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Spire Gatwick Park HospitalSpire Gatwick Park Hospital
North Downs HospitalNorth Downs Hospital
FOOT & ANKLE
Presentation by Chandar Lal
FOOT AND ANKLE EXAMINATION
COMMON FOOT DISORDERS
ANKLE DISORDERS
TENDON DISORDERS
SUBCATEGORIESSUBCATEGORIES
FOOT & ANKLE FOOT & ANKLE EXAMINATIONEXAMINATION
General AspectsGeneral Aspects Gait: tiptoes/heel varus, heel walkingGait: tiptoes/heel varus, heel walking Shoe wear/orthoses Shoe wear/orthoses Expose to kneeExpose to knee Look, feel, moveLook, feel, move Neurovascular statusNeurovascular status Other medical conditions: RA, Gout, Other medical conditions: RA, Gout,
Freiberg’s, stress fractures, sesamoiditisFreiberg’s, stress fractures, sesamoiditis Midfoot: Kohler’s, acc. Navicular, OAMidfoot: Kohler’s, acc. Navicular, OA Ankle: OA, OCD, Tib. Post Tendon, tarsal Ankle: OA, OCD, Tib. Post Tendon, tarsal
tunneltunnel Temperature and pulsesTemperature and pulses Neurologic: sensation, motor, reflexesNeurologic: sensation, motor, reflexes
MOVEMOVE
AnkleAnkle Subtalar jointSubtalar joint MidfootMidfoot HalluxHallux ToesToes Specific TendonsSpecific Tendons
Hallux Valgus and RigidusHallux Valgus and Rigidus Lesser toe deformities Lesser toe deformities
Hammer toe Hammer toe Mallet toeMallet toe Claw toeClaw toe
Flat footFlat foot MetatarsalgiaMetatarsalgia
COMMON FOOT DISORDERS
Commonly seen in femalesCommonly seen in females
82% of women report having foot pain, while 82% of women report having foot pain, while 72% report one or more foot deformities. 72% report one or more foot deformities.
More than 7 out of 10 women develop a bunion, More than 7 out of 10 women develop a bunion, hammertoe, or other painful foot deformity. hammertoe, or other painful foot deformity.
Nine out of 10 women’s foot deformities can be Nine out of 10 women’s foot deformities can be attributed to tight shoes.attributed to tight shoes.
GENERAL PROFILE OF DEFORMITIES
HALLUX VALGUSHALLUX VALGUS
DefinitionDefinition Lateral deviation of great toeLateral deviation of great toe
AetiologyAetiology Familial Familial Inappropriate footwearInappropriate footwear FlatfeetFlatfeet Long first ray Long first ray Incongruous 1Incongruous 1stst MTP joint articular surface MTP joint articular surface Metatarsus primus varusMetatarsus primus varus Rheumatoid arthritis.Rheumatoid arthritis.
HV HV + Claw toes
HALLUX VALGUS HALLUX VALGUS CONTD.CONTD.
PathogenesisPathogenesis Complex deformity with angle between 1Complex deformity with angle between 1stst & &
22ndnd MT > 9 degrees and valgus angle at MTP MT > 9 degrees and valgus angle at MTP joint >20 degrees.joint >20 degrees.
Valgus posture of great toe causing hammer Valgus posture of great toe causing hammer toe like deformity of second toe.toe like deformity of second toe.
Splaying of forefoot causing bunion.Splaying of forefoot causing bunion. Incongruence causing osteoarthritis of 1Incongruence causing osteoarthritis of 1stst
Bunion and inflamed overlying bursa and Bunion and inflamed overlying bursa and skin skin
Valgus and pronation deformity of hallux.Valgus and pronation deformity of hallux. Painful callus on 2Painful callus on 2ndnd toe toe
Second toe is forced into hyperextension Second toe is forced into hyperextension by deviated great toe by deviated great toe
Transfer metatarsalgia/thickened skin Transfer metatarsalgia/thickened skin over MT heads.over MT heads.
Increased valgus angle at first MTP joint Increased valgus angle at first MTP joint Valgus angle at first MTP joint >20 Valgus angle at first MTP joint >20
degrees degrees Angle between 1Angle between 1stst & 2 & 2ndnd MT >9 degrees MT >9 degrees
MANAGEMENTMANAGEMENT
Entire foot must be assessed first.Entire foot must be assessed first.
