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This chapter will focus mainly on the commonly found arthropathies in the ankle and foot, the pathology of the disease, its diagnosis, management and goals of management. The aim of this chapter is to understand how the basic anatomy of the joint is affected in these disorders and its effect as a whole. The learning objectives are as follows: (1) Learning the basic relevant anatomy of ankle and foot, (2) Discuss the causes, diagnosis, investigations and general prognosis. (3) Understanding its impairments, and (4) Providing a framework for the treatment and rehabilitation. It will cover the commonly found congenital and acquired conditions occurring at the ankle and foot.
Mahalaxmi College of Physiotherapy and Rehabilitation Centre, India
*Address all correspondence to: hidivyashri@gmail.com
1. Introduction
About 30 bones make the structure of ankle and foot. This structure can be divided into forefoot, midfoot and hindfoot. The distal ends of tibia, fibula, talus and calcaneum make the hindfoot. The midfoot comprises of navicular and cuboid bones and the forefoot consists of three cuneiforms, five metatarsals, and 14 phalanges. The ankle joint also known as the talocrural joint is a synovial joint of hinge type. Its articular surfaces are made up of the lower end of tibia with medial malleolus, the lateral malleolus of fibula proximally and the body of talus distally. The structure of talus and the two malleoli resembles a mortise which is adjustable and provides mobility and stability. It is supported by the fibrous capsule, the deltoid or medial collateral ligament (MCL) and a lateral collateral ligament (LCL) which has three bands; anterior talofibular ligament, posterior talofibular ligament and calcaneofibular ligament. The MCL controls eversion and pronation of the ankle while the LCL controls inversion and supination. The movements at the ankle joint are dorsiflexion and plantar flexion performed primarily by the tibialis anterior and gastro-soleus respectively. Blood supply to the ankle is provided by the anterior tibial, posterior tibial and peroneal arteries and nerve supply by the deep peroneal and tibial nerves.
There are numerous joints in the foot classified as:
Intertarsal joint that include subtalar or talo-calcanean joint, talocalcaneonavicular joint and calcaneocuboid joint
Tarsometatarsal joints
Metatarsophalangeal (MTP) joints
Interphalangeal joints
The movements permitted at these joints are
Inversion and eversion of foot at subtalar joint
Flexion, extension, abduction and adduction of toes at MTP joints
Flexion and extension at the distal phalanges
The foot has three arches: medial and lateral longitudinal arches and a transverse arch. These arches are integrated fully with one another and enhance the dynamic function of the foot, similar to palmar arches of hand. They are uniquely adapted to serve mobility and stability weightbearing functions by dampening the effect of weightbearing forces, superimposed rotational motions, adapt to changes in supporting surface and distribution of weight through the foot [1].
Lauge-Hansen classification of ankle injuries is the most widely used based on the mechanism of injury (Table 1).
Type of injury
On medial side
Tibio-fibular syndesmosis
On lateral side
Others
Adduction injury
Med. Malleolus fracture with an oblique fracture line
Normal
Avulsion fracture of lat. Malleolus or Lat. Coll. Lig., Injury
—
Abduction injury
Avulsion fracture of med. Malleolus (low) or Med. Coll. Lig. Injury
Normal
Fracture of lateral malleolus at the level of ankle mortise with comminution of its lateral cortex
—
Pronation –external rotation injury
Transverse fracture of med. Malleolus at the level of ankle-mortise
Damaged
Spiral fracture of the fibula above the level of ankle-mortise or no fracture
—
Supination- external rotation injury
Transverse fracture of med. Malleolus at the level of ankle- mortise
Normal
Spiral fracture of the lat. Malleolus at the level of ankle-mortise
Fracture of the posterior malleolus
Vertical compression
Comminuted fracture of med. Malleolus, distal end of tibia and lat. Malleolus
Table 1.
Lauge-Hansen classification.
Fractures around the ankle can also be classified as:
Malleolar fractures or adduction-abduction fractures
Hind foot fractures
Midfoot fractures
Forefoot fractures
Malleolar fractures: Forced abduction produces rupture of medial ligament of ankle, fracture of medial malleolus or of both malleoli. Forced adduction produces rupture of lateral ligament, fracture of lateral malleolus or both malleoli. Fracture of both the malleoli is called Pott’s fracture.
