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E - MSK > Foot and Ankle Conditions > Flashcards

Foot and Ankle Conditions Flashcards

1
Q

When is malleolar grip strongest

A

During dorsiflexion - unstable during plantar flexion

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2
Q

Muscles of dorsiflexion

A

Tibialis anterior
Extensor digitorum longus
Extensor hallicus longus
Peroneus / Fibular tertius

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3
Q

Muscles of plantar flexion

A 
Gastrocnemius
Soleus 
Tibialis posteior
Flexor hallicus longus 
Flexor digitorum longus 
Assisted by plantaris
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4
Q

Muscles of inversion

A

Tibialis anterior and posterior

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5
Q

Muscles of eversion

A

Fibularis longus and brevis

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6
Q

function of arches of foot

A

Shock absorbers

Distribute weight over foot

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7
Q

What is the integrity of the arches of the feet maintained by

A

Shape of united bones
Plantar aponeurosis
Long and short plantar ligaments
Intrinsic muscles of foot

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8
Q

What is a cavovarus foot and causes

A

High arch

  • Neurological impairments i.e. muscle wasting
  • Congenital - clubfoot
  • Post-traumatic
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9
Q

What clinical sign can be seen in cavovarus foot

A

Peek-a-boo sign - can see heels behind arches from anterior view

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10
Q

Clinical features of cavovarus foot and causes

A

Weakness of intrinsic muscles –> toe clawing –> plantar callosities and shoe problems

Plunger effect of proximal phalanges and overaction of peroneus longus –> plantarflexion of MT –> plantar callosities and shoe problems

Weakness of peroneus brevis –> hind foot varus –> ankle instability

Weakness of tibialis anterior –> equinus –> altered gait

Overpull of tibialis posterior –> adduction of foot –> stress fractures of lateral metatarsals

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11
Q

5 questions to ask patient with cavovarus foot

A 
Progressive?
FH?
Muscle pain or weakness? 
Elevated CK?
Altered sensation?
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12
Q

What test can be done to differentiate between a forefoot driven hindfoot varus and a hind foot driven varus?

A

Colemans Block Test - patient stands with 1st ray hanging over the edge of a block and if hind foot varus corrects, then it is compensating for a rigidly plantar flexed 1st ray

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13
Q

What is hallux valgus

A

bunions

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14
Q

cause of hallux valgus

A

Genetic

Footwear - women more affected high heels?

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15
Q

Symptoms of hallux valgus

A

Pressure symptoms from shoes
Pain from crossing over toes
Metatarsalgia (pain at ball of foot)

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16
Q

Pathogenesis of hallux valgus

A

Lateral angulation of the great toe causes tendons pull to be realigned to lateral of centre of rotation of the toe.

This worsens the deformity, resulting in a cycle of increased pull and deformity.

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17
Q

Why does abnormalities of lesser toes occur in hallux valgus

A

As deformity progresses, sesamoid bones subluxation as less weight goes through the great toe

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18
Q

Diagnosis of hallux valgus

A

Clinical exam

X-ray to determine severity

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19
Q

Non-op management of hallux valgus

A

Shoes - wide and high toe box
Orthotics - offload pressure and correct deformity
Activity modification
Analgesia

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20
Q

Operative management of hallux valgus

A

Release lateral soft tissues

Osteotomy (removal) of 1st MT and proximal phalanx

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21
Q

What is hallux rigidus

A

Stiff big toe

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22
Q

Cause of hallux rigidus

A

Genetic - MT head more pointed than rounded

Microtrauma –> arthritis –> HR

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23
Q

Symptoms of hallux rigidus

A

asymptomatic common
pain - at extreme of dorsiflexion
limited RoM

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24
Q

Diagnosis of hallux rigidus

A

clinical - stiff osteophytes on exam

x-ray

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25
Q

Non-op management of hallux rigidus

A

Activity limitation
Shoes with rigid sole (stop bending –> pain)
Analgesia

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26
Q

Op management of hallux rigidus

A

Arthrodesis (joint fusion) to remove dorsal impingement - GOLD
Cheilectomy (remove bone spurs)
Arthroplasty (joint replacement) - good RoM

