limited dorsal flexion with the knee in extension, improvement with knee flexion, patient has complaints of a tight calf, plantar fasciitis. They want you to do stretching. And if that fails, isolated gastrocnemius recession has proven to be very effective for this, as opposed to a partial plantar fascia release if they have Aquinas. There's a 32-year-old male with pain along the plantar heel that is worse in the AM and improves after 10 minutes of walking, very classic for plantar fasciitis. Exam demonstrates zero dorsal flexion with knee extension and 10 degrees of dorsal flexion with knee flexion. That's a positive silver scold exam where they have more dorsal flexion with knee flexion as you're taking the gastroc out of the equation. Non-op treatment has failed. The most appropriate surgical treatment is complete release of the plantar fascia is never the answer. You're only going to do a partial. Release of the abductor hallucis is relevant for Baxter's neuritis or jogger's foot or marathoner's foot. And that will have more medial plantar pain as opposed to isolated plantar pain. A gastrocnemius recession is the best answer. And subchondroplasty of the calcaneus, I put on there because I've seen it. Don't do it. It's not a great idea for the calcaneus because it's sub-Q and you don't want to put some sort of product in there at this time. So the SPN, just the anatomy, we all know this. It actually does work on the legs approximately. Does the dorsum of the foot, not the first web space. And it's at risk during arthroscopy in the lateral portal, lateral portion of the fibula, and then when you do any anterior ankle approach. When you look at sensation loss in the first web space, it is the deep perineal nerve. It does have a motor function. The sensory is the first web space and that's something they may ask you, following such as a Lisfranc injury, a midfoot fusion that you've done. A patient has decreased sensation here. What nerve is injured? It's obviously the DPN. It's at risk when we operate dorsally, midfoot osteophytes, et cetera. The sural nerve is the most common nerve that gets bagged in any foot and ankle operation and it does the dorsal lateral foot, not the plantar lateral foot. And they like to ask that question specifically. Dorsal lateral is a sural nerve. Plantar lateral is actually the lateral plantar nerve. It's at risk during the posterior approach when you do your Achilles repairs or if you fix the posterior malleolus, as you're in the back, you can injure that nerve and you have to be very careful with it. And if you do RF calcaneus, it's obviously always there in calcaneal osteotomies. A 25-year-old female underwent open Achilles repair, however, has a neuropraxia to the sural nerve, the location of the numbness is dorsal medial foot. So it would be the dorsal medial branch of the superficial perineal nerve, typically not injured in most approaches. The medial ankle, that saphenous nerve, dorsal lateral foot, sural nerve, and then the plantar lateral foot is first branch of the lateral plantar nerve. The dorsum of the foot itself is the intermediate branch of the superficial perineal nerve. So if somebody has an ankle arthroscopy or a fibular fracture and they say the dorsum of the foot is now numb or neuropraxic, that means you unfortunately have injured the superficial perineal nerve. So cavovarous foot is this, and you can see it's got a high arch. You have a large sinus tarsae, the first ray is plantar flex. The mechanical effect for sports are a few things. Again, it's a rigid foot that cannot accommodate the ground. So these patients get ankle instability, has been talked about. They get Jones fractures, and they get navicular stress fractures, and they get lesser metatarsal stress fractures. And it's very important that you recognize this foot shape, especially for the test with Jones fractures, navicular stress fractures, because the concern is that you have to do an additional calcaneal osteotomy sometimes in order to correct these patients. They have a rigid foot. They cannot accommodate, so they just load the side of the foot and the medial column in the center of the foot. The orthotic treatment is to unwind the foot, so lateral posting. And you want to accommodate the first metatarsal and lower the arch. If they ask you an orthotic-type question, it is the opposite of the foot shape. So if the foot is high arched, you want to lower the arch. If it's tilted in, you want to push it out. And the way the words work for orthotics is the words that we are putting there, the posting, is where the extra material is. So lateral post means you have more material laterally. Well after the first metatarsal is obvious in a low arch. The Coleman block test is something that's talked about a lot, and unfortunately you have to know it a little bit. It's a one-inch block placed beneath the lateral heel. And the idea is to eliminate the forefoot from the hind foot, so that you can look at the isolated deformity of the hind foot. So to keep it simple, if it corrects, which the testing people will say it's called a positive test, that's called forefoot-driven hind foot varus, which means when you put the Coleman block underneath the heel, the heel will correct, as in this case. You can see there on the picture, the heel is nice and neutral, and that's because when you take the first ray out of the equation, it's not pushing the hind foot into varus anymore, so the foot can go back to its normal position. That means the plantarflex first ray is the cause of the problem, positive Coleman block. The treatment is a dorsiflexion osteotomy of the first metatarsal. So again, positive Coleman block, the first ray is the root cause. The hind foot corrected, so just fix the forefoot, and the hind foot will follow. If there's no correction, that means the hind foot is a fixed deformity, and you need to do both the forefoot and the hind foot. So you do the Coleman block, negative test means there's no correction, that means the hind foot needs a calcaneal osteotomy as well. Flat foot's slightly opposite, and this has been talked about, so I'm just going to go through the orthotic real quick. The orthotic requires what we call a medial post, and you want to support the first metatarsal with medial forefoot support and increase the arch. Very straightforward for the orthotic. It's almost the opposite of the cavus. The 29-year-old male presents with the hind foot varus that corrects with the Coleman block, the most appropriate orthotic is. So what that means is the patient has a supple hind foot, it's mobile, and so you want to correct the shape of the foot. Hind foot eversion makes sense because you're trying to tilt the foot out for A, lower the arch, well up for the first metatarsal, that makes sense. Hind foot inversion, increased arch, and a metatarsal pad doesn't fix the problem because that's for a flat foot, and a metatarsal pad is for neuroma, metatarsalgia-type pain. Hind