Adult Foot and Ankle Disorders

Question 1

how has the big toe changed over time and why?

Answer 1

has become bigger and more vertical to allow weight bearing and ability to push off

Question 2

where are the peroneal tendons and what do they do?

Answer 2

lateral foot
support the ankle (often affected by a sprain)
everts the foot

Question 3

what are the most commonly affected structures in an ankle sprain?

Answer 3

CFL and ATFL

Question 4

what is the acronym for the structures of the medial hindfoot?

Answer 4

Tom Dick and Harry

tp fdl fhl

Question 5

what are the features of the medial and hindfoot?

Answer 5

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

Question 6

what are the features of the lateral and hindfoot?

Answer 6

…

Question 7

what are the features of the posterior ankle and hindfoot?

Answer 7

achilles tendon
calcaneal insertion
retrocalcaneal space
peroneal tendons
FHL

Question 8

what are the features of the anterior ankle?

Answer 8

anterior ankle joint
superficial peroneal nerve
EHL
EDL
saphenous nerve

Question 9

what are the 5 nerves of the foot?

Answer 9

saphenous
superficial peroneal/fibular
deep peroneal/fibular
tibial (branches into 2)
sural nerve

Question 10

what are the features of the plantar surface of the foot?

Answer 10

heel pad
5th metatarsal base
plantar fascia
metatarsal heads
Tib posterior insertion

Question 11

what are the 3 rockers of gait?

Answer 11

1st = heel strike to flat foot
2nd = mid stance
3rd = heel rise

Question 12

what is Thompson/simmons test and what doe sit show?

Answer 12

gentle squeeze on calf muscles should produce a slight movement of the toes
indicates achilles tendon rupture if no movement occurs

Question 13

when does the arch in the foot normally appear?

Answer 13

6-7 years

Question 14

is flat feet always abnormal?

Answer 14

no

usually normal unless asymmetrical

Question 15

what does tibialis posterior dysfunction cause?

Answer 15

most common cause of acquired flatfoot syndrome in adults

can be present for years before diagnosis

Question 16

what is the presenting symptom in tibialis posterior dysfunction?

Answer 16

cant push off properly when walking, can be difficult and painful (esp. on uneven ground)
usually in elderly
pain +/- swelling posterior to medial malleolus (very specific)
change in foot shape
noticeable hallux valgus
lateral wall impingement pain
midfoot and ankle pain

Question 17

what is the course of tibialis posterior?

Answer 17

..

Question 18

what are the risk factors for tibialis posterior dysfunction?

Answer 18

obese middle aged female
age
flat foot
hypertension
diabetes
steroid injection
seronegative arthropathies
idiopathic tendonitis

Question 19

how is TPD treated?

Answer 19

physio often enough if caught early with insole to support medial longitudinal arch
steroid injections?
orthoses to accommodate foot shape
bespoke footwear
surgery

Question 20

what is pes cavus?

Answer 20

high arch??

Question 21

what causes pes cavus?

Answer 21

mostly idiopathic

can be neurological (HSMN, CP, Polio, spina bifida, club foot)

Question 22

what can pes cavus affect?

Answer 22

can cause clawing of toes

Question 23

how is pes cavus treated?

Answer 23

surgery if complex

Question 24

what are the symptoms of plantar fasciitis?

Answer 24

start up pain after rest

can be worse after exercise

Question 25

…..

Answer 25

…..

Question 26

what causes plantar fasciitis?

Answer 26

``` physical overload (exercise, weight etc) seronegative arthropathy diabetes abnormal foot shape improper foot shape ```

Question 27

how is plantar fasciitis treated?

Answer 27

``` NSAIDs night splints taping heel cups/arch supports physiotherapy steroid injections ECSWL surgery rarely usually self limiting ```

Question 28

what is a bunion?

Answer 28

deformity at first MTP joint | AKA hallux valgus

Question 29

what are the risk factors for bunions?

Answer 29

``` age female some are familial shoes general joint laxity rheumatoid splayed forefoot ```

Question 30

what causes pain in bunions?

Answer 30

medial nerve from bursur intrinsic pain in the joint (wear and tear as its not functioning properly) big toe becomes non function so you load through the other 4 toes

Question 31

how is hallux valgus treated?

Answer 31

non-surgical - shoes, padding etc | surgical - not always a great outcome

Question 32

what problems can occur with hallux valgus?

Answer 32

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

Question 33

how is hallux valgus surgery performed?

Answer 33

scarf/akin procedure | break the bone and move the head laterally

Question 34

what is hallux rigidus?

Answer 34

OA of the first MTP joint (big toe)

Question 35

what causes hallux rigidus?

Answer 35

general wear and tear

Question 36

how is hallux rigidus managed?

Answer 36

usually settles a bit with time non-operative - footwear, support etc operative - joint replacement and fusion of the joint

Question 37

how does rheumatoid arthritis affect the foot?

Answer 37

90% of cases affect the feet occurs early in disease usually affects the forefoot can deform the toes

Question 38

describe the pathogenesis of rheumatoid foot?

Answer 38

synovitis > proteinases and collagenases > impaired integrity of joint capsules/ligaments > destruction of hyaline cartilage

Question 39

what is charcots foot?

Answer 39

weakening of the bones in the foot in people with neuropathy (mainly diabetic)

Question 40

how is charcots foot managed?

Answer 40

mainly conservative | surgery in some cases if conservative measures fail?

Question 41

what can happen in charcots foot?

Answer 41

worsening deformity, ulceration, osteomyelitis | midfoot instability

Question 42

what must be considered in charcots foot surgery?

Answer 42

optimise co-morbidities (diet etc) soft tissue envelope from previous surgery location of the deformity timing presence of infection or osteomyelitis (don't operate if present)

Question 43

what type of surgery is done in charcots foot?

Answer 43

fixation surgery primary internal, primary external or combination of both or staged reconstruction

Question 44

when is external fixation used?

Answer 44

high risk patients with poor soft tissue envolope

Question 45

what are the issues with external fixation?

Answer 45

metal scaffold is unpleasant and difficult for the patient exposed to shear not axial forces can injure other leg during sleep etc

Question 46

what is mortons neuroma?

Answer 46

degenerative fibrosis of digital nerve near its bifurcation (between 3rd and 4th does)

Question 47

what are the features of mortons neuroma?

Answer 47

``` forefoot pain (metatarsalgia) burning and tingling in the toes ```

Question 48

who does mortons neuroma usually occur in?

Answer 48

middle aged females

Question 49

how is mortons neuroma diagnosed?

Answer 49

examination - painful when squeezed | US

Question 50

how is mortons neuroma managed?

Answer 50

non-surgical (insoles, injections) | surgical - excision

Question 51

what is tendo-achilles tendinosis?

Answer 51

repetitive microtrauma, failure of collagen with loss of fibre alignment/structure commonly causes by over training (running)

Question 52

what are the features of tendo-achilles-tendinosis?

Answer 52

pain morning stiffness eases with heat and walking

Question 53

how is tendo-achilles tendinosis treated?

Answer 53

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