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15 The Foot andAnkle
Fig. 15.15 Lateral radiographs of the calcaneus
demonstrating Böhler angle (blue star/solid line)
and angle of Gissane (red star/dashed line). These
are important measurements determining the need
for operative intervention of a calcaneus fracture. A
normal Böhler angle is 20–40° with values <20°
indicating a calcaneus fracture due to a collapse of
the posterior facet. A normal angle of Gissane is
120–145°, with an increased angle representing a
collapse of the posterior facet diagnostic of a
calcaneus fracture
377
Fig. 15.16 Two examples of calcaneus fractures comprising the Essex-Lopresti classication of calcaneus
fractures. (a) Joint-depression-type fracture, an intraarticular fracture with signicant comminution that demonstrates a decreased Böhler angle and angle of Gissane. (b)
ment of these fractures is reserved for nondisplaced fractures or poor surgical candidates with
Tongue-type fracture, an extraarticular fracture which is
an avulsion due to contraction of the gastric-soleus complex. Tongue-type fractures have a high rate of skin compromise and require urgent surgical intervention
sist of a subtalar fusion without bone loss or an
intercalary tricortical graft to restore axial height.
severe soft tissue compromise or complicated
medical conditions. Open reduction and internal
xation is indicated for displaced intraarticular
fractures and signicantly displaced extraarticular fractures. Surgical intervention should not
proceed until the soft tissues and excessive swelling have stabilized. Assessment of this can be
done by observation of wrinkling of the lateral
hindfoot soft tissues. If soft tissues are not amenable to open reduction and internal xation,
other techniques including percutaneous xation
and external xation may be utilized. Despite
anatomic reduction and adequate treatment, these
patients often develop subtalar stiffness and
symptomatic osteoarthritis. Salvage would con-
Injury totheMidfoot
The midfoot injuries include those of the tarsona-
vicular, cuboid, cuneiform, and tarsometatarsal
joints. Injuries to the Lisfranc (tarsometatarsal)
joints include subtle sprains to frank fracture dis-
locations. Bony architecture is similar to that of a
Roman arch and designed for stability. The key-
stone of the arch is the second metatarsal, which
has a wedge-shaped base that is recessed between
the medial and lateral cuneiform bones. Strong
plantar interosseous ligaments provide the main
support for the tarsometatarsal joints. There is an
absence of an intermetatarsal ligament between
the rst and second metatarsal joint which makes
378
P. S. Cooper et al.
this area susceptible to injury. The “Lisfranc ligament” spans the plantar lateral aspect of the
medial cuneiform bone and the medial base of
the second metatarsal and resists lateral translation of the lesser metatarsals. Mechanisms of
Lisfranc injury include a direct crush injury to the
midfoot and an indirect twisting-type injury
when an axial load is applied to the heel with the
foot in xed equinus, as in motor vehicle accidents or sporting activities. Up to 20% of these
injuries are missed on initial evaluation because
of their potential subtle nature. Plantar ecchymosis is pathognomonic of a Lisfranc injury
(Fig.15.17c). It is important to obtain standard
three-view radiographs of the injured foot and
look for the appropriate signs of injury. Subtle
injuries can often be elucidated with weightbearing AP foot radiographs including the contralateral foot for comparison. Lisfranc injuries
can be bony (e.g., fractures of the metatarsal
bases) or ligamentous in nature (Fig.15.17a, b).
Treatment involves anatomic reduction of the
involved joints with rigid xation via percutane-
ous method or open reduction internal xation.
Over 80% of patients develop posttraumatic
arthrosis and stiffness, necessitating a fusion of
the involved joints in the most refractory cases.
