Foot & Ankle Flashcards
Causes of ankle OA
idiopathic
consequence of previous injury
What movement of the ankle may result in anterior ankle damage and osteophyte formation
Repeated ankle dorsiflexion
Tx of anterior ankle osteophytes
Cheilectomy - removal of the anterior osteophytes
Surgical options for advanced OA
Arthrodesis
Ankle replacement
Advantage of ankle replacements over arthrodesis
Better functional outcome due to some preservation of motion
Disadvantage of ankle replacements compared to arthrodesis
Ankle replacements put high stress and shearing force across the small ankle bones, resulting in difficulties in fixation and early loosening.
What patient group should ankle replacements be reserved for and why
Elderly - once failure occurs the ankle will require fusion which produces a shortened limb
Advantage of arthrodesis over ankle replacement
re-operation rates are much lower
What is Hallux Valgus
medial deviation of the 1st metatarsal and lateral deviation of the toe itself
In what conditions is Hallux Valgus more common?
Inflammatory arthropathies
Presentation of hallux valgus
rubbing of foot on shoes - bursitis over the 1st metatarsal head (bunion)
What is transfer metatarsalgia
Seen in hallux valgus -
normally all the power goes through the large toe.
The function of the great toe is lost, so the power now goes through the other toes
Tx of hallux valgus
Non-operative:
Shoe accommodations
Spacer in 1st web space to stop rubbing
Operative:
Osteotomies to realign the bones
Soft tissue procedures to correct laxity or tightness of tissues
What is Hallux rigidus
OA of the first MTPj
Tx hallux rigidus
Arthrodesis
What do plantar interdigital nerves arise from
medial and lateral plantar nerves (which have arisen from tibial nerve)
What is Morton’s neuroma
irritated interdigital nerves that have become inflamed and swollen due to repeated trauma, and have formed a neuroma
Presentation of morton’s neuroma
burning pain and tingling radiating into the affected toes
forefoot pain (metatarsalgia)
What foot interspace nerve is most commonly affected in Morton’s neuroma
3rd interspace nerve
then 2nd
Ix for Morton’s Neuroma
Mulder’s click test - squeezing the forefoot reproduces symptoms or produces a characteristic click
USS - demonstrates swollen nerve
Tx Morton’s neuroma
Non-op:
insoles
Steroid and analgesia injections
Op:
Excision of neuroma
Most common MTP for stress #
2nd metatarsal
Tx metatarsal stress #
rest and 6-12 weeks in rigid soled boot
Causes of Achilles Tendonitis
Repetitive strain (From sports)
Quinolone Abx
Inflammatory arthropathies
Tx of Achilles Tendinitis
Rest
Physio
Heel raise in shoe to offload tendon
Splint/boot use
Why should steroids not be used for Tx of achilles tendonitis
Risk of rupturing the tendon
Causes of Achilles Tendon rupture
degenerative changes within in the tendon
recent tendonitis
Test for confirming Achilles Tendon rupture
Simmonds test
no plantar flexion of the foot seen when squeezing the calf
Presentation of Achilles Tendon rupture
unable to weight bear
sudden pain
palpable gap in the tendon
Tx of Achilles Tendon rupture
Non-op:
series of casts in the equinous position - the ankle plantarflexed with toes pointing down, as this closes the gap in the torn tendon
Operative:
suture repair of tendon, fixed with casts for 8 weeks
Origin of the plantar aponeurosis
distal plantar aspect of the calcaneal tuberosity
What is plantar fasciitis
inflammation of the thick supporting arch tissue on the sole of the foot
Causes of plantar fasciitis
diabetes
obesity
poor cushioning in shoes
repetitive stress (sports)
Presentation of plantar fasciitis
start up pain after rest
localised tenderness on palpation of origin of plantar aponeurosis
Tx of plantar fasciitis
rest
NSAIDs
stretching exercises
gel filled heel pad
how long can symptoms of plantar fasciitis take to resolve
up to 2 years
what is pes planus
adult flat foot - medial arch does not develop
causes of pes planus
developmental - ligament laxity
acquired - tibialis posterior tendon stretch or rupture, RA, diabetes with Charcot foot
insertion of the tibialis posterior tendon
medial navicular
function of the tibialis posterior tendon
support the medial arch of the foot
plantarflexes the foot
inverts the foot
stress of the tibialis posterior tendon leads too..?
tendonitis, elongation and eventual rupture
Tx of tibialis posterior tendonitis?
splint of medial arch - aim is to avoid rupture
if this fails - surgical decompression + tenosynovectomy
Symptoms of tibialis posterior tendon elongation
Loss of medial arch
valgus of the heel (“too many toes” showing on lateral border when looking from behind)
flattening of the medial arch of the foot
Potential consequence of tibialis posterior tendon elongation (with regards to the foot)
degenerative OA of the hindfoot and midfoot
Tx of tibialis posterior tendon elongation
a) without OA present
b) with OA present
a) tendon transfer
b) arthrodesis
Most common group to have tibialis posterior tendon dysfunction
Obese middle aged females
hypertensives
diabetes
What is pes cavus
Abnormally high arch of the foot
Causes of pes cavus
Idiopathic
Neuromuscular conditions - hereditary sensory and motor neuropathy cerebral palsy polio spina bifida occulta
What other foot abnormality commonly accompanies pes cavus
claw toes
Tx of pes cavus
If supple -
Soft tissue releases
tendon transfer
If rigid -
Calcaneal osteotomy
If severe -
arthrodesis
Cause of claw toes and hammer toes
acquired imbalance between the flexor and extensor tendons
what are claw toes
hyperextension at the MTPj with hyperflexion at the PIPj and DIPj
what are hammer toes
hyperextension at the MTPj with hyperflexion at the PIPj and hyperextension at the DIPj
Tx of claw and hammer toes
Non-operative:
toe sleeves
corn plasters
Operative: Tenotomy (division of overactive tendon) Tendon transfer Arthrodesis ?toe amputation
