Cortex- Lower Limb: Foot and Ankle Flashcards by Louise Emerson

what can cause ankle OA

idiopathic, primary or consequence of a previous injury

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what are the two surgical options for patients with significant advanced ankle OA

arthrodesis and ankle replacement

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what is hallux valgus

deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself

in severe cases hallux may override the second toe

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who gets hallux valgus

commoner in females (4:1) there a familial tendency

incidence increases with age but can occur in adolescence

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what other conditions is hallux valgus commoner in

RA, inflammatory arthropathies, neuromuscular diseases (multiple sclerosis, cerebral palsy)

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why is hallux valgus painful

joint incongruence and a wideneing forefoot may cause a bunion
great toe and second toe may rub causing ulceration and skin breakdown

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what is a bunion

when rubbing of the foot with shoes causes an inflamed bursa over the medial 1st metatarsal head

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what causes hallux valgus

unknown cause but higher in shoe wearing populations

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what is the conservative treatment for hallux valgus

wider and deeper shoes to prevent bunions

spacer in the first web space

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what is the surgical management for hallux valgus

osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues

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what is surgery cautioned in hallux valgus

if doing for cosmesis many will be unhappy with the result
30% will be dissatisfied due to altered biomechanics of the foot
some have pain of metatarsal heads after surgery

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what is hallux ridigus

OA of the first MTPJ

can be primary (degenerative) or secondary to osteochondral injury

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what is the conservative treatment for hallux ridigus

wearing stiff soled shoes to limit motion at the MTPJ

removal of dorsal osteophytes (cheilectomy) when they impinge during dorsiflexion

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what is the gold standard surgical treatment for hallux rigidus

arthrodesis (stabilisation of a joint by fusion of the bones)
should alleviate pain with the small sacrifice of no motion

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what might be the problem with women an arthodesis

cant wear high heals

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can you do MTP joint replacement in hallux ridigus

yes but failure rates high and once failed salvage surgery is difficult

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what is mortons neuroma

plantar interdigital nerves (from the medial and lateral plantar nerves) overlying the intermetatarsal ligaments can be subjected to repeat trauma
irritated nerves can become inflamed and swollen (forming a neuroma)

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what are the symptoms of a mortons neuroma

burning pain and tingling radiating into the affected toes

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who gets mortons neuroma

women (4 times)

wearing high heals has been implicated as a cause

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what is the most common areas to be affected by mortons neuroma

third interspace nerve

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what might be seen on clinical examination of mortons neuroma

loss of sensation in the affected web space
mulders click test- compression of the metatarsal heads (squeezing forefoot with your hand) may reproduce symptoms or a characteristic click

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what imaging might be useful for the diagnosis of mortons neuroma

ultrasound can demonstrate a swollen nerve

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what is the conservative management of mortons neuroma

the use of a metatarsal pad or offloading insole

steroid and local anaesthetic injections may relieve symptoms and aid diagnosis

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is surgery for mortons neuroma possible

yes but some continue to experience pain and there is a small risk of recurrence

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where in foot do metatarsal stress fractures most commonly occur

in the 2nd metatarsal followed by the 3rd

who get metatarsal stress fractures

runners, soldiers on prolonged marches, dancers, or distance walking in those not used to it

when can x rays show metatarsal stress fractures

after 3 weeks wen resorption at the fracture ends occur or callus begins to appear

what might be useful in diagnosing a metatarsal stress fracture

bone scan

what is the treatment for a metatarsal stress fracture

prolonged rest for 6-12 weeks in a ridgid soled boot

what causes tendonitis of the achilles tendon

repetitive strain (from sports) which leads to a peritendonitis or due to degenerative process with intrasubstance microtears

what can predispose to achilles tendonitis

quinolone antibiotcs (ciprofloxacin), RA, inflammatory arthropathies, gout

what is the treatment for achilles tendonitis

rest, physio, heel raise to offload the tendon, use of a splint or a boot resistant cases may benefit from tendon decompression and resection of paratendon condition usually self limiting

where is the pain in achilles tendonitis

main body of achilles, its insertion at the calcaneus

what does tendonitis predispose to

tendon rupture

why do you never administer steroid injection around the achilles tendon

as risks rupture

who get achilles tendon rupture and why

occurs in middle aged or older groups and is usually due to degenerative changes within the tendon or recent tendonitis

