Disorders of the Foot and Ankle

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Chapter 6

Disorders of the Foot and Ankle

Contents

SECTION 1 BIOMECHANICS OF THE FOOT AND ANKLE

SECTION 2 PHYSICAL EXAMINATION OF THE FOOT AND ANKLE

SECTION 3 RADIOGRAPHIC EVALUATION OF THE FOOT AND ANKLE

SECTION 4 ADULT HALLUX VALGUS

SECTION 5 JUVENILE AND ADOLESCENT HALLUX VALGUS

SECTION 6 HALLUX VARUS

SECTION 7 LESSER-TOE DEFORMITIES

SECTION 8 HYPERKERATOTIC PATHOLOGIES

SECTION 9 SESAMOIDS

SECTION 10 ACCESSORY BONES

SECTION 11 NEUROLOGIC DISORDERS

SECTION 12 ARTHRITIC DISEASE

SECTION 13 POSTURAL DISORDERS

SECTION 14 TENDON DISORDERS

SECTION 15 HEEL PAIN

SECTION 16 THE DIABETIC FOOT

SECTION 17 TRAUMA

TESTABLE CONCEPTS

This chapter provides a review of adult foot and ankle disorders and deformities. Pediatric and congenital deformities are covered in Chapter 3, Pediatric Orthopaedics.

section 1 Biomechanics of the Foot and Ankle

The primary functions of the foot and ankle are to provide support and forward ambulation.

ANATOMY

Ankle

1. Ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus (Figure 6-1).

2. Mortise articulates with the dome of the talus.

3. Mortise widens and ankle becomes more stable in dorsiflexion due to shape of talar dome (wider anteriorly).

4. A simplified model of the ankle joint has a horizontal axis from anteromedial to posterolateral and a coronal axis from superomedial directed distally and laterally to the tip of the fibula (between the malleoli) (Figure 6-2).

5. Responsible for most sagittal plane motion of the foot and ankle

6. 23 to 48 degrees plantar flexion

7. 10 to 23 degrees dorsiflexion

8. Also contributes to inversion/eversion and rotation

Distal tibiofibular joint

Ligamentous anatomy (Figure 6-3)

1. The lateral ankle ligaments function as a restraint to varus forces at the ankle.

2. The distal tibiofibular joint (ankle syndesmosis) and fibula provide stability against lateral talar translation.

3. Deltoid ligament complex—main stabilizer of the ankle during stance

Hindfoot and midfoot

The midfoot begins at the articulation between the navicular and the cuneiforms along with cuboid and the fourth and fifth metatarsals. The midfoot also includes the tarsometatarsal (TMT) joints.

The forefoot includes all structures distal to the TMT joints (Figure 6-5).

The CC and TN joints are collectively referred to as the midtarsal, transverse tarsal, or Chopart joint.

1. This joint is important for providing stability of the hindfoot and midfoot to produce a rigid lever at heel-rise.

2. During heel-strike (hindfoot valgus, forefoot abduction, and dorsiflexion of the ankle), the transverse tarsal joints are parallel and supple, adapting to the uneven ground.

3. During toe-off (hindfoot varus, forefoot adduction, and plantar flexion of the ankle), these joints become divergent and lock, providing stiffness to the foot for forward propulsion (Figure 6-6).

The collective TMT joint complex is referred to as the Lisfranc joint.

The foot is also divided into three columns.

The foot has longitudinal and transverse arches. Stability of these arches is provided by a combination of the bony architecture, ligamentous attachments, and muscle forces.

Ligamentous stability to the midfoot is provided through longitudinal and transverse ligaments on the plantar and dorsal aspects of each joint.

The Lisfranc joint complex has a specialized bony and ligamentous structure, providing stability to this joint.

The midfoot provides an important bridge between the hindfoot and forefoot. It provides both flexibility and stability necessary for normal gait and other activities.

II FOREFOOT

The bony forefoot comprises the metatarsals and phalanges.

The first metatarsal is the widest and shortest and bears 50% of the weight during gait.

The second metatarsal is usually the longest and experiences more stress than the other lesser metatarsals.

The lesser toes are controlled by a balance among them.

