Foot and ankle - madinaortho.com · unlock the midtarsal joint leading to pronation 3]. Knee...

[Foot & Ankle] Page | 11

Gait • SSTTEEPP = The advancement of a single foot • SSTTRRIIDDEE = The advancement of both feet (one step by each side of your body.) • SSTTEEPP LLEENNGGTTHH = longitudinal distance between 2 feet • SSTTRRIIDDEE LLEENNGGTTHH = distance covered during 1 cycle = 2 step lengths • VVEELLOOCCIITTYY = stride length/cycle time (m/s) • CCAADDEENNCCEE = steps /minute • DDOOUUBBLLEE SSUUPPPPOORRTT = both feet on ground • FFLLOOAATT PPHHAASSEE = neither foot is on the ground

PPHHAASSEESS OOFF NNOORRMMAALL GGAAIITT

• 2 periods of double stance 10% each -at these times the body's centre of gravity is at its

lowest Start End Knee Ankle Muscles

STA

NC

E

60%

1st Contact Heal strike Start of double supp 0º 0º Knee starts flex to damp impact

Loading Start of double support Contralateral toe off 15º 15º PF Hams, TA exessive PF Quad, glutei stabilize hip/knee

Mid stance Contralateral toe off COG over ref foot 0º 0º Calf propulsion & dorsi Terminal st COG over ref foot Contralat foot contact 0° 10° DF Subtalar invert & foot locks

Preswing Contralat foot contact Ref toe off 30° 20° PF Toes dorsiflex at MTP

SWIN

G

40%

Initial swing Ref Toe off Max knee flex 60° 10° PF Quad forward leg swing & heal high rise

Mid swing Max knee flex Tibia is vertical 30° 0° TA Dorsi & subtalar 0°

Terminal sw Tibia is vertical Initial contact 0° 0° Ham forward leg swing control foot position at strike

Running: • The two periods of double support are replaced by periods of double float (NWB) • Heel strikes are more forciful

22 | Page [Foot & Ankle] FOOT • The foot contains: 26 bones & 57 joints

ANKLE JOINT 1]. Syndesmosis between the distal tibia and fibula 2]. A diarthrodial mortise between the distal tibia, fibula, and talus.

• Ankle has a larger WB surface area than the hip & knee joints. • Ankle Mortise is a uniplanar hinge joint é its axis line just distal to the palpated malleolar tips • In the axial plane, the ankle axis projects antero-medially 25° • In the coronal plane, ankle axis projects cephalo-medially 10° • Dorsiflexion eversion of the foot • Plantarflexion inversion of the foot •

Ankle stabilisers Static 1]. Bony conformity: with the malleoli act as butress for talus 2]. Talar shape: narrows posteriorly i.e. ant width > post width;

in PF together é lig tautness provide most of the stability 3]. Interosseous membrane 4]. Ant. & post. Talofibular ligaments 5]. Calcaneofibular ligament 6]. Deltoid ligament 7]. Ankle joint capsule Dynamic 8]. Fibular distal movement during FWB 9]. Proprioception

10]. Muscle tone

Subtalar & Chopart’s joint • The subtalar joint can be modelled as a mitered hinge,

& the Chopard joint as a pivot. • Chopart’s joint = Mid-tarsal = CCJ + TNJ • DDUURRIINNGG HHEEAALL SSTTRRIIKKEE:: Leg IR Heel eversion (subtalar valgus) Chopart is // & unlocks

foot pronates to absorb energy • DDUURRIINNGG TTEERRMMIINNAALL SSTTAANNCCEE && PPRREESSWWIINNGG:: Leg ER Ankle PF Heel inversion (subtalar varus)

Chopart locked in supination (forefoot supination)


Foot motion • Supination = 1]. Heel inversion +

2]. Ankle plantar flexion + 3]. Forefoot varus

• Pronation = 1]. Heel eversion + 2]. Ankle dorsiflexion + 3]. Forefoot valgus

Compensatory Mechanisms in Initial Contact • There are 4 shock-absorbing reactions to floor contact:

1]. free ankle plantar flexion, before the pretibial muscle action catches it.

2]. Leg IR evert the heel & unlock the midtarsal joint leading to pronation

3]. Knee flexion restrained by the quadriceps is the second.

4]. Contralat pelvic drop decelerated by the hip abductors. This occurs as weight is rapidly dropped onto the loading limb (large arrow) as the other limb is being lifted (small arrow).

Distal fibula: • Fibula bears 1/6 WB transmitted downward from the knee during static weight bearing. • The distal fibula moves distally ≈ 2.4 mm when changing from NWB to WB; pulled distally

by the contraction of foot flexors. This distal movement ankle stability by: • Deepening the mortise • Tightening the interosseous membrane • Pulling the fibula medially

44 | Page [Foot & Ankle]

Gait Abnormalities

Approach to a limping child • Assess LLD • Check foot for injury , infection, arthritis • Check knee for swelling, tenderness, instability • Check hip for arthritis, dislocation, Transient synovitis, Perthes’, tumour • General assessment for non accidental injury

Causes of Limp (abnormal gait) in Childhood: 1. Short Leg Limp

o Difficult to discern at maturity If discrepancy is less than 2cm o There is pelvic tilt, short leg ankle equinus; and hip & knee of long leg in flexion

2. Antalgic Limp o Stance phase shortened o More gentle heel-strike in painful limb

3. Trendelenburg Gait (Unstable Hip Limp) [1]. Fulcrum - DDH [2]. Lever - short neck [3]. Motor - gluteus medius weakness e.g. polio, OP

4. Stiff Hip Gait o Increased motion of pelvis on lumbar spine during swing o N.B.- limp minimal if hip stiff (fused) in 25o flexion

5. Stiff Knee Gait o Pelvis raised during swing phase so heel will clear floor

6. Gluteus Maximus Weakness o Hip In hyperextension so centre of gravity behind joint

7. Quadriceps Weakness o ‘Back Knee’ gait - knee locked in hypertension during stance phase o Lurching more marked if also weakness of glut max. o May place hand on thigh to assist o Difficulty with stairs

8. Calf Weakness - Calcaneus Gait o Poor push-off due to calf weakness o ‘Hitch’ at each step

9. Tibialis Weakness – High steppage gait (drop foot gait) o Weakness of pre - tibial muscles o Increased flexion of hip and knee to allow ground clearance heel rise

10. Spastic Gait - Cerebral Palsy o Many patterns - hemiplegia, diplegia o Value of gait analysis; short step, unsteady, failure of foot clearnce at swing

11. Shuffling Gait o In parkinsonism; gait is short, é out lifting one’s feet

12. Stamping Gait (Double Tap) o Proprioception or dorsal column affection; DM & tabes dorsalis o Patient does not feel the ground heel rise & strike + wide base + looks at the ground o +ve Rombergism

13. Ataxic Gait (Cerebellar Ataxia) o Wide base (Feet apart) o Tremors and nystagmus o –ve Rombergism

14. Hysterical Gait o Diagnosis by exclusion & history of emotional upset o Bizarre and inconsistent é CP


TTiibbiiaalliiss PPoosstteerriioorr IInnssuuffffiicciieennccyy • Commonest cause of adult acquired flat foot

Anatomy of the foot arches Medial Arch Lateral Arch Transverse Arch

Shape High Arch Low Arch ½ arch

Formation Apex: talus Apex: Talus middle & lat cuneiforms

Ant Pillar: nav, 3cuns, 3MT Ant Pillar: cub + 2 MT Metatarsal bases

Post Pillar: Calcaneus Same

Function Propulsion Wt support Protection

Ligaments 1- Plantar aponeurosis 2- Long plantar 3- Interosseous 4- Spring 5- Deltoid

1- Plantar aponeurosis 2- Short plantar 3- Interosseous

• Deep trans metatarsal

Tendons 1- FHL 2- TA 3- TP 4- Short ms of big toe

1- PL 2- Short ms of little toe

1- Proneus Longus 2- TP 3- Transverse head of Add Hal

Bones Negligible Negligible Most important; the wedge shape of the cuneiforms & the metatarsal bases

Causes of flatfoot deformities CONGENITAL TYPE

1]. Flexible: Localized: Asymptomatic, Symptomatic, flexible, or semiflexible flatfoot Generalized laxity: e.g., Marfan, Ehlers-Danlos, Fragile-X

2]. Rigid: Tarsal coalition, residuals of TEV, congenital vertical talus 3]. Flatfoot with an accessory navicular

ACQUIRED TYPE Flexible:

1]. Traumatic: ........................................... calcaneal #, TNJ #, Lisfranc #, TP & Spring lig rupture 2]. OA & RA: ............................................. TNJ, TMTJ 3]. Tumor

Rigid: 4]. Neuromuscular: ................................ CP, Polio, Charcot 5]. Posterior tibial tendon dysfunction

