The Foot and Ankle

History and Examination Summary

History

1. pain: where,rad,type,when,nocte,agg,rel
2. other: instability,giveway,swell,deformity,cosmesis,stiffness,numb,tinglig
3. function: walking,limp,shoes,sticks,sports,work
4. past;history: treatment,injury,surgery,injections,sim episodes

Exam (Standing)

1. look: shoes,sticks,calipers,front,side,back,single toe rise,Coleman
2. feel: spine
3. move: gait,toe walk,heel walk

Exam (Supine)

1. look: sole of foot(wear pattern),plantar keratoses
   dorsal corns (soft & hard), swelling, deformity, redness, scars,
2. feel: pulses, sole of foot:MT heads,MTP jts,interMT spaces,toe
   tug,"Lachman",plantar fascia, rest of foot/ankle:systematic
3. move: ankle,subtalar,midtarsal,MTP IPJ
4. ligs: ankle-AP drawer etc
5. power,neuro: (tib post, tib ant,peroneals etc.)

Flat Feet

Aetiology

1. External rotation of the lower limb ® tendency to collapse the arch in ambulation
2. Genu valgum ® weight taken on the medial side of the foot
3. Tight tendo achilles
4. Forefoot varus- in walking the forefoot is forced down and medial
5. Congenital vertical talus ® rocker bottom flat foot which is associated with spina bifida and arthrogryposis
6. Tarsal coalition- " peroneal spastic flat foot"
7. Acquired flat foot in the adult:
   1. following Tib post rupture
   2. old Lisfranc injury
   3. inflammatory arthritis of the Hindfoot
   4. Charcots type midfoot or hindfoot
   5. idiopathic OA of the TMT jt

Physiological
Despite the anatomical bony constituents of the arch in the absence of appropriate muscular tone ® collapse of ligamentous supports and the arch can not be maintained

1. Infantile: All infants feet are flat the arch developing after commencement of weight bearing
2. Postural: due to poor muscle tone, increased weight, or muscle weakness following prolonged bed rest
3. Acute strain:

Clinically

Treatment

Where hind foot valgus is a feature, calcaneal opening wedge osteotomy may ® correction. Here an incision in line with the peroneal tendons is made over the lateral aspect of the foot. The peroneal tendons are identified and an opening osteotomy performed in the line of the tendons and then packed with graft. A BK walking cast is applied for six to eight weeks. (Dwyer described a medial opening wedge for persistent calcaneovarus deformity)

Congenital flat foot (vertical talus) requires reduction of the displaced talus involving ETA and medial release to reduce the talus and possible also a lateral release and 'K' wire fixation followed by POP casting

Tight heel cords may need to be stretched or lengthened if resistant

Acquired Flatfoot in the Adult

Aetiology

1. following Tib post rupture
2. old Lisfranc injury
3. inflammatory arthritis of the Hindfoot
4. Charcots type midfoot or hindfoot
5. idiopathic OA of the TMT jt

Tibialis Posterior tendon rupture

Clinically

Treatment

Peroneal Spastic Flat Foot (Tarsal Coalition)

Aetiology

Incidence

Aetiology

Classification

Clinically

X-Rays

Evidence of a tarsal coalition may be seen on lateral radiographs however oblique views or CT may be required (best seen in 45^o oblique radiograph)
Degenerative joint disease may be evident in inflammatory conditions

Treatment

Young people: excision of the bar in the absence of degenerative changes
In talocalcaneal coalition:
if less than 30% of jt, then excise
if greater than 30% arthrodese

Older people: with degeneration of the talo-navicular and subtalar joints a triple arthrodesis
Calcaneal osteotomy either a medial wedge excision or lateral opening wedge to correct associated valgus heel

Prognosis

Cavovarus

Aetiology

1. Neuromuscular imbalance due to weak intrinsics
   Conditions associated with cavus or cavo-varus feet:
   

   Central nervous System

   Cerebral palsy
   Friedreich's Ataxia
   

   Spinal Cord

   Spinal cord tumour
   Spinal dysraphism
   e.g. Tethered cord,Spinal bifida, Diastematomyelia
   Poliomyelitis
   Spinal muscular atrophy
   

