Distal biceps/triceps tendonitis

1. What is the mechanism of distal biceps/triceps tendonitis?
2. What is seen clinically in distal biceps tendonitis?
3. What is seen clinically in triceps tendonitis?
4. What is the treatment of biceps/triceps tendonitis?

Answers:
1. Repetitive overuse.
2. Insidious onset of pain in antecubital fossa, usually after eccentric overload. If avulsion, may be audible snap with obvious deformity, swelling, and ecchymosis.
3. Posterior elbow pain with tenderness over triceps insertion, pain with resisted elbow extension.
4. Rest, ice, NSAIDs, PT with modalities, possible surgical reattachment for avulsion.

Elbow dislocation

1. What is the mechanism of elbow dislocation?
2. What is seen clinically with elbow dislocation?
3. What are other injuries associated with elbow dislocation?
4. What is the treatment for elbow dislocation?
5. What are possible adverse outcomes?

Answers:
1. Fall on outstretched hand. Posterior dislocation is more likely.
2. Inability to bend elbow, pain in shoulder/wrist. On PE, do careful neurovasc eval.
3. Fracture of radial head, median nerve injury, brachial artery injury.
4. Reduction, splint for 10 days, then ROM and NSAIDs.
5. Loss of ROM (esp extension), ectopic bone formation, neurovasc injury, arthritis.

Olecranon bursitis

1. What are other names for olecranon bursitis?
2. What is the mechanism and pathology of olecranon bursitis?
3. What is seen clinically with olecranon bursitis?
4. What is the treatment of olecranon bursitis?

Answers:
1. Draftsman's elbow, Student's elbow, Miner's elbow.
2. Repetitive trauma or inflammatory disorder, resulting in inflammation of the bursa between the olecranon and skin.
3. Swelling, pain, decreased ROM. If hot, there may be infection.
4. Aspiration and culture, rest, NSAIDs, elbow padding.

Lateral Epicondylitis

1. What are some factors that cause lateral epicondylitis (LE)?
2. What is the pathology behind LE?
3. What are the clinical history of LE?
4. What is Cozen's test?
5. Why might X-rays be obtained?
6. What is the treatment for LE?

Answers:
1. Any repetitive sport (e.g. tennis) especially when poor techniques are used with a racket sport (inproper backhand, weak string tension, inappropriate grip size), overuse and poor mechanics.
2. Microtearing of the extensor carpi radialis brevis.
3. Patients c/o tenderness just distal to the LE at the ECR origin, pain and weakness of grip.
4. Cozen's test is when the examiner stabilizes the elbow with a thumb over the LE and there is pain with a fist, forearm pronation, radial deviation, and wrist extension against resistance. There may also be pain with passive extension of elbow with forced wrist flexion.
5. Obtain X-rays if there is suspicion of arthritis or loose body fragments.
6. Conservative treatment includes rest, ice, NSAIDs for 10-14 days. If no improvement, may do PT, splinting, steroid injection, and correction of improper techniques. Surgical treatment of ECRB debridement can be considered.

Medial epicondylitis

1. What are other names for medial epicondylitis?
2. What is the mechanism of medial epicondylitis?
3. What is the difference between medial epicondylitis and little leaguer's elbow?
4. What is seen clinically in medial epicondylitis?
5. What is the treatment of medial epicondylitis?

Answers:
1. Golfer's elbow or little leaguers elbow.
2. Repetitive valgus stress such as in throwing or a back and downward swing such is in golfing.
3. Medial epicondylitis involves inflammation of the common flexor tendon, which may cause hypertrophy of the medial epicondyle. Little leaguer's elbow involves hypertrophy of the medial epicondyle, leading to microtearing and fragmentation of the medial epicondylar apophysis.
4. Tenderness at medial epicondyle that can be reproduced with wrist flexion and pronation.
5. Conservative treatment includes rest, ice, NSAIDs, immobilization, and correction of throwing mechanics. Surgical pinning can be used for unstable elbow.

Elbow anatomy

1. What are the three ligaments of the elbow?
2. What muscles originate at the medial epicondyle?
3. What muscles originate at the lateral epicondyle?
4. What is the normal amount of elbow valgus?

Answers:
1. Medial (ulnar) collateral ligament (key stabilizer of elbow), lateral (radial) collateral ligament, annular ligament.
2. Medial epicondyle: FCR, FCU, FDS, FDP, palmaris longus, pronator teres.
3. Lateral epicondyle: ECRL, ECRB, ECU, EDS, supinator, anconeus.
4. 5 deg in males, 10-15 deg in females, >20 deg is abnormal.

