Disorders of the foot

Dr. Ahmet Hamdi Akgülle

MÜTF Ortopedi ve Travmatoloji
Anatomy and Biomechanics

⚫ 28 bones and approximately 44 joint

⚫ To provide support and forward
ambulation.
⚫ Through rhythmic and alternating
limb and trunk movements, the body
is propelled forward in an energy-efficient fashion.
⚫ Shock absorption and adaptation to uneven ground lessen
energy expenditure and oxygen demand during gait.
Parts of the foot

FOREFOOT
1. Forefoot: metatarsals and
Phalanges. First metatarsal is the
widest and shortest; the second
metatarsal is usually the longest
and experiences more stress than Linsfranc Joint MIDFOOT
the other lesser metatarsals.
Chopart Joint
2. Midfoot: two rows of tarsal
bones that articulate with the forefoot
HINDFOOT
at the Lisfranc joint and with the
hindfoot at the Chopart joint.

3. Hindfoot: The talus and calcaneus and their ligamentous

attachments
 Foot positions versus foot motions

⚫ varus/valgus,
Foot
Foot Varus Valgus

⚫ abduction/adduction,
⚫ equinus/calcaneus

Adduction

Abduction
 Foot positions versus foot motions
⚫ If the heel is in a neutral
position (subtalar neutral), the
forefoot should be parallel with
the floor to meet the ground
flush (plantigrade).
⚫ If the first ray is elevated,
the forefoot is in varus position.
If the first ray is flexed, the forefoot
is in valgus position
Joints
Transverse tarsal joint—The
calcaneocuboid and talonavicular
joints make up the transverse tarsal
joint

•Providing stability of the hindfoot

and midfoot to produce a rigid lever
at heel-rise for toe-off
 The gait cycle
⚫ One full gait cycle, from heel-strike to heel-strike, is termed a
“stride.”
⚫ 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).
Adult Hallux Valgus

⚫ Lateral deviation of the great toe

⚫ Etiology for bunions is multifactorial genetics

and pointed, high-heeled shoes with a narrow toe
box are felt to be the primary contributors to this
deformity.
Other Etiologic Factors:
⚫ Trauma
⚫ Neuromuscular disorders with soft tissue imbalance,
⚫ Pes planus foot
⚫ Connective tissue disorders
with ligamentous laxity
⚫ Instability of the first
tarsometatarsal joint
⚫ Inflammatory arthropathies
(rheumatoid arthritis)
Adult Hallux Valgus
Treatment
⚫ Conservative: Shoe modification, night splints

⚫ Surgery: Many types of osteotomies

Halluks Rigidus
⚫ Osteoarthritis of first MP joint.

⚫ Pain
⚫ Limitation of dorsiflexion

⚫ Dorsal osteophyte

⚫ Gout (differential diagnosis)

Treatment
⚫ Conservative

⚫ Surgical
⚫ Cheliectomy
⚫ Arthordesis
⚫ Arthroplasty
Lesser toe deformities
Hammer-toe deformity

⚫ Overpull of the EDL and

imbalance of the intrinsics.
⚫ Mostly in older women and
may be isolated (usually the second toe)
or multiple, flexible, or rigid.
⚫ Symptoms as the result of painful
corns that arise at the dorsal PIP joint.
⚫ Manual manipulation or use of the “push-up test”
should be performed to determine whether a flexible
or rigid deformity exists.
Treatment
⚫ accommodative footwear
and protective padding

⚫ flexor-to-extensor tendon
transfer of the FDL (flexible HT)

⚫ resection arthroplasty of
the head and neck of the proximal
phalanx or PIP arthrodesis.
(rigid HT)
Mallet-toe deformity
⚫ Isolated flexion deformity at the DIP joint

⚫ Result of a contracted or spastic FDL in association

with attenuation of the terminal extensor tendons.
⚫ Normally idiopathic - 75% of patients with mallet-toe
deformity have elongation of the affected digit.
Treatment

⚫ Treatment modalities similar to hammer-toe

(conservative)

