Ses 4 Foot And Ankle Disorders And Gait Msk Flashcards
Ankle Fractures notion
Trauma
Discontinuation in cortex of tibia, fibula or talus.
Usually an inversion (medial malleolus and lateral ligament) or eversion injury ( lateral malleolus and medial ligaments).
Unstable fractures - talar shift due to disruption of any 2 of syndesmosis, medial or lateral ligaments.
Consider their co-morbidities eg diabetics have longer healing time for bones.
Have to wait for fracture blisters to heal.
Treatment - Open fractures where skin is breached needs urgent surgery with extensive irrigation and debridement to reduce risk of osteomyelitis(infection).
Stable = non-operative -cast
5th metatarsal fracture notion
Trauma
Avulsion fracture = bone breaks due to excessive tension through the inserting tendon.
Fibularis brevis muscle and plantar aponeurosis insert causing significant tension during forced inversion
Typical mechanism of injury: stepping on a curb or climbing steps
Make sure it’s not infused apophysis
sprained ankle - which ligament is most at risk
Trauma
Partial or complete tear of one or more ligaments of the
ankle joint.
conservative management (non-operative).
Forced eversion: medial ligament sprain = deltoid ligament
Forced inversion: lateral ligament sprain
Most common mechanism of injury is an inversion injury affecting a plantar-flexed and weightbearing foot.
In this injury, the anterior talofibular ligament is most at risk of sprain.
Hallux (big toe) Valgus(distal goes lateral)
Lateral (valgus) deviation of hallux while there is medial deviation (varus) of metatarsal.
Joint subluxation.
Causes: - poorly-understood. Exacerbated by tight-fitting shoes and the line of pull of the extrinsic tendons (e.g. EHL tendon).
Most common cause of a ‘bunion’.
Risk factors: Female Age >65 years
Connective tissue disorders that cause ligamentous laxity eg ethers-danlos
Trauma, gout, RA
Management: Analgesia, Supportive footwear, Surgical correction(metatarsal osteotomy and realigning the fragments).
OA of ankle
Causes - Usually secondary:
Post- traumatic eg fracture, severe sprain
Inflammation eg RA
Joint stress eg ballet
Obesity
Primary - idiopathic - better outcome
Joints affected:
Talocrural joint
Subtalar joint
Management:
Arthodesis - good outcome
Arthoplasty - risky
Achilles tendinopathy(causes, where it occurs, risk factors, symptoms and treatment) and rupture(causes, symptoms, diagnosis, treatment)
Notion
Rupture causes:
Overstretching the tendon by falling from height, stepping off kerb, falling with foot outstretched and dorsiflexed, making a push-off with an extended knee
Symptoms/signs:
Sudden pain at back of ankle
Loud pop
Palpable gap in tendon
Pain, swelling, bruising
Cannot tip toe or push off while walking
Diagnosis -Thompson’s test – Calf squeeze and foot plantar flexes.
Ultrasound/ MRI to show gap.
Treatment - conservative, maybe surgical (ends frayed)
Tendinopathy – Repetitive action causing microtears within the tendon - degenerative
Occurs at calcaneal tuberosity or vascular area within tendon.
Risk factors: Trauma, Poor footwear, Obesity, diabetes, exercise frequency eg runners
Symptoms - worse pain in morning and after exercise, swelling, bone spur, thickening of tendon
Treatment: Physio
Lesser toes
Claw toe + Hammer toe
What is claw toe:
Affect all four of the small toes at the same time.
The toes are hyperextended at the MTPJ and flexed at the PIP joint.
Causes:
Muscle imbalance causes ligaments and tendons to become unnaturally tight - neurological damage - stroke, diabetes, cerebral palsy.
Trauma, RA.
Hammer toe what is it:
deformity in which the toe is flexed at the PIPJ.
Causes:
Toe in a flexed position for too long, the muscles contract and shorten, over time, the muscles cannot extend the toe -tight shoe/adjacent hallux valgus.
