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Heel Flashcards

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1
Q

What is calcodynia?

A

Heel pain

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2
Q

What orthopedic test do you preform to check for calcaneal stress fracture?

A

Compression of the calcaneus

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3
Q

What is a calcaneal spur?

A

A traction apophysitis with hyperostosis

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4
Q

Micro-tears and inflammation of the proximal plantar aponeurosis at the medial calcaneal tubercle?

A

Plantar fasciitis

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5
Q

What two structures are implicated in plantar fasciitis?

A

Plantar aponeurosis

Flexor digitorum brevis

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6
Q

What is the quality of the pain in plantar fasciitis?

A
  • stiff
  • sharp pain
  • “rock under heel”
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7
Q

Who commonly gets plantar fasciitis?

A
  • 40-60 year old
  • Under 40 runners
  • Sedentary females who are obese or pregnant
  • military or workers who stand a lot
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8
Q

What activities are provocative for plantar fasciitis?

A

Repetitive traction

Prolonged weight bearing

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9
Q

What is Sever’s disease?

A

Traction apophysitis. Achilles’ tendon or plantar fascia tractioning apophysis causing recurrent periods of avascular necrosis and bony regrowth with neovascularization. Most commonly due to poorly fitting shoes.

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10
Q

What is the typical onset and chronology of plantar fasciitis?

A

Gradual onset due to repetitive overuse and often associated with a change of footwear, walking surface, exercise, job or other activity.
Will have acute, episodic exacerbations
Progresses to sever pain with weight bearing upon prolonged rest

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11
Q

What are the physical exam findings of plantar fasciitis?

A
  • antalgic gait
  • painful ROMs (ankle and toe dorsiflexion)
  • tender medial tubercle of calcaneus and medial longitudinal arch
  • tight triceps surae (gastroc/soleus)
  • tight/weak hamstrings
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12
Q

How do you test to distinguish between functional or structural flat foot?

A

Toe raises and observe arch. If arch formation occurs with toe raise, indicates functional and therefore exercises may help

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13
Q

What is the DDX for plantar fasciitis?

A
  • subtalar joint osteoarthritis
  • metatarsalgia
  • overpronation syndrome
  • heterotrophic calcification

If swelling in foot or leg:

  • compartment syndrome
  • DVT

If swelling in foot:

  • ligamentous sprain
  • flexor hallucis brevis strain
  • abductor hallucis brevis strain

In pediatrics:
- Sever’s disease/traction apophysitis

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14
Q

What is the most common cause of calcodynia in 5-15 year old athletes?

A

Sever’s disease

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15
Q

What motion is palliative for Sever’s disease?

A

Plantar flexion

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16
Q

What is the prognosis for Sever’s disease?

A

Self limiting with rare complications.

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17
Q

What two positive tests would indicated tarsal tunnel syndrome?

A

+ Tinel’s @ medial ankle
+ hyperpronation test

Would also have heel pain and paresthesia

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18
Q

What findings would indicate sural/peroneal nerve entrapment?

A

Lateral ankle pain and paresthesia with + Tinel’s

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19
Q

10-15% of plantar fasciitis cases present with concomitant ______.

A

Lateral calcaneal neuritis

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20
Q

What is lateral calcaneal neuritis?

A

Entrapment of the lateral plantar nerve distal to the medial calcaneal tubercle. Symptoms mimic plantar fasciitis and often accompany it. Heel spur and pronation can exaggerate symptoms

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21
Q

What are some systemic causes of calcodynia?

A
  • STD/STI
  • inflammatory arthropathies (seronegative and seropositive)
  • gout
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22
Q

What is the management in the acute phase of plantar fasciitis?

A 
Control inflammation:
- POLICE
- PT: US< LASER, iontophoresis, ESWT
- acupuncture
- arnica gel, etc.
- heel pad/cups in shoes
- night splints
- orthoses
- taping/bracing
Control faulty biomechanics:
- CMT, subtalar posterior glide restriction 
- home stretch/exercises
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23
Q

What is the management in the sub-acute/chronic phase of plantar fasciitis?

Study These Flashcards
A

Break adhesions:

  • PT: US, ESWT
  • CMT
  • lengthening plantar fascia, triceps surae, hamstrings with foam rolling, cross friction massage, myofascial release or IASTM

If needed:

  • strengthening
  • weight loss
  • knee rehab
24
Q

What is the prognosis for plantar fasciitis?

Study These Flashcards
A

Good if recognized and treated early with conservative management. Expect 50% reduction in subjective indicator within 2-3 weeks and full resolution within months

