Rupture of the Plantar Fascia

Rupture of the Plantar Fascia

Plantar fascia rupture is not a very common injury, and it has the characteristic of acute pain in the arch of the foot. It occurs due to a tear in the plantar fascia, and that tear is painful. Rupture is often associated with long standing flat feet deformity or can occur from steroid injections. Another predisposing factor for plantar fascia rupture is plantar fasciitis.

Anatomy

The plantar fascia is formed by three bands: the medial, the central, and the lateral. The plantar aponeurosis is the central part of the plantar fascia. The plantar fascia is inserted into the medial tuberosity of the

calcaneus and extends distally, becoming broader and thinner. The plantar fascia acts as a bow string.

The rupture of the plantar fascia may be misdiagnosed as plantar fasciitis. When the plantar fascia tears, the patient will describe a tearing pain that usually occurs during athletic activity. The tear may be complete or incomplete. Complete tear of the plantar fascia occurs from sudden trauma or injury. The patient feels “popping” or “snapping” suddenly. Walking will be very difficult with tenderness, swelling and significant bruising on the sole of the foot (the condition is painful). Some patients may have a noticeable tightness of the calf muscle (equinus contracture) in association with rupture of the plantar fascia. Partial rupture is less common and occurs from overuse, as in running. MRI will identify the rupture, and it can also identify if the rupture is partial or incomplete. Rupture is often in the arch of the foot opposed to where the plantar fascia inserts into the heel (calcaneus). Ultrasound has the same accuracy as MRI for imaging the plantar fascia. Interpretation of the plantar fascia rupture may be difficult. You may need dynamic maneuvers with dorsal flexion of the forefoot to stretch the plantar fascia. Usually the proximal part of the plantar aponeurosis is clearly visualized on ultrasound. MRI is probably better in diagnosis plantar fascia rupture.

Treatment of Plantar Fascia Rupture

-Non-Weight Bearing for 2-3 Weeks

-Walking Boot

-Crutches

-Physical Therapy

-Surgical Treatment is the last resort.

-Could be used in some athletes who continue to have pain despite a well conducted conservative treatment

-Surgery is done to release the fascia and the excise the scar

Patients with rupture of the plantar fascia typically achieve a favorable outcome with return to full activity. 

Ganglion Cyst Carpal Tunnel

Ganglion Cysts Pressure Motor Branch of Median Nerve

After passing through the carpal tunnel, the median nerve gives a branch on the radial side called the recurrent motor branch. The recurrent motor branch innervates the abductor pollicis brevis, the flexor pollicis brevis (superficial head), and the opponens pollicis muscles.

The recurrent motor branch of the median nerve has multiple variations of the nerve. 50% are extraligamentous with recurrent innervation. 30% are subligamentous with recurrent innervation. 20% are transligamentous with recurrent innervation. When you release the carpal tunnel, it is important to cut the transverse carpal ligament far ulnarly to avoid cutting the recurrent motor branch of the median nerve. These are the patients that will get motor symptoms after you do carpal tunnel release. There is another entity similar to this entity, and these are the patients that have symptoms similar to carpal tunnel syndrome, but their presentation is not classic. These are the patients that you may need to get an MRI or ultrasound to check the carpal tunnel area. Pain symptoms of carpal tunnel syndrome occur more at night. Self-administered hand diagram is extremely helpful (most specific test for carpal tunnel syndrome). The patient should highlight the areas where they are experiencing the symptoms. The patient may complain of thenar atrophy, weakness, or clumsiness of the hand. The positive compression test (Durkan’s test) is the most sensitive test. You can see the Tinel’s Sign, do the Phalen’s test, or the Semmes Weinstein test. Some physicians believe that EMG doesn’t really increase the diagnostic value of these tests (if you have a combination of these test), and you will proceed with surgery even if the EMG is normal. The problem is, that you will find a group of patients that have weakness and atrophy of the thumb muscles, and the provocative and sensory tests for carpal tunnel syndrome are negative. These are the patients that you will get an MRI to rule out pressure on the motor branch of the median nerve. These are the patients that you will probably find a ganglion cyst pressuring the motor branch of the median nerve.

