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Musculoskeletal MBCHB > Foot and Ankle Conditions > Flashcards

Foot and Ankle Conditions Flashcards

1
Q

What is Achilles Tendonitis?

A

Inflammation of the Achilles tendon

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2
Q

What is the aetiology and risk factors of Achilles tendonitis?

A
  • Can occur due to repetitive strain (from sports) which leads to a peritendonitis or due to degenerative process with intrasubstance microtears

Risk factors

  • Overtraining (sports)
  • Quinolone antibiotics (ciprofloxacin)
  • Rheumatoid arthritis, gout and other inflammatory arthritis
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3
Q

What is the pathophysiology of Achilles tendonitis?

A
  • Repetitive microtrauma, failure of collagen repair with loss of fibre alignments/structure
  • Hypovascular region 2-6cm proximal to insertion
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4
Q

What is the presentation of Achilles tendonitis?

A
  • Pain of the Achilles tendon or at its insertion in the calcaneus
  • Morning stiffness
  • Pain and stiffness eases with walking
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5
Q

What are the investigations of achilles tendonitis?

A
  • Clinical diagnosis
  • Can confirm with USS/MRI if uncertainty
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6
Q

What is the management of Achilles tendonitis?

A
  • Activity modification, analgesia, NSAIDs
  • Physiotherapy
  • Heel raise to offload the tendon and use of a splint or boot
  • Resistant cases may benefit from tendon decompression and resection of paratenon however scars in this area can be problematic and the condition is usually self‐ limiting
  • Tendonitis predisposes to tendon rupture
  • Steroid injection should not be administered around the Achilles tendon due to risk of rupture
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7
Q

What is the aetiology and risk factors of Achilles Tendon rupture?

A
  • Usually occurs in over 40s - tendon degeneration
  • Tendon rupture may follow a single high energy event, but is often the culmination of recurrent minor tears or following recent tendonitis

Risk factors

  • Diabetes
  • RA
  • Steroid use
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8
Q

What is the presentation of Achilles tendon rupture?

A
  • Sudden deceleration with resisted calf muscle contraction (eg lunging at squash) leads to sudden pain (like being kicked in the back of the leg) and difficulty weight bearing
  • Weakness of plantar flexion and a palpable gap in the tendon are usually apparent
  • Unable to tiptoe stand
  • Positive calf squeeze (Simmonds) test
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9
Q

What is the investigation for achilles tendon rupture?

A
  • US or MRI can be used to distinguish between complete and partial tears
    • US is often easier for patients and allows dynamic assessment
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10
Q

What is the management for achilles tendon rupture?

A

Surgical management

  • Suture repair of tendon
  • Wound problems can occur with surgery and can be very problematic if healing does not occur

Conservative management

  • Series of casts in the equinous position
  • The ankle is plantarflexed with the toes pointing down, which closes the gap in the torn tendon over 8 weeks or so
  • This avoids the potential for wound problems and good functional outcome can usually be expected
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11
Q

What is the aetiology of an ankle fracture?

A

Typically an inversion injury with a rotational force applied to the foot

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12
Q

What is the pathophysiology of ankle fractures?

A
  • Commonly ankle fractures are multiple and can affect the lateral malleolus, medial malleolus and posterior malleolus (posteroinferior tibia)
  • Solitary malleolar fractures are often small avulsion fractures or undisplaced
  • Trimalleolar fractures have a particular tendency to instability
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13
Q

How is an ankle fracture assessed?

A
  • Weber Classification - A, B, C
  • Assess of the stability of the fracture
  • Talar shift
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14
Q

What is the presentation of an ankle fracture?

A

Pain and instability

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15
Q

What are the investigations of an ankle fracture?

