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DPT773: MM1 > 2 - Chronic Injuries to the Foot and Ankle > Flashcards

2 - Chronic Injuries to the Foot and Ankle Flashcards

1
Q

What is one of the most common medical diagnoses associated with chronic plantar heel pain?

A

Plantar Fasciitis

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2
Q
  1. After a period of time following initial acute onset, similar to Achilles’ tendinopathy, what changes in the area?
  2. How does the name change?
A
  1. acute inflammatory cells are not found in the area of pain and symptoms
  2. the acute infammatory stage has ended and may now be more correctly termed a “plantar fasciosis”
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3
Q

Why is it difficult to use pathoanatomical explanation?

What does this mean exactly?

A

There are numerous other anatomical structures in the region of the plantar fascia.

I.E. difficult to directly correlate symptoms and pain with inflammation of the plantar fascia

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4
Q

What three instrinsic muscles have the same attachment as the plantar fascia? (3)

A
  1. Flexor digitorum brevis
  2. Abductor halluces
  3. Medial Head - quadratus plantae
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5
Q

What structure blends into the plantar fascia?

A

A layer of connective tissue formed by the fibers of the Achilles tendon at the insertion on the calcaneus continue over the posterior sides and blend with the PF.

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6
Q

What is the most common site of pain and symptoms of plantar fasciitis?

A

at the origin or “enthesis” of the central band of the plantar fascia

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7
Q

T/F: pain and symptoms of plantar fasciitis are reported in the mid-portion

A

True: on occasion pain and symptoms are reported in the mid-portion but the most common site is the origin or “enthesis”

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8
Q

Plantar heel pain can be liked to what two arthropathies?

A

seropositive and seronegative arthropathies

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9
Q

Seronegative arthropathies with associate plantar heel pain include (4):

A
  1. Reiter’s syndrome
  2. Psoriatic arthritis
  3. Ankylosing spondylitis
  4. Systemic lupus erythmatosus
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10
Q

What risk factor has strong association with chronic plantar heel pain?

A

BMI in non-athletic popultion

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11
Q

What risk factors have weak association with chronic plantar heel pain? (5)

A
  1. Increased age
    2) Decreased ankle dorsiflexion
  2. Decreased 1st MTP extension
  3. Prolonged standing
  4. Pronated or supinated foot posture
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12
Q

What factors have no association with chronic plantar heel pain?

A

Non-athletic Population
-Height

Athletic Population

  • Height
  • Weight
  • BMI
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13
Q

Key history findings for chronic plantar heel pain:

-Does pain increase or decrease with weight bearing after a period of non-weight bearing?

A

insidious onset of pain with weight bearing after period of non-weight bearing

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14
Q

Key history findings for chronic plantar heel pain:

-When is it most noticeable?

A

most noticable

  1. AM with 1st step
  2. after inactivity
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15
Q

Key history findings for chronic plantar heel pain:

-Does pain increase or decrease after activity?

A

pain often decreases with activity

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16
Q

Key history findings for chronic plantar heel pain:

-Do patient have an antalgic (painful) gait?

A

can or cannot have an antalgic gait

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17
Q

Key history findings for chronic plantar heel pain:

-What does history indicate in terms of activity levels?

A

history may indicate recent change in level of activity

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18
Q

Key history findings for chronic plantar heel pain:

-What do patients describe in terms of pain location?

A

sharp, localized pain under anteromedial aspect of plantar heel

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19
Q

Key history findings for chronic plantar heel pain:

T/F - complaints of paresthesia (pins and needs) is uncommon

A

true

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20
Q

Specific Exam Procedures:

Where do you palpate?

A

assess for pain beneath anteromedial aspect of heel and NOT directly over bottom

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21
Q

Specific Exam Procedures:

How do you assess plantar tissue restriction?

A

First MTP joint extension

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22
Q

Specific Exam Procedures:

What are the two positions to test Active talocrural joint ROM? What muscles are being tested?