Flat foot
Pes planovalgus
Flat foot is a loss of the medial longitudinal arch.
Valgus angulation of the hindfoot.
Only abnormal from adolescence upwards.
Rigid(no arch at all) and flexible(normal when standing on tip toes).
Causes:
Adolescents- tarsal coalition
Adult acquired - dysfunction of the tibialis posterior tendon - stretching of the spring ligament - talar head displaced inferomedially, flattening the medial longitudinal arch and producing lateral deviation of the hindfoot.
Risk factors:
Genetics – Marfans Syndrome and Downs Syndrome
Adult - Ligament laxity in pregnancy, hypertension, obesity, Diabetes
Treatment:
Adolescence- not orthotics
Adult - orthotics, physio for muscle strength, surgical reconstruction
Diabetes and the foot
Conditions:
Peripheral vascular disease causes ischaemia
Peripheral neuropathy causes loss of sensation
Immunosuppression due to poor glycaemic control
Symptoms:
Deformity
Pain & stiffness
Loss of sensation
Ulcers
Prevention:
Annual diabetic foot check
Self care advice – good fitting shoes, checking the sole of the foot regularly
Tight glycaemic control
Charcot arthropathy
What is it? - Progressive destruction of the bone and soft tissue of the foot.
Characterised by multiple joint dislocations, fractures and deformities.
Usually ankle and foot.
Causes:
Neuropathy - reduced ability to detect touch, temp, pain so keep walking on foot - Repeated microtrauma causing fractures, inflammation causing osteolysis.
Presentation:
rocker-bottom foot
Treatment: Treat the underlying condition
optimisation of glycaemic control and reduction of the load placed on the affected joints.
Compartment Syndrome
Increase in pressure within a CLOSED fascial compartment that compromises the neurovascular
bundle.
6P ’s - Pain (Out of proportion from injury), Paraesthesia, Pulselessness, Perishingly cold, Paralysis, Pallor
Rhabdomyolysis due to muscle necrosis due to ischaemia.
Acute kidney injury due to this.
Volkmann’s ischaemic contracture
Diagnosis:
Can measure compartment pressures - exceeding systolic arterial pressure -loss of peripheral pulses and increased capillary refill time.
Causes: trauma- haemorrhage/oedema
Fascial compartments:
Thigh x3
Leg x4
Arm x2
Forearm x2
Treatment: Fasciotomy
Complications: Operative - Poor surgical technique, necrotic tissue, nerve and vascular injury Post-operative: Inability to close, infection, failure of treatment
Hallux rigidus
OA of 1st MPTJ
Causes: force equivalent to twice the body weight passes through this small joint with each step.
Secondary - gout and septic arthritis.
Symptoms- pain when walking and on attempted dorsiflexion of the toe.
Patients walk on lateral border of foot.
Osteophyte may develop on joint.
Treatment- activity modification, analgesia, orthotics(prevents movement of joint), intra-articular steroid injections, arthodesis, arthoplasty
Surgical management of OA terms
• Arthroplasty = joint replacement
• Arthrodesis = joint fusion
• Excision arthroplasty = surgical removal of the joint with interposition of
soft tissue (e.g. a rolled-up tendon, between the bone ends)
• Osteotomy = surgical cutting of a bone to allow realignment (to take the load off the affected part of the joint)
Define gait and gait cycle
Gait is the mechanism by which the body is transported using co-ordinated movements of the major lower limb joints.
Gait cycle is the period of time from initial contact to next initial contact on the same side of the body.
Describe the phases of the gait cycle notion
60%
Initial contact – heel strikes ground - double support
Loading response - deceleration - shock of the impact is absorbed by the knee and ankle joints.
The person also rocks forwards on their heel to put foot flat in next step.
Mid-stance – the foot is flat on the ground and the centre of gravity of the
body is shifted to front of the foot, ready for forward propulsion.