⚫ Percutaneous FDL tenotomy, excisional arthroplasty

of the DIP joint, middle phalangeal condylectomy
Claw-toe deformity
⚫ Rarely occurs in isolation.
⚫ Hammer toe + Hyperextension of MTP joint
Claw-toe deformity
⚫ Often clawing of all five toes - usually a
neuro-muscular condition
⚫ If present only in the second toe or occasionally the
second and third toes, a neuromuscular cause is less
likely.
⚫ Painful dorsal and terminal end corns.
⚫ Physical examination - assessment of the MTP joint
for instability, evaluation of the extent of deformity,
and documentation of the degree of flexibility.
Treatment

⚫ Nonsurgical treatment identical to hammer toes and

mallet toes
⚫ Semirigid orthotic devices with
metatarsal padding with associated
metatarsalgia
⚫ flexor-to-extensor transfer
⚫ EDB tenotomy and EDL lengthening
⚫ MTP capsulotomy and resection arthroplasty of the
proximal phalanx or PIP arthrodesis.
Crossover second toe

⚫ Multiplanar instability of
the second toe
⚫ Toe lies dorsomedially relative
to the hallux.
⚫ Occurs from attritional rupture of
the lateral cruciate ligament (LCL)
and lateral capsule.
⚫ Medial structures become tight and contracted,
⚫ This imbalance results in medial deviation of the
second toe, which is often progressive.
Treatment
⚫ Soft tissue release of the extensor tendon, dorsal and
medial capsule, and MCL
⚫ Flexor-to-extensor tendon transfer can be performed
to further stabilize the deformity.
⚫ EDB tendon transfer
⚫ Resection arthroplasty of the proximal phalanx or a
distal MT shortening osteotomy (Weil osteotomy)
Tailor’s Bunion(bunionette)

⚫ Enlargement of the fifth

metatarsal bone at the base
of the little toe.
⚫ Symptoms - redness, swelling,
and pain at the site of the enlargement.
⚫ Inherited faulty mechanical structure of the foot, bony
spur, wearing shoes that are too narrow
Three types:
⚫ Type I: enlarged 5th MT
head
⚫ Type II: abnormally
widened 4th to 5th IM
angle
⚫ Type III: lateral bowing of
the 5th MT diaphysis
Treatment

⚫ Shoe modifications
⚫ Oral medications
⚫ Injection therapy
⚫ Padding
⚫ Icing
⚫ Surgery
Interdigital neuritis (Morton
neuroma)
⚫ A compressive neuropathy of the
interdigital nerve, usually between
the third and fourth metatarsals.
⚫ Pathophysiology
⚫ compression/tension around
the intermetatarsal ligament,
⚫ repetitive microtrauma,
⚫ vascular changes,
⚫ excessive bursal tissue,
⚫ endoneural edema
⚫ eventual neural fibrosis
⚫ burning pain and paresthesia are the main symptoms.
Examination
⚫ Exacerbated by footwear
with narrow toe boxes and
high heels
⚫ Palpation between and just
distal to the metatarsal
heads elicits plantar
tenderness.
⚫ Compressing all of the
metatarsals while palpating
the web space structures
can provoke symptoms and
occasionally a bursal “click”
(Mulder click)
Treatment

⚫ NSAIDs and injections

⚫ shoe wear
⚫ Metatarsal pads
⚫ Neurectomy
Pes planus deformity
Pathology
⚫ Most common cause - posterior tibial tendinitis, a
degenerative problem involving the primary dynamic
support for the arch.
⚫ Etiology;
⚫ inflammatory disorders such as RA,
⚫ a zone of hypovascularity 2-6 cm from the attachment
of the tendon on the navicular,
⚫ overload of the arch from activity or obesity.
⚫ Hindfoot is in valgus, the arch is depressed,
and the forefoot is abducted, exposing “too
many toes” when the foot is viewed posteriorly.