Hindfoot fracture is the injury to talus or calcaneum resulting from a fall from height or forced dorsiflexion injury to ankle.
Midfoot fractures: Fracture of the navicular, three cuneiform bones and cuboids usually occurs due to fall of a heavy object on the foot or in roadside accidents.
Forefoot fractures includes the fractures of the phalanges.
Investigations: X-ray, MRI, CT scan.
Treatment: The main aim of treatment is to restore the normal alignment of ankle mortise by accurate reduction of the fracture, relief of pain and restoration of function. The treatment can be conservative using manipulation under general anesthesia and immobilization by a below-knee plaster cast. If conservative management fails or reduction cannot resort by manipulation, then open reduction internal fixation with screws and plates is performed. After a span of 8 weeks mobilization can be initiated (Figure 2) [2].
Figure 2.
Fracture of the 5th metatarsal.
4.2 Fracture of the talus
Most of the injuries are caused by fall from a height on the feet. Most minor fractures occur through the neck of talus, but in some a small chip or flake is detached. In undisplaced fractures through neck of talus, immobilization with below-knee plaster cast for 10–12 weeks is appropriate. In displaced fractures or fracture-dislocations, an open reduction internal fixation is required with cancellous screws. Then a below-knee plaster should be worn for 10–12 weeks. Weight bearing on the affected foot is avoided for the initial 6 weeks, partial weight bearing with crutches is permitted [2].
4.3 Fracture of calcaneus
The majority of fractures of the calcaneus are due to fall from a height onto the heels; thus, both heels may be injured at the same time. The weight thrust is transmitted to the calcaneum through talus thus splitting or breaking the calcaneal tuberosity. It may also shatter the calcaneus completely crushing it to pieces. A minor fracture without compression or a compression fracture is seen.
Clinical features: There is severe localized pain and the patient is unable to bear weight on the heel. There is soft-tissue swelling and tenderness over the calcaneal tuberosity. Movements of the ankle, subtalar and midtarsal joints is restricted. In case of compression fracture, the heel is palpably broadened out sideways. A visible ecchymosis is seen later over the sole of the foot.
Diagnosis can be done using radiography in lateral and axial projection or a CT scan. In case of compression fracture, the upper surface of calcaneus is distinctly flattened, so that the line of the subtalar joint may form almost a straight line with the upper surface of the tuberosity.
Treatment: Protection of the heel by a below-knee plaster for 4 weeks can be done. Open reduction internal fixation in which the calcaneus is exposed from the lateral side, the fragments are levered back to their normal positions and the position is held by packing with cancellous bone grafts and application of plates and screws. Some permanent disability can occur in compression fracture [2, 3].
4.4 Ankle sprain
It indicates a ligamentous injury of the ankle. An inversion injury can cause lateral collateral ligament and an eversion force may result in a medial collateral ligament sprain. The patient gives history of a twisting ankle followed by pain, swelling and tenderness over the injured ligament. Inversion of plantar-flexed foot gives rise to severe pain and denotes talo-fibular ligament sprain. Radiological examination shows no changes in the normal anatomy.
The ankle sprain is of two types:
Pronation or eversion sprain: It is caused due to pronation or eversion of the foot along with internal rotation of the tibia on a fixed foot. It may be accompanied by a fracture along with a tear of deltoid ligament, tibiofibular ligament and interosseous membrane. Tenderness and swelling are present directly over the ligament. All weight bearing activities are painful.
Supination or inversion sprain: It is common of the two types. It occurs due to abrupt adduction-inversion force on the ankle. The tibia rotates externally on the fixed foot with the foot in supination. It causes injury to the anterolateral part of joint capsule, and one or all of talofibular, anterior tibiofibular ligament and calcaneofibular ligament.
Treatment is based on the grades of sprain:
First-degree sprain is a tear of only a few fibers of the ligament. There is minimal swelling and localized tenderness with little functional disability. It can be managed with below-knee plaster cast for 2 weeks followed by mobilization.
Second-degree sprain is where a third to almost all fibers of the ligament are disrupted. Inability to move the limb along with pain and swelling are seen. Immobilization with a below-knee cast for 4 weeks is followed by mobilization.
Third-degree sprain is the complete tear of the ligament. There is sweeling but minimal pain. It is treated using below-knee cast for 6 weeks and followed by mobilization.