Ankle Ligaments Injury, Tests & Assessment

Ankle Ligaments Injury, Tests & Assessment

The ligaments of the ankle are complex. Injury to these ligaments are called ankle sprains. Sprain of the ankle is usually a low ankle sprain. Occasionally, it can be a high ankle sprain. Sprain of the ankle can be confused with other conditions that can happen around the ankle such as:

• ·         Osteochondral lesion
• ·         Peroneal tendon subluxation
• ·         Fracture of the lateral talar process
• ·         Fracture of the anterior process of the calcaneus
• ·         High ankle sprain (syndesmotic injury)

Here are a few tests that are used to test for injury of these ligaments:

  

• Anterior Drawer Test

• Squeeze Test

• External Rotation Stress Test

• Talar Tilt Test (Inversion Test)

If the patient cannot bear weight on the ankle, the patient should get an x-ray. Injury of the deltoid ligament occurs at the medial side of the ankle, and it is usually associated with ankle fractures. Sometimes injury of the deltoid ligament is occult and the patient will need external rotation stress x-rays to demonstrate injury of the deltoid ligament. Injury to the lateral side ligaments is referred to as low ankle sprain. The anterior talofibular ligament is the weakest ligament on the lateral side. The anterior drawer test is done to test the competency of the anterior talofibular ligament. It is done in 20 degrees of plantar flexion and compare it to the other side. A shift of an absolute value of 9 mm on the lateral x-ray or 5 mm compared to the other side is positive. The calcaneofibular ligament is usually injured after the anterior talofibular ligament. The test used to diagnose injury of the calcaneofibular ligament is called the talar tilt test or the inversion test. Less than 5 degrees of tilt is usually normal. The final area of injury is called a high ankle sprain or injury to the syndesmosis. Contrary to a low ankle sprain, a high ankle sprain may require surgery. This is how injury to the syndesmosis occurs. Always check the fibula proximally to avoid missing a Maisonneuve fracture. The Maisonneuve fracture will have a proximal fibular fracture, a syndesmotic injury, and a deltoid ligament injury. This will require surgery. The tests used to diagnose high ankle sprains are the squeeze test and the external rotation stress test. The squeeze test is performed by squeezing the tibia and fibula at mid-calf. This will cause pain at the syndesmosis if a high ankle sprain is present. The external rotation test is the other test used to diagnose a high ankle sprain or an injury of the syndesmosis. The external rotation test is performed by first placing the ankle into a neutral position. Then, apply external rotation stress and finally, get a mortise view radiograph. There is a positive result for syndesmotic injury if the tibiofibular clear space is more than 5mm or if the medial clear space widening is more than 4mm.

Ganglion Cyst of the Foot & Ankle

Ganglion Cyst of the Foot & Ankle

Ganglion Cyst of the Foot & Ankle

Ganglion Cyst of the Foot

Ganglion cysts can occur anywhere. They usually occur at the wrist area, however, ganglion cysts may occur at the foot (usually at the top of the foot). This mass can change in size, and it may grow slowly. The patient notices a mass usually on the top of the foot. The mass is usually asymptomatic. The patient may have a burning sensation due to irritation of the nerve when the ganglion compresses the nerve. The patient may have skin irritation and also may have difficulty walking and wearing shoes. If the ganglion is pushing on a nerve and causing irritation, aspiration or surgical removal of the cyst can help relieving the symptoms. We need to differentiate ganglion cyst of the foot from plantar fibromatosis. Plantar fibromatosis occurs at the bottom of the foot. Ganglion cysts usually occur at the top of the foot. Ganglion cysts will transilluminate. Plantar fibromatosis does not transilluminate

Ganglion Cyst of the Ankle (Tarsal Tunnel Syndrome)

What is Tarsal Tunnel Syndrome?

Tarsal tunnel syndrome is a compressive neuropathy which is caused by compression of the tibial nerve around the ankle region. A ganglion cyst can be one of the intrinsic causes of tibial nerve compression. In the tarsal tunnel, the patient may have pain and burning sensation. An MRI is probably needed for the diagnosis of a ganglion cyst in the tarsal tunnel. They found that they best result after surgery occurs when there is a ganglion cyst compressing on the nerve, and this cyst is removed.