What is the most common cause of acquired flatfoot deformity in adults?
Tibialis posterior dysfunction
Which patients tend to be affected by tibialis posterior dysfunction?
Obese
Female
Increasing age - usually middle aged
Hypertension
Diabetes
History of steroid injections
Seronegative arthropathies
What is the cause of the laxity here?
Left foot pes planus caused by tibialis posterior dysfunction
Arch has flattened so the foot everts
What are the signs and symtpoms of tibialis posterior dysfunction?
Pain and/or swelling posterior to medial malleolus – very specific
Change in foot shape
Diminished walking ability/balance
Dislike of uneven surfaces
More noticeable hallux valgus
Lateral wall “impingement” pain
How can a flexible pes planus be distinguished from a non-flexible pes planus?
Arch is still formed in flexible pes planus when standing on toes
What are the treatment options for tibialis posterior dysfunction?
Physiotherapy
Insole to support medial longitudinal arch
Orthoses to accommodate foot shape
Bespoke footwear
Surgery
Which treatment should not be given for tibialis posterior dysfunction?
Steroid injections
Which classification is used to describe ankle fractures?
Weber's classification
Which kind of ankle fractures are stable?
Distal fibula fracture with no medial malleolus fracture or deltoid ligament rupture
Which ankle fractures are unstable?
Distal fibula fracture with medial malleolus fracture or deltoid ligament rupture
What is the treatment of a stable ankle fracture?
Cast or splint for around 6 weeks
When is rupture of the deltoid ligament suspected?
Bruising and tenderness medially
What is the usual treatment of unstable ankle fractures?
Open reduction internal fixation
What is the treatment of an unstable ankle fracture if there is any talar shift or talar tilt, and why?
Anatomical reduction and rigid internal fixation
Used to minimise the risk of development of OA
What is a pilon fracture?
A fracture of the distal tibia involving its articular surface
What is a Jones fracture?
A fracture of the proximal end of the 5th metatarsal bone
Why can a Jones fracture be problematic?
Higher risk of non-union (around 25%) due to poor blood supply
How do fractures to the base of the 5th metatarsal tend to occur?
Inversion injury with an avulsion fracture at the insertion of the peroneus brevis tendon
How do calcaneal fractures occur, and what other injuries should be looked for?
Fall from height onto heel
Therefore, also look for spinal injuries
What is at risk of developing following a calcaneal fracture?
Compartment syndrome of the foot
What is the prognosis of a calcaneal fracture dependant on?
Degree of involvement of subtalar joint
Degree of communition
When is subtalar arthodesis a treatment option following a calcaneal fracture?
Development of chronic pain from subtalar joint damage
Osteoarthrtitis
How do fractures of the talus tend to occur?
Forced dorsiflexion from rapid deceleration
e.g. RTA, aircraft crash
What is at risk of developing following a talar fracture-dislocation or subluxation?
AVN of the talus
What is a Lisfranc fracture?
A fracture of the base of the 2nd metatarsal is associated with dislocation of the base of the 2nd metatarsal with or without dislocation of the other metatarsals at the tarso‐metatarsal joints
What is the usual presentation of a Lisfranc fracture?
Grossly swollen and bruised foot
Unable to weight bear
May have normal Xray - CT scan if in doubt
What is the treatment for a Lisfranc fracture?
Closed or open reduction with screw fixation
What is the treatment for multiple displaced fractures of the metatarsals?
Stabilisation with K wires
How does plantar fasciitis present?
Heel pain
Fullness or swelling medially to heel
Can be worse after exercise or starting up after rest
What would indicate plantar fasciitis on examination?
Positive tinel's test for Baxters nerve
Swelling medially to heel
What are the causes of plantar fasciitis?
Repetitive stress
Seronegative arthropathies
Diabetes
Obesity
Frequent walking on hard floors
Improper footwear
What is the treatment for plantar fasciitis?
Rest
Achilles and plantar fascia stretching exercises
Gel filled heel pad
NSAIDs
Corticosteroid injections
Usually self-limiting
What is hallux valgus?
Medial deviation of the 1st metatarsal causing deformity of the big toe
What are some of the problems caused by hallux valgus?
Transfer metatarsalgia
Lesser toe impingement
Pain, deformity, cosmesis
Shoe difficulties
Formation of bunions and ulcers
What is the surgery for hallux valgus?
Multiple osteotomies to realign the bones
Soft tissue procedures to tighten slack tissues and release tight tissues
What is hallux rigidus?
OA of the 1st MTPj
What are some of the conservative treatment options for hallux rigidus?
Wearing of stiff soled shoe to limit motion at the MTPJ
Removal of osteophytes
What is the gold standard surgical treatment for hallux rigidus?
Arthrodesis
What is pes cavus?
Abnormally high arch of the foot often related to neuromuscular conditions
What is Morton's neuroma?
Degenerative fibrosis of common digital nerve near it’s bifurcation
How does Morton's neuroma present?
Pain in forefoot
Burning and tingling of toes
Which patients are most commonly affected by Morton's neuroma?
Women aged 45-50
What examination findings would implicate a Morton's neuroma?
Loss of sensation in affected web space
Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic "click"; this is Mulder's click test
What is the conservative management for Morton's neuroma?
Metatarsal pad or offloading insole
Steroid or anaesthetic injections
What is the surgical treatment for Morton's neuroma?
Excision of neuroma
What can be used to diagnose a Morton's neuroma?
Ultrasound - can see an inflamed nerve
What are the causes of Achilles tendonitis?
Repetitive strain
Rheumatoid arthritis
Quinolone antibiotics
Gout
What is the treatment for Achilles tendonitis?
Rest
Physiotherapy
Heel raise
Splint or boot
Tendon decompression
Which patients tend to suffer from Achilles rupture?
Middle aged or older patients due to degenerative changes
What signs on examinaton would indicate an Achilles rupture?
Unable to bear weight
Weak plantar flexion
Palpable painful gap
Positive calf squeeze (Simmonds) test
What is the conservative management of Achilles rupture?
Cast for up to 8 weeks in the equinous position - plantarflexed foot with toes pointing downwards to close gap between ruptured tendon sides
Why do claw or hammer toes occur?
Imbalance of flexor and extensor mechanisms