Foot, Leg and Ankle joint MSK Dx

Plantar fasciitis

• Condition: age 20-60, MOI- gradual with no known cause

• Examination:

  • Painful sole of foot under heel when weight bearing, especially first thing in the morning

  • Pronated foot or flattened arches observed

  • passive great toe extension is painful

  • Plantar aspect of heel is tender on palpation

• Special tests

  • Windlass test

Achilles tendinitis

• Condition: age 20-40, MOI- overuse

• Examination:

  • Jumping and running increase s/s on posterior ankle

  • Slight swelling can be seen on posterior ankle

  • Active and passive dorsiflexion is painful and limited

  • Passive dorsiflexion is limited with knee in the extended position

  • Resisted plantar flexion is painful

Gastrocnemius strain

• Condition: age 20-40, MOI: sudden overload

• Examination

  • Pain in the upper calf

  • Heel raises increase s/s

  • Antalgic gait

  • Active and passive dorsiflexion painful and limited in the extended knee position

  • Pain on resisted plantar flexion

  • Tender mid to upper calf area on palpation

Posterior tibialis tendinitis

• Condition: Age 20-40, MOI- overuse with a flat pronated foot

• Examination:

  • Pain on medial ankle throughout tendon

  • Swelling may be present and tenderness over medial ankle

  • Active and passive plantar flexion and eversion painful

  • Resisted inversion with plantar flexed foot is painful

Anterior tibialis tendinitis

• Condition: Age: 15-45, MOI: overuse

• Examination:

  • S/s increases with repetitive dorsiflexion on anterior lower leg

  • Combined active plantar flexion and inversion movements painful

  • Passive plantar flexion painful

  • Resisted dorsiflexion painful

  • tenderness over the anterolateral lower leg

Medial tibial stress syndrome (shin splints)

• Condition: Age: 15-30, MOI overuse

• Examination:

  • pain on anterior lower leg, posterior -medial lower leg

  • Active combined plantarflexion and inversion painful

  • Resisted plantar flexion and eversion painful

  • Tenderness on posteromedial calf

Anterior Compartment syndrome

• Condition: increased pressure in anterior compartment of leg causing an ischemic condition of the leg, MOI: direct trauma, muscle hypertrophy, fracture

• Examination:

  • severe cramping, diffuse pain, and tightness

  • Pain decreases with rest and increases with activity

  • Pain worsens with stretching

  • Tender and tight compartment on palpation

  • 6p’s Pain, pallor, paresis, paresthesia, pulselessness, palpable tenderness

    • Acute- emergency surgery

Mortons neuroma

• Condition: age 40-60, MOI gradual (unknown)

• Examination:

  • WB increases s/s on sole of foot

  • Pronated foot or flattened arch can be observed

  • passive toe extension painful

  • tenderness with palpation on web spaces of toes

Tarsal tunnel syndrome

• Condition: age 25-50, MOI- posttraumatic, rapid weight gain, fluid retention, inflammatory, abnormal foot/ankle biomechanics, or a valgus foot deformity

• Evaluation

  • s/s on medial malleolus, distribution of posterior tibial nerve up the leg, or down into the medial arch, plantar surface of the foot and toes

  • s/s increases w/ excessive pronation in walking or running

  • Pronated poot, pes planus can be observed

  • Passive plantar flexion and eversion painful

  • Resisted toe flexion painful

• Special tests

  • Tinel’s sign

Metatarsal stress fracture

• Condition: Age 15-45, MOI- overuse

• Examination:

  • s/s increase with WB activities on the forefoot

  • Tenderness over the Fx site

• Special tests

  • palpation, ultrasound, tuning fork, bone scan, MRI, CT scan

Midfoot sprain

• Condition: age 15-40, MOI: high impact landing, foot twisted when in fixed position

• Examination:

  • walking on toes increases s/s on midfoot

  • Generalized tenderness of midfoot

  • pain during passive midfoot pronation and supination while the hindfoot is stabilized

• Special test

  • weight bearing lateral and anterior-posterior radiographs

Severs’s disease

• Condition: Age 8-13 years, traction apophysitis at the insertion of the Achilles tendon, MOI: foot pronation, tight gastroc-soleus complex, jumping or landing from a height

• Examination:

  • limited dorsiflexion and stiffness

  • pain over the posterior-inferior heel, which increases with WB

  • Pain resolves with rest

• Special tests

  • Squeeze test

  • x-ray

Ottawa Ankle Rules

• Performed if there is pain in the malleolar region with any of the following

  • Bone tenderness at the posterior edge of the distal 6 cm or the tip of lateral malleolus

  • Bone tenderness at posterior edge of the distal 6 cm or tip of medial malleolus

  • Inability to bear weight for at least 4 steps immediately after injury at the time of evaluation

• A foot radiograph should be performed if there is pain in the midfoot region and any of the following

  • Bone tenderness at the navicular bone

  • Bone tenderness at the base of the 5th metatarsal