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The Ankle/Foot

Anatomy: -Blood supply: Anterior tibial artery (>dorsalis peds>tarsal artery>arcuate artery)+posterior tibial artery (>medial/lateral plantar artery>plantar arch>digital arteries) -Venous drainage: Great saphenous vein(>dorsal venous arch>digital veins)+small saphenous vein -Lymphatic drainage: (consider lymphadenopathy) Medial superficial lymphatic vessels<superficial inguinal lymph nodes (great saphenous) <deep inguinal (femoral vein) Lateral superficial lymphatic vessels <popliteal lymph nodes -Nerve supply: Foot: Tibial nerve(>medial/lateral plantar nerves)+sup/deep fibular+sural nerve (<tibial nerve+ common fibular nerve) +saphenous+ medial (<tibial) and lateral (<sural) calcaneal branches. Ankle: Tibial and deep fibular -Dermatomes: -Bones: - 5 distal phalanges, 4 middle phalanges, 5 proximal phalanges - 5 metatarsals - navicula, cuboid and 3 cuneiforms - calcaneus and talus - Joints: - 4 distal interphalangeal joints (DIP) of toes 2-5 st - Interphalangeal (1 IP) of great toe and proximal interphalangeal joints (PIP) of toes 2-5 - metatarsophalangeal (MTP), 5 -intermetatarsal -tarso-metatarsal (TMT), 5 -transverse tarsal joints: calcaneocuboid, talonavicular -subtalar -ankle joint

Structure

Ligaments

Type: Hinge-type sinovial joint Articular surfaces: distal end of tibia and fibula and sup aspect of talus Lateral collateral: anterir talo-fibular, post talo-fibular and calcneofibular Medial collateral (deltoid lig): sup: Tibio-navicular, calcneo-tibial, post. Talo-tibial //deep: ant talo-tibial Type: post: plane//ant: ball and socked Articular surfaces: post: talocalcaneal //ant: talocalcaneonavicular

Subtalar joint: Structure

Ligaments

Post: Interosseous talocalcaneal ligament//ant: spring ligament Medial, lateral and post talocalcaneal ligament Transeverse tarsal joints: Calcaneocuboid and Talonavicular Structure Type: calcaneocuboid: plane joint talonavicula: ball and socked Ligaments Spring ligament (calcaneonavicular lig) Long plantar ligament Short plantar ligament Bifurcated ligament (calcaneo-cuboid +calcaneo-navicular) Tarsometatarsal (TMT) st 1 TMT Synovial saddle st st 1 Met + 1 cuneiform dorsal, plantar, and interosseous ligaments

2 -5 TMT

nd

th

Synovial plane nd st nd 2 Met + 1 and 2 cuneiform rd rd 3 Met + 3 cuneiform th rd 4 Met + 3 cuneiform and cuboid th 5 Met + cuboid dorsal, plantar, and interosseous ligaments Synovial plane

Intermetatarsal joints (IMT) Metatarsophalangeal (MTP) MTP

Metatarsal + proximal phalanx Synovial condylar/ellipsoid Flex/ext/abd/add/circumduction 3 lig: plantar, collateral and deep transverse(links heads of Mets together) st 1 MTP has 2 sesamoid bones Synovial Hinge joint Flex/Ext 2 lig: plantar + collateral Medial Superior and inferior. Inferior being Y shaped band Superior and inferior Medial: Bones: clacaneous, talus, navicula, 3 cuniforma, 3 Met Lig: Plantar aponeurosis, spring lig, ant fibres of deltoid lig Musc: FHL, TP, TA, PL, EDL Lateral: Bones: Calcaneous, cuboid, 4 and 5 Met Lig: Long plantar ligament Tarsal arch: cuboid, navicula, cuneiform. PL Posterior metatarsal arch: ADD hallucis Anterior metatarsal arch: intrinsic muscles and ligaments EDB, ADB H, FDB, ABD b Quadratus plantae, Lumbricals FH b, Add H, F minimus b, dorsal interossei, plantar interossei
th th

Interphalangeal joints (IP) Distal & Proximal

Retinaculum Flexor Extensor Peroneal Arches: 2 longitudinal

3 transverse arches

Muscles: superficial group 2nd layer deep group Function: ANKLE JOINT

-Provide mobility in plantar flexion and stability in dorsi-flexion, allowing the ankle to fulfil its role of weight transmission and locomotion; [stability and mobility].
- dorsi-flexion the fibula is directed laterally, superiorly and into slight medial rotation by the shape of the mortise, so guiding the talus medially. So on dorsi flexion in the weight bearing stance phase of walking, as the talus moves medially under influence of the rotating fibula these ligaments (spring ligament) become tense to maintain the position of the talus.

