Regional Foot Pain Flashcards
Describe the symptoms of Plantar Fasciitis.
- insidious onset of first step pain
- inflammation
- pain close to plantar medial heel
What is the pathophysiology of plantar fasciitis?
- considered to be associated with repetitive tensile overloading of the soft tissue attachments e.g. bent foot and heavy load applied through foot
- pathological changes are comparable to those of tendinitis and tendinosis
Plantar Fasciitis is most commonly seen in…
- overweight individuals
- reported more frequently in females
- those with gastroc/soleus complex tightness
What is Plantar Fasciitis incorrectly termed?
- heel spur, due to radiological changes seen
- BUT heel spurs will not cause pain unless #
What is the treatment for Plantar Fasciitis?
- manage symptoms (RICER and rest)
- Stretching of aponeurosis and posterior muscle group
- correct biomechanical factors e.g. taping (first line), orthoses and footwear
- decrease irritation (rest)
- extracorporeal shockwave therapy
- Acupuncture ?
- Surgery ?
What type of footwear should be avoided in plantar fasciitis?
- negative heel shoe such as a soccer shoe
- puts foot into a DF position, which puts more pressure on the PF insertion
- want the patient to stretch but not that much and not whilst they are running
What is the benefit of orthoses in Plantar Fasciitis treatment?
- orthotics can speed the resolution of PF
Describe the symptoms of Achilles Tendinopathy?
- gradual onset
- swelling
- tenderness
- nodules
What is the pathophysiology of Achilles Tendinopathy?
- gradual onset due to overuse
- can be extrinsic/intrinsic
- insertional or non-insertional
- may start as local oedema and progress to degeneration and granulation
What are the precipitating factors for Achilles Tendinopathy?
- biomechanical deficits
- old age
- males
- increased body weight and height
- fluoroquinalone exposure
- tight gastroc/soleus complex
- common in runners
Achilles Tendinopathy is a combination of what degenerative changes?
tendinitis/osis
OR
paratendonitis/osis
What is the treatment for Achilles Tendinopathy?
- eccentric muscle loading (no dynamic stretching)
- rest with gradual return to activity
- heel lifts
- correct biomechanical factors
- steroid injections (last resort)
What is the pathophysiology of Retrocalcaneal Bursitis?
- inflammation of the bursa between Achilles tendon and calcaneus
- due to extrinsic factors
What is the treatment for Retrocalcaneal Bursitis?
- off-loading
- NSAIDs
Retrocalcaneal bursitis can progress into a…
Haglund’s deformity
What is the pathophysiology of Sever’s disease?
- calcaneal apophysitis
- inflammation of the growth plate caused by microtrauma
- self limiting
What factors can contribute to Sever’s?
- rapid growth
- tight calf muscles
- hard surfaces
- poor footwear
- occurs commonly in boys
How is Sever’s treated?
- heel raises
- footwear modifications
- stretching
- NSAIDs
What is a plantar fat pad contusion?
- injury to the protective fat pad on the plantar surface of the calcaneus
- acute or chronic
What is the treatment for a plantar fat pad contusion?
- rest
- use of heel cup
- good footwear
- compression
What is Sinus Tarsi Syndrome?
- injury of the interosseous talocalcaneal ligament within the sinus tarsi
What is the treatment for Sinus Tarsi Syndrome?
- rest
- corticosteroids
- Mx of biomech factors
- surgery (occasionally)
How long does a ligament, tendon and bone take to heal?
- ligament: 12 months
- tendon: 6 months
- bone: 6-8 weeks
What is the pathophysiology of Tarsal Tunnel Syndrome?
- constriction of the Posterior Tib nerve through the tarsal tunnel
What are the symptoms of Tarsal Tunnel Syndrome?
- neural symptoms
- pain extending into the plantar foot
How is Tarsal Tunnel Syndrome diagnosed?
- subjective information
- Tinel’s sign
- evidence of forced/ prolonged pronation
What is Tinel’s sign?