AAeettiioollooggyy ooff TTiibbiiaalliiss PPoosstteerriioorr IInnssuuffffiicciieennccyy

1- Congenital accessory navicular 2- Trauma 3- RA ......................................................... middle age 4- Degenerative tendonopathy ....... old age

PPaatthhoollooggyy:: • Normally TP is the most important for push-off & hind foot inversion (a movement that locks

the midtarsal joint this locking is crucial for push off) • TP vascular supply depends on the synovial diffusion & segmental blood supply • In PTTD: Tear occur at ! hypovascular zone 3-5 cm prox to insertion (distal to MM 1-2cm) • TP loses its excursion elongate attenuation rupture

o Weak push off o Midtarsal collapse oo Unopposed peronei exaggerate the condition

66 | Page [Foot & Ankle] DDiiaaggnnoossiiss

C/O 1]. Post-malleolar or arch Pain 2]. Progressive Flat Foot 3]. Complication: HHAALLLLUUXX VVAALLGGUUSS, metatarsalgia, lesser toe deformity, TTAARRSSAALL TTUUNNNNEELL $$ O/E • Flat foot:

1]. Too many toes 2]. Planovalgus deformity & Achilles lateral deviation (Helbing’s sign) from behind 3]. Midtarsal thrust

• Tibialis posterior 4]. Post-malleolar Tenderness Tenosynovitis 5]. Swelling

• Insufficiency: 6]. Single heel rise (+ve) Degeneration (can’t stand on single tip toe) 7]. MT1 Rise TTEESSTT (+ve) Elongation (tibial ER rise of MT1 even if told not) 8]. Double heel rise Attenuation 9]. Jack wind Disruption (DF of 1st MP fail to correct the planus)

10]. Individual joint flexibility test for fixed deformity é arthrosis Imaging Blackburn Deformity Series (also in pes cavus and deformities)

1]. Standing HHIINNDDFFOOOOTT AALLIIGGNNMMEENNTT view: shows where the valgus is 2]. Standing LLAATTEERRAALL foot show talonavicular j & Meary’s angle 3]. Standing AAPP forefoot and talometatarsal alignment 4]. MMRRII best technique for assessing tendons

PPaatthhoollooggyy::

Meyerson classification

Stage I Stage II Stage III Stage IV Stage V Pathology Peritendonitis Degeneration Elongation attenuation Disruption Excursion Normal Normal Short Insufficient Insufficient Pain After activity Mild medial Mod/ severe lateral Ankle Forefoot Normal Normal Supinated (due to mid tarsal attenuation) Hindfoot Normal Normal Flexible valgus Fixed valgus (subtalar arthrosis) Talus Normal Normal Normal Normal Valgus 1 heel rise - painful + + + MT1 rise - - + + + Too many toes - - + + + Conservative Cast 6-8 wk +

NSAID then AFO Medial arch support + Hinged AFO

Same + steroid inj. in sinus

Rigid AFO Rigid AFO

Operative Tenosynovectomy + FDL transfer Or calc. osteotomy

TP debride + FDL transfer Or calc. osteotomy

FDL+calc.osteot. Or + CCJ bone block fusion

TF Pantalar fusion


Tendo Achilles Tendinitis Tendinosis = tendon degeneration without associated inflammation Peritendinitis = tenosynovitis Tendinitis = inflammation of the tendon PPaatthhooggeenneessiiss::

• Tendinitis occurs in the hypovascular area 2-6 cm above the tendon insertion. • Normally tibia ER in extension; if the foot is over pronated coupled IR of the tibia; so in

over pronated foot there is stress conflict imposed on TA Hypovascular microtears AAeettiioollooggyy

Inserional 1- Over loading of musculotendenious junction:

o Over-training, hill running o Poor running shoes o Running on uneven terrain o Insufficient gastrosoleus strength or flexibility

2- Inflammatory conditions: RA, Reiter’s, AS, Gout Non insertional 3- Functional over-pronation (tibia vara or foot varus) 4- Para-tendinitis may occur in association é tendinitis or as a separate entity

CClliinniiccaall • History of change in training habits. • Tight TA • Heel alignment may be in varus • Localised tenderness + swelling in tendon

RRaaddiioollooggiiccaall • PPAAVVLLOOVV PPAARRAALLLLEELL PPIITTCCHH LLIINNEESS: a line between the anterior

and medial calc tubercles & the other line is // to it from the posterior margin of the posterior calcaneal facet

• MMRRII; distinguish paratenonitis (fluid in the sheath) form tendonitis (class c signal oedema inside the endon)

Insertional Non-insertional Pathology • Involve posterosup. Calc. tubercle

(Haglund’s) & retrocalcaneal bursa 1- Hypovascular degn 3-5cm above insertion

• often associated é calc.bony prominence 2- Paratenonitis ± nodular TA thickening Clinically • Heal pain & swelling • Heal cord pain & swelling

• ± varus heal or tibia vara Conserve 1]. Eccentric calf stretch & physiotherapy

2]. Heal rise (Modify ! heal counter + calc inclination move bursa away from TA)

3]. AFO to overpronation 4]. Avoid steroid

1]. Eccentric calf stretch & physiotherapy 2]. Heal rise 3]. Rest, Ice 4]. Med arch support 5]. Brisement steroid inj into TA sheath??? 6]. US 7]. Phonophoresis

Operative • Excise the Haglund’s + bursa + debride any degenerated tendon

• TA reinforcement transfer

• Paratenon debridement • Excision of TA nodules if > 2/3 TA thickness + • FDL transfer + • Turndown TA flap technique


Tendo Achilles Rupture AAEETTIIOOLLOOGGYY

1]. middle-aged athletes. 2]. 3rd most frequent tendon rupture 3]. Most commonly:

1- Pushing off with WB forefoot while extending the knee 2- Sudden unexpected dorsiflexion of the ankle 3- Violent dorsiflexion of the plantar flexed foot as in a fall from a height.

PPAATTHHOOPPHHYYSSIIOOLLOOGGYY 1]. Hypovascular area of the tendon 2 to 6 cm above the tendon insertion into the calcaneus. 2]. The major blood supply is via its mesotendon mainly through the anterior mesentery. 3]. With increasing age:

a. anterior mesenteric supply b. Changes in collagen cross-linking stiffness and viscoelasticity

4]. Repetitive microtrauma reparative process unable to keep pace attrition 5]. Long term use of Ciprofloxacin collagen alterations increasing risk of tendon rupture.

DDIIAAGGNNOOSSIISS 1]. Dramatic Acute Pain, Swelling 2]. Palpable tendon defect 3]. Inability to do toe-raise on affected side (weak planter flexion is possible by toe flexors) 4]. SSIIMMMMOONNDDSS squeeze test (= Thompson test in USA) 5]. OO''BBRRIIEENN''SS needle test - A 25-gauge needle is placed percutaneously in the midline of the proximal

tendon. Motion of the proximal tendon indicating continuity is detected by observing the needle when the foot is put through passive range of motion.

6]. MMRRII && UUSS in flexion 20 ° to detect tendon gap & interposition Non-operative Operative Regain of function 75% 90% Re-rupture at 1yr 15% 5% Advantages less minor complications return to sports earlier; less calf atrophy;

better ankle movement Disadvantages Less function More complications; infection, wound

NNoonn--ooppeerraattiivvee TTeecchhnniiqquuee::

1]. Indications: a. Acute <48hr b. No tendon diastasis in 20° flexion by US & MRI c. Non athlete d. Steroid induced

2]. Technique a. POP in equinus 4-6wk b. POP in 3cm raised position 4-6 wk c. POP in neutral position 4-6wk d. Shoe raise for 4-6 wk

3]. Success depends on: 1- Time of presentation 2- Tendon diastasis in 20º flexion (plotted by MRI or US) 3- Presence of huge hematoma or soft tissue interposition repair is non tendinous

4]. Alternative Functional Bracing - starting in 45 º of flexion; the functional brace prevents ankle dorsiflexion but allows ankle plantar flexion.


PPrriimmaarryy rreeppaaiirr

1- Acute & subacute ruptures <4wk 2- Athletes 3- If not acute enough 4- Tendon diastasis Techniques:

1]. Direct Repair é nonabsorbable tension suture, using a Modified Kessler stitch through the stump 2.5 cm from the rupture.

2]. Plantaris reinforcement 3]. Percutaneous Repair Webb & Banister via 3 posterior transverse incisions - the middle one

at the level of the rupture & the other two 5cm prox. & distal. Make the proximal incision slightly medial (to avoid the sural nerve).

