L7: Functional Anatomy of the Foot Flashcards
(118 cards)
1
Q
What are the 3 groups bones in the foot?
A
Tarsal bones–> Calcaneous, Navicular, Talus, Cuneiforms and cuboid
Metatarsals–> 1-5
Phalanges–> Proximal, middle and distal
2
Q
What are the 3 regions of the foot? What bones are found there?
A
Hindfoot–> Calcaneous and Talus
Midfoot–> Navicular, Cuboid and Cuneiforms
Forefoot–> Metatarsals and phalanges
3
Q
What are the 3 articulations around the talus?
A
Superiorly–> ankle joint, between the tibia, fibula and talus (talocrural joint)
Inferiorly–> Subtalar joint, between talus and calcaneous
Anteriorly–> Talonavicular joint, between the talus and navicular
4
Q
What is the main function of the talus?
A
Transmit the weight of the body to the foot–> calcaneous
5
Q
How is structure of the talus related to its function?
A
Trochlear articulates with tibia and fibula
Anterior wider than posterior
Provides stability to dorsiflexed foot
6
Q
What is significant about the blood supply to the talus?
A
Retrograde supply
Arteries enter at the distal end of bone
Avascular necorosis if fractured
7
Q
What does the calcaneous articulate with?
A
Largest bone
Inferior to talus
Superiorly–> Subtalar–> (talocalcaneal joint)–> talus and calcaneous
Anteriorly–> Calcaneocuboidal joint –> between calcaneous and cuboid
8
Q
What is an important feature of the calcaneous?
A
Calcaneal tuberosity–> Achilles tendon attaches
9
Q
What are the articulations of the navicular? What is a feature of the navicular?
A
Positioned medially (intermediate row) Posteriorly--> talus Anteriorly--> 3 cuneiform bones Laterally--> Cuboid Inferior part--> tuberosity for insertion of tibialis posterior tendon
10
Q
What are the cuneiforms? What do they articulate with?
A
Medial, intermediate (middle) and lateral
Wedge shaped bones–> helps to form transverse arch
Articulate with navicular–> proximally
1, 2 and 3 metatarsals distally
11
Q
What inserts onto the medial cuneiform?
A
Tibilalis anterior, Tibialis posterior and peroneus (fibularis) longus
12
Q
What is the cuboid? What does it articulate with?
A
Cuboidal shaped bone–> lateral
Proximally–> calcaneous
Distally–> 4 and 5 metatarsals
Inferior part–> groove for tendon of peroneus (fibularis) longus
13
Q
What are the metatarsals?
A
Between phalanges and tarsal bones
Number I-V–> medial to lateral
14
Q
Describe the anatomy of the metatarsals?
A
Convex dorsally
Base –> proximally
Shaft
Neck and head –> distally
15
Q
What do the metatarsals articulate with?
A
Base of metatarsals and tarsals–> Tarsometatarsal joints
Between metatarsals–> Intermetatarsal joint
Between metatarsal and head of proximal phalange–> Metatarsophalangeal joints
16
Q
What are the phalanges?
A
Bones of toes
2-5 have proximal, middle and distal phalanges
1- Great (big) toe only proximal and distal
Base, shaft and head
17
Q
Describe the structure of the ankle joint?
A
Talocurral joint
Hinge joint –> dorsiflexion and plantar flexion
Tibia and fibular form ankle mortise–> bracket shaped socket
Trochlear of talus fits snugly into ankle mortise –> aka Malleolar fossa
18
Q
When is the joint most stable? Why?
A
Dorsiflexion most stable–> anterior part of trochlear of talus is wider so fills ankle mortise better
Plantarflexion less stable–> posterior part narrower
19
Q
What stablisies the ankle mortise?
A
Tibia and fibular held together by strong tibiofibular ligament at distal tibiofibular joint
20
Q
What causes plantarflexion and dorsiflexion?
A
Plantarflexion–> Muscle in posterior compartment of leg–> gastrocnemius, soleus, plantaris and tibialis posterior
Dorsiflexion–> Anterior compartment–> Tibialis anterior, extensor hallus longus, extensor digitorum longus and peroneus tertius
21
Q
What ligaments reinforce the ankle joint?