A
  1. Knee extended (gastrocnemius)

2. Knee flexed (soleus)

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23
Q

Specific Exam Procedures:

T/F: the windless test has low level of sensitivity in diagnosis of plantar fasciitis?

A

True

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24
Q

Specific Exam Procedures:

What 4 tests are done to exam plantar fasciitis?

A
  1. Palpate anteromedial aspect of heel
  2. First MTP joint extension
  3. Active talocrural joint ROM
  4. Windless Test
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25
Q

What is the differential diagnosis?

A
  1. Referred pain secondary to L5-S1 radiculopathy
  2. Heel pad contusion
  3. Calcaneal bone bruise
  4. Calcaneal stress fracture
  5. Soft tissue, primary or metastatic bone tumors
  6. Heel spur
  7. Tarsal Tunnel Syndrome
  8. Sever Disease (calcaneal apophysitis)
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26
Q

What is a key question on history to tell if it is a L5-S1 radiculopathy?

A

previous bout of low back pain

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27
Q

T/F: Heel spurs are correlated with heel pain

A

false: no correlation to heel pain

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28
Q
  1. How are heel spurs confirmed?
  2. What is the incidence in non-symptomatic populations?
  3. Where are they most commonly located?
A
  1. confimed by x-ray
  2. ranges from 15-25%
  3. most commonly located above plantar fascia
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29
Q

What is tarsal tunnel syndrome and what nerve is primarily involved?

A

Entrapment neuropathy of tibial nerve in the region of flexor retinacula

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30
Q

What other nerves can also be entrapped in tarsal tunnel syndrome? (3)

A
  1. Medial calcaneal branches of tibial nerve
  2. Nerve to abductor hallucis
  3. Nerve to abductor hallucis
  4. Nerve to abductor digiti minimi
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31
Q

What symptoms are included with tarsal tunnel syndrome?

A
  1. Burning or tingling sensation

2. Pain in the medial heel region

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32
Q

How is Tarsal Tunnel Syndrome assessed?

A

using the foot eversion and ankle dorsiflexion test (with or without tapping in triangle)

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33
Q

What is the typical patient in clinical scenario for Sever Disease?

A

Active sport-playing child between 10 and 12 years of age

  • affects males more often than females
  • can often occur in midst of growth spurt
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34
Q

Where does pain occur in Sever Disease?

A

over the apophyseal area of 1 or both heels

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35
Q

What motion is limited in patients with Sever Disease?

A

limited ankle dorsiflexion

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36
Q

When do patients with Sever Disease complain of antalgic or painful gait?

A

after activity

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37
Q

What is one of the most common medical diagnoses associated with forefoot pain?

A

Metatarsalgia

38
Q

Metatarsalgia is defined as pain in or about the (3):

A
  1. Head of the metatarsal
  2. Metatarsophalangeal joints
  3. Surrounding soft tissue structures
39
Q

What are common medical conditions that can cause forefoot pain? (2)

A
  1. Rheumatoid arthritis

2. Hallux valgus or bunion

40
Q

Common symptoms of metatarsalgia:

-Location? How to test?

A

patients report pain and tenderness under the metatarsal heads

-palaption of plantar surface of the metatarsal heads

41
Q

Common symptoms of metatarsalgia:

-Gait?

A

Unable to progress through terminal stance during walking because cannot load forefoot (rhematoid artritis walking pattern)

42
Q

Common symptoms of metatarsalgia:

-1st MTP?

A

decreased 1st MTP joint extension with hallux valgus or hallux limitis/rigidus (turf toe)

43
Q

What are the 3 common symptoms of metatarsalgia?

A
  1. pain and tenderness under metatarsal heads
  2. unable to progress through terminal stance
  3. Decreased 1st MTP extension
44
Q

What are the 2 specific examination procedures for metatarsalgia?

A
  1. Palpation of metatarsal heads and assessment of possible callous under metatarsal heads
  2. examine for claw and hammer toes
45
Q

What is done if claw or hammer toes are present?

A

Need to determine if reducible (mobile) or non-reducible

46
Q

What are differential diagnoses for Metatarsalgia?

