1
Q
What is the definition of a differential diagnosis list?
A
ordered list of PLAUSIBLE diagnoses
2
Q
How is the DDx list structured?
A
- most plausible to rule IN 2. 2-3 next most plausible 3. 1-2 Dx to rule OUT
3
Q
What is the purpose of the DDx list?
A
To guide physical exam - select procedures to rule in/out Dxes
4
Q
What are 5 factors to consider that influence the DDx?
A
- epidemiology 2. location 3. etiology 4. quality 5. diagnostic uncertainty
5
Q
What are the 4 general causes of overpronation syndrome?
A
- too much, too fast, wrong time 2. osseous anomalies 3. functional causes 4. neurological
6
Q
Which diagnoses causes the heel to be too supinated/inverted during heel strike? (3)
A
Rearfoot varum, tibia varum, genu varum
7
Q
Which side of the heel will have exaggerated wear in a pt with rearfoot varum?
A
lateral side
8
Q
Which muscles will show fatigue or weakness in a pt with rearfoot varum/
A
gastroc, tib ant., tib post.
9
Q
Tx for rearfoot varum - adjustment?
A
subtalar and midtarsal joints
10
Q
Tx for rearfoot varum - orthotic?
A
medial rearfoot post
11
Q
Which diagnosis requires more pronation to engage the 1st ray in take-off?
A
Forefoot varum
12
Q
Which muscle will be tight in a pt with forefoot varum/
A
tib ant.
13
Q
Which muscle will be weak in a pt with forefoot varum?
A
peroneus longus
14
Q
Tx for forefoot varum - adjustment?
A
midtarsal, intermetatarsal, 1st MTP joints
15
Q
Tx for forefoot varum - orthotic?
A
Medial forefoot post
16
Q
Will a pt with tibia varum over- or underpronate?
A
Either - depends on foot rigidity. Rigid foot = underpronator
17
Q
When would pronation control shoes be appropriate Tx for tibia varum?
A
If pt is overpronating
18
Q
Tx for tibia varum - orthotic?
A
medial rearfoot post
19
Q
Which pt are at an increased risk for inversion sprain? (2x more likely)
A
tibia varum
20
Q
Which msls are weak in a pt with genu varum?
A
hip ext. rotators
21
Q
Which msls are tight in a pt with genu varum?
A
medial hamstrings and gracilis
22
Q
Tx for genu varum - adjustment?
A
back, hip, knee, foot
23
Q
What would cause underpronation in a pt with genu varum?
A
rigid supinated foot
24
Q
Which diagnoses cause the pt to footstrike on the medial side of the heel? (2)
A
genu valgum, rearfoot valgum
25
Which side of the heel will have exaggerated wear in a pt with rearfoot or genu valgum?
medial heel wear
26
Tx for genu/rearfoot valgum - adjustment?
back, hip, knee, foot
27
What is the relationship between flexibility and support in a pt with genu/rearfoot valgum?
increased flexibility requires increased support
28
Which msls will be tight in a pt with genu/rearfoot valgum?
hamstrings, hip and knee rotators
29
Which msls will be weak in a pt with genu/rearfoot valgum?
quads, tib ant., posterior msls
30
Tx for genu/rearfoot valgum - orthotic?
medial post
31
Which 3 first ray abnormalities cause late pronation?
1. hallux valgus 2. morton's foot 3. dorsiflexed 1st metatarsal
32
What is defined as lateral deviation of the 1st toe?
hallux valgus
33
what is defined as an elongated 2nd metatarsal (relative to others)?
Morton's foot
34
What are 5 general Tx approaches for overpronation syndrome?
1. adjusting/mobilization 2. foot exercises 3. taping 4. pronation control shoes 5. orthotics
35
How should you determine what joint/direction to adjust in a pt with overpronation syndrome?
JOINT PLAYS - don't assume medial side needs to be moved superiorly
36
What are 4 examples of foot exercises for pts with overpronation syndrome?
1. short/small foot 2. toe extensions 3. heel walk/toe walk 4. tubing
37
What are short/small foot exercises?
static/standing engagement of intrinsic msls
38
What are some characteristics of pronation control shoes?
stiff shoe, rigid heel counter, straight last, board last
39
What are the two general types of orthotics?
1. accommodative 2. functional
40
Which type of orthotic is most commonly used?
functional - cheaper
41
What condition is defined as "forefoot pain typically localized to the distal intermetatarsal region"?
metatarsalgia
42
Is metatarsalgia always localized?
No - can be generalized foot pain
43
Metatarsalgia - epidemiology? (6)
1. elderly 2. obesity 3. pregnancy 4. footwear (no evidence) 5. recreation/running surface 6. diabetes (weak connection)
44
Metatarsalgia - etiology? (2)
1. repetitive overuse 2. gradual onset of initial symptoms
45
Why does repetitive overuse lead to metatarsalgia?
leads to ligamentous laxity and overpronation
46
What is the quality of pain in metatarsalgia?
dull, achy.