Dependent on compliance and extrinsic factors such as obesity

10% may need injections (steroid, PRP, prolotherapy) or radiofrequency treatment

25
Describe the sheath that surround the Achilles’ tendon
Pseudosheath, not synovial, therefore it has less glide and slide
26
Describe the vascularity of the Achilles’ tendon
There is a critical zone of a vascularity approximately 4.5 cm proximal to insertion that is more prone to ischemic insult
27
Describe the friction on Achilles’ tendon caused during normal gait
Saw-like due to normal M to L and L to M excursion
28
Repetitive injury of the Achilles’ tendon, exhibiting _________ is Achilles tendinopathy.
Lack of flexibility
29
What are the steps of evolution from Achilles tendinopathy to rupture?
- peri-tendinitis (crepitus) from over use - tendinosis, focal pain free degenerative changes - tendinitis, diffuse tendon inflammation and degeneration - rupture
30
What are risk factors for Achilles tendinopathy?
- increased age - overweight - impactful ADL/sport - bouncing/ballistic movements - fluoroquinolones - previous rupture - Haglund’s deformity of the calcaneal tuberosity
31
What are the historical findings for Achilles tendinopathy?
- local acute pain that can refer to ankle or calf | - morning stiffness that progresses with weight bearing
32
What is Haglund’s disease?
Traction apophysitis presenting as a calcaneal bump. Can aggravate Achilles tendinopathy or bursa. Common in pediatric population
33
What is retrocalcaneal and subcutaneous bursitis?
Tissue damage that results in inflammation fo the bursa deep to the Achilles’ tendon and/or subcutaneous calcaneal bursa
34
What is the function of a bursa?
Reduce friction between soft tissue layers
35
What are some causes of calcaneal bursitis?
- shoes rubbing - Haglund’s deformity - insertional calcific tendinopathy of Achilles - acute trauma
36
What are the physical exam findings for Achilles tendinopathy?
- NO swelling - possibly a thickened Achilles’ tendon - tenderness at Achilles insertion
37
What are the physical exam findings for retrocalcaneal bursitis?
- red, swollen, warm and swollen retrocalcaneal bump
38
How is overpronation related to Achilles tendinopathy?
It may be a cause or an effect of Achilles tendinopathy. With calf raises, some inversion should happen to relieve stress on tendon. A hyperpronated foot does not invert with calf raises, keeping a consistent stress on it.
39
What are some orthopedic tests for potential Achilles rupture?
- Hoffa’s - Simmond’s sign - Simmond’s Squeeze - Thompson Squeeze
40
What are key physical exam findings that differentiate retrocalcaneal bursitis from Achilles tendinopathy since they present very similarly?
- Palpation of bursa will be most painful in bursitis | - tendon stretch and resisted muscle testing will be most painful in tendinopathy
41
What is a definitive way to distinguish between bursitis and tendinopathy?
US
42
What is the early treatment for Achilles tendinopathy and calcaneal bursitis?
- POLICE - reduce activity - heel lift/orthoses - NSAIDs PT; US, iontophoresis, ESWT - manipulation - light massage to gastrosoleus - taping/splinting - Vitamin C, calcium, magnesium
43
What is the role of night splinting in treatment of Achilles tendinopathy?
It does not appear to help in the acute phase but can be useful in chronic phase.
44
When should eccentric exercises be implemented in the treatment of Achilles tendinopathy and calcaneal bursitis?
In the early treatment but after POLICE
45
What is the late treatment for Achilles tendinopathy or calcaneal bursitis?
- manipulation - massage (only for tendinopathy) - eccentric multidirectional movements and activity specific loading - splinting (although evidence is controversial) - heel lift
46
If conservative treatment of tendinopathy and calcaneal bursitis fails, referral may be necessary. What are some of the treatment options?
- steroid injection (better evidence for bursitis than tendinopathy) - prolotherapy - extracorporeal shockwave therapy (ESWT - inconclusive evidence)
47
Where and how does the Achilles’ tendon tear?
1-2 inches above insertion and usually full thickness - partial tears are uncommon.
48
What is the epidemiology of Achilles’ tendon rupture?
- age 40 - M>F - young and active boys - those who are intermittently active Incidence is increasing
49
What are some risk factor for Achilles rupture?
- Achilles tendinopathy - recent change in athletic training - fluoroquinolones - over pronation syndrome - previous rupture - steroid or hormone replacement therapy - infection - hypertension - obesity - inflammatory conditions
50
How does an Achilles rupture present?
- usually associated with a traumatic event with audible “pop” - pain is localized to site of rupture - may be mild to severe pain - loss of plantar flexion but can still walk - swelling and ecchymosis (maybe) - muscle retraction - palpable sulcus (“hatchet sign”) in Achilles’ tendon - positive Simmond’s sign and Simmond’s squeeze test
51
What physical exam finding as a very high positive predictive value for Achilles rupture?
“Hatchet/sulcus” sign
52
What special studies are useful for diagnosing Achilles’ tendon rupture?
- for full tears, US | - for partial tears, although rare, MRI is superior
53
When is surgery indicated with an Achilles’ tendon rupture?
- because it is avascular and poor at healing, it is not ideal for all patients - consider surgery in young, active patients - less warranted in older patients with underlying disease or steroid use
54
What is the prognosis for treatment of Achilles’ tendon rupture?
- minimally invasive surgical repair has good prognosis and patient’s return to activity earlier than with conservative care - re-rupture rates and functional outcomes are equal between surgical repair and non-surgical + early mobilizations - conservative care with immobilization has higher rate of rerupture
55
If a patient is a candidate for surgical repair of ruptured Achilles’ tendon, what co treatment can be offered pre and post surgical cast removal?
Pre cast removal: - POLICE - NSAIDs - crutches - early weight bearing after appropriate immobilization in plantar flexed/“Equinus” position Post cast removal: - POLICE - mobilization and exercise - dynamic stretching
56
What is the non-surgical conservative treatment for a ruptured Achilles’ tendon?
- equinus casting/immobilization for 2-3 months - then mobilize (don’t adjust) talocrural and subtalar joints and progress through isometric -> concentric -> eccentric exercises NOTE: partial tear should have PRICE for 2-3 weeks, then casting for 2-3 weeks, then mobilization and exercises

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