Foot and Ankle Conditions Flashcards
What is Achilles Tendonitis?
Inflammation of the Achilles tendon
What is the aetiology and risk factors of Achilles tendonitis?
- 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
What is the pathophysiology of Achilles tendonitis?
- Repetitive microtrauma, failure of collagen repair with loss of fibre alignments/structure
- Hypovascular region 2-6cm proximal to insertion
What is the presentation of Achilles tendonitis?
- Pain of the Achilles tendon or at its insertion in the calcaneus
- Morning stiffness
- Pain and stiffness eases with walking
What are the investigations of achilles tendonitis?
- Clinical diagnosis
- Can confirm with USS/MRI if uncertainty
What is the management of Achilles tendonitis?
- 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
What is the aetiology and risk factors of Achilles Tendon rupture?
- 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
What is the presentation of Achilles tendon rupture?
- 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
What is the investigation for achilles tendon rupture?
- US or MRI can be used to distinguish between complete and partial tears
- US is often easier for patients and allows dynamic assessment
What is the management for achilles tendon rupture?
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
What is the aetiology of an ankle fracture?
Typically an inversion injury with a rotational force applied to the foot
What is the pathophysiology of ankle fractures?
- 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
How is an ankle fracture assessed?
- Weber Classification - A, B, C
- Assess of the stability of the fracture
- Talar shift
What is the presentation of an ankle fracture?
Pain and instability
What are the investigations of an ankle fracture?
- 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
- Pilon fractures are high energy fractures which occur at the bottom of the tibia and involves the ankle joint
- US and MRI may be needed to define soft tissue injury
What is the management of an ankle fracture?
- Determined by Weber classification
- Conservative - cast or moonboot
- Operative - ORIF
What is the aetiology of ankle sprains?
Commonly due to ‘twisted ankle’
What is the pathophysiology of ankle sprains?
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
How are ankle sprains graded?
- 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
What is the presentation of ankle sprains?
- Tenderness and swelling
- Bruising
- Functional loss e.g. pain on weight-bearing
- Mechanical instability
What are the investigations for an ankle sprain?
X-ray to rule out fracture
What is the management of an ankle sprain?
- 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
What is the aetiology of a calcaneus fracture?
- Usually follows axial compression e.g. falling from height onto the heel
- Often intra-articular fracture
What is the presentation of a calcaneus fracture?
- Pain, inability to bear weight
- Significant swelling
- Look for other injuries especially spinal
What are the investigations for a calcaneus fracture?
- 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
What is the management of a calcaneus fracture?
- Cast immobilisation with non weight bearing for 6-12 weeks
- Surgery controversial - high risk of infection/wound breakdown and benefit not proven
What are the complications of a calcaneus fracture?
Risk of compartment syndrome
What are claw and hammer toes?
Conditions that deform the shape of the four smaller toes, leaving them in a curved position
What is the aetiology of claw and hammer toes?
- 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
What is the presentation of claw and hammer toes?
Claw and hammer toes can be painful and can rub on footwear causing corns and skin breakdown
What is the management of claw and hammer toes?
- 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
What is hallux valgus?
Deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
What is the aetiology of hallux valgus?
- 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)
What si the presentation of hallux valgus?
- 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)
What is the management of hallux valgus?
- 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
What is hallux rigidus?
OA of the first MTPJ; can be primary (degenerative) or secondary to osteochondral injury
What is the presentation of hallux rigidus?
- Painful 1st MTP joint
- Stiffness
- Pain increases with activity/aggravated by shoes
- Dorsal exostosis (bone spur)
- IPJ hyperextension
What are the investigations for hallux rigidus?
WB X-ray - AP/LAT and oblique
What is the management of hallux rigidus?
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
What is a lisfranc injury?
Tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal
What is the aetiology of lisfranc injury?
High energy, often have other injuries
What is the presentation of lisfranc injury?
- Severe midfoot pain
- Inability to bear weight
What are the investigations for lisfranc injuries?
- 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
What is the management of a lisfranc injury?
Require fixation - ORIF
What are the complications of lisfranc injuries?
Can cause long term disability, OA
What is a metatarsal stress fracture?
A stress fracture is a break in the bone that happens with repeated injury or stress
What is the aetiology of a metatarsal stress fracture?
- 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
What are the investigations for a metatarsal stress fracture?
- 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
What is the management of a metatarsal stress fracture?
Prolonged rest for 6‐12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms
What is Morton’s neuroma?
Benign fibrotic thickening of a plantar digital nerve due to irritation
What is the aetiology for morton’s neuroma?
- 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
What are the risk factors for morton’s neuroma?
- 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
What is the presentation of morton’s neuroma?
- 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’
What is the investigation for morton’s neuroma?
- 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)
What is the management for morton’s neuroma?
- 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
What is pes cavus?
Abnormally high arch of the foot
What is the aetiology of pes cavus?
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
What is the presentation of pes cavus?
- Pain in the arch of the foot
- Claw toes often accompany pes cavus
What are the investigations of pes cavus?
- WB x-ray of foot
- MRI spine if tumour is suspected
What is the management of pes cavus?
- Soft tissue releases and tendon transfer if supple, or calcaneal osteotomy if more rigid
- Severe cases may require arthrodesis
What is plantar fasciitis?
Degenerative condition of the plantar fascia that causes sharp pain on the bottom of the foot pain
What is the aetiology of plantar fasciitis?
Repetitive stress/overload or degenerative condition
What are the risk factors of plantar fasciitis?
- 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
What is the presentation of plantar fasciitis?
- 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
What is the management of plantar fasciitis?
- 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
What is tibialis posterior tendon dysfunction?
The tibialis posterior tendon inserts predominantly onto the medial navicular and serves to support the medial arch of the foot
What is the aetiology of tibialis posterior tendon dysfunction?
- Cause usually unclear
- Tibialis posterior tendon dysfunction is the most common cause of acquired flat foot in adults
What are the risk factors for tibialis posterior tendon dysfunction?
- Obese middle aged female
- Risk increases with age
- Hypertension
- Diabetes
- Steroid injection
- Seronegative arthropathies
- Idiopathic tendinosis
What is the pathophysiology of tibialis posterior tendon dysfunction?
- 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
What is the presentation of tibialis posterior tendon dysfunction?
- 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
What is the classification for tibialis posterior tendon dysfunction?
- 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
What is the management of tibialis posterior tendon dysfunction?
- 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
What are talus fractures?
- 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
What is the aetiology of a 5th metatarsal fractures?
Inversion injury
What is the pathophysiology of a 5th metatarsal fracture?
- 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
What is the presentation of a 5th metatarsal fracture?
Pain over lateral border of forefoot, especially with weight bearing
What are the investigations of a 5th metatarsal fracture?
- 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
What is the management of a 5th metatarsal fracture?
Treatment can include protected weight bearing, immobilization or surgery depending on location of fracture, degree of displacement, and athletic level of patient