A
Lateral ligaments–> Resist inversion
- -> Anterior talofibular ligament - lateral malleolus and neck of talus
- -> Posterior talofibular ligament - malleolar fossa and lateral tubercle of the talus
- -> Calcaneofibular ligament - tip of lateral malleolus to the lateral surface of calcaneus
Medial ligament–> Resist eversion
–>Medial/ Deltoid ligament - Fibres span out from medial mallelous to talus, calcaneous and navicular
22
Q
Where do inversion and eversion occur? What is there role?
A
Subtalar, calcaneocuboid and talocalcaneonavicular joint
Allows walking on uneven surfaces
Subtalar–> oblique axis–> major joint for inversion and eversion
23
Q
What muscles help produce eversion?
A
Posterior compartment–> Peroneus Longus and peroneus brevis
Anterior compartment–> Peroneus tertius
24
Q
Which muscles help produce inversion?
A
Tibialis anterior and tibialis posterior
25
What are the arches of the foot?
Transverse arch --> half arch
Medial longitudinal arch
Lateral longitudinal arch
Maintained by shape of bones, ligaments of the foot, intrinsic muscles of the foot and long tendon of the extrinsic muscles
26
What are the main weight bearing bones during standing?
Heel and heads of metatarsals
27
What forms the medial longitudinal arch?
Calcaneous, talus, navicular, 3 cuneiforms and medial 3 metatarsals
28
How is the integrity of the medial longitudinal arch maintained?
Plantar aponeurosis and spring ligaments (plantar calcaneonavicular ligament-- binds calcaneum and navicular together)
Tibilalis anterior and peroneus (fibularis) longus tendons
29
What muscles support the medial longitudinal arch?
Tibialis anterior, tibialis posterior, peroneus (fibularis) longus and flexor hallucis longus
30
What forms the lateral longitudinal arch? What helps support this arch?
Calcaneous, cuboid and lateral two metatarsals
| Support- Contraction of peroneus (fibularis) brevis muscle
31
What happens to the arches when standing? What happens when walking?
Arches sink under weight of the body
Individual bones lock together
Ligaments binding them under maximum tension
Foot is immobile pedestal
Tension released--> arches unlock--> mobile lever system with spring-like action
32
What are the muscles in the anterior compartment of the leg?
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus (fibularis) tertius
33
What is the main function of the anterior leg muscles?
Dorsiflex and invert foot at ankle joint
| Extensors--> Extension of the toes
34
What nerves innervate the anterior leg muscles? What is the blood supply?
```
Deep peroneal (fibular) nerve L4-5
Anterior tibial artery
```
35
What is the origin, insertion, innervation and function of the Tibilais anterior?
O: Lateral surface of tibia
I: Medial cuneiform and base of first metatarsal
Passes deep to extensor retinacula at the ankle
Innervation: Deep peroneal (fibular) nerve
F: Dorsiflexion and inversion of the foot
36
What is the origin, insertion, innervation and function of the extensor digitorum longus?
Lateral and deep to Tibialis anterior
O: Lateral condyle of tibia, medial surface of fibula and interosseous membrane
I: Fibres converge into single tendon which passes deep to extensor retinaculum and splits into 4 tendons--> Middle and distal phalanges of 2-5th toes
Innervation: Deep fibular nerve
F: Extension of toes and assists in dorsiflexion
37
What is the origin, insertion, innervation and function of the extensor hallus longus?
```
Deep to EDL and TA
O: Medial surface of fibular shaft
I: Base of distal phalanyx of great toe under the extensor retinaculum
Innervation: Deep fibular nerve
F: Extension of the great toe
```
38
What is the origin, insertion, innervation and function of the peroneus (fibularis) tertius?
Not present in all
O: Medial surface of fibula, inferior to EDL origin
I: Base of 5th metatarsal
Travels with EDL tendon until reaches dorsum of foot, passes deep to extensor retinaculum
Innervation: Deep fibular nerve
F: Eversion and assists in dorsiflexion
39
What muscles are in the lateral compartment of the leg?
