ankle and foot pain

Question 1

an achillles tendinopathy can occur at two locations, which two locations?

Answer 1

1. insertional: at calcaneus
2. non-insertional: occurs 4-5 cm proximal to calcaneus

Question 2

what are s&s of Achilles tendinopathy?

Answer 2

pain in achilles
pain worse with activity
squeeking of ankle during plantarflexion
walking is more comfortable in high heels or open back shoes
ttp: achilles tendon
non-insertional: possible thickening of the tendon of palpation
insertional: possible bony protuberance on calcaneus
non-insertional: possible swelling of tendon

Question 3

what is the treatment for achilles tendinopathy?

Answer 3

NSAIDs
gentle achilles stretching
foot and ankle mobilisation
ultrasound
myofascial release
immobilise
! injection is not indicated because corticosteroids might increase the risk for a tendon rupture!

Question 4

what are s&s of an achilles rupture?

Answer 4

sudden, severe pain in the achilles
bruising and swelling in posterior calf to calcaneus
unable to bear weight
palpable defect in achilles tendon
+ve thompson (calf squeeze) test

Question 5

what is a dancer’s/Jones fracture of the foot?

Answer 5

fracture of 5th metatarsal styloid process (peroneus tertius attachment)

Question 6

what is a bedroom fracture of the foot?

Answer 6

fracture of the 5th proximal phalanx shaft

Question 7

what is the mechanism of injury in a calcaneal fracture?

Answer 7

compression on loading through heel (ef fall from ladder onto heels)
high probability of associated Tx or Lx compression fracture

Question 8

what is the most common site for stress fractures in the foot?

Answer 8

2nd and 3 rd metatarsals

Question 9

what is the most common fracture in running athletes and what are the s&s?

Answer 9

navicular fracture
- pain on forefoot which may come on during or after activity

Question 10

what is the cause of gout/pseudogout?

Answer 10

build up of uric acid crystals within the joint space

Question 11

which joint is most commonly affected in gout?

Answer 11

1st MTP (great toe)

Question 12

what are s&s of gout?

Answer 12

sudden onset
joint red hot and swollen
no systemic symptoms

Question 13

what are risk factors for gout?

Answer 13

alcoholism
diuretics
poor hydration
high purine diet

Question 14

what is hallux valgus deformity of the foot?

Answer 14

lateral displacement of the great toe (may predispose bunion formation) often caused by poor fitting shoes

Question 15

what other condition can be associated with hallux valgus deformity?

Answer 15

pes planus (hyperpronation)
poor intrinsic muscle activation

Question 16

what is metatarsalgia?

Answer 16

refers to pain and tenderness over the plantar head of the metarsals

Question 17

what is morton’s neuroma?

Answer 17

a benign swelling of a nerve in the foot due to a degenerative process

Question 18

what are the possible causes of morton’s neuroma?

Answer 18

prolonged compression (irritation causes oedema)
poor fitting shoes
pregnancy
trauma
RA
hyper pronation
prolonged crouched position
conditions alternating normal weight bearing in the foot

Question 19

who is most at risk to develop morton’s neuroma?

Answer 19

female
<50

Question 20

what are s&s of morton’s neuroma?

Answer 20

severe, burning pain between the 2nd and 4th toes (MC 3rd and 4th)
worse with weightbearing on hard surfaces, wearing tight shoes and activities causing toe extension
relieved by taking shoes of or massaging
localised tenderness over MT head
+ve morton’s neuroma test

Question 21

what is the management for morton’s neuroma?

Answer 21

correctly fitting shoes
calf stretching exercises
orthotic pads
steroid injection or surgical decompression if no relief with conservative care

Question 22

what is the most common site in the foot for OA to occur?

Answer 22

1st metatarsal phalangeal (big toe)

Question 23

what are s&s of 1st MTP OA?

Answer 23

gradually increasing discomfort
reduced ROM (dorsiflexion)
shortened stride lenght

Question 24

what is the management for 1st MTP OA?

Answer 24

roomy protective foot wear
relative stress
SMT of affected joint
home exercises (stretching to into plantarflexion)

Question 25

what is the most common location for osteochondritis dissecans in the foot?

Answer 25

the lateral talar dome

Question 26

what are s&s of osteochondritis dissecans of the talus?

Answer 26

commonly asymptomatic and incidental finding intermittend weight bearing pain (especially when running) symptoms may onset if the osteochondral fragment is detached eg after ankle sprain joint pain, swelling and locking instability

Question 27

what is the mechanism of injury in plantar fasciitis/fasciosis?

Answer 27

disorganisation of local collagen fibres with an increase in fibroblasts numbers + minimal inflammation

Question 28

what are s&s of plantar fasciitis?

