Ankle and foot Flashcards
Red flag: Rheumatoid arthritis of the foot/ankle
- Metacarpophalangeal mainly affected and can involve proximal interphalangeal joint
- Swelling and stiffness
- Nodules
Red flag: Psoriatic arthritis
- Distal interphalangeal joints affected mainly
- Dactylitis
- Nail bed pitting
- Nail bed separation
Red flag: Achilles tendon rupture
- Audible snap during activity
- Sudden significant pain in calf/ankle
- Inability to continue with activity
- Unable to single leg heel raise
- Simmons triad - altered angle of declination, palpable gap and a positive thompson test
Red flag: Charcot foot
A disease which attacks the bones, joints and soft tissue in your feet
- Neuropathy
- Trauma history
- Hot, swollen foot
- Bounding pedal pulses in early stages
- May develop bone infection and/or inflammation of the joint membrane
Red flag: Navicular AVN
- Midfoot pain over the dorsomedial aspect of the foot
- Stiffness in hindfoot/midfoot
Red flag: Compartment syndrome
5 P’s
- Pain
- Pallor
- Paraesthesia
- Pulselessness
- Paralysis
Red flag: Lower limb DVT
- Throbbing or cramping pain in affected leg
- Usually in calf or thigh
- Swelling
- Swollen veins
- Breathlessness or chest pain
Achilles tendinopathy: Pathophysiology
- Mid portion= non-insertional tendinopathy, approx 2-6cm above insertion. Due to poor vascular supply
- Insertional= tendinopathy of the insertion on the calcaneous
Achilles tendinopathy: Mid-portion risk factors
- Certain drugs- e.g corticosteriods
- Diabetes
- History of injury
- Factors associated with training
- Increased cholesterol
Achilles tendinopathy: Insertional risk factors
- Increasing age
- RA
- New exercise
- Inappropriate footwear
Clinical presentation, signs and symptoms of Achilles tendinopathy
- Pain either at mid portion or insertion on the calcaneous
- Aggr factors: activity or direct pressure
- Occur gradually
- Some people can present with both
- Stiffnes in morning and after prolonged rest
- Mid portion= aching pain
- Insertional= sharp pain in heel
Special tests/objective findings for Achilles tendinopathy
- Antalgic gait
- Haglunds deformity (lump on back of heel)
- Pain reproduced with hopping and heel-raise endurance test
- Most demonstrate full range with pain on active plantar flexion
Management of Achilles Tendinopathy
- Education, symptom management and self management
- Rest initially and gradually increase activity
- Modifications of activities
- PEACE & LOVE approach
- Direct to GP
If no improvement in 7-10 days: - Physio: eccentric exercise or a heavy load, slow-speed exercise programme
Achilles tendon tear/rupture: pathophysiology and risk factors
Most commonly seen within people aged between 37 and 43 year old approx.
The tear or rupture of the achilles tendon caused by overstretching of the heel during recreational sports; a forceful plantar flexion of the heel; or a fall from a height
Risks:
- Increasing age
- Achilles tendinopathy
- Poor vascular supply
- Certain drugs e.g corticosteriod
- Sports
- History of injury
Clinical presentation: signs and symptoms of achilles tendon rupture
- Usually a traumatic onset usually during high velocity movement
- Description of being ‘kicked or shot’ in the back of calf
- Sudden pain in calf with an audible snap or pop
- Weakness is a common symptom described particularly when pushing off with the affected foot
- Inability to weight bear however may be able due to other plantar flexors helping with this movement
Special tests/ objective signs for Achilles rupture
- Palpable gap if not too much swelling
- Foot drop may be apparent in gait
- Active plantarflexion may be completely or partially lost
- Greater degree of dorsiflexion available on passive movement
- Thompsons test usually positive with complete ruptures
- Calf muscle atrophy
Management of Achilles rupture
With suspected rupture refer to A+E
Ankle OA: pathophysiology and risk factors
Is a chronic degenerative joint disease which leads to the breaking down of cartilage and other tissues about a joint
Can affect both talocrural and subtalar joints in the ankle
Risks:
- RA
- Obesity
- Intense physical exercise
- Knee OA
- Age
Clinical presentation, signs and symptomsof ankle OA
- Ankle joint pain
- It most commonly affects one joint but can occur bilaterally
- Aggravating factors: weight bearing particularly walking and prolonged standing
- Ease: usually rest
- Stiffness in the joint first thing but less than 30 minutes in duration
- Crepitus in the ankle joint on movement with clicking and crunching being reported
- More commonly seen in patients with manual labour jobs and in those who spend significant periods standing or walking
Management of ankle OA
- Education, symptom management and self management
- Advise on lifestyle modifications
- Direct to GP
- Physio: manual therapy, mobility, strenghtening
- Consider walking aids and CSI
If persistent: referral for arthroplasty or fusion
Morton’s neuroma: pathophysiology and risk factors
Inflammation or thickening of the nerves between the metatarsal bones
- The thickening of the nerve is usually secondary to pressure or repetitive irritation
Risk factors:
- Female
- Associated with tight or high heeled shoes
- Common in runners
- Foot or hallux deformity
Clinical presentation, signs and symptoms of Morton’s neuroma
- Paraesthesia (tingling, prickling, burning sensation) within the affected digital nerve with pain apparent in the corresponding intermetatarsal space (third more commonly than the second)
- Burning and tingling sensation in the third or second intertarsal space
- Feeling of a ‘stone in their shoe’
- Aggr factors: walking, wearing tight shoes, high heels and running
- Ease factors: resting the foot, removing shoes
Special tests/objective signs for Morton’s neuroma
- Thumb index finger squeeze test- positive sign being referred to as a Mulder’s click
- Observation of any plantar calloses around the second and third metatarsal heads can also predispose to this complaint
Management of Morton’s neuroma
- Patient education
- Rest
- Advise for wider fitting shoe is the first line of management
- Orthotics
- Glucocorticosteroid injection
If ineffective: - Surgery to remove the neuroma
What are the common first MTP joint pathologies?