A
  1. Morton’s toe
  2. Stress Fracture
  3. Interdigit nerve compression/neuroma
47
Q

How is Morton’s toe defined?

A

This is an excessively short 1st metatarsal bone, that results in longer 2nd toe and increased stress to the 2nd met head

48
Q

What is the most common location of a stress fracture?

A

2nd or 3rd metatarsal

49
Q

What is interdigital nerve compression/neuroma also referred to as?
Typical complaint?

A
  • Morton’s neuroma or interdigital neuroma

- Typically complain of burning and tingling in toes after activity

50
Q

If suspect a Hallux Limitus/Rigidus, must determine if ___

A

decreased ROM (especially extension) of 1st MTP joint is present

51
Q

Physical examination for hallux limitus/rigidus should include (3):

A
  1. Assessment of 1st MTP joint ROM for decreased extension
  2. Assessment of 1st MTP joint play
  3. Palpation of dorsal aspect of 1st metatarsal head and hallux
52
Q

What is one of the most common cause of MTSS?

A

overuse leg injuries

53
Q

What is the incidence rate for MTSS? (2)

A
  1. Ranges from 13.6% to 20% in runners.

2. Ranges from 7.2% to 35% in military personnel.

54
Q

What etiologies for MTSS have been proposed? (4)

A
  1. Traction induced periostitis
  2. Increased intracompartment pressure
  3. Involvement of tibial cortex possible
  4. Reduction in bone density in symptomatic portion of tibia
55
Q

What are the 6 risk factors associated with MTSS?

A
  1. Female Gender
  2. Previous HX of MTSS
  3. Increased hip external rotation ROM
  4. Increased ankle plantar flexion ROM
  5. Increased BMI
  6. Navicular drop > 10mm
56
Q

What must be kept in mind in terms of BMI?

A

poor indicator of body fat in athletic community and military populations
-increased mass in these populations could be due to lean mass OR fat mass

57
Q

What are the 5 specific examination procedures for MTSS?

A
  1. Pattern of pain in most cases caused by exercise
  2. Pain located along posterior-medial border of tibia
  3. Diffuse pain on palpation of posterior-medial border for at least 5 cm
  4. Shin palpation test
  5. Shin edema test
58
Q 
Specific Exam Procedures MTSS:
How does pain progress with exercise?
-Initally:
-Later:
-Eventually:
A
  • Initally: pain on starting activity that subsides with continued exercise.
  • Later: pain continues during activity
  • Eventually: pain felt after concluding activity
59
Q

Where is pain located for MTSS?

A

located along posterior-medial border of tibia

-usually middle or distal thirds

60
Q

At what size range does diffuse pain occur on palpation for MTSS?

A

posterior medial border FOR AT LEAST 5 cm

61
Q

Where do you palpate for the Shin Palpation Test for MTSS

A

Palpation of distal 2/3 of posteromedial border of tibia and associated musculature

62
Q

How much pressure is applies with a MTSS Shin Palpation Test?

A

enough pressure to squeeze out a sponge?

63
Q

What is a positive MTSS Shin Palpation Test?

A

pain is present

64
Q

How is a MTSS Shin Edema Test performed? What is recorded?

A

sustained palpation (5 sec hold) of the distal 2/3s of medial surface of tibia.

-any sign of pitting edema recorded

65
Q

What are 3 differential diagnoses for MTSS?

A
  1. Stress fracture/reaction
  2. Exertional compartment syndrome
  3. Tibialis Posterior Tendonitis
66
Q

How can a stress fracture/reaction be diagnosed?

A

Localized location of pain

67
Q

How can exertional compartment syndrome be diagnosed?

A

c/o burning, cramping, increased pressure and/or pain over involved compartment

68
Q

How can tibialis posterior tendonitis be diagnosed?

A

replication of pain and symptoms with maximum concentric concentration through available ROM

69
Q

What is the leading cause of acquired flatfoot deformits in adults?

