Common Foot and Ankle Problems

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Common Foot and Ankle Problems

• Christopher Mann
• Consultant Orthopaedic and Trauma Surgeon
• Specialising in Foot Ankle surgery
• Bradford Teaching Hospitals
• Capio Yorkshire Clinic, Bingley
• Nuffield Hospital, Leeds

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overview

• 1. basic anatomy, principles
• 2. hallux rigidus
• 3. hallux valgus (bunion)
• 4. plantar fasciitis
• 5. Mortons neuroma
• 6. hammer, mallet, claw toe
• 7. fifth metatarsal fractures
• 8. is there a fracture? Ottawa rules
• 9. others

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basic anatomy, principles17

• bones tibia? medial malleolus
• fibula ?lateral malleolus
• ankle mortise like tenon mortise
• talus, calcaneus
• navicular 3 cuneiforms
• metatarsals and phalanges
• arches longitudinal, transverse

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basic anatomy, principles 27

• arches bones, ligaments, tendons
• tibialis anterior, extensor hallucis longus both
  easy to feel
• try lifting own big toe and ankle up- feel both
• pulses dorsalis pedis lateral to EHL
• absent in 13
• posterior tibial behind med malleolus

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basic anatomy, principles 37

• tibialis posterior posterior tibia ?
• behind medial malleolus ?
  navicular, all others (apart from1)
• -failure causes arch
  collapse,flatfoot nerves tibial main nerve
• superficial peroneal, deep peroneal,
  sural, saphenous
• Tom Dick A N d Harry, Tom Has A Nasty Dirty Pencil

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basic anatomy, principles 47

• ankle joint ? foot up, down
• subtalar joint complex? hindfoot inversion
  eversion (heel in/out) eg walking on rough,
  uneven, sloping ground
• subtalar jt complex subtalar jt TN CC jts
• foot is floppy when feeling, locked when
  levering
• midfoot some up/down (ankle fusion!), side to
  side

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basic anatomy, principles 57

• history
• look from behind- too many toes sign
• sole for calluses
• shoes for uneven wear
• skin, shape, position
• antalgic gait less time in stance
• feel pulses, sensation, swellings
• move foot ??, heel ?, forefoot, toes ??

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basic anatomy, principles 67

• surgery indicated mainly for PAIN failure of
  nonoperative measures
• safer to operate on the shoe than on the foot
• occasionally stitch in time saves 9
• cosmesis alone very dodgy
• suggest 70 good/satis, 20 equivocal, 10 poor
  results generally (compare with THR!)

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basic anatomy, principles 77

• calluses, corns, keratoses caused by skin
  squashed between bony prominence on inside
  shoe (or ground) on outside
• verrucas can mimic, punctate bleeding when
  shaved
• Rx remove or lessen one or both
• flexible deformity ? soft tissue procedure
  (except inflammatory arthritides do bony)
• fixed deformity ? bony procedure

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hallux rigidus 13

• osteoarthritis of big toe MTP joint
• drugs
• activity modification
• footwear modification
• casting
• orthoses (inserts,splints)
• local corticosteroid injection
• (ambulatory aids, weight loss, physiotherapy)

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hallux rigidus 23

• stiff, knobbly big toe MTPJ
• often subtle, lateral osteophyte
• painful, stiff dorsiflexion eg walking
• often tender dorsally
• Rx stiff soled shoe or rocker bottom or stiff
  insole with soft, roomy upper
• occasionally helped with MUA, injection
• cheilectomy stalactite-ectomy!
• classic generous dorsal resection

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hallux rigidus 33

• cheilectomy doesnt burn bridges but not very
  reliable
• pts can fully weightbear straight away
• most reliable fusion
• non-weightbearing on forefoot for 10-12 weeks
• clinical and radiological union
• angle of set vital
• rarely Kellers, ??replacement

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hallux valgus 14

• bunio turnip
• strict nomenclature unnecessary
• full house
• bunion (enlarged median eminence, bursa)
• hallux rigidus
• 2nd claw toe
• intractible plantar keratoses

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hallux valgus 24

• female male 4 1
• nature AND nurture genes AND shoes!
• familial tendency
• C/O pain, difficulty in shoe fitting
• can be rapidly progressive ( a stitch in
  time)

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hallux valgus 34

• over 150 procedures described!
• first MT deviates medially, hallux laterally
• soft tissues stretched over medial eminence
  contracted on lateral side
• most operations include break re-set 1st MT
  and distal soft tissue procedure
• currently trendy scarf and Aiken osteotomies

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hallux valgus 44

• refer if pain or rapidly progressive or anxious
• preferably try wide and deep shoes first
• refer to specialist capable of individualising
• eg shortening / elevating 1st MT ? lesser MT head
  overload? transfer lesion
• expect no forefoot weightbearing 2 months
• off work 3-4 months
• prolonged stiffness swelling
  numbness top of toe

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plantar fasciitis, heel pain 13

• common, easy to diagnose
• heel spurs not relevant, Xray in specialist
  clinic
• classic start-up pain
• tender over sole heel area
• philosophy of rest gel heel cups
• chemical rest steroid injection
• philosophy of stretch excercises, night
  splints

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plantar fasciitis, heel pain 23

• philosophy of fanning the inflammatory fire
• ultrasound, friction, massage, lithotripsy!
• all to increase blood flow
• correct biomechanical predisposing factors
• I.e.podiatrist, orthotist
• ultrasound-guided injection
• surgery is last resort
• full release can cause flatfoot
• limited release?