Two muscles
Peroneus (fibularis) Longus
Peroneus (fibularis) Brevis
40
What is the innervation of the lateral compartment?
Superficial peroneal (fibular) nerve L4-S1
41
What is the origin, insertion, innervation and function of the peroneus (fibularis) longus?
Larger and more superficial
O: Upper lateral surface of fibula, lateral tibia condyle
I: Posterior to lateral mallelous, across plantar surface of foot onto the medial cuneiform and base of 1st metatarsal
Innervation: Superficial peroneal nerve (L4-S1)
F: Everts and assists in plantarflexion, supports medial and transverse arch of foot
42
What is the origin, insertion and innervation of the peroneus (fibularis) brevis?
Deeper and shorter
O: Inferolateral surface of fibular shaft
I: descends with PL tendon, posterior to lateral mallelous onto tubercle on base of 5th metatarsal
Innervation: Superficial peroneal nerve (L4-S1)
F: Everts foot, support lateral longitudinal arch
43
What muscles are found in the posterior compartment of the leg?
7 muscles --> tibial nerve innervation
Divided into superficial and deep--> layer of fascia
Superficial--> common tendon Calcaneal (Achilles) tendon onto calcaneal tuberosity
--> Gastrocnemius
--> Plantaris
--> Soleus
Deep
- -> Popliteus
- -> Tibialis posterior
- -> Flexor Digitorium Longus
- -> Flexor Hallucis Longus
44
What is the origin, insertion, innervation and function of the Gastrocnemius muscle?
Most superficial
O: Lateral head--> lateral femoral condyle
Medial head--> Medial femoral condyle
I: Calcaneal tendon onto calcaneal tuberosity
Innervation: Tibial nerve
F: Plantarflexion, also assist in knee flexion
45
What is the origin, insertion, innervation and function of the plantaris?
Small muscle, absent 10%, long thin tendon
O: Lateral supracondylar line of the femur
I: Descend medially to insert into calcaneal tendon onto calcaneal tuberosity
Innervation: Tibia nerve
F: Weak plantarflexion, and flexion of leg at knee
46
What is the origin, insertion, innervation and function of the Soleus?
```
Deep to others
O: Soleal line of tibia
I: common tendon onto calcaneal tuberosity
Innervation: Tibial nerve
F: Plantarflexion of foot
```
47
What are the names of the bursae found in the superficial posterior compartment and what is there function?
Subcutaneous calcaneal bursae--> skin and calcaneal tendon
Deep calcaneal bursae--> Calcaneal tendon and calcaneus
Minimise friction
48
What is the origin, insertion, innervation and function of the popliteus muscle?
Superiorly in deep compartment
Posterior to knee joint, forms part of popliteal fossa
O: Tibia proximal to soleal line
I: Lateral condyle of femur (superolateral direction)
Innervation: Tibial nerve
F: Laterally rotates femur on tibia, unlocks the knee so flexion can occur
49
What is the origin, insertion, innervation and function of the tibilalis posterior?
Deepest, between flexor digitorum longus and flexor hallicus longus
O: Interosseous membrane between tibia and fibula and posterior surface of tibia and fibula
I: Plantar surface of navicular and medial cuneiform bone passing posterior to medial mallelous
Innervation : Tibia nerve
F: Plantarflexes the foot, maintains medial arch
50
What is the origin, insertion, innervation and function of the flexor digitorum longus?
Smaller muscle, located medially
O: Medial surface of tibia
I: Common tendon passes posterior to medial mallelous, crosses superfical to FHL tendon, and divides into four tendons onto base of distal phalynx of 2-5
Innervation: tibial nerve
F: Flexes lateral 4 toes, assist in plantarflexion and inversion
51
What is the origin, insertion, innervation and function of the flexor hallicus longus?
Lateral side of deep compartment
O: Posterior surface of fibular,
I: posterior to medial malleous, onto distal phalynx of great toe
Innervation: tibial nerve
F: Flexes great toe, assists in plantarfelexion and inversion
52
What are the main nerves of the leg?
