Chapter 44- leg, ankle and foot Flashcards
Describe a claw toe
- Flexion of the IP joints, hyperextension of the MTPJ
Describe a hammer toe
-Flexion of the terminal phalanx with callosity at the tip of the toe and varus or valgus deformity
Rupture of which tendon will cause a flat foot?
-Tibialis posterior
What are shin splints? what causes it
- Pain in anterior lower leg associated with activity
- Causes include stress fracture, muscle pull on periosteum causing periostitis and chronic compartment syndrome
what investigations can be done if shin splints are suspected
- Bone scan: localised area of uptake for stress fractures or diffuse area in periostitis
- Compartment syndrome can be confirmed by compartment pressure studies performed after the activity has provoked the pain
- Occasionally Xray will reveal a stress fracture
Treatment of shin splints
- Reduce activity levels to avoid occurrence of pain for at least 6 months
- Appropriate cross training
- review with bone scan at 6 months
Treatment of ruptured fibres of gastrocnemius/ soleus/ plantaris
-Acute phase: RICE, analgesics, anti-inflammatories
Post-acute-phase: Physio for cross friction and graduated return to activity. Stretching exercises are important to prevent recurrent injury.
Typical history and examination findings in achilles tendinitis
- Pain on active ankle dorsiflexion
- Local tenderness
- Tendon slightly thickened
- Palpable crepitus on active ankle movement
Treatment of achilles tendinitis
- Rest
- Heel raise of 2 cm
- NSAIDs
- Injection of local cortico steroid (may cause rupture)
- Surgery: persistent or recurrent cases
Typical history of achilles tendon rupture
During strenuous activity, acute pain is felt, often accompanied by a loud snap. The patient may feel like something heavy has struck the leg from behind
Exam findings of achilles tendon rupture
- Limp and patient cannot stand on tip-toe
- Gap may be palpable in the tendon
- Plantar-flexion is weak
- Simmond’s calf squeeze test is positive
Treatment of achilles tendon rupture
- BK POP with foot fully plantar-flexed for 4 weeks followed by foot in mid equinus for further 4 weeks followed by neutral pop for 4 weeks
- Surgical repair in younger patient, those with gap int he tendon and those with a late diagnosis
- Takes 9-12 months to heal. Warn patients and restrict activities
In which two groups does plantar fasciitis occur
- Young runners
- Relatively sedentary middle-aged people
History of plantar fasciitis
- Morning pain, first few steps are most painful, therafter improve
- Start-up pain- after sitting for a period, the first few steps are very painful
- Deep-seated heel pain
Exam findings for plantar fasciitis
localised tenderness over the infero-medial calcaneal border, at the insertion of the plantar fascia
Treatment of plantar fasciitis
- Treatment is patient based stretching
- Tendo-achilles and the plantar fascia must be stretched
- NSAIDs and steroid injections provide temporary relief only and should only be offered as symptomatic relief
What is the presentation of plantar warts (verruca plantaris)
- Flat, clearly circumscribed warts
- Shaving with scalpel produces punctate bleeding
- Side to side squeezing is exquisitely tender in contrast to callosities which are only tender on palpation in the direction of the metatarsal head
- Patient complains of pain on walking
- Sharp, localised tenderness to palpation
Treatment of plantar warts
6 weeks of wart cream (Salicylic acid, lactic acid, colloid)
Underlying conditions that may cause corns/callosities
- conditions causing joint stiffness and deformity- previous trauma or RA
- sensation compromise e.g. Neuropathy
What conditions is claw toe seen in?
- seen in pes cavus and in conditions of muscle imbalance
- associated metatarsalgia, callosities and corns
Treatment of claw toe
Modify footwear
Surgical correction for severe disability
What is the natural history of Hallux valgus
- big toe develops hallux valgus/ valgus deformity of the MTPJ
- may be metatarsus primus varies and the head of the first metatarsal becomes prominent causing a bunion where it is subjected to increased shoe pressure
- OA of first MTPJ may develop due to subluxation
- minor toes may be encroached upon, causing overlapping and claw toes with painful plantar and dorsal callosities that develop
Treatment of hallux valgus
- broad footwear, relieve pressure: bunion pads, soft upper and soft soles
- surgery: combination of soft tissue and bony procedures to correct deformity
What is the consequence of peripheral neuritis in diabetic foot
- Peripheral neuritis-> neuropathic distortion of the joints and stress fractures (a Charcot joint)
- foot becomes deformed causing pressure callosities and pressure sores (ulcers) overlying bony projections that do not heal
- patient is unaware of the trauma to the skin because of reduced sensation