Indications Indications Refractory to conservative management Refractory to conservative management Severe deformity or bunion painSevere deformity or bunion pain
Factors to be considered before surgeryFactors to be considered before surgery Valgus deviation of great toeValgus deviation of great toe Varus deviation of first metatarsalVarus deviation of first metatarsal Arthritis of MTP and IP jointArthritis of MTP and IP joint BunionBunion Metatarso-cuneiform joint instabilityMetatarso-cuneiform joint instability Vascularity & sensibilityVascularity & sensibility
Surgical Procedures Surgical Procedures Soft tissue surgery - rarely indicated in adolescent casesSoft tissue surgery - rarely indicated in adolescent casesBone/joint procedure remains the gold standardBone/joint procedure remains the gold standard
Painful limitation of motion at 1Painful limitation of motion at 1stst MTP joint MTP joint
Pathogenesis:Pathogenesis: synovitis, cartilage synovitis, cartilage destruction, osteophyte proliferation, destruction, osteophyte proliferation, subchondral cysts and sclerosissubchondral cysts and sclerosis
Clinical presentation:Clinical presentation: pain, limited pain, limited dorsiflexion and dorsal osteophyte, dorsal dorsiflexion and dorsal osteophyte, dorsal tendernesstenderness
Aetiology:Aetiology: Trauma, Repeated microtrauma, Trauma, Repeated microtrauma, osteochondritis dissicans and abnormally osteochondritis dissicans and abnormally long first metatarsallong first metatarsal
TREATMENTTREATMENT
Grade I: Mild osteophytes, joint space preservedGrade I: Mild osteophytes, joint space preserved NSAID, orthosis and injectionNSAID, orthosis and injection
Grade II: Moderate osteophyte formation, joint Grade II: Moderate osteophyte formation, joint space space narrowing & narrowing & subchondral sclerosissubchondral sclerosis Cheilectomy: eCheilectomy: excision of 20-35% of dorsal metatarsal head xcision of 20-35% of dorsal metatarsal head
aiming for up to 70aiming for up to 70ºº of dorsiflexion. of dorsiflexion.
Grade III: Severe arthritisGrade III: Severe arthritis Arthrodesis/joint replacementArthrodesis/joint replacement
LESSER TOE LESSER TOE DEFORMITIESDEFORMITIES
Hammer, Claw and MalletHammer, Claw and Mallet Association with HV, RA, DM and NM Association with HV, RA, DM and NM
pads, accommodative shoe wearpads, accommodative shoe wear Surgical treatment: tendon release and Surgical treatment: tendon release and
transfers for flexible deformities; fusion and transfers for flexible deformities; fusion and excision arthroplasties for fixed deformities.excision arthroplasties for fixed deformities.
FLAT FOOT/PES PLANUSFLAT FOOT/PES PLANUS
Flexible (99%) or Rigid (1%)Flexible (99%) or Rigid (1%) Distinguished by Jack test and tiptoeing Distinguished by Jack test and tiptoeing
Pathology - Loss of normal medial Pathology - Loss of normal medial longitudinal arch in combination with valgus longitudinal arch in combination with valgus posture of heel, mild subluxation of subtalar posture of heel, mild subluxation of subtalar joint & eversion of calcaneum joint & eversion of calcaneum
Arch develops till the age of 7-10 years so Arch develops till the age of 7-10 years so there is no treatment requiredthere is no treatment required
15-20% of adults have asymptomatic pes 15-20% of adults have asymptomatic pes planusplanus
TREATMENT OF FLEXIBLE PES TREATMENT OF FLEXIBLE PES PLANUSPLANUS
10-14 years 10-14 years require investigationrequire investigation
Symptomatic patient - rule out Symptomatic patient - rule out accessory navicular or incomplete accessory navicular or incomplete tarsal coalition and treat accordingly.tarsal coalition and treat accordingly.
