Session 5 Foot And Ankle Problems

Question 1

What does hallus valgus (bunions) involve?

Answer 1

• medial deviation of the first metatarsal
• lateral deviation and/or rotation of the hallux
• prominence of the first metatarsal head, with or without an overlying callus

Question 2

What are the causes of bunions?

Answer 2

• overpronated foot
• arthritic metabolic conditions e.g gout, rheumatoid arthritis, psoriatic arthritis
• connective tissue disorders that cause ligamentous laxity = bunions can run in families

Question 3

What group of people are most susceptible to bunions and what makes it worse?

Answer 3

Middle aged women

Made worse by wearing footwear such as high heels and tight shoes as keeps the hallux in vagus deviation.

Also pull of extrinsic tendons e,g extensor hallucis longus makes it worse.

Question 4

What’s hallux rigidus?

Answer 4

Osteoarthritis of the 1st metatarsophalangeal joint, resulting in stiffness of this joint.

Question 5

What causes hallux rigidus?

Answer 5

• Walking put stress on the joint
• gout
• previous septic arthritis

Question 6

What’s Achilles tendinitis and how can it occur?

Answer 6

Inflammation of the Achilles’ tendon

Can occur within the tendon itself = non insertional tendinitis
Can occur at the point the tendon joins to the calcaneum = insertional tendinitis

Question 7

Which groups are more affected by non insertional and insertional Achilles tendinitis?

Answer 7

Non insertional = younger, athletic people

Insertional = any age, inactive or over users e.g people who run marathons

Question 8

What are the signs and symptoms of Achilles tendinitis?

Answer 8

Signs and symptoms

• pain and stiffness along the Achilles’ tendon in the morning
• pain in the tendon or back of heel that worsens with activity
• severe pain 24 hours after exercising
• thickening of the tendon
• swelling that is prevent all of the time but worsens with activity
• a palpable bone spur (in insertional tendinitis)

Question 9

What are the causes of osteoarthritis of the ankle Joint and what are the main complaints?

Answer 9

• post traumatic arthritis = after a traumatic event
• underlying medical conditions e.g rheumatoid arthritis
• no identifiable cause = primary ankle arthritis

Main complaints - pain and stiffness, especially first thing in the morning. Also limited movement of ankle joint.

Question 10

What kind of patients get primary OA?

Answer 10

Older

Will experience less pain and have a better range Of motion than those with primary OA

Question 11

What are the risk factors for OA?

Answer 11

Joint stress (ballet dancers, Football, etc)
Age
Obesity
Family history of OA

Question 12

What’s hammer toe and mallet toe?

Answer 12

Hammer toe = flexion of PIPJ
Mallet toe = flexion of DIPJ 

Most commonly effect the second toe

Question 13

What are the causes of hammer toe and mallet toe?

Answer 13

Causes

• ill fitting pointed shoes
• pressure on the second toe from an adjacent hallux valgus

If a tight shoe causes a toe to stay flexed for too long, muscles contract and shorten = harder to straighten the toe which gets worse over time

Question 14

What pathological changes with age make Achilles rupture more common?

Answer 14

• decreased capillary density and decreased arterial perfusion
• increased stiffness due to decreased elastin, decreased proteoglycans, decreased water content of the tendon and increased cross linking of collagen.
• decreased collagen turnover/synthesis and decreased ability to repair damaged collagen
• calcium deposition

Question 15

What group is most effected by Achilles’ tendon ruptures and by what mechanisms?

Answer 15

Middle aged males most commonly effected

Mechanisms

• forceful push of extended knee (jumping)
• fall with foot outstretched in front and ankle dorsiflexion, forcibly overstretching the tendon
• fall from a height or stepping into a hole or off a kerb

Question 16

What tear is most common and where?

Answer 16

Complete tear more common than a partial tear

The usual site is 6cm above the insertion into the calcaneum

Question 17

What are the signs and symptoms of an Achilles’ tendon rupture?

Answer 17

• sudden/severe pain at back of ankle or in the calf
• the 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 toes

Question 18

What’s the ankle ring??

Answer 18

The ankle joint and associated ligaments can be visualised as a ring in the coronal plane:

The upper part of the ring is formed by the articular surfaces of the tibia and fibula.

The lower part of the ring is formed by the subtalar joint (between the talus and the calcaneus).

The sides of the ring are formed by the medial and lateral ligaments.

Question 19

What does an injury that results in either eversion or external rotation of the foot do?

Answer 19

Can push the lateral malleolus, probably leading to an oblique fracture of it
Will also pull of medial ligaments, leading to a ruptured deltoid ligament or a transverse fracture of he medial malleolus.

Question 20

What does an injury that results in addiction or inversion of the foot do?

Answer 20

Can push the medial malleolus off the tibia = oblique fracture an pull on the lateral structures
Leads to a ruptured lateral ligament or a transverse fracture of the lateral malleolus

Question 21

How does an ankle fracture differ in the way it affects The syndesmosis?

