RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in

irinn

The Foot & Ankle Lecture

Class
Course
Title
Lecturer
Date

Intermediate Cycle 3
Musculoskeletal Education
The Foot & Ankle Lecture
Dr. Martin Kelly
06/01/2016

Learning Objectives
Following this lecture the student should:
1) Understand the normal anatomy of the foot and
ankle
2) Have become familiar with the common pathology
3) Become comfortable with obtaining a history from a
patient with foot or ankle pathology and performing a
physical examination of the foot & ankle
4) Understand the various forms of treatment, both
operative and non-operative for foot & ankle pathology

Bones of the foot

Ankle Joint: Anatomy

Anterior

??

Posteri
or
Medial
??

Lateral

Ankle Joint:
Articulation between the lower end of the tibia, the two malleoli,
Anatomy
and the body of the talus
Synovial hinge joint
Covered with a thin layer of hyaline cartilage

Ankle Joint: Anatomy

Deltoid Ligament
Supports the medial of the joint
Strong ligament
Originates from the medial

malleolus and fans out to attach

at four regions, including the
navicular and talus
A subluxed or dislocated ankle

implies disruption of this

ligament

Ankle Joint: Anatomy

CF
Lateral Ligaments
-Anterior talofibular ligament,
-Posterior talofibular ligament,
-Calcaneofibular ligament
ATFL & PTFL
-Support lateral side of the joint
-From lateral malleolus of Fibula
-To dorsal and ventral ends of
talus
Ankle Joint
-Most stable in Dorsiflexion
-Ankle Sprain most likely to occur
in plantarflexion (ATFL)

PTF

ATF

Ankle Joint Movements:

Dorsiflexion
Occurs at ankle joint
Range of Motion (ROM)
20
Nerve supply:
-Common Peroneal Nerve
- L4/5 S1
Muscles Involved:
- Tibialis Anterior
- Extensor Digitorum
Longus
- Extensor Hallicus
Longus

Ankle Joint Movements:

Plantarflexion
Occurs at ankle joint
ROM 40
Nerve supply:
- Tibial Nerve
- L4/5 S1/2
Muscles Involved:
-Gastrocnemius
-Soleus
-Plantaris
-Deep Flexors
Tibialis Posterior
Flexor Digitorum
Longus
Flexor Halicus
Longus

Subtalar Joint
- Talocalcaneal joint
- Movements:
(i) Inversion of the foot
(ii) Eversion of the foot
-Plane synovial joint

Subtalar Joint
Main Ligament of Joint
-Talocalcaneal Ligament
-Strong band of two partially joined fibres
-Binds Talus & Calcaneus

Subtalar joint: Movements

Inversion
Inversion:
The movement of the sole towards the
median plane
Occurs at:
Subtalar joint
Muscles involved:
- Tibialis anterior (Deep Peroneal Nerve)
- Tibialis posterior (Tibial Nerve)
- Extensor hallucis longus (Deep Peroneal
Nerve)

Eversion

Eversion:
The movement of the sole away from
the median plane
Muscles involved:
- Peroneus longus muscle
-Peroneus brevis muscle
Nerve Supply:
- Superficial Peroneal Nerve

Talocalcaneonavicular Joint:
Anatomy
Ligaments:
Talonavicular Ligament: Connects dorsal surface of neck of Talus and navicular
Plantar Calcaneonavicular Ligament: Spring Ligament
(i) Connects the anterior margin of the sustentaculum tali to the plantar surface of
the navicular bone.
(ii) Supports the head of the talus.
(iii) Maintains Longitudinal Arch
(iv) Bears majority of body weight

Muscles and movements

Anterior compartment
Tibialis anterior
- Dorsiflexion & Inversion
- Deep Peroneal Nerve
Extensor hallucis longus
-Hallux Dorsiflexion
-Role in Inversion & Eversion of Foot
-Deep Peroneal Nerve

Muscles and movements

Anterior compartment
Extensor digitorum
longus
- Dorsiflexion of Rays 2nd5th
- Deep Fibular Nerve L4/5
S1
Peroneus brevis
-Eversion of Foot
-Superficial Fibular Nerve
Peroneus longus
-Eversion of foot
-Superficial Fibular Nerve

Muscles and
movements Posterior
compartment
Gastrocnemius
-Very powerful superficial muscle
- It runs from its two heads just
above the knee (medial and
lateral condyles) to the heel
(Achilles tendon)
-Plantarflexion
-Tibial Nerve

