Common Foot Problems

Question 1

What are the most common cause of posterior heel pain? [1]

Answer 1

Achilles tendon disorders

Question 2

Which antibiotic class [and give an example] is associated with tendon disorders? [1]

Answer 2

quinolone use (e.g. ciprofloxacin) is associated with tendon disorders

Question 3

The Achilles tendon connects which muscles [2] to which bone? [1]

Answer 3

The Achilles tendon connects the calf muscles (gastrocnemius and soleus) to the heel (the calcaneus bone)

Question 4

What are the two types of Achilles tendinopathy? [2]

Answer 4

Insertion tendinopathy (within 2cm of the insertion point on the calcaneus)
Mid-portion tendinopathy (2-6 cm above the insertion point)

Question 5

The typical presentation of Achillese tendinopathy is with a gradual onset of..[5]

Answer 5

• Pain or aching in the Achilles tendon or heel, with activity
• Stiffness
• Tenderness
• Swelling
• Nodularity on palpation of the tendon

Question 6

How do you differentiate Achilles tendinopathy from Achilles tendon rupture? [1]

Answer 6

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.

Question 7

When should you suspect Achilles tendon rupture? [1]

How would you confirm this? [1]

Answer 7

• 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.

Question 8

Where exactly does Achilles tendon rupture occur? [1]

Answer 8

rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region

Question 9

Treatment of Achilles tendinopathy (tendinitis)? [1]

Treatment of Achilles tendon rupture? [1]

Answer 9

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.

Question 10

How would movement person be affected in a Achilles tendon rupture? [2]

Answer 10

Unable to stand on tiptoes on the affected leg alone

Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)

Question 11

What is the role of the plantar fascia? [1]

Which structures in the foot does it attach to? [2]

Answer 11

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

Question 12

What causes plantar fasciitis? [1]

Answer 12

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

Question 13

Describe the clinical presentation of plantar fasciitis

Answer 13

Inferior heel pain on pressure (100%).
- Usually worse on the first steps out of bed in the morning
- May ease on walking but worse with heavy activity or standing
- Tenderness to palpate

Question 14

Describe a clinical test can perform to diagnose PF [1]

Answer 14

Positive ‘windlass test’ (sensitivity 31.8%, specificity 100%):
- if there is pain at the heel area when the toes are passively dorsiflexed (upwards)

Question 15

Treatment for PF?

Answer 15

**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).

Question 16

What is meant by fat pad atrophy? [1]

Answer 16

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.

Question 17

How does fat pad atrophy present? [1]

How can you meaure the level of fat pad atrophy? [1]

Answer 17

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.

Question 18

Describe what is meany by Morton’s neuroma [1]

Answer 18

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.

Question 19

Describe the pathophysiology of Morton’s neuroma [+]

Answer 19

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

Question 20

Describe the presentation of Morton’s neuroma [4]

Answer 20

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

Question 21

What is Mulder’s click? [1]

Answer 21

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

Question 22

Describe the conservative [3] and surgical [2] management of Morton’s neuroma

Answer 22

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.

Question 23

What is a March Fracture? [1]

Answer 23

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.