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plantar fasciitis, heel pain 33

• achilles tendonitis / tendinosis /paratendinosis
• insertional achilles tendinosis
• similar philosophy
• refer, usually get ultrasound

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Mortons neuroma 12

• not really true neuromacallosity of nerve
• passes under deep transverse IM ligament
• typically burning pain in 2 adjacent toe sides
• takes shoe off to rub foot
• O/E positive Mulders click
• ultrasound

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Mortons neuroma 22

• metatarsal dome or pad to spread heads apart
  (proximal to heads!)
• ultrasound-guided injection
• excision- dorsal or plantar. Dorsal better.
• recurrence true stump neuroma!

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hammer, mallet, claw toe 13

• aide-memoir hammer is proximal to mallet in
  alphabet and in toe!
• claw toe where MTPJ extended
• severe claw toe MT head uncovered
• plunger effect of Stainsby makes worse

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hammer, mallet, claw toe 23

• commonest cause of all 3 unknown
• diabetes?periph. neuropathy?intrinsic
• imbalance
• inflammatory arthritis eg rheumatoid ?
  tendon attrition, rupture
• C/O pain at tip, or over affected
  interphalangeal joint

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hammer, mallet, claw toe 33

• try non-operative first toe cap, sleeve, pad
• occasional tendon procedure only (flexible)
• usually fusion but often just one side of joint
• stiff, but corrected shape
• wire emerging from pulp
• full weightbearing unless wire crosses MTPJ
• wire out at 4-6 weeks

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fifth metataral fractures

• common and harmless, heal in 5 weeks
• immobilisation unnecessary but may be required
  for comfort
• pull-off by ?peroneus brevis ?lateral band
  plantar fascia
• intra-articular, yet innocent usually
• Jones fracture of proximal shaft often non-union,
  often needs fixing

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fracture ? Ottawa rules 13

• fracture in less than 15 sprains presenting
• Ottawa ankle rules clinical decision aid to ?
  unnecessary Xrays
• highly accurate at excluding ankle fractures
  after sprain injury
• sensitivity almost 100
• specificity lower, 26
• ? rays by 30-40

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fracture ? Ottawa rules 23

• Accuracy of Ottawa ankle rules to exclude
  fractures of the ankle and mid-foot systematic
  review
• Bachmann et al BMJ 2003326417-419
• medicolegally safe!

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fracture ? Ottawa rules 33

• ankle Xrays only if
• pain in malleolar region AND
• bony tenderness OR inability to bear weight
• specifically posterior distal 6cm or tip of
  medial malleolus or lateral malleolus, base 5th
  metatarsal or navicular
• inability to bear weight both immediately and at
  presentation (4 steps)

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other topics

• 1. rheumatopid forefoot
• 2. ankle hindfoot arthritis
• 3. midfoot arthritis
• 4. diabetic foot
• 5. acquired flatfoot
• 6. ingrown toenail

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rheumatoid forefoot

• customised shoes with insoles
• cant trust soft tissue integrity longterm so
  bony procedures
• stop disease-modifying agents pre-op
• usually hallux MTPJ fusion and lesser MT head
  resection
• reliable but not brilliant after 5-10 years
• other options include shortening lesser MTs and
  preserving lesser MTP joints

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ankle hindfoot arthritis 13

• subtalar joint arthritis often associated with TN
  and CC arthritis
• expected after calcaneal fracture
• end stage tibialis posterior incompetence
• ankle arthritis common after ankle fractures
• usual nonoperative measures but also including
  calliper
• fusion is mainstay of surgical management

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ankle hindfoot arthritis 23

• perhaps 1 in 100 chance of ultimately needing
  amputation?
• ankle replacements still much poorer results than
  THR, TKR.
• 70 survival 7 years
• failed ankle replacement salvage nightmare
• can do round of golf on ankle fusion
• combined (tibio-talo-calc) fusions often nail

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ankle hindfoot arthritis 33

• fusions usually 3 months in plaster, of which
  first 2 non-weightbearing
• double this in diabetics risk of Charcot
• can try arthroscopic debridement and /or
  cheilectomy of ankle prior to fusion

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midfoot arthritis

• quite uncommon as primary
• common after Lisfranc midfoot fracture-dislocation
  s
• usually arch collapses
• Rx customised orthotics, shoes
• often injections diagnostically first
• then fusions

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diabetic foot 12

• vital role of patient education
• regular checks
• risks of Charcot arthropathy and amputation
• double the protection time for all foot and ankle
  fractures, even in young
• even if no obvious neuropathy
• otherwise real risk of destruction

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diabetic foot 22

• diabetes commonest cause of Charcot
• role of walking boot and total contact cast
• surgery if threatened ulceration

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acquired flatfoot 13

• in adults usually due to tibialis posterior
  incompetence / insufficiency
• term covers whole range of pathology from
  synovitis to full rupture
• pain but no deformity
• flexible deformity
• fixed deformity
• fixed deformity, painful arthritis

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acquired flatfoot 23

• too many toes sign
• more subtle difficulty in single heel rise
• mainstay is orthotics
• UCBL insole
• possibly calliper
• ?early debridement
• USS and MRI may mislead (false reassurance)

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acquired flatfoot 33

• surgery when flexible, nonoperative failure
• medialising calcaneal osteotomy and tendon
  transfer
• when rigid, triple arthrodesis
• refer when arch collapse or change in foot shape
  noticed

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ingrown toenail 12

• cut nail square
• avoid constricting shoes
• some pts anatomically predisposed
• 90 growth from germinal matrix
• 10 from nail bed itself
• reasonable to avulse nail as first line
• eg to let infection settle

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ingrown toenail 22

• definitive chemical (phenol) ablation or sugical
  (Zadeks) ablation
• phenol slightly lower recurrence, takes longer to
  heal deep chemical burn
• Zadeks quicker to heal but slightly higher
  (?15) recurrence
• both require weekly dressings for 4-6 weeks

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