Ankle and foot conditions Flashcards
Achilles Tendon Injuries
Can be insertional or nonisertional.
Insertional- if the problem exists at the attachment site of the Achilles on the calcaneus.
Noninsertional- if the symptoms are proximal to the insertional area
Tendon can also be ruptured completely
Noninsertional tendinosis- when there is actual intratendinous degeneration of the Achilles tendon proximal to its attachmnet to the calcaneus
- tendon is typically swollen, and the onset of symptoms is insidious and located within the midsubstance of the tendon.
- not tendinitis though as there is no inflammatory component.
CP:
- tendon becomes thicker and softer
- yellow in color, due to an accumulation of mucinous material within the tendon
prognosis:
- conservative treatment of nontraumatic disorders is often successful
ACHILLES TENDON RUPTURE:
- 30-50 peak ages
- 5x males
- experience sudden pain and an audible pop in the back of their heels. Many report the sensation of being hit, when they have not been.
Ankle Sprains
Very common injury
Differential diagnosis can be-
- 5th metatarsal fractures, tendon injuries.
3 distinct entities:
- lateral sprains (95%)
- medial sprains (5%)
- syndesmotic injuries (high ankle sprains)
Most ankle sprains occur on the lateral side, as the deltoid ligament is very strong, so if it is damaged it can cause an evulsion fracture where it pulls some of the bone off with it.
causes:
- rolling ankle during sports or running
- when ankle is forced to move out of its normal position (excessive supination or pronation)
age group:
- peak incidence- 15-19
risk factors:
- athletic people
- sports like football or runners
CP:
- 3 Grades-
- grade 1- consist of intraligamentous tears with pain but no instability
- grade 2- incomplete tears with pain and mild to moderate instability
- grade 3- complete ligamentous rupture occurs. Pt often cannot tolerate weight bearing on the injured extremity and show gross instability and pain on physical examination.
- acute swelling and ecchymosis (discolouration of skin) occurs almost instantly after an ankle sprain
- pt will be tender overlying the lateral ligamentous structures.
- any tenderness in the medial area should raise concern.
prognosis:
- long term sequelae are common if not treated appropriately
- RICE protocol, typically heal after nonoperative treatment
- rehabilitation important protocol
Fractured Fibula (Nondisplaced/Avulsion Fracture)
Avulsion injuries:
- separation of only a small piece of extra-articular bone, below the level of the ankle joint. Due to a rupture of the ligamentous insertion to bone, in which the attachment fails and pulls a small fragment of bone off the fibula with the ligament.
Nondisplaced fracture:
- where the bone cracks but retains its proper alignment.
Causes:
- occurs because of a rotational injury due to the ankle
- they can occur above, below, or at the level of the ankle joint and generally require acute attention as they are quite painful and patients typically cannot ambulate
age group:
- generally manifest in older populations
risk factors:
- age- increases risk of injury 65+
- obesity
- history of smoking
CP:
- pain and swelling in area of injury
- limiting range of motion, depending on degree of swelling and pain
- evaluate the circulatory and neurologic status of the extremity to detect if there is underlying vascular disease or neuropathy
- ask pt if suffering with Charcot arthropathy (lost feeling in their feet)
prognosis:
- most non displaced fractures do not require surgery
- most can be allowed to be weightbearing as tolerated in a walking boot
- diabetics require double the time of immobilisation as non-diabetics
Retrocalcaneal Bursitis
Pain anterior to the Achilles tendon, inflammation of the retrocalcaneal bursa.
Retrocalcaneal is posterior to the calcaneus
Haglund deformity- an enlarged, prominent position of the posterosuperior aspect of the calcaneus
causes:
- Pes cavus can cause, due to an tight achilles.