Cases of partial rupture are treated conservatively with immobilization by strapping, cast brace or daily open taping. Daily taping and cast bracing helps to prevent disuse atrophy and leads to formation of adhesions. Thus, early mobilization is advised which stimulates healing of torn ligaments, improving strength and stability of the ankle joint. If surgery is performed, it is followed by a POP cast. Additionally, limb elevation to reduce oedema, vigorous toe movements, application of anti-inflammatory and analgesic drugs can be done. Cryotherapy by ice pack, ice massage or ice immersion are effective to reduce pain, oedema and inflammation. Ultrasound is beneficial in improving extensibility of the injured joints. Early mobilization by relaxed passive movements should be started as early as possible in a pain-free range. Deep friction massage is effective in reducing adhesions. Active and progressive resistive exercises should be initiated as soon as possible. Full weight bearing should be started only after 6 weeks [1, 2, 3].
4.5 Recurrent subluxation of the ankle
When the lateral ligaments of the ankle tear and fail to heal properly, the ankle may be persistently unstable with recurrent ‘giving away’ in which the talus moves medially in the ankle mortise. The patient complains that the ankle goes over frequently causing fall. Pain is present at the lateral side of ankle. Oedema is present with tenderness at the site of lateral ligament, the heel can be inverted passively beyond the normal range, dorsiflexion and plantarflexion remain normal.
No changes are seen in routine radiography however the talus may be fully tilted away from the tibiofibular mortise through 20° or more.
Treatment: In mild cases, strengthening of the evertor muscles is sufficient. In severe cases, operation may be required where a new lateral ligament is constructed, usually by using the peroneus longus tendon [4].
Degenerative destruction of cartilage is more common in the hip or knee than the ankle. It is mostly due to a predisposing factor such as a fracture, irregularity of joint surfaces from previous fracture, internal derangements, previous disease, leaving a damaged articular cartilage, mal-alignment of the joint or obesity in some cases.
It shows symptoms of pain progressing over months and years, causing limp. It may go undetectable initially. On examination, hypertrophy of the bone at the joint margins is seen. Movements at the ankle are restricted.
Diagnosis: It can be diagnosed from the history, clinical findings and radiological examination. Sclerosing at the ends of the bones is seen. Erythrocyte sedimentation rate is not elevated.
Radiographic examination: Narrowing of the cartilage space, a tendency to sclerosis of the bone adjacent to the joint, and osteophyte formation at the joint margins.
Treatment: In mild cases, often treatment is unnecessary. However, excessive stress over the joint should be avoided. Analgesic drugs, rest, supportive orthoses and in selective cases, a local injection of hydrocortisone or hyaluronate can be beneficial. Physiotherapy by shortwave diathermy and mobilizing and strengthening exercises are advisable. Surgical treatment can be arthrodesis which provides stable joint [4].
5.2 Rheumatoid arthritis of the ankle
There may be destruction of articular cartilage along with subchondral bone and pain, stiffness and deformity. The cause is unknown. It may be due to autoimmunity of the body destroying its own cells or due to an infection. Middle aged adults are more likely to be affected, women more than men. There is gradual onset with progressive worsening of pain and swelling.
Diagnosis: Rheumatoid factor is found in serum. Erythrocyte sedimentation rate and C-reactive protein are elevated.
Investigations: Rheumatoid nodules may be found in radiographic examination.
Treatment: There is no specific cure although symptomatic treatment can be given. Non-steroidal anti-inflammatory drugs (NSAIDs) and Disease Modifying Anti-Rheumatic Drugs (DMARDs) are the treatment of choice. They may provide an analgesic effect while also reducing inflammatory changes. Rest is advisable followed by physiotherapy when the symptoms reside. Occasionally, an injection of hydrocortisone can be given. Operations such as arthrodesis and replacement arthroplasty are the treatments of choice when conservative management is not helpful [4].
5.3 Tuberculous arthritis of the ankle
Tuberculous arthritis is contracted by people primarily affected by pulmonary tuberculosis. The incidence of ankle joint being affected is quite rare.
Clinical features: Children and young adults are mostly affected. The common symptoms are pain, swelling and deformity of ankle. Increased warmth, swelling and restricted movements are the characteristic features.
Investigations: The earliest change seen in tuberculous arthritis is diffuse rarefaction throughout a fairly large area of bone adjacent to the joint. As the disease progresses, the cartilage and underlying bone erodes reducing the joint space.
