Common Musculoskeletal Problems: Foot and Heel Flashcards
What are the 2 common types of foot deformity?
- Flat feet
- Pronation/eversion
- Stresses the ankle
- Hind foot valgus
- Rigid and inflexible - High arched feet
- Supination/inversion
- Pressure on lateral border and ball of foot
- Hind foot varus
List 8 causes of pain in the foot and heel
- Structural
- Flat or high-arches foot - Hallux valgus/rigidus
+/- OA - Metatarsalgia
- Stress fracture
- Inflammatory arthritides
- Mono (gout), poly (RA), oligo (spondlyo) - Tarsal tunnel syndrome
- Heel pain
- Plantar fasciitis
- Plantar spur
- Calcaneal bursitis
- Achilles tendonitis/bursitis
- Sever’s disease - Arthritis of ankle/subtaloid joint
True or false: flat foot is a pronation deformity causing hind foot varus
False - pronation causing hind foot valgus
True or false: pes cavus is a pronation deformity causing hind foot valgus
False - this is flat foot (pes planus). High arches (pes cavus) causes supination and hind foot varus.
Describe hallux valgus deformity and list 3 causes
Lateral migration of great toe
- Congenital - metatarsus primus varus
- Late-onset - shoe-shape
- Complication of RA
A 50 year old patient presents with a stiff, dorsiflexed and painful great toe. What is the diagnosis and how would you manage this patient?
Hallux rigidus - OA of 1st MTP Rx: - Footwear - Podiatry - Surgical correction (some cases)
List 4 risk factors for developing metatarsalgia
- Women wearing heels
- Following trauma
- Hammer toe
- RA - ‘rheumatoid forefoot’
How does metatarsalgia manifest and how is it managed?
- Pain in ball of foot on weight-bearing
- Callosities and bursae under metatarsal heads
- Misalignment of metatarsals and severe pain in RA
Rx:
- Appropriate footwear
- Podiatry
- Surgery - in RA forefoot
A 45 year old female presents with pain, burning and numbness in their 3rd and 4th toes when walking. What is the diagnosis and how would you manage this patient?
Morton’s metatarsalgia
- Wide cushioned shoes
- Steroid injection
- Surgical excision
What is a march fracture and how is it diagnosed?
Aka ‘stress fracture’ - # of the distal third of one of the metatarsals occurring because of recurrent stress.
- Sudden onset severe weight bearing pain, localised
- Local tenderness and swelling
- Xray: initially normal - Dx delayed until callus formation
- Radioisotope bone scan or MRI reveals # earlier
What is the issue in diagnosing march fracture?
Xray:
- Initially normal
- Dx delayed until callus formation
Radioisotope bone scan or MRI reveals # earlier
How would you manage a stress fracture?
- Reduced weight-bearing for a few weeks
2. Investigate and treat osteoporosis
A patient presents with burning, tingling and numbness of the toes, sole and medial arch. What is the diagnosis? What would you expect to find on examination?
Tarsal tunnel syndrome
- Tenderness below the medial malleolus
- Tinel’s sign - tapping produces shock-like pain
Where should a steroid injection be introduced to treat tarsal tunnel syndrome?
Under retinaculum, between medial malleolus and calcaneus
What is plantar fasciitis and what can it lead to?
Aka calcaneal enthesitis - an inflammation at the insertion of the Achilles tendon into the calcaneum
- Localised pain and tenderness under heel when weight-bearing
May lead to plantar spurs.
What are the risk factors for plantar fasciitis?
- Tight calf muscles
- Pes cavus
- Obesity
- Repetitive or new impact activity, e.g. running
- Spondyloarthritis
What are plantar spurs and what age group do they commonly affect?
Traction lesions at the insertion of the plantar fascia in older people
- Usually asymptomatic
- Painful after trauma
What is an adventitious bursa?
Pressure-induced bursa
How is calcaneal bursitis distinguished from calcaneal enthesitis (plantar fasciiitis) pain?
Sideways compression of heel pad - produces pain in calcaneal bursitis
Diffuse (bursitis) versus localised pain (fasciitis)
A patient present with pain under the heel which is worse in morning as soon as weight is placed on foot. What is your differential diagnosis?
- Plantar fasciitis
- Plantar spurs
- Calcaneal bursitis
How is pain under the heel treated?
- Heel pads
- Reduced walking
- Dorsiflexion splint at night
- Stretch plantar fascia - Injection
- Medial approach with US
Where should a steroid injection be introduced to treat pain under the heel?
Medial approach under US guidance
What is an apophysitis?
An inflammation of an outgrowth, projection, or swelling
What is an enthesitis?
An inflammation at the site where tendons or ligaments insert into bone
What is Sever’s disease?
A traction apophysitis of the Achilles tendon in young people due to inflammation of the calcaneal growth plate.
True or false: Osgood-Schlatter disease is a traction apophysitis of the Achilles tendon in young people
False - this is Sever’s disease. Osgood-Schlatter disease is a similar disorder of the patellar tendon
A patient present with a painful, tender swelling a few centimetres above the ankle posteriorly. They have recently received a course of antibiotics to treat a UTI. What is the most likely diagnosis?
Quinolone-induced Achilles tendonosis
What are the risk factors for Achilles tendon rupture?
- Trauma - repetitive, unaccustomed use, poor sporting technique
- Quinolone antibiotic therapy
- Local injection
How is Achilles tendonosis treated?
Tendonitis
- Rest
- NSAIDs, ice packs
- Steroid injection
- Autologous platelet concentrates - poor evidence
- Casting or splinting (equinus position) or orthosis
- Surgery - for rupture
True or false: the Achilles bursa can be safely injected with corticosteroid
True - lies clearly anterior to tendon; treatment for Achilles bursitis
A patient presents with severe pain in the front of the shin and foot drop. What is the most likely diagnosis?
Anterior tibial syndrome - may require immediate surgical decompression to prevent necrosis
A patient present with lower leg pain that is aggravated by exercise. What is the differential diagnosis?
- Chronic compartment syndrome
- Vascular disorder
- Neurological disorder