AdultsAdults with painful pes planus not with painful pes planus not responding to conservative responding to conservative management will benefit with surgerymanagement will benefit with surgery
Tarsal coalition:Tarsal coalition: calcaneo-navicular & calcaneo-navicular & talocalcaneal; can be bony, cartilagenous or talocalcaneal; can be bony, cartilagenous or fibrous.fibrous.
Commoner in middle-aged women; 85% Commoner in middle-aged women; 85% unilateralunilateral
Aetiology: trauma, ischaemia, entrapmentAetiology: trauma, ischaemia, entrapment Pathology: degenerative rather than a true Pathology: degenerative rather than a true
neuroma with perineural fibrosis and neuroma with perineural fibrosis and demyelination.demyelination.
Diagnosis: symptom of shooting/constant pain on Diagnosis: symptom of shooting/constant pain on walking, relieved by rest and removal of walking, relieved by rest and removal of footwear; clinical sign of third/second cleft footwear; clinical sign of third/second cleft tenderness and palpable click on metatarsal tenderness and palpable click on metatarsal squeeze test.squeeze test.
Treatment: orthoses, injection and excisionTreatment: orthoses, injection and excision
ANKLE DISORDERSANKLE DISORDERS
InstabilityInstability ImpingementImpingement Osteochondritis Dissecans of talusOsteochondritis Dissecans of talus ArthritisArthritis
Posttraumatic in young patientsPosttraumatic in young patients Presentation with persistent pain and Presentation with persistent pain and
swelling with stiffnessswelling with stiffness Diagnosis: clinical tenderness, diffuse Diagnosis: clinical tenderness, diffuse
swellingswelling Imaging: X-rays and MRI scanImaging: X-rays and MRI scan Treatment: undisplaced lesions treated Treatment: undisplaced lesions treated
with rest and cast immobilisation; with rest and cast immobilisation; displaced lesions require arthroscopic displaced lesions require arthroscopic removal/drillingremoval/drilling
ANKLE ARTHRITISANKLE ARTHRITIS
Posttraumatic: rare in commonly Posttraumatic: rare in commonly injured joint; associated with displaced injured joint; associated with displaced intra-articular fractures and significant intra-articular fractures and significant lateral ligament complex injury.lateral ligament complex injury.
Inflammatory: RA in low-demand Inflammatory: RA in low-demand patientspatients
Degenerative: relatively uncommonDegenerative: relatively uncommon Presentation with pain, swelling, Presentation with pain, swelling,
AnatomyAnatomy - posteromedial tendon, origin from - posteromedial tendon, origin from posterior surface of tibia & inserts on to the medial posterior surface of tibia & inserts on to the medial cuneiform cuneiform
Important tendon in foot, affection of which causes Important tendon in foot, affection of which causes more functional disability than TA rupturemore functional disability than TA rupture
PRESENTATIONPRESENTATION Fatigue of foot with limited activity, medial and lateral Fatigue of foot with limited activity, medial and lateral
painpain Flat foot on weight bearingFlat foot on weight bearing Standing tip toe – heel will go into valgusStanding tip toe – heel will go into valgus Clinical examination confirms tenderness, Clinical examination confirms tenderness,
weak/ruptured tendon, hindfoot valgus (flexible/fixed) weak/ruptured tendon, hindfoot valgus (flexible/fixed) and a lack of heel varus on tiptoeingand a lack of heel varus on tiptoeing
Pathogenesis: tenosynovitis, incomplete tear, complete disruptionPathogenesis: tenosynovitis, incomplete tear, complete disruption Two groups of patients:Two groups of patients:
Younger patients with inflammatory arthropathy/traumatic rupture Younger patients with inflammatory arthropathy/traumatic rupture Older, typically female patients with degenerative tears Older, typically female patients with degenerative tears
Tenosynovitis - rest, NSAIDs, short leg Tenosynovitis - rest, NSAIDs, short leg walking cast, orthoses, steroid injection in walking cast, orthoses, steroid injection in tendon sheath, synovectomy.tendon sheath, synovectomy.
Incomplete tear - repair or augmentation Incomplete tear - repair or augmentation with either FDL or FHL.with either FDL or FHL.
