Ankle & Foot Flashcards
What is hallux valgus?
Deformity of the great toe due to MEDIAL deviation of the 1st metatarsal and LATERAL deviation of the toe itself
Name 2 types of conditions that increase an individuals risk of hallux valgus
- RA or other inflammatory arthropathies
- Certain neuromuscular conditions such as MS & cerebral palsy
Rubbing of the greater toe against shoes in hallux valgus can lead to what condition?
Bunion - An inflamed bursa over the medial 1st metatarsal
In hallux valgus, the great toe and second toe may rub against each other, What can this lead to?
Ulceration & skin breakdown
In severe cases of hallux valgus what might happen?
The great toe may override the second toe
Hallux valgus initial management
CONSERVATIVE MANAGEMENT
- Wider footwear to prevent bunions
- Spacers in the first web space to prevent rubbing between toes
Name some indications for surgical management with hallux valgus
- Failure of conservative management
- lesser toe deformities
- lifestyle or functional limitation
- overlapping of great toe & second toe
NOT cosmetic reasons alone
Surgical management of hallux valgus
- Osteotomies to realign bones
- Soft tissue procedures to tighten or release tissue
What do some patients complain of after hallux valgus surgery?
Metatarsalgia - pain in the metatarsal heads
What is hallux rigidus?
OA of the first MTPJ
Hallux rigidus clinical presentation
- Painful, stiff first MTPJ
- Pain worse on activity/ wearing shoes
- Dorsal exostosis (bone spur)
- Reduced MTPJ movement, especially dorsiflexion
- Therefore, IPJ hyperextension
Describe the difference in ROM of the great toe IPJ in Hallux rigidus
Hyperextension
Hallux rigidus investigations
- Clinical diagnosis
- X-ray
Hallux rigidus conservative management
- Weight loss
- Analgesia
- Stiff soled shoe to limit motion
Possible surgical option for hallux rigidus in early stages with dorsal osteophyte impingement
Osteophyte removal (cheilectomy)
Hallux rigidus gold standard treatment
Arthrodesis
(Note - women will no longer be able to wear heels)
What is a Morton’s neuroma
Inflamed plantar interdigital nerves forming a neuroma
Morton’s neuroma clinical presentation
- Burning pain
- Tingling radiating into toes
- Exacerbated - footwear, relieved - massaging foot
- Loss of sensation in affected web space
- Positive mulder’s click test
Describe the clinical test used to test for Morton’s neuroma
Mulder’s click test - squeezing the forefoot with your hands, compressing the metatarsal heads to reproduce symptoms &/ a characteristic ‘click’
Morton’s neuroma investigations
- Mulder’s click test
- X-ray to rule out MSK pathology
- Diagnostic US to demonstrate swollen nerve (low specificity)
Morton’s neuroma risk factors
- Age
- Obesity
- Female
- High heels
Morton’s neuroma management
- Conservative - RICE, weight loss, offloading insole, calf muscle stretching
- Symptom relief - steroid & local anaesthetic injections
- Persistent, resistant symptoms - surgical excision
Metatarsal stress fracture risk factors & clinical presentation. Which MT is most commonly affected?
- Runners, soldiers, dancers etc (repeated stress/injury)
- Pain & inability to weight bear
- 2nd MT most commonly affected
Metatarsal stress fracture investigations
- X-ray - to rule out other pathology.
- NOTE - takes around 3 weeks (when callus forms) for a stress fracture to be seen on an X-Ray.
- Therefore, bone scan may be useful to confirm diagnosis
Metatarsal stress fracture management
Prolonged rest for 6‐12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms
Achilles tendonitis risk factors
- Overtraining (sports)
- Quinolones
- RA & other inflammatory arthropathies
- Gout
Where would pain occur in Achilles tendonitis and what other symptoms would you expect
- Pain at Achilles tendon or at its insertion in the calcaneus
- Worse - Morning, better - walking
Achilles tendonitis investigations
- Clinical diagnosis
- US/MRI if uncertain
Achilles tendonitis management
- Rest, physio, heel raises (offload tendon), splint or boot
Resistant achilles tendonitis management
Tendon decompression and resection of paratendon
Achilles tendon rupture
- history of tendonitis/ tendon degeneration
- sudden deceleration with resisted calf muscle contraction e.g. lunging at squash
Achilles tendon rupture clinical presentation
- weak/no plantarflexion
- palpable gap in tendon
- Positive Simmond’s test
What it is positive simmond’s test and what does it indicate?
No plantarflexion of the foot is seen when squeezing the calf.