-The stabilising collateral ligaments extend from the malleoli inferiorly on each side, with the fibular malleolus extending lower than the medial malleolus and the axis of movement running roughly through its centre. So ligaments running from this malleolus coincide with the axis of movement and are therefore tense throughout all movements except eversion. Medially the ligaments vary in tension throughout movement. - inversion strain, due to the shortness of the medial malleolus, it may act as a pivot against the talus causing avulsion of the ligaments laterally or even fracture of the lateral malleolus (spiral)

- Toe-off: As the medial arch of the foot is flattened by the weight force, not only is the arch restored by the contraction of the muscles in the plantar fascia but also the active contraction of tibialis anterior and posterior, peroneus longus, extensor digitorum longus and extensor hallucis longus as the toe-off is approached. This also helps maintain the position of the talus, particularly as tibialis posterior runs under the sustentaculum tali. FHL supports the talus posteriorly. - The joint capsule is thin A-P but thick Med-Lat FOOT: 1. Provides a stable platform for weight bearing; normally the weight-bearing areas are the st metatarsal heads (2/3 1 MTT, 1/3 rest 4 MTT) and posterior portion of the calcaneum. The centre of gravity on standing falls between the heel and the forefoot through a line joining the navicular tubercle medially and the base of the fifth metatarsal. 2. Provides mobility to support locomotion and also to allow for variation in ground surface below and abnormality of gait from above. Medial adaptability and lateral stability. Medial: Raised nature of the medial arch, talonavicular joint Rotations: occurs mainly at the sub-talar joints and the navicular cuboid articulation. The intertarsal joints give suppleness 3. Force dissipation from above and below: trabeculae and their bony shape up into the soft tissues of the calf, and also by arch capacity to flatten temporarily. 4. Proprioception to inform static and dynamic posture.

Common Problems: Pes planus Collapse of the plantar vault due to weakening or fatigue of the muscular and ligamentous support. In children mobile pes planus is normal due to ligamentous laxity and usually disappears as the child grows. Supportive orthotics or physical exercises may be indicated in some cases, when excessive wear is shown on one aspect of the childs shoe. Rigid pes planus in children is less common and involves a persistent arch deformity on- and offweightbearing. The rigidity is due to muscle spasm / tarsal joint abnormalities. This type should be investigated and the precise cause should be treated In adults, pes planus commonly occurs later in life and usually is associated with ligamentous laxity or O/A changes. Other causes include poliomyelitis, R/A or tendon ruptures. There may be pain on walking or prolonged standing. Navicular tuberosity will be prominent on standing and there will be a valgus deformity at the ankle. Treatment is normally symptomatic. Meyers line, Feiss line, Helbings line Pes cavus The arch is abnormally high and is often associated with a varus strain through the heel and clawing of the toes (due to the pull of the long extensors). The foot is shorter than normal (due to shortening of the foot flexors).This can occur as a result of a congenital problem but can also be acquired due to neurological problems affecting the intrinsic foot muscles. Commonly a patient presents with pain over the plantar aspect of the metatarsal heads because of their prominence (dropped metatarsal heads). It can be associated with other conditions such as spina bifida occulta, peroneal muscular atrophy, Friedreichs ataxia and poliomyelitis. Treatment is often unnecessary however repositioning of tendons and joint fusion may be considered.

