Foot and ankle problems

1. FOOT & ANKLE PROBLEMS
Derek Park
Barnet & Chase Farm Hospitals NHS Trust

2. OUTLINE
• Presentation
• Surface anatomy
• General overview of
common conditions

3. PRESENTATION
• Pain
• Instability
• Shoes
• Trauma

4. WHERE IS THE PAIN
• Non-insertional
midstubstance
Tendoachilles
tendinopathy

5. WHERE IS THE PAIN
• Insertional Tendoachilles
tendinopathy

6. WHERE IS THE PAIN
• Retrocalcanel bursitis

7. WHERE IS THE PAIN
• Precalcaneal bursitis

8. WHERE IS THE PAIN
• Plantar fasciitis
(calcaneal stress
reaction, tarsal tunnel
syndrome)

9. WHERE IS THE PAIN
• Tibialis Posterior
Tendinopathy

10. WHERE IS THE PAIN
• Bunion
• OA 1st MTPJ

11. WHERE IS THE PAIN
• Bunion
• Transfer metatarsalgia

12. WHERE IS THE PAIN
• Morton’s (Interdigital)
neuroma

13. WHERE IS THE PAIN
• Morton’s (Interdigital)
neuroma

14. WHERE IS THE PAIN
• Peroneal tendinopathy

15. WHERE IS THE PAIN
• Lateral ankle ligament
injury

16. WHERE IS THE PAIN
• Sinus tarsi
(syndrome)/Subtalar OA

17. WHERE IS THE PAIN
• Subfibular
impingement/planovalgu
s feet

18. WHERE IS THE PAIN
• Ankle impingement from
synovitis or osteophytes
(footballer’s ankle)

19. OVERVIEW OF COMMON CONDITIONS

20. TENDOACHILLES
PROBLEMS
• Insertional v Non-insertional
TA tendinopathy
• overuse, microscopic trauma
• usually gets better on its own
• GPs: don’t miss ruptures
• GPs: physiotherapy - eccentric
stretching exercises, heel
cups, rest, NSAIDs
• If no better in 6 months refer

21. TENDOACHILLES
• Investigation - usually
USS
• Tx - prolotherapy, ESWT,
gastrocnemius
lengthening, surgery
• Don’t inject steroid

22. PLANTAR FASCIITIS
• DDx (calcaneal stress,
tarsal tunnel, plantar
fibroma)
• 80% get better in 1-2
years
• GP: physiotherapy for gel
cups, night splints,
eccentric stretching
exercises
• If no better in 6 months
refer

23. PLANTAR FASCIITIS
• Investigations - usually
USS
• Tx - Eccentric stretching
exercises, ESWT,
gastrocnemius
lengthening, injection,
surgery

24. TIBIALIS POSTERIOR
TENDINOPATHY
• Adult acquired flat foot - Causes:
• Tibialis Posterior tendon dysfunction
• TA/Gastroc contracture - 2º PTT dysfunction
• Inflammatory arthritis
• Midfoot OA or previous midfoot fracture
• Peroneal muscle spasm
• Neuropathic deformity

25. DEFORMITY

26. RADIOGRAPHS

27. STAGING

28. TREATMENT
• Non-operative: Tibialis posterior eccentric
strengthening exercises, NSAIDs, orthotics
• Operative: depending on stage of disease
• Early stages with no fixed deformity = orthotics &
tendon transfer and heel osteotomy
• Later stages with fixed deformity = triple fusion or
pantalar fusion

29. EARLY STAGES

30. LATER STAGES

31. HALLUX VALGUS
• GPs: wide-toe box
shoes, toe spacers
• Refer if they want
surgery

32. HALLUX VALGUS

33. MTPJ OA
• GPs: limited non-
operative measures
• Refer if symptomatic and
impact on walking & QOL
• Non-operative: orthotics,
MUA + injections
• Operative: cheilectomy
or fusion

34. MORTON’S NEUROMA
• Non-operative: orthoses
in shoes, injection
• Operative: surgical
excision

35. LATERAL LIGAMENT
INJURY
• Non-operative:
Physiotherapy with
neuromuscular
rehabilitation
• Operative (if continued
instability/giving way):
lateral ligament repair