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taking a hx SOAP

-prev injury
-SH-work status

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

foot type:

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

posterior tibial tendinitis common pt

38-58 yo woman who begins an exercise program,

sx of posteerior tibial tendinitis

complian of progressive achy pain in medial arch

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

severe's disease

apophyseal traction in pts with open grwth plates, osgoods of heel,

os trigonum

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 structure

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

microscopic degen

repetitive eccentric overuse overwelms the ability of fibroblasts to repair damaged fibrils, steroid injections inhibit fibroblastic activity (assoc w/ tendon rupture, certain antibiotics too

achilles tendinitis

pain @ posterior heel, proximal to calcaneus, insidious in onset, (stiffness w/ running, morning stiffness-sleeping with pointed toes

swelling, nodule or both in achilles tendinitis

migrates proximally w/ plantar flexion

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,
-fluoroquinolone use
-dx..thompson test, MRI,
tx: surgical repair

thompson test

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

plantar Fasciitis

not a heel spur, morning sx related to fascial tension, pain at medial insertion, windlass maneuver, medial and middle cuniform bones

turf toe

sprain in the 1st TMT Joint

sesamoid pathology

usually in the samll bone in the first ray

Friedberg's infarction

avascular necrosis of the second MT head--possibly following trauma

Morton's Neuroma

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),

tx of mortons nueroma injection:

fairly successful (17/18 pts)
US guided

march fx

~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

MT stress fx most risk for complications when tx'ing

5th MT

zone 1 fx zones of 5th MT

avulsion injury, involves matatasocuboid joint (93%)

zone 2 fx zone of 5th MT

metaphyseal-diaphyseal junction, always an acute fx-true jones fx.

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%)

dx of stress fx

clinical suspincion, xrays (usually neg/periosteal rxn), bone scan, MRI shows edema

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


pain under the ball of foot, can be injured during run/jump,

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?

hallux rigidus

DJ changes @ first MTP joint-older ppl
-limits first MTP joint dorsiflexion
-important consideration in geriatric gait assessment
-dx by palpation, examination, and xray

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