foot eversion and an increased arch are working against each other, so that's not how you would do it. And then hind foot inversion and a lowered arch, again, are working against each other, so the answer should be A. They should all go in concert. Heel growth contracture, I'm going to talk about this a little again because this is a concept in all sports pathology and foot pathology now, Achilles tendonitis, plantar fasciitis, stress fractures, et cetera. So the Achilles is when both the gastroc and the soleus are contracted, and that means, as we all know, when you flex the knee, there's no change in the motion. That means that the gastroc is not excessively tight relative to the soleus. A gastroc contracture is when you have the extension of the knee fully extended, you attempt dorsiflexion of the ankle, you have some limited dorsiflexion, and it improves with knee flexion. There's no magic number that is consistent with a true gastroc contracture. Some of us use three degrees, five degrees, seven degrees. The truth is we use whatever degree in our mind to get the surgery. So we tell the patient, hey, I think you're tight. Let's go do your gastroc. That's really the truth. But five is probably the best answer for the test, but it's extremely variable. If you go to Grand Rapids, everyone has a gastroc contracture. Seattle, everyone does. You go to other practices, no one does. So there's no such thing as, the pathology is kind of still unknown. But for the test, again, five degrees is a good number to say, hey, this is a real gastroc contracture. I should do a gastroc recession. So when you look at flat foot, typically for stage two, we'll do a gastroc recession. Stage three, when you fuse it, we do an Achilles lengthening because you're making them so rigid. In neuropathics, if they ask you this, but hopefully they don't, it's an Achilles lengthening for your diabetic ulcerations. For plantar fasciitis, Achilles tendonitis, it's a very, quote unquote, hot topic. A gastroc anemias recession is kind of how this has been asked for the last few years now. What's the most commonly injured structure during the creation of the anterolateral portal for ankle arthroscopy? This is all pretty straightforward now. It is the superficial perineal nerve. The tendons typically are not injured. You can injure the anterior tip tendon on the medial portal if you get too aggressive. And the posterior tip tendon is hard to injure in general with arthroscopy. A 45-year-old woman has developed pain along the plantar aspect of the heel for the last month. She has pain with the first few steps in the morning. Pain improves until the end of the day. The next treatment option is plantar fasciitis is incorrect, shockwave is incorrect, steroids can be tried, but the most effective is daily stretching and a cushioned heel insert. So stretching, stretching is the most important thing. So for the hallux and lesser toes, which I know you really don't want to deal with at all and refer to your colleague as not an answer on the test, unfortunately, which I know is what you all do, because I'd hate this thing myself. I have to go see some VIP whose 18-year-old daughter has bunions, and trust me, not something you want to do. So hallux valgus angle, the numbers are all kind of the same. About 15 to 10 is what you need to remember. You don't have to sit there and memorize this because you've got more important things to do. So for the testing as a sports surgeon, just remember around 10 degrees. It's kind of a fair number to remember. And if your Alex Vagas angle is bigger than that, and they usually for the test will give you 20, 30, 40 degrees, they're not gonna get you nuances. The inner metatarsal angles, a number between the first and second metatarsal is showing that it's like the, it's showing that the first metatarsals in varus are more medialized and that's why they have a prominence. The surgery is broken down very simply. If you look at the numbers that you're given, if the IM is less than 13, you don't even have to remember the Alex Vagas angle for the test because these are so related. Typically the Alex Vagas angle follows the IMA. So for the testing purposes to keep it simple for yourself, IMA less than 13, just go distal, your standard chevron and soft tissue release. If it's bigger than 13, that just means the deformity is too big for a proximal, for a distal osteotomy. You wanna go proximal because of the mechanical advantage. And they're not gonna ask you, especially on a sports test, what type of osteotomy you're gonna do. It's gonna be a proximal. Metatarsal osteotomy should be the only words that are used and a soft tissue release. And that's because we have a long lever arm, we can correct major deformity. If they harp on the concept of instability of the first TMT joint, they have the positive biting criteria, they're ligamentously lax and they have a bunion. What they're getting at is that the patient needs a lapidus, which is a fusion of the first TMT and stabilization between one and two. And that's the best way to correct a bunion in a ligamentously lax person because if you do a bony correction, ligaments are still loose, it's gonna recur. And those are really the three major ways that you have to remember how to fix a bunion. And then if it's arthritic, and any deformity in orthopedics, as we know if the joint is stiff or arthritic, you have to do a fusion of that joint. So if they have a deformity of the big toe, even without arthritis, but it's non-correctable, you have to do a big toe fusion. So again, if they ask you these as answers, soft tissue procedures alone in the setting of hallux valgus is not indicated, so don't do that. And isolated osteotomies without soft tissue is not indicated. Now for the test, you may have five answers that all are only as bony operations without soft tissue listed. That's okay because they're obviously just focusing on what bony operation to do. But if some have a soft tissue with it and some have no soft tissue with it, you wanna do the one that has a soft tissue correction with it because they want you to understand you never do bony correction in isolation. None of this is really how we operate, per se, in our world, but for the test, that's what you have to answer. And then recurrence. Juvenile hallux valgus recurs heavily. Undercorrection of the IMA is secondary recurrence, and lack of the bony correction is also for recurrence. So the old school silver, where you just whack off the medial eminence, that doesn't work. If you're 95 years old or 90 years old, that's different, but any people that you treat, I'm assuming you're not treating 95 year old athletes, you need to do a real operation. You can't just cut off the medial eminence. It will fail. Hallux varus is basically heterogenic in America. If you go to Asia because they don't wear shoes, and I learned this when I was in India, they all get hallux varus. I actually don't have a lot of