FOOT & ANKLE
MOHAN LAL
Consultant Orthopaedic & Foot/Ankle Surgeon
Surrey & Sussex NHS Trust
Spire Gatwick Park Hospital
North Downs Hospital
Presentation by Chandar Lal
SUBCATEGORIES
FOOT AND ANKLE EXAMINATION
COMMON FOOT DISORDERS
ANKLE DISORDERS
TENDON DISORDERS
FOOT & ANKLE EXAMINATION
General Aspects
Gait: tiptoes/heel varus, heel walking
 Shoe wear/orthoses
 Expose to knee
 Look, feel, move
 Neurovascular status
 Other medical conditions: RA, Gout, CNS
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LOOK
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Deformity
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Arches: cavovarus, planovalgus
Hallux Valgus
Toes: hammer, mallet, claw
Callosities represent pressure
areas
Swelling
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Bilateral (medical)
Unilateral (surgical)
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Focal
Local
Lumps
(heel, bunion, tailor’s
bunion)
Scars
Ulcers
Colour
Trophic changes
Nails
LOOK CONTD.
PES PLANUS
CAVOVARUS
LOOK CONTD.
FEEL
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TA, heel (Haglaund’s, plantar fasciitis)
Peroneal tendons, lateral ligament, 5th MT base, Tailor’s
bunion
Forefoot: Morton’s, MTPJ synovitis, 1st MTPJ,
Freiberg’s, stress fractures, sesamoiditis
Midfoot: Kohler’s, acc. Navicular, OA
Ankle: OA, OCD, Tib. Post Tendon, tarsal tunnel
Temperature and pulses
Neurologic: sensation, motor, reflexes
MOVE
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Ankle
Subtalar joint
Midfoot
Hallux
Toes
Specific Tendons
COMMON FOOT DISORDERS
Hallux Valgus and Rigidus
 Lesser toe deformities
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Hammer toe
 Mallet toe
 Claw toe
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Flat foot
 Metatarsalgia
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GENERAL PROFILE OF DEFORMITIES
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Commonly seen in females
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82% of women report having foot pain, while 72% report one
or more foot deformities.
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More than 7 out of 10 women develop a bunion, hammertoe, or
other painful foot deformity.
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Nine out of 10 women’s foot deformities can be attributed to
tight shoes.
HALLUX VALGUS
Definition
Lateral deviation of great toe
Aetiology
 Familial
HV
 Inappropriate footwear
 Flatfeet
 Long first ray
 Incongruous 1st MTP joint articular surface
 Metatarsus primus varus
 Rheumatoid arthritis.
HV + Claw toes
HALLUX VALGUS CONTD.
Pathogenesis
 Complex deformity with angle between 1st & 2nd MT > 9
degrees and valgus angle at MTP joint >20 degrees.
 Valgus posture of great toe causing hammer toe like
deformity of second toe.
 Splaying of forefoot causing bunion.
 Incongruence causing osteoarthritis of 1st MTP joint.
WHEN TO REFER
Symptoms
 Bunion pain
 Transfer metatarsalgia
 Significant deformity causing:
 2nd
toe deformity
 Shoe wear problems
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Cosmesis – relative contraindication
SIGNS
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Bunion and inflamed overlying bursa and skin
Valgus and pronation deformity of hallux.
Painful callus on 2nd toe
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Second toe is forced into hyperextension by
deviated great toe
Transfer metatarsalgia/thickened skin over MT
heads.
Increased valgus angle at first MTP joint
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Valgus angle at first MTP joint >20 degrees
Angle between 1st & 2nd MT >9 degrees
MANAGEMENT
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Entire foot must be assessed first.