   Peripheral Nervous system

   Hereditary peripheral neuropathies eg CMT
   Traumatic peripheral nerve lesions
   

   Muscle Disease

   Duchenne's muscular dystrophy

2. post ischaemic (Volkmans contracture)
3. Common component of residual club feet
4. Idiopathic

Clinically

May be the presenting abnormality representing the early signs of a progressive neurologic degenerative disease

The idiopathic variety usually noticed at about 10 years of age and it is usually bilateral
ankle: usually reduced dorsiflexion
hindfoot: There is inversion of the heel (calcaneo varus) and inversion of the subtalar jt
forefoot: is plantar flexed ( plantaris deformity) with pronation of the forefoot in relation to the hind foot
MTP joints: hyper extended
Inter-phalangeal joints: are flexed

Weight bearing is via a tripod of the heel, the first and fifth metatarsal heads and associated with hind foot varus which becomes fixed, pressure taken over a small area under the metatarsal heads to allow pain and callosities
Callosities also develop over inter phalangeal joints due to pressure from shoe-wear

Coleman's block test establishes whether the hind foot is fixed or flexible and demonstrates the type of surgical correction required (place the foot obliquely on a 1 - 1.5" block so that the first metatarsal hangs free ® correction of the hind foot during weight bearing- if the hind foot returns to neutral or valgus the deformity is flexible)

Treatment

Young children

strengthening exercises and stretching
ensure footwear has enough room for the toes

Operative:

Flexor to extensor transfers and inter phalangeal joint arthrodesis
- will straighten the toes
if much cavus- Steindlers and short flexor / abductor hallucis release may also be needed to release plantar fascia followed by a BK POP with the foot held in valgus and supination for 6/52 with frequent changes of POP to correct deformity (children aged 4 - 5 years)
Transfer of Tibialis Posterior to the calcaneum may ® correction of calcaneus deformity

Adolescents

if toe deformities become fixed- arthrodese all the PIP jts (so the long flexors no longer bunch the toes up) and the long extensors are reinserted into the MT necks to elevate the forefoot

If hind foot varus is fixed in Coleman's test and the first ray deformity severe calcaneal osteotomy (Dwyer type medial opening wedge or modified Dwyer with a lateral closing wedge osteotomy of the calcaneum) may be indicated (children aged 10 or older)- can be combined with Steindler op

Wedge excision of the tarso-metatarsal joints may be needed for severe deformity in the absence of neurological abnormality- done after maturity

Adults

increased arch support and contact area in appropriate fitting shoes best treatment but if severe painful deformities may require operation

Calcaneocavus

Clinically

Treatment

5-12 years basic principles:

1. stablise ST jt- extra-artic arthrodesis
2. management of bony deformity of calcaneus and ankle
3. release of plantar soft tissue contractures with or without calcaneal posterior displacement osteotomy
4. tendon transfers to improve plantar flexion of os calcis

Ref: Coleman S.S. "Pes Cavus" Current orthopaedics 6: 81-87, 1992

Hallux Valgus

Aetiology

1. metatarsus primus varus which is congenital hereditary factors (55 - 65% positive family history, ? autosomal dominant with variable penetrance)
   
2. Acquired
   1. splayed foot secondary to weak intrinsics occurs with increasing age
   2. Effect of shoe-wear may not produce but contribute to the deformity (Hallux valgus was 70 times more common among shoe wearers in Chinese Hong Kong as compared with the unshod members of the same community)
      

Clinically

Deformity which may or may not be associated with discomfort

75% of patients with hallux valgus present with pain over the medial eminence but may also have pain due to callosities, involvement of the sesamoids or the metatarso-phalangeal joint

In the young may present complaining of the inability to wear fashion footwear

90% of patients presenting for surgery are female but the sex incidence of the condition is probably equal and 50% of surgical cases have unilateral procedures

Second toe may be displaced due to lateral angulation of the great toe which is also often pronated

Condition usually bilateral, worse on one side and commonest in the 6th decade of life in females

General assessment: deformity, age, activity level, shoewear needs, expectations of surgery

Examination

Examine the foot with the patient standing and assess the longitudinal arch of the foot
check circulation and sensation of the foot
Check for plantar callosities
check ROM of MTP joint (in resting position and with the toe alignment corrected) and IP joint as well as the ankle and subtalar movement
Observe walking to see if the hallux is used in its normal push-off function

