Brian Toolan, MD, discusses Adult Foot & Ankle: Injury and Disease.
[MUSIC PLAYING] SPEAKER 1: All right, I'm going to cover both foot and ankle. We'll start with in the foot and work our way up. There's my disclosure slide. So I'll talk about common forefoot fractures that you'll see very routinely coming to your offices. Toe fractures, phalanx fractures, stubbing injury against furniture. It can happen on the stairs as well. Usually this involves the fourth and fifth toe, but you can occasionally get these type of fractures in the phalanx of the great toe. Essentially your treatment is conservative and for comfort. Some people buddy tape the toes together. It certainly has a role. It may provide some stability. Sometimes it causes maceration between the two toes. And sometimes people don't like it because if you move the adjacent toe, it makes the fractured toe hurt. So usually putting them in a stiff soled sandal or shoe for about 10 to 14 days. And then they can transition to some of their more comfort enclosed shoe wear after that. It takes about a month for these fractures to heal. Moving on to metatarsal neck fractures. So these occur when people land on their tiptoes, such as missing the last step on a flight of stairs. What you want to check for in these patients is on the AP view there may be some translation or angulation, and that is usually well tolerated. There's intermetatarsal ligaments between the metatarsal heads that help stabilize them. They tend not to move or displace much. Again, these can be treated with a stiff sandal or a show. For people that are severely painful, have a lot of swelling, you'd put them into a cam boot for a period of time. This is going to take a little longer period of immobilization, more like a month or so before they're comfortable enough to transition back to shoes. You operate on these if they are displaced, but not so much for in this x-ray showing lateral displacement. But what you really want to check for is if there's dorsal displacement, meaning the fractured metatarsal neck dorsiflexes, so now the metatarsal head is no longer present or as present on the plantar aspect of the foot. If you have a fracture of one or two metatarsals and they are very dorsiflexed, that's effectively offloading those metatarsals. It the fracture heals that way, those metatarsal heads won't bear their share of the weight. I'll cause transfer of the weight to the adjacent metatarsals, causing a callous, causing pain. So this is just a demonstration here that when you see patients with metatarsal neck fractures, please palpate under the metatarsal heads gently to feel that the metatarsal heads have the same presence. You can certainly look on an x-ray to evaluate this too, but as you know on a true lateral x-ray, the metatarsals tend to be superimposed. And in fact, if you can see a metatarsal head dorsal to the other metatarsal heads on a true lateral x-ray, you're probably dealing with enough displacement that surgery should be considered to align it. The big thing about these forefoot injuries is managing the soft tissues after the accident. There's a lot of reactive swelling. And they are going to stay swollen for a while. If they keep the foot down, they're trying to go back to their daily activities and kind of hobble along, that dependent adema will be more painful than the fracture itself if it's well immobilized in a sandal or a cam boot. And I counsel the patients that long after the fracture has healed-- for three to six months afterwards-- especially on border toes, the fourth and fifth toe and the great toe if there's a fracture there, the toe looks like a sausage for quite a while. Difficult for shoe wear, rubs in the shoe at the end of the day's activities. Just counsel them that it's going to take some time before the swelling goes down enough that they're comfortable in all their regular shoe wear. There's an example of a metatarsal stress fracture, and these are different than your acute injuries. You need to start to think of some metabolic causes, biomechanical problems that may be associated with why someone has a stress fracture. And the best way I would tell you to identify a stress fracture from an acute fracture is that the x-ray shows both signs of an injury and an attempt at healing. And maybe even multiple attempts at healing. Like that slide to our left here, you can see how the bone is rather bulbous there. And there's healing, and then there's still lucency within it. This person has broken their metatarsal several times and had several episodes of healing, and now they're presenting for yet their fourth or fifth time around with a metatarsal stress fracture. So that's a good key for you to help distinguish acute from stress. Moving on to fifth metatarsal fractures. I've got them aligned here as the good, the bad, and the ugly. And then we'll briefly talk about dancers fractures. So Pseudo-Jones fractures. They're the good fractures. They heal pretty readily. They are the two voracity fractures or the styloid process of the base of the fifth metatarsal. These fracture due to an avulsion mechanism, so either the lateral band of the plantar fascia or the attachment of the peroneus brevis tendon causes the fracture to avulse off the cancellous bed adjacent to the fifth tarsal metatarsal joint. Is they said, these heal very readily. And again, for comfort putting them in a cam boot sometimes for a short period of time. I splint people and keep them non weight bearing. But since these fractures heal so readily, you can let them weight bear when they tolerate it. And again, the 10 to 14 day rule usually holds fast for these type of fractures. There's a close-up of the fracture that you can see there. You can see the transverse fracture line. And a good way to remember that these are the Pseudo-Jones fractures-- the good fractures-- is as the fracture line travels medially, it remains very close or goes into the fifth tarsal metatarsal joint. So fractures that go into the joint, because of the quality of bone healing and the blood supply, they're the good ones. These get into the not-so-good ones when we have the Jones fractures. These are notorious for not healing. The reported incidence of non-union of a Jones fracture in the literature is about 10% to 12%. These are at the junction of the tuberosity and the shaft. Mechanically, they act differently. They see more stress at that location in the bone. But also, there's a watershed area here, the blood supply coming in from the tuberosity and the nutrient artery more proximally in a shaft with its retrograde flow towards the fifth TMT joint creates an area of rarefied blood supply. So increased mechanical stress, decreased blood supply leads to the risk of a nonunion, as I said, about 10% of the times. Athletes are very high demand people, may be indicated early on for operative management to put intramedullary fixation to stabilize their fracture in an attempt to get them back on the field in a sooner space of time. Again, I touched on stress fractures. And you can see here again that appearance of it's been broken and it's been trying to heal. When you see these stress fractures on the lateral border the foot, I just want you to keep in the back of your mind that this is usually someone that has a cavus foot. And I would describe a cavus foot simply to you as someone that's very high arched and they're leaning on the outside border of their foot. So that fifth metatarsal is constantly getting a bending force that's slightly out of plane. Not straight dorsiflexion, but usually dorsiflexion with [INAUDIBLE]. So they're bending the fifth metatarsal towards the fourth metatarsal and that causes these fractures. Usually slightly distal to the Jones fractures, just in the start of the shaft. And again, these are notorious for refracturing many times over and not responding to operative management until you address the cavus foot. Dancers fractures. There's been some controversy. There's been papers calling dancers fractures occurring proximally. They've also been described distally. For my way of remembering it, I refer to these dancers fractures as distal oblique fractures, adjacent to the fifth metatarsal head extending proximally. The thing to