Ankle & Foot Flashcards

1
Q

What is hallux valgus?

A

Deformity of the great toe due to MEDIAL deviation of the 1st metatarsal and LATERAL deviation of the toe itself

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2
Q

Name 2 types of conditions that increase an individuals risk of hallux valgus

A
  • RA or other inflammatory arthropathies
  • Certain neuromuscular conditions such as MS & cerebral palsy
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3
Q

Rubbing of the greater toe against shoes in hallux valgus can lead to what condition?

A

Bunion - An inflamed bursa over the medial 1st metatarsal

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4
Q

In hallux valgus, the great toe and second toe may rub against each other, What can this lead to?

A

Ulceration & skin breakdown

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5
Q

In severe cases of hallux valgus what might happen?

A

The great toe may override the second toe

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6
Q

Hallux valgus initial management

A

CONSERVATIVE MANAGEMENT
- Wider footwear to prevent bunions
- Spacers in the first web space to prevent rubbing between toes

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7
Q

Name some indications for surgical management with hallux valgus

A
  • Failure of conservative management
  • lesser toe deformities
  • lifestyle or functional limitation
  • overlapping of great toe & second toe
    NOT cosmetic reasons alone
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8
Q

Surgical management of hallux valgus

A
  • Osteotomies to realign bones
  • Soft tissue procedures to tighten or release tissue
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9
Q

What do some patients complain of after hallux valgus surgery?

A

Metatarsalgia - pain in the metatarsal heads

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10
Q

What is hallux rigidus?

A

OA of the first MTPJ

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11
Q

Hallux rigidus clinical presentation

A
  • Painful, stiff first MTPJ
  • Pain worse on activity/ wearing shoes
  • Dorsal exostosis (bone spur)
  • Reduced MTPJ movement, especially dorsiflexion
  • Therefore, IPJ hyperextension
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12
Q

Describe the difference in ROM of the great toe IPJ in Hallux rigidus

A

Hyperextension

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13
Q

Hallux rigidus investigations

A
  • Clinical diagnosis
  • X-ray
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14
Q

Hallux rigidus conservative management

A
  • Weight loss
  • Analgesia
  • Stiff soled shoe to limit motion
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15
Q

Possible surgical option for hallux rigidus in early stages with dorsal osteophyte impingement

A

Osteophyte removal (cheilectomy)

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16
Q

Hallux rigidus gold standard treatment

A

Arthrodesis
(Note - women will no longer be able to wear heels)

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17
Q

What is a Morton’s neuroma

A

Inflamed plantar interdigital nerves forming a neuroma

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18
Q

Morton’s neuroma clinical presentation

A
  • Burning pain
  • Tingling radiating into toes
  • Exacerbated - footwear, relieved - massaging foot
  • Loss of sensation in affected web space
  • Positive mulder’s click test
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19
Q

Describe the clinical test used to test for Morton’s neuroma

A

Mulder’s click test - squeezing the forefoot with your hands, compressing the metatarsal heads to reproduce symptoms &/ a characteristic ‘click’

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20
Q

Morton’s neuroma investigations

A
  • Mulder’s click test
  • X-ray to rule out MSK pathology
  • Diagnostic US to demonstrate swollen nerve (low specificity)
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21
Q

Morton’s neuroma risk factors

A
  • Age
  • Obesity
  • Female
  • High heels
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22
Q

Morton’s neuroma management

A
  • Conservative - RICE, weight loss, offloading insole, calf muscle stretching
  • Symptom relief - steroid & local anaesthetic injections
  • Persistent, resistant symptoms - surgical excision
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23
Q

Metatarsal stress fracture risk factors & clinical presentation. Which MT is most commonly affected?

A
  • Runners, soldiers, dancers etc (repeated stress/injury)
  • Pain & inability to weight bear
  • 2nd MT most commonly affected
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24
Q

Metatarsal stress fracture investigations

A
  • 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
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25
Q

Metatarsal stress fracture management

A

Prolonged rest for 6‐12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms

26
Q

Achilles tendonitis risk factors

A
  • Overtraining (sports)
  • Quinolones
  • RA & other inflammatory arthropathies
  • Gout
27
Q

Where would pain occur in Achilles tendonitis and what other symptoms would you expect

A
  • Pain at Achilles tendon or at its insertion in the calcaneus
  • Worse - Morning, better - walking
28
Q

Achilles tendonitis investigations

A
  • Clinical diagnosis
  • US/MRI if uncertain
29
Q

Achilles tendonitis management

A
  • Rest, physio, heel raises (offload tendon), splint or boot
30
Q

Resistant achilles tendonitis management

A

Tendon decompression and resection of paratendon

31
Q

Achilles tendon rupture

A
  • history of tendonitis/ tendon degeneration
  • sudden deceleration with resisted calf muscle contraction e.g. lunging at squash
32
Q

Achilles tendon rupture clinical presentation

A
  • weak/no plantarflexion
  • palpable gap in tendon
  • Positive Simmond’s test
33
Q

What it is positive simmond’s test and what does it indicate?

