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Clinically applied MSK - Roshiva > Foot and Ankle > Flashcards

Foot and Ankle Flashcards

1
Q

What are the bones of the foot?

A

Tarsals:
Proximal: Talus and calcaneus
Intermediate: Navicular
Distal: Cuboid and 3 cuneiforms

5 metatarsals
Phalanges (2 in hallux; 3 in all the other digits)

The first metatarsal has 2 sesamoid bones at its connection with the proximal phalanx.
There’s a tuberosity on the 5th metatarsal bone

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2
Q

What are the joints of the foot?

A

Tarsometatarsal joints (3) = between cuboid bones and cuniform bones with the metatarsals

Metatarsophalangeal joint

Proximal and distal interphalangeal joints

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3
Q

What is the ankle bone?

A

Talus

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4
Q

What is the talus?

A

-The only tarsal that articulates with bones of the leg
(distal tibia and medial malleolus of tibia and lateral malleolus of fibula)

  • Has head, body, neck, trochlea (superior articular surface) –> transmits the weight of the whole body and articulates with the 2 malleoli
  • Most of the surface is covered with articular cartilage so no muscles attach to it
  • Head of the talus lies on the sustenaculum tali of calcaneous
  • Talus is 140-150 degrees of a sphere and tibia covers 70% of it
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5
Q

What is the calcaneous?

A
  • Largest and strongest bone of the foot
  • Articulates with cuboid and talus
  • Sustenaculum tail supports the head of the talus
  • Has a groove for flexor hallicus longus tendon
  • Posterior aspect forms calcaneal tuberosity

-Has peroneal trochlea/tuberosity on the lateral aspect
separating peroneus brevis and its tendon superiorly and peroneus longus tendon inferiorly

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6
Q

What are the characteristics of navicular?

A
  • Attached to talus and cuniforms

- Has tuberosity on plantar surface for attachment of tibialis posterior

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7
Q

What are the characteristics of the cuboid?

A

-Has groove for peroneous longus

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8
Q

What are the characteristics of the cuneiforms?

A
  • Articulates with the navicular and metatarsals 1,2 and 3
  • Shape of the bones create the transverse arch of the foot

-Attachment: tibilais anterior, tibiliatis posterior, peroneous longus, flexor hallicus longus

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9
Q

What are the tibiofibular joints?

A

-Plane synovial joint

Proximal: between the superior ends of tibia and fibula
Distal: between inferior ends of tibia and fibula

-Interosseous membrane (also known as middle tibiofibular joint) = connects the shafts

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10
Q

What is the ankle joint?

A
  • Talocrural joint
  • Articulation of malleoli of tibia and fibula and body of talus
  • Synovial hinge joints
  • Has strong ligaments
  • Tibiofibular ligaments bind the tibia and fibula together to form a socket (mortise) covered in hyaline cartilage. This articulates with trochlea of body of talus
  • Talus is 140-150 degrees of a sphere and tibia covers 70 degrees of it
  • The tibia and fibula are bound together by strong tibiofibular ligaments. Together, they form a bracket shaped socket, covered in hyaline cartilage. This socket is known as a mortise.
  • Allow dorsiflexion, plantarflexion, inversion, eversion, abduction, adduction
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11
Q

What are the 2 types of ligament?

A

Medial (deltoid) ankle ligaments - prevents over-eversion of foot
Lateral ankle ligaments - prevents over-inversion of foot

They mirror each other

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12
Q

What make up the medial (deltoid) ankle ligaments?

A
  • Prevent over eversion of foot
  • Attached to medial malleolous

4 portions:

  • Anterior tibiotalar ligament (deep)
  • Posterior tibiotalar ligament (deep)
  • Tibiocalcancaneal ligament (superficial)
  • Tibionavicular ligament (superficial)

The 2 superficial bands blend into calcanionavicular spring ligament

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13
Q

What make up the lateral ankle ligaments?

A
  • Prevent over inversion of foot
  • Attached to lateral malleolus
  • Anterior talofibular ligament (most frequently damaged as it’s the weakest
  • Posterior talofibular ligament
  • Calcaneofibular ligament
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14
Q

What are the characteristics of the fibula at the ankle joint?

