Common conditions of the lower limb Flashcards

1
Q

What is hip OA?

A

Degenerative condition that involves degeneration of the articular cartilage in the acetabulum and head of the femur

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2
Q

What demographic is hip OA?

A

After 40 years F
After 50 years M

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3
Q

What are the non-modifiable risk factors of hip OA?

A

Advanced age
Family history
History of acute joint injury &/or deformity
Labral tears, ligament laxity, fracture, cam deformity, joint dysplasia

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4
Q

What are the modifiable risk factors of hip OA?

A

Obesity
Biomechanical loading
Hormonal influences on inflammation
Repetitive joint overloading
Certain sports: high intensity, direct joint impact with other individuals
Occupational factors: physical labour
Occupation is non-modifiable for some patients

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5
Q

What are the pathophysiological factors of hip OA?

A

Biomechanical factors
Inflammatory factors
Enzymatic factors

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6
Q

What is the process of hip OA?

A

Cartilage develops small tears that grow larger with more stress > cartilage eventually fragments > chondrocytes attempt to keep up with cartilage loss but eventually cannot > underlying bone becomes exposed > bone rubs on bone resulting in reactive sclerosis and osteophyte formation

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7
Q

What are the clinical features of hip OA?

A

Gradual onset
May be bilateral
Pain is cardinal symptom
Aching and poorly located – groin, buttock, medial thigh, knee
Joint stiffness
Especially in morning (due to articular gelling)
Limited ROM
First movements lost are internal rotation and extension
+/- crepitus, visible deformity, signs of acute or subacute inflammation
+/- weakness, tenderness and spasm/contracture of gluteals, quadriceps; abnormal gait

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8
Q

What is the common aetiology of an SIJ dysfunction?

A

Degeneration
Mechanical disorders
Hyper or hypo mobility
Women following childbirth
Structural abnormalities
Post-traumatic
Severe trauma e.g. MVA, horse-riding accidents
Repetitive rotational stresses

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9
Q

What is the less common aetiology of SIJ dysfunction?

A

Inflammatory disorders e.g. ankylosing spondylitis
Infections

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10
Q

What are the factors that affect SIJ dysfunction?

A

Joint structure
Ligamentous support
Muscular influences

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11
Q

What are the clinical features of SIJ dysfunction?

A

Dull aching pain in buttock, groin or upper thigh
Can mimic pain from the lumbosacral spine or hip joint
+/- sensation of heaviness – usually no accompanying neuro symptoms
Can be unilateral or bilateral
Positive SIJ provocation tests
Imaging may demonstrate certain pathologies

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12
Q

How do hamstring injuries occur?

A

Hamstring injuries occur when they are exposed to large eccentric tensile forces during hip flexion and knee extension
They also play a role in foot and ankle biomechanics

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13
Q

What are the two classifications of hamstring injuries?

A

Type I: long head of biceps at musculotendinous junction
Type II: Semimembranosus occurring near ischial tuberosity

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14
Q

What are the risk factors of hamstring strain injuries?

A

Type I;
Sprinters (during eccentric activation in terminal swing phase)
Usually involve long head of biceps – often at musculotendinous junction
Type II;
Large amplitude, stretching movements
Involve the proximal free tendon of semimembranosus and occur close to ischial tuberosity

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15
Q

What are the risk factors for proximal hamstring tendinopathy?

A

Due to repetitive mechanical overload of tendon (long distance running, jumping, repeated hip flexion)

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16
Q

What are the clinical features of hamstring strains?

A

Type I and II: Sudden onset pain
Moderate to severe depending on grade
Disabling – difficulty walking, unable to run
Pain and weakness on active-resisted muscle testing
Reduced stretch
Marked focal tenderness with palpation
+/- local haematoma, bruising
Important to differentiate referred pain to hamstring region

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17
Q

What are the clinical features of proximal hamstring tendinopathy?

A

Insidious onset pain: lower gluteal region, posterior thigh
Aggravated through passive stretch, active resisted testing, direct palpation of ischial tuberosity
Lumbar flexion can also aggravate (causes compression of tendon against ischial tuberosity and ischiogluteal bursa)

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18
Q

What is greater trochanter pain syndrome?

A

A condition that encompasses the structures surrounding the greater trochanter of the hip: gluteus medius, gluteus minimus tendons, bursae: trochanteric, subgluteal, ITB

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19
Q

What are the risk factors for greater trochanter pain syndrome?