Foot fractures

1. What is a Jones fracture and what is the treatment?
2. What is a Nutcracker fracture and what is the treatment?
3. What is a March fracture and what is the treatment?

Answers:
1. A Jones fx is a transverse fx through the base of the 5th metatarsal. It is treated with NWB cast for 6 weeks and ORIF if nonunion occurs.
2. A Nutcracker fx is a cuboid fx, treated with ORIF.
3. A March fx is a fatigue fx of one of the metatarsals, treated with cast.

Lisfranc joint injury

1. What is a Lisfranc joint injury?
2. How does a Lisfranc injury occur?
3. What is seen clinically with a Lisfranc injury?
4. What is the treatment of a Lisfranc injury?

Answers:
1. Traumatic disruption of tarsometatarsal joints.
2. Direct trauma vs. force applied to heel in line with axis of foot with toes flexed.
3. Vague ankle pain, swelling in dorsum of foot, which is exacerbated by stabilizing the hind foot and rotating the forefoot.
4. If nondisplaced: NWB, immobilization for 6-8 wks. If displaced, surgery is needed.

Toe deformities

1. What is hammer toe? What are the symptoms and treatment?
2. What is claw toe? What are the causes of claw toe? What are the symptoms and treatment?
3. What is mallet toe? What are the symptoms and treatment?

Answers:
1. Hammer toe is a deformity of the lesser toes in which there is flexion of PIP with passive extension of MTP when foot is flat. DIP is not affected. May be caused by tight shoes or trauma. Symptoms include pain in toe. Treatment is toes with roomy toe boxes, 1/2 inch longer than longest toe, and passive strengthening of toes.
2. Claw toe is extension of MTP with flexion of PIP and DIP. Usually caused by incompetence of foot intrinsics, such as from neurologic disorders (diabetes, alcoholism, peripheral neuropathy, Charcot-Marie-Tooth, spinal cord tumors). The main symptom is pain. Treatment includes shoes with soft, high toe boxes, splints, possible surgical correction.
3. Mallet toe is flexion deformity at DIP jt with normal alignment at the PIP and MTP. This is usually caused by jamming injury or tight shoes. Symptoms include pain and callous at the tip of the toe. Treatment includes shoes with high toe boxes and trimming of callous.

Hallux disorders

1. What is a metatarsal phalangeal (MTP) sprain? What are the symptoms?
2. What is hallux valgus?
3. What is hallux rigidus? What are the symptoms?
4. What are the treatment for hallux disorders?

Answers:
1. Acute injury to the ligaments and capsule of the MTP joint, also called "turf toe". Symptoms include acute onset of pain, tenderness, swelling in MTP jt on plantar surface, with pain on passive DF.
2. Lateral deviation of the first toe greater than the normal ankle of 15 degrees, which may lead to bunion.
3. Degeneration of first MTP jt, leading to pain and stiffness (arthritis). Symptoms include pain, swelling, and decreased ROM of MTP jt.
4. RICE, taping, proper footwear. For rigidus, may require surgical debridement.

Morton's neuroma

1. What is a Morton's neuroma?
2. Where is a Morton's neuroma usually located?
3. What is seen clinically in Morton's neuroma? On exam?
4. What is the treatment of Morton's neuroma?

Answers:
1. Irritation and degeneration of the digital nerves in the toes resulting in fibrosis, producing a painful mass near the area of the metatarsal heads.
2. Between 2nd and 3rd, or 3rd and 4th digits.
3. Sharp shooting forefoot pain, commonly with dysesthesia and numbness. Test by squeezing the metatarsal heads together while applying pressure to the interdigit webspace --> pain in plantar webspace is positive.
4. Shoes with soft sole and wide toe box, metatarsal pad, steroid injection. Surgical excision if indicated.

Plantar fasciitis

1. What factors predispose to plantar fasciitis?
2. What are the clinical symptoms of plantar fasciitis?
3. What is the treatment of plantar fasciitis?

Answers:
1. Pes cavus, pes planus, obesity, tight Achilles, HLA-B27, seronegative spondyloarthropathy, ?heel spurs.
2. Tenderness over medial heel and plantar fascia that increases on awakening and decreases with activity.
3. Heel pads, cushion, lift, Achilles and plantar fascia stretching, modalities, NSAIDs, night splints in DF.

Talar dome fracture

1. How does a talar dome fracture occur?
2. What is the Hawkins classification of talar dome fractures?
3. What are complications of talar dome fracture?
4. What is seen clinically in talar dome fracture?
5. What imaging is required to diagnose talar dome fracture?
6. What is the treatment?

