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NMS 2 > Midterm > Flashcards

Midterm Flashcards

1
Q

What is the definition of a differential diagnosis list?

A

ordered list of PLAUSIBLE diagnoses

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2
Q

How is the DDx list structured?

A
  1. most plausible to rule IN 2. 2-3 next most plausible 3. 1-2 Dx to rule OUT
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3
Q

What is the purpose of the DDx list?

A

To guide physical exam - select procedures to rule in/out Dxes

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4
Q

What are 5 factors to consider that influence the DDx?

A
  1. epidemiology 2. location 3. etiology 4. quality 5. diagnostic uncertainty
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5
Q

What are the 4 general causes of overpronation syndrome?

A
  1. too much, too fast, wrong time 2. osseous anomalies 3. functional causes 4. neurological
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6
Q

Which diagnoses causes the heel to be too supinated/inverted during heel strike? (3)

A

Rearfoot varum, tibia varum, genu varum

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7
Q

Which side of the heel will have exaggerated wear in a pt with rearfoot varum?

A

lateral side

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8
Q

Which muscles will show fatigue or weakness in a pt with rearfoot varum/

A

gastroc, tib ant., tib post.

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9
Q

Tx for rearfoot varum - adjustment?

A

subtalar and midtarsal joints

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10
Q

Tx for rearfoot varum - orthotic?

A

medial rearfoot post

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11
Q

Which diagnosis requires more pronation to engage the 1st ray in take-off?

A

Forefoot varum

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12
Q

Which muscle will be tight in a pt with forefoot varum/

A

tib ant.

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13
Q

Which muscle will be weak in a pt with forefoot varum?

A

peroneus longus

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14
Q

Tx for forefoot varum - adjustment?

A

midtarsal, intermetatarsal, 1st MTP joints

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15
Q

Tx for forefoot varum - orthotic?

A

Medial forefoot post

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16
Q

Will a pt with tibia varum over- or underpronate?

A

Either - depends on foot rigidity. Rigid foot = underpronator

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17
Q

When would pronation control shoes be appropriate Tx for tibia varum?

A

If pt is overpronating

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18
Q

Tx for tibia varum - orthotic?

A

medial rearfoot post

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19
Q

Which pt are at an increased risk for inversion sprain? (2x more likely)

A

tibia varum

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20
Q

Which msls are weak in a pt with genu varum?

A

hip ext. rotators

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21
Q

Which msls are tight in a pt with genu varum?

A

medial hamstrings and gracilis

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22
Q

Tx for genu varum - adjustment?

A

back, hip, knee, foot

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23
Q

What would cause underpronation in a pt with genu varum?

A

rigid supinated foot

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24
Q

Which diagnoses cause the pt to footstrike on the medial side of the heel? (2)

A

genu valgum, rearfoot valgum

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25
Q

Which side of the heel will have exaggerated wear in a pt with rearfoot or genu valgum?

A

medial heel wear

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26
Q

Tx for genu/rearfoot valgum - adjustment?

A

back, hip, knee, foot

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27
Q

What is the relationship between flexibility and support in a pt with genu/rearfoot valgum?

A

increased flexibility requires increased support

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28
Q

Which msls will be tight in a pt with genu/rearfoot valgum?

A

hamstrings, hip and knee rotators

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29
Q

Which msls will be weak in a pt with genu/rearfoot valgum?

A

quads, tib ant., posterior msls

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30
Q

Tx for genu/rearfoot valgum - orthotic?

A

medial post

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31
Q

Which 3 first ray abnormalities cause late pronation?

A
  1. hallux valgus 2. morton’s foot 3. dorsiflexed 1st metatarsal
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32
Q

What is defined as lateral deviation of the 1st toe?

A

hallux valgus

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33
Q

what is defined as an elongated 2nd metatarsal (relative to others)?

A

Morton’s foot

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34
Q

What are 5 general Tx approaches for overpronation syndrome?

A
  1. adjusting/mobilization 2. foot exercises 3. taping 4. pronation control shoes 5. orthotics
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35
Q

How should you determine what joint/direction to adjust in a pt with overpronation syndrome?