Soleus
-Orgin of below the knee to the

heel,
-Forms Achilles tendon with
gastrocnemius
-Plantarflexion
-Tibial Nerve

Muscles and movements

Posterior compartment
Plantaris
-Plantarflexion
-Tibial Nerve
Flexor digitorum
longus
-Plantarflexion
-Flexor of 2nd to 5th Ray
-Tibial Nerve
Flexor hallucis longus
-Plantarflexion
-Flexor of Hallux
-Tibial Nerve

Blood supply: Lower Limb

Blood Supply: Pulses of Foot &

Ankle
(i) Posterior Tibial:
- Posterior to medial malleolus
- Deep to flexor retinaculum
(ii) Anterior Tibial
- Between tendons of EHL & EDL
(iii) Dorsalis Pedis
- Anterior tibial becomes dorsalis pedis at
level of malleoli
- Middle third of line drawn from 1 st web
space
to midpoint between the two malleoli

Nerve Supply
Dorsiflexion: L4-5
Plantarflexion: S1-2
Inversion: L4
Eversion: L5-S1

Sensation
Front of knee: L3
Over tibia: L4
Over fibula: L5
Medial side of foot: L5
Lateral side of foot: S1
Middle of calf and hamstrings:
S2
Perineum: S3

History: Foot & Ankle

Pain
Loss function
Swelling
Stiffness
Deformity
(Establish the chronicity of symptoms)

History: Foot & Ankle

Pain
Where?
How long has the whole problem being going on for?

(Acute/chronic)
Does it limit quantifiable activities (i.e. How far can you walk?)
How long does the pain go on for each time?
Is it getting worse?
Night pain (i.e. Does the patient wake from sleep?)
Relieving factors (i.e. Analgesia, walking aids)
Aggravating factors (i.e. Worse in the morning/after exercise)

History: Foot & Ankle

Other important factors in an orthopaedic history
Age
Unilateral v bilateral
Polyarthropathy
Previous history of trauma e.g. Ankle fracture

Medications
Occupation
Hobbies
Walking aids

Examination: Foot & Ankle

Inspection
Look at shoes for signs of abnormal wear
Inspect standing foot and ankle alignment from behind
Note arch height: (Pes Planus vs Pes Cavus)
Inspect for bruising or swelling

Assessment of gait
Always examine the soles of the patient's shoes for signs of asymmetrical
wear
Look for side to side asymmetry or abnormal contact w/ the ground
Note whether gait is heel to toe (normal), flat foot, or toe to heel
Distinguish between Trendelenburg vs antalgic gait
Note whether hammer or claw toe deformities are present during gait cycle

Palpation
Note presence of ankle effusion by noting the fullness on either side of
the Achilles tendon
Note any tenderness
Feel for any gap in the Achilles tendon

Examination: Foot & Ankle

Movement:
Ankle dorsiflexion
Ask the patient to point their toes upwards.

Ankle plantar flexion

Ask the patient to point their toes towards the floor.

Eversion
Ask the patient to tilt their foot out laterally.

Inversion
Ask the patient to tilt their foot out medially
To isolate the sub-talar joint, Inversion and Eversion should be performed with
the ankle fully dorsiflexed

Examination: Foot & Ankle

Special tests
Thompsons test
Have the patients legs hanging about 20-30cm off the bed
Squeeze the calf muscle on the side suspected of Achilles ligament damage
Absence of plantar flexion is a positive test

Foot & Ankle: Common

Pathologies
Osteoarthritis
Ankle Fracture
Hallux Valgus
Achilles Tendon Rupture
Plantar Fasciitis

Osteoarthrit
is A degenerative joint disease
that causes stiffness, pain,
and reduction in movement
Two types
Primary OA:
Affects: middle aged/
elderly,
Aetiology: unknown
Secondary OA:
(common in ankle OA)
Predisposing factors
- Previous ankle fractures,
- Overweight
- Pes planus

OA: Pathogenesis
-Affects weight bearing joints
-Prevalence increases with age
-Disease accelerated by

mechanical instability
stress on jt
increased stress on joint surface
Pathogenesis
(i)Initial changes in articular cartilage
(ii)Fibrillation of cartilage
(iii)Vertical clefts
(iv)Exposure of subchondral bone
(v)Continuous pressure this leads to
sclerosis of subchondral bone
(eburnation)
(vi)Bone degeneration under stress
creates cysts
(vii)At joint margins new bone forms
resulting in spurs

OA: Ankle arthritis on x-ray

Narrowed joint space

OA: How this affects patients

Joint stiffness
Joint swelling
Lost flexibility
Reduced range-of-motion
Difficulty walking
Difficulty with weight bearing, which may

even cause slips and falls

OA: How do we treat it?