The intrinsic tendons pass plantar (providing a flexion force) to the MTP joint axis proximally and pass dorsal to the axis distally (providing an extension force).

1. Plantar migration of this axis after a Weil (oblique shortening) osteotomy of the metatarsal leads to a “cock-up” toe. The tendons are now relatively dorsal to the MTP axis of rotation (Figure 6-7).

2. Loss of intrinsic function as seen in hereditary and motor sensory neuropathy or diabetic neuropathy predictably leads to claw toes.

III FOOT POSITIONS VERSUS FOOT MOTIONS

Foot positions are defined in a manner different from that of foot motions.

The foot positions are

Foot motions in the three axes of rotation are illustrated in Figure 6-8 and summarized in Table 6-1.

1. The critical assessment is to determine the relationship of the forefoot to the hindfoot.

2. If the heel is in a neutral position (subtalar neutral), the forefoot should be parallel with the floor to meet the ground flush (plantigrade).

image If the first ray is elevated, the forefoot is in varus position. If the first ray is flexed, the forefoot is in valgus position. This should not be confused with hindfoot varus or valgus.

image For example, in a long-standing flatfoot deformity the heel is valgus and the forefoot has compensated by going into varus or supinating to keep the flat to the ground.

IV THE GAIT CYCLE

One full gait cycle, from heel-strike to heel-strike, is termed a “stride.”

1. Each stride is composed of a stance phase (heel-strike to toe-off, 62% of the cycle) and a swing phase (toe-off to heel-strike, 38% of the cycle) (Figure 6-10).

2. Walking is defined by a period of double-limb support in addition to always having one foot in contact with the ground throughout the gait cycle.

3. Ground reaction forces are approximately 1.5 times body weight during walking and 3 to 4 times body weight during running.

4. As the speed of gait increases, the stance phase decreases.

Soft tissue contributions to gait mechanics

1. Swing phase

2. Heel-strike

3. Foot flat

4. Toe-off

image Gastrocnemius-soleus complex—concentric contraction

image In addition, as the foot progresses from heel-strike to toe-off, the following changes allow the foot to convert from a flexible shock absorber to a rigid propellant.

image The plantar fascia, which attaches to the plantar medial heel and runs the length of the arch to the bases of each proximal phalanx, is tightened as the MTP joints extend. The longitudinal arch is accentuated.

image The hindfoot supinates, with firing of the posterior tibial tendon.

image The transverse tarsal joint locks and provides a rigid lever arm for toe-off.

section 2 Physical Examination of the Foot and Ankle

INSPECTION

The foot and ankle should be inspected for

1. Symmetry

2. Callouses—areas of abnormally increased pressure

3. Signs of peripheral vascular disease—lack of hair, increased skin pigmentation (hemosiderin deposition)

4. Swelling—symmetric (likely systemic etiology) versus asymmetric (trauma, venous thrombosis, cellulitis, osteomyelitis, focal musculoskeletal etiology) (Figure 6-12)

5. Ecchymosis—plantar ecchymosis associated with tarsometatarsal injury (Lisfranc injury) (Figure 6-13)

6. Alignment

image Neutral

image Cavovarus—elevated longitudinal arch with hindfoot varus and plantar-flexed first ray (Figure 6-14)

image Pes planus—flat longitudinal arch with hindfoot valgus (Figure 6-15)

The patient’s gait should be evaluated.

1. Steppage gait—increased knee and hip flexion during swing phase to ensure that the toes clear the floor (Figure 6-16)

2. Calcaneus gait—increased ankle dorsiflexion during heel-strike

3. Antalgic gait—shortened stance phase on the affected side

II VASCULAR EXAMINATION

III NEUROLOGIC EXAMINATION

The sensory examination should assess the following five cutaneous nerves that supply the feet (Figure 6-17).

1. Saphenous—medial ankle and hindfoot

2. Superficial peroneal (Figure 6-18)

3. Deep peroneal—first dorsal web space

4. Sural—posterolateral border of the leg and the lateral border of the foot (Figure 6-19)

5. Tibial—plantar foot (Figure 6-20)

Inability to sense a Semmes-Weinstein 5.07 monofilament is consistent with neuropathy.

IV MOTOR EXAMINATION

PALPATION AND STABILITY