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X-ray of foot –Standing dorso plantar, oblique &
axial sesamoid views
Medial exostosis (bunion)
Lateral displacement proximal phalanx
Degenerative changes in 1st MTP/IP Joint
Intermetatarsal & Hallux Valgus angles
ANGLES
TREATMENT
CONSERVATIVE TREATMENT
Aim: Relieve pressure over painful bunion prominence
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Properly fitted, low heeled stiff-soled shoes
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Wide, square shaped toe box
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Toe portion stretched to accommodate bunion
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Extra-depth shoe to accommodates dorsiflexed second toe
Splint separates first and second toe
Acute pain management
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Rest
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Apply moist heat
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Analgesics
SURGICAL MANAGEMENT
Indications
 Refractory to conservative management
 Severe deformity or bunion pain
Factors to be considered before surgery
 Valgus deviation of great toe
 Varus deviation of first metatarsal
 Arthritis of MTP and IP joint
 Bunion
 Metatarso-cuneiform joint instability
 Vascularity & sensibility
Surgical Procedures
Soft tissue surgery - rarely indicated in adolescent cases
Bone/joint procedure remains the gold standard
HALLUX RIGIDUS/DORSAL BUNION
Painful limitation of motion at 1st MTP joint
Pathogenesis: synovitis, cartilage destruction, osteophyte
proliferation, subchondral cysts and sclerosis
Clinical presentation: pain, limited dorsiflexion and dorsal
osteophyte, dorsal tenderness
Aetiology: Trauma, Repeated microtrauma, osteochondritis
dissicans and abnormally long first metatarsal
TREATMENT
Grade I: Mild osteophytes, joint space preserved
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NSAID, orthosis and injection
Grade II: Moderate osteophyte formation, joint space
narrowing & subchondral sclerosis
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Cheilectomy: excision of 20-35% of dorsal metatarsal head aiming
for up to 70º of dorsiflexion.
Grade III: Severe arthritis
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Arthrodesis/joint replacement
LESSER TOE DEFORMITIES
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Hammer, Claw and Mallet
Association with HV, RA, DM and NM disorders
Pain, corns, ulcers, shoe wear difficulties
Flexible and fixed
Conservative treatment: manipulation, corn pads,
accommodative shoe wear
Surgical treatment: tendon release and transfers
for flexible deformities; fusion and excision
arthroplasties for fixed deformities.
FLAT FOOT/PES PLANUS
Flexible (99%) or Rigid (1%)
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Distinguished by Jack test and tiptoeing
Pathology - Loss of normal medial longitudinal
arch in combination with valgus posture of heel,
mild subluxation of subtalar joint & eversion of
calcaneum
Arch develops till the age of 7-10 years so there is
no treatment required
15-20% of adults have asymptomatic pes planus
TREATMENT OF FLEXIBLE PES
PLANUS
3-9 years: symptomatic - arch support
10-14 years require investigation
Symptomatic patient - rule out accessory navicular
or incomplete tarsal coalition and treat
accordingly.
Adults with painful pes planus not responding to
conservative management will benefit with
surgery
RIGID PES PLANUS
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Aetiology: Congenital vertical talus & tarsal
coalition
Tarsal coalition: calcaneo-navicular &
talocalcaneal; can be bony, cartilagenous or fibrous.
Symptoms: Foot pain, difficulty walking on uneven
surfaces, foot fatigue, peroneal spasm.
Treatment: 4-6 weeks of cast immobilization;
surgical treatment includes resection of connecting
bar & soft tissue interposition, subtalar arthrodesis,
triple arthrodesis.
METATARSALGIA
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Pressure from subluxed MTPJs with painful callosities
Freiberg’s AVN (treatment: conservative and surgical)
Stress Fractures
Transfer from first metatarsal insufficiency/HV
Sesamoiditis
Morton’s
MORTON’S METATARSALGIA
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Commoner in middle-aged women; 85% unilateral
Aetiology: trauma, ischaemia, entrapment
Pathology: degenerative rather than a true neuroma
with perineural fibrosis and demyelination.
Diagnosis: symptom of shooting/constant pain on
walking, relieved by rest and removal of footwear;
clinical sign of third/second cleft tenderness and
palpable click on metatarsal squeeze test.
