Foot and Ankle Conditions Flashcards
When is malleolar grip strongest
During dorsiflexion - unstable during plantar flexion
Muscles of dorsiflexion
Tibialis anterior
Extensor digitorum longus
Extensor hallicus longus
Peroneus / Fibular tertius
Muscles of plantar flexion
Gastrocnemius Soleus Tibialis posteior Flexor hallicus longus Flexor digitorum longus Assisted by plantaris
Muscles of inversion
Tibialis anterior and posterior
Muscles of eversion
Fibularis longus and brevis
function of arches of foot
Shock absorbers
Distribute weight over foot
What is the integrity of the arches of the feet maintained by
Shape of united bones
Plantar aponeurosis
Long and short plantar ligaments
Intrinsic muscles of foot
What is a cavovarus foot and causes
High arch
- Neurological impairments i.e. muscle wasting
- Congenital - clubfoot
- Post-traumatic
What clinical sign can be seen in cavovarus foot
Peek-a-boo sign - can see heels behind arches from anterior view
Clinical features of cavovarus foot and causes
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
5 questions to ask patient with cavovarus foot
Progressive? FH? Muscle pain or weakness? Elevated CK? Altered sensation?
What test can be done to differentiate between a forefoot driven hindfoot varus and a hind foot driven varus?
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
What is hallux valgus
bunions
cause of hallux valgus
Genetic
Footwear - women more affected high heels?
Symptoms of hallux valgus
Pressure symptoms from shoes
Pain from crossing over toes
Metatarsalgia (pain at ball of foot)
Pathogenesis of hallux valgus
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.
Why does abnormalities of lesser toes occur in hallux valgus
As deformity progresses, sesamoid bones subluxation as less weight goes through the great toe
Diagnosis of hallux valgus
Clinical exam
X-ray to determine severity
Non-op management of hallux valgus
Shoes - wide and high toe box
Orthotics - offload pressure and correct deformity
Activity modification
Analgesia
Operative management of hallux valgus
Release lateral soft tissues
Osteotomy (removal) of 1st MT and proximal phalanx
What is hallux rigidus
Stiff big toe
Cause of hallux rigidus
Genetic - MT head more pointed than rounded
Microtrauma –> arthritis –> HR
Symptoms of hallux rigidus
asymptomatic common
pain - at extreme of dorsiflexion
limited RoM
Diagnosis of hallux rigidus
clinical - stiff osteophytes on exam
x-ray
Non-op management of hallux rigidus
Activity limitation
Shoes with rigid sole (stop bending –> pain)
Analgesia
Op management of hallux rigidus
Arthrodesis (joint fusion) to remove dorsal impingement - GOLD
Cheilectomy (remove bone spurs)
Arthroplasty (joint replacement) - good RoM
Name some lesser toe deformities
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
Causes of lesser toe deformities
Imbalance between flexors and extensors Shoe wear - too short / narrow, high-heels Neurological RA Idiopathic
Non-op treatment of lesser toe deformities
Activity limitation
Shoe wear
Orthotic insoles
Operative treatment of lesser toe deformities
Flexor to extensor transfer
IP joint fusion
MTP joint release
Shortening osteotomy of MT
What is Morton’s neuroma
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
Symptoms of Mortons neuroma
Neuralgic burning pain into toes Intermittent Altered sensation in webspace Tends to affect females 40-60 3rd webspace most common then 2nd
diagnosis of Mortons neuroma
Clinical exam
Mudler’s click (squeeze MT heads together to hear)
USS - best
MRI - good
Treatment of Mortons neuroma
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
Treatment of rheumatoid forefoot
Non-op - shower, orthotics, activity limitation, analgesia
Operative - 1st MTPJ arthrodesis + 2nd-5th toe excision arthroplasty (destructive but helps bad pain)
What is a dorsal foot ganglion
A benign cystic swelling containing gelatinous material arising from a joint or tendon sheath
Symptoms of dorsal foot ganglion
Pain from pressure from shoes or from underlying problem
Treatment of dorsal foot ganglion
Non-op - aspirate
Operative - excision
Treatment of mid foot arthritis
Non-op - shoewear, activity limitation, orthotics
Injections
Operative fusion