A

Compressive loading of lateral soft tissue
Repetitive adduction of hip
Unaccustomed or sustained weight-bearing
Menopause
Direct contusion injury to lateral hip

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20
Q

What is the pathophysiology of greater trochanter pain syndrome?

A

Abnormal hip biomechanics a key factor
Increased compressive forces between ITB and greater trochanter
Compression of underlying gluteal tendons and bursae

Tenocytes respond by secreting larger proteoglycans
Increased water content leads to thicker tendon
Appearance of cartilage-like cells change structure of tendon
Associated thickening of ITB and bursae

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21
Q

What are the clinical features of greater trochanter pain syndrome?

A

Diagnosis of exclusion
Must consider lumbar spine and hip joint pathology
Insidious onset that worsens
Pain and tenderness over greater trochanter
Aggravated by lying on affected side, single leg weight bearing
+/- pain and weakness with active-resisted testing
Trendelenburg: useful as a pain provocation test
FABER: often reproduces familiar pain but ROM is general preserved
Contrast this to hip OA: limited ROM with FABER

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22
Q

What is a labral tear?

A

A tear in the acetabulum of the hip

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23
Q

What are the demographics of a labral hip tear?

A

Any age
F>M 3:1

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24
Q

What does the fibrocartilaginous extension of the acetabular rim do?

A

Enhances hip joint stability
Shock absorption and pressure distribution
Assist with joint lubrication and chondral nutrition

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25
Q

What are the risk factors of hip labral tears?

A

Athletic populations

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26
Q

What is the aetiology of hip labral tears?

A

Trauma (usually compression with a degree of rotation; increased shear forces on outer joint margin)
FAI (esp cam impingement)
Capsular laxity/hypermobility
Degeneration
Developmental dysplasia of hip

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27
Q

What are the types of hip labral tears?

A

Type 1: detachment of the labrum from cartilage at acetabular rim
Type 2: tear within the labrum

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28
Q

What are the clinical features of a hip labral tear?

A

Deep pain (usually groin or anterior hip)
Some patients report pain in buttock
Can be sharp and catching on movement
+/- mechanical symptoms
Snapping clicking or locking
An unstable feeling in the hip like it is going to give way

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29
Q

What is femoroacetabular impingement?

A

Abnormal contact occurs between the femoral head and the acetabulum caused by deformities in the femoral head and/or acetabulum of the innominate

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30
Q

What does FAI predispose?

A

FAI is not itself a pathology but can predispose intra-articular damage (labral tears, hip OA, chondropathy)

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31
Q

What are the classifications of FAI?

A

CAM
PINCER
MIXED

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32
Q

What is a CAM lesion?

A

Extra bone at anterolateral femur
Leads to non-spherical femoral head
Motion (esp IR) forces cam lesion into acetabulum
More common in men

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33
Q

What is a PINCER lesion?

A

Abnormality of acetabulum, leading to over-coverage of femoral head
More common in women

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34
Q

What is a mixed lesion?

A

Presence of both cam and pincer
Most common

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35
Q

What is the aetiology of FAI?

A

Hip loading during adolescence (repetitive, torsional movements)
Causes over activity of epiphyseal plate between femoral head anc neck
Genetics
Slipped capital femoral epiphysis

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36
Q

What are the extrinsic factors causing FAI?

A

Types of sports played and movements involved
Volume of sport/activity
Footwear
Surface

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37
Q

What are the intrinsic factors causing FAI?

A

Reduced hip flexion, internal rotation, hip extension
Poor lumbopelvic control
Increased subtalar pronation

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38
Q

What are the symptoms of FAI?

A

Motion or position-related pain in hip or groin
Pain may also be felt in the back, buttock or thigh
+/- clicking, catching, locking, stiffness, restricted ROM or giving way

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39
Q

What are the clinical signs of FAI?

A

Positive FADIR: limited ROM +/- pain

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40
Q

What are the imaging processes of FAI?

A

Anterio-posterior radiographs of pelvis
Lateral femoral neck view of hip

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41
Q

What is groin pain?

A

Adductor
Iliopsoas
Inguinal
Pubic
Hip related
Other: orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological and surgical

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42
Q

What sports are common for adductor pathologies?

A

AFL, soccer, callisthenics, ice hockey

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43
Q

What is the aetiology of acute adductor strains?