Tibial nerve and common peroneal nerve (superficial and deep peroneal nerve)
53
Describe the course of the tibial nerve?
1. Largest terminal branch of the sciatic nerve (L4-S3)
2. Arise at apex of popliteal fossa
3. Crosses popliteal fossa--> branches to muscles of superficial posterior compartment
- -> also branch combines with common peroneal nerve branch forms sural nerve (cutaneous)--> posterolateral aspect of leg and lateral border of foot
4. Passes deep to solelus muscle, enter deep posterior compartment of leg
5. Between flexor digitroum longus and flexor hallucis longus--> innervates deep muscles
6. Passes beneath flexor retinaulum and posterior to medial mallelous --> medial calcaneal branch to heel
7. Medial and lateral plantar nerves to supply foot
54
What does the sural innervate?
Posterolateral side of the leg
| Lateral surface of foot
55
Give the cutaneous nerve supply of the tibia in the foot?
Medial plantar nerve--> medial side of sole of foot, up to the 3.5 toes (medial to lateral) and up to the heel
Lateral plantar nerve--> lateral side of sole of foot, remaining 1.5 toes
Sural nerve (branch of tibia and common peroneal nerve)--> lateral side of foot
Medial calcanel branches--> Posterior medial aspect of foot
56
Which muscles in the leg are supplied by the tibial nerve?
```
Posterior thigh
--> Long head of biceps femoris
--> Semimembranous
--> Semitendinosus
--> Hamstring component of adductor magnus
Superficial posterior compartment of leg
--> Plantaris
--> Soleus
--> Gastrocnemius
Deep posterior compartment of leg
--> Popliteus
--> Flexor Hallucis Longus
--> Flexor Digitorium Lngus
--> Tibialis posterior
```
57
What does the common peroneal nerve supply?
Small terminal branch of sciatic nerve (L4-S2)
Motor innervation for short head of biceps femoris in the thigh and supplies muscles of anterior and lateral leg (deep and superficial branch respectively)
Cutaneous innervation to skin of anterolateral leg and dorsum of the foot
58
What is the course of the common peroneal (fibular) nerve?
1. Arise from bifurcation of sciatic nerve at apex of popliteal fossa
2. Travels along superolateral border of fossa on medial border of biceps femoris
3. Winds around neck of fibula, pierces peroneus longus muscle and divides into superficial and deep peroneal nerves
4. Before it divides gives off cutanous branches to supply skin of upper lateral leg
59
What does the common peroneal nerve specifically supply?
Short head of biceps femoris
Skin of upper lateral leg
Lateral sural cutaneous nerve joins with medial sural nerve from tibia--> sural nerve
60
What is the course of the superficial peroneal (fibular) nerve?
L4-S1
Bifurcation of common peroneal nerve
Innervates lateral compartment of the leg
Commences at the neck of the fibula
Descends between peroneus longus and brevis and lateral aspect of extensor digitorum longus
Supplies peroneus longus and brevis then commences as cutaneous nerve to supply anterolateral leg
Pierces deep fascia to run subcutanously and supply dorsum of the foot
Excluding the first webspace and the medial and lateral borders of the foot
61
What is the course of the deep peroneal (fibular) nerve?
L4 and 5
Birfurcation of common peroneal nerve
Innvervates anterior compartment of leg
1. Commences at neck of fibular
2. Passes between peroneus longus and neck of fibular
3. Pierces intermuscular septum to enter anterior compartment of leg
4. Pierces extensor digitorum longus and lies adjacent to the anterior tibial artery
5. The two structures pass between the tibialis anterior and extensor digitorum longus (proximal part of leg)
6. Then between tibialis anterior and extensor hallucis longus in distal leg
7. Continues onto the dorsum of the foot to the first webspace
62
What muscles does the deep peroneal nerve supply?
Muslces supplied:
- -> Tibialis anterior
- -> Extensor hallucis longus
- -> Extensor digitorum longus
- -> Fibularis tertius
63
What is the cutaneous innervation of the deep peroneal nerve?