remember about these fractures, they look bad but they heal well. You look at that fracture that I have there-- I'm sorry that the picture's a little bit dark-- but if you look, you can see there's displacement here. But it's mostly rotation. So the distal fragment is rotating. So when you get an AP view, you pick up the rotation. But if you look closely on a lateral and get oblique views, you can see that it's mostly rotation. The shaft is lined up. These will heal in a cast. They can also be treated in a cam boot. Your rule of thumb here is weight bearing is tolerated. But I'd also tell you to remember about these fractures is they will clinically be healed before you really see robust radiographic healing. Usually at a month to six weeks, your patient's very comfortable. They don't have [INAUDIBLE] patient at the fracture site. And you look at the x-ray and there's relatively a paucity of callous formation. But where you should look is proximally and distally. So look proximal medial on the shaft, and then laterally distally you'll see that little fluff of callous there. And that's usually a good sign that you're on the right track. It may take three to four more months before you really see robust callous that the lucency at the fracture line truly dissolves. Moving on to the midfoot. So these are more severe injuries of the tarsal metatarsal joint. We'll talk about Lisfranc injuries and some fractures in the midfoot. I'd like you to remember this slide here. I put this up because if you notice, there's a large bruise in the arch of the foot. As a rule of thumb, if you see someone three to five days, or a week or more out from a foot injury or a foot sprain, and you take off their cam boot or the splinter-- whatever they were put in-- and you see a pretty sizable plantar ecchymosis like this, this is a foot dislocation. This is an injury probably to the tarsal metatarsal joint and the midfoot bones. This happened by relatively high energy, so even though the x-rays may look benign, be very suspicious that there's something more significant going on for this patient. Here's a cartoon of the Lisfranc's tarsal metatarsal joint complex. And you can see that it is formed by the tarsal metatarsal joint articulations 1-2-3-4, and 5. There's also the intertarsal ligaments as well between the lesser metatarsals. But in the bottom of the cartoon, there you can see that it is a true arch. So as long as you have the longitudinal arch that you can see on the medial side of the foot, you have the transverse arch of the foot which is very important for function and alignment. And that's why we are very vigilant about fixing these if there's any displacement with a foot dislocation. Here's two x-rays that show you the variation and the severity of the problem. I don't think you can miss the injury on the slide here on the left, the picture on the left. You can see the first metatarsal is about 50% dislocated, and you can see how the second metatarsal has vacated its articulation with the middle cuneiform. What might be a little more subtle is the x-ray to the right where the circle's a little bit smaller. There's a little more subtle separation between the first and second, and that the second metatarsal does not line up with its respective cuneiform. Both of these are significant injuries. Both of these require a consideration for operative management. I would say, most of the time they are treated operatively. But you can appreciate the difference in picking this up. There's a side view. And here in this case you can actually see the dorsal displacement. So this Lisfranc injury occurred by the foot sort of being folded in half. So they were bending the foot. And you can see the dorsal displacement there that goes along with the two x-rays I showed the slide before. Cuboid fractures and navicular fractures. Well let me begin with Cuboid fractures. Usually the most common type of Cuboid fracture is an avulsion fracture. There's some sort of ankle sprain type mechanism. The patient is planter flexing and inverting their foot, and they tend to avulse off a small corner off of the cuboid. And you can see that a little bit there at the corner of the calcaneocuboid joint. The other mechanism which is much more severe is called a Nutcracker fracture. That's when the cuboid gets crushed together. So you can imagine, if the lateral side of the foot is getting crushed down, that means there's a tensile or distraction force on the medial side of the foot. So if you see someone that looks like the have an accordioned cuboid and they're very tender laterally, don't you be distracted that there's a problem probably on the medial side as well that needs to be dealt with. So Nutcracker fractures are bad. There's an injury on the other side of the foot to cause the cuboid to crush down. Navicular fractures are notorious as well. They too have the same issue that we talked about with fifth metatarsal fractures. There's a watershed area. There's blood supply that comes into the lateral aspect of the navicular and blood supply that comes medially. And in the lateral 2/3 of the navicular, there's that watershed area. It also can be an area of a high stress with certain foot maneuvers. So as you can see on that x-ray there, there's a small linear crack in the navicular and the junction of the middle and lateral thirds of the bone. There can also be stress fractures. And these are more insidious when someone has a navicular stress fracture. They will usually give you a prodrome of pain or ache in the middle of the foot. And if you palpate on a navicular, you can identify any area of point tenderness. These can also be very hard to pick up on an x-ray because of the oblique plane of the fracture. Sometimes it's almost serendipitous that you get a nice x-ray like this where you can see the fracture line. You might just even see sclerosis in the bone if it's a stress-type injury. These are fractures-- if you're suspicious about midfoot pain that no one's put a finger on quite yet, you probably need to get a CAT scan to look for an injury in this bone. Moving back further into the foot, we'll talk about hindfoot fractures and injuries here, fractures of the calcaneus and fractures of the talus. Calcaneal fractures can essentially been divided into two main categories, those that are intra articular-- and the joint we're talking about is the subtalar joint. You can have joint depression type or tongue type fractures here, versus those that are extra articular. Usually exra articular fractures are more benign or a less serious calcaneal fractures. It's the intra articular ones that are more problematic for management and usually need surgery. Joint depression fractures. So the joint gets depressed because you land on it. Either it's a fall from a height, it could be a motor vehicle accident, it could be an industrial injury. But essentially, the force is applied to the plantar aspect of the foot. An axial load drives the talus-- which we'll talk about in a minute. The talus is a very dense, hard bone. It's like a brick, and you're shoving the calcaneus up against that. And it actually creates a die punch type fracture into the subtalar joint, pushing the calcaneal bone down into its own body. And I put this x-ray up to show you that if you're not used to looking at calcaneal fractures, generally when you look at this lateral the calcaneus looks OK. There's no obvious displacement. The contours of the lateral profile of the calcaneus look OK. If you look in the middle of the body, you might be able to see that there's some disruption in there. There's little bone fragments. There's the patient's CAT scan. You can see they have this typically displaced fracture, so the joint is disrupted. So again, plain x-rays may not always be indicative of the severity of the injury. Be suspicious by the mechanism by which it occurred. Tongue-type fractures. Essentially you can think of tongue-type fractures as the Achilles tendon pulling a piece of the calcaneal tuberosity with the subtalar joint attached to it. So again, they are sort of like avulsion fractures that extend into the joint. The thing I want to make you aware of here is, as you can see on this x-ray, as the fracture has been pulled