Flashcards in Session 5 Foot And Ankle Problems Deck (35):
What does hallus valgus (bunions) involve?
- medial deviation of the first metatarsal
- lateral deviation and/or rotation of the hallux
- prominence of the first metatarsal head, with or without an overlying callus
What are the causes of bunions?
- overpronated foot
- arthritic metabolic conditions e.g gout, rheumatoid arthritis, psoriatic arthritis
- connective tissue disorders that cause ligamentous laxity = bunions can run in families
What group of people are most susceptible to bunions and what makes it worse?
Middle aged women
Made worse by wearing footwear such as high heels and tight shoes as keeps the hallux in vagus deviation.
Also pull of extrinsic tendons e,g extensor hallucis longus makes it worse.
What’s hallux rigidus?
Osteoarthritis of the 1st metatarsophalangeal joint, resulting in stiffness of this joint.
What causes hallux rigidus?
- Walking put stress on the joint
- previous septic arthritis
What’s Achilles tendinitis and how can it occur?
Inflammation of the Achilles’ tendon
Can occur within the tendon itself = non insertional tendinitis
Can occur at the point the tendon joins to the calcaneum = insertional tendinitis
Which groups are more affected by non insertional and insertional Achilles tendinitis?
Non insertional = younger, athletic people
Insertional = any age, inactive or over users e.g people who run marathons
What are the signs and symptoms of Achilles tendinitis?
Signs and symptoms
- pain and stiffness along the Achilles’ tendon in the morning
- pain in the tendon or back of heel that worsens with activity
- severe pain 24 hours after exercising
- thickening of the tendon
- swelling that is prevent all of the time but worsens with activity
- a palpable bone spur (in insertional tendinitis)
What are the causes of osteoarthritis of the ankle Joint and what are the main complaints?
- post traumatic arthritis = after a traumatic event
- underlying medical conditions e.g rheumatoid arthritis
- no identifiable cause = primary ankle arthritis
Main complaints - pain and stiffness, especially first thing in the morning. Also limited movement of ankle joint.
What kind of patients get primary OA?
Will experience less pain and have a better range Of motion than those with primary OA
What are the risk factors for OA?
Joint stress (ballet dancers, Football, etc)
Family history of OA
What’s hammer toe and mallet toe?
Hammer toe = flexion of PIPJ
Mallet toe = flexion of DIPJ
Most commonly effect the second toe
What are the causes of hammer toe and mallet toe?
- ill fitting pointed shoes
- pressure on the second toe from an adjacent hallux valgus
If a tight shoe causes a toe to stay flexed for too long, muscles contract and shorten = harder to straighten the toe which gets worse over time
What pathological changes with age make Achilles rupture more common?
- decreased capillary density and decreased arterial perfusion
- increased stiffness due to decreased elastin, decreased proteoglycans, decreased water content of the tendon and increased cross linking of collagen.
- decreased collagen turnover/synthesis and decreased ability to repair damaged collagen
- calcium deposition
What group is most effected by Achilles’ tendon ruptures and by what mechanisms?
Middle aged males most commonly effected
- forceful push of extended knee (jumping)
- fall with foot outstretched in front and ankle dorsiflexion, forcibly overstretching the tendon
- fall from a height or stepping into a hole or off a kerb
What tear is most common and where?
Complete tear more common than a partial tear
The usual site is 6cm above the insertion into the calcaneum
What are the signs and symptoms of an Achilles’ tendon rupture?
- sudden/severe pain at back of ankle or in the calf
- the sound of a loud pop or snap
- palpable and sometimes visible gap or depression in the tendon
- initial pain and swelling followed by bruising
- inability to stand on tip toes
What’s the ankle ring??
The ankle joint and associated ligaments can be visualised as a ring in the coronal plane:
The upper part of the ring is formed by the articular surfaces of the tibia and fibula.
The lower part of the ring is formed by the subtalar joint (between the talus and the calcaneus).
The sides of the ring are formed by the medial and lateral ligaments.
What does an injury that results in either eversion or external rotation of the foot do?
Can push the lateral malleolus, probably leading to an oblique fracture of it
Will also pull of medial ligaments, leading to a ruptured deltoid ligament or a transverse fracture of he medial malleolus.
What does an injury that results in addiction or inversion of the foot do?