Dorsum of foot--> first webspace (skin between first and second toe)
64
What is the course and innvervation of the sural nerve?
Union of the medial and lateral sural cutaneous branches of the tibial nerve and common peroneal respectively
Passes posterior to lateral mallelous
Small cutaneous distribution and no motor branches
-skin over lateral border of foot
65
What is the sural nerve commonly used for?
Surgery --> small supply
| Only small area left deinnervated
66
Explain the arterial supply to the lower leg?
Popliteal artery--> continuation of superfical femoral artery as it passes adductor hiatus
Popliteal fossa--> Genicular branches
Exits popliteal fossa--> between gastrocnemius and popliteal muscle
Inferior border of popliteal muscle--> anterior tibial artery and tibioperoneal trunk
Tibioperoneal trunk--> posterior tibial artery and peroneal (fibular) artery
67
Describe the course of the anterior tibial artery?
Anteriorly between tibia and fibula through gap in interosseous membrane
Between tibialis anterior and EDL --> proximal leg
Between tibialis anterior and EHL --> distal leg
Under extensor retinaculum--> dorsum of foot dorsalis pedis artery
68
Describe the course of the posterior tibial artery?
1. Descends posterior compartment on tibialis posterior muscle, then flexor digitorum longus, tibia and posterior ankle joint
2. Covered superficially by deep transverse fascia of the leg (separates from soleus muscle in superficial posterior compartment)
3. Accompanied by tibial nerve and two vena commitans (sometimes collectively known as tibial veins)
4. Posterior to medial mallelous
5. Enter sole of foot via tarsal tunnel (fibro-osseous tunnel)
with tibial nerve
69
What is the arrangement of the structures behind the medial mallelous?
Tom, Dick And Very Nervous Harry
- -> Tibialis posterior
- -> flexor Digitroum longus tendon
- -> posterior tibial Artery
- -> posterior tibial Vein
- -> tibial Nerve
- -> flexor Hallucis longus
70
What is the course of the peroneal (fibular) artery?
Bifurcation of tibioperoneal trunk at inferior border of popliteus muscle
Decends on medial side of fibula
Fibrous canal between tibialis posterior and flexor hallucis longus
Perforating branches--> penetrate the intermuscular septum --> muscle in lateral compartment
71
What is the arterial supply to the foot?
Two arteries
- Dorsalis pedis (continuation of anterior tibial artery)--> deep branch passes between first and second metatarsals anastomoses with lateral plantar artery to complete the plantar arch
- Posterior tibial --> enters sole through tarsal canal--> divides into lateral and medial plantar arteries--> lateral plantar artery supplies toes via plantar arch
72
Where can the pulses be palpated in the lower limb?
Femoral --> femoral triangle, midway between ASIS and pubic symphysis (mid inguinal point= artery (MIPA))
Popliteal --> deep in popliteal fossa
Posterior tibial --> tarsal tunnel inferior and posterior to medial malleolus
Dorsalis pedis pulse --> dorusm of foot, lateral to extensor hallucis longus tendon
73
What are the deep veins in the leg?
1. Dorsal venous arch in foot--> great (long) and small (short) saphenous veins at medial and lateral ends respecitively
2. Venae comitantes of dorsalis pedis artery on dorsum of foot--> venae comitantes of anterior tibial artery in anterior compartment of leg 'anterior tibial vein'
3. Medial and lateral plantar veins--> plantar venous arch (sole of foot)--> venae comitants of posterior tibial artery 'posterior tibial vein' --> posterior to medial mallelous-> ascend together with posterior tibial artery drain deep and superficial posterior compartments of leg
4. Vena comitantes of peroneal (fibular) artery 'peroneal (fibular) vein'--> posterior tibial vein which unites with anterior--> Popliteal vein --> enters thigh at adductor hiatus--> femoral vein
74
What is the popliteal fossa? What are its borders?