what is the usual history of an achilles tendon rupture

sudden deceleration with resisted calf muscle contraction (lunging at squash) leads to sudden pain (like being kicked in back of leg) and difficulty weight bearing weakness of plantar flexion and a palpable gap in the tendon are usually apparent

what is simmonds test

positive in a torn achilles when no plantarflexion of the foot is seen when squeezing the calf

what is the treatment for a ruptured achilles tendon

controversial: operative and non operative suture repair of the damaged tendon to restore to tension of the tendon followed by 8 weeks of casts non operative- series of casts in the equinous position (ankle plantar flexed with the toes pointing down (closes gap in torn tendon) for 8 weeks

what is plantar fasciitis

self limiting repetitive stress/ overload or degenerative condition of the foot causing inflammation of the plantar fascia

what are the symptoms of plantar fasciitis

pain with walking is felt on the instep of the foot, localised tenderness on palpation of this site

where specifically is pain felt in plantar fasciitis

at the origin of the plantar aponeurosis on the distal plantar aspect of the calcaneal tuberosity

what are causative factors of plantar fasciitis

diabetes, obesity, frequent walking on hard floors with poor cushioning floors cushioning heel fat pad atrophies with age

what is the treatment for plantar fasciitis

rest, achilles and plantar fascia stretching exercises gel filled heel pad corticosteroid injection symptoms may take up to 2 years to resolve surgery avoided due to risk of plantar nerve damage

what is pes panus

flat feet

what causes normal flat feet in adults

failure of medial arch development in childhood

who is more likely to have pen panus

people with ligamentous laxity | has familial tendency

does developmental pes panus need treatment

what are people with developmental pes panus more likely to develop

tendonitis of the tibialis posterior tendon

what can cause acquired flat feet

tibialis posterior tendon stretch or rupture, RA, diabetes with charcot foot

what is charcot foot

neuropathic joint destruction | weakening of bones due to nerve damage

where does the tibialis posterior tendon insert

onto the medial navicular

what does the tibial posterior tendon do

supports the medial arch of the foot platarflexor invertor of the foot

the tibialis posterior tendon is under repeated stress and can degenerate, what can this cause?

tendonitis, elongation, rupture

what else can cause tibialis posterior tendon

synovitis from RA

how should tibialis posterior tendonitis be treated

splint and medial arch support to prevent rupture physio if this fails to settle symptoms, surgical decompression and tenosynovectomy may prevent rupture

what happens if the tibialise posterior tendon elongates or ruptures

medial arch is lost causing valgus of the heel and flattening of the medial arch of the foot subsequent degenerative OA of the hindfoot and midfoot may occur

what surgery can be done in a tibialis posterior tendon dysfunction when the foot is supple with no OA

tendon transfer with a calcaneal osteotomy to reduce stress prevents secondary OA

what is type of surgery can be done in tibialis posterior tendon rupture once OA ensues

arthrodesis

what is pes cavus

abnormally high arch of the foot

what causes pes cavus

idiopathic related to neuromuscular conditions: hereditary sensory and motor neuropathy, cerebral palsy, polio (unilateral), spinal cord tethering from spina bifida occulta

what toe feature often accompanies pes cavus

claw toes

what is the treatment for pes cavus

pain- if supple:soft tissue releases, tendon transfer (lateral transfer of tibialis anterior if more rigid: calcaneal osteotomy severe cases may require arthodesis

what causes claw and hammer toes

an acquired imbalance between the flexor and extensor tendons

describe claw toes

hyperextension at the MTPJ with hyperflexion at the PIPJ and DIP

describe hammer toes

hyperextension at the MTPJ with hyperextension at the DIPJ

claw and hammer toes can be painful and rub on footwear causing corns and skin breakdown. what are the treatment options

toe 'sleeves' corn plasters surgery: tenotomy (division of an overactive tendon), tendon transfer, athrodesis (PIPJ), toe amputation

what prediposes to tibialis posterior dysfunction

``` obesity middle aged females flat foot hypertension diabetes steroid injection seronegative arthropathies idiopathic tenonosis ```

what nerve reacts in the tinels test in plantar fasciitis

lateral plantar nerve

when in tibialis posterior tendon rupture can a tendon transfer be performed and how and why is it done

if the foot remains supple with no OA to prevent secondary OA done with calcaneal osteotomy to reduce stress