Common Foot Problems Flashcards
What are the most common cause of posterior heel pain? [1]
Achilles tendon disorders
What is the blood supply of the Achilles tendon? [1]
Which muscle is attached to the medial tuberosity of calcaneus?
Posterior tibial artery
Abductor hallucis
What creates the Achilles tendon? [1]
The confluence of soleus muscle tendon with medial and lateral gastrocnemius tendons [1]
Which antibiotic class [and give an example] is associated with tendon disorders? [1]
quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
The Achilles tendon connects which muscles [2] to which bone? [1]
The Achilles tendon connects the calf muscles (gastrocnemius and soleus) to the heel (the calcaneus bone)
What are the two types of Achilles tendinopathy? [2]
Insertion tendinopathy (within 2cm of the insertion point on the calcaneus)
Mid-portion tendinopathy (2-6 cm above the insertion point)
Describe the typical presentation of Achilles tendinopathy [5]
- Posterior ankle pain, often severe and exacerbated by physical activity or prolonged standing.
- Pain on palpation of the Achilles tendon.
- Swelling and thickening of the Achilles tendon, which may also feel warm to the touch.
- Pain or aching in the Achilles tendon or heel, with activity
- Stiffness
- Tenderness
- Swelling
- Nodularity on palpation of the tendon
How do you differentiate Achilles tendinopathy from Achilles tendon rupture? [1]
Simmonds’ calf squeeze test:
- patient to lie prone with their feet over the edge of the bed
- feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.
When should you suspect Achilles tendon rupture? [1]
How would you confirm this? [1]
- audible ‘pop’ in the ankle,
- sudden onset significant pain in the calf or ankle
- or the inability to walk or continue the sport.
Ultrasound is used to diagnose Achilles tendon rupture.
Where exactly does Achilles tendon rupture occur? [1]
rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region
Treatment of Achilles tendinopathy (tendinitis)? [1]
Treatment of Achilles tendon rupture? [1]
Achilles tendinopathy (tendinitis):
- simple analgesia and reduction in precipitating activities.
Achilles tendon rupture
- An acute referral should be made to an orthopaedic specialist following a suspected rupture.
How would movement person be affected in a Achilles tendon rupture? [2]
What other symptoms would be present? [4]
Unable to stand on tiptoes on the affected leg alone
Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
Pain and swelling in heel and lower calf
Inability to stand on tiptoe
Inability to plantarflex foot
Positive Thompson test: loss of plantarflexion on squeezing the calf
What is the role of the plantar fascia? [1]
Which structures in the foot does it attach to? [2]
Plantar fascia (or aponeurosis) is a band of fibrous tissue that acts as a shock absorber providing stability within the foot and cushioning for force transmitted through the lower limbs.
Attache the calcaneus, travels along the sole of the foot and connects to the flexor tendons of the toes
What causes plantar fasciitis? [1]
Age: causes degenerative changes in the plantar fascia
Obesity
Foot biomechanics: high foot arch or flat feet can add additional strain
Tight achilles tendon
Prolonged standing or walking
Sudden increase in physical activity
Trauma
Describe the clinical presentation of plantar fasciitis [3]
Inferior heel pain on pressure (100%).
- Usually worse on the first steps out of bed in the morning or after period of inactivity
- pain on medial aspect of heel
- May ease on walking but worse with heavy activity or standing
- Tenderness to palpate
- Pain that worsens after exercise, not during
Describe a clinical test can perform to diagnose PF [1]
Positive ‘windlass test’ (sensitivity 31.8%, specificity 100%):
- if there is pain at the heel area when the toes are passively dorsiflexed (upwards)
Treatment for PF?
Conservative management (recommended on NICE CKS):
* Relative rest (by reduction in activities that worsen it)
* Foot orthotics - these can be over the counter and includes insoles, heel pads and arch supports or custom-made orthotics
* Stretches - of the Achilles tendon and plantar fascia
* Ice - applied through a towel may provide short term symptomatic relief
* Non-steroidal anti-inflammatory medications (NSAIDs) may provide short term pain relief
* Weight loss
Referral to a podiatrist or a physiotherapist is advisable. Orthopaedic referral for refractory plantar fasciitis may be considered for extracorporeal shock wave therapy or surgical release of the plantar fascia (NICE CKS).
What is meant by fat pad atrophy? [1]
Thinning and degeneration of the fat pad of the heel (soft tissue layer in between the skin and the heel bone)
This makes the heel bone more vulnerable to repetitive microtrauma. This can lead to chronic inflammation, bruising, swelling and pain within the heel bone.
How does fat pad atrophy present? [1]
How can you meaure the level of fat pad atrophy? [1]
Symptoms are similar to plantar fasciitis, with pain and tenderness over the plantar aspect of the heel. Symptoms are worse with activities, particularly when barefoot on hard surfaces.
The thickness of the fat pad can be measured with an ultrasound scan.
Describe what is meany by Morton’s neuroma [1]
Morton’s neuroma refers to the dysfunction of a nerve in the intermetatarsal space (between the toes) towards the top of the foot. The abnormal nerve is usually located between the third and fourth metatarsal.
Describe the pathophysiology of Morton’s neuroma [+]
Mechanical stress on the nerve causes microtrauma to nerve and surrounding tissues
Proinflammatory cascade occurs, leads to fibroblast activation and collagen deposits around nerve; causing perineural fibrosis.
As the condition progresses, the nerve undergoes demyelination; affecting nerve signal transmission
The enlargement of the nerve and surrounding fibrotic tissue creates a mass effect - leads to the characteristic symptoms of Morton’s neuroma.
Defo dont need to know this much detail
Describe the presentation of Morton’s neuroma [4]
forefoot pain
- most commonly in the third inter-metatarsophalangeal space
worse on walking.
- shooting or burning pain.
Patients may feel they have a pebble in their shoe
there may be loss of sensation distally in the toes
What is Mulder’s click? [1]
Mulder’s click:
- one hand tries to hold the neuroma between the finger and thumb.
- The other hand squeezes the metatarsals together.
- A click may be heard as the neuroma moves between the metatarsal heads
Describe the conservative [3] and surgical [2] management of Morton’s neuroma
Conservative Management:
* Footwear modification: Advise patients to wear shoes with a wide toe box and low heel. Custom orthotics or metatarsal pads may also be beneficial.
* Analgesia: Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain relief.
* Corticosteroid injection: Intralesional corticosteroid injections can provide temporary relief. However, repeated injections should be avoided due to potential adverse effects such as fat pad atrophy.
Surgical Management:
* Neurectomy: This involves excision of the affected nerve segment and is usually reserved for severe cases or when other treatments have failed.
* Nerve decompression: This procedure aims to relieve pressure on the nerve by cutting nearby structures such as the deep transverse metatarsal ligament.
What is a March Fracture? [1]
March fractures are a subtype of fatigue/stress fractures. They occur due to repeated concentrated trauma to a normal bone, classically the 2nd metatarsal of the foot but can occur in other weight-bearing bones of the lower limb and pelvis.
Describe the specific location of pain in:
- plantar fasciitis [2]
- fat pad atrophy [1]
Plantar fasciitis:
- pain on the bottom of the foot, around the heel and arch
- pain on medial aspect of calcaneus
Fat pad atrophy:
- central heel pain: ‘deep bruising like pain’
How would you differentiate calcaneus stress fracture from plantar fasciitis? [1]
PF pain is worse with initial activity, then relieved
Stress fracture pain will be worse with activity