A
  • X-ray - AP and lateral views
    • Check for soft tissue swelling on x-ray indicating the site of fracture
    • Check bony alignment, as non-uniform ankle joint space indicates instability, often with ligamentous damage
  • CT can be helpful to clarify fracture anatomy, especially for complex ankle fractures (e.g. Pilon)
    • Pilon fractures are high energy fractures which occur at the bottom of the tibia and involves the ankle joint
      • Significant soft tissue problems, often other injuries
      • Damage to joint may lead to OA
  • US and MRI may be needed to define soft tissue injury
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16
Q

What is the management of an ankle fracture?

A
  • Determined by Weber classification
  • Conservative - cast or moonboot
  • Operative - ORIF
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17
Q

What is the aetiology of ankle sprains?

A

Commonly due to ‘twisted ankle’

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18
Q

What is the pathophysiology of ankle sprains?

A

Lateral ankle sprains (85%)

  • Most commonly due to inversion of the plantar flexed foot, which leads to excessive supination of the rearfoot about an externally rotated leg
  • AFTL (weakest ligament) injured first
  • CFL has ~3x higher load to failure than AFTL
  • PFTL rarely torn
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19
Q

How are ankle sprains graded?

A
  • Grade 1: microscopic tear (stretch)
  • Grade 2: partial tear
  • Grade 3: complete rupture
  • Chronic sprains: recurrent sprains or giving way, persisting for more than 6 months
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20
Q

What is the presentation of ankle sprains?

A
  • Tenderness and swelling
  • Bruising
  • Functional loss e.g. pain on weight-bearing
  • Mechanical instability
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21
Q

What are the investigations for an ankle sprain?

A

X-ray to rule out fracture

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22
Q

What is the management of an ankle sprain?

A
  • Initial management - protection, rest, ice, compression and elevation (PRICE)
  • Most patients have an element of functional instability
    • Physio first
    • Arthroscopy for pain
    • Reconstruction if needed
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23
Q

What is the aetiology of a calcaneus fracture?

A
  • Usually follows axial compression e.g. falling from height onto the heel
  • Often intra-articular fracture
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24
Q

What is the presentation of a calcaneus fracture?

A
  • Pain, inability to bear weight
  • Significant swelling
  • Look for other injuries especially spinal
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25
Q

What are the investigations for a calcaneus fracture?

A
  • X-ray - calcaneal compression causes loss of the central peak seen in a normal calcaneus (measured using Bohler’s angle), and bone density will increase
  • CT - calcaneal fractures are often comminuted, anatomy can be clarified by CT
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26
Q

What is the management of a calcaneus fracture?

A
  • Cast immobilisation with non weight bearing for 6-12 weeks
  • Surgery controversial - high risk of infection/wound breakdown and benefit not proven
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27
Q

What are the complications of a calcaneus fracture?

A

Risk of compartment syndrome

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28
Q

What are claw and hammer toes?

A

Conditions that deform the shape of the four smaller toes, leaving them in a curved position

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29
Q

What is the aetiology of claw and hammer toes?

A
  • Occur due to acquired imbalance between the flexor and extensor tendons
  • Claw toes have hyperextension at the MTPJ with flexion at the PIPJ and DIPJ
  • Hammer toes have PIPJ flexion, DIPJ extension and neutral MTPJ
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30
Q

What is the presentation of claw and hammer toes?

A

Claw and hammer toes can be painful and can rub on footwear causing corns and skin breakdown

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31
Q

What is the management of claw and hammer toes?

A
  • Toe ‘sleeves’ and corn plasters can prevent skin problems
  • Surgical solutions include tenotomy (division of an overactive tendon), tendon transfer, arthrodesis (PIPJ) or toe amputation
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32
Q

What is hallux valgus?

A

Deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself

33
Q

What is the aetiology of hallux valgus?

A
  • Exact aetiology unknown
  • Higher incidence in females
  • Familial tendency but no direct genetic link
  • Incidence increases in age but can occur in adolescence
    • Hallux valgus in late adolescence usually has a strong family history
  • Commoner in rheumatoid arthritis and other inflammatory arthropathies as well as some neuromuscular diseases (multiple sclerosis, cerebral palsy)
34
Q

What si the presentation of hallux valgus?

