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Foot and Ankle
Gait
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Stance 62%, swing 38%
Heel strike – heel in varus
Tarsal joints unlock at end of terminal stance
phase
At toe off, 80% body weight on 1st MT, if 2inch heel, then 160%
Tib ant contracts eccentrically at heel strike
Gastroc contracts concentrically at heel rise
and push off, eccentrically at foot flat
Windlass mechanism – plantar fascia, not the
major support of medial arch
(capsuloligamentous midtarsal structures – 1st)
Anatomy
- Sural n. most vulnerable during lateral
approach to calcaneus
o Lateral calcaneal branch at risk – for
sliding calc osteotomy
o Sensory to dorsal 4th web space
- Deep peroneal n.
o Lateral branch most vuln during
removal of calcaneonav bar
o Innervates EDB, EHB M. in foot
o Compressed in ant tarsal tunnel sx
- Sup peroneal n.
o Medial branch vuln during bunion surg
o Lateral cut branch – vuln w/ AL portal
arthroscopy
o Emerges from deep fascia 12-15 cm
proximal to tip of lat malleolus,
stretched w/ ankle sprain – persistent
neuralgia
- Lateral plantar nerve
o Motor to adductor hallucis
o 1st branch to abductor digiti quinti
o Lateral plantar nerve – 1st branch runs
b/w quadratus plantae and FDB
o Everything in foot except that from
medial plantar N.
- Medial plantar nerve
o Innervates AH, FHB, FDB, lumbricals
to 2nd/3rd toes
- FHL
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o Most vuln at PM corner of subtalar jt
during arthrodesis
o Can be substitute for chronic
insertional Achilles tendonitis
o Lies below, deep, dorsal to FDL
tendon at Henry’s knot
Tib ant
o Innervated by DPN
o Elderly can rupture of tendon at
insertion
o Mononeuralgia diabetica – drop foot
PT
o Inserts on every bone in tarsus x first
MT
Transverse MT ligament
o Holds sesamoids together
Deltoid
o Anterior tibiotalar portion MC injured
in sprain
ATFL
o Test w/ ankle in 20 deg in plantar
flexion
o Bassett’s ligament – anomalous slip
of inf tibfib lig
CFL
o Test w/ ankle dorsiflexed
Spring ligament
o Inferior distal edge of sust tali –
origin
o Insertion medial plantar surf of tars
navicular
o MC injured is superomedial portion
o Supports talar head
Plantar aponeurosis
o Insert in flexor tendon sheaths and
prox phalanx
o Very imp to medial arch support
Plantar plate = 2nd MTP jt
o Must become lax before abn dorsal
translation of prox phalanx
o Once attenuated, most deforming
force is EDL (in hammer toes)
Important XX angles
- Hallux valgus < 15
Foot and Ankle
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MT primus varus < 25 (hypermobile 1st ray)
1-2 interMT angle < 19
distal MT articular angle < 15
o shaft – perpendicular line to it and
o line across condyles of MT
Hallux valgus
o Hypermobile 1st ray – lapidus procedure
o Sedentary pt – Keller procedure
 resection arthroplasty
 risks cock-up toe deformity
o Akin – medial closing wedge osteo of prox
phalanx
 for inc DMAA
 conjunction w/ distal MT osteo
o HV < 25 deg, congruent jt
 Chevron (distal)
o HV < 25 deg, incongruent
 Distal ST realignment
 Chevron
o HV 25-40, cong
 Chevron, Akin or
 Mitchell
o HV 25-40, incongruent jt
 Distal ST
 Proximal osteotomy
o Juvenile HV w/ excessive DMMA
 Biplanar osteotomy
 MC complication = recurrence
o Gout
 Arthrodesis or Keller resection
arthroplasty
o RA
 Arthrodesis MTP jt
 MT head resections for lesser toes
deformity
o Down’s, CP, ehler-danlos
 Arthrodesis
o Complications
 MC is recurrence
 Proximal osteotomy
 DF malunion, transfer
metatarsalgia
 Chevron
 Malunion (dorsal)
o
o
o
o
Transfer metatarsalgia 2nd
toe
 Osteonecrosis
 Wrong option
 Mitchell
 Malunion
 Transfer metatars
 Basilar osteotomy
 Malunion dorsal
 Hallux varus (MC
complication 10-13% - but
a lot is asymptomatic)
o Tx w/ MTP
arthrodesis
 May need double metatarsal
osteotomy when severe HV with
excessive DMAA – closing
wedge distally (congruent jt)
 DMMA is distal MT
articular angle – measures
the congruence of 1st MTP
jt
 interobserver reliability for
DMMA is poor
 MC cause of hallux varus with
basilar osteotomy – resection of
lateral sesamoid or medial
eminence resection ?