Conservative
Weight loss
Modify daily activities, walking aids
Physiotherapy
Analgesia: aspirin, paracetamol NSAIDS
Steroid injection into the joint
Orthotics
Dietary supplements (e.g. glucosamine)

OA: How do we treat it?

Surgery: Arthroscopic debridement
Sometimes when OA of the ankle occurs,
-loose pieces of cartilage and bone float around inside
the ankle joint
Loose bodies
Cause irritation in the joint, leading to inflammation.
They can also get caught between the joint surfaces of
the ankle.
The cartilage surfaces of the joint can also become rough,
with flaps of cartilage that peel off the surface. These can
be shaved, making the surface smoother.

OA: How do we treat it?

Surgery: Ankle Replacement
Not as successful as Hip/Knee arthroplasty
Ankle mortoise moves as we walk
- Tibia & Fibula move against one another
- Difficult to get artificial ankle prosthesis to stay
connected to
bone
- Aseptic Loosening is a complication
(After relatively short time)

OA: How do we treat it?

Surgery: Arthrodesis (Ankle fusion)

Fusion of :
- Talus
- Tibia
- Fibula
Eliminates:
- Dorsiflexion
- Plantarflexion
Postop:
- Patients can walk, difficult to run
- Loose ability to push off with toes
Preferred Option:
- Post-traumatic arthritis of the ankle.

Ankle fractures
An ankle injury
- Sprained(soft tissue damage)
- Fractured (broken bone)
Fractured ankle
- There is invariably soft tissue damage (i.e ligaments)
- Can be classified by the involvement of malleoli

Ankle Fracture: Ottawa ankle

rules
X-rays are only required if there is bony pain in the malleolar
zone and any one of the following:
(i) Bone tenderness along the distal 6cm of the posterior edge of the
tibia or tip of the medial malleolus
(ii) Bone tenderness along the distal 6cm of the posterior edge of the
fibula or tip of the lateral malleolus
(iii) An inability to bear weight both immediately and in the
emergency department for four steps
Foot series is only indicated when the patient has pain in the
midfoot zone and one of the following:
(i) Have bone tenderness at the base of the fifth metatarsal or at the
navicular
(ii) Are unable to bear weight both immediately after the injury and
for four steps in the emergency department or doctor's office

Ankle Fractures: Fixation

Open reduction and internal
fixation
(ORIF)

Ankle fracture: Syndesmosis

Tibiofibular Syndesmosis
-

Formed by rough, convex surface of the medial side of the lower

end of the fibula
and rough concave surface on the lateral side of the tibia

Below, to the extent of about 4 mm, these surfaces are smooth,

and covered with
cartilage, which is continuous with that of the ankle-joint

Ankle fractures: Fractures of the

distal fibula
Danis-Weber classification

Type A fractures: are horizontal avulsion fractures found below the mortise. They are stable
and amenable to treatment with closed reduction and casting unless
accompanied by a displaced medial malleolus fracture.
Type B fracture: is a spiral fibular fracture that starts at the level of the mortise. This type of
fracture occurs secondary to external rotational forces.
These fractures may be stable or unstable depending on ligamentous injury
or associated fractures on the medial side.
Type C fracture: is above the level of the mortise and disrupts the ligamentous attachment
between the fibula and the tibia distal to the fracture.
These fractures are unstable and require open reduction and internal fixation.

Ankle fractures

Syndesmosis screw

Ankle fracture: Treatment

Non-operative
Weber A 6 weeks Cast ( weight bearing )
Weber B Undisplaced Cast ( non-weight bearing )
Ankle splints arecommercially available or may be constructed by sandwiching
10-12 layers of plaster between 4 sheets of cotton padding

Ankle fracture: Treatment

Operative:

- (i) ORIF: Open Reduction Internal Fixation

-(ii) Tightrope:
- sutureloop,
- tensioned and secured
- Between 2 metallic buttons
- placed against the tibia and fibula,
- physiologic stabilization of the ankle
mortise.

Ankle fracture: Treatment

ORIF of Weber C fracture

Hallux Valgus
Nomenclature:
-Hallux: Big Toe/1st Ray
-Valgus: Deviation away from midline
The bump:
-The swollen bursal sac and/or an osseous (bony)
deformity that has
grown at the head of the first metatarsal
Bunions
- Caused by a biomechanical abnormality,
- Certain tendons, ligaments, and supportive structures
of the first
metatarsal are no longer functioning correctly
- Caused by a variety of conditions intrinsic to the
structure of the foot
eg. flat feet, excessive ligamentous flexibility,
abnormal bone
structure, and certain neurological conditions
Although some experts are convinced that poor fitting
footwear is the main cause of bunion formation, other
sources concede only that footwear exacerbates the
problem caused by the original deformity