A
  • Usually bilateral
  • May be painful due to joint incongruence
  • May be unable to wear closed shoes - bursa and/or nerve damage
    • A widened forefoot may cause rubbing of the foot with shoes resulting in an inflamed bursa over the medial 1st metatarsal head → bunion
  • The great toe and second toe may rub causing ulceration and skin breakdown
  • In severe cases, the hallux may override the second toe
  • Joint pain indicates OA
  • Transfer metatarsalgia or poor balance indicates defunctioned 1st ray (segment of the foot composed of the first metatarsal and first cuneiform bones)
35
Q

What is the management of hallux valgus?

A
  • Conservative - wearing wider and deeper shoes to prevent bunions, the use of a spacer in the first web space to stop rubbing between the great and second toes
  • Surgical management - osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues
    • Indications: failure of conservative management, lesser toe deformities, lifestyle limitation, overlapping, functional limitation
    • Any surgery may alter the biomechanics of the foot - 30% of patients are not satisfied so surgery should not be performed for cosmetic reasons alone
    • Some patients complain of pain in the metatarsal heads (metatarsalgia) after surgery
    • Surgical correction in adolescents carries a risk of recurrence of the deformity later in life
36
Q

What is hallux rigidus?

A

OA of the first MTPJ; can be primary (degenerative) or secondary to osteochondral injury

37
Q

What is the presentation of hallux rigidus?

A
  • Painful 1st MTP joint
  • Stiffness
  • Pain increases with activity/aggravated by shoes
  • Dorsal exostosis (bone spur)
  • IPJ hyperextension
38
Q

What are the investigations for hallux rigidus?

A

WB X-ray - AP/LAT and oblique

39
Q

What is the management of hallux rigidus?

A

Conservative treatment

  • Weight loss if appropriate
  • Analgesia, NSAIDs, activity modification
  • May involve the wearing of stiff soled shoe to limit motion at the MTPJ
    • A metal bar can be inserted into the sole of a shoe

Surgical management

  • In early cases where dorsal osteophytes impinge during dorsiflexion, removal of osteophytes (cheilectomy) may help
  • Gold standard surgical treatment is arthrodesis
    • Should alleviate pain, no movement of joint
    • Stops women wearing heels
  • 1st MTP joint replacements are in use but failure rates are quite high and once failure occurs, salvage surgery is difficult and results are usually disappointing
40
Q

What is a lisfranc injury?

A

Tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal

41
Q

What is the aetiology of lisfranc injury?

A

High energy, often have other injuries

42
Q

What is the presentation of lisfranc injury?

A
  • Severe midfoot pain
  • Inability to bear weight
43
Q

What are the investigations for lisfranc injuries?

A
  • X-ray - AP and oblique views
    • Fracture may be subtle
    • Alignment is key - assess 1st and 2nd TMT joint congruity on the AP view, assess 3rd to 5th TMT joint congruity on the oblique view
  • CT - Lisfranc fractures usually involve several TMT joints, with multiple ligamentous avulsion fractures, which is shown best by CT
44
Q

What is the management of a lisfranc injury?

A

Require fixation - ORIF

45
Q

What are the complications of lisfranc injuries?

A

Can cause long term disability, OA

46
Q

What is a metatarsal stress fracture?

A

A stress fracture is a break in the bone that happens with repeated injury or stress

47
Q

What is the aetiology of a metatarsal stress fracture?

A
  • May occur in runners, in soldiers on prolonged marches, in dancers or during distance walking in people not conditioned or used to prolonged walks
  • Most commonly occur in 2nd metatarsal, followed by 3rd
48
Q

What are the investigations for a metatarsal stress fracture?