A

JOINT PLAYS - don’t assume medial side needs to be moved superiorly

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36
Q

What are 4 examples of foot exercises for pts with overpronation syndrome?

A
  1. short/small foot 2. toe extensions 3. heel walk/toe walk 4. tubing
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37
Q

What are short/small foot exercises?

A

static/standing engagement of intrinsic msls

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38
Q

What are some characteristics of pronation control shoes?

A

stiff shoe, rigid heel counter, straight last, board last

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39
Q

What are the two general types of orthotics?

A
  1. accommodative 2. functional
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40
Q

Which type of orthotic is most commonly used?

A

functional - cheaper

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41
Q

What condition is defined as “forefoot pain typically localized to the distal intermetatarsal region”?

A

metatarsalgia

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42
Q

Is metatarsalgia always localized?

A

No - can be generalized foot pain

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43
Q

Metatarsalgia - epidemiology? (6)

A
  1. elderly 2. obesity 3. pregnancy 4. footwear (no evidence) 5. recreation/running surface 6. diabetes (weak connection)
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44
Q

Metatarsalgia - etiology? (2)

A
  1. repetitive overuse 2. gradual onset of initial symptoms
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45
Q

Why does repetitive overuse lead to metatarsalgia?

A

leads to ligamentous laxity and overpronation

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46
Q

What is the quality of pain in metatarsalgia?

A

dull, achy.

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47
Q

Which arch will a pt with metatarsalgia have pain in?

A

transverse arch

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48
Q

What condition is often described as “a pebble in my shoe”?

A

specific metatarsalgia - may have callous formation

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49
Q

T/F: metatarsalgia pain is constant in the acute phase

A

False - waxes and wanes b/t latent and acute exacerbations

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50
Q

What determines the severity of metatarsalgia?

A

how many metatarsals are affected and the phase of injury

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51
Q

What is a pertinent negative for metatarsalgia?

A

absense of neuro sx

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52
Q

What are 3 pertinent positives for metatarsalgia?

A
  1. assoc w/ footwear 2. timing w/in gait cycle 3. callous formation
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53
Q

DDx for metatarsalgia? (6)

A
  1. overpronation syndrome 2. mortons neuroma 3. stress fx 4. OA/RA/gout 5. Freibergs dz (osteochondrosis) 6. sesamoiditis
54
Q

Physical exam findings for metatarsalgia? (5)

A
  1. callous formation 2. rigid foot 3. osseous anomalies 4. muscular imbalances 5. splay foot
55
Q

What is defined as “loss of transverse arch d/t laxity of transverse metatarsal ligaments”?

A

splay foot

56
Q

Which msls would be tight in a pt with metatarsalgia?

A

triceps surae

57
Q

Tx for metatarsalgia - ACUTE?

A

rest, ice, indirect U/S, CMT (foot, back, etc), tape, light massage

58
Q

Tx for metatarsalgia - CHRONIC?

A

stretching (triceps surae), strengthening triceps surae, short foot exercises, continue CMT/STM

59
Q

What is the normal ratio for posterior compartment msls: anterior compartment msls?

A

10:1

60
Q

When should you expect to see marked improvement in metatarsalgia pts?

A

w/in 1-3 weeks

61
Q

What should be done for metatarsalgia pts if no significant improvement is seen in 3 weeks?

A

consider ancillary studies depending on etiology

62
Q

Which condition is defined as “inflammation of the proximal attachment of the plantar fascia”?

A

plantar fasciitis

63
Q

What are some common risk groups for plantar fasciitis?

A

athletes, sedentary females, obesity, pregnancy, military/workers who mostly stand

64
Q

What age group has the highest incidence of plantar fasciitis?

A

40-60 yrs (younger in runners)

65
Q

Does plantar fasciitis cause more inflammation at the proximal or distal attachment?

A

usually proximal, rarely distal

66
Q

Why can plantar fasciitis cause bone remodeling?

A

Wolffs law - bone remodeling d/t stress

67
Q

Is plantar fasciitis pain localized or global?