hallux valgus in India because they literally just wear sandals all day. Blew my mind. We talked about hallux valgus. They're like, yeah, we don't see that. They see this. In America, in the West, we cause this. This is not something that occurs. It's all surgical. That's my patient. So what happens is you overcorrect and you shove their big toe into varus. They get pain in the great toe. It's really just flexible versus rigid. So if you see hallux varus on the test for some reason, if it's rigid, you do a fusion. If it's flexible, you do a release of the medial soft tissue and you do a tendon transfer to augment and re-stabilize the big toe. And if the IM angle is too tight, you have to revise it. But for the test, for sports, it's basically flexible, soft tissue release, and EHL or EHB tendon transfer. If it's rigid or painful, you have to do an MTP fusion. Hallux rigidus is commonly asked, even in sports, because a lot of your athletes will have this in their 30s and 40s. It's not like hip or knee arthritis. They come with stiffness, pain, swelling, difficulty with shoe wear, and pain with push-off. And they have that typical bump on the dorsum of the foot. So if you see that bump on the dorsum, it's not hallux valgus, it's hallux rigidus, and they have limited motion versus hallux valgus, which typically should have no limitation of motion. The key x-ray findings, you'll see if they show you them, are this dorsal osteophyte formation and loss of joint space. The easiest way to compare is just looking at the IP joint or the second MTP. If there's less than 50% loss of joint space, they will need a chylectomy. And we'll get into that in a little bit more detail. If there's a rosary change, it's a scout. And if there's this pencil and cup deformity, it's psoriatic arthritis. The conservative treatment, again, as every test question goes, they want you to know the conservative treatment. It is a Morin's extension carbon fiber plate. That is what they're going to ask you, and you need to know that term. Otherwise, high-toe box shoes, steel shanks, stiff shoes are appropriate, but Morin's extension is the commonly asked question for what's the most appropriate orthotic. And the reason is it's a stiff piece of carbon fiber that limits the dorsal flexion, so you don't get that repetitive dorsal impingement. The surgery for the chylectomy. So this is your grade two, grade one, or grade three without a grind. Grind is when you actually load the MTP joint round and round in a circle. If it hurts, it is a positive grind, and that means they need a fusion, which means the central cartilage is gone. If you grind the MTP and it doesn't hurt, despite the x-ray, that means there's still some central cartilage left, and you can just do a chylectomy. So it'll be less than 50% joint loss, negative grind test, pain only at the extreme, a chylectomy where you just take off the top part, top 30% of the metatarsal fat as I demonstrated here is the best answer for these patients. Fusion, grade three plus grind. So grade three means more than 50% joint loss, so it looks bad on x-ray, but they have pain when you actually load the toe. That's a grind test, meaning central cartilage is lost. They want you to do a fusion. If they have pain with any motion or no motion whatsoever, as we all know, if you don't have motion, you can't get motion, you need a fusion and any revision needs to have a fusion. For your own education, a fusion is not that bad. People can play tennis, hike, bike, things like that. It's not terrible, but they're hard for them to be like hardcore marathon runner, sprinters, basketball, football, but people can maintain a reasonably active life after a fusion. They just can't go back to hardcore speed running in general. The one things you may hear about, especially from your foot and ankle partners is something called CARTIVA. A lot of patients come in with this. For the boards, especially for you, do not answer this CARTIVA and any joint replacement is still not a board answer. CARTIVA is very hot topic. It's done a lot. It's on TV, but for right now, please don't answer this for the test, no matter how they push you on the test, because that is the data is not a hundred percent that this is the best thing to do for patients yet. Turf toe, you'll get asked about. This is a hyper dorsiflexion with tearing of the plantar plate. It's a common athletic, not a common, it's actually an uncommon athletic injury originally from the turf. Typically, when you evaluate these patients, you'll have pain, discomfort in the great toe. You want to get bilateral x-rays to exclude proximal migration of the sesamoids, which is consistent with the complete plantar plate rupture as demonstrated here. The treatment is swelling reduction, boot and graphite plate for your grade one, grade two. In return to play is 60 degrees of painless dorsiflexion. That number is important. You should have 60 degrees of painless dorsiflexion. That's for their return to play. I don't know if I put that in the handout or not, but just that's kind of the magic number. And what that means is I'll get into grade three in a second. Grade one is where they have a little bit of pain. They can go back to play immediately. Grade two, they are unable to play for two weeks, but they can go back to play with 60 degrees of motion. And grade three are the bad ones. Proximal sesamoid migration, traumatic bunion deformity, unstable MTP, complete rupture based on the MRI, everything that says grade three. Bob Anderson is really the only one that's published on this, and I just wrote a review article really just saying what he said. There's not a lot of data on this. These people do better with surgery, and that's what they're gonna force you to say. So if you have a high-level athlete with an MRI finding with turf toe with grade three, so sesamoid fracture, sesamoid migration, complete rupture of plantar plate, the best treatment for them is not casting. It is surgical repair. Grade two, partial injury, no injury to the plantar plate or strain. It is taping and then return to play at 60 degrees of motion. The surgical treatment, again, if you do assess the details of this, you're not gonna be asked, but you repair the FHB if you do a sesamoidectomy. If you take out a sesamoid in general, now this is for more sesamoiditis versus turf toe. So sesamoiditis, you'll see in a lot of your athletes, high-level dancers, runners will get this. The key is the treatment is non-op, non-op, non-op with a dancer's pad. That's really the bulk of it. There's no other treatment for these people. Dancer's pad, stiff shoes. If you're gonna operate on them, if you take out the tibial sesamoid, the most common complication is hallux valgus. If you take out the fibular sesamoid, most common complication is hallux varus. And if you take out both, which is never indicated, you get a cock-up toe. So for 52-year-old male, presents increasing pain and deformity and limitation