A
  • Dynamic stabiliser
  • On dorsiflexion, the wider head of the talus is pushing fibula upwards and posterior, separating the malleoli slightly
  • On plantarflexion, posterior compartment of leg helps (gastrocnemius, soleus, plantaris and tibilalis posterior)
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15
Q

What is an ankle sprain?

A
  • Partial/complete tears in ligaments of ankle (lateral ligaments)
  • Occurs via excessive inversion to a plantarflexed
  • Lateral ligaments are weaker
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16
Q

What is the subtalar joint?

A
  • Articulation between talus and sustenaculum tali of calcaneous
  • Made of 3 facets
  • Planar synovial joint
  • The joint is enclosed by a capsule that is supported by posterior, medial and lateral talocalcaneal ligaments
  • Interosseous talocalcaneal ligaments (anterior and posterior) bind the 2 bones together
  • Ligamentum cervicis (attaches calcaneous and talus)
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17
Q

What is the functional way to divide the foot?

A
  • Ankle joint (talocrural joint)
  • Subtalar joint
  • Midtarsal joint (articulations of talonavicular and calcaneocuboid)
  • Tarsometatarsal joints (3 cuneiforms and cuboid articulating with bases of metatarsals) - connected by interosseous ligaments
18
Q

What are the arches of the foot?

A
  • Bones of the foot form transverse and longitudinal arches
  • The calcaneonavicular ligaments help maintain the arches

2 Longitudinal arches (medial and lateral)
-Medial arch is higher up; It is formed by the calcaneus, talus, navicular, three cuneiforms and first three metatarsal bones. Supported by Tibialis anterior and posterior, fibularis longus, flexor digitorum longus, flexor hallucis, and the intrinsic foot muscles; plantar ligaments; medial ligament of the ankle joint; Plantar aponeurosis

  • The lateral arch is the flatter of the two longitudinal arches, and lies on the ground in the standing position. It is formed by the calcaneus, cuboid and 4th and 5th metatarsal bones. It is supported by: Fibularis longus, flexor digitorum longus, and the intrinsic foot muscles; Plantar ligaments; Plantar aponeurosis.
  • The transverse arch is located in the coronal plane of the foot. It is formed by the metatarsal bases, the cuboid and the three cuneiform bones. Supported by Fibularis longus and tibialis posterior; Plantar ligaments; Plantar aponeurosis.
19
Q

What is pes planus (flat feet)?

A

Caused by collapse of medial longitudinal arch of foot.

  • This is flat footedness
  • Most common cause is dysfunction of tibialis posterior dysfunction
  • Tibialis posterior function is inversion and raises arches of the foot
  • Another cause is disruption of plantar calcaneonaviular spring ligament. To assess for it, you stand behind your patient and look at their feet – if you see one foot has too many toes visible and a valgus deformity at the ankle, it’s likely to be pes planus
  • Treatment: orthotics (arch support), physiotherapy, painkillers
  • Surgical option: correction of flexible deformity –> fracture the calcaneous and move it medially then take the flexor digitorum longus and pass it through the navicular (we take the tendon from the Knott of Henry)
20
Q

What is plantar fascitis?

A

-Inflammation of plantar aponeurosis, causing pain in plantar region of foot towards calcaneous

21
Q

What bones form the 3 arches?

A

Medial longitudinal arch: calcaneous, talus, navicular, 3 cuniforms, 1-3 metatarsals

Lateral longitudinal arch: calcaneous, cuboid, 4th-5th metatarsal

Transverse arch: 3 cuniforms, cuboid. 5 metatarsal bases

22
Q

What supports the movement of bones?

A

There are ligaments between each and every bone to support them in their different potential movement directions

e.g
Long plantar ligament, short plantar ligament, spring ligament

23
Q

What muscles help invert the foot?

A

Tibialis anterior

24
Q

What muscles help evert the foot?

A

Peroneus longus

Peroneus brevis

25
Q

What is the plane of movement at the ankle?

A

-Supination, pronation, plantar flexion, dorsiflexion

  • Supination/pronation = transverse plane
  • Plantar flexion/dorsi flexion = sagittal
  • Abudction/adduction = coronal
26
Q

What is the Anchilles tendon?

