Adult Foot and Ankle

Question 1

What are important features of the lateral and hindfoot anatomy?

Answer 1

Distal fibula and fibular shaft, ankle lateral gutter and syndesmosis, lateral wall calcaneus, peronei, CFL and ATFL, sural nerve

Question 2

What are important features of the medial and hindfoot topography?

Answer 2

Medial malleolus, anteromedial tibiotalar joint, deltoid ligament, PTT, FDL, FHL, posterior tibial artery

Question 3

What are some features of the anatomy of the posterior ankle and hindfoot?

Answer 3

Achilles tendon, calcaneal insertion, retrocalcaneal space, peroneal tendons, FHL

Question 4

What are some aspects of the anterior ankle topography?

Answer 4

Anterior ankle joint, superficial peroneal nerve, EHL, EDL, saphenous nerve

Question 5

What are some important features of the plantar topography?

Answer 5

Heel pad, 5th metatarsal base, plantar fascia, metatarsal heads, tibialis posterior insertion

Question 6

What are some features of pes planus (flat feet)?

Answer 6

Normal variant, occurs in 20% of population, familial, associated ligament laxity, when developmental its causes no problems and requires no treatment

Question 7

What is a sign of flexible pes planus?

Answer 7

Flexible flat feet form an arch when patient tip toes

Question 8

What is the most common cause of acquired flat feet in adults?

Answer 8

Tibialis posterior deformity (up to 10% of elderly women, usually present for years prior to diagnosis)

Question 9

Where does the tibialis posterior pass?

Answer 9

Courses immediately posterior to medial malleolus

Question 10

Where does the tibialis posterior attach?

Answer 10

Navicular tuberosity and plantar aspect of medial and middle cuneiforms

Question 11

What are the functions of the tibialis posterior?

Answer 11

Primary dynamic stabiliser of medial longitudinal arch (elevates arch)
Invertor and plantar-flexor

Question 12

What are the risk factors for tibialis posterior dysfunction?

Answer 12

Obese middle aged female, risk increase with age, flat foot, hypertension, diabetes, injected steroids, seronegative arthropathies, idiopathic tendonosis

Question 13

What are some features of the pain caused by tibialis posterior dysfunction?

Answer 13

pain and/or swelling posterior to medial malleolus, lateral wall “impingement” pain, midfoot and ankle pain

Question 14

What are some signs of tibialis posterior dysfunction?

Answer 14

Change in foot pain, diminished walking ability/balance, dislike of uneven surfaces, more noticeable hallux valgus, can’t single heel raise

Question 15

What are the types of tibialis posterior dysfunction?

Answer 15

Type I = swelling, tenderness, slightly weak muscle power
Type II = planovalgus, midfoot abduction, passively correctable
Type III and IV = fixity and mortise signs

Question 16

How are tibialis posterior dysfunctions treated?

Answer 16

Physio, insole to support medial arch, no injected steroids, orthoses to suit foot shape, bespoke footwear, surgery

Question 17

What are the causes of pes cavus?

Answer 17

Most commonly idiopathic

Other causes mostly neurological = HSMN, cerebral palsy, polio, spina bifida, club foot

Question 18

How does pes cavus present and how is it treated?

Answer 18

Often clawing of toes

Surgery complex if required = soft tissue releases, tendon transfers, calcaneal osteotomy, arthrodesis (fusion)

Question 19

What are some features of the pain associated with plantar fasciitis?

Answer 19

Start-up pain after rest, may be worse after exercise

Question 20

What are some signs of plantar fasciitis?

Answer 20

Fullness or swelling of plantarmedial aspect of heal, tenderness plantar aspect of heel and/or plantarmedial aspect of heel, Tinel’s test positive for Baxter’s nerve

Question 21

What may cause plantar fasciitis?

Answer 21

Physical over-load = obesity, over-exercising

Seronegative arthropathy, diabetes, planovalgus or carovarus feet

Question 22

What are some treatments of plantar fasciitis?

Answer 22

NSAIDs, night splints, taping, heel cups, medial arch supports, physio, steroid injections, ECSWL, surgery (50% success, better if acute onset)

Question 23

How long does plantar fasciitis usually last for?

Answer 23

Usually self limiting over 18-24 months

Question 24

What is the epidemiology of hallux valgus?

Answer 24

Increases with age, usually bilateral, 3 times more likely in men, adolescent subgroups exist

Question 25

What are some causes of hallux valgus?

Answer 25

Familial, shoes, general joint laxity, connective tissue disease, rheumatoid arthritis, splayed forefoot associated with loss of muscle tone and age

Question 26

What are some complications of hallux valgus?

Answer 26

Transfer metatarsalgia, lesser toe impingement, pain, deformity, cosmesis, shoe difficulties

Question 27

What are some supportive treatments for hallux valgus?

Answer 27

Shoe modifications and padding

Question 28

When is surgery indicated for hallux valgus?

Answer 28

Failure of conservative treatments, pain, lesser toe deformities, lifestyle limitations, overlapping ulceration, functional limitation

Question 29

What are the surgical options for hallux valgus?

Answer 29

Osteotomies (cutting bone) or Aiken technique (break bone and move head laterally) Aim is to realign hallux and decrease HV angle

Question 30

What are some features of hallux rigidus?