Can push the medial malleolus off the tibia = oblique fracture an pull on the lateral structures
Leads to a ruptured lateral ligament or a transverse fracture of the lateral malleolus
How does an ankle fracture differ in the way it affects The syndesmosis?
If the fracture is below the distal tibiofibular joint, the syndesmosis will be intact and after reduction the ankle will be relatively stable.
If it is above the tibio fibular joint, the syndesmosis ligament must have been torn and this is unstable fracture and requires surgical fixation.
What is a claw toe?
Affects all small toes at the same time
Toes are hyperextended at the MTPJ and flexed at the PIP joint and sometimes the DIP so that it curls under the foot. Corns may develop over the top of the toe or under the head of the metatarsal.
What causes claw toe?
Results from a muscle imbalance which causes the ligaments and tendons to become unnaturally tight, usually due to neurological damage and may be secondary to conditions such as cerebral palsy, stroke, diabetes or alcohol dependence.
Trauma, inflammation and rheumatoid arthritis can also cause claw or.
What’s an ankle sprain?
Partial or complete tear of one or more ligaments of the ankle joint
What factors contribute to an increased risk of ankle sprains?
- weak muscles/tendons that cross the ankle joint, especially the perineal muscles
- weak of lax ankle ligaments: this can be hereditary or due to over-stretching of ligaments as a result of repetitive ankle sprains
- inadequate joint proprioception
- slow neuromuscular response to an off balance position
- running on uneven surfaces
- shoes with inadequate heel support
- wearing high heeled shoes dye it the weak position of the ankle joint with the elevated heel and a small base of support.
Why do ankle sprains occur?
Excessive stress on the ligaments of the ankle. Can be caused by excessive external rotation, inversion or eversion of the foot caused by an external force.
When the foot is moved past its range of motion, the excess stress puts a strain on the ligament. If the strain is great enough to the ligaments past the yield point, then the ligament becomes damaged or sprained.
The most common mechanism of injury is an inversion injury affecting a plantar flexed and weight bearing foot. In this injury, the anterior talofibular ligament is most at risk of sprain.
What is flat foot?
Implies the medial Arch of the Foot has collapsed so that the medial border almost touches the ground
Most young children appear this way as their arches haven’t fully developed and they have a lot of subcutaneous adipose tissue in their foot.
What does flat foot result from??
Excessive stretching of the spring ligament and plantar aponeurosis
Stretching of the ligaments results in the Tatar head being displaced inferomedially flattening the medial longitudinal arch and producing some lateral deviation of the foot.
How can flat foot develop in adulthood and what are the risk factors?
- prolonged stress
-normal ageing process (tibialis posterior dysfunction is a common cause as it helps support the arch of the foot whilst walking)
- pregnancy (increased laxity of ligaments)
What foot diseases can occur with diabetes mellitus?
Destruction of the tissue of the foot
What’s charcots arthropathy and how do patients feel?
Involves progressive destruction of the bones, joints and soft tissue, most commonly in the ankle and foot.
A combo of neuropathy, abnormal loading of foot, repeated microtrauma and metabolic abnormalities of bone leads to inflammation causing osteolysis, fractures, dislocation and deformities.
Patient has reduced ability to feel touch, temperature and pain due to neuropathy. It also leads to muscle spasticity e.g tight Achilles’ tendon, which exacerbates the deformity.
A rocker bottom foot may develop.
What is compartment syndrome?
Trauma to facial compartments may lead to haemorrhage and/or oedema and cause a rise in intracellular compartmental pressure = compartment syndrome
What are the clinical signs of compartment syndrome?
- severe pain in limb which is excessive for the degree of injury, increasing and not relieved by analgesia
- pain is exacerbated by passive stretch of the muscles
If suspected, surgical decompression should be done on all affected compartments.
What are the short term consequences of compartment syndrome?
Increase in intracompartmental pressure leads to decreased perfusion of the muscle. Ischaemic muscle releases mediators which further increase capillary permeability and exacerbate the rise in intracompartmental pressure. In severe untreated cases, rhabdomyolysis and acute kidney injury can result
Nerovascular signs develop lat in the process and are often underdeveloped at the time of diagnosis. If the compartment pressure exceeds the systolic arterial pressure there will be a loss of peripheral pulses and increased capillary refill time. Nerve fibres are susceptible to ischaemia, the thin cutaneous nerve fibres are affected more quickly than motor fibres so distal paraesthesia precedes loss of motor function .