of great toe motion. His exam demonstrates pain throughout the mid-range of motion. First, MTP, has arthritis. Treatment may include all of the following except. So carbon fiber insert's appropriate. Infusion's appropriate. Anti-inflammatory's appropriate. But sesamoidectomy is absolutely not appropriate for this type of patient. For the lesser toes, we're getting closer now. So the hammer toes, this is definitely something nobody, no, you guys definitely don't wanna talk about, but keep it quick for you, all right? Everything in my world, in foot and ankle, is flexible or fixed. That's how we think. I don't know if that applies in sports as much, but for us it does. And that's how you think about these questions. If it's a flexible deformity, you can correct it even though it's kinda tight, and you can do a simple flexor tenotomy, or what they call a flexor to extensor tendon transfer. And that's if it's rigid. And you may see this in your athletes because their shoe wear is tight. High-level bikers with their stiff shoes. Runners, as they're running, they may get, that's when they may ask you this, because they may get irritation of the lesser toes. If it's rigid and they have that dorsal prominence and pain, a PIP fusion or arthroplasty is the best thing to do. And all that is, is we use a fancy word of arthroplasty. We just go there, cut out a little bit of bone at the level of the PIP joint and shoot a wire across, or you put a screw to fuse it. If there's recurrent or spastic, in general we always do a fusion. The difference between a claw toe and a hammer toe is this. So if you look at a hammer toe, it is just a PIP flexion. When you have the foot off the ground, the lesser toes are still neutral at the MTP. A claw toe's like this, where the toes are intrinsically elevated at the MTP joint, and it's not because the PIP is flex and forcing the MTP dorsal flex. So what we do is we take the foot off the ground, you'll see all the toes are clawed, or that they are not secondary to the floor. These people have problems. Typically there's something wrong with them neurologically. Whether they know it or not, you don't get clawed toes of all five toes. And if anybody here in the audience does, go see a doctor, because it's not right. What you have, and I'm joking, but it's kind of serious actually. You have hyperextension of the MTP, which is important. You get secondary contractions of the lesser toes, as we know, and it's typically multiple toes. That's important because that goes down to a more neurologic or autoimmune issue. It's an imbalance between extrinsics and intrinsics, as we all know, and the treatment varies based upon the rigidity of the deformity. So we always do an MTP capsulotomy to release the joint. We lengthen the extensor tendons, and then you have to decide if it's reducible or not at that point. For the test, so if they give you a claw toe, you're gonna do a capsulotomy, lengthening. If it reduces, correct the lesser PIP joint, done. If it's irreducible or dislocated, this is how they like to ask the question. So you do a claw toe correction. It's not reducible intraoperatively. You do what they call a wild osteotomy or some sort of shortening osteotomy. And the complication from that osteotomy is a floating toe. So you do this type of operation. You get the toe back down. But what happens is, unfortunately, the toe just kind of floats a little bit because you have the intrinsics or dorsal to the center of rotation. And so this is a very non-satisfying operation. But again, dislocated toe for a claw toe, you can't reduce it. Do the, the next step is an osteotomy to reduce the toe. Not a metatarsal heterosection. Cross-over toe is definitely a sports type thing because I'll tell you, we, you know, you have your Lachman test for the knee. Well, we took it for the toe. So, you know, we got all sportsy on you guys. It's a plantar plate rupture. And this is the key thing that they want you to know. So cross-over toe is not where the toe is extended. It's where it's going into slight varus deviation, typically. So it's going towards the great toe. It's associated with a bunion. A lot of times it's attenuation of the plantar plate and the lateral collateral ligament. The etiology is a long second ray that's been proven. Instability or hallux valgus. And a lot of times it's our fault where we do a steroid injection in the MTP joint. I would advocate if any of you do inject the toes, don't inject the second MTP. Neuroma's fine, but joint injections cause this. And it is a real issue for patients and can be a litiginous issue as well. The critical exam finding is the vertical toe Lachman. And while it's a kind of dumb test, but what we do is we take the proximal phalanx, actually we'll shuck it dorsal plantar. There is some motion associated with that if you do your own toes or check your own patients, which I'm sure you don't. The differences for us is that we're looking for pain. So pain with the Lachman, it's not like your Lachman where you're looking for motion. Our physical exam finding is pain with the motion. If you have that, it's pathognomonic for a plantar plate rupture. That's been proven with correlative MRIs. You don't have to get one, and that's what they may tell you. So patient comes in, runner with inflammation, swelling of the second MTP joint, and you do the physical exam finding is positive for a vertical Lachman. What is the primary pathology? And the answer is a plantar plate rupture because they're getting at this particular problem. The surgical treatment, if it's dislocated or irreducible, you go back to that osteotomy that I just mentioned, the wild osteotomy. Otherwise, these are the different options for soft tissue correction, but for the test now for a crossover toe, plantar plate rupture, vertical Lachman, it's a plantar plate repair. We actually have a Scorpion too that we use or mini Viper or something like that. We took all your sports equipment and miniaturized it and use it for the toe. The surgery is not that great, just so you know, as you would be, as you assume. But keep that in mind, that's a definite sports type question that they may ask. Fibrose infraction is a common thing, and again, it's in younger athletes, secondary to repetitive overuse and overload. It is osteonecrosis of the lesser metatarsal head, second, more than third, more than fourth, but does not have to be isolated to the second. That's a common misconception. What you get is flattening, AVN. You can see the flattening there. You can get, as time goes on, you can get arthritis. So if a patient comes in with this type of x-ray, this is the x-ray that they will give you. They will not give you anything too complex. It's always pretty flat and wide, and that's consistent with fibrose infraction. It can be atrogenic if you have a bad operation where you elevate the first ray, then they're gonna overload. But for sports, it's typically gonna be an overused, young, 19, 