Week 8 finished

Question 1

Case info:

Answer 1

Laura is a 43 year-old mother of 4 who works long hours on her feet as a theatre nurse. Laura decided recently that the long hours were taking a toll on her and preventing her from supporting her kids through their high school exams so she cut her work back to three days per week.
Laura says she used to be quite active but for the last five or six years her work schedule has limited her ability to do any regular exercise, she thought working less was a good excuse to re-join the gym and get back into shape. She is about 15kg overweight but otherwise healthy.
Laura presents to your clinic with left heel and plantar pain. She says she had something similar years ago but it went away after seeing a podiatrist who taped her foot. She notes that the pain is particularly severe each morning on rising and also occurs toward the end of, and after her nursing shifts. She thinks the problem began after jogging on the treadmill six weeks ago.

Question 2

1. Review the bones of the foot and ankle and their relationships to one another.

Answer 2

Tarsals:

• Talus
• Calcaneus
• Cuboid
• Navicular
• 3 x cuneiforms

Metatarsals x 5

2 x sesamoid bones

14 x phalanges

Question 3

2. List the major ligaments supporting the talocrural and subtalar joints.

Answer 3

Medial Collateral (Deltoid) Ligament

• Fan-shaped ligament arising from the tibial malleolus and attaching to the navicular (anteriorly), talus and calcaneus (posteriorly & inferiorly).
• It limits medial distraction

Lateral Collateral Ligament

• Composed of the anterior (weakest) and posterior (strongest) talofibular ligaments and the calcaneofibular ligament.
• Inferior extensor retinaculum and superior peroneal retinaculum contribute to stability. Generally weaker and more prone to injury than the deltoid ligament.

Question 4

3. What movements are available at the talocrural and subtalar joints? What is the most stable position for each joint?

Answer 4

Talocrural joint:

• Dorsiflexion and plantar flexion across an oblique axis through the 2 malleoli and the body of the talus. This means that the movement at this joint actually occurs across 3 planes.
• Inclined laterally 10 degrees to horizontal
• Rotated laterally 20-30 degrees to coronal.

Most stable position is in Dorsiflexion.

Subtalar joint:

• Pronation and supination across an oblique axis so that movement occurs over all 3 planes.
• Supination = calcaneal adduction, inversion and plantar flexion.
• Pronation = calcaneal abduction, eversion and dorsiflexion

Most stable position is Supination as ligamentous tension draws the joint surfaces together

Question 5

What is the normal ROM of the talocrural joint?

Answer 5

20 degrees DF

30-50 degrees PF

Question 6

4. What is the major function of the mid- or transverse- tarsal joints?

Answer 6

It allows independent movement of the forefoot and rear foot and allows the foot to change according to the terrain.

Question 7

What is the transverse tarsal joint made of?

Answer 7

The talcalcaneaonavicular joint and the calcaneocuboid joint.

Question 8

5. Define the following conditions which affect the digits:

a. Metatarsalgia

Answer 8

Is pain at the metatarsal heads often associated with weight gain, pes planus and poor intrinsic muscle use preventing toe weight bearing and increasing metatarsal head weight bearing.

Question 9

5. Define the following conditions which affect the digits:

b. March fracture

Answer 9

• Stress fracture of the metatarsals (usually 2nd or 3rd) typically associated with excessive walking.
• Tender lump in the neck of the met. Predisposed by calf tightness.

Question 10

5. Define the following conditions which affect the digits:

c. Frieberg’s disease

Answer 10

Is avascular necrosis of met head

Question 11

5. Define the following conditions which affect the digits:

d. Morton’s neuroma

Answer 11

• Usually affects women around 40-50.
• An enlargement of the plantar digital nerves – usually between 3rd and 4th digits.
• The enlargement gets compressed between the ground and the transverse metatarsal ligaments and is irritated.

Question 12

5. Define the following conditions which affect the digits:

e. Sesamoiditis

Answer 12

Inflammation of the sesamoid bone

Question 13

5. Define the following conditions which affect the digits:

f. Hammer toe

Answer 13

• Associated with metatarsophalangeal extension and fixed PIP flexion – usually accepted but some undergo surgery.
• Imbalance of flex/ext associated with weakness of the interossei and lumbricals.

Question 14

5. Define the following conditions which affect the digits:

g. Hallux valgus

Answer 14

• Commonest deformity of foot – associated with shoes (not seen in people who’ve never worn shoes) especially high heels.
• May consist of metatarsal splaying with valgus hallux causing crowding of other toes and likely bunion – often leads to OA.
• Also associated with pes planus.