Diamond shaped depression --> posterior surface of knee
Superomedial border --> semimembranousus
Superiolateral border --> biceps femoris
Inferomedial border --> Medial head of gastrocnemius
Inferolateral border --> Lateral head of gastrocnemius and plantaris
Floor--> popliteal surface of femur, posterior surface of joint capsule and oblique popliteal ligament and popliteus muscle
Roof--> Popliteal fascia and skin
75
What structures pass through the popliteal fossa?
Popliteal artery
Popliteal vein
Short (small) saphenous vein (drains into popliteal vein in popliteal fossa)
Tibia nerve and medial sural cutaneous branch
Common peroneal (fibular nerve) and lateral sural cutanous branch
Popliteal lymph nodes
76
Which order are the structures that pass through the popliteal fossa in?
Popliteal vessels and tibial nerve cross fossa vertically
Tibia nerve is most superficial
Popliteal vein lies deep to nerve
Popliteal artery is deepest of all
77
What is compartment syndrome?
Trauma to fascial compartment
| Haemorrhage--> Increase in intracompartmental pressure
78
What are the clinical signs of compartment syndrome? How is it treated?
Severe pain in the limb--> excessive for injury
Not relieved by analgesia
Pain increased by passive stretch
Surgical decompression (fasciotomy)
79
What are the short and long term consequence of compartment syndrome?
Short--> decreased muscle perfusion, ischemia--> mediator--> ↑vascular permeability exacerbating problem
Rhabdomyolysis (muscle necrosis)--> acute kidney injury
Neurovascular--> loss of peripheral pulse, increased capillary refill time--> distal paraesthesia precedes loss of motor function
Long--> acute kidney becomes chronic
--> necrotic muscle --> fibrosis--> Volkmann's ischemia contracture (permanent contracture of muscle groups)
80
How do fractures to the ankle occur?
Inversion or eversion injury
| Ligaments can cause bone to break or direct break
81
What needs to be considered when a patient comes in with a broken ankle?
Co-morbidities (diabetes, neuropathy, peripheral vascular disease, smoking etc)
Can affect fracture healing
Integrity of overlying tissue--> fracture blisters healed before surgery
82
What is an open ankle fracture?
One where the overlying skin tissue is breached
Fracture communicates with external environment
Risk of osteomyelitis (infection of bone)
83
Ankle joint and ligaments can often be considered as a ring, what structures form the parts of that ring?
Proximal (superior): Tibia and fibular connected by syndesmotic ligaments (Ant and post tibiofibular lig)
Medial surface: Medial (deltoid) ligament
Inferior surface: Subtalar joint (between talus and calcaneous)
Lateral surface: Lateral ligament complex (anterior talofibular, talocalcaneal and posterior talofibular)
84
What is talor shift?
Ankle fracture--> common, two points of ring break, syndesmosis, medial or lateral ligament etc.
Ankle mortise unstable--> widens--> Talus shifts medially or laterally within ankle joint
e.g. forced eversion--> push against lateral mallelous, oblique fracture of lateral malleolus--> pull on medial ligaments--> rupture deltoid or medial malleolus
85
How are ankle fractures treated?
```
Stable fractures (1 ring breakage)--> aircast boot or fibroblast cast--> no operation required
Patients can safely weight bear and low rate of complications (secondary osteoarthritis)
Unstable fractures (2 ring breakage)--> surgical stabilisation --> high risk
```
86
What is a sprained ankle?
Partial or complete tear of one or more ligaments of joint
| 90% heal with time
87
What contributes to an increased risk of ankle sprains?
Weak muscles/tendons in ankle joint (esp peroneal muscles)
Weak or lax ankle ligaments (hereditary or repetitive ankle sprains)
Inadequate joint proprioception
Slow neuromuscular response to off-balance position
Running on uneven surfaces
Shoes with inadequate heel supports
Wearing high heeled shoes--> weak position of joint (platarflexion)
88
What causes ankle sprains?
Excessive strain on ligaments--> past yield point--> sprained
Inversion, eversion or external rotation
89
What is the most common form of ankle sprain?
Inversion injury to plantarflexed and weightbearing foot
| Anterior talofibular lig most at risk
90
Why is it not uncommon in an ankle sprain to find a 5th metatarsal tuberosity fracture?