4]. Ma & Griffith: Uses medial & lateral percut. wounds risk of sural n entrapment. 5]. Post-op: same as in conservative management but é 2wk intervals & return to sport after 8m

Reconstructive operations: ffoorr nneegglleecctteedd rruuppttuurreess:: ((>> 44wwkk))

Options: 1- Tendon diastasis <3cm .......... Lindholm Turndown flap ± Teuffer augment 2- Tendon diastasis 3-8 ............... Abraham V-Y advancement é the v arms being 1½ the

length of tendon gap ± Teuffer 3- Tendon diastasis >8 ............... Bisworth Achilloplasty


Peroneal Tendon Ruptures Pathogenesis: • Injury of the etendon swelling proximal to bony fulcrum (LM for PV & cuboid tunnel for

PL) tendon excursion tendon more susceptible to injury Sobel Classification

Level Tendon Restraint Pathology Clinically Zone I LM PB Superior Peroneal

Retinacula 1].Tendinites 2]. Attritional splits 3]. Dislocation

Mimic ankle sprain

Zone II Cuboid tunnel Lat Calc Wall

PL Bony truph Os Peroneum Lateral foot pain

Pathology: ZZOONNEE II 1- Dislocation:

Aetiology: 1- Lax SPR may lead to PB sublux 2- Lat. Malleolar geometry:

• 80% stable concave • 20% narrow sulcus sublux

3- Severe inversion inj SPR avulsion ± fibular rim # • Clinically may mimic lat. ankle sprain é point tenderness over ATFL or

retromalleolar “usually reports treatment as chronic sprain” 4- Peroneus quartus anomaly PB entrapment in Zone 1 Clinically: • Ask the pt to dorsiflex while resist in plantarflexion dislocation

2- Tendinopathy: • Confuse é lateral ankle instability • Retromalleolar crepitus • Rupture DD

1]. Post ankle impingement 2]. Sinus tarsi $ 3]. Subtalar arthrosis 4]. Lat. Ankle instability

Treatment: 1]. Conserve

• RICE: rest, ice, compression, elevation 2]. Operative:

a. SPR: i. Direct repair ii. Soft tissue augment (fibular periosteum) iii. Deepening of fibular groove or Bone block iv. Rerooting under calcaneo-fibular lig.

b. Tendon nodule excision + debridement + tenodesis to PL


ZZOONNEE IIII

AAeettiioollooggyy: 1]. Acute: inversion injury os peroneum fracture 2]. Chronic: tenosynovitis

CCPP:: 1]. Lat foot pain 2]. Weak MT1 plantar flexion 3]. Chronic: Lateral instability

PPXXRR: Proximal migration of os peroneum # DDDD: multipartite os peroneum (Tc) TTTTTT::

1- Acute repair + os peroneum excision 2- Chronic:

POP 6-8 wk Debridement Os peroneum excision + proximal PL tenodesis to PB

• NB: loss of PL function pes cavovarus

Tibialis posterior tendon injury Tears bet inferior retinaculum & insertion of the tendon into the medial cuneiform & MT1 AAeettiioollooggyy: attritional injury 2ry to exostosis CCPP::

1]. Steppage gait 2]. Unable to heel walk

TTTTTT:: 1]. Acute: 1ry repair 2]. Chronic: extensor ms transfer


Osteochondritis Dissicans of the Talus AAeettiioollooggyy::

• Post-traumatic or idiopathic osteonecrosis Posteromedial lesions: ..................................................... (55%)

• Impaction of talus on tibia, as plantar-flexed ankle is forced into inversion & ER • these lesions are deeper and cup shaped

Anterolateral lesions: ........................................................ (45%) • Impaction of talus on fibula as dorsi-flexed ankle is forced into inversion • these lesions tend to be shallow

EExxaammiinnaattiioonn::

• palpate just posterior to the medial malleolus with the ankle dorsiflexed RRaaddiiooggrraapphhss::

• Osteochondral # may be anterior or posterior to dome, requiring plantar or dorsiflexion of ankle to be visible on mortise view

• if radiographs are negative consider repeat radiographs in 2-4 weeks • Hawkin’s sign: is the subchondral radiolucency that appear é

revascularization RRaaddiiooggrraapphhiicc CCllaassssiiffiiccaattiioonn::

PXR findings may or may not correlate ώ arthroscopic findings nor prognosis

Berndt & Harty PXR Staging I: Subchnodral Compression # II: Partially detached fragment III: Completely detached, non-displaced fragment IV: Detached and Displaced fragment V Radiolucent fibrous defect (LLOOOOMMEERR’’SS modification of the same classification)

Bone Scan: (100% sensitive) a Negative TC = No OCD CT for accurate delineation of bony lesion MR Scan: for Dx & staging (very sensitive & detect bone œdema)

Hepple MRI Staging 1 Articular damage only 2 a

cartilage injury + underlying fracture bone œdema

b No bone œdema 3 detached & undisplaced 4 detached & displaced 5 subchondral cysts

TTrreeaattmmeenntt::

1]. NNOONN OOPPEERRAATTIIVVEE TTRREEAATTMMEENNTT: - no evidence that non wt bearing cast offers improved results over wt bearing casts; - no evidence that patients need to be immobilized if they are kept non wt bearing


22]].. OOPPEERRAATTIIVVEE TTRREEAATTMMEENNTT::

OOCCDD

<12 y Usually heal

spontaneously

>12 Usually

progress

Usually heal spontaneous

• PWB

• ROM

Anterolat

AARRTTHHRROOSSCCOOPPIICC

Posteromedial

MMAALLLLEEOOLLAARR OOSSTTOOEETTOOMMYY

Stage I Stage II, III

Fixation

Stage D

Fragment removal and reconstruction

(usually swollen and larger)

Drilling via single puncture

Or Retrograde transtalar

drilling via sinus tarsi

Biodegradable

Metal • Herbert Screw • K-wire

Osteochondral • OATS • Allograft

Cartilage alone • ACI • MACI

Soft tissue coverage

• Periosteal • Fascia

Matrix scaffolds • Collagen • Carbon fiber • PLA

Different types of chondroses Osteochondrosis Disease Site AVN 1]. Legg –Clave-Perthes’ disease. Upper Femoral Epiphysis Crushing 2]. Kienbock’s disease Lunate

3]. Preiser’s disease Scaphoid 4]. Panner’s disease Capitulum 5]. Scheuermann’s disease Vertebral Bodies 6]. Kohler’s disease Tarsal Navicular 7]. Freiberg’s disease 2nd Or 3rd Metatarsal Head 8]. Blount’s Knee ? 9]. Theimann’s disease Multiple Phalanges

10]. Friedrich’s disease Sternal End Of The Clavicle OCD 11]. OCD Knee

12]. OCD Talus 13]. OCD Patella 14]. OCD 1st MT Head 15]. OCD Capitulum 16]. Buschke’s disease Medial Cuniform

Traction apophysitis 17]. Osgood –Schlatter’s disease Tibial Tuberosity 18]. Johansson-Larsen syndrome Patella 19]. severs disease Calcanius 20]. Iselin’s disease Tuberosity Of 5th MT 21]. Mandl’s disease Greater Trochanter


Osteochondroses Of The Foot & Ankle SEVER'S DISEASE

• Pain at Achilles tendon insertion • usually 8-12 years old • density + fragmentation of calcaneal apophysis - normal variant • symptomatic treatment

KOHLERS'S DISEASE • AVN of navicular • very rare usually 4-8 years old (Brailsfords disease it is the counterpart that occurs in old ♀) • DDx: infection • ttt:

o symptomatic treatment revascularize o may need cast during initial illness o long term prognosis good

ISELIN'S DISEASE • Apophysitis of 5th MT base

FREIBERG'S DISEASE • Avascular necrosis of a lesser metatarsal head with infraction • usually in teenagers or young adults • usually 2nd MT • possibly caused by trauma

Smillie Classification (1967) 1 # alone 2 surface contour altered 3 central portion depressed 4 loose body separation 5 Flattening

CClliinniiccaall ffeeaattuurreess

• pain in MTPJ • stiffness • swelling • sometimes large palpable

osteophytes TTrreeaattmmeenntt

Non-surgical management • analgesia • orthosis • shoe adaptation • steroid injections into joint Surgery • simple debridement and cheilectomy • metatarsal head osteotomy • excision arthroplasty


Rheumatoid Foot IInnttrroodduuccttiioonn

5]. 70-90% of rheumatoids have foot involvement 6]. 15% present initially with foot complaints.

SSTTAAGGEESS

Stage 1 synovitis Stage 2 Joint erosion & tendon dysfunction Stage 3 Progressive deformities

CCLLIINNIICCAALL Present with Pain or Deformity.

1]. Forefoot: i. Swelling of the MTPJs

ii. Hallux Valgus iii. Claw toes iv. Bursae, nodules, dorsal corns, plantar callosities v. Morton's neuroma

2]. Hind foot & ankle vi. PTTD

vii. Pes plano valgus (most common) ð PTTD or TNJ or Subtalar arthritis viii. Tarsal Tunnel Syndrome - 2ry to synovitis of contents.