X-Rays

Weight bearing AP+ lat films of the foot required to assess degree of deformity and indicates the type of surgery required

1. Hallux-Valgus angle (angle between the longitudinal axis of the proximal phalanx and first metatarsal) should be less than 20^o
2. The distal metatarsal articular angle indicates congruency of the joint and the presence of subluxation and should be less than 10^o
3. The inter-metatarsal angle is that between the long axis of the first and second metatarsal and should be less than 10^o
4. Angulation of the first metatarsocunieform jt
5. the lengths of the 1st and 2nd metatarsals
6. the 1st talometatarsal angle on the lat film
7. the generalised metatarsus adductus
   

In the AP film about 20 - 30% of the fibular sesamoid is exposed normally, this is increased in hallux valgus

Patho-physiology

Sesamoids of the great toe and the long flexor tendons become displaced laterally and once this occurs tends to increase the deformity

Increased inter-metatarsal angle is not associated with an alteration in the angle subtended between the long axis of the medial cuneiform and the first metatarsal, suggest not metatarsus primus varus but really lateral or valgus displacement of the second and subsequent toes (metatarsus secundus valgus)

If the hallux valgus angle exceeds 25^o or is associated with subluxation of the joint the condition will surely progress

Muscle imbalance is not important primarily but contributes to further development of the deformity once established due to displacement of the abductor hallucis to the plantar aspect of the great toe, the tendons of FHL and EHL become bow-strung across the valgus angle and further contribute to an increasing deformity

Treatment

Surgery indicated for cosmesis, to enable appropriate footwear to be worn, painful bunion, painful corns, overriding 2nd toe, deformity

Aim of any treatment is to restore the normal anatomy
- realign the hallux, remove the medial eminence, reduce the intermetatarsal angle
- if present- lateral soft tissue contracture is released

Resection of the medial eminence is done parallel to and flush with the MT shaft

For distal osteotomies~ 1 deg correction is obtained for each mm of lat translation of the MT shaft The procedure of choice varies wrt age:

Adolescent:

Basal procedures are not safe until after skeletal maturity as 1st MT physeal arrest may accur
soft tissue correction and distal bony procedures are appropriate
-In adolescents once skeletally mature operation may prevent progression of deformity ( basal osteotomy for metatarsus primus varus)

Middle age:

Elderly:

in the low demand older pt Kellers or silastic implant are appropriate

The procedure of choice varies with degree of deformity:

Mild

(intermetatarsal angle less than 15^o, MTP jt congruent, HV angle less than 30^o ):
excise bunion
If interMT angle is normal (less than 10^o), then the HV can be corrected by a medial closing wedge osteotomy of the prox phalanx (Akin procedure)
either: a soft tissue procedure
eg McBrides operation: via med incision removal med eminence. Then via dorsal incision in 1st web release of the contracted structureson the lat side
or: a distal osteotomy
e.g. Chevron, Wilson, Mitchell

Moderate (intermetatarsal angle 15-20^o) :

Excise bunion
Best treated with a soft tissue release and a proximal MT osteotomy
Prox MT osteotomy either crescentic or closing wedge
rigid fix with screw
If the inter-metatarsal angle is too large (greater than15^o) or the hallux valgus angle greater than 35^o a chevron can usually not correct it sufficiently
The Mitchell's type is effective with slightly greater deformity and can be used with the inter-metatarsal angle > 15^o and the hallux valgus angle less than 40^o again +/- distal soft tissue procedure

Severe (intermetatarsal angle > 20^o and HV angle > 40^o)

Excise bunion
Distal soft tissue procedure and prox soteotomy +/-arthrodese 1st MTP jt
If severe subluxation or degeneration of MTP jt, fusion but IP joint should be mobile

Complications

1. Recurrence: esp in adolescents (up to 30% )
   due to inadequate soft release and failure to correct alignment
   
2. Hallux varus: esp in soft tissue proc eg McBride with lat soft tisssue release +/- excision of lat sesamoid, overexcision of medial eminence and med reefing
   -correction with either a soft tissue procedure
   e.g. Johnson proc- fusion of IP jt, harvest EHL tendon,rerouting EHL under transverse intermetatarsal lig + through drill hole in prox phalanx. commbined with med capsulotomy + abductor release
   or by arthrodesis
   