proximally, it's also been pulled posteriorly by the pull of the Achilles tendon. And look at the skin there where they have the arrow come up. You can see how the skin is being tented internally. I don't have a clinical picture to show you, but usually what you'll find in a patient like this is you look directly at the back of the heel and they've got this sort of cherry red spot. Maybe not so bright red, but sort of violet to darker red type spot there. And you'll think, I think this fracture needs surgery, but the skin's not in such good shape. So there's no rush to send it to the surgeon. He's got to wait for the skin to heal anyway. And I would tell you the exact opposite is true. I usually want to get to these fractures early on and stop that internal pressure that can lead to skin breakdown, exposure of the calcaneal bone, and the Achilles tendon. And then we have a real problem of osteomyelitis and an infected Achilles. So these are relatively urgent problems when you see a silhouette like this showing the calcaneal bone tenting the skin. Anterior process fractures. So these are those extra articular fractures I just spoke of a minute ago. These can happen from inversion injuries. So these are the same mechanisms that cause ankle sprains. In fact, an anterior process of the calcaneus fracture is kind of high on the list of suspects for an ankle sprain that does not get better. If you palpate by the fibula and literally move your finger or slightly rotate it more distally, you'll be palpating the anterior process of the calcaneus. So a lot of times, people think that they still are tender over their anterior [INAUDIBLE] ligament rupture, and it's really that you're pressing on their anterior process of calcaneus fracture that has been yet to be appreciated. And you can see right there the little avulsion of that piece. So I'm not quite sure if I'm using the laser pointer correctly here. The upper button? There we go, I'm sorry. Thank you, Sherman. So if you look right there, there's the anterior process. It's displaced from its bed here. There's soft tissue attachments that tend to avulse that off. So sometimes you see this anterior process fracture. And I talked to you before about cuboid fractures. They tend to happen here. So again, there's usually a delay in diagnosis. But you want to be suspicious based on examining your topographical anatomy. Be sure you know where you're pressing. You may identify a fracture instead of a chronic ankle sprain. There's a close-up. Talus fractures. These too can be divided into higher energy injuries and a lower energy injuries. The high energy injuries involve the neck and the dome. And then we'll talk about lower energy injuries as avulsion fractures around the edges of the talus that usually involved the subtalar joint. So talar neck fractures. These are bad actors. These again occur from motor vehicle accidents, falls from a height, industrial injury. So there's a fracture through the neck of the talus in the x-ray right here. These can have problems with blood supply to the talus. The blood supply to the talar body gets disrupted. So not only do you have a fracture and displacement of that fracture, and a sub-- I'm sorry, I keep hitting the wrong button here-- and a subtalar joint injury. If you look here, the subtalar joint is dislocated. So it's a fracture dislocation, a Hawkins type two injury. But the long term is, if you get this all lined up and get the fracture fixed well, you still run into the possible catastrophe of them getting avascular necrosis of the talar body. And that's bad because it affects both the function of the ankle joint and the subtalar joint, causing arthritis in both of those locations. Here's a real smash here. This is unfortunately someone that fell from quite a height and essentially pulverized their calcaneal dome. This needs prompt surgery. There's usually tenting of the skin, as there's a lot of displacement of the foot relative to the ankle. And again, the same things apply here. Because of the disruption to the very specific blood supply to the talar body, these people usually go on to a very high incidence, approaching 100%, of getting avascular necrosis of the talar body with arthritis of the subtalar joint and the ankle joint. There's a lateral there. And you can appreciate how it's crushed down. And it may be subtle to see, but the hindfoot tends to tip into varus because of the way the bone breaks, and the position and the pull of the soft tissues. So this could be someone that shows up in the emergency room unable to bear weight, very swollen foot. But when you look at it, it reminds you a bit of a club foot. The arch is rotated in towards the side, there's a little bit of planter flexion, and the heel's tipped in. These need to be reduced and stabilized just to try to help line up the fracture fragments, rest the soft tissues. And in very urgent cases, if you're unable to reduce it and the joint is very dislocated, you may take them urgently to surgery to manage this problem. And there's the bad problem. There's an example of a white talus. White Christmas is a great thing. White talus, not so great. This is a bad problem, because there's no way really to revascularizae the talus. That is a very specific blood supply. And once you lose it, what you watch for is not because this is painful to the patient. Dead bone doesn't necessarily hurt. But because of repetitive use of the bone, the microfracturing of the trabeculi within the talar dome, you tend to watch the talar body flatten like a pancake. So now you have deformity as well as arthritis in the ankle and subtalar joint. And this can be hard to remedy. It usually requires a complex hindfoot reconstruction with fusion of the ankle joint and the subtalar joint with large bone graft. Now moving on to one of the more pedestrian talar injuries, as I talked about there's the lateral process. You can feel this if you feel the tip of your fibula. At the very tip of the fibula, move your finger about a finger breadth anteriorly. You'll be pressing on the lateral process of the talas. And this is another suspect in the list of ankle sprains that did not get better. People can avulse off this small corner bone, be quite painful, quite problematic, and again delay in diagnosis that has some consequences for long term function. Then there is the posterior process. So this is the posterior process of the talas. There's really a posterolateral and a posteriomedial tubercle between which the flexor hallucis longus tendon runs. When you have a large enough fracture here that breaks the back 25% or 30% of the talas off, that is often associated with a dislocation or subluxation of the subtalar joint. And my CT scan picture there to the right shows you how the heel is tipped in there. So they heel is tipped towards the midline as this talar body fracture where the piece has been extruded out the back of the ankle, causes the subtalar joint to sublux into this varus position. So they tend to show up with a foot that kind of reminds you of a club foot. Moving on to some of the common conditions or diseases that involve the foot, I'll present these series of topics by talking about clinical presentation, talking about the primary pathology or the root cause of the problem, but some of the secondary manifestations, because often that's what the patients come in for. And you've got to work your way back into the primary pathology to be very effective in treating these conditions to give them good initial treatment and long term care. So hallux valgus. Patients come in complaining that they have an ugly bunion on the medial aspect of their foot. It rubs in the shoes, gets red, hot, and swollen. It can be very problematic and very uncomfortable for them. You may also appreciate that with patients that have a severe hallux valgus deformity, there's also that hammer toe there. And they're kind of giving you the crossing their toes sign right there, because this joint is starting to flex up or extend up so much. And it's overlapping the hallux valgus. So it's giving it space for the hallux valgus to deform even more so. And you can see here, it's touching her third toe. But this toe is actually dislocated, so it's really an extreme form of