Answer 30

Osteoarthritis of 1st MTP joint, non-operative management or surgery (joint replacement or fusion)

Question 31

What are some features of rheumatoid foot?

Answer 31

Affects feet in 90% of rheumatoid patients, occurs early in disease, most common reason for surgery of the forefoot

Question 32

What are some features of the pathogenesis of rheumatoid foot?

Answer 32

Synovitis, proteinases and collagenases, impaired integrity of joint capsule/ligaments, destruction of hyaline cartilage

Question 33

What are some challenges associated with rheumatoid foot?

Answer 33

Multi-joint disease = disability, slower rehab, use of crutches Systemic effects = vasculitis, ischaemia, ulceration, neuropathy, anaemia, immunosuppression Psychosocial

Question 34

What are some features of rheumatoid of the hindfoot?

Answer 34

Talocalcaneal interosseous ligament, unstable subtalar joint (calcaneus drifts into valgus), medial arch collapses (flat feet), often require multiple joint fusions

Question 35

What is Morton's neuroma?

Answer 35

Degenerative fibrosis of digital nerve near it's bifurcation

Question 36

What are some features of Morton's neuroma?

Answer 36

Get forefoot pain = metatarsalgia, burning and tingling in toes Mean age 45-50, more common in females, investigated with USS, can be given insoles or injections, can be excised operatively

Question 37

What are some features of tendo-Achilles tendinosis?

Answer 37

Repetitive microtrauma, failure of collagen repair with loss of fibre alignment/structure, hypovascular region 2-6cm proximal to insertion, can be mid-substance or distal

Question 38

What are some risk factors of tendo-Achilles tendinosis?

Answer 38

Over-training, steroids, ciprofloxacin, connective tissue diseases

Question 39

How can tendo-Achilles tendinosis present and how can it be diagnosed?

Answer 39

Pain, morning stiffness, eases with heat or walking | Diagnosis = USS, MRI

Question 40

What are some management options of tendo-Achilles tendinosis?

Answer 40

No steroid injections, activity modifications, analgesia, NSAIDs, shockwave therapy, orthotics, physio, surgery

Question 41

What are some features tendo-Achilles rupture?

Answer 41

Usually aged >40, often pre-existing tendinosis, caused by deceleration with resisted calf contraction, people often think someone has hit them

Question 42

What are the signs of tendo-Achilles ruptures?

Answer 42

Unable to weight-bear, weak plantar flexion, palpable painful gap, positive Simmond's (calf squeeze) test

Question 43

How are tendo-Achilles ruptures treated?

Answer 43

Operative or non-operative, both involve an extended recovery/cast time, functional outcome normally good

Question 44

What are some features of claw, hammer and mallet toes?

Answer 44

Acquired imbalance between flexors and extensors, can cause painful callus/corns with skin breakdown

Question 45

What are some surgical techniques used to treat claw, hammer and mallet toes?

Answer 45

Tenotomies (division of tendons), tendon transfer, fusion (PIP), amputation

Question 46

What causes ankle sprains?

Answer 46

Twisting forces = commonly inversion/twisting on planted foot Due to elastic limit of ligaments, typically lateral ligaments (ATFL, CFL)

Question 47

What are some features of ankle sprains?

Answer 47

Longer to resolve than fractures, pain, bruising, tenderness, graded 1-3 (grade 3 is complete rupture)

Question 48

What are some treatments for ankle sprains?

Answer 48

``` Non-operative = RICE, physio (strength, stability, proprioception) Operative = Brostrom Gould (improves stability be repairing lateral ligaments), Chrisman Snook (long recovery and often causes post-operative stiff ankle) ```

Question 49

What causes ankle fractures?

Answer 49

Caused by twisting forces (common injury)

Question 50

What are some ways to classify ankle fractures?

Answer 50

Weber classification = A-C | Lauge Hansen = based on foot position and force applied

Question 51

What is a stable ankle fracture?

Answer 51

Distal fibula fracture with no medial malleolus fracture or deltoid ligament rupture

Question 52

What is an unstable ankle fracture?

Answer 52

Distal fibula fracture with medial malleolus fracture or deltoid ligament rupture

Question 53

What is a Pilon fracture of the ankle?

Answer 53

High energy injury, significant soft tissue problem, often have other injuries, damage to joint may lead to osteoarthritis, may need amputation

Question 54

What cause 5th metatarsal fractures?

Answer 54

Inversion injury, very common injury

Question 55

What are some examples of 5th metatarsal fractures?

Answer 55

Avulsion by peroneus brevis tendon = heal predictably in moonboot Jones fracture = poor blood supply, 25% risk of non-union Proximal shaft = common site for stress fracture

Question 56

What are some features of a Lisfranc injury to the foot?

Answer 56

Tarsometatarsal fracture dislocation, high energy, require fixation, risk of osteoarthritis, often subtle on imaging

Question 57

What are some features of a calcaneus fracture?

Answer 57

Fall from height, often also have spinal injury, often intra-articular, significant swelling, risk of compartment syndrome

Question 58

What are some features of a talus fracture?

Answer 58

Caused by forced dorsiflexion/rapid deceleration, talus has reversed blood supply, risk of avascular necrosis and osteoarthritis