3. Transfer metatarsalgia- if shorten 1st ray
4. AVN of MT head - avoid significant stripping of both dorsal and lat sides of the distal MT
5. Nonunion of osteotomy- rare- less than 1%

Prognosis

Hallux Rigidus

Clinically

Treatment

In early stage:

avoid high heel shoes
incorporate a rigid shank along the med border of the shoe
Rocker bottom shoe

Mild - mod disease:

chielectomy- excision of the dorsal osteophyte
wedge osteotomy of the neck of the proximal phalanx may be useful to redirect the arch of extension

Severe disease or failed chielectomy:

arthrodesis- hallux in 15^o valgus and 25^o DF of hallux wrt the MT
optimum position = parallel to the plane of support on weight bearing- this takes into account any cavus or planus deformity
Fusion of the MTP joint, the IP joint should be mobile and the position of the fusion will vary for men and women depending on the normal shoe heel height

Silastic joint replacement- not recommended - only for elderly with low demand

Toe Deformities

Claw Toes

Treatment:
If the deformity is passively correctable, consider flexor to extensor transfers
Inter phalangeal arthrodesis if the MTP joint is mobile and enlocated- this allows the long flexors to flex the MTP jts rather than bunch up the IP jts
Excision of the metatarsal heads 2 - 5 through a plantar incision and fusion of the 1st if the MTP joint is involved
Extensor tenotomies may be used in combination with the above

Hammer Toes

Aetiology:

long toe short shoe
Similar to the Boutonniere deformity of the hand and may be related to extensor mechanism failure

Treatment:
Excision and shortening of the Prox inter-phalangeal joint (no fixation required)

Mallet Toes

Treatment:
flexible- FDL division at DIP jt
fixed- DIP excision arthroplasty

Curly toes

Treatment
flexor tenotomy of both FDL and FDB via an incision over prox phal

Ref: Ross and Menelaus: " open flexor tenotomy for hammer toes and curly toes in childhood" JBJS 66B: 770, 1984

Over-lapping 5th Toe

Ref: Cockin J." Butlers operation: an overriding 5 th toe" JBJS 50: 78, 1968

- a release of the toe via a racquet incision. Extensors released,capsule released, toe realigned - "changing the gears", immobilised for 3-4 wks

Paralysed Foot

Upper Motor Neuron Lesions

Lower Motor Neuron Lesions

Peripheral Nerve Injuries

Treatment

The Painful Foot

Painful Heel

Children:

Severs disease (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:

Calcaneal knobs (often bilateral) usually female 15 - 20 years
Appropriate foot-wear and occasionally excision

Young Adults:

Bursitis above the Achilles tendon insertion or plantar fasciitis (enthesopathies)

Older Adults:

Policeman's heel, patients usually aged 40 - 60 years and the pain subsides after 6 - 12 months (sometimes called plantar fasciitis- pathology unknown)
- heel padded, cortisone injection, surgery not indicated
Pagets may affect the calcaneum resulting in a chronic ache
Chronic bone infection (Brodies abscess with sclerotic margin)

Painful Tarsus

Kohlers disease

(osteochondritis of the navicular) usually children less than 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
Brailsfords disease similar to Kohlers but older women affected

The "overbone"

In adults with high arches, ridge of bone on dorsal surfaces of the med cunieform and 1st metatarsal- adjust shoes, bevel lump

Painful Forefoot

Metatarsalgia:

Symptom not a diagnosis and may be primary or secondary to other conditions
Primary metatarsalgia due to chronic imbalance in weight distribution between the toes and metatarsal heads due to absent or ineffective muscle function
Secondary metatarsalgia may be due to conditions such as rheumatoid arthritis, gout, neuromuscular disorders, stress fracture, Mortons neuroma, plantar fasciitis, tarsal tunnel syndrome, intermittent claudication and osteoarthritis
Any foot condition with faulty weight distribution may cause this condition

Treatment:

In primary metatarsalgia treatment should be directed towards unloading the areas subjected to increased pressure
In secondary metatarsalgia the underlying condition must be identified and treated as well as the mechanical imbalance