47
Which arch will a pt with metatarsalgia have pain in?
transverse arch
48
What condition is often described as "a pebble in my shoe"?
specific metatarsalgia - may have callous formation
49
T/F: metatarsalgia pain is constant in the acute phase
False - waxes and wanes b/t latent and acute exacerbations
50
What determines the severity of metatarsalgia?
how many metatarsals are affected and the phase of injury
51
What is a pertinent negative for metatarsalgia?
absense of neuro sx
52
What are 3 pertinent positives for metatarsalgia?
1. assoc w/ footwear 2. timing w/in gait cycle 3. callous formation
53
DDx for metatarsalgia? (6)
1. overpronation syndrome 2. mortons neuroma 3. stress fx 4. OA/RA/gout 5. Freibergs dz (osteochondrosis) 6. sesamoiditis
54
Physical exam findings for metatarsalgia? (5)
1. callous formation 2. rigid foot 3. osseous anomalies 4. muscular imbalances 5. splay foot
55
What is defined as "loss of transverse arch d/t laxity of transverse metatarsal ligaments"?
splay foot
56
Which msls would be tight in a pt with metatarsalgia?
triceps surae
57
Tx for metatarsalgia - ACUTE?
rest, ice, indirect U/S, CMT (foot, back, etc), tape, light massage
58
Tx for metatarsalgia - CHRONIC?
stretching (triceps surae), strengthening triceps surae, short foot exercises, continue CMT/STM
59
What is the normal ratio for posterior compartment msls: anterior compartment msls?
10:1
60
When should you expect to see marked improvement in metatarsalgia pts?
w/in 1-3 weeks
61
What should be done for metatarsalgia pts if no significant improvement is seen in 3 weeks?
consider ancillary studies depending on etiology
62
Which condition is defined as "inflammation of the proximal attachment of the plantar fascia"?
plantar fasciitis
63
What are some common risk groups for plantar fasciitis?
athletes, sedentary females, obesity, pregnancy, military/workers who mostly stand
64
What age group has the highest incidence of plantar fasciitis?
40-60 yrs (younger in runners)
65
Does plantar fasciitis cause more inflammation at the proximal or distal attachment?
usually proximal, rarely distal
66
Why can plantar fasciitis cause bone remodeling?
Wolffs law - bone remodeling d/t stress
67
Is plantar fasciitis pain localized or global?
Usually very localized
68
Which direction does plantar fasciitis pain usually radiate?
distally. Rarely radiates proximally
69
Is plantar fasciitis gradual or sudden onset?
gradual
70
What is the general chronology of plantar fasciitis pain?
morning stiffness/pain that lessens as day continues
71
What is the quality of plantar fasciitis pain?
stiffness alternating with sharp pain.
72
What can "tired and achy feet" be a sign of?
EARLY plantar fasciitis
73
What tends to make plantar fasciitis worse?
prolonged static or dynamic wt bearing
74
Which condition is a common comorbidity w/ plantar fasciitis?
achilles tendinopathy
75
What are some other possible associated symptoms with plantar fasciitis? (4)
1. swelling (unilaterally) 2. bruising (rare) 3. achilles tenderness 4. recent fever
76
Possible DDx for plantar fasciitis?
Calcaneal bursitis, overpronation syndrome, metatarsalgia, achilles tendinopathy, subtalar DJD, Dupuytren's contracture, inflammatory arthropathies
77
Which condition would have PE findings of a tender medial calcaneal tubercle, tender medial longitudinal arch, and a positive Stretch Test?
plantar fasciitis
78
Which muscles would be tight in pt with plantar fasciitis?
triceps surae
79
which muscles would be weak in pt with plantar fasciitis?
dorsiflexors and inverters (tib ant/post)
80
Tx for plantar fasciitis - ACUTE?
POLICE, PT, heel pads/cups, mobilization/manipulation, night splints, footwear advice, taping/bracing, acupuncture
81
What does POLICE stand for?
Protect, Optimally Load, Ice, Compress, Elevate
82
What type of night splints should be used for plantar fasciitis?
splints that promote dorsiflexion
83
How should you tape for plantar fasciitis?
Teardrop taping - use flexible tape, ie Elastikon
84
Tx for plantar fasciitis - CHRONIC?
continuous U/S, ESWT, CMT, STM, myofascial release, stretching, rehab, wt loss, acupuncture, injections (prolotherapy)
85
What type of exercises should be implemented in a rehab program for plantar fasciitis?
stretch triceps surae, short foot exercises, marble exercises, knee rehab
86
Has shockwave therapy been shown to be effective in improving plantar fasciitis?
yes - meta analysis of 11 RCTs
87
have night splints and foot orthoses been shown to be effective in treating plantar fasciitis?
