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A physical therapist reviews a patient’s past medical history which includes a fracture of the os peroneum. Which scenario is most consistent with the clinical presentation of this pathology?

1. Lateral foot pain and weakness in eversion and plantar flexion
2. Anterior ankle pain and swelling with difficulty walking
3. Pain originating in the midfoot radiating to the toe region
4. Pain and tenderness in the ball of the foot and great toe

Transcript

Welcome back to the Scorebuilders’ Question and Answer Podcast! This podcast provides members of the Scorebuilders’ team with the opportunity to explore challenging multiple-choice examination questions with students actively preparing for the licensing examination. My name is Scott Giles and I will be your host for today’s journey.

Ready? Let’s go!

A physical therapist reviews a patient’s past medical history which includes a fracture of the os peroneum. Which scenario is most consistent with the clinical presentation of this pathology?

1. Lateral foot pain and weakness in eversion and plantar flexion
2. Anterior ankle pain and swelling with difficulty walking
3. Pain originating in the midfoot radiating to the toe region
4. Pain and tenderness in the ball of the foot and great toe

An understanding of the typical clinical presentation of common and in some cases uncommon (i.e., os peroneum fracture) medical diagnoses is essential for both differential diagnosis and developing appropriate plans of care.

Let’s talk about the os peroneum.

Os Peroneum
The os peroneum is one of several accessory ossicles of the foot and ankle, located lateral to the cuboid within the distal peroneus longus tendon. 

The os peroneum is typically asymptomatic, but can be fractured or displaced with a peroneus longus tendon tear, either from direct injury or indirectly from abrupt foot dorsiflexion or inversion.

Let’s explore each of the options:

Option 1 - Lateral foot pain and weakness in eversion and plantar flexion
Physical examination findings of an os peroneum fracture often include lateral foot pain, edema, and weakness in eversion and plantar flexion due to the involvement of the peroneus longus tendon.

Option 2 - Anterior ankle pain and swelling with difficulty walking
Anterior ankle pain and swelling with difficulty walking are characteristic symptoms of a variety of ankle conditions including a high (syndesmotic) sprain. This type of injury involves the high ankle ligaments connecting the tibia to the fibula as opposed to the more commonly injured lower ankle ligaments. 

The location of the os peroneum within the peroneus longus tendon is more likely to produce pain in the lateral midfoot region than the anterior ankle. 

Option 3 - Pain originating in the midfoot radiating to the toe region
Pain originating in the midfoot radiating to the toe region is more characteristic of Morton's neuroma. This condition affects the ball of the foot, most commonly the area between the third and fourth toes. Patients with Morton's neuroma often feel as if they are standing on a pebble in their shoe or a fold in their sock. 

The originating area of the pain and the radiating pattern are inconsistent with the area affected with an os peroneum fracture.

Option 4 - Pain and tenderness in the ball of the foot and big toe
Pain and tenderness in the ball of the foot and great toe is more characteristic of a metatarsophalangeal joint sprain (i.e., turf toe).This condition occurs when the great toe remains on the ground and the heel lifts resulting in hyperextension of the great toe. This condition is common in selected athletic pursuits (e.g., football, soccer) when an athlete suddenly pushes off on their toes to sprint. 

The originating area of the pain is inconsistent with the area affected with an os peroneum fracture.

The correct answer is Option 1

Let’s explore the all student data:
42% of students selected Option 1, Lateral foot pain and weakness in eversion and plantar flexion, the correct response
25% of students selected Option 2, Anterior ankle pain and swelling with difficulty walking
17% of students selected Option 3, Pain originating in the midfoot radiating to the toe region
16% of students selected Option 4, Pain and tenderness in the ball of the foot and great toe

System Classification
This question is a Musculoskeletal System question which represents approximately 27% of all exam items.

Content Outline Classification
This question is a Foundations for Evaluation, Differential Diagnosis, and Prognosis question which represents approximately 33% of all exam items.

Level Classification
This question is a Level 1 question since the question requires students to possess basic foundational academic knowledge. Remediation of Level 1 questions occurs through academic review of entry-level content using textbooks, review books, Basecamp, and flash cards.

Thanks for joining us on the Scorebuilders Q and A podcast! See you next week!