FOOT Flashcards
What are the 3 groups of bones in the feet?
Tarsals
Metatarsals
Phalanges
What are the tarsal bones?
Proximal - talus, calcaneus
Intermediate - navicular
Distal - cuboid, medial lateral and intermediate cuneiform
What are the metatarsals?
The forefront bones 1-5 before the phalanges
What are the 2 groups of muscles acting on the foot?
Extrinsic muscles = arise from the leg and responsible for eversion, inversion, plantar and dorsiflexion
Intrinsic muscles - located within he foot and responsible for fine motor actions of the foot
What are the 2 intrinsic muscles within the dorsum of the foot?
The extensor digitorum brevis and extensor hallucis brevis
Action of the extensor digitorum brevis?
Extension of the lateral 4 toes
Function of extensor hallucis brevis?
Extension of the great toe
What are the 10 intrinsic muscles located in the plantar aspect of the foot?
First layer - abductor hallucis, flexor digitorum brevis, abductor digiti minimi
Second layer - quadratus plantae and lumbricals
Third layer - flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis
Fourth layer - plantar interossei and dorsal interossei
Function of abductor hallucis?
Abduction and flexion of the big toe
Function of flexor digitorum brevis?
Flexion of the lateral 4 toes at the the proximal interphalangeal joints
Function of abductor digiti minimi?
Abduction and flexion of the little toe
Function of quadratus plantae?
Assists flexor digitorum longus in flexion of the lateral 4 toes
Function of the lumbricals?
Flexion at metatarsophalngeal joints and extension at interphalangeal joints
Function of flexor hallucis brevis?
Flexion of great toe at MTP joint
Function of adductor hallucis?
Adduction of great toe
Function of flexor digiti minimi brevis?
Flexion of little toe at MTP joint
Function of plantar interossei?
Adduction of lateral 3 digits and flexion at MTP joints
Function of dorsal interossei?
Abduction of lateral 4 digits and flexion at MTP joints
Symptoms of medial plantar nerve entrapment?
Paraesthesia of medial sole of foot and plantar aspect of 1st and second toes
Pain of medial plantar arch and heel
What causes medial plantar nerve entrapment?
“Joggers foot”
Repetitive foot eversion e.g. running, space occupying lesions of the foot, tenosynovitis of flexor hallucis longus or flexor digitorum long jaw tendons etc
What is Hallux valgus?
A bunion
Valgus deformity of the big toe
What causes bunions?
Wearing overly tight shoes, high heeled shoes, FHx, RA
Presentation of bunions?
Slow development of….
Obvious valgus deformity of the foot and a bony enlargement of the first metatarsal head
Gait deviations
Irritation of skin around the bunion and blisters may form
Difficulties finding properly fitting footwear
Treatment of bunions?
Change in footwear
Use of orthotics
Rest, ice, analgesia
If the discomfort persist then surgery may be done
What is hallux rigidus?
OA of the MTP joint of the big toe
What can be precipitating factors for hallux rigidus?
Normal wear and tear
Traumatic injury of big toe in the past
Poor foot alignment - pes planus or bunion
Presentation of hallux rigidus?
Pain in MTPJ of big toe at top of joint during activity
Swelling
Redness
Stiffness
Management of hallux rigidus?
Analgesia, ice, activity modification
Footwear - stiff-soled shoes or a standard shoe with a Morton’s extension insert
Corticosteroid injections
If not effective surgical options include…
Cheilectomy - removal of bony spurs
Arthrodesis - fusion of bones together
Arthroplasty - joint replacement
What is Morton’s neuroma?
A benign tumour of the interdigital nerve in the forefoot due to entrapment e.g. wearing tight shoes, running, other foot problems
How does Morton’s neuroma present?
Persistent burning or sharp pain in the ball of the foot which radiates into the toes, especially during weight bearing activities - most commonly between base of 3rd and 4th toes but it can occur between the 2nd and 3rd toes
Sensation of having a pebble/marble under their foot as they walk
Tight shoes such as high heels exacerbate this
Some may feel numbness q
What test can you do to clinically diagnose a Morton’s neuroma?
Mulder’s click - with 1 hand clasp the metatarsal heads and then place the thumb of the other hand on the plantar surface of the foot in the intermetatarsal space at the site of suspected neuroma. Squeeze the metatarsal heads together ans then exert pressure on the interdigital space. You may feel a mass displace towards the plantar surface of the foot - palpable click and pain
Diagnosis of Morton’s neuroma?
USS
Treatment of Morton’s neuroma?
Rest, ice, analgesia, wide shoes, insoles, lose weight, avoid high impact activity
Steroid injections
Radiofrequency ablation
Surgery - neurectomy
What is plantar fasciitis?
Inflammation of the plantar fascia which is a thick connective tissue attaching to the calcaneus of the heel and traveling along the sole of the foot before branching out and connecting to flexor tendons of the toes
Caused by micro tears of the plantar fascia usually as a result of overuse
How does plantar fasciitis present?
Gradual onset of pain on the plantar aspect of the heel which is worse with pressure, particuarly when walking.standing for prolonged periods. Also worse first thing in morning
Difficult to raise toes off the floor
Tenderness to palpation
Management of plantar fasciitis?