Hallux rigidus

This causes extreme stiffness of 1 MTPJ. It is secondary to conditions st such as O/A, local trauma, osteochondritis dissecans of 1 met head and gout. It affects men more often than women and the pain is aggravated by walking up slopes or high heels. There is gross reduction in dorsiflexion usually by osteophytic growth. A patient will roll their weight around lateral edge of foot to avoid stressing the hallux. Treatment initially conservative, rocker-soled shoes or very firm soled shoes, thus reducing the need to dorsiflex when walking. Surgical treatment will remove osteophytes and undertake an osteotomy of proximal part of 1st phalanx. Arthrodesis of 1st MTPJ or replacement of 1st MTPJ are other possibilities A very common condition with an unknown cause. Most common in 50+ st women often with a strong family history. Varus of 1 metatarsal predisposes to an increased hallux valgus. It is often asymptomatic, but if there is pain it may be due to: st bursitis over the 1 MTPJ (bunions) hammer toe deformity metatarsalgia st O/A of the 1 MTPJ Treatment can be symptomatic using sponge pads, splints while corrective treatment is surgery either: st osteotomy of 1 metatarsal (adolescents) release of AddH tendon on lateral side of Hallux and possibly st trimming head of 1 metatarsal rarely fusion of 1st MTPJ not completely successful as all surgical options remove/ modify the normal function of the joint and hence reduce the natural push off while walking P.F: Metartasus varus, footwear, pes planus st nd This is metatarsalgia of the 1 and 2 Met normally due to abnormal mechanics of the area: st -Short 1 Met st -Excessive mobility of the 1 Met at its base -Post displacement of the sesamoids nd -Thickening of the shaft of the 2 Met due to excessive wb leading to callus formation and depression of the transverse arch An entrapment neuropathy of the interdigital nerve may be due to formation of a neurofibroma of the digital nerve. It is a swelling that normally forms where rd th the interdigital nerve branches into the digits normally at the 3 and 4 toes Pt wants to keep the shoes off and tends to complain of P&N and numbness The PIP is fixed in flexion with hyperextension of DIP, it is not painful of itself, but causes corns and calluses which are. May require corrective surgery if severe

st

Hallux valgus

Mortons syndrome

Mortons neuralgia

Hammer toes

Osteochondritis Characterized by interruption of blood supply in particular to the epiphysis, followed by localised bony necrosis and later regrowth of the bone in the shape adopted after the necrosis phase. Usually self limiting, lasting less than 3 years and spontaneously re-hardenening Unknown aetiology, however onset often relates to trauma or stress on the area affected This is an avascular necrosis of the navicular. There is pain in the hindfoot and the navicular is tender to touch. It causes mid tarsal pain and limp.child tends to weight bear on lateral foot. The bone reforms over subsequent 2-3years original shape is changed,

Kohlers O/C (navicular)

but there is a good functional result X-ray: Shows squarer and denser navicula Ttt: rest and occasionally plaster cast

Freiburgs O/C (2nd metatarsal head) Paratendonitis

Affects the 2 met head, normally in adolescents and tends to be asymptomatic st until the deformity predisposes to early O/A of the 1 MTP joint. X-Ray shows dorsal displacement of the head. Causes stiffness, O/A and altered foot mechanics The Achilles tendon is protected by paratendon, a cross between a bursa and a fascial sheath. It reduces friction but also protects the tendon. However, if the paratendon becomes tight or suffers trauma it tends to stenose preventing the tendon from running freely, causing pain on excess use, and may become inflamed. Here a bursa exists to protect the tendon and its paratendon from friction with skin and any footwear. It tends to be prone to trauma from badly fitting shoes and becomes red and swollen. This may cause a reduction in comfortable heel movement and so problems elsewhere. It commonly occurs in runners and ballet dancers, where, if chronic, excision may be attempted. Osteochondritis of tha calcaneous causing necrosis. calcaneal apophysitis repeated microtrauma at attachment of Achilles tendon > 10-13 yrs (cf Osgood-Schlatters) if severe a short cast for 2-12 weeks It usually resolves in about a year without treatment, however occasionally a small heel raise (put into both shoes) is sometimes used to reduce tension on the insertion. Inflammation of the pad of fatty tissue under the promince of wb part of the calcaneum. Normally due to changes in wb mechanics: shortening of grastrocs complex, altering the part of the calcaneum that is in contact with the ground; development of pes planus putting different stress on the heel. Simply due trauma with hard surfaces. Tenderness under the heel and pain on standing and walking. Inflammation of the plantar aponeurosis at its attachment to the heel, normally due to overuse. The fascia may fatigue and give ischaemic pain. There may be an associated bony spur at insertion point that may be the site of pain. There is tenderness on palpation esp. over insertion points. Pain on standing and walking. Agg: exx . PF: ant wb, weight increase and pes planus. Ttt may just involve soft heel pads (with a hole over the calcaneal spur) and arch support for a while to ease pressure or NSAIDs and ice. Persistent/severe cases may require cortisone injections but these are painful and success is limited. Excision of the calcaneal spur may be necessary again with limited success Proliferation of bone on the plantar surface of the calcaneum and into the plantar fascia. Due to pressure or traction on the calcaneum causing osteoblastic activity, often associated with plantar fasciitis. There tends to be point tenderness on the heel and X-Rays confirm diagnosis. Formation of a nodule in the fibrous tissue of the fascia. Uncommon but may be associated with Dupuytrens contracture of the hand or be trauma related. Can be pre-cancerous and excision may be performed if its nature is in doubt, but may recur Result of a vertical compression force, such a fall. There will be difficulties wb and heel will appear broad as inflammation fills the hollows. If minor, prognosis