A

Usually very localized

68
Q

Which direction does plantar fasciitis pain usually radiate?

A

distally. Rarely radiates proximally

69
Q

Is plantar fasciitis gradual or sudden onset?

A

gradual

70
Q

What is the general chronology of plantar fasciitis pain?

A

morning stiffness/pain that lessens as day continues

71
Q

What is the quality of plantar fasciitis pain?

A

stiffness alternating with sharp pain.

72
Q

What can “tired and achy feet” be a sign of?

A

EARLY plantar fasciitis

73
Q

What tends to make plantar fasciitis worse?

A

prolonged static or dynamic wt bearing

74
Q

Which condition is a common comorbidity w/ plantar fasciitis?

A

achilles tendinopathy

75
Q

What are some other possible associated symptoms with plantar fasciitis? (4)

A
  1. swelling (unilaterally) 2. bruising (rare) 3. achilles tenderness 4. recent fever
76
Q

Possible DDx for plantar fasciitis?

A

Calcaneal bursitis, overpronation syndrome, metatarsalgia, achilles tendinopathy, subtalar DJD, Dupuytren’s contracture, inflammatory arthropathies

77
Q

Which condition would have PE findings of a tender medial calcaneal tubercle, tender medial longitudinal arch, and a positive Stretch Test?

A

plantar fasciitis

78
Q

Which muscles would be tight in pt with plantar fasciitis?

A

triceps surae

79
Q

which muscles would be weak in pt with plantar fasciitis?

A

dorsiflexors and inverters (tib ant/post)

80
Q

Tx for plantar fasciitis - ACUTE?

A

POLICE, PT, heel pads/cups, mobilization/manipulation, night splints, footwear advice, taping/bracing, acupuncture

81
Q

What does POLICE stand for?

A

Protect, Optimally Load, Ice, Compress, Elevate

82
Q

What type of night splints should be used for plantar fasciitis?

A

splints that promote dorsiflexion

83
Q

How should you tape for plantar fasciitis?

A

Teardrop taping - use flexible tape, ie Elastikon

84
Q

Tx for plantar fasciitis - CHRONIC?

A

continuous U/S, ESWT, CMT, STM, myofascial release, stretching, rehab, wt loss, acupuncture, injections (prolotherapy)

85
Q

What type of exercises should be implemented in a rehab program for plantar fasciitis?

A

stretch triceps surae, short foot exercises, marble exercises, knee rehab

86
Q

Has shockwave therapy been shown to be effective in improving plantar fasciitis?

A

yes - meta analysis of 11 RCTs

87
Q

have night splints and foot orthoses been shown to be effective in treating plantar fasciitis?

A

Recent evidence is limited and inconsistent

88
Q

How soon should you see a 50% improvement in a pt with plantar fasciitis?

A

within weeks

89
Q

How soon should you expect to see full resolution of plantar fasciitis?

A

within months (dependent on compliance)

90
Q

Which condition is defined as “tendon injury characterized by pain, swelling and tenderness at or near the Achilles region?”

A

achilles tendinopathy

91
Q

When should the condition be referred to as achilles tendinITIS?

A

in presence of inflammation - usually ACUTE phase

92
Q

When should the condition be referred to as achilles tendinOSIS?

A

in absence of inflammation - usually CHRONIC phase

93
Q

What are 3 epidemiology categories to consider for achilles tendinopathy?

A
  1. Age 2. overweight/obesity 3. impactful ADL/profession
94
Q

Why is there an increasing prevalence of achilles tendinopathy proportional to age?

A

diminishing fat pad, circulation, and flexibility

95
Q

What are 3 etiologies/risk factors for achilles tendinopathy?

A
  1. repetitive overuse 2. sports training errors 3. fluoroquinolones (in older pts)
96
Q

What are fluoroquinolones?

A

anti-microbial drugs with a strong association with achilles tendinopathy

97
Q

What are 3 notable Hx findings in a pt with achilles tendinopathy?

A
  1. localized acute pain 2. assoc. with ballistic movements 3. morning “stiffness” w/ or w/o pain
98
Q

Where is pain localized to in achilles tendinopathy?