Achilles tendon rupture
Achilles tendon rupture investigations
US (or MRI) to distinguish between complete and partial tears
Achilles tendon rupture treatment is controversial. Describe & compare the two main options
Surgical management
- Surgical repair & then 8 weeks of series of casts
- Slightly lower re-rupture rate
Non-operative management
- series of casts in equinous position
(the ankle platarflexed with the toes pointing down)
- avoids surgical complications
What tissue is affected in plantar fasciitis
It is a degenerative condition of the plantar fascia
Plantar fasciitis risk factors
- Physical overload - excessive exercise or weight (obesity)
- Diabetes
- Age - the cushioning heel fat pad atrophies with age
- Abnormal foot shape - splanovalgus or cavovarus
- Frequent walking on hard floors with poor cushioning in shoes
Where & when is pain experienced in plantar fasciitis
PATIENT DESCRIPTION
- on the bottom of your foot,
- around their heel &/ inner arch
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ANATOMICAL DESCRIPTION
- at the origin of the plantar aponeurosis
- distal plantar aspect of the calcaneal tuberosity
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EXACERBATING FACTOR
- exercise
Clinical signs of plantar fasciitis on examination
- Swelling on plantarmedial aspect of heel
- Tenderness on palpation of plantar(medial) aspect of heel
Plantar fasciitis investigations
Clinical diagnosis (history & examination)
Plantar fasciitis management
Self-limiting
- Rest, stretches (achilles & plantar fascia), gel filled heel pad
- Steroid injections for symptomatic relief
- NO surgery (risk to nerves)
Are patients with generalised ligamentous laxity more likely to have pes planus or pes cavus
Pes planus - Patients with generalized ligamentous laxity are more likely to have flat feet.
Name a condition that people with flat feet (pes planus) are at higher risk of?
Tibialis posterior tendonitis
Flat feet is a normal variation affecting up to 20% of the population as their medial arch doesn’t develop in childhood. However, for some people flat feet is acquired secondary to another condition. Name some of these.
Tibialis posterior tendon stretch or rupture
Rheumatoid arthritis
Diabetes with Charcot foot (neuropathic joint destruction)
Compare mobile vs rigid vs acquired flat feet (pes cavus)
Mobile flat feet (most common)
- flat foot on WB (standing)
- arch forms with dorsiflexion of great toe (sitting/ tip-toeing)
- may be related to ligamentous laxity
- no structural abnormality
- is a normal child variant
- in adults, may relate to tibialis posterior tendon dysfunction
- no surgery
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Rigid flat feet
- flattened arch regardless of load or great toe dorsiflexion
- suggests underlying bony abnormality called tarsal coalition
- may also represent underlying inflam/neuro disorder
- structural abnormality
- may require surgery
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Acquired flat feet
- occurs secondary to e.g. Charcot foot in diabetes, tibialis posterior tendon rupture/ dysfunction, RA
- can be rigid or flexible
Where does the tibialis posterior tendon insert and what is its function
- Inserts onto medial navicular
- Supports medial arch of medial
- Also plays a role in plantarflexion and foot inversion
What else, other than repetitive strain, tendonitis and injury, can cause the rupture of tibialis posteriro tendon?
Synovitis from RA can also result in tendon rupture
What is the most common cause of acquired flat foot in adults
Tibialis posterior tendon dysfunction
Tibialis posterior tendon dysfunction risk factors
- Obesity, age, hypertension, diabetes, inflam arthropathies
- tendonitis, steroid injections
What happens as a result of tibialis posterior tendon rupture
Loss of medial arch (flat foot) &
Heel valgus
Tibialis posterior tendon dysfunction clinical presentation
- Pain and/or swelling posterior to medial malleolus
- loss of medial arch/ heel valgus
- diminished walking ability, dislike of uneven surfaces
- lateral hind foot impingement pain (due to transfer of WB)
Tibialis posterior tendon dysfunction is diagnosed clinically and then classification guides treatment. Describe an example classification guide
- Type I: swelling, tenderness, slightly weak muscle power
- Type II: planovalgus, midfoot abduction, passively correctable, cannot single heel raise
- Type III and IV: fixity and mortise signs
Tibialis posterior tendon tendonitis treatment
- Initial - Medial arch splint (to avoid rupture)
- Persistent - surgical decompression & tenosynovectomy
Tibialis posterior tendon elongation/rupture treatment
Rupture with no OA
- tendon transfer +/- calcaneal osteotomy (to prevent OA)
Rupture with secondary OA & severe symptoms
- Arthrodesis
Pes cavus (abnormally high foot arch) aetiology
Idiopathic OR
Neuromuscular e.g. HSMN, cerebral palsy, polio, spinal bifida etc
What toe deformity often accompanies pes cavus
Claw toes
Pes cavus pain treatment
Supple - soft tissue release & tendon transfer
Rigid - calcaneal osteotomy
Severe cases - Arthrodesis
Pes cavus investigations
- WB x-ray of foot
- MRI spine if tumour is suspected
Describe a claw toe, hammer toe
- Claw toe - MTPJ hyperextension, PIPJ hyperflexion, DIPJ hyperflexion
- Hammer toe - MTPJ neutral, PIPJ hyperflexion, DIPJ hyperextension
Claw & hammer toe management
- Conservative - toe ‘sleeves’ & corn plasters to prevent skin issues
- Surgical - tenotomy, tendon transfer, PIPJ arthrodesis or toe amputation