Terminal stance – Ankle plantarflexes
Pre-swing – The metatarsophalangeal joints flex to give a ‘push off’ by the toes - double support.
40%
Initial swing – the knee flexes - double support
Mid-swing – the hip flexes and the pelvis ‘swings’ forwards. Foot off the ground and not plantarflexed - ankle neutral.
Terminal swing – the knee extends, and the foot is prepared for heel strike.
Define step, stride and cadence
Stride: The distance from initial contact with one leg to the next
initial contact with the same leg
Step: The distance from initial contact with the one leg to initial
contact with the opposite leg
Cadence: The number of steps per minute
Describe the differences between walking and running
Double support replaced by double float
Sprinting = 40% stance and 60% swing
Identify the muscles used in normal gait
Tibialis anterior prevents slapping of foot to ground during heel strike. It eccentrically contracts to lower it gently.
Gastrocnemius and soleus do concentric contraction for pla
Trendelenburg gait
In the stance phase of the Trendelenburg gait, the pelvis drops on the unaffected side. The patient then tries to compensate by swinging their torso over towards the affected side. The resulting gait is ‘waddling’.
Causes:
SGN leisons
Trauma eg dislocation or fracture of GT where G.medius attaches
Muscle pain and inhibition of function (e.g. in hip OA)
Biomechanical hip instability (e.g. developmental dysplasia of the hip).
Hemiplegic gait
A hemiplegic gait is due to paralysis of one side of the body.
Lean towards the unaffected side of the body then circumduct (swing) the paralysed leg.
The patient cannot bear much weight on the paralysed leg so can only take a short step with the unaffected leg.
Gait = short step with unaffected leg followed by circumduction of the affected leg.
Causes - trauma to CNS eg stroke, head injury, spinal injury
The patients have spasticity (continuous contraction) of the affected side of the body. The spasticity is most severe in the flexor muscles of the upper limb and the extensor muscles of the lower limb as these are the dominant muscle groups = flexed upper limb and an extended lower limb.
Diplegic gait
spasticity affects both lower limbs.
Feet close together - narrow gait + forefoot makes the initial contact with the ground
Spasticity In:
Hip adductors so scissoring
Hamstrings so knee flexed
gastrocnemius + soleus so plantarflexion
Causes:
Cerebral palsy
High-steppage gait
Swing phase - the absence of dorsiflexion so under gravity is plantarflexed.
Patient has to flex the hip much more than usual in order to lift their foot high off the ground and stop their toes from dragging along the floor.
Heel strike - eccentric contraction of the tibialis anterior muscle is absent so foot slaps.
If superficial peroneal nerve isn’t damaged will compensate with eversion flick.
Causes:
Common peroneal nerve palsy e.g. trauma to the nerve following a fracture of the neck of the fibula
Sciatica (L4 myotome dorsiflexes the ankle)
Neuromuscular disease
Parkinsonian gait
Patients with Parkinson’s Disease find it difficult to initiate movement. To counteract this they flex their neck and trunk forwards to move their centre of gravity in front of their lower limbs.
They also take very short steps, known as a shuffling gait. Festinant gait, which is the tendency to take accelerating steps.
Loss of arm swing whilst walking.
Ataxic gait
Clumsy, staggering movements with feet wide apart.
Patients often hold their arms outwards to help them to balance.
Whilst standing still, the patient’s body may sway back and forth and from side to side – this is called titubation.
Patients will not be able to walk in a straight line.
Causes:
Proprioceptive
Cerebellar disease - inherited or acquired eg stroke or acute alcohol intoxication
Vestibular - damage to balance organs
Antalgic gait
Want to reduce pain in affected limb
So shorten stance phase on affected and shorten swing phase on unaffected limb - this is uneven.
Walking stick used in the hand opposite the painful limb. They can lean
towards the walking stick, shift their centre of gravity away from
the painful limb and therefore reduce the load through it during the
stance phase.