20-year-old athlete. Early treatment, if they have synovitis only without deformity, you do a synovectomy. Typically, that's not gonna be asked. The classic one that you'll get is this third one, flattening, chondrocollapse, and you wanna do a rotational osteotomy to correct this patient. That is the most commonly-typed question, and if there's end-stage arthritis, you have to do some sort of metatarsal head arthroplasty, but that they would unlikely to ask you on a sports test. So it's this x-ray, as I showed above, that oblique x-ray or the AP, flat metatarsal head, pain, swelling in the second toe, limited range of motion, young athlete, it's Friberg's infraction. The answer is, besides the usual stiff soled shoe and all that, the surgical treatment is a derotational osteotomy or dorsal closing-edge osteotomy to get the good plantar cartilage dorsally. Nerve disorders, tarsal tunnel, just quickly. Orthotics for valgus to decrease the nerve tension, stockings for edema, and cortisone. Surgical treatment, this is what they want you to know in red, is you wanna divide not only the tarsal tunnel, but the deep and superficial abductor hallucinator fascia, because that's where the digital nerves run after they arborize from the main branch. If you don't release that abductor hallucinator fascia, you can still get compression there and incomplete relief of their pain. If you're gonna treat tarsal tunnel, the data has shown that it's better if you get to within a year, versus waiting two, three years. Morton's neuroma is an entrapment neuropathy under the transverse metatarsal ligament. There is some perineural fibrosis, which is important to know. It's not just compression, there's intrinsic degeneration of that nerve. There's just something wrong with it, and that's why release of the inner metatarsal ligament is not that effective. The test finding you have to know is for exam, they have pain radiating to the toes, not just pain in the lesser metatarsal head. So if somebody comes in with pain, and they have radiating pain, electrical numbness, tingling into the second, third, or third, fourth toes, they're going towards a neuroma, and you'll have this Mulder's sign, which is a compression of the foot as you go from plantar to dorsal in the appropriate web space. And if they have pain with it, it's a positive Mulder's sign. You always get x-rays just to make sure, but there's no appropriate need for diagnostic imaging anymore. However, in our practical world that we live in, everyone gets an MRI and ultrasound just to cover yourself, but for the test, you do not need an MRI ultrasound. It's just not necessary. We do it for the patient's mental sanity more than necessary. Morton's neuroma conservative treatment is you can do a steroid injection. That may be a test question, and that's okay. For diagnostic and therapeutic purposes, it can get complete resolution in 20, 30% of the time. The other one that they may ask you or put on there is alcohol sclerosing injection to kill the nerve. That is not appropriate and not an answer for the test for sure. Surgical treatment is excision, 80, 95% satisfaction, but ligament release is not appropriate, and that's because the nerve is pathologic. Whether you go dorsal or plantar, it doesn't seem to matter. Plantar, you get a 5% rate of painful scar, and dorsal, you actually miss the nerve and hit the artery, excise the artery 5% of the time, and that's a fun pathology to get back if you ever do that. Baxter's neuritis. This is jogger's foot. This is what they will ask you a lot of, so this is going towards your runners and heel pain, which is a commonly kind of asked question and something, unfortunately, you probably have to see. Jogger's foot is compression of the first branch of the lateral plantar nerve, also known as Baxter's nerves or the nerve to abductor digiti quinti. They're all the same. The key innervation is the abductor digiti minimi or quinti. The exam is that they have inferior medial heel pain, pain with compression of the abductor, where plantar fascia only has pain over the plantar fascia. Stress fracture is positive calcino squeeze test, and fat pad atrophy is pain on the tuberosity from inferior to posterior, and they may just tell you to you. They may show you a diagram of it, but those are the four things that you have to think about. The surgical treatment for this is obvious. It's just release of the abductor hallucis. You get the deep and superficial fascia, and that solves the problem. This is what was described, and if you have the diagnosis correct, it's actually quite a nice surgery to do. So how do you differentiate for the test? Plantar fasciitis has plantar heel pain directly over the plantar fascia, inferior, not medial, where Baxter's nerve is medial heel pain, compression with abductor hallucis, and if they've had surgery, you can injure the nerve, but they still may have some plantar heel pain. There's a crossover between the two, but first branch has medial heel pain as well. Diabetic feet, and it's not gonna take too long. It's neuropathic, not ischemic, loss of protective sensation. Predictive signs for foot complication is a history of a foot ulcer. So if they had a foot ulcer, they have a high chance of getting an amputation. That's what they're getting at. If you don't feel the 5.07 filament, that means you're at a high risk for getting an ulcer. The treatment, if somebody comes in or they ask you a patient with a diabetic with a foot ulcer, that you don't see tendon or bone, just a simple ulcer, grade one, grade two, which is skin and subcutaneous tissue. It's total contact casting and non-weight bearing to get them off that foot. If you have to operate, and I don't know why they would ask you guys this type of a question, but if you do, recurrent ulcers, it's always recurrent. You never operate on the first time you see a diabetic. You try to cast them, accommodative shoe. If that fails, if they have a recurrent ulcer, you want to do an exostectomy to take out the bump. If it's a stable deformity, if it's unstable, it's a straightforward realignment arthrodesis. If they have a forefoot ulcer, this is the only thing they may ask you. Again, you want to go back to the Achilles and do Achilles lengthening to get the pressure off the front of the foot. And that's a commonly asked type of question. If there's osteo or gangrene, you have to amputate. There's nothing too complicated about that. The one thing they keep asking us nowadays is us to be doctors, not surgeons, which I guess is appropriate, but we don't like to do it. You have to get the biologic level and the vascular level. So if they try to trick you, which they like to do this now, they want you to look at the nutrition of the patient. So if they tell you there's a patient on the floor with a wound that's infected on the foot or ankle, doesn't matter, and they give you some random lab values, and they have a low albumin, low lymphocyte count, what's