Answers:
1. Shear force on anterior lateral surface of talus or compression on posterior medial surface. (Inversion/PF or Eversion/DF)
2. 3 types: type 1 is a nondisplaced fx of talar neck, type 2 is a displaced fx of talar neck with ankle joint intact, type 3 is a displaced fx of talar neck with dislocation of body of talus from subtalar and ankle joints.
3. Avascular necrosis of talar body, displaced bone fragment into joint space.
4. Small painful effusion, decreased ROM in the setting of chronic ankle injury.
5. Mortise view of ankle, MRI.
6. Conservative tx is NWB. Surgical ORIF if indicated.

Tibialis anterior hyperactivity

1. What sort of deformity is caused by tibialis anterior hyperactivity?
2. What sort of patients is tibialis anterior hyperactivity seen in?
3. How is tibialis anterior hyperactivity treated?

Answers:
1. Equinovarus deformity, with Achilles shortening.
2. CP, CVA, TBI.
3. SPLATT: Split Anterior Tibial Tendon Transfer. Half of tendon is attached to site of origin while distal end of lateral half is tunneled into the 3rd cuneiform and cuboid bones, creating an eversion force. Procedure often done with Achilles lengthening.

Tibialis anterior tendon injury

1. How is the TA often injured?
2. What is seen clinically with TA injury?
3. What is the treatment of TA injury?

Answers:
1. Tenosynovitis, rupture (usually degenerative or from eccentric overload).
2. Pain along insertion at medial aspect of base of first metatarsal and first cuneiform, h/o chronic ankle pain, foot slap, increased pain with DF and passive PF.
3. Conservative vs. surgical, depending on age and level of function.

Sinus tarsi syndrome

1. What is the sinus tarsi?
2. What is the mechanism of sinus tarsi syndrome?
3. What is seen clinically in sinus tarsi syndrome?
4. What is the treatment of sinus tarsi syndrome?

Answers:
1. A small osseous canal which runs into the ankle under the talus bone.
2. Excessive foot pronation causing adduction of the talus, often with h/o arthritis or prior ankle injury.
3. Pain on the anterolateral aspect of the foot/ankle over the sinus tarsi, which resolves with injection of local anesthetic into the sinus tarsi.
4. Conservative treatment is the same as for ankle sprain, surgical treatment includes decompression of the tunnel.

Syndesmosis Sprain

1. What is the ankle syndesmosis?
2. How does a syndesmosis sprain occur?
3. What is the clinical picture of a syndesmosis sprain?
4. What imaging is required to diagnose a syndesmosis sprain?
5. What is the treatment of syndesmosis sprain?

Answers:
1. Fibrous joint keeping together tibia and fibula that maintains integrity of ankle, made up of four ligaments.
2. Hyperdorsiflexion and forceful eversion, or direct blow to foot with ankle in external rotation.
3. Chronic pain and swelling in anterior ankle. Positive squeeze test (tenderness on compression of distal tib-fib) and stress test (knee at 90 deg, ankle neutral, pain with forceful ext rot of foot).
4. Plain films to r/o tib-fib widening and r/o Maisonneuve fx (prox fibula fx resulting from ruptured anterior tibiofibular ligament).
5. Conservative treatment is usually used. Surgical treatment includes a screw to stabilize ankle mortise.

Retrocalcaneal bursitis

1. What is retrocalcaneal bursitis and who is it usually seen in?
2. What is the mechanism of developing retrocalcaneal bursitis?
3. What is Haglund's deformity?
4. What is Sever's disease?
5. What is seen clinically in retrocalcaneal bursitis?
6. What is the treatment of retrocalcaneal bursitis?

Answers:
1. Inflammation of the bursae between the superior calcaneus and distal Achilles or behind the Achilles. It is usually seen in women wearing high heeled shoes.
2. Repetitive pressure and shearing from shoes causing bursa inflammation.
3. Enlargement of posterosuperior tuberosity.
4. An independent area of ossification separated from main bone at cartilaginous plate, in young population.
5. Tenderness and swelling at the distal Achilles.
6. Change footwear. Surgical excision of bursae if this fails.

flexor hallucis longus injury

1. What is another name for FHL injury?
2. What is the origin and insertion of the FHL?
3. How is the FHL injured?
4. What are the symptoms of FHL injury?
5. What is the treatment of FHL injury?

