Stress fracture corresponds to a change in the bone's 1 resulting from application of 2
1. Mechanical integrity
2. Unusual Repetitive stress
Epidemiolgy: Occurs in 1 of general population 2 of college sports 3 of all forefoot of the foot are 4
1. 1% 2. 2-8% 3. 20% 4. Calcaneus
Different type of fractures are: 1. 2.
1. Fatigue fracture 2. Insufficiency fracture
Fatigue fracture: 1 normal but abnormal 2 and 3 e.g. new activity or too much of repeated activity
1. Bone 2. Muscle stress 3. Fatigue
Insufficiency fracture 1 weak Most commonly seen in women with 2 but also seen in 3 and 4
1. Bone 2. OP 3. post-menopausal 4. amenorrhea
Calcaneus is an interface for A and B
A: weight transmission
What are the pathogenesis for the pathomechanics theory?
Weakness of C
Rather than a compressive force a D would occur perpendicular to primary trabuculae
A: over activity
B: mechanical advantage
C: one of tethering structures
D: shearing force
what are the risk factors for Calcaneal stress fracture:
1: gender ?
3: bone condition?
Low level of 5?
7? food related
8 ? merphology
10? 11? 12?
1. female (39% of all FF)
2. Obesity, long distance runners and army recruits
4. Prior stresst fracture
5. Low level of physical fitness
7. Nutrition - calorie intake, calcium deficiency
8. Arch morphology e.g. Pes cavus
9. Biomechanical like overpronation, genu valgum
10. Physiological bone turn over 11. muscle flexibility 12. joint ROM
what are the clinical presentation for calcaneal stress fracture?
1? pain : onset ? days
can initially be a 2? type pain which radiates
3? pain on weight-bearing
Focal 4? and mild5?
Tenderness 6? of wall of calcaneus
Can be without 7?
Previous history of 8?
Sudden increase in 9?
Increase in 10?
1. Prodromal pain, 7-10 days
2. mechanical type pain
4. oedema 5. warmth
6. medially and laterally
8. high impact exercise
9. training program features
10. body weight
what is the clinical assessment for calcaneal stress fracture?
1 ?compression of heel
2? normal within first 3? weeks
MRI may show 4? if present ( may be negative especially if there is poor blood supply as it will not demonstrate 5?)
6? scan useful in special situations
Screen for 7?
1. Medial to lateral
2. x-rays 3. 2-3 weeks
4. oedema in bone and soft tissue 5. oedema
6. CT scan
7. intrinsic and extrinsic factors
Clacaneal stress fracture
whilst x-ray and MRI are definitive 1? should be performed routinely as part of plantar heel presentation.
Management of calcaneal stress fracture
1? for upto 8 weeks encouraged
2? to achieve pain relief
3? insoles to prevent fracture
4? cast, can be used to achieve pain releif and protect
Severe case may require 5?
6? activities encouraged
Assess risk of 7?
1. Rest and ice
2. strapping and accomodaive shoes
3. shock absorbing insoles
4. short leg cast
5. NWB cast with crutches
6. NWB e.g. swimming
15-20% of neural heel pain is the 1? nerve (Alshami)
2? is the most reported cause of heel pain
2. Media calcaneal nerve
Look closely at the image and remember the structure?
what are the clinical presentation for Neural origin?
Pain- described as 1?
Pain is worst with 2?
Pain may be present at 3?
Post static 4?
1. sharp, shooting, burning, localised and radiating
2. activity (during and after) and improves with rest
3. night result of venostosis
5. sensory distrubnaces: tingling, numbness around medial and plantar ascpect of heel
Where are the common sites with maximal tenderness for heel pain?
1. plantar fasciitis
2. entrapment of 1st b. plantar nerve
3. true isolated plantar fasciitis
4. fat pad atrophy
What are the Neurodynamic tests for neural origin heel pain?
1? test: passive extension of 2? while ankle is held in DF and Eversion
Modified 3? EXAM
4? test - Tibial Nerve
5? test: Tapping along the course of the nerve. positive with 6?
1. Dorsiflexion/eversion 2. MTPJ
3. Modified straight leg raise: leg extension, hip flexion and ankle D/F (Exam)
4. Plantar felxion inversion test
5. Tinel's test 6. tingling along the nerve distribution
Electrodiagnostic tests for neural origin heel pain:
1? and 2? studies
Can reveal abnormalities in 3? and 4?
