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taking a hx SOAP
differential dx of medial foot pain (think in terms of structure)
bone: stress fx medial maleolus, talus, navicular
-ligaments/fascia (spring ligament, plantar fascitis)
-nerve (posterior tibial nerve entrapment, tarsal tunnel syndrome)
-tendon (tibialis post, flexor halucis, flexor digitorum
-somatic dysfxn: arch dysfunction - cuneform, navicular, talus
stress fx, medial foot pain
tends to be insidious in onset, and worse w/ wt bearing, particularly w/ >than body wt like running
arch determiens where stresses are transmitted, pes cavus (high arch) and pes planus (low arch)
fxnal arches of the foot
arches are formed by dense connective tissue suspended between the bony surfaces of foot to maintain foot structure upon WB and aid in shock absorption
1. lateral longitudinal arch
2. medial longitudinal arch
3. distal metatarsal arch
4. proximal transverse arch
lateral longitudinal arch (LLA)
calcaneus, cuboid, 4th and 5th MT
-common dysfxn is inferior cuboid SD which is most freq 2° to a talocalcaneal dysfxn in which the talus is anterior and the calcaneus is IR
medial longitudinal arch (MLA)
calcaneus, talus, navicular, cuneiforms and 1st three MTs
-major shock absorbing arch; MC dysfxn is anteromedial lesion of talus on the calcaneus, which move the navicular inferiorly=freq cause of foot pain
distal MT arch
articlation of MT heads with the phalanges
-free of muscle attachments to foot can adjust to uneven ground; arch flatten with WB
proximal transverse arch
rigid arch which maintains the osseous architecture of foot while the more flexible longtiudinal and MT arches provide fxn of foot.
medial longitudinal arch
tibialis anterior increases the arch, tibialis posterior eccentrically contract to preserve arch; longitudinal muscles prevent sep of bone, keystone shaped bones-cuneiform, strut ligamnets = spring ligament
fxnal arch assessment
inspection, fxnal (forward squat test, assess arch pronation (arch rolls medially) as well as heel cord tightness
when assessing gait...
look for limp or dysnfxn, watch alignment of hips, knees, ankle, watch for how weight is transferredand dysfsxnal firing patters
exam for post tibial tendinits
pain w/ posterior tibialis MMT (manual msucel test) and unilateral pronation on forward squat test
workup and tx for post tibial tendinitis
xray, and cast or boot w/ orthotic x 3-4wks, reproduce arch, then PT, surgical consult, significant risk of DJD w/ rupture
what is haglunds deformity?
pump bump, retrocalcaneal bursitis on the back side of leg where achilles attaches to calcaneous
During ossification of the talus, under certain circumstances a secondary ossification center may develop for the lateral tubercle of the bone. This may be to applied stress during the early teens or a fracture at that part of the bone.
tendon and paratendon, histopath:
1. degen and disorder of collagen fibers
2. increased vascularity
3. mucoid collagen degeneration
mucoid collagen degeneration
causes the affected region to soften, lose its normal glistening white appearance and become grey/brown. light microscopy reveals collagen fibers that are thinner than normal, characteristic hierarchal structure is lost
repetitive eccentric overuse overwelms the ability of fibroblasts to repair damaged fibrils, steroid injections inhibit fibroblastic activity (assoc w/ tendon rupture, certain antibiotics too
pain @ posterior heel, proximal to calcaneus, insidious in onset, (stiffness w/ running, morning stiffness-sleeping with pointed toes
risk factors for achilles tendinitis
age, cavus feet, tibia vara, heel & forefoot varus deformities, overuse/jumping
achilles tendinitis tx
stretching of gastroc and soleus,
-eccentric exercise a potent stimulus for linear collagen and recovery from tendinosis
-somatic dysfxn ? examine foot and correct
achilles tendon rupture
-hx of actiivty w/ sudden pop like someone shot me in the back of the leg,
-dx..thompson test, MRI,
tx: surgical repair
passive plantar flesion of foot w/ squeeze of the gastroc, if there is complete tear, no plantarflexion,
Lateral Plantar nerve entrapment
lancinating pain that radiates, may persist at rest, tinels sign at lateral plantar tunnel reproduces pain, conservative (surg alteranative
not a heel spur, morning sx related to fascial tension, pain at medial insertion, windlass maneuver, medial and middle cuniform bones
fibrosis of perineural area of common digital nerve leads to entrapment, usually btwn 3 and 4 MT (2nd or 3rd MT space), sharp, stabbing, lancinating pain, worse when wearing shoes, affects women more toe box size. prox to transverse intermetatarsal ligament
dx of mortons neuroma
clinical, palpation of distal intermetatarsal spaces, (proximal to transverse intermetat ligament), Mulder's sign (pain w/ compression of MT heads laterally, relieved by plantar pressure directed dorsally, Laseague's sign +
work up for morton's neuroma
xrays are primarily obtained to look for osteophytes or masses in the MT heads that could potentially compromise the interdigital nerve space
tx of mortons neuroma
conservative: neuroma pads, icing pos exercise, orthotics or arch taping, NSAIDs, larger toe box, injection (steroid, neurolytic/anesthetic),
~90% of all metatarsal stress fx, occurs at the neck of the 2nd, 3rd and 4th (4th most common), esp common in runners, dancers have similar hist and pain in 1st MT, work up: xrays (50% will be negative, bone scan), tx'd w/ stiff shoe for 4-6 wks
zone 3 fx of 5th MT
stress fx of proximal 1.5 cm of shaft, always have prodromal sx or radiographic signs of ongoing stress (3%)
gen tx principles for stress fx phase I
modified rest. pain control, brace/stiff-shoe/cast, limit motions, muscular strength and endurance, stretching and flexibility, maintaining fitness/ cross training
gen tx principles for stress fx phase II
gradual reintro of sport, continued phase I objectives, risk factor modification, biomechanical factors, orthotics, OCPs, calcium, bracing, metabolic and nutritional factors
injuries of sesamoids
-sesamoiditis: bone bruise
-stress vs true fx vs bipartitie sesamoid
-typically medial is most involed
exam of sesamoids
pain on palpation, pain on plantar 1st MTP joint, pain w/ maximum dorsiflexion 1st ray, inability to push off
hallus valgus, valgus deformity at 1st MTP joint, assoc w/ shoes w/ tight toe box, tx (orthotics, wide toe box, surgery after conservative measures fail, OMT/somatic dysfxn?
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