Midterm Flashcards
What is the definition of a differential diagnosis list?
ordered list of PLAUSIBLE diagnoses
How is the DDx list structured?
- most plausible to rule IN 2. 2-3 next most plausible 3. 1-2 Dx to rule OUT
What is the purpose of the DDx list?
To guide physical exam - select procedures to rule in/out Dxes
What are 5 factors to consider that influence the DDx?
- epidemiology 2. location 3. etiology 4. quality 5. diagnostic uncertainty
What are the 4 general causes of overpronation syndrome?
- too much, too fast, wrong time 2. osseous anomalies 3. functional causes 4. neurological
Which diagnoses causes the heel to be too supinated/inverted during heel strike? (3)
Rearfoot varum, tibia varum, genu varum
Which side of the heel will have exaggerated wear in a pt with rearfoot varum?
lateral side
Which muscles will show fatigue or weakness in a pt with rearfoot varum/
gastroc, tib ant., tib post.
Tx for rearfoot varum - adjustment?
subtalar and midtarsal joints
Tx for rearfoot varum - orthotic?
medial rearfoot post
Which diagnosis requires more pronation to engage the 1st ray in take-off?
Forefoot varum
Which muscle will be tight in a pt with forefoot varum/
tib ant.
Which muscle will be weak in a pt with forefoot varum?
peroneus longus
Tx for forefoot varum - adjustment?
midtarsal, intermetatarsal, 1st MTP joints
Tx for forefoot varum - orthotic?
Medial forefoot post
Will a pt with tibia varum over- or underpronate?
Either - depends on foot rigidity. Rigid foot = underpronator
When would pronation control shoes be appropriate Tx for tibia varum?
If pt is overpronating
Tx for tibia varum - orthotic?
medial rearfoot post
Which pt are at an increased risk for inversion sprain? (2x more likely)
tibia varum
Which msls are weak in a pt with genu varum?
hip ext. rotators
Which msls are tight in a pt with genu varum?
medial hamstrings and gracilis
Tx for genu varum - adjustment?
back, hip, knee, foot
What would cause underpronation in a pt with genu varum?
rigid supinated foot
Which diagnoses cause the pt to footstrike on the medial side of the heel? (2)
genu valgum, rearfoot valgum
Which side of the heel will have exaggerated wear in a pt with rearfoot or genu valgum?
medial heel wear
Tx for genu/rearfoot valgum - adjustment?
back, hip, knee, foot
What is the relationship between flexibility and support in a pt with genu/rearfoot valgum?
increased flexibility requires increased support
Which msls will be tight in a pt with genu/rearfoot valgum?
hamstrings, hip and knee rotators
Which msls will be weak in a pt with genu/rearfoot valgum?
quads, tib ant., posterior msls
Tx for genu/rearfoot valgum - orthotic?
medial post
Which 3 first ray abnormalities cause late pronation?
- hallux valgus 2. morton’s foot 3. dorsiflexed 1st metatarsal
What is defined as lateral deviation of the 1st toe?
hallux valgus
what is defined as an elongated 2nd metatarsal (relative to others)?
Morton’s foot
What are 5 general Tx approaches for overpronation syndrome?
- adjusting/mobilization 2. foot exercises 3. taping 4. pronation control shoes 5. orthotics
How should you determine what joint/direction to adjust in a pt with overpronation syndrome?
JOINT PLAYS - don’t assume medial side needs to be moved superiorly
What are 4 examples of foot exercises for pts with overpronation syndrome?
- short/small foot 2. toe extensions 3. heel walk/toe walk 4. tubing
What are short/small foot exercises?
static/standing engagement of intrinsic msls
What are some characteristics of pronation control shoes?
stiff shoe, rigid heel counter, straight last, board last
What are the two general types of orthotics?
- accommodative 2. functional
Which type of orthotic is most commonly used?
functional - cheaper
What condition is defined as “forefoot pain typically localized to the distal intermetatarsal region”?
metatarsalgia
Is metatarsalgia always localized?
No - can be generalized foot pain
Metatarsalgia - epidemiology? (6)
- elderly 2. obesity 3. pregnancy 4. footwear (no evidence) 5. recreation/running surface 6. diabetes (weak connection)
Metatarsalgia - etiology? (2)
- repetitive overuse 2. gradual onset of initial symptoms
Why does repetitive overuse lead to metatarsalgia?
leads to ligamentous laxity and overpronation
What is the quality of pain in metatarsalgia?
dull, achy.
