Foot And Ankle Flashcards
How many bones are in the foot
26
What are the proximal tarsal bones
Calcaneus
Talus
Bones in the mid foot
Navicular
Cuboid
Cuneforms
Bones that make up the forefoot
Metarsals and phalanges
Joints that articulate with the talus
Talonavicular joint
Ankle joint - talus articulates with the tibia and fibula
Subtalar joint - talus articulates with the calcaneus
What holds to talus in place and what inserts into the talus and how is this different to other bones
The talus is held in place by ligaments
No muscles insert into the talus
This increases its risk of avascular necrosis
What structures lie behind the medical malleolus
T - tibialis posterior D - flexor digitorum longus A - Posterior tibial artery V - post tib vein N - post tib nerve H - flexor hallucis longus
What is the knot of Henry
The intersection of the flexor hallucis longus and the flexor digitorum longus
Cross point and the medial plantar surface of the foot
What does ‘beef to the heel‘ mean
The muscle belly of the flexor hallucis longus inserts into the great distal phalanx
What is important to determine in a foot and ankle hx
SOCRATES
- PMH, DHx, FHx, SHx
Regard patient holistically regarding the benefit of surgery
Comorbidities
The disability the pathology causes
Anything that might impede the success of surgery
Remember to address the patients concerns and symptoms as you are going to treat the patient and their symptoms the pathology is secondary
Foot and ankle - examination
The examination is used to confirm the diagnosis
Look - inspection - walking aids, shoes for patterns of wear, hairy patch spinal dysraphism, scoliosis, leg for overall limb alignment
Look for varus valgus Iimb and then assess gait looking ofr the three phases of gait - the heel strike, mid stance and toe off - symmetrical and even throughout
Foot weight bearing so stood, pea planus, pes cavus, toe deformities - hammer claw, halux valgus
Ensure to look for scar, swelling, erythema
Face wall - calf musculature, too many toes sign - should see 2 if more post tib tendon issue
Bilateral heel raise - valgus to inversion
Single leg raise - valgus to varus and problem - musculature or post tib tendon
Close inspection - between toes callus or corn
Feel
1) tendoachilles
2) perineal tendons
3)lateral mallelous
4)joint line
5)Medial mallelous
6) post tib tendon -insertion
7) plantar fascia
8) sinus tarsi
9) base of 5th metatarsal head
10) extensor tendon
11) bunion
12) meta tarsal heads
13) bunionette
Move
Proximal to distal
Ankle range of movement - dorsi and plantar flexion on the ankle
Subtalar movement - stabilise talus with one hand move the hind foot inversion and eversion
Midtarsal - stabilise midfoot - adduction or abduction
1st metatarsal - stabilise midfoot - depress 1st metatarsal
Check movement of the toes
Tendon function
Post tib tendon - plantar flexed and inverted position hold foot in position like stone and tell them to resist pressure you apply and feel the tendon
Perineal tendon- dorsiflex and evert - hold like stone and resist your movement - palpate tendon and assess function
Tibialis anterior - dorsiflex and invert - hold like stone resist movement
Ankle instability - anterior drawer test- relax foot and plantar flex - stabilise ankle and drawer the other foot forward - anterior talofibular ligament laterally
Lateral ligamentus complex - invert foot and feel the ligaments below lateral malleolus excessive opening up = incompetence
OA at 1MT - axial grind - pain - look at face - stabilise foot and move up and down - hallucinations rigidus
Tendoachilles - Simmons manoeuvre- patient prone, relax foot - squeeze calf should see plantar flexion of the foot if the Achilles is intact
Pes cavus - hindfoot varus - Coleman block test - put patient on a a wooden block allow the 1st MT head to be depressed - hindfoot goes from varus to valgus position - flex hindfoot moment at subtalar joint
Complete - NV status and joint above and below
Investigations
Plain film radiograph Exclude serious or similar diagnoses CT MRI - soft tissue deformity US Diagnostic fluid May be therapeutic fluid removal
Diff diag
Adults
Arthritis Instability Deformity Nerve entrapment Tendon disease
Diff diag children
Flat feet Heel pain Club foot Curly toes Poly/syndactyly
Tx
Con - non-op Advice and reasses - don’t make patient afraid to come back Podiatry Orthotics Physio Med- analgesia, steroid injections Surg Soft tissue procedures - curettage Bone and joint op - fusion osteotomy
Axial (x-section of ankle) groups
Groups are in relation to the Achilles’ tendon - medial to achilles tendon Medial malleolus Flexor hallucis longus Flexor digitorum longus Post tib NAV Tibialis posterior - Lateral to the Achilles’ tendon Lateral malleolus Fib longus and breves Sural nerve Short saph v Terminal branches of fib artery - anterior Saph nerve Long saph v Tib ant Ext hall long Superficial fib Ex dig L Fib tertios Deep ( just infront of talus) Deep fib nerve Dorsalis pedis artery