A

Sudden onset, usually occur during explosive actions (kicking, reaching with leg, sudden COD, forceful eccentric contraction
Usually affects the musculotendinous junction sometimes the tendon itself
Overuse-type injuries: gradual onset, pain aggravated by sprinting, cutting changes of direction, kicking
Usually accompanied by post-activity pain and stiffness

44
Q

What is the pathophysiology of adductor strains?

A

Pain medially in groin (esp. adductor longus tendon)
Acute strain: bruising, swelling, warmth; antalgic gait
Gradual onset: progressive deterioration with continued activity
+/- stiffness, tightness or weakness

45
Q

What is the diagnostic criteria of adductor strains?

A

Adductor tenderness and pain on active resisted adduction

46
Q

What is the second most common injury of the groin?

A

Iliopsoas

47
Q

What are iliopsoas groin injuries?

A

Second most common injury of the groin
Pain in anterior part of proximal thigh – more laterally than adductor related groin pain
Often seen in conjunction with adductor issue or an intra-articular problem (plays large compensatory role)
+/- snapping when hip is extended from flexed position

48
Q

What is the diagnostic criteria of iliopsoas strains?

A

Iliopsoas tenderness
Pain on resisted hip flexion &/or pain on passive stretch of the hip flexors

49
Q

What are the clinical features of knee OA?

A

Gradual onset
Joint pain
Stiffness
Swelling, warmth, redness
+/- crepitus; feeling of giving way

Decreased ROM – can be due to pain osteophytes, joint mice
Bony deformity
Crepitus

50
Q

What is the aetiology of ACL injuries?

A

Sudden change in direction or cutting manoeuvres
Internal tibial rotation on fixed knee
Single-leg landings

51
Q

What is the pathophyisiology of ACL injuries?

A

Often disabling (functional impairment)
Risk of chronic instability
Often occur in combination with other injuries (MCL, meniscus, chondral damage)

52
Q

What are the clinical features of ACL injuries?

A

Audible pop/crack or sensation of subluxation at onset
Knee pain and widespread tenderness
Reduced ROM and functional impairment due to pain or tense effusion due to haemoarthrosis
+/- joint line tenderness due to associated meniscal injury
Lachman test most sensitive

53
Q

What is the aetiology of PCL injuries?

A

Direct blow to anterior tibia on a flexed knee
Hyperextension injury

54
Q

What is the level of disability of a PCL injury?

A

Minimal

55
Q

What are the clinical features of PCL injuries?

A

Vague symptoms such as unsteadiness or discomfort (may not recall pop or tear)
Mild effusion
Pain in the posterior aspect of knee
Pain with kneeling
Subacute injuries: vague anterior pain, pain with deceleration/running, descending inclines
Posterior draw test most sensitive

56
Q

What is the aetiology of MCL injuries?

A

Excess valgus force at knee – can be direct blow or non-contact
Excess external tibial rotation

57
Q

What is the incidence of MCL injuries?

A

More common than LCL

58
Q

Which cruciate ligament is more commonly associated with MCL injuries?

A

Grade III MCL associated ACL tears

59
Q

What are the clinical features of MCL injuries?

A

Grade I: local tenderness; usually no swelling
Pain with valgus stress test
Grade II: marked tenderness, localised swelling
Pain and laxity with valgus stress test, distinct end point
Grade III: localised swelling, feeling of instability
Gross laxity on valgus testing with no end point
Amount of pain is variable due to complete disruption of ligament

60
Q

What is the aetiology of LCL injuries?

A

Excess varus force at knee – can be direct blow or non-contact
Hyperextension injury

61
Q

Which nerve is commonly injured in LCL injuries?

A

Common peroneal nerve injury has been reported – 1/3 LCL injuries

62
Q

What are the clinical features of LCL injuries?

A

Pain and perceived side to side instability near extension
Difficulty walking on uneven group or stairs
Localised bruising and swelling
Varus stress test – variable amounts of pain and laxity depending on grade
Common peroneal nerve involvement (foot drop or paraesthesia)

63
Q

What is the aetiology of meniscal injuries?

A

Excessive shear stress to a semi-flexed knee
Rotational and compressive forces (twisting injury with anchored foot)
Consider degenerative meniscal tears in older patient with a history of knee trauma or known meniscal/cartilage pathology

64
Q

Which meniscus is more affected?

A

Medial

65
Q

Why is the medial meniscus more susceptible to injury?

A

Less mobile due to attachments

66
Q

What are the clinical features of meniscal injuries?