the next appropriate step? The next most appropriate step is not to do surgery. It's nutritional improvement followed by surgical debridement. It's not surgical debridement first, because they don't want you just to be a surgeon that just cuts and cuts. So if they have any type of nutritional abnormality, improve the nutrition, then do your surgery, even if there's a hole in the foot. Charcot neuroarthropathy is different than Charcot Marie Tooth. This is slightly different. This is from your, nowadays in America, diabetes. I'm sure syphilis is going to make a comeback, given the drug resistance we're seeing nowadays with everything, so keep an eye out for that. But initially, you get edema, warmth, and redness. That's when the foot is, simplest way I think about it, it's getting attacked by its own self. Bones get destroyed, ligaments get destroyed. You have a lot of instability. And it looks like an acute osteo. It just looks very weird. The difference is that there's typically no infection. There's no hole in the foot, so there's no ulcer. If there's no ulcer and the foot looks like it's infected, it's probably Charcot on a diabetic. Keep that in mind. The best way to evaluate that is to elevate, and then it'll decrease after a few hours and look normal. Patients will typically say it looks fine in the morning, looks terrible in the afternoon. In the acute phase, it's just total contact casting. You want to stabilize edema control. Bisphosphonates are not proven, and you're trying to get them to the subacute chronic stages. And then surgery is stuff that we do that you don't have to know. But they may ask you this to differentiate infection versus Charcot. So again, fat, swollen foot, and a diabetic without an ulcer is Charcot. Fat, swollen foot with an ulcer is an infection. That's the simplest breakdown of it. Ankle arthritis has been talked about, so I'm just going to blow through this stuff. Most importantly, I'm going to talk to you about ankle replacement and adjacent joint arthritis. So adjacent joint arthritis, because it's all in your handout, so for ankle fusion, the most common complication over the long term is subtalar arthritis. And that's because you just put stress on the hind foot. As far as there's differentiating literature about the impact on the knee, some say ipsilateral knee, some say no impact on the knee. And Salzman's literature will tell you there's no increase of knee arthritis. But if the question comes up for your test, it is ipsilateral knee is the only other answer that makes any sense if they ask you for other proximal joints if you've had an ankle fusion. For ankle replacements, if you're not keeping up with this literature over every month, is that it is actually no longer experimental. It is an acceptable treatment and now becoming a large push. If they ask you this question, I'm not going to go to belabor all the reviews. But which operation would you pick? And that's probably the only thing you need to know. So if somebody has a bad deformity or no motion or stiff, you want to fuse them. If they're diabetic, heavy, labor, young, anything that sounds really weird, fuse them. For replacement, if the ankle is neutral, it's a thinner patient, good motion, they're actually older, greater than 50, and there's no deformity, that is a great replacement candidate because they have motion, they're not going to overload it, and they'll do pretty well. So they'll lead you down the golden path if they're going to ask you this type of a question. If it sounds weird, just fuse them. High in foot arthritis, if you get this question at all, it's really subtalar arthritis is from two causes typically, either idiopathic, which is fine, or from a calcaneus fracture. If it's from a calcaneus fracture, what they want you to look at is the height of the calcaneus. And they'll give you the common complaints of the patient. If the patient states they have ankle pain or anterior impingement after a calcaneus fracture, they don't want you to do a subtalar fusion in situ because that's not going to solve their ankle pain. And the reason is the talus, which should be declinated about 23 degrees is flat as a horizontal in this case. So you have to lengthen that and increase the declination. So they'll ask you to do a bone block subtalar arthrodesis. Even if the x-ray looks terrible, but the patient has no ankle pain or ankle impingement, don't do a subtalar fusion. They're going to give you that ankle pain that I've written in their anterior impingement. If that's the case, calcaneus fracture, arthritis, bone block subtalar fusion. Otherwise, it's an in situ fusion. As we talked about by Corey, flat foot. If they're rigid or rheumatoid, you can do a triple arthrodesis as well. The triple is for rigid deformities. It can correct anything. And so for the test, if somebody has hindfoot arthritis that's not a calc fracture, you're going to be looking towards triple. Try to avoid isolated TN fusion, isolated CC fusion. It's typically not going to be asked. So it's a triple arthrodesis. If there's any hindfoot arthritis or deformity that's not from a calc fracture, an Achilles lengthening may be asked. We do that in almost every case or a gas rock recession. Something to decrease the stress on the foot. The union rates, what they're going to ask you if they ask you this is that it's associated for non-union with a prior ankle fusion. And the reason is it's all mechanics. The ankle is solid as a rock. When you're trying to do the subtalar fusion, there's a lot of stress on the fusion. So they have a higher non-union rate. And so typically if we do a subtalar fusion under an ankle fusion, we'll fire screws all the way into the ankle as well, into the tibia, to minimize that phenomenon from happening. Smokers don't do as well, and avast necrosis doesn't do well either, but the number one is prior ankle fusion. Midfoot arthritis, you see this dorsal exostosis. You can get a progressive flatfoot and helicore contracture, and they like this question. Patient had an isolated trauma in the past. They had progressive flatfoot. You get abduction through the joints, narrowing. You can see the arthritis here. It's pretty straightforward, and if you look at it compared to a standard flatfoot, there's no abduction through the tail and navicular joint. It's just the midfoot. The orthotics are always the same. You want to limit midfoot motion. You rocker bottom sole and a cushioned heel to minimize stress on the midfoot. You can always put a steel shank in the shoe. The surgical treatment is straightforward, and our world is fusive. You do a midfoot fusion or a tarsometatarsal arthrodesis. And this is shocking, but it had to be studied this way that you have to correct the deformity. If you don't correct the deformity, you perform a fusion in situ. They do poorly, which now is common sense, but when this was first done, it wasn't that obvious what to do. Helical contraction, all these