A
  • X-ray - AP and oblique views
  • X-rays may not demonstrate a fracture for around 3 weeks until resorption at the fracture ends occurs or callus begins to appear so a bone scan may be useful to confirm the diagnosis
49
Q

What is the management of a metatarsal stress fracture?

A

Prolonged rest for 6‐12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms

50
Q

What is Morton’s neuroma?

A

Benign fibrotic thickening of a plantar digital nerve due to irritation

51
Q

What is the aetiology for morton’s neuroma?

A
  • Plantar interdigital nerves (from the medial and lateral plantar nerves) overlying the intermetatarsal ligaments can be subjected to repeated trauma
  • Irritated nerves can become inflamed and swollen (forming a neuroma)
  • The third interspace nerve is most commonly involved followed by the second
52
Q

What are the risk factors for morton’s neuroma?

A
  • Age - mean age 45-50
  • Obesity
  • Female - women are four times more commonly affected and the wearing of high heels has been implicated as a cause
53
Q

What is the presentation of morton’s neuroma?

A
  • Burning pain and a tingling that radiates to the affected toes
  • Pain exacerbated by footwear, and relieved by removal of shoe, massaging foot and changing footwear
  • Loss of sensation in the affected webspace
  • Mulder’s click test - medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic ‘click’
54
Q

What is the investigation for morton’s neuroma?

A
  • X-ray (AP/LAT/oblique WB) to rule out MSK pathology
  • Diagnostic US - swollen nerve (poor specificity if <6mm in diameter - risk of false positive)
55
Q

What is the management for morton’s neuroma?

A
  • Conservativemanagement**involves RICE, stretching calf muscles,theuseofametatarsalpad or offloadinginsole, weight loss if appropriate and activity modification/management advice
  • Steroid and local anaesthetic injections may relieve symptoms and aid diagnosis
  • Surgical management - neuromas can be excised, however some patients continue to experience pain and there is a small risk of recurrence
    • Indications: symptoms persist after 2-3 months of footwear modification and metatarsal pads/metatarsal dome, inadequate response to corticosteroid injection
56
Q

What is pes cavus?

A

Abnormally high arch of the foot

57
Q

What is the aetiology of pes cavus?

A

Can be idiopathic but is often related to neuromuscular conditions including Hereditary Sensory and Motor Neuropathy, cerebral palsy, polio(unilateral) and spinal cord tethering from spina bifida occulta

58
Q

What is the presentation of pes cavus?

A
  • Pain in the arch of the foot
  • Claw toes often accompany pes cavus
59
Q

What are the investigations of pes cavus?

A
  • WB x-ray of foot
  • MRI spine if tumour is suspected
60
Q

What is the management of pes cavus?

A
  • Soft tissue releases and tendon transfer if supple, or calcaneal osteotomy if more rigid
  • Severe cases may require arthrodesis
61
Q

What is plantar fasciitis?

A

Degenerative condition of the plantar fascia that causes sharp pain on the bottom of the foot pain

62
Q

What is the aetiology of plantar fasciitis?

A

Repetitive stress/overload or degenerative condition

63
Q

What are the risk factors of plantar fasciitis?

A
  • Physical overload - excessive exercise, excessive weight (obesity)
  • Diabetes
  • Age - the cushioning heel fat pad atrophies with age
  • Abnormal foot shape - planovalgus or cavovarus
  • Frequent walking on hard floors with poor cushioning in shoes
64
Q

What is the presentation of plantar fasciitis?

A
  • Start up pain after rest on the instep of the foot (at the origin of the plantar aponeurosis on the distal plantar aspect of the calcaneal tuberosity)
  • Pain can be worse after exercise
  • Fullness or swelling on plantar medial aspect of heel
  • Localised tenderness on palpation of the plantar aspect of heel and/or plantar medial aspect of heel
  • Tinel’s test positive for Baxter’s nerve
65
Q

What is the management of plantar fasciitis?

