Chapter 44- leg, ankle and foot

Question 1

Describe a claw toe

Answer 1

• Flexion of the IP joints, hyperextension of the MTPJ

Question 2

Describe a hammer toe

Answer 2

-Flexion of the terminal phalanx with callosity at the tip of the toe and varus or valgus deformity

Question 3

Rupture of which tendon will cause a flat foot?

Answer 3

-Tibialis posterior

Question 4

What are shin splints? what causes it

Answer 4

• Pain in anterior lower leg associated with activity

- Causes include stress fracture, muscle pull on periosteum causing periostitis and chronic compartment syndrome

Question 5

what investigations can be done if shin splints are suspected

Answer 5

• Bone scan: localised area of uptake for stress fractures or diffuse area in periostitis
• Compartment syndrome can be confirmed by compartment pressure studies performed after the activity has provoked the pain
• Occasionally Xray will reveal a stress fracture

Question 6

Treatment of shin splints

Answer 6

• Reduce activity levels to avoid occurrence of pain for at least 6 months
• Appropriate cross training
• review with bone scan at 6 months

Question 7

Treatment of ruptured fibres of gastrocnemius/ soleus/ plantaris

Answer 7

-Acute phase: RICE, analgesics, anti-inflammatories
Post-acute-phase: Physio for cross friction and graduated return to activity. Stretching exercises are important to prevent recurrent injury.

Question 8

Typical history and examination findings in achilles tendinitis

Answer 8

• Pain on active ankle dorsiflexion
• Local tenderness
• Tendon slightly thickened
• Palpable crepitus on active ankle movement

Question 9

Treatment of achilles tendinitis

Answer 9

• Rest
• Heel raise of 2 cm
• NSAIDs
• Injection of local cortico steroid (may cause rupture)
• Surgery: persistent or recurrent cases

Question 10

Typical history of achilles tendon rupture

Answer 10

During strenuous activity, acute pain is felt, often accompanied by a loud snap. The patient may feel like something heavy has struck the leg from behind

Question 11

Exam findings of achilles tendon rupture

Answer 11

• Limp and patient cannot stand on tip-toe
• Gap may be palpable in the tendon
• Plantar-flexion is weak
• Simmond’s calf squeeze test is positive

Question 12

Treatment of achilles tendon rupture

Answer 12

• BK POP with foot fully plantar-flexed for 4 weeks followed by foot in mid equinus for further 4 weeks followed by neutral pop for 4 weeks
• Surgical repair in younger patient, those with gap int he tendon and those with a late diagnosis
• Takes 9-12 months to heal. Warn patients and restrict activities

Question 13

In which two groups does plantar fasciitis occur

Answer 13

• Young runners

- Relatively sedentary middle-aged people

Question 14

History of plantar fasciitis

Answer 14

• Morning pain, first few steps are most painful, therafter improve
• Start-up pain- after sitting for a period, the first few steps are very painful
• Deep-seated heel pain

Question 15

Exam findings for plantar fasciitis

Answer 15

localised tenderness over the infero-medial calcaneal border, at the insertion of the plantar fascia

Question 16

Treatment of plantar fasciitis

Answer 16

• Treatment is patient based stretching
• Tendo-achilles and the plantar fascia must be stretched
• NSAIDs and steroid injections provide temporary relief only and should only be offered as symptomatic relief

Question 17

What is the presentation of plantar warts (verruca plantaris)

Answer 17

• Flat, clearly circumscribed warts
• Shaving with scalpel produces punctate bleeding
• Side to side squeezing is exquisitely tender in contrast to callosities which are only tender on palpation in the direction of the metatarsal head
• Patient complains of pain on walking
• Sharp, localised tenderness to palpation

Question 18

Treatment of plantar warts

Answer 18

6 weeks of wart cream (Salicylic acid, lactic acid, colloid)

Question 19

Underlying conditions that may cause corns/callosities

Answer 19

• conditions causing joint stiffness and deformity- previous trauma or RA
• sensation compromise e.g. Neuropathy

Question 20

What conditions is claw toe seen in?

Answer 20

• seen in pes cavus and in conditions of muscle imbalance

- associated metatarsalgia, callosities and corns

Question 21

Treatment of claw toe

Answer 21

Modify footwear

Surgical correction for severe disability

Question 22

What is the natural history of Hallux valgus

Answer 22

• big toe develops hallux valgus/ valgus deformity of the MTPJ
• may be metatarsus primus varies and the head of the first metatarsal becomes prominent causing a bunion where it is subjected to increased shoe pressure
• OA of first MTPJ may develop due to subluxation
• minor toes may be encroached upon, causing overlapping and claw toes with painful plantar and dorsal callosities that develop

Question 23

Treatment of hallux valgus

Answer 23

• broad footwear, relieve pressure: bunion pads, soft upper and soft soles
• surgery: combination of soft tissue and bony procedures to correct deformity

Question 24

What is the consequence of peripheral neuritis in diabetic foot

Answer 24

• Peripheral neuritis-> neuropathic distortion of the joints and stress fractures (a Charcot joint)
• foot becomes deformed causing pressure callosities and pressure sores (ulcers) overlying bony projections that do not heal
• patient is unaware of the trauma to the skin because of reduced sensation