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