Foot pain, Plantar fasciitis and Stress fractures

Question 1

Risk factors for stress fractures

Answer 1

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

Question 2

clinical presentation of stress fracture

Answer 2

insidious onset of localized pain, point tenderness at fracture site (generally at navicular or metatarsals), possible negative XR in first 6 weeks

Question 3

management of stress fracture

Answer 3

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

Question 4

what can also predispose someone for a stress fracture?

Answer 4

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

Question 5

can XR see stress fracture?

Answer 5

can be negative up to 6 weeks after symptom onset and so it’s a clinical diagnosis.

Question 6

what to screen for when patient has stress fracture and female athlete triad?

Answer 6

estrogen and nutrient deficiencies and so screen for an eating disorder.

Question 7

plantar surface of heel pain and worse with initiating running or first steps of the day

Answer 7

plantar fasciitis

Question 8

burning pain or stiffness 2-6 cm above the posterior calcaneus

Answer 8

achilles tendinopathy

Question 9

Morton Neuroma clinical features

Answer 9

numbness and pain between 3 and 4th toes

clicking sensation when palpating the space between 3 and 4th toes while squeezing the metatarsal joints

Question 10

tarsal tunnel syndrome:

Answer 10

compression of tibial nerve at the ankle

burning and numbness and aching of the distal plantar surface between toes and foot.

Question 11

where does stress fractures most commonly happen?

Answer 11

in 2nd, 3rd, 4th metatarsal shafts.

Question 12

physical exam of stress fractures

Answer 12

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

Question 13

diagnosis stress fracture

Answer 13

clinically. XR can be normal up to 6 weeks after symptom onset. MRI or bone scan be done for definitive diagnosis .

Question 14

Mulder sign

Answer 14

clicking sensation that occurs with this space is palpated and the metatarsal joints are squeezed simultaneously

this is associated with Morton’s Neuroma

Question 15

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

Answer 15

Plantar fasciitis

Question 16

Sesamoiditis

Answer 16

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

Question 17

interdigital nerve compression is also known as

Answer 17

Morton’s neuroma

Question 18

what causes Morton’s neuroma?

Answer 18

high heeled shoes, runners, people with flat feet.

see repetitive injury leads to painful enlargement of plantar digital nerve between the metatarsal heads

Question 19

what are signs and symptoms of morton’s neuroma?

Answer 19

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

Question 20

treatment of morton’s neuroma?

Answer 20

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

Question 21

charcot joint is from

Answer 21

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.

Question 22

pain maximum upon 1st stepping out of bed, local point tenderness with dorsiflexion of the toes

Answer 22

plantar fasciitis

Question 23

sudden onset pain and loss of height of the arch and visible swelling and ecchymosis

Answer 23

ruptured plantar fascia

Question 24

bone infection/ metastasis -

Answer 24

see constant throbbing pain and nocturnal worsening

Question 25

worse with activity pain and palpation of bone elicits tenderness

Answer 25

calcaneal stress fracture

Question 26

pain, paresthesia and numbness on the sole of the foot. Percussion tenderness over the posterior tibial nerve in the tarsal tunnel

Answer 26

tarsal tunnel syndrome

Question 27

risk factors for plantar fasciitis

Answer 27

overweight individuals, runners/joggers, ballet dancers, and those who engage in prolonged standing, and those with flat feet (pes planus)

Question 28

Treatment of plantar fasciitis:

Answer 28

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.

Question 29

heel spurs

Answer 29

from inflammation of the fascia and seen with plantar fasciitis. THis is likely reactive bone formation.

Question 30

tarsal tunnel syndrome

Answer 30

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

Question 31

paresthesias and pain in distribution of middle foot (sole of foot and distal toes and foot)

Answer 31

see tarsal tunnel syndrome

Question 32

positive Tinel’s sign of ankle

Answer 32

tarsal tunnel syndrome

Question 33

treatment of tarsal tunnel syndrome

Answer 33

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.

Question 34

mulder sign:

Answer 34

numbness or tingling between third and fourth toes and clicking sensation

Seen with Morton’s neuroma.