Ankle Sprains
Ligamentous disruptions, partial and complete,
are common about the ankle. The most common
ligament to be injured is the anterior talobular
ligament (Fig.15.18). Inversion stress testing can
elicit pain and demonstrate instability on radio-
graphs (Fig.15.19). Partial injuries can be treated
with either a fracture boot or a brace with pro-
gression as tolerated back to activity. A complete
ligament disruption (grade III) can be similarly
managed with nonoperative treatment the vast
majority of the time. In the case of severe recur-
rent instability, operative intervention consisting
of repair may be necessary. Repairs are divided
into anatomic and non-anatomic. Anatomic
repairs involve repairing the ligaments primarily
ab c
Fig. 15.17 (a) AP foot radiographs of a bony Lisfranc
injury at the second and third metatarsal bases. (b) AP
foot radiograph of a ligamentous Lisfranc injury. Notice
the separation of the bases of the rst and second metatar-
sal bases. (c) An example of plantar ecchymosis, pathog-
nomonic for a Lisfranc injury. This patient also has
ecchymosis extending dorsally over the hallux
cd
15 The Foot andAnkle
Fig. 15.18 Anatomic specimen of right ankle
showing lateral ligament structures from
anterolateral view. (a) Anterior inferior tibiobular
ligament with three bands. (b) Anterior talobular
ligament, somewhat atrophic. (c) Calcaneobular
ligament. (d) Cervical ligament. (Reprinted from
Coughlin and Mann’s Surgery of the Foot and
Ankle, 10th edition, Haskell A & Coughlin MJ,
Athletic Soft Tissue Injuries of the Foot and Ankle,
Waldrop III NE, p.1463, Copyright Elsevier
(2024), with permission from Elsevier)
a
379
b
Fig. 15.19 Varus and valgus stress views of the ankle.
Positioning for varus (a) and valgus (b) stress views of the
ankle is illustrated. Varus stress in ankle plantar exion
tests for anterior talobular and calcaneobular ligament
insufciency. Valgus stress tests for deltoid ligament
insufciency. The use of stress radiography remains controversial because reliability may be compromised by the
large range of normal variation in joint laxity. In the acute
trauma setting, local analgesia probably increases accuracy. An abnormal varus or valgus stress examination is
regarded as demonstrating either (a) talar tilt greater than
or equal to 10° more than the normal side or (b) greater
than or equal to 3mm discrepancy in lateral ankle joint
opening distance between the injured and normal side, as
measured from the most lateral aspect of the talar dome to
the adjacent tibial articular surface. In the example here,
an abnormal varus stress radiograph (d) is shown relative
to the normal side (c). (Reprinted from Coughlin and
Mann’s Surgery of the Foot and Ankle, 10th edition,
Haskell A & Coughlin MJ, Imaging of the Foot and Ankle,
Linklater JM, Read JW, Sofka CM, Hayter CL & Dimmick
SJ, p. 62, Copyright Elsevier (2024), with permission
from Elsevier)
380
P. S. Cooper et al.
and reinforcing the injured tissues with a second
layer utilizing the inferior extensor retinaculum
(modied Broström). Non-anatomic repairs
require reconstructing the ligaments with a
“cable” using either local tissue (spitting the peroneus brevis) or allograft.
Injuries oftheForefoot
Fractures of the sesamoid bones occur relative
to direct trauma or use or both injuries associated with hyperdorsiexion of the rst metatarsal phalangeal joint. Bipartite sesamoid bones
(congenital separation of the two poles of the
sesamoid) occur in approximately 25% of individuals, the majority involving the tibial sesamoid bone. If the sum of the parts is greater than
the adjacent sesamoid, then a congenital condition is more likely. Management is mostly conservative. However, a severe turf toe injury with
complete transection of the plantar plate frequently requires operative repair, particularly in
the elite athlete. Phalangeal fractures may be
either displaced or nondisplaced and angulated.
Closed manipulation is often needed under local
anesthetic; then taping the affected toe to the
adjacent toe as a splint mechanism or “buddy
taping” is done with wearing of a stiff-soled
shoe or sandal.
Acquired Deformities oftheFoot
andAnkle
Deformities oftheForefoot
Hallux Valgus
This is a condition of medial prominence of the
rst MTP joint with lateral drifting of the big
toe (Fig.15.20). It is almost exclusively related
to shoe wear. Radiographically, it is dened as
an MTP joint angle of more than 15° (the hallux
valgus angle or HVA) and an angle between the
rst and second metatarsals that is more than 9°
(intermetatarsal angle, or IMA). Symptoms
include pain, swelling, and inammation over
the medial rst MTP joint related to shoe wear.
