Foot and Ankle Conditions

Question 1

List common foot and ankle conditions

Answer 1

• Bunions
• Hallux rigidus
• Osteoarthritis of ankle
• Achilles tendonitis
• Achilles tendon rupture
• Ankle fracture
• Sprained ankle
• Flat foot
• Claw toe
• Hammer toe and mallet toe
• Diabetes mellitus affecting the foot

Question 2

Describe the presentation of bunions

Answer 2

• Hallux valgus
• Medial deviation of the first metatarsal
• Lateral deviation and/or rotation of the hallux
• Prominence of the first metatarsal head, with or without an overlying callus
• Cosmetic, pain, difficulty with shoes

Question 3

Describe the causes and risk factors of bunions

Answer 3

• Risk factors - females (high heels), middle aged
• Cause may be due to trauma, gout, rheumatoid arthritis, connective tissue disorder
• High heeled shoes do not cause bunions, but exaggerate it

Question 4

Describe hallux rigidus and its presentation

Answer 4

• Osteoarthritis of the 1st metatarsophalangeal joint
  
  • Joint is under lots of stress when walking
• Presentation - pain in metatarsal phalangeal joint, lump over joint, stiffness, pain on movement
  
  • May compensate by walking on the outside of their foot
    
    • Range of dorsiflexion of big toe reduced

Question 5

Describe presentation and risk factors of osteoarthritis of ankle joint

Answer 5

• Usually occurs in a joint that has previously suffered trauma - post traumatic arthritis
• Some occur due medical condition (gout, RA) or no identifiable cause
• Risk factors - joint stress (ballet dancer, footballer), age, obesity, family history of OA
• Presentation - pain, stiffness especially in morning

Question 6

Describe achilles tendonitis and its cause

Answer 6

• Inflammation of the Achilles tendon
  
  • Can occur within the tendon itself or at the point of insertion into the calcaneus
• Commonly occur due to years of overuse - sprinters, runners

Question 7

Describe symptoms and signs of achilles tendonitis

Answer 7

• Pain and stiffness along the Achilles tendon in the morning
• Pain in the tendon that worsens with activity
• Severe pain 24 hours after exercising
• Thickening of the tendon
• Swelling that is present all the time but worsens with activity
• Palpable bone spur

Question 8

Describe typical cause of achilles tendon rupture and location

Answer 8

• Rupture most commonly occurs in middle aged male during recreational sports
  
  • Forceful push-off with an extended knee (during jumping)
  • Fall with the foot outstretched in front and the ankle dorsiflexed
  • Falling from a height
• Usual site of complete tear is the vascular watershed area
  
  • Hypovascular space 6cm above calcaneus insertion which lacks blood supply and therefore weak and susceptible to rupture
• Plantaris running beside can still provide some movement

Question 9

Describe the signs and symptoms of achilles tendon rupture

Answer 9

• Sudden and severe pain at the back of ankle or in calf
• Sound of a loud pop or snap
• Palpable gap or depression in the tendon
• Initial pain and swelling followed by bruising
• Inability to stand on tip toe or push off whilst walking

Question 10

Describe how to test for Achilles tendon rupture

Answer 10

• Thompson’s test / Simmond’s test

- Kneel on chair, squeeze calf and foot should move if normal

Question 11

Describe how ankle fractures occur

Answer 11

• Fracture causing internal/external rotation or inversion/eversion can push the medial or lateral malleolus, thus causing a fracture at the site
• Can also rupture the medial or lateral ligaments on the opposite side

Question 12

Differentiate between stable and unstable ankle fracture

Answer 12

• If the fracture is below the tibiofibular joint, the ankle will be relatively stable
• If the fracture is above the tibiofibular joint, the ankle is unstable and requires surgical fixation
• Talar shift - talar move out of mortise - equal space within ankle joint
  - Means unstable fracture

Question 13

Describe ankle sprain including cause and consequence to 5th metatarsal

Answer 13

• Ankle sprain refers to partial or complete tear of one or more ligaments of the ankle joint
• Most common mechanism is an inversion injury affecting a plantarflexed and weightbearing foot
• Commonly in ankle fractures, the 5th metatarsal is fractured as the fibularis brevis tendon is attached to the tuberosity of the 5th metatarsal

Question 14

Describe the risk factors of sprained ankle

Answer 14

• Weak muscle/tendons
• Weak or lax ankle ligaments - hereditary or due to overstretching of ligaments due to repetitive sprains
• Inadequate joint proprioception
• Slow neuromuscular response to an off balance position
• Running on uneven surfaces
• Shoes with inadequate heel support
• Wearing high heeled shoes

Question 15

Describe flat foot

Answer 15

• (Pes Planus)
• Loss of medial longitudinal arch
• Most children appear flat footed as their arches have not fully developed
  
  • Only a problem if it persists during or after adolescence
• Results from excessive stretching of plantar calcaneonavicular ligament and plantar aponeurosis
• Presents with pain behind medial malleolus, change of shape

Question 16

Describe claw toe

Answer 16

• Commonly affects all 4 of the small toes at the same time
  
  • Often hyperextended at the MTPJ and flexed at the PIP joint (and sometimes DIP joint)
• Due to muscle imbalance causing ligaments and tendons to become unnaturally tight
  
  • Commonly secondary to neurological damage including cerebral palsy, stroke, diabetes, alcohol

Question 17

Describe hammer toe and mallet toe

Answer 17

• Hammer toe is when the toe is flexed at the PIPJ whereas a mallet toe is flexed at the DIPJ
  
  • Can affect any toe but most common in second toe
• Causes include ill-fitting pointed shoes and pressure on the second toe from adjacent hallux valgus
• A tight shoe can cause muscles to contract and shorten - thus difficult to straighten

Question 18

Describe how diabetes causes foot problems

Answer 18

• Infection, ulceration or destruction of the tissues of the foot
• Peripheral neuropathy, ischaemia due to peripheral arterial disease or combination may lead to foot ulcers
• Affects nerves and desensitisation - cannot detect injury
• Immunosuppressed and thus injury causes infection
• Rockerbottom foot may develop as middle of foot has all weight bearing

Question 19

Describe Charcot arthropathy

Answer 19

• Progressive destruction of the bones, joints and soft tissues most commonly in ankle or foot
• Over stress joint and hit foot against objects
• Leads to bone deformity and bone loss - loss of weight bearing ability
• Loss of bone stock, soft bone due to inflammation, lack of pain as a reminder
• Patients often obese, cognitive problems, immunocompromised, self neglect