Treatment: orthoses, injection and excision
ANKLE DISORDERS
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Instability
Impingement
Osteochondritis Dissecans of talus
Arthritis
Posttraumatic
 Inflammatory
 Degenerative
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ANKLE INSTABILITY
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Repeated acute inversion injuries/laxity
Presentation with pain and instability
Diagnosis: tenderness, anterior draw
Imaging: stress X-rays, MRI
Treatment
Conservative - physiotherapy, splints
 Surgical – primary repair/reconstructive procedures
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ANKLE IMPINGEMENT
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Repeated sporting dorsiflexion injuries
Presentation with anterior ankle pain
Diagnosis: clinical anterior tenderness and ±
anterior osteophytes on X-rays
Treatment
Conservative: activity modification/NSAIDs
 Surgical: open/arthroscopic decompression
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OSTEOCHONDRITIS DISSECANS
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Posttraumatic in young patients
Presentation with persistent pain and swelling
with stiffness
Diagnosis: clinical tenderness, diffuse swelling
Imaging: X-rays and MRI scan
Treatment: undisplaced lesions treated with rest
and cast immobilisation; displaced lesions
require arthroscopic removal/drilling
ANKLE ARTHRITIS
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Posttraumatic: rare in commonly injured joint;
associated with displaced intra-articular fractures
and significant lateral ligament complex injury.
Inflammatory: RA in low-demand patients
Degenerative: relatively uncommon
Presentation with pain, swelling, stiffness,
limited mobility, limping.
ANKLE ARTHRITIS (CONTD.)
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Diagnosis: clinical swelling, tenderness, ↓ROM
Imaging: X-rays, bone scan to assess
surrounding joints
Treatment
Conservative: NSAIDs, walking stick, weight
reduction and activity modification.
 Surgical: arthroscopic/open decompression; ankle
arthrodesis (up to 25% non-union, 3 month casting);
ankle replacement gives satisfactory mid-term results
in properly selected low-demand patients (long-term
results?)
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ANKLE ARTHRITIS (CONTD.)
TENDON DISORDERS
Commonly affected tendons:
Tibialis posterior
 Tibialis anterior
 Peroneus tendons
 Tendoachillis
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TIBIALIS POSTERIOR TENDON
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Anatomy - posteromedial tendon, origin from posterior surface
of tibia & inserts on to the medial cuneiform
Function - plantar flexion, inversion, stabilizes medial
longitudinal arch
Important tendon in foot, affection of which causes more
functional disability than TA rupture
Aetiology - trauma, chronic flat foot, inflammatory arthropathy,
degenerative tendonopathy, chronic tenosynovitis, abnormal
insertion, steroid use.
Deformity - collapse of medial longitudinal arch, hindfoot
valgus, midfoot abduction, forefoot pronation
PATHOLOGY/PRESENTATION
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Pathogenesis: tenosynovitis, incomplete tear, complete disruption
Two groups of patients:
 Younger patients with inflammatory arthropathy/traumatic
rupture
 Older, typically female patients with degenerative tears
PRESENTATION
 Fatigue of foot with limited activity, medial and lateral pain
 Flat foot on weight bearing
 Standing tip toe – heel will go into valgus
 Clinical examination confirms tenderness, weak/ruptured tendon,
hindfoot valgus (flexible/fixed) and a lack of heel varus on tiptoeing
MANAGEMENT
Imaging: X-ray (degeneration), MRI
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Tenosynovitis - rest, NSAIDs, short leg walking cast,
orthoses, steroid injection in tendon sheath,
synovectomy.
Incomplete tear - repair or augmentation with either
FDL or FHL.
Complete disruption – repair in traumatic young cases;
tendon transfer with medial calcaneal displacement
osteotomy (mobile hindfoot) and subtalar/triple
arthrodesis (fixed hindfoot).
Satisfactory results in spite of prolonged rehabilitation
TIBIALIS ANTERIOR
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Anatomy:
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Origin - lateral condyle of tibia, proximal 2/3 of lateral
surface of tibia, interosseous membrane
Insertion - base of first metatarsal and medial plantar
surface of 1st cuneiform
Action - dorsiflexes and inverts foot
Disorders are common in athletes and old age group
Diagnosis- weakness of dorsiflexion of foot, pain, use
of toe extensors for dorsiflexion of foot.
Treatment- steroid injection or synovectomy . Tendon
repair rarely required as deformity is not functionally
significant.
PERONEAL TENDONS
Anatomy:
Peroneus longus & brevis are posteolateral tendons originating
from fibula and interosseous membrane and are inserted at base
of I & V MT respectively.
PERONEAL TENDONS (CONTD.)
