Disorders of the Foot and ankle

Question 1

Joints of the Foot and Ankle (5)

Answer 1

Ankle - hinge - 30deg dorsiflexion, 45deg plantarflexion. Subtalar joint - Inversion & Eversion. Hindfoot/Heel - varus & valgus. Midfoot - Supination & pronation. Forefoot - Rotation, adduction and abduction

Question 2

Function of the foot and ankle

Answer 2

Weight bearing - requires correct alignment (varus deformity is main problem. Gait - Stance (Heel strike -25%, stance - 40%, Heel/Toe off - 35%) and swing phase

Question 3

Disorders of the foot can be

Answer 3

Traumatic Degenerative

Inflammatory Other

Question 4

Inspection of the foot CCCSD

Answer 4

Colour, Swelling, Deformity, Corns, Callosities

Question 5

Palpation of the foot TTSSP

Answer 5

Temperature, Tendernes, Swelling/lumps, Sensation/parasthesia, Pulses

Question 6

Corns

Answer 6

Hyperkeratosis which develop in response to pressure during walking - they develop a pointed structure which can cause ulceration if there is a sensitivity or weakness in the skin (diabetes)

Question 7

Bunions

Answer 7

A bony deformity caused from a valgus deviation of the big toe and subsequent inflammation and protrusion of the metatarsophalangeal joint with possible inflammation of the bursa - caused by genetic factors and ill-fitting shoes

Question 8

Functional assessment of the foot

Answer 8

Observe the gait pattern - standing on tiptoes. Inspect movement at individual joints. look for signs of muscle weakness (arch collapse if peroneals and tibialis) and nerve damage. Assess wear pattern on shoe soles

Question 9

Management of functional foot problems

Answer 9

Conservative - insoles/orthotic shoes, injections or medications
Surgical - osteotomy, excision arthroplasty, arthrodesis, joint replacement arthroplasty

Question 10

Degenerative joint disease

Answer 10

OA - wear and tear over time

Worse in the old and the obese

Question 11

Inflammatory joint diseases

Answer 11

RA, Gout or psoriatic arthritis

Question 12

Rocker bottom foot

Answer 12

congenital vertical talus - prominent heel and rounded sole of the foot - related to trisomy 13, 18 and 9

Question 13

Flat foot

Answer 13

medial arch is low, normally develops at 5-6yrs, after this can be congential (joint laxity) or acquired (muscle/tendon deficiencies–> polio, Degenerative–>RA or Charcoats)
Opposite of pes Cavus deformity (excessive arch)

Question 14

Consequences of Flat foot

Answer 14

Foot strains, Recurrent falls and Shoes wear badly

Could also lead to knee, hip and back problems later

Question 15

Charcot’s foot

Answer 15

Neuropathic arthropathy - gradual progressive degeneration of a weight bearing joint - can occur in any joint when there is loss of peripheral sensation, proprioception and motor control (mainly diabetes)

Question 16

Treatment of flat foot

Answer 16

Early and flexible - insoles, muscle exercises and rarely surgery
Early and fixed (bony deformity) - operative treatment
Adult acquired - insoles and augmentation of tibialis posterior where it is weakened

Question 17

Treatment of Pes Cavus

Answer 17

Only treatment is operative

Question 18

Treatment of bunions

Answer 18

Change shoes

if severe can perform osteotomies or arthroplasties

Question 19

Hallux Rigidus

Answer 19

Stiffness of the 1st MTP causing pain on walking, swelling and tenderness over the joint and restricted dorsiflexion
Treat with arthrodesis or replacement

Question 20

Osteochondritis

Answer 20

A derangement of bone growth similar to AVN which can be post-traumatic or idiopathic
Examples include - Osteochondritis dissecans of the talus, Kohler’s/Navicular and Freiberg’s/2nd metatarsal

Question 21

Metatarsalgia

Answer 21

Pain in the metatarsals - can be due to a number of causes:

stress fractures, morton’s neuroma, Frieberg’s disease, Gout, RA

Question 22

Painful heel

Answer 22

Plantar fascitis, calcaeal knob, nerve entrapment syndromes, achilles tendonitis

Question 23

Morton’s neuroma

Answer 23

a benign neuroma of an intermetatarsal plantar nerve, most commonly between the 2nd and 3rd toes. Can cause pain, burning or numbness and is usually treated conservatively with steroid injections or orthotic shoes
Can be removed surgically

Question 24

Achilles tendon rupture

Answer 24

Due to degenerative changes typically 4-6cm above the insertion - prevents tiptoe walking and can be diagnosed by Symmond’s test - can be treated by cast fixing foot plantar flexed for 8wks or operative repair and cast

Question 25

Symmond’s test

Answer 25

Squeezing the calf and watching for movement of the foot, if there is none then it could indicate achilles tendon rupture

Question 26

Toe deformities

Answer 26

Most common in women and in later life
Can be hammer, claw or mallet
Can be treated conservatively or surgically

Question 27

Achilles tendinitis/Bursitis

Answer 27

Pain, swelling and tenderness over the tendon near the insertion -- pain worsened by passive dorsiflexion. Do not give injections as risk of rupture is high (in elderly). Common in sports involving jumping
Treat conservatively (RICE)

Question 28

Plantar fasciitis

Answer 28

Most common cause of heel pain – in the undersurface of the heel (medial longitudinal arch) when weight bearing due to repetitive microtrauma in obese pts – mostly in middle or old age – Linked to abnormal foot mechanics

Question 29

Stress fractures of the metatarsal

Answer 29

Any MT after increased activity - greater risk in osteoporosis –> presents with dull ache along shaft which is worse on exercise and tenderness with swelling over the dorsal aspect

Question 30

Plantar metatarsal bursitis

Answer 30

Can affect deep or superficial bursa acute or chronically
A throbbing pain under the metatarsal head
May be due to inflammatory arthritis or sport

Question 31

Subtypes of plantar fascitis

Answer 31

Fast growing nodules in fascia (‘true’ plantar fasciitis)

Fibrous nodules with contracture of the fascia (plantar fibromatosis)

Question 32

Calcaneal apophysitis

Answer 32

A dull ache behind the heel of 8-13yrs boys of gradual onset which is worse on heel lift. Due to chronic strain at the attachment of posterior apophysis of the calcaneus

Question 33

Plantar calcaneal bursitis

Answer 33

Inflammation of the bursa beneath the plantar aspect of the calcaneal tuberosities – burning, aching pain with tenderness on the heel surface

Question 34

Ottawa rules for if a patient requires an X-ray after an ankle injury

Answer 34

sensitivity close to 100%
Need an X-ray if anyone of:
Bony tenderness at the lateral malleolus OR at the medial malleolus
Inability to walk four weight bearing step immediately after the injury and in the AnE

Question 35

Genetics of Talipes equinovarus

Answer 35

Can be idiopathic or teratological (cerebral palsy, spina bifida etc)
20% are associated with distal arthrogryposis, congential myotonic dystrophy, myelomeningocele, amniotic band, Trisomy 18 etc.