Look for: 3]. Vascular status - PVD or rheumatoid vasculitis 4]. Neurology - neuropathic process more common in rheumatoids. 5]. Tendonitis or ruptures (tibialis posterior, proneal) 6]. Primary deformity - Forefoot or Hindfoot 7]. Which joint is the cause of pain and/or deformity (may need diagnostic injections)

TTRREEAATTMMEENNTT Conservative 1. Medications 2. Footwear - shoes should not be made to correct the deformity, but rather be adjusted to it. Surgery Pre-op precautions:

• Check the positions of the knees & hips (should correct these first for ankle & hindfoot problems)

• Skin condition • Medications - methotrexate & corticosteroids may need to be stopped.


Fusion Position oo 00ºº FFLLEEXXIIOONN EEXXTTEENNSSIIOONN oo 00 MMEEDDIIOO--LLAATTEERRAALL oo HHIINNDD FFOOOOTT VVAALLGGUUSS 55--1100ºº oo EERR 55--1100ºº oo <<11CCMM PPOOSSTT DDIISSPPLLAACCEEMMEENNTT ((

MMIIDDFFOOOOTT LLOOAADDIINNGG))

SSUURRGGEERRYY Ankle Joint 11-- AARRTTHHRROOSSCCOOPPIICC SSYYNNOOVVEECCTTOOMMYY

• useful for cases of marked synovitis & minimal articular damage

22-- SSUUPPRRAAMMAALLLLEEOOLLAARR OOSSTTEEOOTTOOMMYY • for stiff hindfoot in equino-varus.

33-- AANNKKLLEE AARRTTHHRROODDEESSIISS

• Operation of choice: 1- Arthroscopic arthrodesis if minimal osteoporosis & destruction. 2- Intramedullary nail through heel 3- Dowel arthrodesis 4- Square cut arthrodesis 5- Arthroscopic arthrodesis 6- Mini-open Meyerson arthrodesis 7- Charley external fixator if gross deformity

44-- AANNKKLLEE AARRTTHHRROOPPLLAASSTTYY • Indication = severe destruction with a stiff, non-deformed hindfoot (or triple arthrodesis) • 2 main types = 1. semi-constrained (Mayo) and 2. LCS prosthesis. • Failures were awful & complication rates high. • This may be improving with newer designs (eg. STAR prosthesis). • Note requirements for a joint replacement prosthesis are:

1- Permit normal motion 2- Eliminate pain 3- Accept a salvage procedure 4- Give stability 5- Have no adverse effects on surrounding joints 6- Good fixation 7- Tolerate repeated loading

anklereplacementSTAR1



anklereplacementSTAR4 star

Hindfoot • 2 main forms of RA affect the hindfoot:

Type Synovitis Deformity Arthrodesis Loose mobile synovitis Mobile planovalgus Arthrodesis is difficult Stiff dry less synovitis fixed deformity Responds well to arthrodesis

TTrreeaattmmeenntt • Talonavicular fusion - operation of choice for early cases since it will stabilize the hindfoot

by reducing subtalar motion by 90%. • Triple arthrodesis if the deformity is severe - screws are better than staples.


Forefoot

1]. Synovectomy of MTPJs - best synovectomy is excision arthroplasty. 2]. Metatarsal oblique Osteotomies (HHEELLAALL) 3]. Claw toes: DuVries excision arthroplasty or PIP fusion + MTP dorsal capsulotomy 4]. Excision of MT heads + proximal 1/3 Proximal phx 5]. Pobble amputation - amputation of all the lesser toes at the MTPJs - only for severe deformity

& pain.

Tendons 1]. Tibialis Posterior tendon rupture Pesplanus 2]. Tendoachilles insertion rupture Hitching gait (calcaneus gait) 3]. Peroneal tendons rupture Peroneal muscle spasm (pes planus) 4]. Tarsal tunnel syndrome

Other Structures

1]. Neuropathic joints 2]. Rheumatoid nodules (indicative of aggressive disease) 3]. Rheumatoid ulcers 4]. Stress fractures


Hallux Valgus DDeeffiinniittiioonn: it is a big toe deformity in ώ there is:

1]. Bunion: prominent eminence of the MT1 head 2]. Hallux valgus 3]. Hallux valgus interphalangeal 4]. Metatarsus primus varus 5]. Hallux lateral deviation 6]. Hallux pronation 7]. Lateral subluxation of sesamoids 8]. Overcrowded toes

Aetiology 1. HHEERREEDDIITTAARRYY FFAACCTTOORRSS: 60% +Ve Family History:

1]. MMEETTAATTAARRSSUUSS PPRRIIMMUUSS VVAARRUUSS 2]. MMEEDDIIAALL SSLLAANNTTEEDD MMCC11 (First Metatarso Cuneiform Joint) 3]. HHYYPPEERRMMOOBBIILLEE MMCC11 4]. HHYYPPEERR PPRROONNAATTEEDD 11SSTT RRAAYY 5]. AATTYYPPIICCAALL MMTT11 LLEENNGGTTHH

22.. AACCQQUUIIRREEDD • Splayed Foot secondary to weak intrinsics in elders • Fashionable Shoes for women (Narrow toe box & high heal) • Hallux valgus was 70 times more common among shoe wearers

Anatomical Considerations Angles 1]. InterMetatarsal Angle IMTA 2]. Hallux Valgus Angle HVA 3]. Distal Metatarsal Articular Angle DMAA 4]. Interphalangeal joint Angle 5]. 1st MTP joint Congruence

Normal Angle Values IMT <9º. HVA <15º. DMAA <15º.

Stabilizers: • Static:

1]. Bony congruence of MTP & MC 2]. Capsule 3]. Ligaments:

i. Collateral ii. Hood ligament

4]. Sesamoid (intra FHB) stabilized by: i. Their bony configuration ii. Sesamoid ligaments iii. Intersesamoid ligaments

• Dynamic: 1]. Abductor Hallucis 2]. FHB (Flexor Hallucis Brevis) 3]. Adductor Hallucis (transverse & oblique heads)


CCllaassssiiffiiccaattiioonn

HVA IMTA Incongruent MTPJ

Normal <15º <9º No Mild 15-30º 9-15º No Moderate 30-40º 15-20º. Yes (unless abnormal DMAA) Severe >40º > 20º Yes

MMaannaaggeemmeenntt History • Age • What is the chief complaint? • Medial Pain é taking off shoe (≠ OA é WB shod or not) • Intractable plantar keratosis

Examination • Observe gait to see if the hallux is used in its normal push-off

function • See if there is a predisposing factor (liable for recurrence)

o Valgus knee & pes planovalgus & pronated hallux are liable for recurrence o Pronated forefoot o lesser toe deformities o OA, RA o HHYYPPEERRMMOOBBIILLEE MMTT11 by comparing MC1 motion é contralat side & é MC2 (if IMTA >15º)

• Plantar keratosis: IP MTP1 MTP2

Excessive Hallux pronation Equinus Short MT1 Cavus Long MT2 Prominent sesamoid Dorsiflexed or hypermobile MT1 Plantar flexed MT1 Hammer 2nd toe

• Is the deformity Correctable without pain o Check ROM of MTP Joint (after realignment to normal); predict postop mobility o Check ROM of IP Joint (Hallux valgus interphalangeus) o Check ROM of Ankle and Subtalar movement - ? TA tightness

• Grinding Pain on passive movement of MTPJ = MTPJ OA. • Neurovascular assessment

Juvenile Hallux Adult onset IMTA HVA DMAA Congruence Congruent Incongruent

XX--RRaayyss WWEEIIGGHHTT BBEEAARRIINNGG AAPP ++ LLAATT ++ AAXXIIAALL SSEESSAAMMOOIIDD VVIIEEWWSS

1]. Hallux valgus angle 2]. Inter-metatarsal angle 3]. DMAA < 10-15º: between prox articular edge & MT1 axis 4]. Angulation of MCJ1 5]. OA 1st MTPJ and IPJ 6]. JJOOIINNTT CCOONNGGRRUUEENNCCEE 7]. LLEENNGGTTHHSS OOFF TTHHEE 11SSTT && 22NNDD metatarsals 8]. SSEESSAAMMOOIIDD PPOOSSIITTIIOONN & OOAA & CCRREESSTTAA EERROOSSIIOONN (using the metatarsal bisect

method; positions 4-7 = lateral subluxation + cresta erosion soft tissue release)

2200 | Page [Foot & Ankle] Treatment

Non-operative treatment • Treatment should always begin conservatively

1]. Wider shoe with a broader toe box 2]. Low soft heel 3]. Orthoses are not helpful

Operative Treatment • 3 groups:

1]. Congruent joint 2]. Incongruent or subluxed joint 3]. Joint with arthrosis

Ideal Hallux Valgus Surgery • Correction of the IMT and HV angles • Creation of a congruent MTP1 é sesamoid realignment • Bunionectomy is done // and flush é MT1 shaft • Retention of function and ROM of the 1st MTPJ • Maintenance of normal weight bearing mechanics


OOsstteeoottoommiieess PPrroo’’ss aanndd CCoonnss

Precautions and advantages Disadvantages Akin • Mild

• Can correct DMMA • Done é others

Chevron • Mild/mod deformity • Pt >60 y have less satisfactory outcome ð pain & stiff • Stable when fixed • Max displacement 30% (5mm=5ºcorrection) • can correct DMAA (if + med wedge) • AVN 4-20% (does not always mean bad result)

Mitchell • Moderate/severe deformity • Shortens 1st ray • Can plantar flex/displace distal part • Transfer metatarsalgia

Basal • Moderate/severe deformity • DMAA must be <20º.