a hammer toe deformity. If you also look closely at these people with hallux valgus deformities, you may appreciate that there's relative flattening of their arch. And I would like to explain to you that the primary pathology here is not so much the medial eminence. It's not that there's an enlarged medial eminence. There is reactive bone that forms there. But what tends to happen is back here at the tarsal metatarsal joint-- remember, I talked about that with the Lisfrancs injuries-- that those joints are very important for maintaining not only the longitudinal but the transverse arch of the foot. If you have instability here with elevation of the first metatarsal, it tends to contribute to the deformity you see more distally. The hallux valgus, the painful bunion. If the bone is mobile in the dorsal plantar plane, if the first metatarsal is elevated-- like we talked about metatarsal neck fractures being elevated takes the weight off of that respective bone-- well, if you have elevation or dorsiflexion of the first metatarsal, it tends to cause the weight to transfer to the second metatarsal, leading to the hammer toe problem. So here's a busy slide, but what I'm trying to point out here in the slide to the left-- I keep doing that. I apologize for that. You can see, I'm measuring the inner metatarsal angle here, which is widened. But what I also want to show you on this lateral view when you look closely is the talas and the first metatarsal should line up. And you can see here, there's a relative dorsiflexion of the forefoot relative to the hindfoot. And I've blown up the picture here to show you that there's actual dorsal translation of this first metatarsal. So it elevates up and tends to increase the inner metatarsal angle. And the more that these bones separate or widen and the toe drifts towards the second and third toe, it makes the bunion stand out more here. So again, it's not so much that there's extra bone there, there is. But it's more the angulation of the toe, the widening of the metatarsals being contributed to by the elevation back here at the tarsal metatarsal joint that people get severe bunions. And here's a test of hypermobility. My fingers are on the second metatarsal head and the hand that you can see is on the first metatarsal head. You can see the hammer toe that this lady has. Then when I apply a force with my thumb, pushing up on the first metatarsal, so you can see how I can elevate it above the level of the second and third metatarsal. And if you look more closely, you can appreciate how the bunion seems to be more prominent. Because again, not only is the metatarsal elevating up, or dorsiflexing, it's also coming out of the picture I'm showing you toward us, making it more prominent. So it's a biplanar type motion that's contributed to hallus valgus deformity. So what do people usually notice? My toe looks rotated. Well, if I'm having pain also on the medial side of my foot, I may roll up and try to walk on the lateral side of my foot. So the patient may also complain of fifth toe pain. Also, as the foot gets wider, as this bunion gets bigger, it tends to rub over here in the shoe on the fifth toe, because people tend to wear shoes that are at least a size smaller for the width of their foot than they should be. I also showed you before how the arch sags. And there's other associated problems such as calf tightness and the hammer toes that we talked about. How would I like to recommend treating these patients? Well after that discussion of what seems to be the problem, that's why I recommend using an orthotic to help support the medial longitudinal arch. Try to counteract that hypermobility. Do physical therapy to work on the muscles that strengthen control of the arch and help prevent that hypermobile [INAUDIBLE] from contributing to a second hammer toe. And then lastly, always wear shoes that fit your foot. And I know that this can be a battle, because you're not going to get someone that's wearing this to ever wear something like this. So it's always incremental change and trying to get people to see the point that you're making. And you've got to wear what's comfortable. I know there's certainly professional attire, not everything works for every occasion. But generally, make people understand that the shape of your foot is very important in the comfort of your shoe. And they have to match. Hammer toes. Talked about them just on the slides before. Essentially, think of them as curly toes. So there's flexion at the IP joint, and there's extension at the MTP joint. So the toe's kind of cocked up there. These people complain of a painful callous on the plantar aspect of the foot. They may tell you that oftentimes after being on their feet throughout the day, they feel like there's a bunched up sock or a pebble right at the base of the second and third toe. There isn't and the sock's not bunched up. What that is is inflammation of the planter plate, one of the stabilizers of the undersurface of the MTP joint. So that's getting thick and swollen. And that's actually what they're feeling. They also may tell you that they have this horrible callous on the IP joint on the top of the toe, because it rubs against the top of the shoe. There's the callous there and there. So again, what causes these-- or what causes them to be painful, as we said before-- if the first ray is not caring its share of the weight, you tend to overload the second and third. So there's this sort of overload capsulitis. The plantar aspect of the joint gets swollen, gets inflamed, causes that bunched up sock feeling, and contributes to the deformity of the toe. There can also be other causes for hammer toe deformities, especially when you see really tight hammer toes on both feet. Think that you might be dealing with someone with a neuromuscular problem? It can also be associated with certain types of diagnosis attributable to pes cavus, or a club foot. Also, they can be traumatic or acquired. Like if someone told you, I was in a motor vehicle accident, and I had a bad tibia fracture, and something happened to my ankle. And then three to six months after the surgery, I started noticing my toes curling up. They may have had a compartment syndrome causing contracture in the muscles in their calf, both the flexors and extensors. And now you're seeing the [INAUDIBLE] of that with really tight claw toes. So here's the tendon imbalance I was alluding to before. When you look here, there's the planter plate. So the picture to the right shows you the planter plate. This is what gets inflamed. And when it gets inflamed, it gets attenuated. When it gets attenuated, it allows the proximal phalanx to rotate into dorsiflexion. And in severe cases, if this ruptures then the toe can start to dislocate. So you can see the proximal phalanx dislocate on top of the metatarsal. Now, how do you counteract that? Well the natural state is that your extensor tendons on the dorsum help stabilize the MTP joint, and your flexors work on the toes themselves. These are the intrinsic muscles in the foot. And if you notice, those arrows are skinnier compared to the EDL and the flexors. So what happens is an imbalance-- happens because of the EDL and the flexors having more pull than the intrinsics. And the intrinsics can't make up for this stretching of the plantar plate. And then you see the hammer toe deformity develop. So it's a combination of stretching the joint and imbalance of the tendon pull that control the joints of the toe. There's an example. If you notice, as that toe starts to curl up like that, it tends to pull the fat pad out from under the metatarsal head. So people call that fat pad migration. So your panning under the metatarsal head tends to be attenuated. That hurts. Also, as the deformity worsens and the toe sort of drives into this position-- and this is technically called a claw toe, but I put this cartoon in to show, now the proximal [INAUDIBLE] is acting like a plunger pushing the metatarsal head down through the bottom of the foot. So there's more pressure. And as we said before, I've been talking to you before about, if you elevate the metatarsal you take weight off of it. Well, if you depress it or push it down, you're putting more weight on it. And the