patients. Subtalar dislocations, which are traumatic. If it's a medial subtalar dislocation, so distal relative to proximal, the block to reduction is the lateral structure, so the extensor digitorum brevis or the perineal tendons. They should all be attempted to be reduced closed. If it's unsuccessful, then you have to do an open reduction, and these are the two structures laterally that prevent a medial subtalar dislocation from popping back in place. And if it's the opposite, a lateral subtalar dislocation, it's the posterior tibial tendon. The treatment is closed reduction. You put them in a cast, or some people put them in a boot nowadays, depending on what you read. And if the open reduction should only be done if the closed reduction fails, there is no role for primary ligamentous repair despite what you think and what I think. They actually sock in pretty quickly. Post-reduction, they want you to get a CT scan to assess for intraarticular fractures or loose bodies. So subtalar dislocation, reduced closed. If unable to reduce, open reduction. The structures have been listed there for you, medial lateral. Post-reduction, you need a CT scan to assess for loose bodies or intraarticular fractures that may need a removal or fixation. Calcaneus fractures, just beware of the wound. They have a high wound complication with open procedures, and there's a lot of data that suggests nonoperative management is equivalent to surgery for outcomes. So for a sports exam, mostly what they will ask is the complication following RIF of calcaneus, and it's an infection. The complication following nonoperative intervention is subtalar arthritis and deformity, which is a short, fat heel that we talked about before. So who should get an operation? People that should get an operation with the RIF, if they show you this type of case, it's severe deformity, so that's a dislocated subtalar joint, or if you're walking on the fibula. Tongue-type fractures. This question, every tongue type should get surgery that day, and this is a sports-type question. So if you see a tongue-type calc fracture, even if it doesn't look that bad to your eyes, that patient needs emergent RIF, and this is the only one that's allowed percutaneous for an exam. If you don't, they get a high risk of that post-tribute necrosis, and it's a disaster. So tongue-type calc fracture, the question may be listed as splinted or closed reduction, followed by wound exam. The answer is actually emergent RIF, but only for this particular fracture. So four-year-old female fell during a hike and sustained a lateral subtalar dislocation, always distal relative to proximal. In the emergency room, the doctor's having difficulty reducing the joint. The most common obstacle reduction of the dislocation is, so it's lateral relative to medial, so it's going to be something on the medial side, the posterior tip tendon, not the EDB, not the anterior tip, which is also medial, that's just too dorsal. The Lisfrank ligament is just there. The Lisfrank, as we're getting close, we all know this is a ligament between the medial cuneiform and the second metatarsal. There's nothing between the first and second metatarsal stabilizing it. There's three different parts of it, but the most relevant is that it's the plantar ligament, the interosseous in between, and there's the plantar ligament between medial cuneiform and second and third base. The reason why that's relevant is, when you get your MRIs and CT scans, you'll see a fleck fracture of the plantar aspect of the base of the second. That is complete disruption of the stabilizing ligaments of the midfoot, and that needs to have surgery. It's not actually the dorsal part that's relevant, it's all plantar and center. So when you get that CT MRI, it's a plantar comminution or plantar second metatarsal base injury, that's highly unstable, that needs to be stabilized. The diagnosis is typically indirect, especially for sports, so they're playing soccer, football, they get hit on the back, and that's the story that they'll give you. It's a loading of a plantar flex foot, and the dorsal ligaments will give and the foot will fail in sequence. It's football, rugby, tuck from behind, soccer, et cetera. The radiographs, they have to be weight-bearing, so the questions will go sequentially almost every time. Patient comes in playing football, soccer, what have you, pain, discomfort in the midfoot with swelling, non-weight-bearing radiographs are shown here, and they may look like this. What's the next most appropriate step? The next most appropriate step is weight-bearing X-rays prior to obtaining advanced imaging, because with weight-bearing X-rays, you'll see diastasis. All these numbers are in there for you to review. The most important thing is that God made everything line up. Nothing is asymmetrical in the foot. So the second is aligned with the medial cuneiform, and the space between the intercuneiform joint and the base of the second and the medial cuneiform is the same. There should be no difference. On the oblique, which I didn't show, but the oblique, the third and fourth line up, and the medial aspect of the third and lateral cuneiform line up, and the medial of the fourth and the cuboid line up. Everything just lines up. There's no reason to make this more complicated than it needs to be. If you see this fleck fracture here, that is a sign of an unstable lisfranc injury. It's not small enough that can be ignored. It has to be treated surgically. Is ORI after treatment of choice, or is a fusion now the best answer? This is very relevant for your high level athletes. The answer is not that simple. So this is ORIF that I did. This is back in Michigan with Bruce, and I put a ton of screws in this patient. One of them was one of the actual coaches, Bruce, for Michigan soccer, and I gave him first TMT arthritis because all those screws are not benign. So we've kind of gone into this. We've got a lot of arthritis despite doing what we thought was a good job. So I'll get to the two differences in a second, but non-operative management is not indicated only for a lisfranc strain, where the ligament is intact, weight-bearing x-rays are normal, they have pain, but the ligament's intact, and that's the only one you can do non-operative management. If there's any injury to the lisfranc ligament, diastasis on x-ray, that needs to have appropriate surgical correction. Percutaneous fixation, which has been done, which I'm a fan of, in subtle injuries is wrong. Don't do it. The only answer is ORIF, which is open reduction. You cannot visualize the joints properly, and so theoretically, you'll get a non-atomic reduction in arthritis. That's a discussion for a different day, but for your test, percutaneous is always wrong. A fusion is best answered for your purely ligamentous dislocations, so your car accident type patients where the foot is completely dislocated, you have dorsal subluxation, or if there's heavy articular comminution. So