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Pathology:
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Tenosynovitis - common in high arch foot because of
increase in excursion.
Sprain/ subluxation - inversion ankle injuries.
Symptoms: pain in the outer part of the ankle or just
behind the lateral malleolus. This pain commonly
worsens with activity and eases with rest.
Diagnosis:
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Examination - tenderness/subluxation
X-rays to exclude fracture
MRI
PERONEAL TENDONS (CONTD.)
Treatment
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Non-surgical
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Rest, short-leg walking cast/brace, lateral heel wedge,
physical therapy, NSAIDs and Cortisone injection
Surgical
Tenosynovectomy and repair of split
 Stabilisation of dislocating tendons by groove deepening,
peroneal retinaculum reconstruction and bone block
procedures
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ACHILLES
TENDINITIS/TENDINOSIS
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Tendinosis - there will be clinical inflammation, but objective
pathologic evidence for cellular inflammation is lacking
Tendinitis - there will be a peritendinous inflammation
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Seen in adults in their 30s and 40s
Most commonly affects runners
Heel cord contracture can exacerbate symptoms
Two types:
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Non-insertional
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Occurs proximal to retrocalcaneal bursa
Generally responds well to non-operative treatment
Insertional
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Tenderness is localized to calcaneal tendon insertion
More difficult to treat
TREATMENT
Conservative
 Rest, ice, NSAIDs, physical therapy, orthoses
Operative
 Achilles tendon decompression and debridement if
unrelieved by 6 months of conservative measures
 90% will have significant relief of symptoms; 10% will
have some symptom improvement
 Complete symptomatic cure not guaranteed
ACHILLES TENDON RUPTURE
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Common sporting incidence affecting the young to
middle-aged
Mechanism usually involves loading on a dorsiflexed
ankle with the knee extended (soleus and gastroc on
maximal stretch) or repeated microtrauma
Consider systemic conditions such as gout or
hyperparathyroidism (esp. with pure avulsion injury);
previous steroid injections
Disabling condition requires approx. 6 months to
recover when treated adequately
ACHILLES TENDON RUPTURE
(CONTD.)
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Diagnosis (suspect in all ankle injury cases):
Characteristic history
 Classical signs:
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Local tenderness and gap
Hyper-dorsiflexion at ankle
Thompson/Simmonds test
Imaging:
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Ultrasound and MRI scan in doubtful cases
TREATMENT
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Non-operative treatment is indicated in older patients
and minimally displaced ruptures and involves serial
casting over 10-12 weeks (complete equinus, mid
equinus, neutral walking).
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Operative repair is indicated in younger patients with
clinically displaced ruptures, delayed presentation (4872 hours) and neglected ruptures followed by similar
casting regime.
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Complications: wound healing and sural nerve injury
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Consider DVT prophylaxis
NON-OPERATIVE VS. OPERATIVE
Return to the Patient
preinjury
satisfaction
level of
activity
Re-rupture
69%
Nonoperative
66%
Up to 33%
Operative 83%
93%
2-3%
HEEL PAIN
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Commonly caused by plantar
fasciitis.
Heel spurs often associated.
Pain is worst on waking up.
Causes - obesity, excessive
walking/sporting activity,
tight plantar fascia &
flattening of the arch.
Treatment – orthoses,
physical therapy, injection,
NSAIDs and (rarely) surgical
release in resistant cases.
RETROCALCANEAL BURSITIS
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Two bursae: retrocalcaneal (subtendinous) bursa
& subcutaneous calcaneal bursa
Causes
Repetitive trauma from shoe wear and sports
 Gout, RA and ankylosing spondyloarthropathies
 Bursal impingement between the Achilles tendon
and an excessively prominent posterior-superior
aspect of the calcaneus (Haglund deformity).
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Symptoms: pain, swelling, shoe wear difficulty
Signs: tenderness, lump, inflammation
MANAGEMENT
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Imaging: X-rays for calcification and Haglund deformity.
Conservative: physical therapy, appropriate shoe wear,
injection (risk of tendon rupture).
Surgical Intervention includes resection of Haglund
deformity (removal of the calcaneal superoposterior
prominence), excision of the painful bursa and debridement of
tendon insertion
THANK YOU