A

Variable amounts of pain and joint line tenderness
Aggravated by knee hyperflexion e.g. squatting
+/- joint effusion
Small tears may have minimal or delayed symptoms
Severe tears: pain and reduced ROM
+/- intermittent locking due to impingement of torn flap
+/- clicking or clunking
Meniscal tests: McMurray’s, Thessaly

67
Q

Which knee bursae is most commonly affected?

A

Pre-patellar

68
Q

Which bursae is most associated with rheumatological conditions?

A

Pes anserine bursa

69
Q

What are the clinical features of bursitis?

A

Anterior knee pain and superficial swelling
History of knee trauma or repetitive compressive forces
Consider knee effusion and patellar tendinopathy

70
Q

What are the extrinsic factors of patellofemoral pain?

A

PFJ load crated by the ground reaction force
Body mass
Speed of gait
Surfaces
Footwear
Type and intensity of activity
Duration of activity

71
Q

What are the intrinsic factors of patellofemoral pain?

A

Influence magnitude and distribution of load

72
Q

What are the local factors of patellofemoral pain syndrome?

A

Patellar position and tracking
Quadriceps (esp vastus) dysfunction: weakness, delayed activation, atrophy

73
Q

What are the remote factors of patellofemoral pain syndrome?

A

Consider weakness, hypo/hypermobility
Increased hip IR, increased adduction
Increased knee valgus; dynamic foot function
Poor trunk and pelvic control

74
Q

What are the clinical features of patellofemoral pain syndrome?

A

Anterior knee pain: non-specific or vague – can be medial, lateral or infrapatellar
Worse with weight-bearing (running, stairs, hills)
PFJ taping shoulder relieve
Tenderness on palpation of patellofemoral joint line
Reduction in, or pain reproduced on, patellofemoral joint ROM
+/- swelling in suprapatellar/infrapatellar region
+/- wasting of VMO
+/- crepitus on knee activation
+/- abnormal patellar position (superior sitting patella)

75
Q

What is achilles tendinopathy?

A

A chronic overuse injury affecting the achilles tendon

Achilles has 10x body weight pass through it

76
Q

What is the aetiology of achilles tendinopathy?

A

Chronic overuse injury
Repeated load overwhelms the ability of tendon to withstand and heal microtrauma
Recall that: tendon blood supply is poor, esp. distally

77
Q

What are the risk factors of achilles tendinopathy?

A

Advanced age: poor conditioning
Overuse: inadequate recovery
Change in training activity or surface
Footwear
Biomechanical factors (muscle weakness, decreased flexibility)

78
Q

What are the clinical features of achilles tendinopathy?

A

Posterior heel pain
Often first noticed on waking, following a recent increase in training volume/intensity
Pain is worse at the start of activity; morning stiffness and pain post-activity is common
Palpable tenderness of the tendon
+/- palpable thickening of tendon or palpable crepitus – due to fibrinous exudate in the peritendon
Achilles rupture will present with obvious swelling and deformity

79
Q

What are the two common types of ankle sprains?

A

Lateral: anterior talofibular ATFL (most common)
Medial: deltoid

80
Q

What are lateral ankle sprains?

A

Lateral:
Anterior talofibular ATFL (most common)
Calcaneofibular CFL
Posterior talofibular PTFL

81
Q

What are medial ankle sprains?

A

Medial (deltoid ligament) – due to forced eversion
Far less common but more debilitating
May occur with fracture e.g. medial malleolus, talar dome

82
Q

What are the risk factors for lateral ankle sprains?

A

Usually inversion and plantarflexion
Weight bearing activity on uneven surface e.g. grass
Activities requiring rapid change in direction (football, netball, tennis, basketball)
Lack of strength and stability in the ankle due to previous injury
Congenital ligamentous laxity (connective tissue disorder associated with hypermobility)
Acquired ligamentous laxity (pregnancy)

83
Q

What is a grade I ankle sprain?

A

Grade I: MILD
Slight stretching and microscopic tearing of ligament fibres
Mild tenderness and swelling around the ankle

84
Q

What is a grade II ankle sprain?

A

Grade II: MODERATE
Partial tearing of the ligament
Moderate tenderness and swelling around the ankle
Hypermobility on testing but a firm end point

85
Q

What is a grade III ankle sprain?

A

Grade III: SEVERE
Complete tear of the ligament
Significant tenderness and swelling around the ankle
Gross laxity on testing without a discernible end point

86
Q

What are the clinical features of ankles sprains?