what do you answer for the test? Purely ligamentous dislocation subluxation, primary arthrodesis. Fracture, bony lisfranc, ORIF. Your athletic stress-unstable injury, the patients that you see, the answer is still really ORIF. Doing a fusion in a 19-year-old athlete for the test is not the best thing to do, so it's not just ligamentous injuries. It's kind of got a bad name. When you talk to Kotsia, who wrote one of the similar articles about this, is that it was taken a little too far, so athletes do not need fusions. If it's a subtle weight injury, you want to reduce some stabilization, they'll do okay, but if it's a dislocation or a common knooted injury, you need a fusion, and I hope that makes some sense. There is some use of these suture button-type fixations, these fancier ways to fix it without screws. Don't answer that for the test. For the test, it's a screw, and the next five, 10 years, that might change, but for right now, it's ORIF or a fusion. One thing they'll tell you, there's less revision surgery with arthrodesis, because once it's fused, it's fused and it's done, but that doesn't mean that that's the right answer for a young athlete with stress only. So the Jones fractures or fifth metatarsal fractures, zone one is a tuberosity avulsion, zone two is your standard Jones, and zone three is your diaphyseal stress fractures. So this is an avulsion fracture, it doesn't look that great, looks like that should be fixed, but don't touch it. It's not in between the fourth, fifth intermetatarsal junction. Sir Robert Jones described it as 20 millimeters from the tip of the fifth metatarsals. You can actually measure it, and that's where he described Jones fractures. These people, zone one, weight-based tire and a post-op shoe or boot, it's not neglect. I've seen these treated neglectfully, and that's when they can get pain. If you treat them with a boot for five, six weeks, they'll do fine, or a post-op shoe, something to stabilize it. Surgery is very rarely indicated, and at least for your test, there's no rule for surgery, at least for the test. I can't imagine them showing you some crazy x-ray where they want you to fix it. These, for you, are very important. So watershed zone with difficult healing, this is a Jones fracture, as you know. In a non-athlete, acute injuries, non-weight-bearing in a cast for six weeks is fine, but in an athlete or anybody that really considers themselves an athlete nowadays, you do an RAF with a screw. For your test, if they ask you, 50-year-old recreational athlete gets a Jones fracture, that actually is supposed to be treated with a cast, not a screw. Your 25-year-old elite athlete, baseball player, gets a Jones fracture, that gets treated with a screw. And so even though people think they're an athlete, if they give you the story that one's not that athletic, casting non-weight-bearing six weeks followed by a boot actually does quite well. There's some recent articles saying you can actually let them walk in a boot, but don't put that for the test. And so not all Jones fractures need surgery. For your hyper-elite athletes, you may have read that people are doing concentrated bone marrow and shooting that in there, augmenting with bone graft. For the test, you don't do that. That literature has not been borne out. And so for the test, it's just a screw without augmentation at this point. This is from Quill's original surgery. So elite athletes, we fix them because they have a high refracture rate. They may heal, but they refracture a lot. Zone three, it looks like this. It's a distraction-type injury. They have chronic pain prior to the injury. Then they have a sudden episode where it gives. These people all need surgery. There's no question. Metatarsal stress fractures, and we'll be done here in a second, symptoms, insidious onset, swelling, the treatment's weight-bearing a boot, and just want to evaluate for metabolic bone disease. That's probably the most relevant thing they're going to ask you. You can't just treat and forget. You have to check vitamin D, et cetera. And if the young female patient, look for the female triad, as you all know. They want you to look for the cause. Navicular stress fractures, vague dorsal midfoot pain. They call it the end spot. Technically, it's the dorsal aspect of the ankle or foot. So what the differences will be, they may show a patient with an ankle. If they're pointing posteriorly towards the ankle joint, it's ankle pain. Could be ankle impingement, OCD. If they're pointing down at the level of the ankle, it's actually the navicular, and that's that so-called end spot. It's usually in athletes, obviously. Cabus foot, think about that. Vague pain, runners, repetitive impact. The treatment is actually non-weight-bearing in a boot or a cast. There's some controversy in the last few years. Do not operate on these people unless you have no choice. The outcomes are actually better with non-op intervention, as opposed to operative intervention. If they don't get better, and you get failure of non-op intervention after three, four months, then you can do surgery, which is just oring up with a bone graft. They don't do so well with surgery, so keep that in mind. Lateral process fractures. Your snowboarders, your athletes get this inversion injury. It mimics a lateral ankle sprain. CT is very sensitive. The AP radiograph is where you'll see it the most. The treatment's straightforward. If it's a big piece that's one centimeter in size and it's displaced, you have to fix it. If it's less than 2 millimeter displaced, you can leave it alone. So 2 millimeters is the magic number, which means if you see the fracture displaced, you should fix it, because your eyes can tell only after 2 millimeters of displacement. So if it looks displaced to you, get the CT and plan on fixing it. If it's comminuted and giblets, you just take it out. If it looks totally anatomic, non-weight-bearing six weeks. And this is important not to miss, because an ankle sprain is treated with functional rehab, where a lateral process fracture needs surgery and non-weight-bearing. So 18-year-old male experienced persistent lateral ankle pain two weeks after injury while snowboarding. X-rays were negative for fracture. The most appropriate treatment is assurance it's fine. No PRP, no. You want a CT scan to evaluate for lateral process tailless fracture, because that's your high-level suspicion. 21-year-old female elite runner, sudden pain along the lateral aspect of her foot. She had soreness in the same area for two weeks. She has a fifth metatarsal Jones fracture with sclerosis. Sclerosis meaning she has prodromal pain. The treatment is not bone stem, PRP, or cast. Prodromal pain, athlete with a fracture is a repair of the fifth metatarsal with an IM screw. Thank you very much.

foot and ankle conditions

symptoms

treatment options

surgical interventions

gait cycle

foot pathologies

muscle function

plantar fasciitis

hallux valgus

turf toe