Week 4 - J - Foot&ankle (2) - Achilles tendonitis/rupture,Plantar fascitis,Pes panus/cavus,Tibialis posterior dysnfunction,claw/hammer toes

Question 1

Tendonitis of the Achilles tendon can occur due to repetitive strain (from sports) which leads to a peritendonitis or due to degenerative process with intrasubstance microtears What are predisposing factors to tendonitis of the achilles tendon? (same as for extensor mechanism of knee)

Answer 1

* Quinolone antibiotics (eg cirpfloxacin)

* Diabetes

* Rheumatoid arthritis

* Other inflammatory arthropathies

* Gout

Question 2

What is the main symptoms of achilles tendonitis? What is the treatment?

Answer 2

Main symptoms is pain of the achilles tendon or at its insertion in the calcaneus Treatment is RICE

* Rest, ICE, compression, elevation

* Use a heel raise to offload the tendon and the use of a splint or boot

Question 3

Tendonitis predisposes to tendon rupture. What injections should not be administered around the Achilles tendon due to risk of rupture?

Answer 3

Steroid injection should not be administered around the Achilles tendon due to risk of rupture.

Question 4

Which age group do patellar tendon ruptures occur in? Which age group do quadriceps tendon ruptures occur in? Which age group do achilles tendon ruptures occur in?

Answer 4

Patellar tendon ruptures 40 years of age

Achilles tendon ruptures in middle aged or older groups

Question 5

Tendon rupture usually occurs in middle aged or older groups and is usually due to degenerative changes within the tendon or recent tendonitis. What is the history typically in a person with achilles tendon rutpure?

Answer 5

Usually occurs due to a sudden deceleration with resisted calf muscle contraction (eg lunging at squash) which leads to a sudden pain, very loud pop and difficulty weight bearing (feels like being kicked in the back of the leg)

Question 6

What is seen on clinical examination in achilles tendon rupture? What is the test that is carried out on examination?

Answer 6

Weakness of plantar flexion and a palpable gap in the tendon are usually apparent

No plantarflexion of the foot is seen when squeezing the calf muscles - Simmond’s test (aka simmonds thompson test)

Question 7

Treatment of achilles tendon rupture remains controversial and the options are non-operative management or operative repair. What is the surgical management of achilles tendon ruptures? Which patients usually recieve this?

Answer 7

Surgical management is to suture repair the demaged tendon to restore the tension of the tendon - repair is portected in a series of cases for around 8 weeks

Usually preferred in young, athletic patients as wound problems can be problematic if healing does not ccur

Question 8

What is the non-operative management of achilles tendon rupture?

Answer 8

Non-operative management involves a series of casts that fixate the foot in the equinous position

Ankle plantarflex with the toes pointing downward - closes the gap in the torn tendon

Again over 8 weeks or so

Question 9

Name a pro of surgical management in achilles tendon rupture Name a pro of conservative management in achilles tendon rupture

Answer 9

Surgical management restores tension of the tendon more accurately and may have a slightly lower-rupture rate

Non-operative management avoids the potential for wound problems which can be very problematic

Question 10

What is plantar fasciitis?

Answer 10

Plantar fasciitis is an inflammation of the fibrous tissue (plantar fascia) along the bottom of your foot that connects your heel bone to your toes

Question 11

Why is plantar fasciitis thought to occur? What are risk factors?

Answer 11

Plantar fasciitis is another repetitive stress / oerload or degenerative condition of the foot

Risk factors include diebetes, obestiy and frequent walking on hard floors

Question 12

What are the symptoms of plantar fasciitis? What is the treatment of the condition?

Answer 12

Symptoms

Pain with walking felt on the instep of the foot and heel (at the origin of the plantar aponeurosis on the distal plantar aspect of the clacaneal tuberosity)

Treatment is proper stretches (avoid immobility)- it is self limiting

Question 13

What is the proper term for flat foot? What percentage of the population does it occur? Which people are more likely to have it?

Answer 13

Flat foot is properly known as pes planus

20% of the population have flat foot where the medial arch does not develop in childhood

Patients with generalised ligamentous laxity are more likely to have flat feet

Question 14

What are the two types of flat feet and how do you determine between the two?

Answer 14

The key is to determine if the flat feet are mobile or fixed

JACK’s TEST determines Mobile/flexible flat feet are those where the flattened medial arch forms with dorsiflexion of the great toe

Fixed flat feet’s medial longitudinal arch does not reappear with dorsiflexion of the big toe

Question 15

What tendon may people with flat feet be at higher risk of inflaming?

Answer 15

Flat footed people may be at higher risk of tendonitis of the tibialis posterior tendon.

Question 16

Tarsal coalation (where the bones of the hindfoot have an abnormal attachment) is a cause of developmental (fixed) flat foot What are some causes of acquired flat feet?

Answer 16

Acquired flat foot may be due to tibialis posterior tendon stretch or rupture, rheumatoid arthritis or diabetes with Charcot foot (neuropathic joint destruction).

Question 17

Where does the tibialis posterior tendon insert? What are its functions?

Answer 17

Tibialis posterior tendon inserts into the medial navicular of the foot

It serves to support the medial arch of the foot as well as being a plantarflexor and invertor of the foot

Question 18

The tibialis posterior tendon is under repeated stress What can develop due to this? (especially with degeneratin)

Answer 18

Due to the repeated stress that the tibialis posterior is under, it can develop tendonitits, elongation and eventually rutpure

Synovitis from RA can also result in tendon rupture

Question 19

How should tendonitis of the tibialis posterior tendon be treated?

Answer 19

Tendonitis should be treated with a splint with a medial arch support to avoid rupture

Question 20

lint fails to settle symptoms, what be be required to prevent rupture of the tibialis tendon?

Answer 20

Surgical decompression and tenosynovectomy may prevent rupture of the tendon

Question 21

What is abnormally high arch of the foot known as? What are different causes?

Answer 21

Pes cavus is abnormally high longitudinal arches of the foot

Often idiopathic but causes include neuromuscular conditions (eg spina bifida, cerebral palsy, polio, muscular dystrophy)

Question 22

What deformity of the toes normally accompanies pes cavus? What may severe causes require as treatment?

Answer 22

Claw toes normally accompany pes cavus

Severe cases of pes cavus may require arthrodesis

Question 23

Why do claw and hammer toes occur?

Answer 23

Claw toes and hammer toes occur due to acquired imbalance between the flexor and extensor tendons

Question 24

Describe both claw and hammer toes?

Answer 24

Claw toes have hyperextension at the MTP joints with hyperflexion at the PIPJ and DIPJ

Hammer toes are similar but have hyperextension at the DIPJ

Question 25

What can the presenting symptoms of claw and hammer toes be? What can be done to reduce these symptoms?

Answer 25

Claw and hammer toes can be painful and can rub on footwear causing corns (foot calluses) and skin breakdown

Toe sleeves and corn plasters can prevent skin problems

Question 26

What are the surgical solutions to claw and hammer toes?

Answer 26

Surgical solutions include tenotomy (division of an overactive tendon), tendon transfer, arthrodesis (PIPJ) or toe amputation.