fat pad being pulled out from underneath, this is why people get painful calluses on the balls of their feet. How do you manage this? We need to take the weight of the area that hurts. This shows you a variety of metatarsal pads. It's a little bit of a misnomer. I mean, they're metatarsal pads, but you want to pad the shaft, not the metatarsal heads. You're trying to float the metatarsal head to take the pressure off of the metatarsal head and the MTP joint. So these pads go proximal to where the calluses are on the bottom of the foot. Again, appropriate show wear is always important. And doing physical therapy to try to strengthen those intrinsic muscles. And the simple take home message I want to give you about how you strengthen your intrinsic muscles is essentially scrunching your toes. So that's the old picking up marbles with the toes, scrunching a towel that is on the floor. That's how you strengthen those intrinsic muscles to counteract the over pull of the long extensor and the long flexor. Moving on to posterior tibial tendinitis and the associated deformity with it called flat foot or pes planal valgus. So these are folks that come in-- and the summertime is sort of the ramp-up time when I see a lot of seasonal posterior tibial tendinitis. People come in saying, I was on a trip out of the country. I was in Europe walking on the cobblestone paths of Europe, and I started having ankle sprain pain. But I didn't fall. I didn't twist it. Didn't have an accident. But just walking day after day on our walking tour feels like I sprained my ankle. And what they actually end up doing, because of the uneven surface of the cobblestones making them use their posterior tibial tendon a lot, they start to have mechanical elongation an inflammation, and they notice a loss of their arch. In very severe cases, when the arch flattens people feel like they're falling out of their shoes on the inside. And this picture here to the left shows that. There's the person standing on the ground there. And you can sort of see some hindfoot valgus. And we'll talk about the too toes sign. But if you look at the picture underneath, you'll notice there's a loss of the arch there. The midfoot's getting wider. They're losing the natural contour of the arch, and that's why I say it feels like they're falling out of their shoes on the medial side. There's the flat foot deformity. The foot should be a triangle on a lateral view with the calcaneus pointing up and the metatarsals pointing down. You can see here almost inverting that. It's almost getting to be what we'd refer to as a rocker bottom. The middle of the foot is lower than the front and the back of the foot. Here's the test for posterior tibial tendon function called the single heel rise test. You can have them stand on their two toes and go up and do this, but this is a little more effective. So what will happen, as they rise up on the tiptoe, think of the heel tipping into [INAUDIBLE]. So it will be slanted this way. That means the posterior tibial tendon is working. If it doesn't slant that way, then there's some attenuation or dysfunction of the posterior tibial tendon. Too many toes sign. Well as I showed you on that slide before, and I'll show you again here, as the heel drifts out into valgus, the midfoot and forefoot tends to abduct. So when you look at somebody from behind, you see too many of their toes. I can see three of this gentleman's metatarsal shaft and respective toes, whereas on his other side where his foot's a bit straighter, I can only see really the fifth and maybe part of the fourth. So that is a way to identify the pes planal valgus deformity of abduction of the midfoot. I see too many toes when I look at them from behind. So as I said before, this becomes a problem of attrition or dysfunction of the posterior tibial tendon. It can be inflammation, elongation, swelling, and in extreme cases, it could be actually frank rupture. But if the tendon doesn't work, it doesn't lock the arch of the foot. And if you can't lock the arch of the foot, it tends to flatten out in that rocker bottom deformity that I showed you in the x-ray before. So this dynamic insufficiency of the posterior tibial tendon not locking the arch of the foot starts to cause everything else on the undersurface of the foot to stretch out. So again, the static structures are failing as well as the dynamic structures, and the foot's getting flatter and flatter over time with pain. Here's a way to show you that in an x-ray. I mentioned before about the abduction, or the too many toes sign. Well here it is demonstrated radiographically. There's the talar head, there's the navicular, the posterior tibial tendon attaches here. So if it can't pull the navicular over the head of the talas, you get this uncoverage. But you can also imagine that if the midfoot's going laterally like this, when I look at them from behind I'll see a lot of their lateral metatarsals. So that's uncovering of the talar navicular joint that you can appreciate on an x-ray. What are some of the secondary manifestations? Well, if the tendon doesn't work, the foot gets flat. As the foot tends to get flatter, there's also an associated development of an Achilles tendon contracture. It gets tighter. So if your Achilles tendon is very tight, you're again putting a lot of bending force in the medial longitudinal arch of the foot, flattening it further. Those are the first two and three stages of posterior tibial tendon dysfunction. One is tendinitis, two is a flexible flat foot, three is the flat foot gets rigid. And then when the ankle tips out of the mortise-- meaning that the ankle starts to tip into valgus along with the hindfoot-- that's stage four. And then you will see arthritis in the joint. And in severe cases, because there's so much valgus tilting of the ankle joint, sometimes patients come in with these non-traumatic fractures about two inches, three inches above the level of the ankle joint. That is the talas pushing and bending on the fibula, creating a bending force here that leads to this stress appearing type fracture of the fibula. If you see someone with this, you're probably looking at someone with a very flat foot. How do we treat this? Rest and immobilize it. Put them in a cast, put them in a cam boot, whatever they're willing to tolerate. And for the sake of comfort, we'll rest the posterior tibial tendon to try to stop the inflammation and the elongation of the tendon. Once you cool it off, then you want to build it back up. So they're going to be doing physical therapy to strengthen the posterior tibial tendon function. They'll also be working on their intrinsic muscles and some of the other secondary stabilizers of the arch to help dynamically support the arch so they're not stretching the static structures and the ligaments on the undersurface of the foot. I know there's been some literature that's says orthotics don't work. And I would tell you that if you don't give them the correct orthotics that help support the medial and longitudinal arch, you're doomed for the orthotic to really not be very helpful. So I'd tell you that there's a very detailed way to be writing these physical therapy prescriptions and these orthotic prescriptions to make them valuable to try to help the patient with their posterior tibial tendon dysfunction. There's an example of putting someone in an Arizona brace. So if they can't get out of the cam boot-- and they obviously can't wear the cam boot for the rest of their life-- now we're statically stabilizing the foot with a short ankle brace that extends down into the arch. The opposite of a flat foot is a cavus foot. And I alluded to that before. And you can see here that this is someone walking on the lateral border of their foot. A lot of overload on the lateral border of the foot. They'll tend to have callusing under the metatarsal heads and especially on the lateral border of the foot. They may give you a history that they have weak ankles. They roll their ankles as a kid, it doesn't take much for them to roll their ankle now. They don't go up and down inclines very much. They avoid walking across the lawn, because it tends to aggravate their ankle and the foot. So there's many causes of this too. I go back to