Peroneous (fibularis) brevis is attached to the 5th metatarsal tuberosity
Inversion injury under tension it can be pulled off
91
What is a common injury to the calf in middle aged adults?
Achilles tendon rupture
92
What is Achilles tendon rupture?
```
Occurs in vascular 'watershed'--> area with little blood supply and decreased thickness (6cm above insertion on calcaneal tuberosity)
Complete tear (rupture) more common than partial
```
93
What can cause the Achilles to rupture? What is the mechanism?
Sudden explosive exercise
Mechanism:
Forceful push-off with extended knee
Fall with foot outstretched and dorsiflexed
Falling from height, or abruptly stepping into a hole or off the curb
94
What are the signs and symptoms of Achilles rupture?
Sudden severe pain at the back of ankle/calf (feels like it has been kicked)
Sound of large pop or snap
A palpable gap or depression in tendon
Initial pain and swelling followed by bruising
Inability to stand on tip toe or push off whilst walking
95
What is used to diagnoses Achilles tendon rupture?
Thompson's test (Simmond's test)
--> pt lies face down on table
--> squeeze persons calf, if foot doesn't move Achilles ruptured
MRI and ultrasound can be used to confirm
96
How is Achilles tendon rupture treated?
Usually aircast boot used with wedge shaped sole to dorsiflex foot
Surgery avoided--> 5-10% pt suffer from complications
97
What is Hallux Valgus? How is it caused?
aka bunion--> bony deformatity at 1st MTPJ
Big toe deviated laterally
--> First metatarsal deviated varus
--> Valgus/ lateral rotation of hallux
--> Prominence of the first metatarsal head, with or without an overlying callus
Poorly understood cause
Secondary cause to trauma, arthritic/metabolic conditions such as gout, rheumatoid arthritis and psoriatic arthritis and CT disorders that cause ligaments to be lax
Heels can exacerbate the problem
Once present line of intrinsic tendons worsens the problem
98
How is Hallux Valgus treated?
Surgery should not be carried out for cosmetic reasons alone
Encourage change in activity and footwear
Surgery--> break 1st metatarsal re-allign bones (metatarsal osteotomy) using pins/screws
99
What is Hallux rigidus? What causes it? What are the symptoms?
Osteoarthritis of 1st MTPJ--> stiffness
Dorsiflexion restricted--> dorsal bunion develops on top, may rub on patients shoe
Joint under stress when walking
Secondary causes include gout, septic arthritis
Pain on walking and dorsiflexion of toe
Severe- pain at rest
Compensate by walking on lateral aspect of foot
100
How is Hallux rigidus treated?
Activity modification
Analgesias
Orthotics--> rigid sole--> prevents dorsiflexion of 1st MTPJ
Intra-articular steroid injections
Surgery if not resolved--> fusion (arthrodesis) of 1st MTPJ stop movement--> joint 'fractured' excised--> stablised with screws --> normal bone healing fuses joint
Arthroplasty (replacement) of joint surfaces
101
What is osteoarthritis of the ankle joint?
```
Nearly always secondary arthritis
70-80% of cases in a joint that has previously experienced a fracture--> post traumatic arthritis
12% due to inflammation in ankle joint
Joint stress also contributes
Some have no identifiable cause
```
102
How is osteoarthritis treated?
Gold standard--> fusion (arthrodesis)
No dorsiflexion or plantar flexion but other movements possible
No affect on walking
```
Ankle arthroplasty (joint replacement)
Risks with operation, prosthetic loosening and prosthetic infection
```
103
What different deformaties can you get with the toes?
Claw toe
Hammer toe
Mallet toe
Curly toes
104
What is characteristic of a claw toe? What causes it?
4 small toes
Hyperextension at the MTPJ
Flexed at PIP joint (sometime DIP too)
Corns may develop on dorsal surface of toe or under head of metatarsal
Neurological damage, secondary to trauma, inflammation, cerebral palsy, stroke etc...
Muscle imbalance
105
What is characteristic of a hammer toe and mallet toe? What causes them?