Question 15

5. Define the following conditions which affect the digits:

h. Hallux rigidus

Answer 15

Pain on walking, unable to extend toe, decreased stride length

Question 16

6. What is the relationship of pes planus to all of these conditions? https://open.spotify.com/track/1Je1IMUlBXcx1Fz0WE7oPT

Answer 16

• Pes Planus (flat foot) = poor arches -> lack of support and distribution of forces.
• Increases weight distribution towards the medial side of the foot -> predisposing one to metatarsalgia, sesamoiditis and March fracture, etc
• Flattened foot -> broader -> shoes are tighter-> predispose one to Hallux Valgus and even Rigidus

Question 17

7. Trigger points in extensor digitorum longus and tibialis anterior can cause toe and foot pain. Which conditions do these mimic?

Answer 17

The pain can feel as though its originating from the joint when in fact its originating from tibialis anterior.
This pain is often falsely attributed to arthritis, “turf toe” or gout. (trigger points that mimic gout and actual gout can commonly coexist).

Question 18

8. List the structures passing under the flexor retinaculum. What is tarsal tunnel syndrome?

Answer 18

The flexor retinaculum creates the tarsal tunnel posterior and inferior to the medial malleolus. It encloses:

• the tendons of the flexors of the ankle and foot
• posterior tibial artery and vein
• posterior tibial nerve

TOM DICK AND VERY NAUGHT HARRY (ANT TO POST)

Tarsal tunnel syndrome is analogous with carpal tunnel syndrome.

• involves heel pain from compression of the tibial nerve often by inflamed flexor tendons.
• The pain is often worse at night and patient may get up and stamp foot, walk or twist foot.

Question 19

9. List the tarsals forming the transverse arch and the medial longitudinal arch. Which tarsal is the key in each arch?

Answer 19

TRANSVERSE ARCH: Best visualised at the level of the anterior row of the tarsal bones.
Formed by:
- the metatarsal bases
- cuboid
- 3 cuneiforms
** the medial cuneiform is the keystone of the arch.

MEDIAL LONGITUDINAL ARCH: 
Formed by:
 - the calcaneus
 - the talus
 - the navicular
 - the three cuneiforms
 - the first 3 metatarsal bones
** talus forms the keystone of the arch.

Question 20

10. List the dynamic and static supports of each of the plantar arches.

Answer 20

TRANSVERSE ARCH:
- Tibialis anterior: originates in the upper two-thirds of the lateral surface of the tibia and interosseous margins, and inserts into the medial cuneiform and medial and plantar surfaces of the first metatarsal.

• Peroneus Longus: head and proximal 1/3 of the lateral surface of the fibula and crosses the plantar surface of the foot to attach to the lateral sides of the medial cuneiform and 1st metatarsal base.

GENERAL LONGITUDINAL ARCH:
- Flexor digitorum longus: arises from the posterior surface of the body of the tibia and inserts into the bases of the last phalanges of the second, third, fourth, and fifth toes.

• Flexor hallucis longus: arises from the inferior two-thirds of the posterior surface of the body of the fibula and inserts into the base of the last phalanx of the great toe.
• Peroneus Longus: head and proximal 1/3 of the lateral surface of the fibula and crosses the plantar surface of the foot to attach to the lateral sides of the medial cuneiform and 1st metatarsal base.

MEDIAL LONGITUDINAL ARCH:
- Plantar calcaneonavicular ligament (spring ligament) is the main ligamentous support - anterior margin of the sustentaculum tali of the calcaneus to the plantar surface of the navicular.

• Tibialis posterior - Runs posterior to the medial malleolus and inserts on the navicular, cuneiforms, cuboid and bases of 2nd to 4th metatarsals.

LATERAL LONGITUDINAL ARCH:
Long plantar ligament supports the lateral aspect of the longitudinal ligament.

Question 21

11. What is policeman’s heel?

Answer 21

Policeman’s heel refers to tenderness under the calcaneous in the location of the fibro-fatty tissue. If this tissue degenerates or spreads out its cushioning affect is reduced and inflammation or contusion of the underlying calcaneous may ensue. Can be differentiated from plantar fasciitis as stretching the plantar surface does not aggravate policeman’s heel.

Question 22

12. Describe the anatomy of the Achilles (calcaneal) tendon.

Answer 22

• Begins as a continuation of the gastroc aponeurosis about halfway down the calf.
• Fibres are joined by the soleus, Soleus inserts medial and gastrocs inserts laterally on calcaneus.
• Insertion of gastroc soleus and plantaris
• Inserts on posterior surface of the calcaneous.
• Myofascially continuous with plantar fascia
• Fibres wrap around each other and assist recoil. (Typically the fibres wind 90 degrees so the gastroc ends up attaching more laterally – wind up to store energy.)