w/ Keller –
 MC compl – recurrence
 Worst is cockup toe
 FHL cut – causes this
 Clawed hallux – caused by loss of
intrinsics
 Uniplanar hallux varus – tx w/
taping
 Multiplanar – always
symptomatic
 Tx: EHL transfer deep to
transverse metatarsal
ligament (w/ IP fusion)
Lapidus
 Severe HV w/ hypermobile 1st ray
Continued pain after osteotomy = fusion
Complications w/ 1st MT-1st cuneiform
Foot and Ankle
 Transfer metatars
o Tx failed total MTP jt replacement –
arthrodesis w/ interpositional BG
o RA
 Tx: arthrodesis of MTP jt
 MT head resection of lesser toes for
deformity
Metatarsus Quintus Valgus Deformity
- HV for 5th toe
- Tx: oblique mid-diaphyseal osteotomy
Sesamoid injuries
- Fractures
- Tibial sesamoid MC injured b/c of weight
bearing
- Functions
o Absorbs wb pressure during stance
o Reduce friction at MT head
o Provide fulcrum for short flexors for
power
o Protect FHL
- Bipartite sesamoid always in tibial sesamoid 10-15% of population, 25% bilateral
- 1st MTP jt dislocation – sesamoids retracted
proximally
o results in clawed, or intrinsic minus
hallux
- bone scan – can distinguish b/w bipartite vs.
fracture
- no tibial shaving in plantar flexed MT, or
forefoot valgus
- proper branch of medial plantar nerve MC
injured in tibial sesamoid excision
- proper branch to lateral hallux at risk for
fibular sesamoid resection
o at risk for hallux varus
- sesamoiditis
o reiter’s dz
o psoriatic arthritis
o seronegative RA
- prominent sesamoids
o tx: sesamoid shaving or
sesamoidectemy for refractory callus
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o don’t remove both – can lead to cockup deformity
high-performance athlete
o separation of > 3mm or gross motion
– cannot bone graft
 Tx: sesamoidectemy
Synovitis 2nd MTP jt
- positive Lachman test for MTP instability
- TTP plantar plate, dorsal lateral side
- Hammer toe often present
- Decreased flexion of MTP jt
- Dislocation is long-term complication
(untreated)
- Tx: rocker-bottom shoe
- Tx: oblique shortening MT osteotomy (Weil)
o Distal, oblique MT osteotomy
o Also treats claw toes, “floating toe”
o Results in distal plantar displacement
o Complication: cannot get 2nd toe to
ground (dorsiflexion posture caused
by interossei subluxing dorsally)
- If HV deformity – it must be corrected even
if asx before crossover toe deformity is
corrected (for placement)
Freiberg’s infarction
- AVN of 2nd MT head
- 2nd decade of life female
- flat MT head
- Tx: SLWC
- Can lead to deformity
Hammer toes
- Flexion contracture at PIP jt
- FDL tenotomy and condylectemy or
arthrodesis
- Flexible – flexor to extensor transfer
- If fixed flexion contracture – don’t
arthrodesis
o Resect condyles of proximal phalanx
- Don’t choose Devries Partial resection of MT
head for claw toe
Bunionette deformity
Foot and Ankle
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IM angle > 8 deg,
Then, oblique mid-diaphyseal rotational
osteotomy
o If plantar callosity, then biplanar
osteotomy (for DF)
Type I – enlarged 5th MT head
o excision lateral eminence
Type II – cong lat 5th MT bow
o Lateral condylectemy, chevron
Type III – inc 4-5 intermet angle
o Lateral condylectemy, chevron
o lateral capsular plication
Never take out MT head
Claw toe MTP jt, Hammer toe PIP jt
- Claw toes always have MTP jt hyperextension
(ass w/ PIP, DIP jt flexion)
- Clawed toe – distal MT oblique osteotomy,
FDL transfer
- Weil osteotomy
Morton’s neuroma
- 3rd web space 80-90%
- cause of perineural fibrosis
- MC cause of failure – inadequate excision of
common digital nerve
- Recurrent sx – can be caused by recurrent
neuroma
o Most likely cause of recurrent sx
- Transverse MT ligament is offender
- Tx: long plantar incision b/w MT heads 3rd/4th
heads
Midfoot arthritis
- Tx: fusion of naviculocuneiform and/or 1st-3rd
TMT jts
- important to preserve motion of 4-5 MT-cuboid
articulation b/c of stance phase of gait
Ankle instability