A
  • Rest, NSAIDs
  • Night splints, taping, heel cups or medial arch supports
  • Physiotherapy - achilles and plantar fascia stretching exercises
  • Corticosteroid injection may alleviate symptoms
  • Symptoms can take up to two years to resolve
  • Surgical release of the plantar fascia risks injury to the plantar nerves and it is unclear whether there is an actual benefit
66
Q

What is tibialis posterior tendon dysfunction?

A

The tibialis posterior tendon inserts predominantly onto the medial navicular and serves to support the medial arch of the foot

67
Q

What is the aetiology of tibialis posterior tendon dysfunction?

A
  • Cause usually unclear
  • Tibialis posterior tendon dysfunction is the most common cause of acquired flat foot in adults
68
Q

What are the risk factors for tibialis posterior tendon dysfunction?

A
  • Obese middle aged female
  • Risk increases with age
  • Hypertension
  • Diabetes
  • Steroid injection
  • Seronegative arthropathies
  • Idiopathic tendinosis
69
Q

What is the pathophysiology of tibialis posterior tendon dysfunction?

A
  • The tendon is under repeated stress and particularly with degeneration can develop tendonitis, elongation and eventually rupture
  • Usually present for years prior to diagnosis
  • Elongation or rupture leads to loss of the medial arch with resulting valgus of the heel and flattening of the medial arch of the foot
70
Q

What is the presentation of tibialis posterior tendon dysfunction?

A
  • Pain and/or swelling posterior to medial malleolus - very specific
  • Change in foot shape
  • Diminished walking ability/balance
  • Dislike of uneven surfaces
  • More noticable hallux valgus
  • Lateral wall ‘impingement’ pain
  • Midfoot and ankle pain
71
Q

What is the classification for tibialis posterior tendon dysfunction?

A
  • Type I: swelling, tenderness, slightly weak muscle power
  • Type II: planovalgus, midfoot abduction, passively correctable
    • ‘Too many toes’, cannot single heel raise
  • Type III and IV: fixity and mortise signs
72
Q

What is the management of tibialis posterior tendon dysfunction?

A
  • Physiotherapy
  • Tendonitis should be treated with a splint with a medial arch support to avoid rupture
  • Orthoses to accommodate foot shape, bespoke footwear
  • If this fails to settle symptoms, surgical decompression and tenosynovectomy may prevent rupture
  • DO NOT use steroid injections
  • Surgical options for rupture:
    • If no secondary OA present, a tendon transfer may be performed to try to prevent secondary OA with a calcaneal osteotomy to reduce stress
    • Once OA ensues, the most appropriate surgical treatment if symptoms are severe is arthrodesis
73
Q

What are talus fractures?

A
  • Forced dorsiflexion/rapid deceleration
  • Talus has reversed blood supply - risk of AVN
  • Risk of OA
  • The fibia and fibula are paired bones forming an elongated ring with the talus - bony ring injuries usually involve disruption at >1 site
74
Q

What is the aetiology of a 5th metatarsal fractures?

A

Inversion injury

75
Q

What is the pathophysiology of a 5th metatarsal fracture?

A
  • Avulsion by peroneus brevis tendon: heal predictably in moonboot, do well
  • Jones fracture: poor blood supply, 25% risk non-union
  • Proximal shaft: common site for stress fracture
76
Q

What is the presentation of a 5th metatarsal fracture?

A

Pain over lateral border of forefoot, especially with weight bearing

77
Q

What are the investigations of a 5th metatarsal fracture?

A
  • Clinically resemble a lateral malleolar fracture - check this area on a lateral x-ray
  • 5th MT base fractures are transverse, so don’t confuse with the normal longitudinal adolescent ossification centre
78
Q

What is the management of a 5th metatarsal fracture?

A

Treatment can include protected weight bearing, immobilization or surgery depending on location of fracture, degree of displacement, and athletic level of patient

Musculoskeletal MBCHB (21 decks)

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