Question 23

On questioning, you find that Laura works on concrete and lino flooring and generally wears ballet flats under her booties at work. She has tried massaging and icing her feet but this provides only temporary relief.
Clinical application

Answer 23

xx

Question 24

13. List the causes of heel pain.

Answer 24

• Planatar fasciitis
• Calcaneal bursitis
• Fat pad iritiation
• Gout
• L5 disc herniation (causing S1 radiculopathy)
• Tarsal tunnel syndrome
• Entrapment of the lateral plantar nerve
• Rupture of the plantar fascia
• Calcaneal stress fracture
• Achilles tendonitis (tear, rupture, inflammation, soleus rupture will refer pain down the posterior aspect of the calcaneus.
• Bone bruises
• Haglund’s deformity (bony growth at the back of
  the heel)
• Sever’s disease (Growth plate closes around 11,
  consider up to age of 15)
• Soft-tissue sarcoma of the foot (rare)
• Stress fractures of the heel.
• Infection

Question 25

14. What might cause pain in the medial plantar aspect of the foot

Answer 25

• Tear of tendons of:
  - tibialis anterior
  - tibialis posterior
  - peroneus longus
• Plantarfasciitis
• Tenosynovitis
• Tarsal tunnel syndrome
• Metatarsalgia
• Sesamoiditis
• March fracture (Navicular stress fracture)
• Frieberg’s disease - avascular necrosis of met head.
• Hammer toe
• Hallux valgus
• Hallux rigidus
• TP referral
• Gout
• Intrinsic mm spasm

Question 26

15. Entrapment of which nerve(s) may cause heel and plantar pain?

Answer 26

Posterior tibial nerve (branches into medial and lateral plantar nerves)

Medial calcaneal nerve

Question 27

16. What factors may be contributing to this patient’s condition?

Answer 27

• Overweight
• Poor choice in foot wear
• Biomechanics – Pes Planus
• Standing long periods of time
  o Surface is the most important (she’s on concrete)
• Netball
  o Especially if she is not training approtialy.

Question 28

17. What is plantar fasciitis? What factors contribute to this condition? What is the clinical presentation?

Answer 28

• Inflammation of the plantar fascia at its attachment to the calcaneus, characterised by a gnawing pain or
  discomfort in the heel that radiates along the sole of the foot.
  PRESENTING COMPLAIN: usually burning, stabbing or aching pain in the heel or foot.
  o Site: medial aspect of heel.
  o Onset: insidious, with no history of trauma.
  o Pattern: worse in morning, pain gradually decreased with movement, may have post-activity ache.

AGG FACTORS: long periods of standing or physical activity, hard surfaces, increase activity, poor footwear, increased age (PF is more fibrous).

• May have other associated symptoms (altered biomechanics).
  - pes cavus: poor biomechanics so the elastic structures cannot reduce ‘jarring’ of foot properly.

Question 29

18. How may pes cavus and pes planus precipitate plantar fasciitis?

Answer 29

• Pes planus
  o On weight bearing, pronation of the foot lengthens and places extra tension through the plantar fascia.
• Pes cavus
  o Excessive supination, also causes shortening of the plantar fascia.
  o If congenital, means plantar fascia is ACTUALLY shorter.

Question 30

19. How is the plantar fascia related to the Achilles tendon?

Answer 30

Myofascially related

Question 31

20. How might hamstring shortening relate to the development of plantar fasciitis?

Answer 31

• Biomechanically
  o Hamstrings are compromised in flexing the knee, if tight
  
  • In running, may miss heel strike, therefore they will overprontate, and put extra stress on the plantar fascia.
    o Also the gastrocnemius has to compensate by contracting more, increasing pull on calcaneus (rotating it
    anteriorly and lengthening the plantar fascia)
• Myofascially
  o The hamstring tightness, increases tension in the SBL (superficial back line) -> has consequences in the gastrocs and even the plantar fascia with which it is continuous.

Question 32

21. What is a heel spur? What is the clinical significance of heel spurs?

Answer 32

• Growth of bone extending from calcaneous towards toes.
• Calcaneal spur (usually not significant as they rarely cause pain, but can be associated with plantar fascitis)
• More likely to be micro-tears in plantar facsica causing the pain.
• 15% of unsymptomaic population will have, only 50% will have one
  - Ie if someone has been diagnosed by GP, only because they have a heel spur, doesn’t mean its plantar fasciaitis

Question 33

22. How can myofascial continuity be used to explain the relationship between the plantar fascia, low back pain, posture and headache?

Answer 33

Superficial back line