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27
Q

Name some lesser toe deformities

A

Claw toes - dorsiflexion of proximal phalanx on lesser MTP joint with flexion of both proximal and distal IP joints (2nd-5th toes)

Hammer Toe - bent PIPJ of 2nd, 3rd or 4th toe

Mallet Toe - bent DIPJ of 2nd, 3rd or 4th toe

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28
Q

Causes of lesser toe deformities

A 
Imbalance between flexors and extensors 
Shoe wear - too short / narrow, high-heels
Neurological 
RA
Idiopathic
29
Q

Non-op treatment of lesser toe deformities

A

Activity limitation
Shoe wear
Orthotic insoles

30
Q

Operative treatment of lesser toe deformities

A

Flexor to extensor transfer
IP joint fusion
MTP joint release
Shortening osteotomy of MT

31
Q

What is Morton’s neuroma

A

A mechanically induced, degenerative neuropathy where the common digital nerve is relatively tethered to one MT and movement in the adjacent MT causes mechanical shear

The 3rd MT joint is quite rigid, so thought that it rubs against the 2nd / 4th MTs resulting in the nerve getting pulled down

32
Q

Symptoms of Mortons neuroma

A 
Neuralgic burning pain into toes 
Intermittent 
Altered sensation in webspace 
Tends to affect females 40-60 
3rd webspace most common then 2nd
33
Q

diagnosis of Mortons neuroma

A

Clinical exam
Mudler’s click (squeeze MT heads together to hear)
USS - best
MRI - good

34
Q

Treatment of Mortons neuroma

A

Steroid injection for small lesions
Surgery - excision of lesion + section of normal nerve
- causes numbness and recurrence as nerves attempt to regenerate but if there is no end for it to join up with then another neuroma can form

35
Q

Treatment of rheumatoid forefoot

A

Non-op - shower, orthotics, activity limitation, analgesia

Operative - 1st MTPJ arthrodesis + 2nd-5th toe excision arthroplasty (destructive but helps bad pain)

36
Q

What is a dorsal foot ganglion

A

A benign cystic swelling containing gelatinous material arising from a joint or tendon sheath

37
Q

Symptoms of dorsal foot ganglion

A

Pain from pressure from shoes or from underlying problem

38
Q

Treatment of dorsal foot ganglion

A

Non-op - aspirate

Operative - excision

39
Q

Treatment of mid foot arthritis

A

Non-op - shoewear, activity limitation, orthotics
Injections
Operative fusion

40
Q

What is plantar fibromatosis

A

Ledderhose disease - dupuytrens of the foot, progressive disease - is usually asymptomatic unless very large or on WBing area

41
Q

Treatment of plantar fibromatosis

A

Non-Op - avoid pressure, shoewear, orthotics
Operative excision - 80% recurrence
RT - recurrence high

Excision + RT best for low recurrence but high risk of complications

42
Q

What is achilles tendinitis / tendinosis

A

A degenerative overuse condition (no inflammation) resulting in pain and swelling of calf

43
Q

Types of achilles tendinosis

A

Insertional - within 2cm of insertion, degenerative
Mid-Substance - middle of tendon (2-7cm)
Bursitis - retro- or superficial-calcanea
Paratendinopathy - inflammation and/or degeneration of the thin membrane around the achilles tendon

44
Q

Causes of Achilles tendinopathy

A

Paratendonopathy - athlete, 30-40, MALE

Tendonopathy - non-athlete, >40, obese, steroids, DM

45
Q

Symptoms of achilles tendinopathy

A

Pain during and after exercise
Difficulty fitting shoes
RUPTURE - sudden painful blow with audible pop

46
Q

Diagnosis of achilles tendinopathy

A

Clinical - Simmonds Triad test for rupture

  • look for angle of dangle
  • feel - palpate for gap along length of tendon
  • move - calf squeeze
47
Q