- TT instab freq ass w/ subtalar instab
- CT analysis show hindft varus and altered
mortise (post fib position) more prevalent in pt
w/ chronic lat ankle instab
- Tx:
o modified Brostrom procedure w/
imbrication of ant talofib lig & augm
w/ inf ext retinaculum (Gould
modification)
 superior outcome compared to
fx rehab or nonanatomic
reconst
o hindft varus driven by plantar flexed
1st MT
 surg should include DF 1st MT
osteotomy
Ankle arthritis
- cartilage in ankle has factors that protect
from primary degen
- early degen dz creates sx confined to ant
ankle
- improved union rates in complex hindft
arthrodesis w/ implantable bone stim
- ankle replacement (Agility) req syndesmotic
arthrodesis to inc surf area for tib comp
Osteochondral Lesions
- outcome of osteochond t-x form knee to
ankle have promising results
- lateral defects may be tx w/ release and
tightening of ant talofib lig and calcanfib lig
Tarsal tunnel sx
- poor correlation b/w EMG/NCV & outcome
- earliest abn – sensory latency increase of
lateral plantar nerve
- release of transverse retinacular ligament
- intrinsic weakness late
- is a clinical dx
- take down abd hallucis for distal release
- peroneus brevis is anterior to posterior
tibialis M at insertion point
- common to see ganglion cyst
Anterior tarsal tunnel sx
- contents: EHL, TA, EDL, DP artery, DPN
- DPN – impingement by distal margin of inf
extensor retinaculum
Foot and Ankle
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Athlete w/ multiple ankle sprains – prox
entrapment sup extensor retinaculum
Pt w/ degen changes – elderly is ant tarsal
tunnel
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Anterior horn cell
Tx conservatively
Only operate on fixed instability
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RF positive in 80%
Sx RA hindfoot valgus
MC hindfoot jt: talonavicular
MC presentation: metatarsalgia
Hyperextension deformities of MTP jt
Recurrence of callosities MC complications
after forefoot surgery
If hindfoot valgus asx, then nonop
o Caused by talocalcaneal interosseus
ligament insufficiency
Tx for hallux valgus: forefoot – arthrodesis of
1st MTP jt, resection 4 MT heads
MC failure of triple – not enough correction
of equinus
RA
UMN injury
- SPLATT, TAL if equinus > 10 deg
- No arthrodeses
CMT
- Weak TA, strong PL = plantar flexed 1st ray
- Weak PB/ strong PT = adducted forefoot
- Plantar fascia contracts, weak intrinsics – claw
toes
- Hindfoot varus is driven by forefoot equinus
(locks TT jt)
- Sensory component
o Callosities of heel, MT heads, base of
5th
o Can have charcot arthropathies
- Calc pitch angle > 30 deg
- Connexin 32 abn in X-linked
- AD form – Type I
o Duplication of chrom 17
o Peripheral myelin protein 22 abnormal
in type IA
o NCV is abnormal
- Type II – AR form
o 5-15 yrs of age
o males
o no NCV abnormalities
- Cavovarus foot
o Elevated longitudinal arch
o Fixed plantar flexion of forefoot
o 1st metatarsal and varus deformity of
hindft
o Tx:
 Dorsiflexion osteotomy (flexible
hindft)
 Calcaneal osteotomy (rigid
hindft)
Polio
- Calcaneal posturing from weak GCS
- Viral infx
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Psoriatic arthroplasty
- Dactylitis of lesser toe – sausage
- Reddish cyanosis, thickened
- Peak 20-40 yrs
- Nail pitting, no skin lesions
Lyme dz
- Spirochete
- Red bull’s eye rash
- Tick bite
- Tx: doxy
- Takes 5-6 mo for serologies to turn positive
Hallux rigidis
- Pain at midrange of motion is adv arthritis
- Type I, minimal loss of motion
- Type II: mild to moderate loss of motion,
dorsal osteophyte
o Tx w/ dorsal cheilectemy (see if there
is jt space)
o remove ¼ art surf of MT head
- Type III
o Arthrodesis
 comp screw & dorsal plate is
most stable
Foot and Ankle
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hallux in slight valgus, slight DF
relative to plantar foot
o Better if pt has pain @ midrange of
motion
 Loss of 50% MT head cartilage