⚫ Flexible pes planus is passively correctable to a

plantigrade foot(Jack Test), and bracewear may
improve the alignment and reduce pain.
• Fixed type is rigid, unbraceable and may
require surgical correction. (Tarsal coalition)
Pes cavus deformity

⚫ Etiology
•Unilateral cavus
–tethering of the spinal cord or spinal cord tumors.
•Bilateral cavus
–Hereditary (most common CMT disease - peroneal
muscle atrophy) The tibialis anterior, EDL, and
peroneus brevis musculature are initially affected.
–The mixed motor sensory neuropathies such as CMT
have variable penetrance; therefore, the severity of
each cavus foot may differ.
Heel Pain
Plantar fasciitis
⚫ Typically exquisite pain
and tenderness over the
plantar medial tuberosity
of the calcaneus at the
proximal insertion of the
plantar fascia.
⚫ Worst with the first step
in the morning or after
prolonged sitting.
Pathology:
⚫ microtears at the origin of the plantar fascia, which
initiates inflammation and an injury-repair process
that leads to a traction osteophyte.
⚫ Significantly bilateral symptoms
⚫ pain and tenderness at the origin of the abductor
hallucis = entrapment or inflammation of lateral
plantar nerve.
⚫ 10% develop persistent, disabling symptoms.
⚫ Treatment
•Nonoperative
–Achilles tendon stretching, cushioned heel inserts, night
splints, walking casts, cortisone injections, and
anti-inflammatory medications.
•operative
–Release of the plantar fascia (medial one third)
–Complete release (may lead to dorsolateral foot pain)
–If entrapment of the lateral plantar nerve is suspected,
concomitant release of the deep fascia of the abductor
hallucis may be warranted.
Bony causes
Stress injury

⚫ Calcaneal stress fractures (in the active individual or

military recruit)
–Scintigraphy to diagnose, but MRI is the more sensitive
and specific test
–%50 in the posterior aspect of the calcaneus
–%50 in the anterior and middle portions of the bone.
Retrocalcaneal bursitis/Haglund's
deformity
⚫ Inflammation of the bursa that lies between the anterior
surface of the Achilles tendon and the posterosuperior
aspect of the calcaneus

⚫ Together with insertional tendinitis and Haglund's

deformity (prominence of the posterosuperior calcaneal
tuberosity)
⚫ Deep posterior heel pain, fullness and tenderness with
palpation medial and lateral to the tendon, and increased
pain with ankle dorsiflexion.
⚫ X-ray: Haglund's deformity
Treatment

⚫ Nonoperative
–similar to that for tendonitis
–Steroid injection (intratendon injection should be
avoided because it is believed to increase the risk of
rupture)
⚫ Operative treatment
–débridement of the retrocalcaneal bursa along with
excision of the Haglund deformity when present.
Insertional Achilles tendinitis

⚫ Enthesopathy
⚫ Symptoms localized to the insertion of the tendon on
the posterior calcaneus
⚫ Progressive enlargement of the bony prominence of
the heel along with pain caused by direct pressure
from shoe wear.
⚫ Imaging and histopathology; tendinosis, cystic
changes in the posterior tuberosity, bone spur
formation, and/or intratendinous ossification
Treatment
⚫ Nonoperative
–ice, anti-inflammatory
medications, modification of
activity and shoe wear, heel
lifts, stretching, and silicone
heel sleeves/pads
⚫ Operative
–degenerative portions of the
tendon can be excised,
heterotopic bone can be
removed, and any
re-anchoring or repair of the
Achilles can be performed.
Noninsertional Achilles
tendinitis/tendinosis
⚫ Pain, swelling, and warmth during and after running
exercises
⚫ multifactorial; training errors and poor lower extremity
alignment
⚫ inflammation of the paratenon alone, peritendinitis with a
component of tendinosis, or tendinosis alone
⚫ In molecular: the excessive repetitive loading of the
Achilles tendon affects the collagen cross-linking and
structural stability of the tendon that are thought to lead to
the pathology of tendinosis.
⚫ localized app. 2-6 cm proximal to the insertion of the
tendon. (hypovascular region)
Treatment

•Nonoperative:
–ice, anti-inflammatory medicines, stretching the
Achilles, eccentric strengthening exercises, heel lifts
that can be gradually shortened, and iontophoresis
•Operative:
–excision of the thickened and inflamed paratenon
–For more than 50% degenerative involvement of the
Achilles, a tendon transfer with FHL is recommended.
Achilles Rupture
⚫ ‘Weekend warriors’
⚫ ‘Snap’ – non-traumatic

⚫ Thompson test
⚫ Gap

⚫ Conservative
⚫ Surgical Repair
Ankle Sprain
⚫ ATFL
⚫ Common

⚫ Ottawa criteria

⚫ PRICE
⚫ (Protect- Rest- Ice –Compress- Elevation)
Thank you