age group:
- manifests in younger population
risk factors:
- athletes that train uphill due to extreme doors flexion
CP:
- pain anterior to achilles
- dull, aching pain in area that’s aggravated
- pain onset is not acute, if there is acute onset then it should be considered as a Achilles Rupture
- shouldn’t be mistaken for a ‘dumb bump’ (pre-achilles bursa)
- dorsiflexion aggravate some pain, due to pressure on bursa from achilles
prognosis:
- nonsurgical management
- stretching achilles can be good treatment
Bunion/Hallux valgus
Deformity involving the 1st metatarsophalangeal joint resulting in medial deviation of 1st metatarsal and corresponding lateral deviation of the great toe
cause:
- narrow footwear
- must rule out RA, neurologic disorder or a connective tissue disorder
age group:
- mostly an adult problem
- 30-50
- can occur younger ages
risk factors:
- occurs more in ppl that wear shoes
CP:
- pain and deformity of 1st MTP joint
- large bump over 1st MTP joint
- pt complain with way shoes fit
- deformity worsen during weight bearing
- palpation of medial eminence will produce pain
prognosis:
- shoe-wear modification necessary
- night splints
- surgical intervention, if conservative efforts fail to improve
Metatarsalgia
Pain at plantar aspect of the lesser second, third and/or 4th metatarsal heads. on the ball of the foot.
Metatarsalgia is common.
causes:
- prolonged wieght-bearing activities (standing, walking and running).
- intense training or activity can cause it
- excess weight
- stress fractures- small breaks in metatarsals
- Mortons neuroma
- look for atrophy of fat pad- can cause metatarsalgia
risk factors:
- participating in high-impact sports
- shoes that dont fir properly
- overweight
- other foot problems
- inflammatory arthritis
CP:
- onset of pain is gradual and insidious
- tenderness to palpation of lesser MTPJ’s
- pt may present with an area of thickened, keratotic skin or callus at affected joint
prognosis:
- if left untreated- can affect other areas of the body, due to limping
- modify shoe wear
- most patients, conservative treatments are highly successful
Plantar Fasciitis
Plantar Fascia- band of fibrous tissue extending from the plantar calcanea tuberosity to the flexor tendon expansion in the forefoot.
Function is to support the longitudinal arch of the foot in what is called a ‘windlass mechanism’.
Inflammation of the plantar fascia on the bottom of the foot
cause:
- repetitive weight bearing and pressure trauma to the plantar fascia
age group:
- 40-60
risk factors:
- obesity
- work related weight bearing
- decreased ankle dorsiflexion
- runners
CP:
- insidious onset of heel pain
- worse symptoms upon getting out of bed in the morning and at the end of the workday
- pain is non radiating and eases with rest
- plantar fasciitis test to test for it
prognosis:
- treatment mainly nonsurgical
- well padded shoes advised. Night splints
- over 90% of pt that suffer with plantar fasciitis respond to conservative treatment.
- stretching become permanent part of a pt’s routine as it will help alleviate symptoms and may help prevent future episodes
Interdigital Neuritis (Morton Neuroma)
Thickening of the tissue around a nerve in your foot that’s been irritated or damaged
causes:
- occurs in response to irritation, pressure or injury to one of the nerves that lead to your toes
age group:
- middle-aged women who have history of wearing shoes with narrow toe box, or high heels, which can increase the plantar pressure in the forefoot
CP:
- pinpoint burning or tingling pain worsened by shoewear
- symptoms often alleviate by removing shoes and massaging the toes
- may report decreased sensation
- pain on palpation, maybe fat pad atrophy
prognosis:
- symptoms can be eased by treatments pt can do themselves
- pt can often be treated successfully with conservative measures alone
Congenital Talipes (idiopathic club-foot)
Foot curved downward and inwards
Skin and soft tissues of the calf and the medial side of the foot are short and under-developed.
causes:
- cause unknown
- present at birth
age group:
- present at birth
- boys 2x
risk factors:
- family history can increase risk
CP:
- deformity obvious at birth, foot is turned and twisted inwards so that the sole faces posteromedially
- infant must always be examined for associated disorders such as congenital hip dislocation and spina bifida
prognosis:
- if condition not corrected early, secondary growth changes occur in the bones and these are permenant
- even with treatment, the foot is liable to be short and the calf may remain thin
Metatarsus Adductus
Medial deviation of the foot from the level of the forefoot with respect to the hind foot.
2 types:
- flexible- presents with adduction of the 5 metatarsal bones at the tarsometatarsal joint
- rigid- presents with medial subluxation of the tarsometatarsal joints. There is values of the hind foot and the navicular is later to the head of the talus
causes:
- caused by in-utero position and constriction of the foetus. (Also called ‘pigeon toes’).
CP:
- forefoot is adducted and sometimes supinated, but the mid foot and hind foot are normal
- older children may present with an in-toe gait
prognosis:
- the majority of cases (90%), either improve spontaneously or can be managed non-operatively using serial corrective cases followed by straight-last shoes.