Diagnosis: In the active phase of tuberculosis, the erythrocyte sedimentation rate is raised. While healing, it gradually lowers. Pus culture from the abscess often reveals tubercle bacilli.
Treatment: Treatment of tuberculosis with anti-tuberculous drugs; rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin is essential to prevent further spread. In the early stages, immobilization using plaster cast or splint of the affected joint is advisable to provide pain relief and joint stability for healing for 4 to 4 months. Meanwhile, abscesses should be drained frequently. If disease progresses and the articular cartilage erodes further, a further period of immobilization and fusion of the joint is advisable [4].
5.4 Gouty arthritis
Gout is associated with disturbed purine metabolism. It is characterized by deposition of uric acid salts, especially sodium biurate or monosodium urate crystals in the connective tissue such as cartilage, walls of bursae and ligaments. Excessive consumption of purine-rich foods such as liver, kidneys, fish, seafood, beer or heavy wines are some of the underlying causes. In addition to dietary factors, comorbidities such as obesity, hypertension, metabolic syndrome, type 2 diabetes mellitus, and chronic kidney disease are contributing factors.
Clinical features: The patient is almost always over 40 and males are more commonly affected than females. Arthritis occurs in recurrent attacks, first attacking the great toe, later to the tarsus and ankle. An acute onset is sudden at night. The affected joint is severely painful, swollen, reg and glossy. Deposition of uric acid (tophi) occur at the joints.
Investigations: There are no significant changes in acute gout seen in radiography. In chronic cases, the bone ends show clear-cut erosions adjacent to articular surfaces.
There may be mild leucocytosis and elevated erythrocyte sedimentation rate. Plasma uric acid level is raised. On aspiration of the swollen joints, turbid fluid comes out.
Treatment: for acute attacks, non-steroidal anti-inflammatory drugs such as indomethacin, or naproxen can be given. Colchicine, allopurinol are sometimes used. The affected joint is rested until symptoms subside. Aspiration of effusion may be followed by instillation of hydrocortisone [4].
5.5 Neuropathic arthritis of the ankle
Neuropathic arthritis is uncommon but well recognized in the ankle, the underlying pathology being diabetic neuropathy, syringomyelia, cauda equina lesion, tabes dorsalis, leprosy, syphilis or stroke. The ankle is one of the most commonly affected joint.
Clinical features: Middle aged adults are usually affected. Swelling and joint instability are common symptoms. Pain may be present while the range of movement is restricted with significant laxity leading to instability.
Treatment: In some cases, the best treatment is to provide support to the joint with a suitable orthosis. Occasionally, arthrodesis may be performed but is difficult. The primary underlying neurological disorder should be treated [4].
Club foot is a term synonymous to Congenital Talipes Equino Varus (CTEV). It is one of the commonest congenital anomalies found characterized by plantar flexion (equinus) at the ankle joint, inversion at subtalar joint and adduction of the forefoot.
It can be classified as primary or idiopathic and secondary to paralytic disorders like polio, spina bifida, etc. It may be detected anytime since birth to late childhood.
Clinical features
Raised and shortened inner border of foot.
Exaggerated longitudinal arch.
Inverted and small heel.
Significant limitation of eversion and dorsiflexion.
Outer border of foot is convex and weight-bearing.
Bony prominences are felt on the lateral side of foot, the head of talus and lateral malleolus.
Diagnosis: Usually, in newborns the foot can be dorsiflexed so that the dorsum of foot touches the shin of tibia. This can be used as a screening test in mild cases of clubfoot.
Investigations: X-rays can be done in antero-posterior and lateral views. The talo-calcaneal angle in a normal foot is more than 350, but is reduced in CTEV.
Treatment: The principle of treatment of CTEV is the correction of the deformity and its maintenance. There are non-operative and operative methods to do so.
Non-operative methods: In the conventional Kite method, correction of forefoot adduction followed by heel inversion, cavus and equinus at the end is the sequence. Dorsiflexion of the foot along with pressure on the inner border of heel corrects the cavus, equinus and inversion of the heel. In children above 2 years of age, passive manipulation as mentioned above is carried out and maintained by strapping, splinting or below-knee POP cast. A Dennis Brown splint or Wheaton brace can be used.