Range of motion of the rst MTP joint should
be assessed, and AP and lateral radiographs are
taken to determine the degree of hallux valgus
deformity, the associated metatarsus primus
varus, joint congruity, and degenerative
changes, as well as position of the sesamoids.
Treatment of hallux valgus deformity in the
early stages is conservative and includes shoe
modication to a high, wide toe box and a soft
leather upper portion of the shoe. Orthotic
devices can be helpful. When conservative
measures are not successful, surgical proce-
dures are recommended. These include a sim-
ple exostectomy, soft tissue repair, proximal
metatarsal osteotomy, distal metatarsal osteot-
omy, resection arthroplasty, proximal phalan-
geal osteotomy, and arthrodesis. Rarely is a
simple exostectomy or soft tissue procedure
performed in isolation. In cases of mild to mod-
erate hallux valgus angles (<30°) where the
joint is congruous, a distal type of procedure
like the chevron osteotomy is indicated. In
more severe angled bunions with incongruous
joints, a proximal osteotomy in conjunction
with a distal soft tissue release is best suited.
Hallux Varus
This is a medial deviation of the great toe at the
MTP joint. The causes include complications
from overcorrection of hallux valgus surgery or
rupture of the conjoined tendon as seen in rheu-
matic conditions. Treatment in early or exible
cases consists of an abductor hallucis release
with transfer of the extensor hallucis brevis. In
more advanced cases, salvage with fusion of the
metatarsophalangeal joint will leave satisfactory
results.
Hallux Rigidus
Hallux rigidus is degenerative arthritis at the rst
MTP joint (Fig.15.21). Patients present with an
enlarged, warm, and swollen rst MTP joint,
with a decreased range of motion, predominantly
in dorsiexion. Shoes with elevated heels tend to
increase pain. Initial treatment is conservative
with orthotic devices and shoe modications to
reduce the stress across the rst MTP joint.
Surgical intervention includes resection arthro-
plasty, cheilectomy, metatarsal or phalangeal
osteotomy, or arthrodesis.
cd
15 The Foot andAnkle
381
Fig. 15.20 (a) Classic
abnormalities in a
bunion: 1, hallux valgus;
2, the exostosis; and 3,
metatarsus primus varus.
(Reprinted from
Orthopedic Clinics of
North America, 20(4),
Mann RA, The Great
Toe, p.524, Copyright
Saunders (1989), with
permission from
Elsevier) (b) Clinical
photo of a bunion
deformity. (c) Diagram
of the intermetatarsal
angle (IMA), hallux
valgus angle (HVA) and
(d) distal metatarsal
articular angle (DMAA).
Normal values: IMA is
<9°, HVA <15° and
DMAA <10°. In this
patient, there is a severe
hallux valgus deformity
with a HVA of 55°, IMA
of 16°, and DMAA of
41°
a
b
Lesser Toe Deformities
There are three common lesser toe deformities:
claw, hammer, and mallet (Fig.15.22). In contrast to the hallux, the lesser toes have proximal,
middle, and distal phalanges, and they have two
exor tendons (FDB and FDL) and a complex
extensor mechanism for each toe. Over time,
imbalances in the tendons, muscles, and collateral ligaments can cause deformity. High heels
and ill-tting shoes are often implicated.