A way to diagnose irritated nerves by tapping on the nerve.
How is Tarsal Tunnel Syndrome treated?
Correct pronation so less tension on nerve.
What is the pathophysiology of Tarsal Coalition?
- tarsal bones develop a bridge between them (fibrous, osseous, cartilaginous)
- bones don’t separate during childhood, and they progressively ossify with age
What are the symptoms of Tarsal Coalition?
- majority are asymptomatic into adulthood
- symptomatic coalitions present in teenage years
- ossification of the bar will correspond with onset of symptoms
- cause painful flatfoot
- ankle sprains common
What coalition bars are common in Tarsal Coalition?
- calcaneonavicular most common followed by middle facet of talocalcaneal joint
- single coalition most common but more can be found
What coalition bar will ossify first?
- calcaneonavicular at 8-12 years
- talocalcaneal at 12-15 years
Treatment of tarsal coalition generally involves…
Surgery. Those who do not get surgery before 18 years old don’t fare well.
Is tarsal coalition genetic?
Yes it can be passed down and it is more common in boys than girls.
What comprises the mid-foot?
Cuboid, navicular, cuneiforms and surrounding soft tissues.
What is the pathophysiology of Adult Acquired Flatfoot Deformity (AAFFD)?
- progressive flattening of the medial longitudinal arch (MLA)
- can progress to deformity if not arrested
What is the most common aetiology of AAFFD?
- tib post dysfunction or insufficiency
What symptoms are related to AAFFD?
- pain along the tendon
- inability to complete a single leg raise
What is the treatment for AAFFD?
- physio
- taping
- orthosis (put into supinated position)
- shoe wear modifications
What form of tendinitis/opathy is most common in the mid-foot?
- extensors
- tib ant
How is tendinitis in the mid foot diagnosed?
Objective testing - palpation, passive motion and resisted motion
How is mid foot tendinitis treated?
- manage inflammation (NSAIDs)
- electrotherapeutic modalities
- soft tissue therapy (massage)
- concentric and eccentric exercises (to build strength)
- correct biomechanical factors
What is the pathophysiology of a Lisfranc fracture?
Injury, dislocation, or fracture of one or more of the tarsal in relation to the mid foot junction (generally traumatic).
What are the three classifications of a Lisfranc fracture?
- homolateral - all 5 mets are displaced in the same direction
- isolated - one or two mets are displaced from others
- divergent - mets are displaced in the sagittal or frontal plane
What is the treatment for Lisfranc fracture?
Casting or surgery.
What is the pathophysiology of a sprain?
Damage to one or more ligaments in a joint, may be preceded by a sudden sharp pain.
How are sprains classified?
- First degree: fibres stretched but in tact.
- Second degree: tear of part of a ligament, up to a third.
- Third degree: complete rupture of the ligament, frequently involves an avulsion #.
In which group/s of people are mid foot sprains most common?
- gymnasts
- jumpers
- footballers
What mid foot ligament is commonly sprained?
Spring ligament
What are the symptoms of a ligament sprain?
- localized tenderness
- limitation in joint movement
How is a mid foot sprain treated?
- acute Rx involves RICER
- taping
- orthoses
- NSAIDs
- corticosteroids
What is the pathophysiology of Cuboid Syndrome?
- subluxation of the cuboid
- often associated with peroneal tendinopathy, excessively pronated feet, or lateral instability
What are the symptoms of Cuboid Syndrome?
- pain with lateral WBing
- can see displacement sometimes
- history may include inversion sprain
How is Cuboid Syndrome treated?
- reduce subluxation
- manage associated inflammation
What is the pathophysiology of Kohler’s Disease?
- temporary avascular necrosis of the navicular bone
- navicular is subject to repetitive compressive forces
- navicular is more vulnerable to compressive damage as it is the last bone to ossify
What are the symptoms of Kohler’s Disease?