neuromuscular type problems that lead to imbalance in the tendon pull. And there can also be, as a result of fractures of the calcaneus or the talas, as I talked about before in the position of the subtalar joint, they give someone a cavus foot or a club-foot-like deformity. So what happens here? Well, as that foot gets into this deformed position and there's over pull of particular muscles, it tends to restrict ankle joint and foot joint range of motion. So you may see these people have very stiff midfoot and forefoot. You can't really flexibly correct their foot very well. And because of the rigidity of the joints and the lateral overload on the border of the foot, you'll tend to see those stress fractures in the fourth and fifth metatarsal. Just like the flat foot can have the ankle tilt into valgus, the cavus foot tends to tip into varus. So here's an example of that, where this is someone with a cavus foot that's been longstanding. There's disruption and attenuation of the lateral ankle ligaments. And you can see, the talas is tipped within the ankle joint. And in severe cases, they start to have pain at the medial malleolus, because there's literally impingement of the talas against the medial malleolus. And if this condition can last long enough, the eccentric loading of the joint tends to lead to an arthritic change here. So now you have someone that has a cavus foot underneath a rigid and stiff arthritic ankle joint. And this is very problematic to fix. And suffice to say, usually you need to straighten out the foot, as well as dealing with the ankle arthritis, to get them a lasting result. Again, orthotics and bracing. If the deformity is still flexible, you should try to reposition it. And this is just demonstrating in the slide that I showed you before, when I compensate for some of the primary deformities of a cavus foot where the first ray is plantar flexed-- so if the first ray is plantar flexed, it tends to tip people up on the lateral border of the foot. By standing on this block, I'm subtracting out the effect of the first metatarcal, and you can see how that hindfoot got straighter compared to the slide I showed you before. So orthotics that help correct the alignment of the foot, working on muscle strengthening exercises such as strengthening the paraneus brevis will help balance the foot. And again, proper shoes that these orthotics can fit in go a long way to making the patient comfortable and functional. Moving to the back of the foot, posterior heel pain or Hegglin syndrome. So this is that pump bump the usually on the posterolateral corner of the calcaneus. It can be very swollen. It can get red, much like the medial [INAUDIBLE] of someone with a severe symptomatic hallux valgus. They also will tell you that they feel stiffness along their Achilles tendon in their heel, and this rubs in their shoe. These are classically the people that show up with backless shoes, or flip-flops, or clogs because they don't want the counter of the shoe rubbing on that pump bump where my finger is pointing. What's another thing you might see on the x-ray? Well, what causes this? We believe there's an associated problem with tightness of the Achilles tendon. So increased pull of the Achilles tendon on the bone tends to cause these traction spurs. And you can see a very significant example of it there as I point to the back of the calcaneus. There's just this large icicle, so to speak, of bone. And that's within the Achilles tendon. That's because of traction of the Achilles tendon on its insertion. There's also been degeneration of the Achilles tendon in its distal aspect. That tendon is being replaced by bone and other stiff scar tissue. So that's why the patient also reports stiffness or tightness in the back of their ankle. To get a spur like this takes probably a decade or more to develop. So this is someone that's been dealing with a tight Achilles for quite a long period of time to get to this significant problem. As I alluded to in the last slide, so it's not only the spur, it's not only the bony prominence, is also insertional Achilles tendinitis. And with that you can also have retro calcaneal bursitis. So on the cartoon right here I'm pointing to the bursa of the Achilles tendon. So this can get quite inflamed between the Achilles tendon and the calcaneal tuberosity. This is best appreciated on examination by pinching just in front of the Achilles tendon at the level of the calcaneus. You can elicit some very exquisite tenderness with palpation if you have a very inflamed retro calcaneal bursa here. Along with-- as we talked about before-- the Hegglins deformity, that bone on the posterolateral corner of the calcaneus. So what do we want to do here? We want to reduce the inflammation, oral anti-inflammatories, local modalities often help. Efficacy, there's been some question in the literature of local or topical steroids. But essentially anti-inflammatories and immobilization. Put it at rest first. Quiet down the inflammation. Take away the traction force, and then mobilize them with physical therapy. What we're trying to do in physical therapy is stretch the Achilles tendon elsewhere to decrease the pull at its insertion point onto the clacaneus. In mild cases where the patient may not want to go into a cam boot for a period of time or it's just not symptomatic enough to warrant that, sometimes just putting a heel lift or a pad counter in the shoe. So if I lift up the heel, I'm putting slack in the Achilles tendon. Less pull onto the bone, less pain, less inflammation. Also tends to open up the space where the bursa is. So a heel lift can be very comfort producing for a patient. But beware, you start lifting the heel up, you may over time develop a tighter and tighter Achilles tendon. And then before you know it, the patient tells you that they need to wear those stiletto heels I showed you in a couple slides ago just to keep having enough slack in their Achilles tendon so it doesn't hurt. So you can do that, but you've got to work on the primary issue here, stretching the Achilles to get it more flexible and stop the traction phenomenon at its insertion. Planter faciitis. This is ubiquitous. I mean, you've certainly all may have personally experienced it. You've probably seen plenty of patients with it, and you probably know the classic story. But to review it briefly here, this is a 24-day cycle of pain, as I like to explain it. And we'll go through the reasons why each part of the day has a certain problem associated with it. In the morning, they get out of bed. It feels like there's a red hot poker poking them in the planter aspect of the foot. That's that morning pain. Sometimes that pain gets reproduced when they've been sitting after a while and they've been watching TV, or reading the paper, or sitting at their office desk and it's time to get up for lunch. And they can get that sharp start up pain happening after being seated for a while. What tends to happen is they get into the afternoon part of the day. They feel like an ache or a throb in their foot. They want to take their shoe off, and they want to massage their foot and just knead those muscles in the arch of the foot because they're so uncomfortable. This can also happen within activity change. I see a lot of people seasonally who've been riding the train or using the car in the winter months because of the bad weather. And then when spring and summer hits-- which is usually around what, July 15 we have summer here? But when the weather changes, now everyone wants to get out and walk, the activity change tends to be associated with some planter fascial symptoms. And I've circled there in the cartoon right at the origin of the planter fascia, which is the plantar medial aspect of the foot. Pointing to your right there in a clinical exam, my index finger is pointing to the mid-substance of the planter fascia, and the black circle is at the origin. So usually people have tenderness and palpation at the black dot. But in some variation, they have mid-substance plantar fascial pain where my index finger is pointing. So how do I explain this to you? Well, I think the root of the problem here is there's increased arch strength. So there's tension being placed on the arch