Can return false positive 5? for 6 nerve compression and less accurate for smaller
Quantitative sesory testing
QST generate 8, 9, 10
1. Electromyography 2. Nerve conduction studies
3. Medial Plantar Nerve 4. Lateral Plantar Nerve
5. 50% 6. large nerve compression
7. to determine pain mechanism by assessing function of both large and small sensory nerve fibres
8. vibratory 9. thermal 10. painful stimuli
High resolution MRI
Allows to differentiate between of neuropathic conditions related to 1? 2? 3? 4? and 5?
Tibial nerve best visualized on 6? images of leg and ankle joint
Terminal tibial nerve best visualized on 7?
1. trauma 2. entrapment 3. iatrogenic injury 4. tumours 5. tumour like lesions
7. axial images around tarsal tunnel
8. short axis oblique coronal images more distally
Neural origin- heel pain
Conservative treatment (limited evidence)
similar to other plantar heel pain. 1? 2? 3? 4? 5? 6? 7? 8?
9? immobalization ? knee 10? in 11? and 12? position
Is considered when the conservative treatments have failed
Surgical 13? of the nerve
1. Rest 2. NSAIDS 3. CCS injections 4. ESWT 5. Laser therapy 6. Orthotics 7. strapping 8. Stretching
9. Nerve 10. extension 11. Supine 12. Slump
Heel Pad Atrophy
Fat pad is optimized for 1?, act as a 2? shock absorbing layer
Load bearing capacity is clinically impaired in various conditions such as 3? 4? 5? 6? 7?
Fat pad atrophy results from atrophy of 8? with degenaration of the 9?
1. load bearing 2. hydraulic
3. diabetes 4. RA 5. traume 6. steroid use 7. old age
8. the adipose tissue
9. collagenous septae
What are the clinical presentation for Heel Pad Atrophy?
Can be 1?, occurs after 2?
Pain is most intense over the 3?
Pain does not 4?
5? and 6? are non-tender
1. bilateral 2. walking, standing and at rest
3. the central portion of the Focal point
5. Medial calcaneal tuberosity 6. plantar fascia
Fat Pad Atrophy
Ultrasound can diagnose if thickness of FP is 1?
Other tools include: 2?
1. less than 3 mm
2. Plain radiography
3. Visual copressibility index: compare loaded heel pad thickness to unloaded : in a normal patient the second is half.
How to differentiate between Fat Pad Atrophy and Plantar Fascia?
1? applied first
2? applied second
Wear both tapes for first 3?
then remove 4 remaining
1. Fat Pad compression taping
2. 3 way modified low dye
3. 24 hrs
Fat Pad Atrophy
Determine if any difference between taping, if more 1? involvement, the 2? will feel
better. Can guide orthotic prescription.
1. fat pad
2. fat pad compression taping
What are the management options for fat pad atrophy?
1. Ensure excellent cushioning in footwear
2. Prescribe a deep heel cup to cushion the fat
pad, preventing spread. Can also use a heel aperture
filled with poron to provide additional cushioning
3. Autolipotransplantation, involving harvested
adipose tissue from calf
4. liquid silicone injections
Those with plantar heel pain have 1? postulated to increase loads on PF.
greater total rearfoot eversion and peak PMPj DF
the functional risk factors for Plantar fascia:
Prolonged foot pronation causes 1?
Muscles that may be involved with increased pronation are
2? caused by weakness reducing ability to pronate or resupinate the foot.
Proximal muscles that may be involved 3?
Intrinsic foot musculature
1. muscle weakness, achilles tightness, structural foot deformities.
2. Posterior tibialis, FDL, FHL, Peroneus longus, Achilles
3. GMed, G Min, TFL
The Anatomic risk factors for Plantar Fascia:
Foot type 4?
2. Tibial Torsion
3. Femoral Anteversion
4. PF symptoms found in supinated and pronated
What are the clinical assessments for Plantar Fascia?
• Palpable tenderness over the insertion of plantar fascia at the medial calcaneal tubercle.
• Diffuse tenderness along lateral and medial calc, DDx would be calcaneal #
• Positive windlass manoeuvre: pain with passive DF of hallux,
loading PF. Not often seen clinically only in severe cases whereby rupture/ tear is present.
• No swelling, is rare usually indicates other pathology
What are the diagnostic imaging for plantar fascitis?
Ultrasound: Diagnosis > 4mm, decreased echogencity, -compare bilaterally?
In acute, U/S may show hypervascularity and of surrounding tissues.
U/S is as reliable as MRI, cheaper more timely.
U/S can also be used to determine treatment outcome,
pre and post exam reveals PF to reduce in thickness in
response to Tx.
Plantar spurs are of no diagnostic value unless there is a fracture
What are the treatment options for Plantar Fasciopathy?
2. Orthotic therapy
6. Heel Pads
• Other treatments