Foot and Ankle Flashcards
How is the foot divided up?
What constitutes each part?
Forefoot – metatarsals and phalanges; Midfoot – cuneiforms, cuboid and navicular; Hindfoot – talus and calcaneus
What arteries do you absolutely need in order to keep the foot alive?
Only either the dorsalis pedis or posterior tibial
What things do you examine in the foot and ankle examination?
Exposure – up above the knee; if in tight jeans or trousers then put the patient in a gown
Look – calf wasting, alignment and arches of foot; side view as well
Gait
Feel
Move – done before feeling – ask patient to flex and back again
Neurological – check for sensation at all nerve sites
Vascular - pulses
Special tests
Pes planus
Aka?
What is it?
What causes it?
How common is it?
Acquired flat feet in adults is associated with what?
What are flat footed people at risk of, related to this?
What other ligamentous problem is it associated with?
Treatment?
Flat foot
Medial longitudinal arch is collapsed; arch forms when patient stands on the tip toes
20% of general population; often familial
Acquired flat feet in adults is associated with dysfunction of the posterior tibialis tendon (a dynamic stabilizer of the medial arch) - may be due to stretch or rupture
Risk of tendonitis in the PTT
Associated with generalized ligamentous laxity
Mostly asymptomatic so no treatment; orthotics aren’t proven to do anything
Tibialis posterior dysfunction
Where does the tibialis posterior tendon insert?
What is its funtion?
What does repeated stress cause?
The tibialis posterior tendon inserts predominantly onto the medial navicular and serves to support the medial arch of the foot (as well as being a plantarflexor and invertor of the foot). The tendon is under repeated stress and particularly with degeneration can develop tendonitis, elongation and eventually rupture. Synovitis form RA can also result in tendon rupture.
Dysfunction of the tibialis posterior tendon
Common or uncommon?
Typical patient?
Course of presentation?
Most common cause of acquired flatfoot deformity in adult
Most commonly elderly women; starts off as obese middle aged woman and then progresses into later life
Usually present for years prior to diagnosis - patient has multiple medical consultations where it is often missed
Tends to present late
What motions of the foot does the posterioe tibialis tendon allow?
Inversion
Plantar flexion
Risk factors for posterior tibialis tendon dysfunction?
Pes planus Hypertension Diabetes Steroid injections Seronegative arthropathies Tendinosis of unknown aetiology
What do most patients with PTT dysfunction report about their feet?
Symptoms?
“My foot shape has changed”
Pain and/or swelling posterior to medial malleolus – very specific
Change in foot shape
Diminished walking ability/balance
Dislike of uneven surfaces
More noticeable hallux valgus
Lateral wall “impingement” pain – fibula against calcaneus
The first thing the patient tends to remember is pain and swelling just behind the medial malleolus
Eventually ends up that they can’t push up off of their foot
What can you see on examination of a foot with PTT elongation or rupture??
Heel valgus
Boggy swelling
Front of foot peaking out at the side when viewed from behind
Treatment for posterior tibialis tendonitis?
What should you avoid giving?
Physiotherapy is the main treatment
Insole to support medial longitudinal arch is very important to avoid rupture
NO steroid injections, unless there is synovitis in the joint
NSAIDs can be given to relieve inflammation
If it fails to settle after this, surgical decompression and tenosynovectomy may prevent rupture.
Pes cavus What is this? Causes? What do you see on inspection? Management?
Abnormally high arch in the foot
Can be idiopathic but is often related to neuromuscular conditions
Can see varus heel, clawing of toes
Most used management is orthotics; surgery if required may be complex
Plantar fasciitis Common or uncommon? What time of day does it occur at and what do patients commonly complain of? What causes it? Risk factors? Clinical symptms?
Very common
Mostly occurs first thing in the morning with stabbing pain on the plantar surface of the foot which eases off gradually through the day and can be worse after exercise
Caused by repetitive stress/overload or degeneration - self limiting
DM, obesity, frequent walking on hard floors
- Acute stabbing pain + agony
- Fullness or swelling plantarmedial aspect of heel
- Tenderness over plantar aspect of heel and/or plantarmedial aspect of heel
Plantar fasciitis
Which test is positive for which nerve?
Treatment?
Tinel’s test positive for Baxters nerve
Treatment is usually conservative
NSAIDs
Night splints - very useful but uncomfortable for patients
Heel cups or medial arch supports
Physiotherapy
Steroid injection
Surgery - 50% success, better if acute onset
NB – plantar fasciitis is usually self-limiting and will typically resolve within 18-24 months. Rest, Achilles and plantar fascia stretching exercises and a gel filled heel pad may help. Corticosteroid injection may also alleviate symptoms.