A

localized to achilles tendon, may radiate to entire calf or ankle

99
Q

Does the morning stiffness assoc. with achilles tendinopathy get better or worse as the day progresses?

A

Worsens with wt bearing or participation in aggravating activities

100
Q

Possible DDX for achilles tendinopathy?

A

plantar fasciitis, calcaneal bursitis, reactive arthritis, drug side effects

101
Q

Will you typically see swelling/bruising/deformity with achilles tendinopathy?

A

NO

102
Q

Will you tend to see over-or underpronation in a pt with achilles tendinopathy?

A

Overpronation - may be cause OR effect

103
Q

What is the hallmark location for tenderness on palpation in a pt with achilles tendinopathy?

A

1-2 in. above calcaneal tuberosity

104
Q

Which motion will be diminished in achilles tendinopathy?

A

dorsiflexion

105
Q

Which joints will likely be restricted with achilles tendinopathy?

A

talocrural and subtalar

106
Q

What motion may produce pain in a pt with achilles tendinopathy?

A

stretching or active toe raises

107
Q

Tx for achilles tendinopathy - ACUTE?

A

POLICE, PT, CMT, STM, taping/splinting, nutrition

108
Q

Have night splints and orthoses been shown to be effective in treating achilles tendinopathy?

A

No - studies showed that night splints did not seem to make a difference. Inconclusive evidence on orthoses

109
Q

Tx for achilles tendinopathy - CHRONIC?

A

contrast therapy, CMT, STM, splinting

110
Q

If you are not seeing results after Tx for achilles tendinopathy, what are some possible referral alternatives? (4)

A
  1. topical NSAIDs 2. injections 3. prolotherapy 4. surgical repair
111
Q

Which condition is defined as “tissue damage and resultant inflammation of the retrocalcaneal bursa”?

A

retrocalcaneal bursitis (RCB)

112
Q

What is the function of a bursa?

A

reduce friction b/t soft tissue layer

113
Q

What is RCB aka?

A

subcutaneous calcaneal bursitis

114
Q

Risk factors for RCB? (5)

A
  1. poorly fitting shoes 2. repetitive microtrauma 3. acute trauma 4. osseous deformity 5. overpronation (?)
115
Q

How do you differentiate the cause of painful “pump bumps”?

A

Texture - SOFT = swollen bursa, HARD = osseous anomaly

116
Q

DDX for RCB?

A

plantar fasciitis, achilles tendinopathy, sever’s dz, Fx, inflammatory arthritides, infection (TB)

117
Q

What is the result of a posterior/calcaneal squeeze in a pt with RCB?

A

reproduces CC pain

118
Q

Tx for RCB?

A

POLICE, PT, short foot exercises, injections (?)

119
Q

In RCB pts, will you see a reduction in swelling or pain first?

A

Reduction in pain first

120
Q

how soon should you expect to see a reduction in pain in RCB pts?

A

1 wk

121
Q

How soon should you expect to see a reduction in swelling in RCB pts?

A

3-4 wks

122
Q

Which has the best prognosis: plantar fasciitis, achilles tendinopathy, or RCB?

A

RCB

123
Q

Which condition is defined as “traction apophysitis at cartilagenous growth center into which the achilles tendon inserts on the calcaneus”?

A

Sever’s dz

124
Q

What condition in the knees is a good analogy for Sever’s dz?

A

Osgood-Schlatter

125
Q

What age group is at the highest risk for Sever’s dz?

A

boys age 7-15, girls age 5-13

126
Q

What is the most common cause of heel pain in athletes aged 5-11 years?

A

Sever’s dz

127
Q

What are two other risk factors for Sever’s dz (besides age group)?

A

overweight/obesity, poorly fitting shoes

128
Q

Tx for Sever’s dz?

A

POLICE, PT, short foot exercises, injections (?)

129
Q

When should xray be considered for pts with Sever’s dz?

A

in cases that are unresponsive to care (last ditch study)

130
Q

What is the prognosis for Sever’s dz?

A

self-limiting - usually respond quickly to treatment

NMS 2 (1 decks)

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