Keller’s • Low demand pt • No shortening

• Lots • OA

Fusion • If OA, recurrent, salvage • 15º valgus, 10º dorsiflexion

• Non union

Complications 1- Recurrence:

Juvenile HV (up to 30%) inadequate soft release and failure to correct alignment severe ffot pronation metatarsus adductus long or short MT1

2- Hallux varus: esp. in soft tissue proc eg McBride with lat soft tissue release +/- excision of lat sesamoid, overexcision of medial eminence and med reefing

3- Transfer metatarsalgia 4- AVN of MT head - avoid significant distal stripping of both dorso-lateral aspect of MT1 5- Non-union of osteotomy 6- Infection, dehiscence, adherent scar, paresthesia, and slough

Contraindications: 1- Spasticity 2- Equinus contracture 3- Marfan 4- Ehler Danlos 5- Short MT1

Prognosis · 80/90% of patients will have good or excellent clinical and radiological results · The operation is only if pre-operative planning, post-operative positioning and immobilisation

2222 | Page [Foot & Ankle] CCHHEEVVRROONN::

• Osteotomy distal to articular surface by 1cm • Angle of osteotomy 50-60º • Plantar limb is longer (to avoid injury of the metatarso-sesamoid joint) • Every 1mm lateral displacement = 1º correction of the IMTA • width of MT at osteotomy = 15mm Q we can displace only 1/3 of the width ∴ max

correction = 5º in IMTA • It can correct the DMAA if + medial closing wedge • Contraindications:

1- >50 y 2- >15º IMTA 3- >30º HVA

• Complications: 1- AVN head (bl.supply is intraosseous & extraosseous from dorsolat surface ∴ avoid

lateral tissue stripping & DSTP distal soft tissue procedure) 2- Under correction if the indication is stretched

Proximal Osteotomies: 1- Crescent osteotomy:

• Approach via dorsal incision over the proximal 1/3 • Concavity must be face proximal and toward heel to avoid overcorrection • Technically difficult • May produce dorsally united MT1

2- Proximal chevron: • Easy • Avoid the dorsal malunion • More cancellous bone union & more stable

Distal Soft Tissue Procedures (DSTP) 1- McBride

• Elements: 1- Adductor hallucis release (care must be taken not to injure the lat head of FHB

Hallux varus) 2- Bunionectomy 3- Medial capsular reefing 4- Lateral sesamoid excision

2- Mann modification of mcbride: • Elements:

1- Adductor hallucis release and reattached to soft tissue between MT1 & MT2 2- Bunionectomy 3- Medial capsular reefing 4- Lateral capsular release 5- Intermetatarsal ligament release

Indications: • Must be incongruent • Mild Incongruent cases alone (as chevron correct 5º alone) • Moderate to severe Incongruent cases + crescent osteotomy • Passively correctable (not rigid) otherwise DSTP will give no result • No facet at the lateral aspect of the MT1 base (not rigid)


Akin Proximal Phalangeal Osteotomy • 8 mm proximal to the articular cartilage • Medially based osteotomy • Usually combined é other procedures e.g.

Chevron osteotomy Mitchell Osteotomy • Lateral displacement osteotomy of the distal MT • It is a double step plantar flexion osteotomy

(biplaner osteotomy) • Can correct congruent HV either mild or severe

Scarf Osteotomy • Z-shaped distal rotational osteotomy along the MT

shaft • Angulate and displace • Big contact area & better healing and stability • Can correct DMMA in moderate to severe cases

Lapidus • Fusion of the MT-Cuneiform j • ± TA tendon to navicular ± FHL to dorsal surface • The joint is irregular calling for an expert surgeon • May produce shortening and angulation of the

MT1

Hallux Rigidus • Hallux rigidus is a degenerative arthritis that

affects MTP joint as a result of wear and tear on the joint surface over time.

• The condition may follow an injury to the joint or, in some cases, may arise é no well-defined injury

• CP: limited ROM + tenderness • Treatment by:

o Shoe modification o Cheilectomy o Fusion

Hallux Extensus: FHL injury or its sesamoids. ttt: Jone’s transfer Hallux Saltans: FHL triggers at the posteior process of the talus Pseudo Hallux Rigidus: FHL locked trigger at the same site


Ankle Instability Definition • It is the loss of the normal relationship among all parts of the ankle joint along the normal

arc of motion and usually results when the ankle is twisted, or inverted

Anatomical considerations

• Ankle joint stabilizers: ........................... see before • Ankle motions & subtalar .................... see before • Normally:

o Deltoid is the 1ry restraint to abduction o Anterior & posterior capsule are the restrait for AP o ATFL is the 1ry restraint to anterior drawer & inversion o CFL is the 1ry restraint to inversion o PTFL is the 1ry restraint to posterior drawer

Pathophysiology: • Type I collagen density and orientation depends dynamically

on mechanical stress • joint capsule excursion muscle sharing in stress

absorption sprain rate • Ankle joint is a ginglymus synovial joint é combined movement in dorsiflexion &

plantarflexion directions > 100° & bone-on-bone abutment occurs beyond this range • Ankle spurs may occur at any of the bony ligament attachments. An anterior spur observed

on lateral radiograph at the neck of the talus. This occurs ð ossification of organized hematoma associated with anterior ligament sprains.

• CFL ligament is thicker, cordlike, and stronger than ATFL & the PTFL is the strongest and runs horizontally from the inner fossa of the lateral malleolus to the posterior talar tubercle

• A 4th strong lig. -syndesmotic lig- is rarely sprained ð its great strength, but usually occur as a part of an ankle #. It has deep and superficial, (ant & post) portions. This tibiofibular ligament holds the distal tibia and fibula together at the ankle joint and maintains the integrity of the ankle mortice. It takes a great amount of force to strain this ligament, which normally does not have much excursion. A tear of this lig necessitates surgery as widened mortice for a short time ankle OA

Aetiology of Traumatic

• The muscle of inversion is slightly stronger than the foot evertors. When the foot lands in an awkward manner there is a tendency for the heel to invert and create stress on lat ligaments

• The foot is not designed to withstand Inversion Strain as that is not the position of its normal functions & when occurs forces of WB stresses the lateral ligaments especially the ATFL & CFL

• Severe high energy trauma: causes Ankle Syndesmosis injury, “High Ankle Sprain” • Predisposing factors:

o Ligamentous laxity o LLD o Tibial vara & ankle varus o Forefoot valgus o Talar & calcaneal torsion o Uncompensated equinus

o Rigid plantarflexed first ray o Poor muscle tone o Poor proprioception o Inadequate training or experience o Obesity


Diagnosis

Clinically • History of inversion-type twist of the foot &pt can almost always walk on the foot carefully • Pain & Tenderness antero-laterally • Swelling • Bruising • Painful ROM • +ve Anterior Drawer ATFL: (knee

flexed & equinus to relax the gastroc & neutralize any bony stabilizing factor) then compare > 4mm difference or overall 10mm subluxation is +ve

• Prone Anterior Drawer test is done é the pt in prone position é feet hang over the end of the examining table. Pushes the heel forward é one hand & note ant movement & skin dimpling on both sides of the Achilles tendon.

• +ve Inversion/ Eversion Stress Test o With plantarflexion ATFL is more vertical and best to be evaluated o With dorsiflexion CFL is more vertical and best to be evaluated o Neutral position will confirm a diagnosis of double ligamentous disruption o Both ankles are also tested for comparison.