Answer 21

If the fracture is below the distal tibiofibular joint, the syndesmosis will be intact and after reduction the ankle will be relatively stable.

If it is above the tibio fibular joint, the syndesmosis ligament must have been torn and this is unstable fracture and requires surgical fixation.

Question 22

What is a claw toe?

Answer 22

Affects all small toes at the same time

Toes are hyperextended at the MTPJ and flexed at the PIP joint and sometimes the DIP so that it curls under the foot. Corns may develop over the top of the toe or under the head of the metatarsal.

Question 23

What causes claw toe?

Answer 23

Results from a 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.

Trauma, inflammation and rheumatoid arthritis can also cause claw or.

Question 24

What’s an ankle sprain?

Answer 24

Partial or complete tear of one or more ligaments of the ankle joint

Question 25

What factors contribute to an increased risk of ankle sprains?

Answer 25

• weak muscles/tendons that cross the ankle joint, especially the perineal muscles
• weak of lax ankle ligaments: this can be hereditary or due to over-stretching of ligaments as a result of repetitive ankle sprains
• inadequate joint proprioception
• slow neuromuscular response to an off balance position
• running on uneven surfaces
• shoes with inadequate heel support
• wearing high heeled shoes dye it the weak position of the ankle joint with the elevated heel and a small base of support.

Question 26

Why do ankle sprains occur?

Answer 26

Excessive stress on the ligaments of the ankle. Can be caused by excessive external rotation, inversion or eversion of the foot caused by an external force.

When the foot is moved past its range of motion, the excess stress puts a strain on the ligament. If the strain is great enough to the ligaments past the yield point, then the ligament becomes damaged or sprained.

The most common mechanism of injury is an inversion injury affecting a plantar flexed and weight bearing foot. In this injury, the anterior talofibular ligament is most at risk of sprain.

Question 27

What is flat foot?

Answer 27

Implies the medial Arch of the Foot has collapsed so that the medial border almost touches the ground

Most young children appear this way as their arches haven’t fully developed and they have a lot of subcutaneous adipose tissue in their foot.

Question 28

What does flat foot result from??

Answer 28

Excessive stretching of the spring ligament and plantar aponeurosis

Stretching of the ligaments results in the Tatar head being displaced inferomedially flattening the medial longitudinal arch and producing some lateral deviation of the foot.

Question 29

How can flat foot develop in adulthood and what are the risk factors?

Answer 29

Due to

• injury
• prolonged stress
• normal ageing process (tibialis posterior dysfunction is a common cause as it helps support the arch of the foot whilst walking)

Risk factors

• pregnancy (increased laxity of ligaments)
• obesity
• hypertension
• diabetes

Question 30

What foot diseases can occur with diabetes mellitus?

Answer 30

Infection
Ulceration
Destruction of the tissue of the foot

Question 31

What’s charcots arthropathy and how do patients feel?

Answer 31

Involves progressive destruction of the bones, joints and soft tissue, most commonly in the ankle and foot.

A combo of neuropathy, abnormal loading of foot, repeated microtrauma and metabolic abnormalities of bone leads to inflammation causing osteolysis, fractures, dislocation and deformities.

Patient has reduced ability to feel touch, temperature and pain due to neuropathy. It also leads to muscle spasticity e.g tight Achilles’ tendon, which exacerbates the deformity.

A rocker bottom foot may develop.

Question 32

What is compartment syndrome?

Answer 32

Trauma to facial compartments may lead to haemorrhage and/or oedema and cause a rise in intracellular compartmental pressure = compartment syndrome

Question 33

What are the clinical signs of compartment syndrome?

Answer 33

• severe pain in limb which is excessive for the degree of injury, increasing and not relieved by analgesia
• pain is exacerbated by passive stretch of the muscles

If suspected, surgical decompression should be done on all affected compartments.

Question 34

What are the short term consequences of compartment syndrome?

Answer 34

Increase in intracompartmental pressure leads to decreased perfusion of the muscle. Ischaemic muscle releases mediators which further increase capillary permeability and exacerbate the rise in intracompartmental pressure. In severe untreated cases, rhabdomyolysis and acute kidney injury can result

Nerovascular signs develop lat in the process and are often underdeveloped at the time of diagnosis. If the compartment pressure exceeds the systolic arterial pressure there will be a loss of peripheral pulses and increased capillary refill time. Nerve fibres are susceptible to ischaemia, the thin cutaneous nerve fibres are affected more quickly than motor fibres so distal paraesthesia precedes loss of motor function .

Question 35

What are the long term consequence ?

Answer 35

Rhabdomylosis can result in acute kidney injury which may become chronic.

The necrotic muscle may also undergo fibrosis leading to volkmanns ischaemic contracture, a permanent and disabling conatracture of the affected muscle groups.