Which arch will a pt with metatarsalgia have pain in?
transverse arch
What condition is often described as “a pebble in my shoe”?
specific metatarsalgia - may have callous formation
T/F: metatarsalgia pain is constant in the acute phase
False - waxes and wanes b/t latent and acute exacerbations
What determines the severity of metatarsalgia?
how many metatarsals are affected and the phase of injury
What is a pertinent negative for metatarsalgia?
absense of neuro sx
What are 3 pertinent positives for metatarsalgia?
- assoc w/ footwear 2. timing w/in gait cycle 3. callous formation
DDx for metatarsalgia? (6)
- overpronation syndrome 2. mortons neuroma 3. stress fx 4. OA/RA/gout 5. Freibergs dz (osteochondrosis) 6. sesamoiditis
Physical exam findings for metatarsalgia? (5)
- callous formation 2. rigid foot 3. osseous anomalies 4. muscular imbalances 5. splay foot
What is defined as “loss of transverse arch d/t laxity of transverse metatarsal ligaments”?
splay foot
Which msls would be tight in a pt with metatarsalgia?
triceps surae
Tx for metatarsalgia - ACUTE?
rest, ice, indirect U/S, CMT (foot, back, etc), tape, light massage
Tx for metatarsalgia - CHRONIC?
stretching (triceps surae), strengthening triceps surae, short foot exercises, continue CMT/STM
What is the normal ratio for posterior compartment msls: anterior compartment msls?
10:1
When should you expect to see marked improvement in metatarsalgia pts?
w/in 1-3 weeks
What should be done for metatarsalgia pts if no significant improvement is seen in 3 weeks?
consider ancillary studies depending on etiology
Which condition is defined as “inflammation of the proximal attachment of the plantar fascia”?
plantar fasciitis
What are some common risk groups for plantar fasciitis?
athletes, sedentary females, obesity, pregnancy, military/workers who mostly stand
What age group has the highest incidence of plantar fasciitis?
40-60 yrs (younger in runners)
Does plantar fasciitis cause more inflammation at the proximal or distal attachment?
usually proximal, rarely distal
Why can plantar fasciitis cause bone remodeling?
Wolffs law - bone remodeling d/t stress
Is plantar fasciitis pain localized or global?
Usually very localized
Which direction does plantar fasciitis pain usually radiate?
distally. Rarely radiates proximally
Is plantar fasciitis gradual or sudden onset?
gradual
What is the general chronology of plantar fasciitis pain?
morning stiffness/pain that lessens as day continues
What is the quality of plantar fasciitis pain?
stiffness alternating with sharp pain.
What can “tired and achy feet” be a sign of?
EARLY plantar fasciitis
What tends to make plantar fasciitis worse?
prolonged static or dynamic wt bearing
Which condition is a common comorbidity w/ plantar fasciitis?
achilles tendinopathy
What are some other possible associated symptoms with plantar fasciitis? (4)
- swelling (unilaterally) 2. bruising (rare) 3. achilles tenderness 4. recent fever
Possible DDx for plantar fasciitis?
Calcaneal bursitis, overpronation syndrome, metatarsalgia, achilles tendinopathy, subtalar DJD, Dupuytren’s contracture, inflammatory arthropathies
Which condition would have PE findings of a tender medial calcaneal tubercle, tender medial longitudinal arch, and a positive Stretch Test?
plantar fasciitis
Which muscles would be tight in pt with plantar fasciitis?
triceps surae
which muscles would be weak in pt with plantar fasciitis?
dorsiflexors and inverters (tib ant/post)
Tx for plantar fasciitis - ACUTE?
POLICE, PT, heel pads/cups, mobilization/manipulation, night splints, footwear advice, taping/bracing, acupuncture
What does POLICE stand for?
Protect, Optimally Load, Ice, Compress, Elevate
What type of night splints should be used for plantar fasciitis?
splints that promote dorsiflexion
How should you tape for plantar fasciitis?
Teardrop taping - use flexible tape, ie Elastikon
Tx for plantar fasciitis - CHRONIC?
continuous U/S, ESWT, CMT, STM, myofascial release, stretching, rehab, wt loss, acupuncture, injections (prolotherapy)
What type of exercises should be implemented in a rehab program for plantar fasciitis?
stretch triceps surae, short foot exercises, marble exercises, knee rehab
Has shockwave therapy been shown to be effective in improving plantar fasciitis?
yes - meta analysis of 11 RCTs
have night splints and foot orthoses been shown to be effective in treating plantar fasciitis?
