Rearfoot Conditions/Posterior Heel Pain Flashcards
What are the common causes of Posterior Heel Pain
1 = 2
2 =2
3 =1
Soft Tissue:
* Inflamattion of Deep or Superficial Retrocalcaneal Bursae
* Inflamattion of Achilles Tendon (Rupture/Partial Rupture)
Bone Pathology:
* Haglunds Deformity (Boney Prominence Posteriolateral Calcaneus where Achilles Tendon Inserts)
* Posterior Heel Spur
Local Trauma
What is a Superficial Calcaneal Bursitis
What are the clinical features = 3
How can this pathology be managed = 3
Adventisious Bursa which forms between Calcaneal prominence or Achilies Tendon and the skin in response to friction/stress
Clinical Features:
* Inflamattion of Posterior Heel
* Hypertrophy of Superficial Fascia and Bone
* Antalgic Gait (Reduced Stance Phase due to Pain)
Management:
* Accomidative Footwear
* Clinical padding to reduce stress
* Heel Raise
Differential Diagnosis
Insertional Achilles Tedinopathy
What is a Retrocalcaneal Bursitus
Causes = 3
What are the clinical features = 3
How can this pathology be managed = 4
True Anatomical Bursa which forms between the calcaneus and the anterior surface of the Achillies Tendon
Causes:
* Over training
* Compressive Footwear
* Haglunds Deformity
Clinical Features:
* Diffue Pian posterior Calcaneus
* Soft tissue swelling medial or lateral Achillies insertion
* Antalgic Gait (Reduced Stance Phase due to pain)
Managment:
* Heel Raise
* Calf stretches
* Footwear advice
* Guided Steroid Injection
Differential diagnoses:
* Insertional Achillies Tedniopathy
* Severs disease
What is Achillies Tedinopathy
2
Pathological changes to the Achillies Tendon due to overuse or excesive stress (Load) upon the tendon
A lack of flexibility or a stiff Triceps Surae / tendon can increase the risk of these injuries.
Describe the location of both Mid Portion and Insertional Achillies Tedinopathy.
What is the fundamental difference between Mid Portion and Insertional Achillies Tedinopathy?
Mid-portion effects the narrowing in the tendon above the insertion (2-5cm above insertion)
Insertional is located lower as the tendon turns into bone and inserts into the calcaneus (At the Calcaneum)
Main difference is mid portion is irritated by end range of motion where Insertional tendinopathy is not.
List some of the known Tendon injury risk factors
6
Age - Decreased collagen synthesis
Sex - Spike and subsequent fall in collagen during menstural cycle
Medication - Increase risk of rupture when takin Fluroquinoline and Prednisolone
Smoking
Nutrition
Genetics
List possible differential diagnosis for Achillies Tedniopathy
Ankle Impingement
Retrocalcaneal Bursitus
Plantaris Tedinopathy
Haglunds Deformity
List possible treatment options for Achillies Tedinopathy 10
Firstline management NICE = Patient education
- Eccentric Strengthening (Alfredsons Protocol)
- Orthotcis device/ Heel raise
- Footwear advice
- Activity Modification
- Improve flexibility of the ankle and tricep surae
- ESWT Shockwave therapy
- High Volume Injection
- Low level Laser
- Topical GTN
Which test can be used to diagnose Achillies Tedinopathy
a) Hubschers Manovere
b) Royal London Hospital Test
c) Silverskiold test
d) Mulders Click
B) Royal London Hospital Test
- Patient in Prone
- Palpate Achillies Tendon for Tenderness
- Maximally Dorsiflex the ankle
- Posotive test is indicated if the pain in the tender spot initially found is absent in maximally dorsiflexed position
Define Adult Accquired Flat Foot 3
- First described as Posterior Tibial Tendon Dysfunction
- Pathology defined by the collapse of the medial longitudinal arch of the foot continued progressive valgus deformity of the foot and ankle.
- Also described as Pes Plano Valgus
Describe PTTD 4
- Degenerative and progressive tendinopathy of the Posterior Tibal Tendon
- Leads to significant changes in foot mechanics, plantar foot pain and MLA Arch Dysfunction
- Leading cause of adult acquired flat foot
- Failure of the Tendon affects surrounding ligamnets and leads to Osseus involvement and deformity
Explain why Posterior Tibial Tendon Dysfunction couild cause failure in the Plantar Ligaments? 4
The Plantar ligaments including Long and Short Plantar ligaments are insertion point for the PTT
The Intrinsic tension in the posterior tibialis muscle helps maintain integral tightness in these ligaments.
If tension from PTT is lost it can result in failure of the Plantar Ligament
PT assists in dynamic maintenance of the arches of the foot
Describe the signs and Symptomns of PTTD
7
- Sharp pain and swelling along the medial aspect of the foot and ankle exacerbated by excercise/activity
- Standing on their toes may be painful
- As the medial longitudinal arch collapses, the deformity of the foot increases
- In severe cases the distal fibula will come into contact with the calcaneus leading to compression of the Subtalar Sinus (Sinus Tarsi Syndrome)
- Difficulty/inability to perform unilateral heel raise. Limited calcaneal inversion upon ascent
- Impaired subtalar mobility long term (Subtalar Osteoarthritis / Ankle Osteoarthritis / Tarsal Coalition)
- Impairded Mobility
List the stages of AAFF/PTTD
Stage 1 = Tendonitis
Stage 2 = Elongated Tendinopathy
Stage 3 = Subtalar OA Changes
Stage 4 = Deltoid Laxity (Ankle Valgus)
The first two stages have only soft tissue problems while the third and fourth stages have resulted in associated joint osteoarthritis
What are the Possible Differential diagnosis for PTTTD 10
Baxter’s Nerve Entrapment / Popliteal Nerve Entrapment.
Trauma.
Flexible Flatfoot.
Subtalar Coalition.
Flexor Tendinopathies.
Tarsal Tunnel Syndrome.
Plantar Fasciopathy.
Achilles Tendinopathy.
Spring Ligament Injury.
Limb Length Discrepancy (One foot more pronated)