and being placed on the plantar fascia as the arch is flattening. This increased planter fasial strain can be very painful, and it works its way out throughout the day's activities. It can also be caused by fat pad atrophy, and I usually see that in rheumatologic or other systemic problems. That's when someone has diffused heel pain, not the pain that I showed you where the black circles are. So here's a cartoon to try to demonstrate that. We'll call that a normal arch. So there's a little triangle I'm putting here. Imagine this is the calcaneus and these are all the bones of the forefoot and the metatarsal. Now we'll add in the plantar fascia. That kind of completes the triangle. So the plantar aspect of the triangle is the plantar fascia. And it's the two bony struts of the calcaneus and the forefoot. Now I'll flatten the arch. And this is a schematic, but you get the idea here. Well, all of a sudden as the arch flattens, there's more divergence between the hindfoot and the forefoot. Well, my plantar fascia needs to get longer. So now there's more tension on the plantar fascia. And where does that tension manifest itself? Back here where it's attached to the calcaneus. So that's why people tend to hurt in that plantar medial aspect. So now the plantar fascia needs to get longer, and it can't necessarily do that so easy. So the arch starts to sag, you get a little bit of a pes planovagus deformity. And associated with that, there's usually an Achilles tendon contracture. So how do we attack this problem? Well, you need to reduce the inflammation. If the problem is that the arch tends to be flattening during the course of the day, we need to consider ways to support the arch. That usually is orthotics. And you want to put an arch support, a navicular pad, and sometimes and even bigger pad call a Morton's Extension to help prop up the medial longitudinal arch so it doesn't sag through the day's activities. Physical therapy will be directed to strengthening the muscles that support the arch of the foot. So here comes the 24-hour cycle part of this. At night you get off your feet. There's no tensile force being applied to your plantar fascia. It tends to contract. It's been inflamed, you get off the feet, it tends to tighten up, and that's why that first step in the morning is murder, because you have this very contracted planter fascia pulling on the insertion of the calcaneus. So now you want to break that nighttime cycle of letting the plantar fascia get contracted. So you sleep in a night splint that helps hold up the foot. So you can't have that plantar flexion of the arch that relaxes the planter fashia so it can tighten. So it's orthotics by day, night splints at night, physical therapy, and the judicious use of anti-inflammatories for the initial pain relief. Avoid steroid injections. They're associated with an incidence of rupturing the planter fascia, and there's no going back once the planter fascia is ruptured. That can be a very problematic consequence of injections. Pareneal tendinitis. This is at the posterolateral corner of the fibula. And this is a dramatic example here of someone actively everting their foot. And you can see how they're bow stringing their paraneal tendons. This is most likely the paraneus brevits that's starting to pop out from behind the corner of the fibula. There's supposed to be a nice strong retinaculum right here. And you can start to appreciate that, how the tendon's bulging here, and then it's not so bold as you get to the tip of the fibula. That's because a retinaculum is keeping the tendon from frankly dislocating from behind the fibula. People report problems with pulling or swelling. They might even feel popping or snapping in the posterolateral corner of their ankle. They think that they're having an ankle sprain that hasn't gotten better, and its paraneal tendinitis. And this can often be associated with ankle sprain symptoms. So it goes together, but it's pain behind the fibula, not pain in front of the fibula where the ligaments are. And also, with severe cases and longstanding cases, you'll notice that when you actually have them do active resisted eversion of the foot, which is what the paraneus brevis does, they will have pain in this location. So this can be a combination of tendon instability or frank subluxation of the paraneal tendons from behind the fibula. What it can also be is that the paraneus longus is abrating into the paraenus brevis. So think of one tendon sawing into the other tendon. So that can also cause flattening and longitudinal attrition of the paraneus brevis tendon, which is the one that's commonly torn. The retinacula can be disrupted. And that can be from an overuse situation, or a traumatic injury where the retinaculum no longer functions as a restraint to keep the paraneal tendons behind the fibula. It can also be a result of posterolateral impingement, due to calcaneus fracture or pes planovalgus. So here's the overuse phenomenon. There's someone with a very varus foot. The orange shows you on the left picture where the paraneus brevis is. So that's working double-time to try to counteract the hindfoot there. So that's why paraneal tendinitis goes with hindfoot varus, often in people with a pes cavus foot. The picture next to it, the x-ray shows you how you can have impingement. So this is somebody who had a calcaneus fracture right here. And there's this displacement of a heel calcaneal fracture. They also had some avulsion injury to their fibula, so they have an icicle hanging down there. Well, this is where the paraneal tendon should be. And there's not a lot of room for them because of the bone of the fibula and the calcaneus. So there's impingement or entrapment of the paraneal tendonds there causing pain. As I said before, what are some of the things to look out for? Beware of hindfoot varus, the pes cavus foot and association with paraneal tendinitis. You can also see it with longstanding ankle instability. The ligaments don't work, so the tendon works overtime to compensate for them. Again, you've seen these slides before. Reduce the inflammation by rest, and immobilization, anti-inflammatories. When that cools off, work on eversion strengthening. And you may need to use an orthotic to counteract those people that have varus hindfoot. You need to put the hindfoot into valgus so the paraneal tendons don't have to work so hard. And then you see my repetition of my mantra, don't inject tendons. Don't inject fascia. But you can have problems with that. It can work wonders in the short term, but if the tendon ruptures, we have another issue to deal with. In my x-ray here, I'm showing is one of these little pathognomonic signs that rarely show up, but I'm showing it to you here. If someone has a traumatic injury and they disrupt their superior pareneal retinaculum, they can also get an avulsion fracture at the corner of their fibula. So there's this little bone that's actually being pulled up from the posterior aspect of the fibula. And you see it there displaced laterally. And in severe cases like this can actually be subluxed between the fracture and the fibula, and sitting there entrapped for a long period of time. And that's something that requires surgery to address this problem. Hallux rigidus, painful stiff big toe. Patient has a dorsal bunion, not necessarily a medial bunion. So the dorsal bunion rubs on the top of their shoe, gets red, gets swollen. And you may also notice that they tell you that in severe cases, with tight fitting shoes, they get numbness in the medial aspect of the big toe. I'm sorry, it gets numb where the digital nerve runs. I think I may just move on ahead there for the sake of time. So cumulative trauma can contribute to this. Increasing joint stresses causes degeneration of the joint and the manifestations of a stiff toe with a bony osteophyte and pain. Reduce inflammation, rest it. High, wide toebox shoes accommodates the problem. Higher toebox shoe keeps the dorsal bunion from rubbing in the top of the shoe. Shoes with a stiff sole and a rocker bottom prevent you from having to bend your toe. The pain usually happens from extreme dorsiflexion and extreme plantar flexion. Well, you don't go into extreme planter flexion with gate very