The clinical picture is typical. Patients complain particularly of a sharp pain following rest particularly first thing in the morning. Initially walking helps and patients frequently describe having to break down adhesions with sharp knife like pain as they take their first steps. Symptoms recur with increasing activity. On examination the area is tender to palpation and the there may be decreased dorsiflexion. Abnormalities on plain films have long been associated with plantar fasciitis however the presence of a bony spur alone is not significant as the vast majority of these are asymptomatic. Rather than looking at the bony spur, the soft tissues around the spur should be examined and in many cases a swollen plantar fascia can be identified
The soft tissue abnormalities include diffuse oedema surrounding the os trigonum and changes within the flexor hallucis longs tendon sheath. Increased fluid within flexor hallucis longs tendon sheath is unfortunately a common occurrence in asymptomatic individuals as the tendon sheath frequently communicates with the tibiotalar joint. Because of this communication, additional signs to confirm true FHL tenosynovitis need to be sought. These include synovial thickening or gadolinium enhancement on MR and increased Doppler signal indicating associated tenosynovitis on ultrasound. Posterior impingement syndrome may be treated by ultrasound guided injection of local anaesthetic and corticosteroid in and around the accessory ossicle or prominent Stieda process. If this fails to achieve a long term result, surgical excision of the os trigonum is indicated
TENNIS LEG
Tennis leg is the name given to an acute injury of the gastrocnemius/soleus complex. The term is rather non specific and has been applied to a number of specific injuries. These include musculotendinous junction injuries of the achilles, separation of the aponeurosis between the medial head of gastrocnemius and soleus (adjacent image), muscle tear of the medial head of gastrocnemius and injuries to the plantar is muscle or tendon
Problems related to the Sural Nerve are uncommon but include
• Neurilemmoma
• Traumatic injuries
• Injury during achilles repair
• Snapping around back of Achilles