Rest, ice, analgesia
Orthotics
PT
Steroid injections
Specialist management is rarely needed: extracorporeal shockwave therapy or surgery
Causes of plantar fasciitis?
Recently stared exercising on hard surfaces
Exercise with a tight calf or heel
Overstretching sole of foot during exercise
Recently started doing a lot more walking/running/standing
Wearing shoes with poor support
Very overweight
What is fat pad atrophy?
When the fat pad under the calcaneus which usually protects the heel from impact atrophies
This can occur with age or inflammation from repetitive impacts
Local steroid injections in the foot can also cause it
Presentation of fat pad atrophy?
Pain and tenderness over the plantar aspect of the heel
Symptoms worse with activities, particularly when barefoot on hard surfaces
How is fat pad atrophy diagnosed?
USS to measure the thickness of the fat pad
Management of fat pad atrophy?
Comfortable shoes with custom insoles
Adaptive activities e.g avoiding high heels
Weight loss
What is a hammer toe?
When the toe is bent at the proximal interphalangeal joint
What causes hammer toes?
Muscle imbalance that puts pressure on the toe tendons and joints
Wearing shoes that dont fit properly e.g. Shoes that narrow toward the toe or high heels
Also caused by hallux valgus or high feet arches
Presentation of hammer toe?
Swelling or redness
Inability to straighten the toe
Difficulty walking
A corn or callus on the top of the middle joint of the toe or on the tip of the toe
Treatment of hammer toe?
Change foot wear
Exercises to help strength and stretch the muscles
Surgery can be done also if severe e.g. Arthrodesis
What is claw toe?
Dorsiflexion of proximal phalanx on MTP joint and concurrent flexion of PIP and DIP joints
What is mallet toe?
Flexion at the distal interphalangeak joint of the toe
Causes of mallet toe?
Restrictive shoes
Arthritis
Trauma
Claw toe causes?
Shoes that dont fit properly
Diabetes or alcoholism - neuropathy weakness muscle in foot
What is metatarsalgia?
A common injury
A term used to refer to any painful foot condition affecting the metatarsal region of the foot e.g. bunions, fat pad atrophy, high arched feet, arthritis, gout, pes cavus
What is a sprain?
A stretching, partial or complete tear of a ligament
What are the 2 types of ankle sprains?
High ankle sprains - involving the syndesmosis bindings the distal tibia and fibula together
Low ankle sprains - involving the lateral collateral ligaments
What most commonly causes low ankle sprains?
> 90% are inversion injuries causing damage to the anterior talofibular ligament
Presentation of low ankle sprains?
Pain, swelling, tenderness over affected ligaments
Sometimes bruising
Usually able to weight bear unless severe
Grading of a low ankle sprains?
Grade 1 - stretch/micro tear - minimal bruising and swelling
Grade 2 - partial tear - moderate bruising and swelling with minimal pain on weight bearing
Grade 3 - complete tear - severe bruising, swelling and pain on weight bearing
Why should radiographs for ?ankle sprains be done according to the Ottawa ankle rules?
As 15% of sprains are associated with a fracture
Management of a low ankle sprains?
Rest, ice, compression, elevation
Orthosis, cast, crutches may be required short term
If symptoms fail to settle or there is significant joint instability then an MRI and surgical intervention may be contemplated, but this is rare.
What causes a high ankle sprain?
These are very rare!!
External rotation of the foot causes the talus to push the fibula laterally
Presentation of a high ankle sprain?
Pain, swelling, bruising
Weight bearing very painful
What is the Hopkins squeeze test?
Squeeze the tibia and fibula together starting just below the knee and work down to the malleolus
Sign of a high ankle sprain - the more proximal pain is felt, the more sevee the injury!
Investigation for ?high ankle sprain?
XR - widening of tibiofibular joint or ankle mortise
MRI if high suspicion but normal XR
Tx of high ankle sprains?
If no diastasis then non-weight-bearing orthosis or cast until pain subsides.
If diastasis or failed non-operative management then operative fixation is usually warranted.
What is a Charcot joint?
A joint that has become badly disrupted and damages secondary to a loss of sensation
Most commonly seen in diabetics
Features of a Charcot joint?
Typically a lot less painful than expected due to sensory neuropathy - most report some pain
Swollen, red, warm joint
What is talipes eqinovarus?
Club foot
Inverted and plantar flexed foot
Most common associations for club foot?
Most commonly idiopathic
Spina bifida
Cerebral palsy
Edward’s syndrome
Oligohydramnios
Arthrogryposis
What is osteomyelitis?
Infection of the bone
What are the 2 subclassifications of osteomyelitis?
Haematogenous osteomyelitis - from bacteraemia
Non-haematogenous osteomyelitis - from contiguous spread of infection from adjacent soft tissues to the bone OR from direct injury to the bone
Risk factors for haematogenous osteomyelitis?
Sickle cell anaemia
IVDU
Immunosuppression - meds, HIV
Infective endocarditis
Risk factors for non-haematogenous osteomyelitis?
Diabetic foot ulcers
Pressure sores
DM
PAD
What is the most common microorganism that causes osteomyelitis?
Staph aureus
What is the most common microorganism that causes osteomyelitis in sickle cell patients?
Salmonella species
Investigation for osteomyelitis?
MRI
