Adult Foot and Ankle Flashcards
What are important features of the lateral and hindfoot anatomy?
Distal fibula and fibular shaft, ankle lateral gutter and syndesmosis, lateral wall calcaneus, peronei, CFL and ATFL, sural nerve
What are important features of the medial and hindfoot topography?
Medial malleolus, anteromedial tibiotalar joint, deltoid ligament, PTT, FDL, FHL, posterior tibial artery
What are some features of the anatomy of the posterior ankle and hindfoot?
Achilles tendon, calcaneal insertion, retrocalcaneal space, peroneal tendons, FHL
What are some aspects of the anterior ankle topography?
Anterior ankle joint, superficial peroneal nerve, EHL, EDL, saphenous nerve
What are some important features of the plantar topography?
Heel pad, 5th metatarsal base, plantar fascia, metatarsal heads, tibialis posterior insertion
What are some features of pes planus (flat feet)?
Normal variant, occurs in 20% of population, familial, associated ligament laxity, when developmental its causes no problems and requires no treatment
What is a sign of flexible pes planus?
Flexible flat feet form an arch when patient tip toes
What is the most common cause of acquired flat feet in adults?
Tibialis posterior deformity (up to 10% of elderly women, usually present for years prior to diagnosis)
Where does the tibialis posterior pass?
Courses immediately posterior to medial malleolus
Where does the tibialis posterior attach?
Navicular tuberosity and plantar aspect of medial and middle cuneiforms
What are the functions of the tibialis posterior?
Primary dynamic stabiliser of medial longitudinal arch (elevates arch)
Invertor and plantar-flexor
What are the risk factors for tibialis posterior dysfunction?
Obese middle aged female, risk increase with age, flat foot, hypertension, diabetes, injected steroids, seronegative arthropathies, idiopathic tendonosis
What are some features of the pain caused by tibialis posterior dysfunction?
pain and/or swelling posterior to medial malleolus, lateral wall “impingement” pain, midfoot and ankle pain
What are some signs of tibialis posterior dysfunction?
Change in foot pain, diminished walking ability/balance, dislike of uneven surfaces, more noticeable hallux valgus, can’t single heel raise
What are the types of tibialis posterior dysfunction?
Type I = swelling, tenderness, slightly weak muscle power
Type II = planovalgus, midfoot abduction, passively correctable
Type III and IV = fixity and mortise signs
How are tibialis posterior dysfunctions treated?
Physio, insole to support medial arch, no injected steroids, orthoses to suit foot shape, bespoke footwear, surgery
What are the causes of pes cavus?
Most commonly idiopathic
Other causes mostly neurological = HSMN, cerebral palsy, polio, spina bifida, club foot
How does pes cavus present and how is it treated?
Often clawing of toes
Surgery complex if required = soft tissue releases, tendon transfers, calcaneal osteotomy, arthrodesis (fusion)
What are some features of the pain associated with plantar fasciitis?
Start-up pain after rest, may be worse after exercise
What are some signs of plantar fasciitis?
Fullness or swelling of plantarmedial aspect of heal, tenderness plantar aspect of heel and/or plantarmedial aspect of heel, Tinel’s test positive for Baxter’s nerve
What may cause plantar fasciitis?
Physical over-load = obesity, over-exercising
Seronegative arthropathy, diabetes, planovalgus or carovarus feet
What are some treatments of plantar fasciitis?
NSAIDs, night splints, taping, heel cups, medial arch supports, physio, steroid injections, ECSWL, surgery (50% success, better if acute onset)
How long does plantar fasciitis usually last for?
Usually self limiting over 18-24 months
What is the epidemiology of hallux valgus?
Increases with age, usually bilateral, 3 times more likely in men, adolescent subgroups exist
What are some causes of hallux valgus?
Familial, shoes, general joint laxity, connective tissue disease, rheumatoid arthritis, splayed forefoot associated with loss of muscle tone and age
What are some complications of hallux valgus?
Transfer metatarsalgia, lesser toe impingement, pain, deformity, cosmesis, shoe difficulties
What are some supportive treatments for hallux valgus?
Shoe modifications and padding
When is surgery indicated for hallux valgus?
Failure of conservative treatments, pain, lesser toe deformities, lifestyle limitations, overlapping ulceration, functional limitation
What are the surgical options for hallux valgus?
Osteotomies (cutting bone) or Aiken technique (break bone and move head laterally)
Aim is to realign hallux and decrease HV angle
What are some features of hallux rigidus?
