1. FOOT & ANKLE MOHAN LAL Consultant Orthopaedic & Foot/Ankle Surgeon
Surrey & Sussex NHS Trust
Spire Gatwick Park Hospital
North Downs Hospital
Presentation by Chandar Lal

2. SUBCATEGORIES FOOT AND ANKLE EXAMINATION COMMON FOOT DISORDERS
ANKLE DISORDERS
TENDON DISORDERS

3. 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

4. LOOK Deformity Callosities represent pressure areas Swelling
Lumps (heel, bunion, tailor’s bunion)
Scars
Ulcers
Colour
Trophic changes
Nails
Deformity
Arches: cavovarus, planovalgus
Hallux Valgus
Toes: hammer, mallet, claw
Callosities represent pressure areas
Swelling
Bilateral (medical)
Unilateral (surgical)
Focal
Local

5. LOOK CONTD.
PES PLANUS
CAVOVARUS

6. LOOK CONTD.

7. FEEL 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

8. MOVE
Ankle
Subtalar joint
Midfoot
Hallux
Toes
Specific Tendons

9. COMMON FOOT DISORDERS Hallux Valgus and Rigidus Lesser toe deformities
Hammer toe
Mallet toe
Claw toe
Flat foot
Metatarsalgia

10. GENERAL PROFILE OF DEFORMITIES
Commonly seen in females
82% of women report having foot pain, while 72% report one or more foot deformities.
More than 7 out of 10 women develop a bunion, hammertoe, or other painful foot deformity.
Nine out of 10 women’s foot deformities can be attributed to tight shoes.

11. HALLUX VALGUS Definition Lateral deviation of great toe Aetiology
Familial
Inappropriate footwear
Flatfeet
Long first ray
Incongruous 1st MTP joint articular surface
Metatarsus primus varus
Rheumatoid arthritis. HV
HV + Claw toes

12. 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.

13. WHEN TO REFER Bunion pain Transfer metatarsalgia
Symptoms
Bunion pain
Transfer metatarsalgia
Significant deformity causing:
2nd toe deformity
Shoe wear problems
Cosmesis – relative contraindication

14. SIGNS Bunion and inflamed overlying bursa and skin
Valgus and pronation deformity of hallux.
Painful callus on 2nd toe
Second toe is forced into hyperextension by deviated great toe
Transfer metatarsalgia/thickened skin over MT heads.
Increased valgus angle at first MTP joint
Valgus angle at first MTP joint >20 degrees
Angle between 1st & 2nd MT >9 degrees

15. MANAGEMENT Entire foot must be assessed first.
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

16. ANGLES

17. TREATMENT CONSERVATIVE TREATMENT
Aim: Relieve pressure over painful bunion prominence
Properly fitted, low heeled stiff-soled shoes
Wide, square shaped toe box
Toe portion stretched to accommodate bunion
Extra-depth shoe to accommodates dorsiflexed second toe
Splint separates first and second toe
Acute pain management
Rest
Apply moist heat
Analgesics

18. 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

19. 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

20. TREATMENT Grade I: Mild osteophytes, joint space preserved
NSAID, orthosis and injection
Grade II: Moderate osteophyte formation, joint space narrowing & subchondral sclerosis
Cheilectomy: excision of 20-35% of dorsal metatarsal head aiming for up to 70º of dorsiflexion.
Grade III: Severe arthritis
Arthrodesis/joint replacement

21. LESSER TOE DEFORMITIES
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.

22. FLAT FOOT/PES PLANUS Flexible (99%) or Rigid (1%)
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

23. 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

24. RIGID PES PLANUS
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.

25. METATARSALGIA 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

26. MORTON’S METATARSALGIA
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

27. ANKLE DISORDERS Instability Impingement
Osteochondritis Dissecans of talus
Arthritis
Posttraumatic
Inflammatory
Degenerative

28. ANKLE INSTABILITY 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

29. ANKLE IMPINGEMENT 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

30. OSTEOCHONDRITIS DISSECANS
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

31. ANKLE ARTHRITIS
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.

32. ANKLE ARTHRITIS (CONTD.)
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?)

33. ANKLE ARTHRITIS (CONTD.)

34. TENDON DISORDERS Commonly affected tendons: Tibialis posterior
Tibialis anterior
Peroneus tendons
Tendoachillis

35. TIBIALIS POSTERIOR TENDON
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

36. PATHOLOGY/PRESENTATION
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

37. MANAGEMENT Imaging: X-ray (degeneration), MRI
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

38. TIBIALIS ANTERIOR Anatomy:
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.

39. 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.

40. PERONEAL TENDONS (CONTD.)
Pathology:
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:
Examination - tenderness/subluxation
X-rays to exclude fracture
MRI

41. PERONEAL TENDONS (CONTD.)
Treatment
Non-surgical
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

42. ACHILLES TENDINITIS/TENDINOSIS
Tendinosis - there will be clinical inflammation, but objective pathologic evidence for cellular inflammation is lacking
Tendinitis - there will be a peritendinous inflammation
Seen in adults in their 30s and 40s
Most commonly affects runners
Heel cord contracture can exacerbate symptoms
Two types:
Non-insertional
Occurs proximal to retrocalcaneal bursa
Generally responds well to non-operative treatment
Insertional
Tenderness is localized to calcaneal tendon insertion
More difficult to treat

43. 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

44. ACHILLES TENDON RUPTURE
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

45. ACHILLES TENDON RUPTURE (CONTD.)
Diagnosis (suspect in all ankle injury cases):
Characteristic history
Classical signs:
Local tenderness and gap
Hyper-dorsiflexion at ankle
Thompson/Simmonds test
Imaging:
Ultrasound and MRI scan in doubtful cases

46. TREATMENT Consider DVT prophylaxis
Non-operative treatment is indicated in older patients and minimally displaced ruptures and involves serial casting over weeks (complete equinus, mid equinus, neutral walking).
Operative repair is indicated in younger patients with clinically displaced ruptures, delayed presentation (48-72 hours) and neglected ruptures followed by similar casting regime.
Complications: wound healing and sural nerve injury
Consider DVT prophylaxis

47. NON-OPERATIVE VS. OPERATIVE
Return to the preinjury level of activity
Patient satisfaction
Re-rupture
Non-operative
69%
66%
Up to 33%
Operative
83%
93%
2-3%

48. HEEL PAIN 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.

49. RETROCALCANEAL BURSITIS
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).
Symptoms: pain, swelling, shoe wear difficulty
Signs: tenderness, lump, inflammation

50. MANAGEMENT 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

51. THANK YOU