• The Kleiger Test for deltoid ligament. The patient sits é the knee 90° flexed & foot must be relaxed and NWB. The foot is rotated laterally. +ve test pain & talus displace from the medial malleolus, In high ankle sprains this test elicits pain at the syndesmosis

• Squeeze test: both leg bones are squeezed together at the mid calf pain at lower leg. • Cotton test: é distal tibia supported é one hand the other try to displace the foot é fibula lat

Investigations

1]. Plain radiography: AP standing, lateral, and ankle mortise in 15º IR 2]. EUA - Stress x-rays under anaesthesia (GA or peroneal block) ± KT-1000 arthrometer

o Anterior drawer 5mm shift o Inversion talar tilt views 10 º difference (= the angle between the plafond & dome )

3]. Arthrography: 10ml injection into the joint. If > 10ml capsular disruption (not after 5days) o Dye spil laterally = CFL rupture o Dye spil antero-lat =ATFL rupture o Peroneal tenography dye in joint CFL, ATFL, peroneal injury

4]. CT: for associated OCD 5]. MRI: best 6]. US assessment is used by the japannese 7]. Arthroscopy

Treatment

Non-operative: most patients will improve with it In severe strains, protect ankle with pneumatic brace or taping for sports for 3-6mo

Non-Operative Treatment Phase 1 RICE (immobilize in POP for 2-3wks) + brace ± taping (controversial) Phase 2 Peroneal & dorsiflexors strengthening/ TA stretching/Isometric exercise using rubber band Phase 3 Proprioceptive training. When pain & swelling gone. = Wobble Board exercises. Progress thro

functional activities- walking, running, figure-of-eight running, hopping, jumping & cutting.

2266 | Page [Foot & Ankle] Operative Treatment Prior to considerations for surgery, ensure that Subtalar Instability is not present

Indications: 1]. Failed non-operative management 2]. +ve anterior drawer & talar tilt tests clinically 3]. stress x-rays

o Tibiotalar tilt > 20 deg. o Anterior translation > 5mm.

Aims • Restore functional stability. Techniques • The methods of reconstruction fall into two general types:

o non-augmented o Augmented.

Non-Augmented methods: • Brostrom repaired the free ends of the ligaments é fine continuous sutures. • Karlsson reinserted the lig into fibula through drill-holes, but this caused shortening of lig • Gould = Karlsson + repair of lateral talocalcaneal lig

+ suturing of the lateral extensor retinaculum to fibula. This modification is important in patients é subtalar laxity.

Advantages: 1. Restore normal anatomy & mechanics 2. Preserve motion of the subtalar joint 3. No associated donor-site morbidity 4. No eversion weakness ð sacrifice of peroneal tendon 5. Single, smaller cosmetic incision Disadvantages: 1. Inability to achieve stability with only the weak & attenuated local tissues 2. Failure to reconstruct the calcaneofibular ligament adequately 3. Failure to address the relatively frequent problem of subtalar instability.

Augmented methods Employ the peroneus brevis tendon to limit instability of the ankle.

Evans Watson-Jones Chrisman- Snook (preferred) Peroneus brevis tendon is anchored to fibula, limiting inversion of ankle and anterior talar translation indirectly, while also subtalar motion

Evans tenodesis + the graft is routed anteriorly through the talar neck to reconstruct ATFL.

Peroneus brevis graft is brought through the fibula from ant. to post. to reconstruct ATFL. It is then brought post. & inferiorly to the calcaneus to reconstruct CFL.


Preferred Operative Technique: • Longitudinal incision, running just posterior to the prominence of the lateral malleolus. This

incision can be extended to allow harvest of the peroneus brevis tendon if augmentation of the reconstruction is found to be necessary.

• The anterior talofibular ligament and the calcaneofibular ligament are reconstructed. • The ligaments are divided just distal to their fibular attachments. • The joint is inspected and debrided as necessary. • Occasionally, one or both ligaments are avulsed from the fibula with a piece of bone. This

so-called Os Subfibulare should be excised. • The bone at the anatomic attachment sites of

the ATFL & CFL is roughened, and the ligaments are reefed and reattached to the fibula with the use of drill-holes. The repair is oversewn with the proximal stump of the lig to reinforce the repair.

• During the repair: o Ankle in neutral o Foot in eversion

• Augmented reconstruction é peroneus Brevis if:

o ATFL & CFL are so disrupted and frayed that they cannot be repaired

o Hypermobility of the subtalar joint o Previous failed reconstruction of the

ankle. • Expose the peroneus brevis, while maintaining the integrity of the superior peroneal

retinaculum • Anterior third of the tendon is isolated distally and split from the distal position to the

musculoskeletal junction. This tendon portion is transected at its proximal aspect. A drill hole is made through the distal fibula, and the split portion of the peroneus brevis is passed through this hole. The tendon is tensioned with the foot in mild plantar flexion and eversion.

• This augmentation procedure results in significant loss of eversion and inversion.

Post-operatively: 1]. 0-2 wk NWB + BK cast é ankle in neutral and the foot in eversion. 2]. 2 weeks WB as tolerated. 3]. 6 weeks ROM + progressive resistance exercises + proprioceptive exercises 4]. 3 mo full sports activities can be resumed with the ankle taped or braced. • Most athletes should continue to use tape or a brace indefinitely during sports activities, but

bracing is not routine after 3 months for most work-related activities or ADL


1].Ant. Lat malleolar br. ......... 100% 2].Prox Lat tarsal br. ................ 100% 3].Distal lat tarsal br ................. 70% 4].Peroneal artery .................... 30%

Chronic Inversion Injury BBoonnyy LLiiggaammeennttoouuss TTeennddoonn SSoofftt ttiissssuuee

1]. Osfibulare avulsed # 2]. Ant calcaneal process 3]. Lateral talar process 4]. Ostrigonum (Shepherd’s #)

1]. Ankle sprain (ATFL, CFL) 2]. High ankle sprain=syndesmosis 3]. Lat Talo-Calcaneal lig

1]. Peronei 2]. FHL

1]. Ant-lat Impingement $ 2]. Posterior impingement $ 3]. Anterior impingement $ 4]. Sinus tarsi $ 5]. Fibrous TC coalition

ggggggbiiiiiii

Antero-lateral Impingement Lesions • Related to scarring of the lateral talo-malleolar recess (miniscoid lesion):

1- Scarred superior portion of anterior talofibular lig (ATFL) 2- Scarred distal portion of antero-inferior tibio fibular lig (AITFL)

CCPP:: 1]. Antero-lateral ankle pain 2]. Catching & Giving way 3]. Local injection to exclude sinus tarsi pain

TTrreeaattmmeenntt:: • Arthroscopic debridement: Complete AITFL excision + Partial ATFL excision

Sinus Tarsi Syndrome AAnnaattoommyy:: (Talus Bl.supply) ......................................................... see subtalar instability diagram

AA]].. Tarsal Canal: lies obliquely between the TCN joint & TC joint; and contains: 11]].. Anterior and posterior interosseous TC ligaments 22]].. Artery of tarsal canal: from PPOOSSTT TTIIBBIIAALL a. ........ form anastmotic sling with a. of sinus tarsi 33]].. Deltoid a.: supply medial 1/3 talar body .......... branch from the a. of tarsal canal

BB]].. Sinus Tarsi: it consists of the concavity between the talus and the calcaneus at the lateral end of the tarsal canal, 1 finger antero-inferior to Lat Malleolus; and contain: 11]].. Ligamentum Cervicis Tali 22]].. Interosseous TC ligament 33]].. Fibroadipose Tissue ““HHOOKKEE’’SS TTOONNSSIILL”” 44]].. Origin of the EDB 55]].. Artery of sinus tarsi mainly from DDOORRSSAALLIISS PPEEDDIISS branches 66]].. All covered by the root of the inferior extensor retinaculum

PPaatthhooggeenneessiiss:: 1]. Partial tears interosseous Talocalcaneal lig 2]. Lax TC & cervical lig supination at heel strike stretch lateral lig peroneal ms 3]. Scarring of sinus tarsi fat pad 4]. Synovitis

CCPP:: • Pain similar to antero-lat impingement $ • Local inj. into sinus tarsi completely relief the pain • Unstable propulsion on uneven surfaces ð

IINNVV:: • Peroneal EMG before and after local injection

TTTTTT:: • Steroid inj. • Immobilization, peroneal training • Debridement of the scarred fat ““HHOOKKEE’’SS TTOONNSSIILL”” &preserve IO ligament


Syndesmotic Injury (High Ankle Sprains)

FFoorrmmeedd ooff :: 1]. AITFL 2]. PITFL 3]. Transverse ligament 4]. IOM (interosseous membrane)

MMeecchhaanniissmm ooff iinnjjuurryy;; 1]. Pronation ER 2]. Hyper dorsiflexion

CCPP:: 1- Point tenderness over syndesmosis 2- SSQQUUEEEEZZ test: squeeze mid calf pain at AITFL 3- ER stress test: (like Kleiger’s test)