Osteoarthritis of 1st MTP joint, non-operative management or surgery (joint replacement or fusion)
What are some features of rheumatoid foot?
Affects feet in 90% of rheumatoid patients, occurs early in disease, most common reason for surgery of the forefoot
What are some features of the pathogenesis of rheumatoid foot?
Synovitis, proteinases and collagenases, impaired integrity of joint capsule/ligaments, destruction of hyaline cartilage
What are some challenges associated with rheumatoid foot?
Multi-joint disease = disability, slower rehab, use of crutches
Systemic effects = vasculitis, ischaemia, ulceration, neuropathy, anaemia, immunosuppression
Psychosocial
What are some features of rheumatoid of the hindfoot?
Talocalcaneal interosseous ligament, unstable subtalar joint (calcaneus drifts into valgus), medial arch collapses (flat feet), often require multiple joint fusions
What is Morton’s neuroma?
Degenerative fibrosis of digital nerve near it’s bifurcation
What are some features of Morton’s neuroma?
Get forefoot pain = metatarsalgia, burning and tingling in toes
Mean age 45-50, more common in females, investigated with USS, can be given insoles or injections, can be excised operatively
What are some features of tendo-Achilles tendinosis?
Repetitive microtrauma, failure of collagen repair with loss of fibre alignment/structure, hypovascular region 2-6cm proximal to insertion, can be mid-substance or distal
What are some risk factors of tendo-Achilles tendinosis?
Over-training, steroids, ciprofloxacin, connective tissue diseases
How can tendo-Achilles tendinosis present and how can it be diagnosed?
Pain, morning stiffness, eases with heat or walking
Diagnosis = USS, MRI
What are some management options of tendo-Achilles tendinosis?
No steroid injections, activity modifications, analgesia, NSAIDs, shockwave therapy, orthotics, physio, surgery
What are some features tendo-Achilles rupture?
Usually aged >40, often pre-existing tendinosis, caused by deceleration with resisted calf contraction, people often think someone has hit them
What are the signs of tendo-Achilles ruptures?
Unable to weight-bear, weak plantar flexion, palpable painful gap, positive Simmond’s (calf squeeze) test
How are tendo-Achilles ruptures treated?
Operative or non-operative, both involve an extended recovery/cast time, functional outcome normally good
What are some features of claw, hammer and mallet toes?
Acquired imbalance between flexors and extensors, can cause painful callus/corns with skin breakdown
What are some surgical techniques used to treat claw, hammer and mallet toes?
Tenotomies (division of tendons), tendon transfer, fusion (PIP), amputation
What causes ankle sprains?
Twisting forces = commonly inversion/twisting on planted foot
Due to elastic limit of ligaments, typically lateral ligaments (ATFL, CFL)
What are some features of ankle sprains?
Longer to resolve than fractures, pain, bruising, tenderness, graded 1-3 (grade 3 is complete rupture)
What are some treatments for ankle sprains?
Non-operative = RICE, physio (strength, stability, proprioception) Operative = Brostrom Gould (improves stability be repairing lateral ligaments), Chrisman Snook (long recovery and often causes post-operative stiff ankle)
What causes ankle fractures?
Caused by twisting forces (common injury)
What are some ways to classify ankle fractures?
Weber classification = A-C
Lauge Hansen = based on foot position and force applied
What is a stable ankle fracture?
Distal fibula fracture with no medial malleolus fracture or deltoid ligament rupture
What is an unstable ankle fracture?
Distal fibula fracture with medial malleolus fracture or deltoid ligament rupture
What is a Pilon fracture of the ankle?
High energy injury, significant soft tissue problem, often have other injuries, damage to joint may lead to osteoarthritis, may need amputation
What cause 5th metatarsal fractures?
Inversion injury, very common injury
What are some examples of 5th metatarsal fractures?
Avulsion by peroneus brevis tendon = heal predictably in moonboot
Jones fracture = poor blood supply, 25% risk of non-union
Proximal shaft = common site for stress fracture
What are some features of a Lisfranc injury to the foot?
Tarsometatarsal fracture dislocation, high energy, require fixation, risk of osteoarthritis, often subtle on imaging
What are some features of a calcaneus fracture?
Fall from height, often also have spinal injury, often intra-articular, significant swelling, risk of compartment syndrome
What are some features of a talus fracture?
Caused by forced dorsiflexion/rapid deceleration, talus has reversed blood supply, risk of avascular necrosis and osteoarthritis