What is plantar fibromatosis
Ledderhose disease - dupuytrens of the foot, progressive disease - is usually asymptomatic unless very large or on WBing area
Treatment of plantar fibromatosis
Non-Op - avoid pressure, shoewear, orthotics
Operative excision - 80% recurrence
RT - recurrence high
Excision + RT best for low recurrence but high risk of complications
What is achilles tendinitis / tendinosis
A degenerative overuse condition (no inflammation) resulting in pain and swelling of calf
Types of achilles tendinosis
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
Causes of Achilles tendinopathy
Paratendonopathy - athlete, 30-40, MALE
Tendonopathy - non-athlete, >40, obese, steroids, DM
Symptoms of achilles tendinopathy
Pain during and after exercise
Difficulty fitting shoes
RUPTURE - sudden painful blow with audible pop
Diagnosis of achilles tendinopathy
Clinical - Simmonds Triad test for rupture
- look for angle of dangle
- feel - palpate for gap along length of tendon
- move - calf squeeze
Investigations for achilles tendinopathy
USS, MRI if diagnosis unclear
Treatment of achilles tendinopathy
Activity modification, weight loss, shoes w slight heel Physio - eccentric stretching Extra-corporeal shockwave treatment Immobilisation Surgery - gastrocnemius release - release and debridement of tissues
What is plantar fasciitis
A chronic degenerative change of the plantar fasciitis, presumable due to repetitive micro tears
Pathological changes in plantar fasciitis
Fibroblast hypertrophy
Absence of inflammatory cells
Dysfunctional and disorganised blood vessels and collagen
Avascularity
Causes of plantar fasciitis
Athletes who rapidly increase intensity of training Running in unpadded shoes Obesity Occupations involving prolonged standing Foot rotational deformities Tight gastro-soleus complex
Symptoms of plantar fasciitis
Pain first thing in morning
Pain on WBing after rest (post-static dyskinesia) at the origin of plantar fascia
Frequently long lasting (2y +)
DDx for plantar fasciitis
Nerve entrapment syndrome
Arthritis
Calcaneal pathology
Diagnosis of plantar fasciitis
Clinical
X-ray, MRI, USS if unsure
Treatment of plantar fasciitis
Orthothic heel pads, taping Stretching techniques, night splints Rest, change training, weight loss NSAIDs Physio Cortisone injections Extracorporeal Shockwave therapy
Treatment of ankle arthritis
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
What is posterior tibial tendon dysfunction
Acquired adult flatfoot
Presenting with pain and swelling of medial hindfoot and may also have change in the shape of the foot
What shape changes of the foot occur in posterior tibial tendon dysfunction
Valgus heel (heel rotates lateral when seen behind) Flattened longitudinal arch Abducted forefoot
Diagnosis of posterior tibial tendon dysfunction
Double and single heel raise - heels should swing from valgus to varus as heel raises
Management of posterior tibial tendon dysfunction
NSAIDS, rest, immobilisation
Orthotics - medial arch support
Hindfoot Osteotomy + Tendon transfer (if early)
Arthrodesis - triple fusion of subtalar, talonavicular, calcaneo-cuboid (later)
Causes of diabetic foot ulcer
Neuropathy - unaware of trauma to foot
Autonomic Neuropathy - lack of sweating –> dry cracked skin –> more sensitive to microtrauma
Poor vascular supply
Treatment of diabetic foot ulcer
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
What is Charcot neuropathy
A destructive process of bone and joint, typically seen in a foot that has lost its protective sensory innervation.
Clinical presentation of Charcot neuropathy
Suspect in any patient with diabetes and neuropathy who presents with a warm, swollen, red foot - NB often not painful
Pathophysiology of Charcot neuropathy
Neurotraumatic - lack of proprioception and protective pain sensation
Neurovascular - abnormal ANS –> increased vascular supply and bone resorption
What bone changes is Charcot neuropathy characterised by
- Fragmentation
- Coalescence
- Remodelling
Diagnosis of Charcot
Clinical
X-ray
MRI
management of Charcot
Prevention
Immobilisation and casting (non-Wing until fragmentation resolved)
Correct deformity which can –> ulceration –> infection –< amputation