• Knee 90º & foot neutral • ER torque to foot anterior pain at AITFL, PITFL, IOM

4- CCOOTTTTOONN test: • Neutral ankle & subualar • Try to displace fibula posterolateral displacement is +ve

PPXXRR:: 1]. PXR: AP & mortise + ER stress if negative 2]. Tc99 hot spot 3]. High resolution axial CT: demonstrate TTIILLLLAAUUXX CCHHAAPPOOTT occult avulsion #

CCoommpplliiccaattiioonnss:: 1- Fibular shortening +ER ankle incongruence OA 2- IOM heterotopic ossification pain and limitation of dorsiflexion

TTrreeaattmmeenntt:: 1]. Open reduction + cleaning of all soft tissue + syndesmotic screw 2]. IOM heterotopic bar excision

• NB: PITFL may accompant AITFL or syndesmotic inj scarring • ttt: arthroscopic debridement


Subtalar Instability • CFL & Interosseous ligament play a very important role in subtalar stability

AAnnaattoommyy::

• ÆÆttiioollooggyy: inversion injury • CCPP::

o Difficult to differentiate from lateral ankle instability o Tender sinus tarsi

• PPXXRR: may not differentiate form lateral ankle instability

o AP talar tilt o Lateral anterior drawer o 40º stress Broden view: knee 90º , Ankle 0º, IR 40º & Beam 10,20,30.40º cephalad

• TTtttt: o Chrisman Snook o Broström Gould


Posterior Impingement Syndromes Mechanism Of Injury: • full WB in maximum plantar flexion of the ankle • either Demi pointe or full pointe position • 7 -10 % of the population & 50’% bilateral

Types: 1 Os Trigonum Syndrome

• = Talar Compression Syndrome • Occurs In Ballet Dancers

Pathology: o Non-united posterolateral tubercle of posterior process of the talus o United os trigonum is called trigonal process (Stieda’s Process) o When steida is # Shepherd’s # (DD Cedell’s # of postero-medial tubercle of talus)

2 FHL Tendinopathy o = Dancers tendonopathy

Pathology: o FHL tendon passes through fibrocartilagenous retinaculum bet lat and med tubercles

of the posterior process of talus to sustentaculum tali o Tendonopathy of the FHL triggering of FHL at the retinaculum Hallux Saltans o If FHL nodule is locked at the retinaculum Pseudo Hallux Rigidus

CP: • Posterolateral ankle pain • Tenderness behind the proneals • Pain by passive ankle PFlexion (Plantar Flexion Sign) in OsTrigonum $ ≠ FHL tendinopathy • Local lidocain injection posterior to the peroneal sheath at site of compression

Treatment: 1]. Activity modification 2]. Steroid injection after +ve lidocain injection test 3]. Os trigonum removal (between the FHL and peronei) 4]. If FHL tendonopathy medial approach to release and debride the tendon

ggggggbiiiiiii

Anterior ankle impingement • Due to osteophytes • Pain in dorsi flexion

PXR • Lateral standing to assess the amount to be excised • 60º regain of anterior tibio talar angle is mandatory

Treatment:: • Cheilectomy open or arthroscopic


Painful Foot Painful Heel

Children: 1. SSEEVVEERRSS DDIISSEEAASSEE (apophysitis) usually male aged about 10 years with increased density and

fragmentation of the calcaneal apophysis Raise heel and avoid strenuous activities, severe cases may require POP

Adolescents: 2. WWIINNTTEERR CCAALLCCAANNEEAALL KKNNOOBBSS (bilat.retrocalcaneal bursitis) ♀15-20y, more in winter & high heels Young Adults: 3. HHAAGGLLUUNNDD’’SS BBUUMMPP + Retrocalcaneal Bursitis above the Achilles tendon insertion 4. PPAAIINNFFUULL HHEEEELL PPAADD:: young athlete after vigorous fall on the heel inflammation, necrosis,

and detachment of the fat pad Older Adults: 5. PPLLAANNTTAARR FFAASSCCIIIITTIISS (enthesopathies) may occur also in young adults .....Most common 6. CCAALLCCAANNEEAALL LLEESSIIOONNSS: Stress#, Brodies, Cysts, Osteoid osteoma, Pagets .chronic ache 7. Entrapment of 11SSTT BBRR OOFF LLAATTEERRAALL PPLLAANNTTAARR NN (between AbH fascia & quadratus plantae) 8. Tarsal Tunnel Syndrome

Painful Tarsus (midfoot)

11-- KKOOHHLLEERRSS DDIISSEEAASSEE (osteochondritis of the navicular) usually children < 5 years old present with a painful limp and tender warm swelling over the navicular Rest and strap for a few weeks results in relief and eventually ® normal looking navicular

2- BBRRAAIILLSSFFOORRDDSS disease similar to Kohlers but in older women ± chopart’s joint degeneration 33-- TTHHEE ""OOVVEERRBBOONNEE""

In adults with high arches, ridge of bone form between dorsal surfaces of the med cunieform &MT1: adjust shoes, bevel lump

Painful Forefoot

1- MMEETTAATTAARRSSAALLGGIIAA: Symptom not a diagnosis = generalized ache of the forefoot. May be 1ry or 2ry to a variety of conditions that cause a mismatched wt distribution AA.. Primary metatarsalgia due to chronic imbalance in weight distribution between the toes

and metatarsal heads due to absent or ineffective muscle function BB.. Secondary metatarsalgia caused by:

1. Intractable plantar keratoses (most common) 2. OA 3. RA 4. gout 5. Distal plantar fasciitis 6. intermittent claudication

22-- LLOOCCAALLIIZZEEDD:: 1- SSTTRREESSSS FFRRAACCTTUURREE 22-- FFRREEIIBBEERRGG''SS IINNFFRRAACCTTIIOONN:: OCD of the MT2 head (rarely MT3) mostly young females 33-- MMOORRTTOONN’’SS NNEEUURROOMMAA 44-- TTAARRSSAALL TTUUNNNNEELL $$ 55-- SSEESSMMOOIIDDIITTIISS


Tarsal Tunnel Syndrome = Compression of the tibial nerve in the tarsal tunnel AANNAATTOOMMYY:: The tarsal tunnel is formed by the flexor retinaculum behind and distal to the medial malleolus Contents from ant. to post.: (Tom Dick ANd Harry)

1]. Tibialis Posterior Tendon 2]. Flexor Digitorum Longus tendon 3]. Posterior Tibial artery 4]. Posterior Tibial Nerve 5]. Flexor Hallucis Longus tendon

PPOOSSTTEERRIIOORR TTIIBBIIAALL NNEERRVVEE • Branch of sciatic, enters the deep post leg compartment bet the two gastroc heads • It passes deep to soleus, and travels distally bet it and the posterior tibialis muscle. • 3 terminal branches in the tarsal tunnel

o Medial plantar nerve: sensory to med plantar aspect of foot from big toe to medial ½ of 4th toe Motor to abd hallucis, FDB & 1st lumbrical

o Lateral plantar nerve: Sensation to the 4th & 5th rays & toes Motor to ADQ, the interossei, adductor hallucis, 2nd to 5th lumbricals.

o Calcaneal branch: provides sensation to the heel pad. AAEETTIIOOLLOOGGYY::

1. Flexor Digitorum Accessorius ms (anatomical variation) 2. Proliferative synovitis - Rheumatoid 3. Ganglia & Lipomas 4. Varicosities 5. Neurilemomas

EEXXAAMMIINNAATTIIOONN:: • Insidious onset of symptoms in the sensory distribution of the involved nerves • Pain radiates along the plantar side of the foot • Paresthesias, & atrophy of foot intrinsics • +ve Tinel sign behind medial malleolus • Manual compression for 30 sec. may reproduce symptoms

IINNVVEESSTTIIGGAATTIIOONNSS:: • Nerve Conduction Studies: sensory conduction studies are more sensitive than motor. • MRI - 88% +ve

DDDDXX • stress fractures (identified on 45º medial oblique view) • inflammatory arthritides • plantar fasciitis

TTRREEAATTMMEENNTT:: .....................................................Depends on the aetiology 1]. Rheumatoid synovitis ................................ rest & NSAIDs. 2]. Space occupying lesions .......................... surgical decompression. 3]. Steroid injections are a useful temporizing measure. 4]. Surgery:

a. Curved incision that follows the nerve posterior to the medial malleolus. b. The flexor retinaculum is divided from proximal to distal, down to the abductor hallucis

fascia. [Picture] c. The calcaneal branch or branches are protected as they extend posteriorly d. The medial and lateral plantar nerves are followed and freed beneath the abductor

hallucis. e. The deep fascia of the abductor hallucis should be divided if it is tight.