Complete disruption – repair in traumatic Complete disruption – repair in traumatic young cases; tendon transfer with medial young cases; tendon transfer with medial calcaneal displacement osteotomy (mobile calcaneal displacement osteotomy (mobile hindfoot) and subtalar/triple arthrodesis hindfoot) and subtalar/triple arthrodesis (fixed hindfoot). (fixed hindfoot).
Satisfactory results in spite of prolonged Satisfactory results in spite of prolonged rehabilitationrehabilitation
Origin -Origin - lateral condyle of tibia, proximal 2/3 of lateral condyle of tibia, proximal 2/3 of lateral surface of tibia, interosseous membranelateral surface of tibia, interosseous membrane
Insertion -Insertion - base of first metatarsal and medial base of first metatarsal and medial plantar surface of 1st cuneiformplantar surface of 1st cuneiform
Action -Action - dorsiflexes and inverts foot dorsiflexes and inverts foot Disorders are common in athletes and old age Disorders are common in athletes and old age
groupgroup Diagnosis- weakness of dorsiflexion of foot, Diagnosis- weakness of dorsiflexion of foot,
pain, use of toe extensors for dorsiflexion of pain, use of toe extensors for dorsiflexion of foot.foot.
Treatment- steroid injection or synovectomy . Treatment- steroid injection or synovectomy . Tendon repair rarely required as deformity is Tendon repair rarely required as deformity is not functionally significant.not functionally significant.
PERONEAL TENDONSPERONEAL TENDONS
Anatomy:Anatomy:
Peroneus longus & brevis are posteolateral Peroneus longus & brevis are posteolateral tendons originating from fibula and interosseous tendons originating from fibula and interosseous membrane and are inserted at base of I & V MT membrane and are inserted at base of I & V MT respectively.respectively.
Pathology:Pathology: TenosynovitisTenosynovitis - common in high arch foot - common in high arch foot
because of increase in excursion.because of increase in excursion. Sprain/ subluxationSprain/ subluxation - inversion ankle injuries. - inversion ankle injuries.
Symptoms:Symptoms: pain in the outer part of the pain in the outer part of the ankle or just behind the lateral malleolus. ankle or just behind the lateral malleolus. This pain commonly worsens with activity This pain commonly worsens with activity and eases with rest. and eases with rest.
Diagnosis:Diagnosis: Examination - tenderness/subluxationExamination - tenderness/subluxation X-rays to exclude fractureX-rays to exclude fracture MRIMRI
SurgicalSurgical Tenosynovectomy and repair of split Tenosynovectomy and repair of split Stabilisation of dislocating tendons by Stabilisation of dislocating tendons by
groove deepening, peroneal retinaculum groove deepening, peroneal retinaculum reconstruction and bone block proceduresreconstruction and bone block procedures
Tendinosis - there will be clinical inflammation, but Tendinosis - there will be clinical inflammation, but objective pathologic evidence for cellular objective pathologic evidence for cellular inflammation is lacking inflammation is lacking
Tendinitis - there will be a peritendinous Tendinitis - there will be a peritendinous inflammationinflammation Seen in adults in their 30s and 40sSeen in adults in their 30s and 40s Most commonly affects runnersMost commonly affects runners Heel cord contracture can exacerbate symptoms Heel cord contracture can exacerbate symptoms
Two types:Two types: Non-insertionalNon-insertional
Occurs proximal to retrocalcaneal bursaOccurs proximal to retrocalcaneal bursa Generally responds well to non-operative treatmentGenerally responds well to non-operative treatment
InsertionalInsertional Tenderness is localized to calcaneal tendon insertion Tenderness is localized to calcaneal tendon insertion More difficult to treatMore difficult to treat
debridementdebridement if unrelieved by 6 months of if unrelieved by 6 months of conservative measuresconservative measures
90% will have significant relief of symptoms; 90% will have significant relief of symptoms; 10% will have some symptom improvement10% will have some symptom improvement
Complete symptomatic cure not guaranteedComplete symptomatic cure not guaranteed
ACHILLES TENDON ACHILLES TENDON RUPTURERUPTURE
Common sporting incidence affecting the Common sporting incidence affecting the young to middle-agedyoung to middle-aged