Operative methods:
Soft tissue release and external fixation: The tight structures on the medial side of foot are divided; tibialis posterior tendon, talonavicular joint capsule, tendon sheaths of long flexors, capsule of subtaloid joint, plantar calcaneonavicular ligament and origin of plantar muscles and fascia. Z-plasty is used to lengthen the Tendo-Achilles. Then the foot is immobilized in a POP cast for 4–6 weeks.
Bony correction: Triple arthrodesis or subtaloid-midtarsal arthrodesis is used for bony corrections.
Wedge tarsectomy: A wedge from the tarsus-calcaneum, cuboid and talus of the foot is removed. POP cast is applied after correction by manipulation and maintained for 6 weeks.
Physiotherapy management: Graded manipulation by passive movement is done to correct the deformity. The most important factor is maintenance of optimal alignment. Immobilization by adhesive plaster can be done in mild cases extending from the medial condyle of knee, passing under the heel to pull it into valgus and taken right up to outside of the knee. Another strip extends from the lateral malleolus, dorsum of foot, below the great toe to pull the foot into valgus position and ending on the outer side of knee. This is continued for 2 months.
Night splints or resting posterior corrective splints should be worn to prevent recurrence. Ambulatory training with maintenance of foot in corrected position should be taught [1, 2, 3, 4].
6.2 Rocker bottom flat foot
Also known as Congenital vertical talus, this is referred to flattening of the longitudinal arch of foot. The talus is distorted plantarward and medially, calcaneus in equinus, foot dorsiflexed, convex sole with deep creases on dorsolateral aspect of foot.
Diagnosis: The deformity is seen as flattening of medial arch of foot. The sole is convex as both talus and calcaneus are in equinus and the foot is dorsiflexed at midtarsal joints. There is localized tenderness. Movements of the tarsal joints, supination and pronation, are painful and restricted. X-ray of foot is performed for investigations.
Management: It is difficult to treat this condition conservatively due to its high recurrence rate. Wedging casts, braces, modified shoes can be used for correction of deformity. Ambulatory training with optimal positioning of foot should be initiated early. Suitable footwear with or without arch support can be advised.
Surgical management can be done by release of soft tissue contractures, ORIF with Kirschner wires, Grice arthrodesis of subtalar joints, Triple arthrodesis of subtalar and midtarsal joints can be the treatment of choice. Postoperatively, the foot is immobilized in a plaster cast with foot dorsiflexed [5].
6.3 Pes planus
Also known as the Flat Foot, the deformity is characterized by depression of the medial longitudinal arch. This causes an excessive stress over the entire foot during weight bearing.
Causes: Congenital, Potts’ fracture, ligament laxity, injury to the calcaneum, bony ankylosis of talocalcaneal bar, cause a flat foot even during non-weight bearing whereas peroneal spasm, rheumatoid arthritis and tuberculosis cause flattening of foot during weight bearing.
Types: There are four principal types;
Flexible: with normal peroneals
Rigid: with normal peroneals
Rigid: with spastic peroneals
Rocker bottom (vertical): position of talus distorted obliquely downward.
Clinical features: Usually except for spasmodic variety, there is no pain. However, pain may arise on weight bearing. There may be localized tenderness. The longitudinal arch is diminished. The movements of the tarsal joints are painful and restricted.
Investigations: A clinical examination and an X-ray examination in the AP and lateral views can be performed.
Treatment: In children below 3 years of age, shoes with medial arch support should be used. Custom prosthesis for children in 3–10 years of age can be used. In the later stages, a well-molded orthosis should be worn. Manipulation under anesthesia in children followed by POP cast for 2–4 weeks.
Surgical management by Triple arthrodesis is a treatment of choice as it provides a means of deformity correction and stabilization. Post-operatively, a POP cast is advised for 2–4 weeks, followed by modified shoes with arch support should be worn. Modified Hook-Miller’s procedure or Durban’s flat foot plasty are some other options.
Physiotherapy management:
Strengthening and endurance exercises in warm water.
Corrective gait training in the presence of orthoses, weight bearing on the lateral border of foot without orthoses.
Toe curling exercises even when shoes are worn.
Specific exercises for the medial longitudinal arch and transverse arches supporting muscles including posture correction [4].