A
  • Calcaneal tendon
  • Posterior compartment
  • Formed by gastrocnemius and soleus muscle
  • Gastrocnemius is the superficial layer and attaches above knee joint; soleus is deeper and smaller

-Allow plantar flexion

  • Gastrocnemius (attaches at femoral condyles) and soleus (origin is soleal line in tibia)
  • Unite to form the Anchilles tendon which inserts into posterosuperior calcaneous (insertion is 2cm, proper tendon is 8cm)
  • Largest strongest tendon of foot
27
Q

What is Anchilles tendon rupture?

A
  • More likely to occur in people with history of calcaneal tenditis (chronic inflammation of the tendon)
  • Usually sustained during forceful plantarflexion

Symptoms: audible snap, pain described as being kicked in the leg

Thompson’s test: clinical examination procedure for discovering signs of Anchilles tendon rupture.
Absence of plantar flexion when patient kneels on chair and examiner squeezes calf muscles –> indicates anchilles tendon rupture

28
Q

What are the intrinsic muscles of the foot?

A

1st layer (most superficial):

  • Abductor hallicus (abducts and flexes)
  • Abductor digiti minimi (abducts and flexes)
  • Flexor digitorum brevis (primary flexor of PIP joint)
  • Flexor digitorum longus (primary flexor of DIP joint, metatarsophalangeal joint, foot inversion and plantarflexion)

2nd layer:

  • Flexor digitorum longus
  • Flexor accessorius (quadratus plantae) - assists in flexing flexor digitorum longus
  • Lumbricals (arises from flexor digitorum longus) - allows proximal phalanx flexion and distal phalanx extension. Lumbrical failure can cause Hammer toe

3rd layer:

  • Flexor Hallicus brevis ( Flexes the proximal phalanx of the great toe at the metatarsophalangeal joint.)
  • Digiti minimi
  • Adductor hallucis (Adduct the great toe. Assists in forming the transverse arch of the foot)

4th layer:

  • Plantar interossei - adduction (3 of them)- Adduct digits three to five and flex the metatarsophalangeal joints.
  • Dorsal interossei - abduction (4 of them) - Abduct digits two to four and flex the metatarsophalangeal joints
29
Q

What are the dorsal intrinsic muscles of the foot?

A
  • extensor hallicus brevis

- extensor digitorum brevis

30
Q

What is plantar fascia?

A
  • Thickest fascia in the body (Fibrous aponeurosis that supports the arch of the foot)
  • It’s continuous with the Anchilles tendon at the calcaneous
  • Provides 25% of stability of medial arch
  • Plantar fascia is made up of 3 parts: medial, central and lateral bands.
  • Central plantar fascia is thickest and strongest
  • The windlass mechanism loads energy in the fascia by using 1st toe extension
  • Toe dorsiflexes which increases the tension in the plantar fascia which raises arch of the foot and tightpacks the bones of the midfoot —> allows the foot to become a rigid lever
  • Inflammation is called plantar fasciitis. Results from repetitive microtrauma as people age. More common is older people
  • Presentations of plantar fasciitis: heel pain, swelling, impaired function, tight gastrocnemius
31
Q

What is the neurovascularity of the foot and ankle?

A
  • Anterior and posterior tibial arteries
  • Saphenous veins
  • Tibial nerve
  • Common peroneal nerve (split into superficial and deep nerves)
32
Q

What are the divisons of the foot?

A
  • Hindfoot = calcaneus and talus
  • Midfoot = navicular, cuboid, cuniforms
  • Forefoot = metatarsals and phalanges
  • Transverse tarsal joint separates the hindfoot and midfoot
  • Tarsometatarsal joint separates midfoot and forefoot
33
Q

What is Anchilles tendinopathy?

A
  • Anchilles tendon wears especially in athletes and overweight people
  • There are 2 types – insertional and non-insertional
  • Insertional: affects distal 2cm of tendon, found in 40–50-year-olds, patients tend to be overweight and female – there is degenerative and repetitive loading. Enthesopathy (a lump at insertion) is a common sign
  • Non-insertional: affects 2-7cm from the insertion. Affects younger people, patients are more athletic; repetitive microtrauma leads to inflammation and neoangiogenic
34
Q

What is Anchilles tendon rupture?