Hallux Valgus
As the toe moves further and further into
valgus:
-First metatarsal head becomes more prominent

(first
metatarsal exostosis) and a protective bursa
may develop
over it (bunion)
-Friction against the shoe may give rise to
inflammatory changes within it (bursitis)
2 OA changes in first MP joint
As the great toe moves laterally it crowds the
other toes, and may come to lie above, or
more commonly below the other toes

Hallux Valgus
Mechanics of the forefoot are disturbed,
Leads to: - Spreading of the forefoot
- Callus formation under metatarsal heads
- Anterior metarsalgia (forefoot pain)

Hallux Valgus: Treatment

Conservative
1. Follow the advice given by a Podiatrist
2. Use felt pads to help keep pressure off the
painful area of the bunions.
3. Wear shoes that are wide and deep to
accomodate the bunions. Fitting of footwear
is very important. Avoid the use of high heel
shoes.
4. Use exercises to keep the joint mobile
5. Night splints may help with the bunion
symptoms. The aim of these are to hold the
toe in a more correct position.

Hallux Valgus: Treatment

Surgical: Goals
(i) Removing the abnormal bony enlargement of the first metatarsal
(ii) Realigning the first metatarsal bone relative to the adjacent metatarsal bone
(iii) Straightening the great toe relative to the first metatarsal and adjacent toes
(iv) Realigning the cartilagenous surfaces of the great toe joint
(v) Addressing arthritic changes associated with the great toe joint
(vi) Repositioning the sesamoid bones beneath the first metatarsal bone
(vii) Shortening, lengthening, raising, or lowering the first metatarsal bone
(viii) Correcting any abnormal bowing or misalignment within the great toe

Hallux Valgus: Treatment

Surgical: Chevron Osteotomy
-

Very rare that a bunion can be treated by simply shaving down the bump of the
bone.
Invariably, the deformity will recur and both the bunion and the hallux valgus will
return.
Therefore, the shaving of the bunion, called an exostectomy, is performed in
conjunction with a cut of the first metatarsal bone (which is called an osteotomy).

Depending on the severity of the deformity, this osteotomy can be done either
- at the end of the metatarsal (a distal osteotomy)
- or if the deformity is more severe, the osteotomy is performed at the base of
the first metatarsal
(a proximal osteotomy).
Chevron osteotomy
- A distal metatarsal osteotomies that is performed is called the.
- Typically a small screw is inserted into the bone to hold the metatarsal head in
place
- Speeds up bone healing.
- Following a chevron osteotomy, walking is permitted in a surgical shoe the
next day after surgery,
and the shoe is worn for approximately three to four weeks before a more
comfortable

Hallux Valgus: Treatment

Surgical: Chevron Osteotomy

An operation which is
used frequently is called
the chevron osteotomy.
It is a V-shaped bone cut
made in the metatarsal

Once the V-cut in the

metatarsal is made,
the bone is shifted over
and the remaining
edge of the bone is
shaved down as shown
here.

Before

After

Achilles Tendon Rupture

Typically:

- Males 30 50 yrs
- Weekend warriors
- Occurs approximately 2-6 cm the
"watershed zone"
above the calcaneal insertion of the tendon
- Will often complain of a snap or like
being kicked
Mechanisms of injury:
- Sudden forced plantar flexion of the foot,
- Unexpected dorsiflexion of the foot,
- Violent dorsiflexion of a plantar flexed
foot.
- Other mechanisms include direct trauma

The estimated peak load is 6-8 times the

body weight during running with a tensile

Achilles Tendon
Rupture
Examination
Palpable gap 2-3cm above insertion
Thompsons test

Achilles Tendon
Rupture
Treatment: Conservative
- Casting
- Placed in cast in equinis (plantar flexion)
- Some Studies state the rerupture rate up to
20-40%
- Recent trials have showed increased success
with conservative management

Treatment: Surgery
-Techniques: modified Kessler
Krackow,
Bunnell technique

Plantar Fasciitis
Typically
-Middle aged men,
-Overweight
- C/O pain first step of day
- Among sports people, common in runners
Usually marked and well localized tenderness
on the medial aspect of the heel towards its
plantar surface
In some cases there may be some local detachment of the plantar
fascia, with ossification and the formation of a calcaneal exostosis
(heel spur)

Treatment of Plantar Fasciitis

Usually self-limiting
- Pain is due to degenerative changes in the plantar fascia.
Conservative
Rest
NSAIDs
Physiotherapy
Night splints
Orthotics
Local steroid injection

Surgical
Plantar Fascia release (last resort)