Investigations for achilles tendinopathy

A

USS, MRI if diagnosis unclear

48
Q

Treatment of achilles tendinopathy

A 
Activity modification, weight loss, shoes w slight heel 
Physio - eccentric stretching 
Extra-corporeal shockwave treatment 
Immobilisation 
Surgery 
- gastrocnemius release
- release and debridement of tissues
49
Q

What is plantar fasciitis

A

A chronic degenerative change of the plantar fasciitis, presumable due to repetitive micro tears

50
Q

Pathological changes in plantar fasciitis

A

Fibroblast hypertrophy
Absence of inflammatory cells
Dysfunctional and disorganised blood vessels and collagen
Avascularity

51
Q

Causes of plantar fasciitis

A 
Athletes who rapidly increase intensity of training
Running in unpadded shoes 
Obesity 
Occupations involving prolonged standing
Foot rotational deformities 
Tight gastro-soleus complex
52
Q

Symptoms of plantar fasciitis

A

Pain first thing in morning
Pain on WBing after rest (post-static dyskinesia) at the origin of plantar fascia
Frequently long lasting (2y +)

53
Q

DDx for plantar fasciitis

A

Nerve entrapment syndrome
Arthritis
Calcaneal pathology

54
Q

Diagnosis of plantar fasciitis

A

Clinical

X-ray, MRI, USS if unsure

55
Q

Treatment of plantar fasciitis

A 
Orthothic heel pads, taping 
Stretching techniques, night splints 
Rest, change training, weight loss
NSAIDs
Physio 
Cortisone injections
Extracorporeal Shockwave therapy
56
Q

Treatment of ankle arthritis

A

Non-Op

  • weight loss
  • activity modification
  • physio
  • analgesia and steroid injections

Operative

  • Arthrodesis (GOLD)
  • Arthroscopic Anterior Debridement (if symptoms exclusively anterior)
  • Joint replacement - maintains RoM
57
Q

What is posterior tibial tendon dysfunction

A

Acquired adult flatfoot

Presenting with pain and swelling of medial hindfoot and may also have change in the shape of the foot

58
Q

What shape changes of the foot occur in posterior tibial tendon dysfunction

A 
Valgus heel (heel rotates lateral when seen behind)
Flattened longitudinal arch 
Abducted forefoot
59
Q

Diagnosis of posterior tibial tendon dysfunction

A

Double and single heel raise - heels should swing from valgus to varus as heel raises

60
Q

Management of posterior tibial tendon dysfunction

A

NSAIDS, rest, immobilisation
Orthotics - medial arch support
Hindfoot Osteotomy + Tendon transfer (if early)
Arthrodesis - triple fusion of subtalar, talonavicular, calcaneo-cuboid (later)

61
Q

Causes of diabetic foot ulcer

A

Neuropathy - unaware of trauma to foot
Autonomic Neuropathy - lack of sweating –> dry cracked skin –> more sensitive to microtrauma
Poor vascular supply

62
Q

Treatment of diabetic foot ulcer

A

Prevention - control diabetes, smoking, improve vascular supply, splints, shoe wear, prevent infection and deformity, good nutrition

Surgery

  • Improve vascular supply
  • Debride ulcers and get samples for microbiology
  • Correct deformity to offload area
  • amputation
63
Q

What is Charcot neuropathy

A

A destructive process of bone and joint, typically seen in a foot that has lost its protective sensory innervation.

64
Q

Clinical presentation of Charcot neuropathy

A

Suspect in any patient with diabetes and neuropathy who presents with a warm, swollen, red foot - NB often not painful

65
Q

Pathophysiology of Charcot neuropathy

A

Neurotraumatic - lack of proprioception and protective pain sensation
Neurovascular - abnormal ANS –> increased vascular supply and bone resorption

66
Q

What bone changes is Charcot neuropathy characterised by

A
  1. Fragmentation
  2. Coalescence
  3. Remodelling
67
Q

Diagnosis of Charcot

A

Clinical
X-ray
MRI

68
Q

management of Charcot

A

Prevention
Immobilisation and casting (non-Wing until fragmentation resolved)
Correct deformity which can –> ulceration –> infection –< amputation

E - MSK (29 decks)

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