Flat-foot (per planovalgus)
Apex of longitudinal arch has collapsed and the medial border of the foot is in contact (or nearly in contact) with the ground; the heel becomes valgus (medial malleolus closer to the floor) and the foot pronates at the mid foot.
congenital vertical talus:
- neonatal form in which the arch is sometimes reversed leading to a ‘rocker bottom’ appearance.
Flat foot in children and adolescents:
2 forms of the condition:
- flexible (most common)- often appears in toddlers as a normal stage of development, usually disappears after a few years when medial arch development is complete.
usually no symptoms
deformity becomes noticeable when the younger stands
- rigid- cannot be corrected passively. examiner should be alerted to an underlying abnormality.
teenagers sometimes present with a painful rigid flat foot.
causes:
- genetics- can be genetic, as a Childs arches form, their arch may be smaller than it should be cause pes planus.
age group-
- common among children and adolescents
- can also be developed as someone gets older and seen in adults
CP:
- appearance of flat foot can be normal and asymptomatic
- when weight bearing, the foot is turned outwards, the medial border of the foot is in contact with the ground and the heel becomes valgus. (medial malleolus is closer to the ground than the lateral malleolus).
flat foot in adults:
- could have been asymptomatic but starts presenting nagging pain due to a change in daily activities.
- more recent deformities may be due to an underlying disorder such as RA or generalised muscular weakness
- unilateral flat foot should make clinician think of tibias posterior synovitis or rupture.
- onset insidious, affecting one foot much more than the other.
- systemic factors- obesity, diabetes, corticosteroid medication or past surgery
pes cavus
Foot is highly arched and the toes are drawn up into a ‘clawed’ position, forcing the metatarsal heads down into the sole.
causes:
- all forms of pet cavus due to some type of muscle imbalance.
- pes cavus can cause retrocalcaneal bursitis
age group:
- becomes noticeable 8-10 years before there are any symptoms
CP:
- callosities may appear under metatarsal heads.
-deformity usually obvious
- pain under metatarsal heads may be felt or over the toes where shoe pressure is most marked
- walking tolerance usually reduced
Hallux valgus
Where 1st metatarsal joint is affected and is often accompanied by significant functional disability and foot pain and reduced QOL.
Abduction of the 1st metatarsal and the phalanges adduct
usually bilateral
causes:
- not fully known
-factors to consider- footwear (tight), severe flatfoot, associated with hip and knee OA, associated with a higher BMI, systemic disease
age group:
- women between 50-70
CP:
- often no symptoms other than deformity
- pain could be due to:
- shoe pressure
- splaying of the forefoot and muscle strain (metatarsalgia)
- associated deformities of the lesser toes
- secondary OA of the 1st metatarsophalangeal joint
Hallux Rigidus
Type of degenerative arthritis that affects the big toe joint
causes:
- occurs when cartilage covering the ends of the bone in your big toe joint is damaged or lost
- leads to joint space narrowing, and can lead to painful osteophytes being formed
- may be due to trauma or osteochondritis dissecans of the 1st metatarsal head
- in older people- it is usually caused by long-standing joint disorders such as gout, pseudogout or OA
age group:
- older people
- men and women affected equally
CP:
- pain on walking, especially on slopes or roguh ground
- MTP joint feels knobbly, a tender ‘bunion’ may be felt
- dorsiflexion of the toe is restricted and painful. plantar flexion is also limited
Deformities of the lesser toes
Hammer toe
claw-toe
mallet-toe
overlapping-toe
hammer toe:
- deformity that causes your toe to end or curl downwards instant of point forward.
- can affect any toe (usually 2nd or 3rd digit)
claw toe-
- toes bent into abnormal claw shape
- often associated with pes cavus, muscle imbalances or occasionally a neurological condition.
- also seen in RA
- no cause found
CP:
- pain in forefoot and under metatarsal heads
- usually bilateral
- walking may be severely restricted
- painful corns and callosities develop
- skin can ulcerate
mallet toe:
- upward bend of the toe. May cause the toe to look curled instead of flat
- happens mostly to 2nd toe. due to it being the longest of 4 lesser toes
- collosity can appear at tip of the toe
overlapping toe:
- often when valgus big toe, forces the 2nd toe to sit on top of the hallux.
- overlapping toe may fall back into position once valgus big toe has been adjusted.
- overlapping 5th toe is an anomaly