- gradual pain in medial aspect of foot
- painful limp
- shift of weight laterally to relieve pressure on MLA
- pain, tenderness and swelling in the area of the navicular
- tib post contraction may be painful
What is the prognosis for Kohler’s Disease?
- self limiting with good prognosis if well managed
- bone will regain normal shape before foot completes growth
- normal ossification reach at 2 y.o.
How is Kohler’s Disease treated?
- cast (WBing or NWBing)
- rest
- orthoses
What age is Kohler’s Disease most common?
3-7 years old
mainly boys
What is the pathophysiology of HAV?
- abduction and external rotation of the first toe
- adduction and internal rotation of the 1st met
- displacement of hallux at 1st MPJ
- displacement of met at met/cuneiform joint
When is abduction of the hallux considered a deformity?
When it is greater than 10-12 degrees.
What is the pathophysiology of Hallux Limitus?
- painful passive and active motion around the MPJ
- cause can be functional or structural
What are the symptoms of Hallux Limitus?
- dorsal exostosis may be evident
- limited ROM at 1st MPJ
What is the Hallux Rigidus?
- end point of hallux limitus
What is the treatment for hallux rigidus and limitus?
- biomechanical evaluation and management
- shoewear modifications
- surgical intervention may be required
What is the pathophysiology of sesamoiditis?
- gradual onset of pain over medial or lateral sesamoid with a limited, painful active ROM
What are the differential diagnoses for sesamoiditis?
- bipartite sesamoid
- osteochondritis dissecans
- sesamoid #
How can you distinguish between a bipartite sesamoid and a sesamoid #?
Bipartite sesamoids will have smoother edges whereas # sesamoids will demonstrate irregular edges on a radiograph.
What is the pathophysiology of Morton’s Neuroma?
- painful compression of nerve, usually between 3rd/4th
- tumour on nerve, tends to be benign
- interdigital nerve can be compressed during toe off
What are the symptoms of Morton’s Neuroma?
- burning and tingling down the interspace of involved toes
- radiating pain to the toes
- vague pain radiating up the leg
- worse in high heels or shoes with a narrow toe box
What is the treatment for Morton’s Neuroma?
reduce or remove pressure with padding or surgical excision.
- acute: a met dome
- chronic: surgery
What is the pathophysiology of Turf Toe?
Acute or traumatic tear of joint capsule from met head and subluxation or dislocation of 1st MPJ
How is Turf Toe caused?
hyperextension, hyperflexion or valgus injury
What is the treatment for Turf Toe?
- reduce activity
- wear an orthosis that block dorsiflexion (force hallux rigidus)
What is the pathophysiology of Freiburg’s Infraction?
- avascular necrosis of met head/s
- caused by repetitive stress with micro # at the junction of the metaphysics and growth plate
- # deprive epiphysis of adequate circulation
In which group of people does Freiburg’s infraction most commonly occur?
- prepubescent girls
- people whose 1st toe is shorter than their 2nd - more pressure through the second
What are the symptoms of Freiburg’s Infraction?
- pain in forefoot
- localized to head of 2nd met
What is the pathophysiology of Tailor’s Bunion?
- created by a wide 4th/5th IM angle
- 5th toe lies contracted in a dorsal medial direction over the 4th toe
- offending agent is usually the condyle of the proximal phalanx of 5th toe
What are the symptoms of Tailor’s Bunion?
- plantar callus due to concomitant PF of the 5th
- soft corn under 5th
- bunionette
What is the pathophysiology of Claw toes?
- hyperextension at the MPJ, flexion at the proximal and distal IPJs
- caused by an imbalance between extensor tendons and flexor tendons
- simultaneous contraction of extensors and flexors
- flexed IPJs are constantly irritated by shoe and painful met callosities develop
What is the differential diagnosis for claw toes?
- hammer toes
What are the predisposing conditions for claw toes?
- Rheumatoid arthritis
- Age
- Diabetes
- Compartment syndrome involving deep posterior compartment
- Polio
- Charcot Marie Tooth
- Stroke
- Pes Cavus foot