If runner, cheilectemy and Moberg (resection
of dorsal head)
o To give additional DF
Pes planus
- If rigid, then arthrodesis
- w/ advancing dz
o subfibular impingment dev w/ TTP
over peroneals
o medial pain subsides, and subfib lat
foot pain has greatest sx
- Stage II flatfoot
o UCBL or AFO
o Surg: FGHL transfer w/ miedial
displacement calc osteotomy or lat
column lengthening
- lat column lengthening ass w/ higher compl
rate (nonunion) than med calc displ
- Achilles lengthening req to tx equinus
- Check for tarsal coalition
PTT insufficiency
- Dynamic stabilizer of medial arch
- 25% traumatic event
- at risk zone: b/w medial malleolus and
tuberosity of navicular
- Stage I – mild weakness, hindft mobile
o tenosynovectemy
- Stage II – PTT elongated, flexible hindfoot but
in valgus
o Fdl transfer, tal, calc osteotomy (lateral
column lengthening in peds), spring
ligament repair
- Stage III – fixed deformity – arthrodesis
- Stage IV – talus is tilted in valgus – lateral
ankle is bad
o Tibiotalocalcaneal fusion
Peroneal tendon
- Split PB tears @ fibular groove MC
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PL tears at cuboid groove (os peroneum)
More than 50% tear – transfer to PL
If less than 50%, then longitudinal split
Acute dislocations
o Tx: repair of superior peroneal
retinaculum
o Subluxation leads to longitudinal
tears over time
FHL tendon injuries
- Post ankle pain – poorly localized
- Ballet dancer
o FHL triggering
o Os trigonum is lateral to FHL
 Off talus
 Excision if symptomatic
o MC cause of recurrent ankle sprains –
weak peroneal muscles
- Repair FHL only if it is proximal to pulleys
Chronic insertional Achilles tendonitis
- Pathology is anterior (retrocalcaneal bursa)
- > 50% involved – debridement w/ FHL
transfer
- < 50% - just debridement
- MRI – bulging tendon seen anteriorly –
thickening of peritenon
- Operative tx: may remove 1/3 to ½ of
insertion
- May take 12 mo to recover
- FHL transfer
o long tendon harvest (plantar foot)
gives 3 cm more tendon than short
FHL harvest
Plantar fasciitis
- No endoscopic release – MPN injury is MC
complication
- only medial 1/3 of fascia should be released
- Entrapment neuropathy of nerve to abductor
digiti quinti (lateral plantar nerve) – common
o Release is ok – must release abd
hallucis tendon distally
Diabetic foot
Foot and Ankle
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Lab test most predictive of wound healing –
serum albumin level decreased
Charcot arthropathy
o Tx NWB in SLC
o Indium WBC study combined w/ MRI
– test for Charcot vs. infx
Plantar ulcers: tx w/ Achilles lengthening
Arthrodesis
- Subtalar – 5-7 deg in valgus
- Ankle – neutral DF, ER, hindfoot slight valgus
- 1st MTP jt arthrodesis
o 10-15 deg valgus
o 20 deg DF to long axis of digit
Tarsal coalitions
- nonop initially, usu short-leg waking cast x 6
wks
- resect if > 50% of jt
- excessive heel valgus ass w/ tarsal coalition –
tx: closing wedge sliding osteotomy of
calcaneus
- middle facet resection coalition
o MC injury is to FDL
Rigid clubfoot
- Arthrogryposis – do talectemy
Hindfoot valgus
- Fixed deformities (decreased subtalar and
transverse tarsal jt mvt)
o Tx: triple arthrodesis
- Flexible deformities
o Tx: medial sliding calcaneal osteotomy,
FDL t-x
Plantar fibromatosis
- Cell: fibromyoblast (like dupuy’s)
Exercise-induced compartment sx
- MC affect medial compartment
DM
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w/in 3 yrs of LE amputation, 30% of DM pt
lose contralateral leg, 50% die
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½ of these amputations are preventable
hindft ulcers respond poorly to total contact
casting (midft/foreft ok)
Charcot
- Stage I
o edema, warmth, XX evidence of
fragmentation
- Stage II – proliferative phase
o bony destruction
- Stage III
o coalescence and remodeling w/
healing
- goal is to avoid deformity such as arch
collapse through remodeling phase