Recent evidence is limited and inconsistent
88
How soon should you see a 50% improvement in a pt with plantar fasciitis?
within weeks
89
How soon should you expect to see full resolution of plantar fasciitis?
within months (dependent on compliance)
90
Which condition is defined as "tendon injury characterized by pain, swelling and tenderness at or near the Achilles region?"
achilles tendinopathy
91
When should the condition be referred to as achilles tendinITIS?
in presence of inflammation - usually ACUTE phase
92
When should the condition be referred to as achilles tendinOSIS?
in absence of inflammation - usually CHRONIC phase
93
What are 3 epidemiology categories to consider for achilles tendinopathy?
1. Age 2. overweight/obesity 3. impactful ADL/profession
94
Why is there an increasing prevalence of achilles tendinopathy proportional to age?
diminishing fat pad, circulation, and flexibility
95
What are 3 etiologies/risk factors for achilles tendinopathy?
1. repetitive overuse 2. sports training errors 3. fluoroquinolones (in older pts)
96
What are fluoroquinolones?
anti-microbial drugs with a strong association with achilles tendinopathy
97
What are 3 notable Hx findings in a pt with achilles tendinopathy?
1. localized acute pain 2. assoc. with ballistic movements 3. morning "stiffness" w/ or w/o pain
98
Where is pain localized to in achilles tendinopathy?
localized to achilles tendon, may radiate to entire calf or ankle
99
Does the morning stiffness assoc. with achilles tendinopathy get better or worse as the day progresses?
Worsens with wt bearing or participation in aggravating activities
100
Possible DDX for achilles tendinopathy?
plantar fasciitis, calcaneal bursitis, reactive arthritis, drug side effects
101
Will you typically see swelling/bruising/deformity with achilles tendinopathy?
NO
102
Will you tend to see over-or underpronation in a pt with achilles tendinopathy?
Overpronation - may be cause OR effect
103
What is the hallmark location for tenderness on palpation in a pt with achilles tendinopathy?
1-2 in. above calcaneal tuberosity
104
Which motion will be diminished in achilles tendinopathy?
dorsiflexion
105
Which joints will likely be restricted with achilles tendinopathy?
talocrural and subtalar
106
What motion may produce pain in a pt with achilles tendinopathy?
stretching or active toe raises
107
Tx for achilles tendinopathy - ACUTE?
POLICE, PT, CMT, STM, taping/splinting, nutrition
108
Have night splints and orthoses been shown to be effective in treating achilles tendinopathy?
No - studies showed that night splints did not seem to make a difference. Inconclusive evidence on orthoses
109
Tx for achilles tendinopathy - CHRONIC?
contrast therapy, CMT, STM, splinting
110
If you are not seeing results after Tx for achilles tendinopathy, what are some possible referral alternatives? (4)
1. topical NSAIDs 2. injections 3. prolotherapy 4. surgical repair
111
Which condition is defined as "tissue damage and resultant inflammation of the retrocalcaneal bursa"?
retrocalcaneal bursitis (RCB)
112
What is the function of a bursa?
reduce friction b/t soft tissue layer
113
What is RCB aka?
subcutaneous calcaneal bursitis
114
Risk factors for RCB? (5)
1. poorly fitting shoes 2. repetitive microtrauma 3. acute trauma 4. osseous deformity 5. overpronation (?)
115
How do you differentiate the cause of painful "pump bumps"?
Texture - SOFT = swollen bursa, HARD = osseous anomaly
116
DDX for RCB?
plantar fasciitis, achilles tendinopathy, sever's dz, Fx, inflammatory arthritides, infection (TB)
117
What is the result of a posterior/calcaneal squeeze in a pt with RCB?
reproduces CC pain
118
Tx for RCB?
POLICE, PT, short foot exercises, injections (?)
119
In RCB pts, will you see a reduction in swelling or pain first?
Reduction in pain first
120
how soon should you expect to see a reduction in pain in RCB pts?
1 wk
121
How soon should you expect to see a reduction in swelling in RCB pts?
3-4 wks
122
Which has the best prognosis: plantar fasciitis, achilles tendinopathy, or RCB?
RCB
123
Which condition is defined as "traction apophysitis at cartilagenous growth center into which the achilles tendon inserts on the calcaneus"?
Sever's dz
124
What condition in the knees is a good analogy for Sever's dz?
Osgood-Schlatter
125
What age group is at the highest risk for Sever's dz?
boys age 7-15, girls age 5-13
126
What is the most common cause of heel pain in athletes aged 5-11 years?
Sever's dz
127
What are two other risk factors for Sever's dz (besides age group)?
overweight/obesity, poorly fitting shoes
128
Tx for Sever's dz?
POLICE, PT, short foot exercises, injections (?)
129
When should xray be considered for pts with Sever's dz?
in cases that are unresponsive to care (last ditch study)
130
What is the prognosis for Sever's dz?
self-limiting - usually respond quickly to treatment
NMS 2
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