6.4 Pes cavus
There is a significant exaggeration of the longitudinal arch of the foot with dropping of the tarsus. It is also known as contracted foot, and can be associated with equinovarus or calcaneal deformities. The paralysis of plantar flexors results in unopposed action of the dorsiflexors thus causing pes cavus. The anterior transverse arch is dropped. When the intrinsic muscles are paralyzed, their stabilizing action is lost thus causing uncontrolled action of the long toe flexors, which causes clawing of the toes. The anterior tibial muscles thus exert excessive pull, resulting in raising of the anterior part of calcaneum and depression of the anterior transverse arch with the hyperextension of the MTP and flexion of the IP joints.
Treatment: If treatment is started in the early stages with customized shoes and physiotherapy, it helps to control the deformity. In the later and neglected stages, surgical intervention is needed.
Steindler’s Operation: All the muscles below the calcaneum and the plantar fascia are divided. They slide forward and get attached to the bone distally thus correcting the cavus deformity. Then a POP cast is applied in the corrected position for 3–4 weeks.
Lambrinudi’s Operation: The arthrodesis of the IP joints corrects the clawing of toes, the long toe flexors act as support for the metatarsal heads. This helps to redistribute the muscle power in the foot.
Fasciotomy: Plantar fascia along with the tendons of extensor digitorum longus are divided. The foot is stretched and stabilized, the deformity corrected and immobilized in a plaster cast for 3–4 weeks (Figure 3).
Figure 3.
Pes Cavus.
Physiotherapy management:
For conservatively managed cases
Pain control by pain-relieving modality, faradic foot bath and exercises under warm water
A sand bag or a weight can be placed on the dorsum of foot to maintain the contact of foot with ground. Stretching technique can be used.
Movements such as dorsiflexion with toe extension stretches the longitudinal arch. Resisted toe extension prevents clawing of the toe.
Corrective shoes with soft padding
For surgically managed cases
Exercises of the joints free from immobilization
When plaster is removed, active exercises of the ankle, foot and metatarsophalangeal joints
Stretching of the longitudinal arch by weigh bearing and weight transfers
It is characterized by abnormal abduction of the first metatarsal with adduction of the phalanges. A false bursa may be formed over the first metatarsal head, which may be thickened and enlarged. This is known as ‘bunion’. The articular cartilage inflames, erodes, atrophies. New bone forms on the medial side of the metatarsal head also known exostosis or spur. The extensor hallucis tendon is shortened and displaces laterally.
Causes: Rheumatoid arthritis, Gout, wearing pointed shoes with high heels, idiopathic, etc.
There are no other symptoms. It acts as a mechanical disadvantage thus increasing the deformity. Intrinsic muscles also cannot act effectively. These adequacies result in the dropping arch and foot eversion.
Treatment:
In severe cases, surgical management is necessary.
Arthroplasty: The bunion and exostoses are excised, shortened and soft tissues are divided. The joint is aligned in the maximally correct position.
Keller’s operation: The excision of base of proximal phalanx with the bunion and medial portion of the head of metatarsal.
Mayo’s operation: Excision of the metatarsal head. Firm dressings or plaster cast for 2–3 weeks after surgery.
Arthrodesis: Fusion of the metatarsophalangeal joint of the big toe.
Mitchell’s osteotomy: Osteotomy of the neck of the first metatarsal.
Mild cases can be managed by physiotherapy and proper footwear.
Relaxed passive stretching of abduction of the toe
Straight inner border footwear with wedge between the great toe and second toe helps in maintaining constant abduction stretch on the great toe. Night splints may be worn.
Vigorous active exercises for the strengthening the lumbricals and interossei.
Weight bearing on the lateral aspect of the foot to avoid pressure and pain
Faradic foot bath to relieve pain, improve circulation and induce contractions of the intrinsic muscles.
Active fanning of the toes in the warm water with assisted abduction of great toe.
Gait training and ambulatory activities can be started gradually to avoid limping (Figure 4) [2].
Figure 4.
Hallux Valgus.
6.6 Morton’s toe
It is also termed as Metatarsalgia and defined as the deformity of foot characterized by development as neuroma, usually of the most lateral branch of the medial plantar nerve, between the 3rd and 4th, or less frequently between any two metatarsal heads.
Diagnosis:
Pain, which increases while walking
Disability
Restricted and painful movements of the toe.
Investigation: X-ray of foot.
Management:
Conservative management
Analgesics – NSAIDs, Paracetamol
Corrective foot wear and avoid narrow toe shoes
Gait training with metatarsalgia foot support
Surgical management: Excision of the neuroma followed by immobilization. Weight bearing after 1–2 weeks [2, 4].