Freibergs disease:

Crushing type of osteochondritis affects young adults and usually females
Head of 2nd metatarsal wide, squared and thick

Stress fracture:

Usually in the 2nd or 3rd metatarsal neck and usually associated with increased physical activity

Mortons Metatarsalgia:

Painful neuroma of the digital nerve at the level of the metatarsal necks just proximal to the division of the nerve to the 3rd and 4th toes
Usually women aged 40 - 50 years with sharp intermittent pain into the toes but usually only when shoes are worn
Clinically tenderness is localised to the neuroma and may be associated with decreased sensation in the cleft
Treatment: adequate foot-wear, but may require operation

Tarsal Tunnel Syndrome:

Pain in the medial part of the forefoot unrelated to weight bearing
Often worse at night and relieved by walking around
The tibial nerve is trapped beneath the flexor retinaculum. The post tibial artery + vein and tibial nerve lie between the fibrous septae that separate the tendons of FDL and FHL- the tarsal tunnel.
May be secondary to pressure from outside the tunnel ( eg displaced #'s of tibia, talus or os calcis, tenosynovitis or ganglia of the adjacent tendon sheath) or within the tunnel ( eg varicosities, neural tumour)
EMG studies show slowing of conduction

Treatment

anti-inflammatories, rest and local steroid injection and if unsucessful, decompression of the nerve

Plantar Fasciitis:

Pain at the attachment of the plantar fascia to the medial tubercle of the calcaneus. Treat with NSAIDs and orthosis, rarely needing release of plantar fascia.

Intractable plantar keratosis:

most common cause of metatarsalgia
DDX- plantar wart, neuroma
- due to localised pressure under a MT head

Treatment:

padding, footwear modification
osteotomy of MT neck- do with precision- fixation preferred,
avoid osteotomies that seek own level

Ligament Injuries

Clinically

History

usually of an inversion injury
important to accurately delineate mechanism - gives clues to structures injured

Examination

Inspect for swelling
palpate for tenderness over each ligament
Anterior drawer test - knee flexed, ankle PF 10 deg,slight IR to relax deltoid lig, compare with other side. Positive test indicates torn ant talo-fib lig( major restraint to anterior shift)

Talar tilt test- similar positon - ankle 10 deg PF, slight IR, palpate jt line as do test, compare with other side. Positive test indicates torn ant talo-fib and calcaneo-fib ligs
(Almost impossible to injure the calcaneo-fib lig alone - the ant talo-fib lig is torn first, then the calcaneo-fib lig, rarely then the post talo-fib lig- finally the ankle would then dislocate)

Investigation

Plain XR
Stress views

1. anterior talar shift stress test - position as above
   - the ant talo-fib lig is the primary restraint to anterior shift
   - a side to side difference of >3 mm = torn ant talo-fib lig
   
2. talar tilt stress test- position as above
   - the calcaneofib lig is the major restraint to "tilt"
   - a side to side difference of 10 deg or more = torn ant talo-fib
   and calcaneo-fib lig
   

Ultrasound
ankle arthrography/peroneal tenography:
the ant talofib lig is a capsular lig- tear will show dye leakage
the calcaneo-fib lig is extracapsular and closely related to the peroneal sheath
- tear will show dye leaking into peroneal sheath on ankle arthrography,
or leakage of dye into jt on peroneal tenography

MRI- demonstrates tears but other tests are less expensive- thus indications limited

Classification

grade 1:

stretch of the lig without macroscopic tearing, little swelling or tenderness, little or no functional loss

grade 2:

partial macroscopic tear of the tendon, mod pain, swelling, tenderness. Some loss of motion, mild instability of jt

grade 3:

complete rupture of the lig, severe loss of function , swelling, tenderness, major instability

Treatment

If residual problems of instability despite program of exercises and strapping or use of a splint, then reconstruction indicated

Procedure used not critical- results good/ excellent ~ 85% for all- options are:
- late direct repair of the torn ligs (Brostrom)
- augmented reconstruction eg peroneus brevis (Evans, Watson-Jones)