A
  • Patient history: patient doesn’t usually do sports but decides to do it for leisure; previous history of Anchilles tendon
  • Feels like they’ve been kicked in the back of the leg
  • Compare the left with right
  • Assess the contour of the anchilles tendon, swelling, plantarflexion, palpate length of tendon, feel for gap, check if neurovascular is intact

-Simmons (Thompson’s test) – squeeze the calf muscles and see if the foot plantarflexes – if it doesn’t plantarflex, the anchilles tendon is not in tact

Non-surgical treatment:

  • Temporary dorsal plaster to maintain full equinis for 2-3 weeks
  • Patient is then put in walker boot with wedges to force plantarflexion. The wedge is removed every week to gradually return the foot to the neutral position
  • The idea of all these is to plantarflex the foot to close any gaps in the tendon

Surgical treatment:

  • Repair or reconstruction
  • Repair = acute phase
  • Reconstruction = when 2 ruptured ends can’t unite. Usually use flexor hallicus longus tendon – you lose a bit of toe flexion but it fixes the gaping hole in the Anchilles
  • They carry a high risk of infection as that area is relatively avascular
  • The sural nerve is at risk laterally
35
Q

What are ankle sprains and fractures?

A
  • Supination, adduction, plantarflexion and inversion is a common mechanism of injury for lateral ankle fractures and sprains – swelling and bruising
  • Look for swelling, soft tissues and deformity, bone tenderness, neurovascular, look for range of motion
  • Treated following BOAST guidelines
  • For more straightforward closed fractures = place patient in cast or boot
36
Q

What is ankle instability?

A
  • After ankle sprain, there is often development of ankle instability
  • The ATFL is the most commonly injured ligament
  • Calcaneofibular ligament is the second most common injury
  • The PTFL is the strongest of the 3 lateral ligaments and is rarely injured
37
Q

What is ankle osteoarthritis?

A
  • Leads to pain and reduced range of motion
  • Treatment: steroid injections and painkillers, orthotics
  • Surgical: fusion of joint
38
Q

What is midfoot osteoarthritis?

A
  • Presents with pain on weightbearing and movement, deformities and osteophytes
  • Steroid injections can be used diagnostically – can eliminate pain helping localise the affected joint
39
Q

What is Lisrane fracture?

A

-The Lisfrane joint is the 2nd TMT joint – key as it acts as keystone for transverse arch

  • These fractures are fracture dislocations at this joint
  • Can be caused by direct trauma (direct force on the foot); indirect trauma (torsional forces); axial loading of joint
  • Diagnosis is difficult and often missed which can lead to long term complications
  • Bruising on plantar surface
  • Hard to pick up on X-rays. Look at CT
  • Non-operative = immobilisation in a cast for 8 weeks
  • Surgical = Open reduction and internal rotation – a dorsal incision is made, the articulation is reduced and stabilised with screws. Complications: swelling, post-traumatic osteoarthritis, neurovascular injury
40
Q

What is Hallus valgus?

A

-This is a bunion – lateral deviation of the hallux

  • Risk factors: inflammatory arthritis, shoe wear, female sex
  • Often associated with pes planus
  • Non-operative: splinting
  • Operative: breaking and realigning
41
Q

What are some toe deformities?

A
  • Hammer toe: PIPJ flexion with DIPJ extension
  • Claw toe: PIP and DIP flexion
  • Mallet toe: DIPJ flexed, PIPJ extended
42
Q

What is interdigital (Morton’s) Neuroma?

A
  • Compressive neuropathy of the interdigital nerve
  • The transverse metatarsal ligament compresses the nerve and causes degradation

-It manifests as pain between the metatarsal heads and reduced sensation in the toes

  • Mulder’s click test involves compressing the metatarsal heads and feeling the neuroma pop or click out
  • If steroid injections don’t work, the neuroma can be excised surgically

Clinically applied MSK - Roshiva (8 decks)

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