Answer 28

mostly UL heel pain (if BL consider spondylonegative arthropathy) pain on the plantar aspect of the heel typically increased across the course of the day worse with standing and walking after sitting, getting out of bed relieved with walking around for a little bit after standing up tenderness over the medial calcaneal tuberosity +ve windlass test tight achilles hyper pronation of foot crepitus

Question 29

which imaging would you refer to for plantar fasciitis?

Answer 29

US

Question 30

who is most at risk to develop plantar fasciitis?

Answer 30

obese >40

Question 31

what is the management plan for plantar fasciitis?

Answer 31

correct mechanical changes in LL stretching and massaging achilles and calf orthotic prescription

Question 32

what is sinus tarsi?

Answer 32

injury to the anatomical tunnel between the tarsal and calcaneus (lateral foot)

Question 33

what are the possible causes of sinus tarsi?

Answer 33

ankle inversion sprain repetitive load on a hyper-pronated ankle

Question 34

what are s&s of sinus tarsi?

Answer 34

pain anterior to lateral malleolus feeling of instability within the ankle trouble walking on uneven surfaces

Question 35

in which conditions is bilateral heel pain common?

Answer 35

ankylosing spondylitis reiter's syndrome reactive arthritis psoriatic arthritis enteropathic arthropathy

Question 36

what is the most commonly sprained ligament in the ankle?

Answer 36

anterior talo-fibular ligament (ATFL) (calcaneofibular ligament CFL and then posterior talo-fibular ligament) due to plantar flexion-inversion

Question 37

what is the mechanism of injury in a deltoid ligament sprain?

Answer 37

forced eversion

Question 38

what is the mechanism of injury for a high ankle sprain (distal tib-fib syndesmosis)?

Answer 38

forced external rotation (particularly in dorsiflexion)

Question 39

what are s&s of an ankle sprain?

Answer 39

pain, bruising and swelling over the area of ligament inability to weightbear ttp over ligament and muscular attachment points (eg fibular head) +ve ligament laxity tests +ve syndesmosis stress test

Question 40

which muscle may cause ATFL pain post-ligament healing time?

Answer 40

fibularis/peroneal brevis

Question 41

what are the characteristics of a grade 1 ankle sprain?

Answer 41

stretch of ligament pain, stiffness little to no swelling no bruising -ve anterior draw test -ve talar tilt test (inversion stress) return to play in 1-10 days

Question 42

what are the characteristics of a grade 2 ankle sprain?

Answer 42

partial tear moderate swelling and tenderness some bruising severe difficulty walking anterior draw test: increased laxity -ve talar tilt test return to play 2-4 weeks

Question 43

what are the characteristics of a grade 3 ankle sprain?

Answer 43

ruptured ligament severe swelling and tenderness substantial bruising unable to support weight +ve anterior draw test +ve talar tilt test return to play: 5-8 weeks (with optimal rehab)

Question 44

what is the stage 1 (onset of weight-bearing 0-2 weeks) management for an ankle sprain?

Answer 44

RICE and NSAIDs treat myofascial distortion taping, bracing to allow weight bearing but early introduction of dynamic ROM gentle ankle adjustments

Question 45

what is the stage 2 (begins when patient can weight bear, 2-4 weeks) management for ankle sprain?

Answer 45

begin exercises to increase peroneal dorsiflexion strength achilles stretches continue until full ROM and 80% normal ankle strength

Question 46

what is stage 3 (reduce risk or restrains, 4-6 weeks) for ankle sprain?

Answer 46

ankle proprioception training progressive plyometric training

Question 47

what are s&s of a high ankle sprain or distal tibiofibular syndesmosis?

Answer 47

pain and tenderness proximal to lateral malleolus inability to weight bear +ve syndesmosis stress test

Question 48

what is the imaging of choice for a suspected distal tibiofibular syndesmosis?

Answer 48

arthroscopy

Question 49

what are the s&s of tendinopathy in the ankle?

Answer 49

pain and swelling around the insertion of the tendon decreased ROM tendons may also feel more prominent

Question 50

what is the treatment of choice for tendinopathy in the ankle?

Answer 50

NSAIDs partial immobilisation cross-friction massage ultrasound

Question 51

what are common s&s for peroneus tendinitis/dislocation?

Answer 51

pain in PROM in inversion pain on RROM in eversion (common in athletes and ballet dancers)

Question 52

what are s&s for tibialis posterior tendinitis?

Answer 52

pain on PROM in eversion RROM in inversion and plantar flexion common in middle aged females, ballet dancers and those with pes planus

Question 53

what are the s&s of a tibialis posterior tendon rupture?

Answer 53

occurs post inflammation, degeneration or trauma causes medial arch collapse --> flat foot + gross eversion of the foot too many toe signs +ve single heel raise test often does not cause any pain

Question 54

what is the most common cause of a tibialis anterior tendinitis?

Answer 54

downhill running