Prognosis:

ref: Kannus and Renstrom "Current concepts review: Treatment for acute tears of the lateral ligaments of the ankle" JBJS 73A:305-312, 1991
Marder "Current Methods for evaluation of ankle ligament injuries"JBJS 76A:1103,1994
Colville " Reconstruction of the lateral ankle ligaments" JBJS 76A: 1092, 1994

Achilles Tendon Rupture

Clinically

Examination:

Simmond's test is diagnostic (may also be called Thompsons test)
Active plantar flexion is less reliable- can occur via other tendons that pass behind med malleolus

Investigation:

Ultrasound, MRI: both will demonstrate tear if clinically in doubt

Treatment:

Operative- posteromed skin incision -allows access to plantaris to augment repair, Suture (kessler/Bunnell with peripheral suture), repair paratenon separately

Late repair of chronic rupture- difficult to approximate ends- can supplement repair with plantaris, fascia lata, a strip of fascia turned down from prox tendon. Can also supplement with FDL, FHL, peroneus brevis

Complications

Prognosis

ref : Carr and Norrish" the blood supply of the calcaneal tendon" JBJS 71B: 100-101, 1990

Ankle Arthroscopy

Indications

Portal Placement

1. Anterolat- at level of ankle jt, just lat to peroneus tertius and EDL
   - care re superficial peroneal n
   - views lat gutter, med aspect of ankle jt
   
2. anterocentral- bw EHL and EDL at level of ankle jt
   not routine- risk to NV bundle
   
3. anteromed - just med to tib ant at level of jt line
   - risk great saphenous vein + saphenous nerve
   - transilluminate from lat side to avoid these
   

1. posteromed-made at level of jt line just med to tendo achilles, well lat to FHL- risk to NV bundle- thus not recommended
   
2. posterolat- just lat to tendo achilles at level of jt line
   - risk to sural n, small sapphenous v, peroneal tendons
   - good view of post comp
   
3. trans tendo achilles
   

Pt Positioning

Ankle arthrodesis

Indications

1. post traumatic OA
2. AVN of body of the talus
3. infectious arthritis that does not respond to chemotherapy or other measures
4. equinus deformity that does not respond to bracing
5. OA or RA of ankle
6. salvage of TAR

Technique

fusion in

more than 5 deg calcaneus results in a stiff gait with poor push off
too much equinus will not allow the foot flat onto the ground,

best position

= neutral in sagittal plane, ~ 5 deg ER
shifting talus post on tibia will preserve heel prominence and improve gait

Charnley:

Principle is to apply compression - if using the Charnley device aim for pin placement in the talus ant to the mid point of the body to counteract the pull of the tendo achilles

Results

ref: Sonnabend and Duckworth " A new technique of ankle arthrodesis" ANZ J Surg 62:965, 1992

Technique:

Longitudinal ant approach, just lat to ant NV bundle,
subperiosteal exposure of bone
Mark tibia to ensure correct alignment
cut tibia first
talus cut next- parallel to distal tibial cut
articular surfaces of the malleoli + med and lat surfaces of talus bared with burr or saw or osteotome
position talus under tibia in desired alignment
cannulated screw fixation- 2 guide wires placed retrograde through cut tibial surface to emerge through posterior tibial cortex, one medial and one lat to tendo achilles- these should diverge slightly through the tibia- they will then converge in the talus. A 3rd wire is inserted in the midline ,~ 3 cm above the distal end of the cut tibia
bones then reduced, all 3 wires advanced into talus (I-I control), measured, drilled, screwed
graft packed into any spaces

Postop backslab for 48 hrs , then BKPOP, NWB 6/52, TPT 8/52
Results 11 of 12 fused, 1 painless fibrous ankylosis

Total Ankle Replacement

Due to the high complication rate and poor long term clinical results arthrodesis should be the first line treatment for the painful arthritic ankle regardless of the underlying pathological process

4 year follow up: talar collapse in 1/3 and loosening in 1/3
ROM usually poor (less than 30^o mean 20 - 25^o) and mainly plantar-flexion
Relief of pain achieved in only 46% of cases where as arthrodesis ® relief in 60 - 75%

TAR (In rheumatoid):

Not produced any significantly good results to date. May only be indicated in pan-talar OA in order to maintain some movement after a triple arthrodesis.
Poor wound healing is a problem
Infection rate between 2% and 5%
High loosening rate early.