The leg and foot

Question 1

Medial tibial stress syndrome - What is it?

Answer 1

Periostitis (inflammation of the band of tissues that surrounds the periosteum) of medial margin of tibia, although no unanimity of opinion regarding definition. Exertional lower leg pain posteromedial tibial border. Linear, not focal.

Question 2

What is medial tibial stress syndrome often wrongly referred to as…

Answer 2

‘Shin splints’

Shin splints is an umbrella term including compartment syndrome , stress fractures, muscle hernia, tendon strain.

Question 3

Clinical features of medial tibial stress syndrome

Answer 3

Pain on loading (usually running, climbing etc) distal medial
margin tibia. Eases with rest. Often assoc with change in work/athletic routine, type/volume activity, footwear etc.

Usually full painless ROM all joints. Resisted movements usually
painless. Possible pain on repeated hopping or, if severe, repeated p.flexion + inversion.

Often ↑ pronation. Tenderness+ along distal medial tibia.

Possible minor swelling in medial compartment.

X-Rays will be negative. MRI Ix of choice.

Question 4

Medial tibial stress syndrome- treatment

Answer 4

Stop aggravating activity to prevent chronicity

If athlete, can maintain fitness using non-WB, non-impact activtiy

Crucuial to identify precipitative factor(s) + address accoridngly. May include:

 Compressive strapping
 Stretching + Strengthening, possible mobilisations
 Orthotics
 Activity modification and gradual return
 NSAIDs, acupuncture, ice etc

Question 5

Stress fracture - lower limb
What is it

Answer 5

repetitive/excessive stress on bone → accl normal
bone remodeling → microfractures due to insufficient time for
bone to repair → bone stress injury → stress #.

Question 6

% of sporting injuries- stress fractures lower limb

Answer 6

10% (Robertson and Wood, 2017)

Question 7

Stress fracture - Lower limb

Answer 7

 Tibia –75% of all stress #’s. Prox to mid-point. Can occur
anterior or posteromedial diaphysis
 Fibula –usually distal third
 Navicular
 2nd -4thmetatarsals (usually 2nd)
 5thmetatarsal –base
 Sesamoids –great toe
 Can also occur medial malleolus and calcaneus
 Ant tibial, navicular, med malleolus, 5thMT + sesamoids are
‘high-risk’ as ↑ chance → to full fracture and/or non-union

Question 8

Stress fracture - lower limb (Clinical features)

Answer 8

 Pain localised over # site on activity, nearly always WB/impact

 Usually assocwith a change in activity egvolume/nature

 Often deep ache, initially eases with rest, but steadily ↑ to
include night pain + resting pain

May be assocwith problems with bone health eg↓ vit D, ↓ calcium, eating disorders, osteoporosis.

More common in females, espabnormal/absent menstruation

 Exam often unremarkable. Posstenderness over # site on
percussion. Also single leg hopping + tuning fork. However, no single test of proven reliability

 X-Rays commonly clear, espin first 4-8wks. MRI Ix of choice

Question 9

Stress fracture- lower limb treatment

Answer 9

 Physiotherapist’s primary job is to diagnose

 History + knowledge of common stress # sites will raise level of suspicion

 REST, REST, REST from causative activity. This may include splinting, boot, POP, NWB or simple activity
modification

Maintain fitness whilst fracture healing

 Rehabilitation when fracture healed → graded rtnto activity

May need to assess progress with imaging

 Surgery if # does not heal. Much more common in high risk
stress #’s

Question 10

Ankle sprain- what is it?