Hallux valgus Aka? What is this? Which people does it tend to occur in? Male to female ratio? Cause? Which MSK conditions is it associated with? What is a splayed forefoot associated with?
Aka bunions
This is a deformity of the big toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
Tends to occur in hypermobile people, also adolescent supgroup
1:3
Something provokes the big to drift out medially, kind of towards the positon it is in in apes. This something is usually wearing shoes that are too tight for you
Rheumatoid arthritis + other inflammatory arthropathis as well as some neuromuscular diseases
Associated with loss of muscle tone and age
What problems does hallux valgus cause?
When should orthotics be used?
Transfer metatarsalgia Lesser toe impingement Pain, deformity, cosmesis Shoe difficulties NB – orthotics should only be used to protect the tissues which are giving you pain.
What are the four main causes of pain in hallux valgus?
- 1st MTP joint
- Neuralgic pain on the inside of the joint - because a digital nerve is stretched by the bump
- Impingement on the overcrowded toes
- Transfer metatarsalgia – weight bearing is transferred from the big toe to the other toes of that foot
Management of hallux valgus
Non-operative?
Operative?
Non-operative - shoe modifications, padding between first two toes
Operative
- Indications – failure of non-op, pain, lesser toe deformities, lifestyle limitation, overlapping, ulceration, functional limitation
- Many osteotomies (not core) – distal osteotomy is the most common procedure done
- Aim to realign the hallux and decrease the HV angle
- Correct any lesser toe deformities at same time (soft tissue releases, osteotomies, fusions)
Despite being commonest pathology, it is the major headache of orthopaedics – there are loads of operations which shows we aren’t good at it
Hallux ridigus Aka? Most common complaint? Natural coarse of the problem? Treatment? When should surgery be considered? Gold standard surgical treatment?
Osteoarthritis of the 1st MTP jointIt can be primary (degenerative) or secondary to osteochondral injury
Most common complaint is pain
after around two years the pain stops and goes down
Conservative treatment - stiff rigid insole to stop the toe bending and limit motion at the MTPJ
If the pain is either very severe, or doesn’t subside after trying non-operative measures, then consider surgery, which is either joint replacement or fusion (arthrodesis).
The gold standard surgical treatment is arthrodesis. Successful fusion should alleviate pain with the sacrifice of no motion (the toe is usually pretty stiff anyway)
What is the main goal in surgery for rheumatoid foot?
The primary goal is to fuse the big toe in a position where the patient can put weight through it and balance – rigid heel or forefoot will do this
Morton's neuroma What is this? Where does it typically occur? Common or uncommon? What is the underlying pathology? What is the most common age group affected? More commonly male or female?
This is degenerative fibrosis of a digital nerve near its bifurcation, most commonly between 3rd and 4th metatarsals. It is very common.
The underlying pathology is irritated nerve -> inflammation -> neuroma formation. It’s is a degenerative process, causing fibrosis of the digital nerve.
What do patients with Morton’s neuroma complain of?
What aggravates it?
Patients typically complain of burning forefoot pain (metatarsalgia) and tingling with numbness in the affected toes. It is aggravated by movement as the nerve sits right between the metatarsal heads so when the foot moves you knock the nerve.
What does clinical examination of Morton's neuroma show? What is Mulder's click test? Which investigation might be useful? Conservative management? Surgical management?
Clinical examination may reveal loss of sensation in the affected web space. Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic “click”; this is Mulder’s click test.
Ultrasound may be used for diagnosis by demonstrating a swollen nerve.
Conservative management involves the use of a metatarsal pad or offloading insole. Steroid and localanaesthetic injections may relieve symptoms and aid diagnosis.
A neuroma can be excised. However, some patients continue to experience pain and there is a small risk of recurrence.
What causes tendonitis of the achilles tendon?
What does this result in?
What are the risk factors for this?
Tendonitis of the Achilles tendon is caused by repetitive microtrauma and a failure of collagen repair with loss of fibre alignment/structure, resulting in a hypovascular region 2-6cm proximal to the insertion.
RF
- Over-training
- Some drugs e.g. Ciprifloxacin, steroids -> these generally reduce tendon strength and make them more likely to tear
- Cumulative trauma disorders (CTDs)