Answers:
1. Dancer's tendonitis.
2. Origin is distal fibula and interosseous membrane. Insertion is base of distal phalanx of great toe.
3. It is injured by repetitive push-off maneuvers causing inflammation of the synovium.
4. Tenderness along tendon at the posteromedial aspect of great toe, increased with PF and passive DF.
5. Same tx as lateral ligament sprain.

Achilles tendon disorders

1. What is the mechanism of Achilles tendonitis/rupture?
2. What are the risk factors for Achilles injury?
3. How does Achilles tendonitis/rupture present?
4. What is the treatment of Achilles tendonitis?
5. What is the treatment of Achilles rupture?

Answers:
1. Tendonitis occurs by repetitive eccentric overload causing inflammation and microtears. Rupture occurs by sudden push-off with foot in extension position.
2. Hyperpronation, tight hamstrings and heel cords, pes cavus, genu varum, age, increase in mileage or intensity, change in footwear.
3. Tendonitis presents with posterior ankle pain, swelling, worse with push-off. Rupture presents with sudden audible snap with immediate swelling, ecchymosis and PF weakness, positive Thompson test.
4. Rest, ice, NSAIDs, short-term immobilization, stretching and strengthening, heel lifts, steroid injection near tendon.
5. Conservative treatment includes bracing in PF for 8-12 wks with gradual increase in activity. Surgery includes tendon repair with cast for 2 wks.

Tibialis posterior tendon injury

1. Where does the tibialis posterior originate and insert?
2. What is the function of the tibialis posterior?
3. How is the TP usually injured?
4. What is seen clinically in TP injury?
5. What is the treatment?

Answers:
1. Origin is interosseous membrane and posterior surface of tibia and fibula. Insertion is the tuberosity of the navicular cuboid and base of 2-4 metatarsals.
2. PF and inversion of foot, maintains medial longitudinal arch.
3. Injured by repetitive forceful inversion, often associated with an accessory navicular.
4. Insidious onset of posteromedial ankle pain, medial hindfoot swelling, increased pain with pushoff. If rupture, will have "too many toes" sign.
5. Treat same as lateral ankle sprain, may need orthotics. If rupture, may need tendon transfer.

Medial ankle sprain

1. What is the occurrence rate of a medial (deltoid) ankle sprain?
2. How do medial ankle sprains usually occur?
3. What are common complications?
4. What is seen clinically in a medial ankle sprain?
5. What is the treatment?

Answers:
1. 5%
2. Foot in pronated everted position with internal rotation of upper body (foot strikes ground instead of ball in soccer/football).
3. Syndesmosis ankle injuries, Maisonneuve fractures.
4. Medial foot swelling, ecchymosis, pain with eversion. Anterior drawer negative.
5. Same treatment as lateral ankle sprain.

Peroneal tendon injury

1. Where do the two peroneal tendons insert?
2. What is the function of the peroneus longus?
3. What is the mechanism of peroneal tendon injury?
4. What is seen clinically with peroneal tendon injury?
5. What is the treatment of peroneal tendon injury?

Answers:
1. Peroneus brevis: base of 5th metatarsal. Peroneus longus: base of 1st metatarsal.
2. Plantarflexes ankle and everts foot.
3. Rupture is caused by repetitive forceful eversion causing inflammation or degeneration. Dislocation can be caused by sudden DF, common in a skiing injury.
4. Swelling in retromalleolar area, sudden weakness with inability to evert foot. Provocative test is pain with resisted DF and eversion.
5. If just tenosynovitis, should be treated similarly to lateral ankle sprain. If rupture or dislocation, send for ortho eval.

Lateral ankle sprain

1. How does a lateral ankle sprain occur?
2. What is the function of the CFL?
3. What are two provocative tests used in ankle sprain?
4. What imaging should be done for ankle sprain?
5. What is the treatment of ankle sprain?

Answers:
1. Inversion of PF foot.
2. Stabilize ankle during inversion.
3. Anterior drawer to test integrity of ATFL, talar tilt to test integrity of CFL and ATFL.
4. X-rays, possible stress views (ant drawer, talar tilt).
5. For grades 1+2, RICE, NSAIDs, analgesics, early mobilization with ROM, strengthening, proprioception exercises, taping, bracing, and modalities. For grade 3, do a 6 month trial of rehab and bracing, then consider surgical ligament repair.

Ankle anatomy: ligaments

1. What are the ligaments of the lateral ankle?
2. What are the ligaments of the medial ankle?
3. What are the ligaments of the anterior ankle?
4. What is the Lisfranc ligament?