nd

Posterior tendoachilles bursitis

Severs disease

Inferior Calcaneal bursitisTender Heel Pad

Plantar fascitis

Calcaneal spur

Plantar fibromatosis

Calcaneal #

O/A subtalar joint

avulsion fracture

Pott's fracture, (Dupuytren fracture) Avascular necrosis of the talus (# Neck)

march fracture Charcotts foot

is good, but if it involves the sub-talar joint then can be serious. Check for spinal # and future possibility of O/A Wear and tear process which affects foot mechanics Causes: bone eburnation, osteophytes, cysts, narrowing of the interart space PF: previous calcaneal # or severe pes planus treatment generally the same for sprained or fracture; but if avulsion is severe may require a cast for 6-8 weeks. commonly at the ankle usually lateral malleoli following a severe force via the ligament(s). These either resist, tear (sprain) or avulse the bone at its th attachment. + Base of the 5 Met due to spasmodic contraction of fibularis brevis after of ankle sprain. need to X-ray to confirm diagnosis a bimalleolar ankle fracture. Injury is caused by a combined abduction and external rotation of the foot from an eversion force. An avulsion fracture of medial malleoli (at attachment of deltoid ligament), the talus forced laterally and fractures fibular malleoli or superior to syndesmosis. trauma and nontraumatic. In the case of trauma, a fracture (breaking) of the bone disrupts the blood supply to the bone leading to AVN. There are many causes of nontraumatic AVN. These include idiopathic (no cause is ever found), steroids (eg. anabolic and high dose corticosteroids (prednisone) given for such diseases as rheumatoid arthritis, lupus, and cancer), excess alcohol consumption, sickle cell anemia, radiation treatments, and chemotherapy. Stress fracture of the shaft of 2nd or 3rd metatarsal after heavy or unaccustomed exercise neuropathic joints, often called Charcot joints, are caused by loss of sensation in the joint so that it is severely damaged and disrupted A common medical condition where one or more of the ligaments of the ankle is torn or partially torn. The anterior talofibular ligament is one of the most commonly involved ligaments in this type of sprain. Approximately 70-85% of ankle sprains are inversion injuries. Ankle sprains are classified as grade 1, 2, and 3A grade 1 sprain is defined as mild damage to a ligament or ligaments without instability of the affected joint. A grade 2 sprain is considered a partial tear to the ligament, in which it is stretched to the point that it becomes loose. A grade 3 sprain is a complete tear of a ligament, causing instability in the affected joint. Bruising may occur around the ankle. In medicine, the Ottawa ankle rules are a set of guidelines for clinicians to help decide if a patient with foot or ankle pain should be offered X-rays to diagnose a possible bone fracture. Ankle X-ray is only required if there is any pain in the malleolar zone and any one of the following: Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR An inability to bear weight both immediately and in the emergency department for four steps.

Ankle sprain

Additionally, the Ottawa foot rules indicate whether a foot X-ray series is required. It states that it is indicated if there is any pain in the midfoot zone and any one of the following: Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR Bone tenderness at the navicular bone (for foot injuries), OR An inability to bear weight both immediately and in the emergency

department for four steps.

Anterior tibio-talar impingement spurs

Diabetic foot

Tibio talar spurs and osteochondral lesions of the talus are the most common osseous lesions of the ankle joints. They give chronic inflammatory synovitis, fibrosis and hyalinised connective tissue. They are commonly found after and inversion sprain, there is a prevalence of these spurs in athletes and as many as 50 of the dancers are found to have them. Not all the spurs develop symptoms, but, if dysfunction occurs the persisten pain and swelling over the ant ankle develops. Lat X-Ray view, sometimes just seen in MRI Ttt: Heel raise to surgery Microneurovascular dysfunction, loss of nocicepative reflex and inflammatory response. Foot problems are very common in diabetics due to the effects of the peripheral vascular disease causing claudication, trophic skin changes, ulceration and gangrene. This can often result in the amputation of the lower extremity: 1. Peripheral vascular disease causing claudication, trophic skin changes, ulceration, gangrene 2. Peripheral Neuropathy may cause foot/ankle defor mities and even Charcots joints 3. Osteoporosis 4. Infection