often, but extreme dorsiflexion causes the joint to hinge. So the proximal phalanx bumps against the first metatarsal. So if you wear shoes with a rigid bottom and a rocker on the forefoot, you're going to limit the motion. You're going to limit that impaction on the top half of the joint and help them tremendously with their pain. Here's what you can do surgically for that. Although you can resect that osteophyte, but there's reasons you've got to consider. So here's someone with that large dorsal osteophyte there and on their proximal phalanx. You can imagine if the toes not bending normally and there's this hinging motion, this is slamming against that. And that's how we usually explain this phenomenon of these two dorsal osteophytes. You can do a [INAUDIBLE] and a joint debridement, which is taking off that dorsal osteophyte, resecting in enough so it does not impinge. There's been biomechanical studies that just because you take off the osteophyte doesn't mean that you restore the normal ball and socket rotational motion. There can still be hinging. And in fact, in extreme cases, cadaver studies have shown you take off a lot of this bone-- because a lot of people advocate resecting the [INAUDIBLE] very aggressively. What you have happening is you can see dynamically that the proximal phalanx just hinges into the defect. So you still have abnormal motion, still have trauma to the joint. That can be an underlying problem. That's why in severe cases, where there's end stage arthritis of the MTP joint, you would consider an MTP arthrodesis. Fusion works very well when you position the toe properly. A lot of people have a fear of fusion, because you wonder what's going to be on the other side if I can't bend my big toe. But suffice it to say that MTP arthorodesis has good clinical data the shows long term outcomes that people in some cases and in a few studies have actually returned to modest recreational sports. So you can live with an MTP fusion, and live well, and do the recreational activities that you'd like. Lastly, just a brief word about diabetic foot. You certainly are probably well aware of this. Neuropathic ulcerations form. They lack protective sensation on the undersurface of their foot. That combined with an underlying deformity, which could be as simple as a hammer toe, causes skin breakdown to increase pressure and shear. Once you have the integrity of the skin disrupted, it's not a barrier to infection, and then you have progression from an infected ulcer to an infected deep ulcer involving the tendon. And the deep structures, when it gets down to bone it can lead to osteomyelitis and or septic arthritis if its underlying a joint as well. And then you're dealing with a situation of loss of a part of the foot to deal with the infection. It can be associated with peripheral vascular disease, but not necessarily. You can also just have peripheral neuropathy, that lack of protective sensation, de-innervation of the intrinsic muscles of the foot contributing to tone and forefoot deformities. And as you know, the autonomic nervous system, you get dry, cracked skin, which is a further loss of a barrier to infection in the subcutaneous tissues. Check the monofilaments, see if they have monofilament sensation. So that's 10 grams of pressure on the planter aspect of the foot. Look for hammer toes, and look for that dry, cracked skin for patients that are at risk for these type of diabetic foot problems. Usually what you see here is what you get. There's nothing else going on. They come in because there's an ulceration on the plantar or mediolateral border of the foot. Education, prevention. Appropriate shoes and orthotics. Your total contact type orthotics to stop the shear on the plantar surface of the foot. Patients have to get very good at inspecting their feet, and sometimes the simple trick of wearing white cotton socks. You can put colored over that. If you can't see the bottom of your foot, look for drainage on the sock, and that might tip you off that you're having an incipient ulceration on the plantar aspect of the foot. And minor problems need to be treated promptly, because they very rapidly get to be major infections, and again, lead to loss of limb. Lastly, some common problems here. I'm going to go through quickly here. Ankle sprains, very ubiquitous, 30,000 injuries daily. Wide variety of pain, and they can last after more than three months. And that's the unresolved ankle sprain. There's both an anatomic and a severity of the disruption of the ligament. These are the most common of the ATFL and CFL being involved. You'll see tenderness, and swelling, and ecchymosis on the lateral aspect of the ankle. Stress testing done when the acute symptoms are down, can demonstrate an anterior drawer or a calcaneal inversion test. There's the inversion test there, checking to see if I was showing the anterior drawer before. Rest, ice, immobilization, compression are your mainstays for the initial course of treatment, which then you can initiate physical therapy for gait. Balance proprioception eversion strengthening. Get the paraneal tendons working again to help stabilize the foot to prevent dynamic inversion of the foot and control the edema to help facilitate the functional recovery. Medial ankle sprains, the take-home point here is they're rare. It's the donut effect. Is a closed ring. It's got to be broken in two spots. So if someone's come in and they've told you, or they've been told that they have a severe deltoid sprain, look elsewhere. They may have a proximal fibular fracture or a syndesmonic injury. And the same relates to the syndesmosis as well. Lastly, Achilles tendon rupture. These are eccentric contracture of the Achilles tendon. The tensile force causes the tendon to disrupt. The patients classically tell you, I got kicked, or something popped in the back of my ankle. And beware, especially in the older folks, they actually can walk on their ruptured Achilles tendon. For That reason, there can be a delay in the diagnosis. So be suspicious and palpate the Achilles tendon to pick this up. There's the Thompson test. The best way to remember this is I squeeze the calf, I should see the ankle plantar flex. If that doesn't happen, I have a negative Thompson's test, and I have disruption of the Achilles. In chronic cases-- and this is an older patient-- you can see the gap that's been there because the tendons have been separated for many months. And also, the other thing. Before you do the Thompson's test, just take a look. There should be about five to seven degrees of resting equinus when you lie prone, as you can see in the picture to the left. I'm demonstrating over there with my hands on the picture to the right that if the Achilles tendon is ruptured, when they lie prone their ankle drops to 90 degrees. So that can be another confirmatory observational phenomenon that the Achilles tendon is completely disrupted. Operative versus nonoperative. The mainstay here is if you operate on it, the rerupture rate is lower. Match the expectations of the patient with the choice of treatment. Tennis leg, this happens in the medial aspect of the leg. This tends to get better in two or three months. It can be confused with a DVT if you palpate on the medial aspect of the medial head of the gastroc, that's where they usually have pain. You can put them in a heel lift, that helps. And then lastly, Achilles tendonosis. So severe degeneration above the insertion. A thick, fibrotic tendon. You can see calcification on an x-ray and they'll tell you that it's hard to push off. You can get an MRI to quantitate the tendonosis and see where the disease is. And again, immobilize it, rest it, and then work on physical therapy. And then lastly, ankle arthritis. Many mainstays of treatment here, non-operative to limit ankle joint range of motion. Here's a severe case with osteophyte and loss of joint space. Put them in a brace, rocker bottom shoes to limit the bending. Ankle replacement has some promising results, or you can fuse them. And I'm going to stop right here to stop talking about ankle fractures, but essentially I think that's been talked about in the past. Ankle fractures in terms of what are operative and non-operative. Thank you very much.