Answers:
1. Anterior talofibular ligament, posterior talofibular ligament, calcaneofibular ligament.
2. Deltoid ligament, which consists of 4 parts, broken down into deep and superficial.
3. The 4 syndesmotic ligaments maintain the integrity of the distal tibia and fibula: anterior tibiofibular ligament, posterior tibiofibular ligament, transverse tibiofibular ligament, and interosseous ligament.
4. Connects 2nd metatarsal head to 1st cuneiform.

Ankle anatomy: bones

1. Why does the talus often have healing complications?
2. What are the seven tarsal bones?
3. Where are the two sesamoid bones located?
4. What other bones are in the foot?

Answers:
1. Fragile blood supply.
2. Talus, calcaneus, navicular, cuboid, and three cuneiform bones.
3. Located on the plantar surface of the head of the first metatarsal.
4. 5 metatarsals and 14 phalanges.

Stress fractures

1. What is the most common location for a stress fracture in running sports?
2. What factors predispose to stress fractures?
3. What are the symptoms of stress fracture?
4. How is a stress fx diagnosed?
5. What is the treatment for stress fx?

Answers:
1. Tibia
2. Females with late menses, low body wt, poor nutrition, tobacco/alcohol use, low bone density, over-pronation (genu valgum), leg length discrepancy, lack of flexibility, abrupt increases in training intensity, running on hard surfaces or worn out shoes.
3. Pain at onset of activity that grows more severe, localized to fracture site. Night pain may occur. There is tenderness at fracture site, as well as possible swelling and redness.
4. Plain films should be done first, although the fx may not be seen for 2-3 wks after symptoms develop, appearing first as periosteal thickening, followed by cortical lucency. Bone scan is very sensitive but non-specific. MRI is now first line since it is sensitive and specific.
5. If there is pain with ambulation, pt should be NWB for 7-10 days. At least 1-2 wks of pain-free ambulation before returning to impact activity, which should be started cautiously and increased incrementally. Predisposing factors should be addressed.

Medial tibial stress syndrome

1. What is the pathophysiology behind shin splints?
2. What is the main predisposing factor to shin splints?
3. What is the presentation of shin splints?
4. What imaging is done for shin splints?
5. What is the treatment?

Answers:
1. Chronic traction on the periosteum at the periosteal-fascial junction, with possible detachment of periosteum from the bone. Avulsion may occur at the attachment of the soleus to the medial tibia.
2. Hyperpronation.
3. Gradual onset of pain at the posteromedial border of the tibia, which may decrease with exercise and increase after the exercise is completed. History may include excessive use of foot flexors or repetitive running on hard surfaces, recent footwear change. Exam shows tenderness on palpation along medial border of tibia.
4. Bone scan may show uptake along medial tibial border. MRI will r/o stress fx.
5. Rest with avoidance of inciting activity, icing, stretching, return to activity on soft level surfaces when pain free for several days. Orthotics for overpronation. Fasciotomy of posteromedial fascia.

Acute compartment syndrome

1. What happens in acute compartment syndrome (ACS) and what is the timeline?
2. What is the most common cause of ACS? What area is usually affected?
3. What are the complications of untreated ACS?
4. What are the symptoms of ACS?
5. How is ACS diagnosed?
6. How is ACS treated?

Answers:
1. Intracompartmental tissue pressure becomes elevated and venous pressure elevates to obstruct outflow. Necrosis can occur in 4-8 hrs.
2. Trauma associated with fractures of the long bones of the leg or forearm. It usually affects the volar forarm or anterior compartment of leg.
3. Volkmann's ischemic necrosis, which results in claw hand or foot caused by contractures of ischemic muscle.
4. Pain, paresthesias, and paralysis distal to the involved compartment. There is extreme pain on stretching of long muscles, but pulses are usually normal.
5. Manometry: diastolic pressure - intracompartmental pressure < 20 mmHg.
6. Fasciotomy.

Chronic exertional compartment syndrome

1. What occurs in CECS?
2. What are the clinical symptoms of CECS?
3. How is CECS diagnosed?
4. What is the best treatment for CECS?

Answers:
1. Pressure increases occur during and after exercise and nerve impingement and tissue ischemia can occur.
2. Pain with exercise that increases as the activity increases and diminishes after it stops. Weakness and numbness corresponds to the compartment being compressed (anterior and lateral CECS causes symptoms in deep peroneal distribution, deep posterior CECS in tibial nerve distribution). On palpation, the compartment may be firm and distal pulses may be diminished.
3. Compartment pressure studies measured pre and post exercise. A delay in return to pre-exercise pressure levels of 6-30 mins is required for diagnosis.
4. Fasciotomy.