Hammer Toe--> Flexed at PIP joint
Mallet toe--> Flexed at DIP joint
most common on second toe
Ill fitting pointed shoes, pressure on second toe from hallux valgus, tight shoe (muscles contract and shorten)
106
What are the characteristics of curly toes? Why do they develop? What are the symptoms and treatment?
Congenital and usually involves 3-5th digit
Bilateral
Family history
Develop--> tendons of FDL or FDB (intrinsic muscle of foot) are too tight
Most children assymptomatic
Treatment--> conservation with passive extension of toes and stretching of flexor tendons
Surgery rarely needed--> only considered for 6yrs+ whose toes cause pain on activity
107
What is Achilles tendinopathy? What causes it? What are the risk factors? What are the signs and symptoms? How is it treated?
Degenerative not inflammatory process
Develops--> point of insertion or at vascular 'watershed'
Follows many years of overuse or people who are inactive
Risk--> obesity and diabetes
Signs and symptoms--> Pain and stiffness in tendon in morning or after activity (or at back of heel)
--> Severe pain 24hrs after activity
--> thickening of tendon
--> Swelling present, worse during activity
--> Palpable bone spur
Treated--> Physiotherapy, improved vascularity of tendon
108
What is flat foot (pes planovalgus)?
Medial arch of foot has collapsed
| Valgus angulation of hindfoot
109
Why are flat feet common in childern?
Fat pad under feet
Arches not developed
Medial longitudinal arch develops around 5 yrs old
Abnormal if redevelops in adolescence
110
What is the difference between flexible and rigid flat feet?
Flexible--> no medial arch whilst standing normally, on tip toes medial arch appears and hindfoot valgus deviation returns to normal
Rigid--> Always abnormal, tarsal coalition (failure of tarsal bones to separate)
- -> Tip toes no arch appear and valgus hindfoot remains
- -> often symptomatic and require treatment
111
What is adult acquired flat foot? Who is it most common in? What are the risk factors?
Dysfunction of tibialis posterior tendon
Normally supports medial arch of foot
Occurs in middle age --> mainly women--> history of change in shape of foot and pain behind medial malleolus
Risk factors--> Obesity, hypertension, diabetes, temporarily during pregnancy (lax ligaments)
112
How does dysfunction of the tibialis posterior result in lateral deviation of hindfoot? How is it treated?
Stretching of spring ligament (plantar calcaneonavicular ligament) and plantar aponeurosis
Talar head displaced inferomedially
Flatterning of medial longitudinal arch--> lateral deviation of hindfoot
Treatment: orthotics (insoles), physiotherapy to strengthen muscles, some require surgical reconstriction if OA develops then may require fusion of bones
113
How does diabetes mellulitis affect the foot?
Approx 15% of diabetic patients affected
Loss of sensation (peripheral neuropathy), ischemia, microvascular disease, immunosupression poor glycaemic control--> foot ulcers, severe infections and other serious complications
Patients weight bear on significant soft tissue abnormalities--> makes problem worse
114
How is the risk of foot disease reduced?
Regular diabetic foot clinics
Checked for corns, callouses, cracks, dry skin
Shoes are checked for suitable protectiveness
Education on how to look after feet and reduce chances of complications
Tight glycaemic control emphasised --> prevent neuropathy and vascular disease problems
115
What can poorly controlled diabetes lead to in the feet?
Charcot arthropathy
116
What is Charcot arthropathy?
Progressive destruction of bones, joints and soft tissues
Combination of factors --> inflammation--> osteolysis (bone resorption), fracture, dislocation and deformitiy
Neuropathy--> loss of sensation--> walk on deformed foot making it worse
117
What is rocker-bottom foot?
Rounded sole of foot
118
What is the treatment for Charcot arthropathy?
Optimisation of glycaemic control and reduce load on joint--> put into plaster cast for 18months to 2years
Difficult because reduced bone stock and bones are soft (due to inflammation)
Patients don't experience pain --> not reminded to stop weight bearing
Often obese--> increased load
Poor glycaemic control and therefore have secondary immunosupression
