Disorders of the Foot and ankle Flashcards
Joints of the Foot and Ankle (5)
Ankle - hinge - 30deg dorsiflexion, 45deg plantarflexion. Subtalar joint - Inversion & Eversion. Hindfoot/Heel - varus & valgus. Midfoot - Supination & pronation. Forefoot - Rotation, adduction and abduction
Function of the foot and ankle
Weight bearing - requires correct alignment (varus deformity is main problem. Gait - Stance (Heel strike -25%, stance - 40%, Heel/Toe off - 35%) and swing phase
Disorders of the foot can be
Traumatic Degenerative
Inflammatory Other
Inspection of the foot CCCSD
Colour, Swelling, Deformity, Corns, Callosities
Palpation of the foot TTSSP
Temperature, Tendernes, Swelling/lumps, Sensation/parasthesia, Pulses
Corns
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)
Bunions
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
Functional assessment of the foot
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
Management of functional foot problems
Conservative - insoles/orthotic shoes, injections or medications
Surgical - osteotomy, excision arthroplasty, arthrodesis, joint replacement arthroplasty
Degenerative joint disease
OA - wear and tear over time
Worse in the old and the obese
Inflammatory joint diseases
RA, Gout or psoriatic arthritis
Rocker bottom foot
congenital vertical talus - prominent heel and rounded sole of the foot - related to trisomy 13, 18 and 9
Flat foot
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)
Consequences of Flat foot
Foot strains, Recurrent falls and Shoes wear badly
Could also lead to knee, hip and back problems later
Charcot’s foot
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)
Treatment of flat foot
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
Treatment of Pes Cavus
Only treatment is operative
Treatment of bunions
Change shoes
if severe can perform osteotomies or arthroplasties
Hallux Rigidus
Stiffness of the 1st MTP causing pain on walking, swelling and tenderness over the joint and restricted dorsiflexion
Treat with arthrodesis or replacement
Osteochondritis
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
Metatarsalgia
Pain in the metatarsals - can be due to a number of causes:
stress fractures, morton’s neuroma, Frieberg’s disease, Gout, RA
Painful heel
Plantar fascitis, calcaeal knob, nerve entrapment syndromes, achilles tendonitis
Morton’s neuroma
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
Achilles tendon rupture
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
Symmond’s test
Squeezing the calf and watching for movement of the foot, if there is none then it could indicate achilles tendon rupture
Toe deformities
Most common in women and in later life
Can be hammer, claw or mallet
Can be treated conservatively or surgically
Achilles tendinitis/Bursitis
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)
Plantar fasciitis
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
Stress fractures of the metatarsal
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
Plantar metatarsal bursitis
Can affect deep or superficial bursa acute or chronically
A throbbing pain under the metatarsal head
May be due to inflammatory arthritis or sport
Subtypes of plantar fascitis
Fast growing nodules in fascia (‘true’ plantar fasciitis)
Fibrous nodules with contracture of the fascia (plantar fibromatosis)
Calcaneal apophysitis
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
Plantar calcaneal bursitis
Inflammation of the bursa beneath the plantar aspect of the calcaneal tuberosities – burning, aching pain with tenderness on the heel surface
Ottawa rules for if a patient requires an X-ray after an ankle injury
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
Genetics of Talipes equinovarus
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.