Common adult presentation
Ankle pain
Foot pain
Heel pain
toe pain
Ankle pain caused by what
Injury recurrent micro injury, bigger injury - can lead to arthritis
Twist - potential underlying osteochondral defect
Sprain- instability
Break - deformity
Can lead to these problems esp if no tx well from the start
Long term complication of severe sprain or ankle fracture
Arthritis
What are the features of moderate arthritis
Pain
Swelling
Stiffness
What are the radiological signs of severe OA
L - loss of joint space
O - osteophytes
S - subchondral cysts
S - sunchondral sclerosis
What is a common occurrence of a severe sprain
osteochondral injury
Symptoms of an osteochondral injury
Dull deep ache
Severe disabling
Cause of osteochondral injury following minor trauma
Intrinsic defect of the talar cartilage
Tx of osteochondral injury
Manage con with rest analgesia
Definitive - surg arthroscopic tx curettage
What causes ankle instability
Ligament sprain
Mx of ankle instability
RICE Rest Ice Compress Elevate
Which examination finding positive in ankle instability
Anterior drawer
Stablise talus and pull the foot forwards
Arthritis mx
Conservative - keep active, weightloss help, muscle strengthening physio etc
Med - analgesia
Severe - surgery, arthroplasty - total ankle replacement artherosclerosis - ankle fusion
What will foot deformity affect
Gait, posture and proximal joints
What is the aim of tx in foot deformity
Flexible foot Foot not too cavus or planus Comfortably fits a shoe Pain free NV not compromised
Common causes of foot pain
Arthritis/ RA
Metatarsalgia
Tarsal Tunnel syndrome
Tibialis posterior tendon dysfunction
What is metatarsalgia
Pain in the ball of the foot can b due to a mild deformity Morton’s neuroma can cause it Overweight Shoes Running Flat feet Bursitis or arthritis
What is tarsal tunnel syndrome
Tibialis nerve entrapment under the flexor retinaculum
A person with flat feet is at risk
What can cause tibialis posterior tendon deformity
Injury or trauma
Rupture can be complete or incomplete can both cause adult flat foot due to the short exclusion of the tendon
Tendinosis from repeated micro trauma
2 insertion point into the navicular tuberosity and the 2,3,4 metatarsal heads
What causes the signs of tibialis posterior tendon deformity
As the tendon loses its function the medial longitudinal arch of the foot collapses which causes a relative internal rotation of the tibia and talus
There is eversion of the subtalar joint which forces the heel into a valgus allignment and abduction at the talonavicular joint. Varus alignment of the heel causes a lateral shift in the normal axis of the Achilles’ tendon which in time will lead to a contracture. As the deformity gets worse, the distal fibula comes into contact with the lateral calcaneus, causing lateral hindfoot pain.
What are the signs associated with a tibilalis posterior ligament deformity
Flat foot
Valgus heel deformity
Single limb heel rise - difficulty performing this test
Too many toes
What are the symptoms tibilais post deformity
Can get pain and swelling along the path of the tendon particularly behind the medial malleolus
Tx tibialis post deformity
Con - orthotics
Surg - depends on the stage of the deformity whether the deformity is still flexible or has become fixed
calcaneus osteotomy, post tib tendon excision
Causes of heel pain
Achilles tendinopathy Plantar fasciitis Haglunds deformity Nerve entrapment Tumour Stress fracture - march fracture Inflammatory enthesopathy - inflammation of the attachment of muscle or ligament to a bone
What is plantar fasciitis
The plantar fascia supports tot he arch of the foot - most common cause of plantar heel pain
Degenerate changes from micro trauma not inflammatory as the name might suggest
Symptoms of plantar fasciitis
Initial insidious onset of pain
Intense pain during the first steps of walking or after a period of inactivity
Lessening pain with moderate foot activity but worsening later during the day after long periods of standing or walking
Exam features
Tenderness on palpation of the plantar heel area
Limited ankle dorsiflexion (with knee is extension) and a positive Windlass st - reproduction of pain by extension of the first metatarosphalangeal joint
Antalgic gait (abnormal walking to avoid joint pain) or limping
Diff diag of plantar fasciitis
Achilles tendinitis Calcaneus stress fractures Fat pad atrophy Sub-calcaneal bursitis Nerve entrapment Peripheral neuropathy rupture, neoplasm and vascular insufficiency
Mx plantar fasciitis