The deformities differ by their angulation at
the metatarsophalangeal (MTPJ), proximal
interphalangeal joint (PIPJ), and distal interphalangeal joint (DIPJ). Claw toes are characterized by hyperextension of the MTPJ and exion
of the DIPJ.This is resultant from hyperextension of the MTPJ causing stretched intrinsic
muscles. This stretches the plantar exor tendons and results in hyperexion of the distal two
joints. Hammer toes have normal or hyperex-
Mallet
382
Fig. 15.21 AP radiograph of severe hallux rigidus evident by joint space narrowing, loss of cartilage, subchondral sclerosis, and osteophytes causing loss of motion at
the rst metatarsal phalangeal joint. This patient also has
metatarso-sesamoid arthritic changes with osteophytes off
the bular sesamoid. (Reprinted from Reconstructive Foot
and Ankle Surgery: Management of Complications, 3rd
edition, Myerson MS & Kadakia AR, Arthrodesis of the
Hallux Metatarsophalangeal and Interphalangeal Joints,
p.417, Copyright Elsevier (2019), with permission from
Elsevier)
tended MTPJ, exion of the PIPJ, and neutral or
hyperextension of the DIPJ.The starting deformity is at the PIPJ, which can occur with poor
shoe wear pushing the PIPJ into exion. The
extensors then are unable to x the PIPJ abnormality and cause DIPJ hyperextension. Mallet
toes are exed at the DIPJ and normal at the
MTPJ and DIPJ.This can also occur due to poor
tting shoe wear.
The abnormal joints can cause painful calluses in shoes. Treatment is either symptomatic
management with shoe wear modication or surgical with soft tissue releases or fusions.
P. S. Cooper et al.
Hammer
Claw
Fig. 15.22 Diagram of lesser toe deformities. (Reprinted
from Surgery (Oxford), 34:9, Montgomery HC & Davies
MB, Common disorders of the adult foot and ankle,
p.477, Copyright Elsevier (2016), with permission from
Elsevier)
Injuries oftheTendons oftheFoot
andAnkle
Tendinitis is a nonspecic term for a variety of
pathological conditions of tendons. Tendinitis is
the inammatory process of the structures of the
connective tissue structure surrounding a tendon. Tendinosis is characterized by intratendinous degeneration commonly manifesting as
longitudinal vertical cleavage tears or splits
within a tendon.
Management is often conservative with rest
and immobilization with anti-inammatory medications. Common disorders of tendons are those
involving the peroneal tendon complex, the anterior tibial tendon, the Achilles tendon, the posterior tibial tendon, and the FHL tendon.
Peroneal Tendon Pathology
Peroneal tendon disorders include injury and
degeneration of the peroneus brevis or longus
and instability of the peroneal tendon complex.
15 The Foot andAnkle
383
Peroneus brevis tendon injuries may manifest as
tenosynovitis, a longitudinal split in the tendon,
and subluxation or frank dislocation of the tendon. The patient may have a history of an inversion supination sprain and/or a foot with a high
arch. Radiographic studies are often normal.
Indications for operative treatment are persistent
pain and failure of conservative treatment with
cast/boot immobilization for 2–3 weeks and
physical therapy. Goals of surgery are to reconstruct the superior peroneal retinaculum, perform
a tenosynovectomy when applicable, and repair
any longitudinal splits in the tendon. If a cavus
deformity is present, consideration may be made
to simultaneously surgically correct the bony
deformity.
Cavovarus Foot Deformity
Cavovarus foot is a complex deformity characterized by plantar exion of the rst ray, hindfoot varus, and equinus (Fig. 15.23c). It can
present in pediatric or adult years and results
from several etiologies, including hereditary and
motor and sensory neuropathies (e.g., polio,
Charcot–Marie–Tooth), arthrogryposis, cerebral
palsy, cerebrovascular accidents causing cerebral injury, posttraumatic from compartment
syndrome or talar neck malunion. This subsequently causes an imbalance of the muscular
forces on the foot depending on the affected
weak muscles, most often a strong tibialis posterior and a strong peroneus longus overpowering
a weak tibialis anterior and a weak peroneus brevis, The imbalances of foot during stance often
lead to abnormal loading of the lateral border of
the foot and the rst or lateral metatarsal heads,
leading to ulcers, stress fractures, and secondary
osteoarthritis of overloaded joints due to the
abnormal forces.
The Coleman block test is an important tool to
determine if the deformity is driven (Fig.15.23a,
b). In this test, the patient stands with a block
under the lateral forefoot: if the hindfoot varus
corrects, then the deformity is exible and is
forefoot-driven. If the deformity does not correct,
it is either rigid or hindfoot-driven. With a exible varus deformity, the varus positioning of the
hindfoot is secondary to the abnormal plantar
exion of the rst ray. Management is often surgical, aimed at tendon rebalancing with transfers
and releases, osteotomies to correct hindfoot
varus and equinus before the deformity becomes
rigid. Once a rigid deformity exists, fusions are
generally required to correct the deformity.