A

No plantarflexion of the foot is seen when squeezing the calf.
Achilles tendon rupture

34
Q

Achilles tendon rupture investigations

A

US (or MRI) to distinguish between complete and partial tears

35
Q

Achilles tendon rupture treatment is controversial. Describe & compare the two main options

A

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

36
Q

What tissue is affected in plantar fasciitis

A

It is a degenerative condition of the plantar fascia

37
Q

Plantar fasciitis risk factors

A
  • 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
38
Q

Where & when is pain experienced in plantar fasciitis

A

PATIENT DESCRIPTION
- on the bottom of your foot,
- around their heel &/ inner arch

————————————————————————————

ANATOMICAL DESCRIPTION
- at the origin of the plantar aponeurosis
- distal plantar aspect of the calcaneal tuberosity

————————————————————————————

EXACERBATING FACTOR
- exercise

39
Q

Clinical signs of plantar fasciitis on examination

A
  • Swelling on plantarmedial aspect of heel
  • Tenderness on palpation of plantar(medial) aspect of heel
40
Q

Plantar fasciitis investigations

A

Clinical diagnosis (history & examination)

41
Q

Plantar fasciitis management

A

Self-limiting
- Rest, stretches (achilles & plantar fascia), gel filled heel pad
- Steroid injections for symptomatic relief
- NO surgery (risk to nerves)

42
Q

Are patients with generalised ligamentous laxity more likely to have pes planus or pes cavus

A

Pes planus - Patients with generalized ligamentous laxity are more likely to have flat feet.

43
Q

Name a condition that people with flat feet (pes planus) are at higher risk of?

A

Tibialis posterior tendonitis

44
Q

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.

A

Tibialis posterior tendon stretch or rupture
Rheumatoid arthritis
Diabetes with Charcot foot (neuropathic joint destruction)

45
Q

Compare mobile vs rigid vs acquired flat feet (pes cavus)

A

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

————————————————————————————

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

————————————————————————————

Acquired flat feet
- occurs secondary to e.g. Charcot foot in diabetes, tibialis posterior tendon rupture/ dysfunction, RA
- can be rigid or flexible

46
Q

Where does the tibialis posterior tendon insert and what is its function

A
  • Inserts onto medial navicular
  • Supports medial arch of medial
  • Also plays a role in plantarflexion and foot inversion
47
Q

What else, other than repetitive strain, tendonitis and injury, can cause the rupture of tibialis posteriro tendon?

A

Synovitis from RA can also result in tendon rupture

48
Q

What is the most common cause of acquired flat foot in adults

A

Tibialis posterior tendon dysfunction

49
Q

Tibialis posterior tendon dysfunction risk factors

A
  • Obesity, age, hypertension, diabetes, inflam arthropathies
  • tendonitis, steroid injections
50
Q

What happens as a result of tibialis posterior tendon rupture

A

Loss of medial arch (flat foot) &
Heel valgus

51
Q

Tibialis posterior tendon dysfunction clinical presentation

A
  • 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)
52
Q

Tibialis posterior tendon dysfunction is diagnosed clinically and then classification guides treatment. Describe an example classification guide

A
  • 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
53
Q

Tibialis posterior tendon tendonitis treatment

A
  • Initial - Medial arch splint (to avoid rupture)
  • Persistent - surgical decompression & tenosynovectomy
54
Q

Tibialis posterior tendon elongation/rupture treatment

A

Rupture with no OA
- tendon transfer +/- calcaneal osteotomy (to prevent OA)

Rupture with secondary OA & severe symptoms
- Arthrodesis

55
Q

Pes cavus (abnormally high foot arch) aetiology

A

Idiopathic OR
Neuromuscular e.g. HSMN, cerebral palsy, polio, spinal bifida etc

56
Q

What toe deformity often accompanies pes cavus

A

Claw toes

57
Q

Pes cavus pain treatment

A

Supple - soft tissue release & tendon transfer
Rigid - calcaneal osteotomy
Severe cases - Arthrodesis

58
Q

Pes cavus investigations

A
  • WB x-ray of foot
  • MRI spine if tumour is suspected
59
Q

Describe a claw toe, hammer toe

A
  • Claw toe - MTPJ hyperextension, PIPJ hyperflexion, DIPJ hyperflexion
  • Hammer toe - MTPJ neutral, PIPJ hyperflexion, DIPJ hyperextension
60
Q

Claw & hammer toe management

A
  • Conservative - toe ‘sleeves’ & corn plasters to prevent skin issues
  • Surgical - tenotomy, tendon transfer, PIPJ arthrodesis or toe amputation