Most make a recovery in 6 months Rest - long periods of standing and walking Wear shoes with a good arch support Insoles, heel pads Analgesia and required If overweight - lose weight Ice pack Self - physio - exercises stretches Med - steroid injection Surg - extra corporeal shockwave therapy Surgical division of the plantar fascia
Achilles tendinitis mx
Steroid injection- Evidence has shown they aren’t beneficial
orthotics
Physio
Eccentric loading exercise
ESWT inc blood supply inc healing process
Surgery
Types of heel tendon pathologies
Non-insertional
insertional
Plantar fasciitis
Common children foot conditions
Flat foot Heel pain Club foot Curly toes Poly/syndactyly
Flat feet is it a problem ? What is it also called
Can be normal fo children to have flat feet their feet are still developing and their is a spectrum of foot shape and on one end is flat and that’s still normal
Problem when it is fixed or painful
Pes planus
How to check if a flat foot deformity is fixed
On tip toe the arch reforms so no tx is required
T of flat foot in children
A only conservative as many children age they grow out of the flat foot
Heel stretching
Orthotics
Surgery rarely
Heel pain in children
Cause
What to exclude
Mx
Tarsal tunnel
Rare plantar fasciitis
Exclude - tumour, infection, trauma
In active child rest more
Types of gait disturbance in children
Toe walking
In toeing
Out toeing
exclude a foot deformity rarely a ‘foot’ issue
Club foot Long name
Congenital talipits equinovarus
What signs does the deformity have
C: cavus
A: adduction
V: varus
E: equinus - plantar flexion
Foot cannot be passively exerted and dorsiflexed through the normal range
Tx of club foot
Ponsetti casting
Foot is manipulated and placed in a plaster cast, correction is gradual
If its not worked = surgery
Serious conditions to exclude
Tumour Acral lentiginous- subungual melanoma
Infection - necrotising fasciitis
Trauma or non-accidental injury
Disabling -dysplasia
What is non -accidental injury
Children possible cause
SmAll fracture v important
As up to 50% whose NAI are missed will have a fatal injury
Pes cavus - what is it
High arch
Claw toe
Cause pes cavus
Neuromuscular - Charcot Marie tooth
Hereditary motor and sensory neuropathy
Also be idiopathic
Tx pes cavus
Underlying
Symptoms
What is osteomyelitis
Bone and joint infection
Causes of osteomyelitis
Acutely haematogenous
Secondary to contagious local infection
Direct inoculation from trauma or surgery
Clinical features of osteomyelitis
Adults is affects cancellous bone - feet/ vertebrae
Children - vascular Bon e- femurs
Lead to cortexerosion - holes - cloacae
Exudation of pus lifts up the periosteum interrupting blood supply to underlying bone and necrotic fragments of bone may form- sequestrae
New bone may form. Involucrum
Tx ab
Common toe problems
Hallux valgus Bunion/bunionette Hallux rigidus Corn and callus Nail problem Morton’s neuroma
What is hallux rigidus
1st MTPJ OAmarked loss of dorsiflexion and pain
wHat do you need to exclude in hallux rigidus
Gout
Most commonly effects the 1st MTPJ - podagra
Tx of hallux rigidus
Con - rocker-bottom shoes
Steroid injection
Surg - cheilectomy arthroplasty
What is hallux valgus
Deformity on the 1st MTPJ lateral deviation of >15 deg
Bunion
What is a bunion
Medial prominence produced by the varus deformity of 1st metatarsal head
Unsightly and some have pain, can’t wear normal shoes
Complications of hallux valgus
Toe crowding
Mid foot arthritis
Corns, calluses
Flat feet
Tx hallux valgus
Con - pain relief, orthotics
Surg - make foot fit the shoe, soft tissue release can be more than one operation
Causes of bunion and lesser toe deformity
Biomechanical risk factors
Weight high
Tight /high heel shoe
What is the difference between a callus and a corn
Corn - dorsum of the foot
Callus - plantar surface
Describe a hammer toe
Extended MTP
Hyperflexed DIP
Extended DIP
What is hammer toes associated with
Contracture of the flexor digitorum longus
Which toes is most likely affected with hammer toe
2nd toe
Describe deformity of a Claw toe
Extended MTP
Flexed PIP and DIP
Toe digs into the foot
Tx claw toe
Tatar’s also shortening or PIP arthrodiesis
Describe the deformity of a mallet toe
Flexion deformity of the DIP alone
Tx mallet toe
Flexor tenotomy
DIP joint arthrodiesis
What is a Morton’s neuroma
Symptomatic perineural fibrosis around a plantar digital nerve of the foot. The conditions is though to be to chronic entrapment of the nerve by the intermetatarsal ligament
Non-neoplasticism
Tx Morton’s neuroma
Orthotics
Steroid injection
Neuroectomy
Ingrown toe nail long name
Onychoncryptosis
Cause of ingrown toe nail
Incorrect nail cutting +- pressure of shoes predisposes lateral nail digging into flesh - an get infection and is known as proud flesh
Mx ingrown toe nail
Let the nail grow out and cut straight
Treat proud flesh with cotton wool soaked surgical spirit
Surg - recurrent = hole nail removal or wedge excision