Recent evidence is limited and inconsistent
How soon should you see a 50% improvement in a pt with plantar fasciitis?
within weeks
How soon should you expect to see full resolution of plantar fasciitis?
within months (dependent on compliance)
Which condition is defined as “tendon injury characterized by pain, swelling and tenderness at or near the Achilles region?”
achilles tendinopathy
When should the condition be referred to as achilles tendinITIS?
in presence of inflammation - usually ACUTE phase
When should the condition be referred to as achilles tendinOSIS?
in absence of inflammation - usually CHRONIC phase
What are 3 epidemiology categories to consider for achilles tendinopathy?
- Age 2. overweight/obesity 3. impactful ADL/profession
Why is there an increasing prevalence of achilles tendinopathy proportional to age?
diminishing fat pad, circulation, and flexibility
What are 3 etiologies/risk factors for achilles tendinopathy?
- repetitive overuse 2. sports training errors 3. fluoroquinolones (in older pts)
What are fluoroquinolones?
anti-microbial drugs with a strong association with achilles tendinopathy
What are 3 notable Hx findings in a pt with achilles tendinopathy?
- localized acute pain 2. assoc. with ballistic movements 3. morning “stiffness” w/ or w/o pain
Where is pain localized to in achilles tendinopathy?
localized to achilles tendon, may radiate to entire calf or ankle
Does the morning stiffness assoc. with achilles tendinopathy get better or worse as the day progresses?
Worsens with wt bearing or participation in aggravating activities
Possible DDX for achilles tendinopathy?
plantar fasciitis, calcaneal bursitis, reactive arthritis, drug side effects
Will you typically see swelling/bruising/deformity with achilles tendinopathy?
NO
Will you tend to see over-or underpronation in a pt with achilles tendinopathy?
Overpronation - may be cause OR effect
What is the hallmark location for tenderness on palpation in a pt with achilles tendinopathy?
1-2 in. above calcaneal tuberosity
Which motion will be diminished in achilles tendinopathy?
dorsiflexion
Which joints will likely be restricted with achilles tendinopathy?
talocrural and subtalar
What motion may produce pain in a pt with achilles tendinopathy?
stretching or active toe raises
Tx for achilles tendinopathy - ACUTE?
POLICE, PT, CMT, STM, taping/splinting, nutrition
Have night splints and orthoses been shown to be effective in treating achilles tendinopathy?
No - studies showed that night splints did not seem to make a difference. Inconclusive evidence on orthoses
Tx for achilles tendinopathy - CHRONIC?
contrast therapy, CMT, STM, splinting
If you are not seeing results after Tx for achilles tendinopathy, what are some possible referral alternatives? (4)
- topical NSAIDs 2. injections 3. prolotherapy 4. surgical repair
Which condition is defined as “tissue damage and resultant inflammation of the retrocalcaneal bursa”?
retrocalcaneal bursitis (RCB)
What is the function of a bursa?
reduce friction b/t soft tissue layer
What is RCB aka?
subcutaneous calcaneal bursitis
Risk factors for RCB? (5)
- poorly fitting shoes 2. repetitive microtrauma 3. acute trauma 4. osseous deformity 5. overpronation (?)
How do you differentiate the cause of painful “pump bumps”?
Texture - SOFT = swollen bursa, HARD = osseous anomaly
DDX for RCB?
plantar fasciitis, achilles tendinopathy, sever’s dz, Fx, inflammatory arthritides, infection (TB)
What is the result of a posterior/calcaneal squeeze in a pt with RCB?
reproduces CC pain
Tx for RCB?
POLICE, PT, short foot exercises, injections (?)
In RCB pts, will you see a reduction in swelling or pain first?
Reduction in pain first
how soon should you expect to see a reduction in pain in RCB pts?
1 wk
How soon should you expect to see a reduction in swelling in RCB pts?
3-4 wks
Which has the best prognosis: plantar fasciitis, achilles tendinopathy, or RCB?
RCB
Which condition is defined as “traction apophysitis at cartilagenous growth center into which the achilles tendon inserts on the calcaneus”?
Sever’s dz
What condition in the knees is a good analogy for Sever’s dz?
Osgood-Schlatter
What age group is at the highest risk for Sever’s dz?
boys age 7-15, girls age 5-13
What is the most common cause of heel pain in athletes aged 5-11 years?
Sever’s dz
What are two other risk factors for Sever’s dz (besides age group)?
overweight/obesity, poorly fitting shoes
Tx for Sever’s dz?
POLICE, PT, short foot exercises, injections (?)
When should xray be considered for pts with Sever’s dz?
in cases that are unresponsive to care (last ditch study)
What is the prognosis for Sever’s dz?
self-limiting - usually respond quickly to treatment