A

Pain on weight bearing in lateral ankle
Associated inversion injury incident +/- audible snap, crack or tear
Feeling of instability
Swelling, bruising and level of disability can be variable
Manual stress testing is most reliable and valid when performed 5-7 days post injury
Anterior draw test
Pain with passive stretch: plantarflexion, inversion
Tenderness on palpation of ligaments (grade III tears are least painful)
+/- injury to peroneal muscles

87
Q

What is morton’s neuroma?

A

A swelling of nerve and scar tissue arising from mechanical compression of the interdigital nerve
Usually between 3rd and 4th metatarsal heads

88
Q

How common are morton’s neuroma?

A

Fairly common and occurs at any age

89
Q

What are the risk factors for morton’s neuroma?

A

Excessive pronation or compression of the foot leads to metatarsal hypermobility and nerve impingement e.g. high-heeled shoes, narrow fitting footwear

90
Q

What are the clinical features of morton’s neuroma?

A

Gradual onset pain on plantar surface of forefoot which might radiate into toes

Moves from an ache to a sharp burning pain
Paraesthesia and numbness are common
Feels like ‘walking on marble’
Aggravated with compression/weight bearing of forefoot
Relieved by rest, massage, removal of compression
Localised tenderness in the web space
A clicking sensation can develop due to chronic proliferation – may be detectable on palpation
+/- deficit in toe tip sensation

91
Q

What is the aetiology of shin splints?

A

Running

92
Q

What is the aetiology of anterior stress shin splints?

A

Overuse of TA, EHL, EDL
Pain anterolateral aspect leg
Aggrvated by heel strike, down hill running, over striding

93
Q

What is the aetiology of medial tibial stress shin splints?

A

Involvement of TP, FHL, FDL +/- soleus
Pain with toe off

94
Q

What are the risk factors for shin splints?

A

Athletic populations
More common in women
Poor technique or training errors
Poor footwear of hard surfaces
History of previous stress fractures

95
Q

What are the range of biomechanical contributors to shin splints?

A

Muscle weakness and decreased flexibility
Higher BMIL increased calf girth
Excessive pronation, tibial torsions, hip ER/IR, leg length discrepancy, increased Q angle
Metabolic issues - ? Lower bone density

96
Q

What is the pathophysiology of shin splints?

A

Repetitive traction during physical activity
Progressive micro-trauma of fascia and muscles attaching to tibia

97
Q

What are the clinical features of shin splints?

A

Gradual onset anterior shin pain – usually dull and achy
Worse with activity, relieved by rest or stretching
Tenderness on palpation of tibial borders and on passive stretch
Few visible signs: ankle Rom usually normal
No neuro or vascular features
No special tests except to exclude other conditions

98
Q

Which aspect of the tibia is most commonly affected by stress fractures?

A

90% is posteromedial tibia

99
Q

What are the risk factors of tibial stress fractures?

A

Athletes involved in impact, running and jumping sports – esp with rigid surfaces

100
Q

What are the intrinsic factors of tibial stress fractures?

A

Lower limb biomechanics
Limb length discrepancy

101
Q

What are the clinical features of tibial stress fractures?

A

Gradual onset leg pain – aggravated by exercise +/- recent increase in training intensity/duration
Pain can occur with walking, at rest of even at night
Localised tenderness over medial border of tibia
Biomechanical issues common in lower limb

102
Q

What is plantar fasciopathy?

A

An overuse condition of the plantar fascia at its calcaneal attachment
Most common cause of plantar heel pain
Originally termed plantar fasciitis – now known that degenerative processes are involved

103
Q

What are the risk factors of plantar fasciopathy?

A

Weight and BMI (increased mechanical load)
Prolonged standing work (especially hard surfaces)
Physically active populations (high-volume, repetitive training e.g. running)
Foot biomechanics
Flexibility and strength
Decreased flexibility of ankle joint
Myofascial tightness of calf; hamstrings; gluteal region
Decreased torque of plantarflexion; toe flexion

104
Q

What is the pathophysiology of plantar fasciopathy?

A

Deterioration of collagen fibres
Increased secretion of ground substance proteins
increase vascularity

105
Q

What are the clinical features of plantar fasciopathy?

A

Gradual onset pain
Inferior medial aspect of heel
Initially, worse in morning (first step pain)
Decreases with activity but returns post-activity

Severe cases: pain with standing, non-weight bearing, night pain

Palpable tenderness along medial tuberosity of calcaneus and down the medial/central aspects of plantar fascia
Reproduction of pain with passive stretch