Mechanism usually involves loading on a Mechanism usually involves loading on a dorsiflexed ankle with the knee extended dorsiflexed ankle with the knee extended (soleus and gastroc on maximal stretch) or (soleus and gastroc on maximal stretch) or repeated microtraumarepeated microtrauma
Consider systemic conditions such as gout Consider systemic conditions such as gout or hyperparathyroidism (esp. with pure or hyperparathyroidism (esp. with pure avulsion injury); previous avulsion injury); previous steroidsteroid injections injections
Disabling condition requires approx. 6 Disabling condition requires approx. 6 months to recover when treated adequatelymonths to recover when treated adequately
Diagnosis (suspect in all ankle injury Diagnosis (suspect in all ankle injury cases):cases): Characteristic historyCharacteristic history Classical signs:Classical signs:
Local tenderness and gapLocal tenderness and gap Hyper-dorsiflexion at ankleHyper-dorsiflexion at ankle Thompson/Simmonds testThompson/Simmonds test
Imaging:Imaging: Ultrasound and MRI scan in doubtful casesUltrasound and MRI scan in doubtful cases
TREATMENTTREATMENT Non-operativeNon-operative treatment is indicated in older treatment is indicated in older
patients and minimally displaced ruptures and patients and minimally displaced ruptures and involves serial casting over 10-12 weeks involves serial casting over 10-12 weeks (complete equinus, mid equinus, neutral (complete equinus, mid equinus, neutral walking).walking).
OperativeOperative repair is indicated in younger patients repair is indicated in younger patients with clinically displaced ruptures, delayed with clinically displaced ruptures, delayed presentation (48-72 hours) and neglected presentation (48-72 hours) and neglected ruptures followed by similar casting regime.ruptures followed by similar casting regime.
Complications: Complications: wound healing and sural nerve wound healing and sural nerve injuryinjury
Consider DVT prophylaxisConsider DVT prophylaxis
NON-OPERATIVE VS. NON-OPERATIVE VS. OPERATIVEOPERATIVE
Return to the Return to the preinjury preinjury level of level of activityactivity
Patient Patient satisfactionsatisfaction
Re-Re-rupturerupture
Non-Non-operativeoperative
69%69% 66%66% Up to Up to 33%33%
OperativeOperative 83%83% 93%93% 2-3%2-3%
HEEL PAINHEEL PAIN Commonly caused by Commonly caused by
plantar fasciitis.plantar fasciitis. Heel spurs often Heel spurs often
associated. associated. Pain is worst on waking Pain is worst on waking
up. up. CausesCauses - obesity, - obesity,
excessive excessive walking/sporting activity, walking/sporting activity, tighttight plantar fascia & plantar fascia & flattening of the arch.flattening of the arch.
TreatmentTreatment – orthoses, – orthoses, physical therapy, physical therapy, injection, NSAIDs and injection, NSAIDs and (rarely) surgical release (rarely) surgical release in resistant cases.in resistant cases.
RETROCALCANEAL RETROCALCANEAL BURSITIS BURSITIS
Two bursae: rTwo bursae: retrocalcaneal (subtendinous) etrocalcaneal (subtendinous) bursa & subcutaneous calcaneal bursabursa & subcutaneous calcaneal bursa
CausesCauses Repetitive trauma from shoe wear and sports Repetitive trauma from shoe wear and sports Gout, RA and ankylosing spondyloarthropathiesGout, RA and ankylosing spondyloarthropathies Bursal impingement between the Achilles tendon Bursal impingement between the Achilles tendon
and an excessively prominent posterior-superior and an excessively prominent posterior-superior aspect of the calcaneus (Haglund deformity). aspect of the calcaneus (Haglund deformity).
MANAGEMENTMANAGEMENT Imaging:Imaging: X-rays for calcification and Haglund deformity. X-rays for calcification and Haglund deformity. Conservative:Conservative: physical therapy, appropriate shoe wear, physical therapy, appropriate shoe wear,
injection (risk of tendon rupture).injection (risk of tendon rupture). Surgical Intervention Surgical Intervention includes resection of Haglund includes resection of Haglund
deformity (removal of the calcaneal superoposterior deformity (removal of the calcaneal superoposterior prominence), excision of the painful bursa and debridement of prominence), excision of the painful bursa and debridement of tendon insertiontendon insertion