Answer 10

Tearing of ankle lgts/capsule due to excessive force.
GrI = microtearing, grossly intact; GrII = incomplete tear; GrIII =
rupture

Question 11

Inversion sprains

Answer 11

most common (85% of all ankle sprains) + often cited as most common sports injury. Ligaments injured =
ant talofibular lgt (ATFL) → calcaneofibular lgt (CFL) →
calcaneocuboid lgt (CCL) → post talofibular lgt (PTFL)

Question 12

High ankle sprains

Answer 12

1-11%
- distal tib/fib syndesmosis is
damaged, (dorsiflexion/external rotation force)

Question 13

Eversion sprains

Answer 13

strong + extensive deltoid lgt is
damaged. Often this leads to bony avulsion

Question 14

Intra-articular damage - ankle sprains

Answer 14

Can occur + is frequently missed, with serious repercussions for the pt eg osteochondral damage, talar
dome #

Question 15

Ankle sprain - clinical features

Answer 15

Sudden traumatic onset
Pain, swelling, bruising, possible instability

Question 16

What must you check for with ankle sprain

Answer 16

Effusion –swelling post jteither side of Achilles. A missed
effusion, and, therefore, a missed intra-articular lesion in an
ankle, which is then treated as a conventional lat lgtsprain, is
one of the most common, avoidable causes of patients having
to retire from sport/activities
 Lgttear/instability –inversion +/-pflexion(ATFL), dflexion
(CFL); drawer test, palpation
 Deltoid lgtavulsion
 High ankle sprain tests –dflexion+ extrotation, squeeze test
 Talardome #, osteochondral lesion –punch test
May need X-Rays and/or MRI
 Beware persistent/disproportionate pain in a seemingly mild
ankle sprain

Question 17

Ankle effusion

Answer 17

 X-Ray showing classic
teardrop shape to anterior
ankle effusion. However, it
is the posterior aspect of
the effusion that is normally
easiest to detect clinically,
although it tends to be less
defined radiographically.

Question 18

Ankle sprain - treatment

Answer 18

Crucial to diagnose nature and severity of injury as accurately as possible, although often have to wait until acute phase has settled.

Acute phase- rid swelling/effusion, protect lgts from further damage + maintain movt in pain free range - PRICE, strapping, splinting, rehab, possible boot/POP

Rehab phase- mobilisation of foot/ankle jts, strapping, progreeive rehab to address strength + proprioception. Gradually progress to include WB + impact type exercises, depending upon pt’s objectives.

May need strapping/splinting on return to sport.

Question 19

Persistent pain after ankle sprain…

Answer 19

Needs to be reviewed and if not investigated.

Osteochondral lesions, talar dome fractures, navicular fractures with possible subsequent AVN, avuslion fractures and syndesmosis disruption/instability are all frequently missed.

Question 20

What is plantar fasciitis

Answer 20

Inflammation of the plantar fascia, usually
medial calcaneal tubercle, due to repetitive, excessive,
unaccustomed or prolonged stress

Question 21

Plantar fasciitis

Answer 21

Pain under heel on rising, prolonged walking or standing. Often eases initially with exercise
 Also aggravated by walking uphill + unsupportive/worn shoes
May have restricted calf or ankle or foot, esp mid
tarsal joint. Particularly linked with hyperpronation + pes planus
 Associated with obesity, standing jobs, high impact
sports

Question 22

Plantar fasciitis treatment

Answer 22

 Identify aggravating/precipitative factor(s) and address.
This could include footwear, weight, ergonomics, posture, leisure/sporting activities
 NSAIDs, ice
 Stretches/soft tissue work to calf/fascia
Mobilisations to ankle, foot
 Strapping
 Heel pads and/or orthotics
 Injection
 Dry needling
 Shockwave

Question 23

Orthotics

Answer 23

 Based on the theory that small alterations in the biomechanics of the foot/ankle will have a ‘knock-on
effect’ up the lower limb and beyond.

 Thus, biomechanical anomalies in the lower limb can cause an array of lower limb/back problems, ranging
from sciatica to plantar fasciitis.

 These anomalies may be congenital, developed or
acquired.

 An orthotic purports to correct these biomechanical
anomalies.

Question 24

Orthotics solution:

Answer 24

 History, history, history
 Look for changes –activities, lifestyle, footwear,
disease profile, imaging.
 The default position should be to use orthotics as a last resort, unless there are very persuasive clinical
arguments to the contrary
 Can use them as a temporary measure much more
frequently
 Always follow up the patient