A

Tibialis Posterior Tendon Dysfunction

70
Q

What is the main function of tibialis posterior?

A
  1. Main dynamic stabilizer of medial longitudinal arch.

- Concentrically contrasts in late stance phase to stabilize the midfoot and hindfoot which enhances foot stability

71
Q

Clinical presentation of Tibialis Posterior Tendon Dysfunction:
Stage 1 -

A

Stage 1 -

  • Mild swelling
  • medial ankle pain
  • normal but possibly painful heel raise
  • NO deformity
72
Q

Clinical presentation of Tibialis Posterior Tendon Dysfunction:
Stage 2 -

A

Stage 2 -

  • Progressive medial arch flattening with abducted forefoot (indicative of midfoot involvement)
  • typically unable to perform heel raise
  • hindfoot still flexible (can be placed in neutral)
  • but tendon can be functionally incompetent or ruptured
73
Q

Clinical presentation of Tibialis Posterior Tendon Dysfunction:
Stage 3 -

A

All signs of STAGE 2 except
-hindfoot and midfoot is fixed
-forefoot abducted
Can have calcaneal-fibular pain 2o to lateral abutment

74
Q

Clinical presentation of Tibialis Posterior Tendon Dysfunction:
Stage 4 -

A

Continued progression from STAGE 3

-with marked forefoot abduction

75
Q

Specific Examination Procedures for Tibialis Posterior Tendon Dysfunction (2):

A
  1. Pain along distal path of posterior tibialis tendon

2. Possible replication of symptoms with contraction of muscle through max excursion

76
Q

What does the achilles tendon have instead of a tenosynovial sheath?

A

peritendinous tissue or paratenon

77
Q

What is the acute inflammatory of the achillies tendon termed?

A

peritendonitis

78
Q

Why is achilles tendinitis a misnomer?

A

Inflammatory cells are not often seen in biopsy specimens of chronically inflammed tendons, except in tendon rupture.

Thus, cannot label and itis.

79
Q

How is achilles tendinosis defined?

A

Tendon degeneration without histological or clinical signs of intratendinous inflammation.

80
Q

How is achilles tendinopathy defined?

A

Term used to descrive the combination of pain, swelling, and impaired performance associated with achilles tendon injury.

81
Q

Mulitiple etiologies have been proposed for achilles tendinopathy including (4):

A
  1. Over-training (repetitive stress)
  2. Anatomical Malalignment
  3. Repetitive jumping activities
  4. Footwear
82
Q

What are the common symptoms of paratenonitis - the first stage of achilles tendonitis?

A
  1. pain
  2. acute edema
  3. hyperemia
    of paratenon
83
Q

physiologically what happens with paratenonitis?

A

usually have infiltration of inflammatory cells and exudates filling the tendon sheath

84
Q

clinically what are symptoms of paratenonitis?

A

clinically, can feel crepitus edema along the tendon sheath

85
Q

What are the most common sites of achilles tendinopathy? (2)

A
  1. Mid-tendon (termed watershed area)

2. Insertional - pain in the posterior heel region at the tendon attachment

86
Q

During what general portions of gait cycle do patients with achilles tendinopathy complain of pain?

A

those portions of gait cycle when calf muscle group active

-Especially terminal stance

87
Q

What 6 specific examination procedures are done for achilles tendinopathy?

A
  1. Thompson’s (Simmond’s) test
  2. Palpation of the achilles tendon
  3. Ankle dorsiflexion range of motion
  4. Arch sign
  5. Royal London Hospital Test
  6. Assessment of foot posture and mobility
88
Q

Where should the achilles tendon be palpated with tendinopathy?

A

full length of tendon including calcaneal insertion

89
Q

What two tests can be done to asses foot posture and mobility for achilles tendinopathy?

A
  1. Foot Posture Index

2. Navicular Drop Test

90
Q

What two differential diagnoses can be made for achilles tendinopathy?

A
  1. Flexor hallucis tendonitis

2. Retrocalcaneal calcaneal bursitis

DPT773: MM1 (6 decks)

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