foot and ankle problems

Question 1

what makes up the ring the ankle joint can be visualised as

Answer 1

proximal part of the ring is made by the articulating surfaces of the tibia and fibula united at the inferior tibiofibular joint by syndesmotic ligaments
the medial side is formed by the medial (deltoid) ligament
the inferior part is formed but the subtalar joint (between the talus and the calcaneus )
the lateral side of the ring is formed by the lateral ligament complex ( Anterior talofibular, posterior talofibular,Calcaneofibular).

Question 2

what does forced eversion or external rotation of the foot cause

Answer 2

pushes against the lateral malleolus potentially leading to oblique fracture of lateral malleolus and will pull on the medial ligaments leading to a ruptured deltoid ligament or a transverse fracture of the medial malleolus.

Question 3

what does a forced adduction or inversion of the foot cause

Answer 3

pushes the medial malleolus of the tibia (oblique fracture ) and pulls on the lateral structures leading to a ruptured lateral ligaments or a transverse fracture of the lateral malleolus.

Question 4

what is talar shift

Answer 4

when there is disruption of any two out of the syndesmosis, medial or lateral ligaments , the ankle mortise becomes unstable and widens so that the talus can shift medially or laterally within the ankle joint.

Question 5

how are stable ankle fractures treated

Answer 5

non-operatively

with an aircast boot or a fibreglass cast for comfort.

Question 6

what is an ankle sprain

Answer 6

partial or complete tear of one or more ligaments of the ankle joint.

Question 7

factors that contribute to increased risk of ankle sprains

Answer 7

weak muscles/tendons that cross the ankle joint
weak ankle ligaments - can be hereditary or due to overstretching of ligaments as a result of repetitive ankle sprains.
slow neuromuscular response to an off balance position
running on uneven surfaces
wearing high heeled shoes

Question 8

in an inversion injury affecting a plantar flexed and weight bearing foot which ligament is most at risk of sprain

Answer 8

anterior talofibular ligament

Question 9

in a severe sprain of the ankle why is it common to find that the patient has an evulsion fracture of their fifth metatarsal tuberosity?

Answer 9

the fibularis brevis tendon is attached to a tubercle on the base of the 5th metatarsal. in a inversion injury, it is under tension and can pull off a fragment of bone at its insertion site.
*children aged 10-16 can have ab unfused 5th metatarsal apophysis which can be seen on foot x rays and can be confused with a 5th metatarsal fracture.

Question 10

mechanisms of injury causing achilles tendon rupture

Answer 10

making a forceful push-off with an extended knee
a fall with the foot outreached in front and the ankle dorsiflexed forcibly outstretching the tendon.
falling from a height or abruptly stepping into a hole or off a kerb.

Question 11

symptoms and signs of an achilles tendon rupture

Answer 11

sudden and severe pain at the back of the ankle or in the calf
sound of a loud pop or snap
palpable and sometimes visible gap or depression in the tendon
initial pain and swelling followed by bruising
inability to stand on tip toe or to push off whilst walking.

Question 12

how can you test for a ruptured achilles tendon

Answer 12

Thompson’s test (sometimes called Simmond’s test)
squeeze calf muscle and this should lead to plantar flexion of the foot but if the foot doesn’t move there is a tendon rupture.

Question 13

what is hallux valgus

Answer 13

varus deviation of the first metatarsal
valgus deviation and/or lateral rotation of the hallux
prominence of the first metatarsal head with or without an overlying callus.

Question 14

what is hallux rigidus

Answer 14

osteoarthritis of the 1st metatarsophalangeal joint.

Question 15

symptoms of hallux rigidus

Answer 15

pain in the metatarsophalangeal joint on walking and on attempted dorsiflexion of the toe.
in many cases there is pain on rest.
patients tend to compensate for the pain by walking on the outside of their foot (inverting it and walking on the lateral border).
dorsal bunion may develop on top of the joint

Question 16

what is arthroplasty

Answer 16

joint replacement

Question 17

what is arthrodesis

Answer 17

joint fusion

Question 18

what is excision arthroplasty

Answer 18

surgical removal of the joint with interposition of soft tissue

Question 19

what is osteotomy

Answer 19

surgical cutting of a bone to allow realignment

Question 20

treatment for hallux rigidus

Answer 20

-initially involves activity modification , analgesia, orthotics or aids and sometimes intra-articular steroid injections.
-rigid sole orthotic id a very stiff shoe insert that prevents motion of the 1st metatarsophalangeal joint. this will help prevent pain caused by dorsiflexion of the toe whilst walking.
if conservative management fails surgery may be considered : arthrodesis(fusion) of the 1st metatarsophalangeal joint.
arthroplasty (replacement) of the 1st metatarsophalangeal joint may be considered.