- OA
- Hallux Valgus (bunion)
- Hallux rigidus (restriction in flexion and extension leading to OA)
Risk factors for pathologies of the MTP joint
- Increased age
- Female
- Arthritis - commonly RA
- Neuromuscular disorders
- Acute and repetitive articular trauma
Clinical presentation, signs and symptoms of first MTP joint pathologies
- Stiffness and pain within first MTP
- Aggr factors: that require dorsiflexion of MTP joint and walking
- Localised pain, stiffness and enlargement of MTP joint
- Ease factors: rest
- Palpation is painful
Special tests/ objective signs on examination for first MTP joint pathologies
- Antalgic gait
- Crepitus
- AROM and PROM may be restricted particularly into extension
- Wasting of the intrinsic muscles of the foot
Management of first MTP joint pathologies
- Education, symptom management and self management
- Advise on lifestyle modifications
- Direct to GP
- Physio: joint mobs, strengthening and gait re-education
- Referral to podiatry for orthoses
- CSI
If no improvement: Surgical management
Ankle ligament injuries: pathophysiology and risk factors
A sprain or tear to the lateral or medial ligament complex
Lateral: ATFL, CFL, PTFL. Caused by inversion, rapid shift of body weight over the affected ankle followed by rolling outwards casuing excessive inversion and plantarflexion
Medial: PTTL, TCL, TNL and ATTL
Caused by: eversion, ankle rolls inwards causing excessive eversion
Lateral sprains are more common
Risks:
- History
- Increased weight
- Participation in sports
- Foot anatomy
Clinical presentation, signs and symptoms for ankle injuries
- Unable to weight bear
- Tenderness, swelling and bruising (depending on side)
- Bony tenderness can sometimes be apparent and fracture should be potentially suspected if the tenderness is within the areas identified within the OTTAWA rules
- Pain restricted ROM
- A soft or springy end feel is usually apparent
- Tenderness over affected ligament
Special tests/objective signs for Ankle ligament injuries
- Anterior draw test and talar tilt- pain and laxity
- Syndesmosis squeeze
- Poor balance, proprioception and weakness in gluteals
Management of ankle ligament injuries
- Education, symptom management and self management
- PEACE and LOVE
- Advice continuing activities within pain limits
- Direct to GP
- Physio: mobility, manual therapy, strengthening
No improvement and significant laxity: Surgical reconstruction
Plantar fasciopathy: pathophysiology and risk factors
Thickening and degeneration of tissue affecting the plantar fascia at the bottom of your foot, usually felt at the heel.
Multifactoral: poor or delayed healing and abnormal biomechanics
Risks:
- Age (40-60)
- Female
- Excessive foot pronation
- High arches
- Tight achilles or gastroc
- Overweight
- Running
Signs and symptoms of Plantar fasciopathy
- Pain in the medial plantar heel region
- Pain worsens throughout the day
- Gradual onset (if sudden onset with trauma can be ruptured)
- Aggr factors: prolonged weight bearing
- Restricted dorsiflexion
Special tests/Objective signs for Plantar Fasciopathy
- Positive Windlass test
- Antalgic gait
- Restricted dorsiflexion
Management of plantar fasciopathy
- Education, symp management
- Advise on activity modifications, good foot wear, insoles and heel pads
- Advise on weight loss
- GP
- Ice application
- Self stretches
If persistent: - Physio - for tendon loading
- Referral to podiatry
- Glucocorticosteroid injection
Failure from conservative: - Ortho or podiatry for SWT
If tried for 6-12 months: - Surgery