DDEEEEPP PPEERROONNEEAALL NNEERRVVEE EENNTTRRAAPPMMEENNTT AANNTTEERRIIOORR TTAARRSSAALL TTUUNNNNEELL SSYYNNDDRROOMMEE

AAeettiioollooggyy:: Can occur as the nerve passes under the inferior extensor retinaculum. Other causes include:

• compression against dorsal osteophytes on the tarsal bones • shoe wear that is tight over the dorsum of the foot.

Patients complain of aching over the dorsum of the foot with numbness or pain in the first webspace. If the lateral branch of the nerve is involved, the extensor brevis will show signs of atrophy. Medial branch entrapment causes a sensory deficit in the first webspace. Nonsurgical treatment involves shoe modifications & NSAIDs or steroid injection. Surgery is indicated for persistent symptoms and is directed toward decompression of the nerve by the release of the tight retinaculum and the removal of any osteophytes.

SSUUPPEERRFFIICCIIAALL PPEERROONNEEAALL NNEERRVVEE EENNTTRRAAPPMMEENNTT

• The Superficial Peroneal nerve passes through the fascia about 10 cm above the ankle to become subcutaneous. It branches into the medial & intermediate dorsal cutaneous nerves just proximal to the ankle which supply sensation over the dorsum of the foot except for the first webspace.

• Entrapment may occur where the nerve passes through the fascia of the lateral compartment.

SSUURRAALL NNEERRVVEE EENNTTRRAAPPMMEENNTT

• A branch of the tibial nerve that accompanies the small saphenous vein. • It provides sensation to the calf, lateral heel, and lateral border of the foot. • Entrapment of the sural nerve is rare, because it is protected over its course by subcutaneous

tissue & does not pass under restraining fascial edges or against bones. • It can become entrapped against a fracture fragment of the lateral malleolus, tarsal bones, or

fifth metatarsal, or against an adjacent ganglion.

NNEERRVVEE SSIITTEE CCAAUUSSEE SSYYMMPPTTOOMM

ILIO-INGUINAL Hypertrophied abdominal ms Intense training Pain & parasthesia OBTURATOR Hip adductor Skaters Medial thigh pain FEMORAL LAT. CUT. ASIS

Meralgia paresthetica Tight belt Lateral thigh pain

SCIATIC Ischial tuberosity, pyriformis ms Pyriformis Sciatica SAPHENOUS Hunter’s canal Quad or sartorius Infero-medial knee pain COMMON PERONEAL Fibular head Direct blow Foot drop SUPERF PERONEAL 12 cm above Lat.Maleolus, as it

pierce the deep fascia Inversion injury Dorsal foot pain &

paresthesia SURAL 12 cm distal to Lat Maleolus Jone’s fr Lat. foot parasthesia DEEP PERONEAL Inf. extensor retinaculum

(anterior tarsal tunnel $) Inversion injury Sole pain & parasthesia

POSTERIOR TIBIAL Flexor retinaculum (Tarsal tunnel $)

FDL accessorius, RA, tumors, ganglion

Sole pain & paresthesia

1ST LAT.PLANTAR Bet AHL fascia, quadratus plantae High heels Plantar fasciitis MEDIAL PLANTAR Henry Knot (cross of FDL & FHL) Orthotics Big toe pain & parasthesia INTERDIGITAL Bet MT3-4 plantar to deep MT lig

(Morton’s Neuroma) Push phase in runners

Digital pain, parasthesia, dead toe


Plantar Fasciitis Clacaneal Spur

DDeeffiinniittiioonn:: • It is the most common cause of subcalcaneal heel pain

EEppiiddeemmiioollooggyy • More common in Middle aged males • More in athletes especially joggers • More in overwt

PPaatthhooggeenneessiiss TThheeoorriieess:: 1- DDEEGGEENNEERRAATTIIVVEE TTHHEEOORRYY: ð repetitive trauma degeneration at the origin of the plantar fascia

micro tears inflammation extend to med calcaneal br of the post tibial n 2- FFAATT PPAADD TTHHEEOORRYY:: degenration of the fat Pad with age and overwt collagen and water

elasticity make the underlying structures more liable to microtrauma 3- CCAALLCCAANNEEAALL SSPPUURR TTHHEEOORRYY:: calcaneal spur was long attributed to be a cause of the plantar fasciitis,

a relation ship never well established. Now it is accepted that the spur is more likely to be a sequela to the fasciitis rather than a cause; ð repetitive trauma & inflammation

4- NNEEUURROOGGEENNIICC TTHHEEOORRYY:: entrapment of the 1st branch of the lateral plantar nerve between abductor hallucis fascia & quadratus plantae muscle

PPaatthhoollooggyy:: AAnnaattoommyy:: • Heel pad is a honey comb like structure that is made of many fibrous compartment • Inside the fibrous compartments there are fat globules that help shock absorption • Plantar aponeurosis is divided into 3 slips: medial (over abd Hallucis), lateral (over Abd quinti), &

central ώ is the plantar fascia that originate from medial calcaneal tuberosity MMaaccrroossccooppiiccaallllyy • Heel pad shows water content and collagen & elasticity but thickness • Plantar fascia is degenerative, é microtears & inflammatory cells • Plantar fascia may eventually rupture completely or in a partnother entity of the disease is the

distal plantar fasciitis

DDiiaaggnnoossiiss:: CClliinniiccaallllyy:: • Pain:

o Gradual onset o Dull aching (may be neuritic if lateral plantar n is entrapped) o Worst at morning fades with first few steps o at the end of the day

• Inability to WB if the pain is severe • Swelling & erythema

EExxaamm:: • Tenderness over the medial tuberosity • +ve stress test: é hyper extension of the toes tenderness • +ve tinel sign if nerve entrapment • Examination of motor and sensory PPXXRR AP & Lateral standing • Spur is found 50% a finding never been fully explained • fat pad thickness OOtthheerr RRaaddiiooggrraapphhiicc • Tc to exclude stress # when exhausted conservative ttt does not relieve the condition • EMG of the abd Digiti quinti • MRI & US: heel pad thickness • HLA-B27: in seronegative arthropathy


TTrreeaattmmeenntt::

CCoonnsseerrvvaattiivvee • 80% effective but take a long time 1- NSAIDs 2- Steroid injections: may produce fat pad atrophy, plantar fascia rupture (avoid to be given in the

fat septa 3- Night splint: seem to give fair good results (prevent contractures of the fascia 4- Heel cushions: mechanical loading and direct trauma & stretch of the fascia 5- Walking Othosis: toes hyperextension windlass effect & stretch of plantar fascia 6- Calf stretching exercise 7- US & iontophoresis SSuurrggiiccaall • Patient must be informed that the surgery may not give the desired result 1- Plantar fascial release (releasing the medial half only will give the same result & the recovery

time): o Through medial longitudinal incision o Fascia is identified and release the medial 1/3 and excised 1cm o Superior elevation of the abd hallucis & release its fascia o Calcaneal spur is deep to the FHB ώ should be partially released to get it

2- Calcaneal spur excision 3- Spur excision + portion of the medial tuberosity (to broaden the WB area) 4- Release of the deep fascia of abductor Hallucis ms ± neurolysis of the n to abd digiti quinti 5- Endoscopic plantar fascial release (95% effective; but demanding, not in nerve entrapment as the

fascia over the abd hallucis cannot be released)


Turf Toe DDeeffiinniittiioonn::

• Tender stiff big toe after severe dorsiflexion EEppiiddeemmiioollooggyy

• More in footballers and contact sports MMEETTAATTAARRSSAALL FFAATT PPAADD

• When the toes extend beyond 50° MT fat pad islocked under the MT heads

AAeettiioollooggyy • Sprain of the plantar capsule of 1st MTP joint of big toe • Occurs due to hyper dorsiflexion of big toe

DDiiaaggnnoossiiss:: CClliinniiccaallllyy:: • Stiff • Swollen • Painful PPXXRR && TTcc • Rule out stress # of the proximal phx of the big toe

TTrreeaattmmeenntt:: • Motion • RICE

Sassamoiditis Misnormer as the inflammation actually is around the sesamoid bones of the MT1 (particularly the medial sesamoid) PPaatthhoollooggyy::

1- Acute sessamoiditis: due to acute trauma or unaccustomed effort 2- Chronic sessamoiditis:

Chronic displacement AVN Infection (in DM)

3- Sesamoid chondromalacia: due to undue stresses over the medial sesamoid 4- Bipartite or multipartite sesamoid: malformation that cause chondromalacia and usually

mistaken as a fracture CClliinniiccaallllyy::

• Pain: Under the head of the MT1 head by walking & WB

• Tenderness that by passive dorsiflexion TTrreeaattmmeenntt::

• Wt reduction • Pressure pad in the shoe • Local steroid injection • Sesamoid shaving • Sesamoid excision (care must be taken not to injure the FHB tendon)

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