Foot pain, Plantar fasciitis and Stress fractures Flashcards
All foot and ankle related problems
Risk factors for stress fractures
repetitive exercises (running and gymnastics), abrupt increase in physical activity inadequate calcium and vitamin D intake decreased caloric intake female athlete triad: low caloric intake, hypomenoarrhea, low bone density
clinical presentation of stress fracture
insidious onset of localized pain, point tenderness at fracture site (generally at navicular or metatarsals), possible negative XR in first 6 weeks
management of stress fracture
reduced weight bearing for 4-6 weeks, analgesics for 4-6 weeks and gradual resumption of activity when pain free.
referral to orthopedic surgeon for fracture at high risk for malunion (anterior tibial cortex, 5th metatarsal
what can also predispose someone for a stress fracture?
abrupt increase in activity or intensity of training, obesity, prior stress fracture, low bone mineral density and ill fitting shoes, poor running mechanics (pes planus or flat foot)
female with eating disorder
can XR see stress fracture?
can be negative up to 6 weeks after symptom onset and so it’s a clinical diagnosis.
what to screen for when patient has stress fracture and female athlete triad?
estrogen and nutrient deficiencies and so screen for an eating disorder.
plantar surface of heel pain and worse with initiating running or first steps of the day
plantar fasciitis
burning pain or stiffness 2-6 cm above the posterior calcaneus
achilles tendinopathy
Morton Neuroma clinical features
numbness and pain between 3 and 4th toes
clicking sensation when palpating the space between 3 and 4th toes while squeezing the metatarsal joints
tarsal tunnel syndrome:
compression of tibial nerve at the ankle
burning and numbness and aching of the distal plantar surface between toes and foot.
where does stress fractures most commonly happen?
in 2nd, 3rd, 4th metatarsal shafts.
physical exam of stress fractures
see focal tenderness holding the corresponding toe at the same level as metatarsal and pushing along the long axis of metatarsal (axial loading) can elicit pain
diagnosis stress fracture
clinically. XR can be normal up to 6 weeks after symptom onset. MRI or bone scan be done for definitive diagnosis .
Mulder sign
clicking sensation that occurs with this space is palpated and the metatarsal joints are squeezed simultaneously
this is associated with Morton’s Neuroma
point tenderness and burning pain in the plntar area of rearfoot that worsens with first steps in morning. Pain improves with activity during the day but can be worse if standing all day
Plantar fasciitis
Sesamoiditis
focal pain at the sesmoid bones of the plantar surface of the 1st metatarsophalangeal joint
pain worsens with walking, running and dorsiflexion of great toe
interdigital nerve compression is also known as
Morton’s neuroma
what causes Morton’s neuroma?
high heeled shoes, runners, people with flat feet.
see repetitive injury leads to painful enlargement of plantar digital nerve between the metatarsal heads
what are signs and symptoms of morton’s neuroma?
numbness and burning pain and see this pain located along plantar aspect of forefoot between 3 and 4th metatarsals.
May also describe stepping on a marble between her toes
treatment of morton’s neuroma?
need orthotic footwear and NSAIDs
Steroid injections can be used for symptomatic relief.
Surgical excision is for people who fail conservative therapy and remain symptomatic for >1 yr
charcot joint is from
progressive degenerative joint disease due to peripheral neuropathy
see swelling ,erythema and loss of sensation near peripheral neuropathy and see shoes swelling erythema and loss of joint sensation near joint.
pain maximum upon 1st stepping out of bed, local point tenderness with dorsiflexion of the toes
plantar fasciitis
sudden onset pain and loss of height of the arch and visible swelling and ecchymosis
ruptured plantar fascia
bone infection/ metastasis -
see constant throbbing pain and nocturnal worsening
worse with activity pain and palpation of bone elicits tenderness
calcaneal stress fracture
pain, paresthesia and numbness on the sole of the foot. Percussion tenderness over the posterior tibial nerve in the tarsal tunnel
tarsal tunnel syndrome
risk factors for plantar fasciitis
overweight individuals, runners/joggers, ballet dancers, and those who engage in prolonged standing, and those with flat feet (pes planus)
Treatment of plantar fasciitis:
most have complete resolution of pain within one year with conservative measures
treat with stretching exercises, , short term NSAIDs use, silicone heel shoe inserts
If those fail, can get steroid injections, which provide temporary relief.
Shock wave therapy and surgery are those for people who fail at 6-12 months.
heel spurs
from inflammation of the fascia and seen with plantar fasciitis. THis is likely reactive bone formation.
tarsal tunnel syndrome
compression of posterior tibial nerve compression as it passes under flexor retinaculum posterior to medial malleolus
seen in ankle fracture and dislocation of of talus, calcaneus or medial malleolus and scar tissue, bony spurs or bone cartilege fragments can compress nerve
also seen in RA or malignnacy
paresthesias and pain in distribution of middle foot (sole of foot and distal toes and foot)
see tarsal tunnel syndrome
positive Tinel’s sign of ankle
tarsal tunnel syndrome
treatment of tarsal tunnel syndrome
clinical diagnosis but EMG can be helpful.
Treatment is NSAIDS, shoe modification, steroid injectio nand decompressive nerve surgery in refractory cases
Severe nerve injury can cause atrophy of intrinsic foot muscles.
mulder sign:
numbness or tingling between third and fourth toes and clicking sensation
Seen with Morton’s neuroma.