Question 21

what is the major difference between OA of the ankle and of the hip

Answer 21

Nearly all cases of OA of the ankle are secondary arthritis

Question 22

treatment for OA of the ankle

Answer 22

arthrodesis(fusion)

arthroplasty (joint replacement) - carries more risks : prosthetic loosening and prosthetic infection

Question 23

Features of claw toe

Answer 23

often affect all four of the small toes at the same time
toes hyperextended at the metatarsophalangeal joint and flexed at the PIP joints.
corns may develop over the dorsum of the foot or under the head of the metatarsal.
cause: muscle imbalance which causes the ligaments and tendons to become unnaturally tight usually due to neurological damage and may be secondary to conditions such as cerebral palsy, stroke , diabetes or alcohol dependence.

Question 24

What is a hammer toe and mallet toe

Answer 24

hammer toe is a deformity in which the toe is flexed at the proximal interphalangeal joint whereas a mallet toe is flexed at the distal interphalangeal joint.

Question 25

causes of hammer toe and mallet joint

Answer 25

ill-fitting pointed shoes - if a tight shoe can cause a toe to stay in a flexed position for too long the muscles contract and shorten. makes makes it harder to extend toe and over time you won’t be able to extend toe without the shoe.

pressure on second toe from an adjacent hallux valgus.

Question 26

cause of curly toes

Answer 26

because the tendons of the flexor digitorum longus or flexor digitorum brevis are too tight.

Question 27

what is achilles tedinopathy

Answer 27

degenerative change of achilles tendon
can develop at the point of insertion of the achilles tendon into the calcaneum which is called insertional tendinopathy.
or at the vascular ‘watershed’ area within the achilles tendon (non-insertional tendinopathy)
can follow after many years of overuse or in inactive people.

Question 28

symptoms and signs of achilles tendionopathy

Answer 28

pain and stiffness along the achilles tendon in the morning.
pain in the tendon or at the back of the heel that worsens with activity
severe pain 24 hours after exercising
thickening of tendon
swelling that is present all the time but worsens during activity
palpable bone spur

Question 29

treatment of achilles tedinopathy

Answer 29

physiotherapy especially eccentric stretching exercises to try and improve the vascularity of the tendon and promote healing.

Question 30

what is pes planovalgus

Answer 30

flat foot
medial arch of the foot has collapsed so that the medial border almost touches the ground. valgus refers to the valgus angulation of the hind foot.

Question 31

what is flexible flat feet

Answer 31

when a patient has no medial arch whilst standing normally but when standing on tip toes a normal medial arch appears and the hind foot returns from deviation into a normal alignment.

Question 32

what causes rigid flat feet

Answer 32

tarsal coagulation

failure of the tarsal bones to separate during embryonic development.

Question 33

what does acquired flexible flat foot in adults result from

Answer 33

dysfunction of the tibialis posterior tendon which usually supports the medial longitudinal arch of the foot whilst walking.

Question 34

risk factors of adult acquired flat foot

Answer 34

obesity 
hypertension 
diabetes 
middle aged women 
can occur temporarily during pregnancy due to increased laxity of the ligaments.

Question 35

what is checked for in a diabetic foot clinic

Answer 35

corns, callouses , cracks , dry skin

Question 36

what is Charcot arthropathy

Answer 36

caused by poorly controlled diabetes
involves progressive destruction of the bone, joints and soft tissues.
most common involves affects the ankle and foot.

Question 37

treatment of Charcot arthropathy

Answer 37

optimisation of glycemic control
reduction of the load placed on joints- difficult as there is reduced bone stock and bones are soft due to inflammation. and patients can be obese.