Foot drop

Foot drop can be caused by nerve damage alone (common peroneal &piriformis). However, it is also caused by muscle or spinal nerve trauma, abnormal anatomy, toxins or disease. Diseases that can cause foot drop include stroke, Amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease), muscular dystrophy, Charcot Marie Tooth disease, multiple sclerosis, Cerebral palsy and Friedreich's ataxia. It may also occur as a result of hip replacement surgery.

Rheumtological conditions: Unilateral O/A: Talo-crural O/A, subtalar O/A, Hallux Rigidus

Def: a non inflammatory degeneration of synovial joints marked by degeneration of the articular cartilage, hypertrophy of bone at the margins with associated changes in the synovial membrane Age/Sex: 2F:1M, 55 Aetiology: Primary: Non underlying cause Secondary: congenital/developmental, metabolic, inflammatory, traumatic Pathophysiology: Breakdown of articular surface, synovial irritation,remodelling,eburnation & cyst formation, disorganisation Clinical signs & symptoms: Onset: Insidious Symptoms: Burning/Aching, stiffness, crepitus/clicking Pain behavior: Agg:activity,PM + Rel: Rest

Signs: Swelling, crepitus, reduced ROM, wasting, deformity Test: X-Ray: Reduced joint space, subchondral sclerosis, osteophytic grow, deformity, subchrondral cyst Reiters/reactive Def: Inflammatory arthritis as a result of an infection elsewhere in the body. Age/Sex: 5M:1F, 20-40 Aetiology: Pt gets an infection as GI/STD. 2-6 weeks later abnormal immunological response will occur. HLA-B27 Pathophysiology:Immune system tries to fight the infection, so inflammation ensues. Scraps of the bacteria travel to the joints and triggers arthritis. Signs and symptoms: pain in the knees when sees and pees Articular features: Onset: Rapid Symptoms: Unilat knee/foot/ankle, pain, LBP Extraarticular: Fever Urethritis Conjuntivitis Keratoderma blenhorragieum Pericarditis Test: increased ESR, HLA-B27

Psoriatic arthritis

Def: Inflammatory joint disease linked with psoriasis Age/Sex: M:F , 36-46 Aetiology: Stress, trauma, hormonal, infection, genetics (HLA-B27) Pathophysiology: Inflammation of the synovial membrane Articular features: Onset: Insiduous Symptoms:Unilateral distal joint pain, pitting nails, sausage fingers Extra-articular features: Skin lesions esp. scalp Iritis/Conjunctivitis Test: X-Ray: pencil in cup, sacroilitis Increased ESR + HLA-B27

Enteropathic

Def: Inflammatory bowel Disease associated with inflammatory arthritis Age/Sex: M:F , 25-55, 1 in 5 pts with chrons disease or UC may get this

Pathophysiology: Theory 1: AI Theory 2: Gi inflammation leads to increased permeability so more bacterial antigens are absorbed which then lodge in to the MSk causing inflammation Clinical signs and symptoms: Peripheral arthritis/enthesitis Axial arthritis/enthesitis IBS symptoms too Test: increased ESR, HLA-B27, barium meal to identify bowel lesions Def: Inflammatory arthritis of peripheral joint/tendons due to monosodium urate crystal deposition Age/sex: M25:F1, 40-60 Aetiology: Hyperuricaemia (raised uric acid in blood) Pathophysiology: Monosodium urate crystals are high in blood and so they deposit in the synovium and other connective tissue Clinical signs and symptoms: st Onset: Sudden onset (acute inflammatory monoarthritis of the 1 MTP) Test: Joint aspiration, increased ESR and CRP Pseudogout Bilateral: RA

Gout

Def: Chronic systemic inflammatory disease Age/Sex: 3F:1M, 30-40 Aetiology: genetics (HLA-DR4), environmental (viral, bacterial),AI, hormonal Pathophysiology: Inflammatory reaction in the synovium Pannus Effusion distends the capsule and stretches ligaments Laxity, joint deformity and rheumatoid nodes Clinical signs and symptoms:

Other conditions c bilateral presentation: Unilateral: Neural claudication Vascular claudication Billateral: Peripheral neuropathy Diabetes