6.7 Hammer toe
It is a fixed flexion deformity of the proximal interphalangeal joint and flexion or extension at the distal interphalangeal joint of the toe, usually with the hardening over the prominent proximal joint. There is usually a contracture of the second toe which may be congenital or familial in origin. Tight shoes also produce a hammer toe. The long extensor tendons contract along with the overlying skin.
Treatment: The toe may be strapped to the neighboring toes in the corrected position with adhesive plaster or with kinesio-taping. Corrective splint (Hallux Valgus Splint) should be used even during rest to maintain constant stretch. Relaxed passive stretching helps stretch the short muscles.
Surgical management: Excision of the proximal interphalangeal joint helps to correct the deformity. In severe cases, arthrodesis of the first interphalangeal joint can also be performed. Surgery is followed by immobilization for 4–6 weeks after which weight bearing can be permitted.
Postoperatively, mobilization and stretching of the metatarsophalangeal and interphalangeal joints should be performed. Following all the procedures, maintenance of the correct alignment along with other routine procedures are adopted [4].
6.8 Calcaneal spur
Constant overstrain of the plantar fascia causes stripping of the periosteum over the calcaneum. The gap thus formed is filled up by the bony proliferation, resulting in a bony spur formation. Occasionally, a bursa may form over the bony spur which gets inflamed resulting in pain. It may be painful. It is a manifestation of the plantar fasciitis.
Clinical features: Pain, swelling, deformity, pain during walking.
Investigations: An X-ray of the foot in the AP and lateral views: Seen as a transverse ridge or bar of bone over the calcaneal tuberosity.
Treatment:
Conservative management
Pain relieving techniques such as infrared radiation, shortwave diathermy, hydrocollator packs.
Analgesics: NSAIDs, corticosteroids.
Shoe with wedge or a SORCO rubber heel pad to relieve strain from the fascia.
Faradic current to induce contractions in the intrinsic muscles, improving muscle tone, power and circulation.
Exercises in warm water can be encouraged before initiating weight bearing.
Surgical management: Excision of the spur can be performed if pain is persistent followed by weight bearing after 3–4 weeks (Figure 5) [2, 4, 5].
A repeated series of microtrauma to plantar fascia due to sustained stress of weight-bearing due to jumping, running, hopping results in plantar fasciitis. A significant amount falls over the plantar fascia stabilizing the foot from the heel raise to the toe-off phase of gait when the MTP joint are extended.
Clinical features: Pain over the inner aspect of heel or sole in weight-bearing positions. The pain is usually worse in the morning when the patient steps down from the bed or rises on the ground for the first time. Tenderness is present on palpation over the inner part of calcaneus which is the site of origin of plantar fascia.
Investigation: X-ray of the heel shows a bony spur over the calcaneum.
Treatment: A soft cushion or a silicon heel pad can be used within the shoes along with NSAIDs. A local steroid injection can be given in the plantar fascia at the tender point to relieve pain [2, 4].
7.2 Bursitis
Inflammation of the bursa is termed as bursa. It may be due to a mechanical irritation or from bacterial infection. Bursitis can be of two types:
Irritative bursitis: It is caused due to overpressure or friction and occasionally due to a gouty deposit. Inflammation of the bursa results in effusion of clear fluid into the sac or bursa. With prolonged inflammation, the sac thickens and induces pressure erosion on the adjacent bone. Some commonly seen bursitis are:
Prepatellar bursitis Housemaid’s knee.
Infrapatellar bursitis Clergyman’s knee.
Olecranon bursitis Student’s elbow.
Ischial bursitis Weaver’s bottom.
On lateral malleolus Tailor’s ankle.
On great toe Bunion.
Treatment: Analgesics and rest in some cases can be sufficient along with removal of causative factor. In some cases, a local injection of hydrocortisone can be given. Rarely, excision of the bursa is required.
Infective bursitis: a bursa may become infected by a pyogenic or tubercular infection. It is commonly seen in the trochanteric bursa or prepatellar bursa. It has to be treated with surgical drainage and antibacterial drugs [4].
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Written By
Divyashri Nazare
Submitted: 30 March 2023Reviewed: 05 April 2023Published: 18 October 2023
Open access peer-reviewed chapter