Anterior Tibial Tendon Pathology
Injuries of the anterior tibial tendon are rare.
Tenosynovitis may result from irritation by shoe
wear but is often attributed to an underlying rheumatic condition. Full rupture is due to wear associated from the superior border of the extensor
retinaculum. Often when the tendon ruptures,
proximal retraction results in a mass above the
ankle joint, the so-called pseudotumor. Surgery is
indicated for a young, active individual with an
acute rupture. Neglect will result in a profound
foot drop requiring an ankle–foot orthosis (AFO)
long term or a tendon transfer.
Achilles Tendon Disorders
Disorders of the Achilles tendon include peritendinitis, tendinosis, partial and complete rupture,
and insertional tendinitis with retrocalcaneal bursitis. Achilles tendinitis is painful inammation
and degeneration of either the surrounding peritenon (peritendinitis) or tendon (tendinosis) or
both that occur proximal to the insertion site of
the Achilles in the calcaneus. This is often seen in
runners with tight Achilles tendons and poor exibility. Treatment is often conservative with a
period of immobilization to allow inammation to
subside and followed by physical therapy, stretching, and eccentric strengthening of the Achilles
tendons daily, except in advanced cases of tendinopathy. When conservative measures fail,
debridement of the Achilles tendon can be done
surgically where the tendon is approached medially, split longitudinally to debride, and repaired
side to side. When tendinitis occurs at the Achilles
tendon insertion onto the posterior aspect of the
calcaneus, it is called “insertional Achilles tendinitis.” The insertion site typically calcies forming a posterior enthesophyte that can be visualized
on a lateral radiograph. Often, there is also an
enlarged posterior-superior calcaneal process
called a Haglund’s deformity (Fig.15.24). This
384
a bc
P. S. Cooper et al.
Fig. 15.23 The Coleman block test is performed by placing a block under the lateral foot and allowing the rst
metatarsal to come to the ground. (a) and (b) In these photographs, the foot is quite rigid, and no correction of the
heel varus took place. (c) This patient was an adolescent.
The heel corrected into neutral with the test, suggesting
Fig. 15.24 A lateral radiograph of the calcaneus showing
a Haglund’s deformity, an enlargement of the posteriorsuperior calcaneal process
tendinitis is also associated with a retrocalcaneal
bursitis which is inammation of the bursa
directly anterior to the Achilles tendon at its insertion. Conservative treatment includes a period of
immobilization, heel lifts to shorten the Achilles
tendon and take the pressure off the insertion,
stretching and eccentric strengthening exercises
through physical therapy, and modication of
shoe wear. When conservative measures fail, sur-
more of a forefoot-driven varus deformity. (Reprinted
from Reconstructive Foot and Ankle Surgery: Management
of Complications, 3rd edition, Myerson MS & Kadakia
AR, Cavus Foot Correction, p. 142, Copyright Elsevier
(2019), with permission from Elsevier)
gery consists of debridement of the calcied
insertion Achilles tendon, and resection of the calcaneal posterior-superior tuberosity, in addition to
reattachment of the Achilles tendon.
Ruptures of the Achilles tendon can be acute
or chronic. They commonly occur in middleaged men at the hypovascular zone of the Achilles
tendon approximately 3–5cm above the insertion
site due to the “watershed” of the proximal and
distal blood supply. Ruptures occur because of
forceful eccentric contraction of the elongating
tendon. They rarely result from direct trauma.
Symptoms include severe pain at the back of the
calf. Patients often describe being hit in the back
of the leg and an audible “pop.” Palpating a defect
above the Achilles insertion with the patient in a
prone position conrms the diagnosis. Two ndings are consistent with complete rupture of the
tendon. The rst is loss of passive resting tension
in comparison to the opposite extremity which
causes the foot to be at right angle to the remainder of the lower extremity (Fig.15.25). Normal
tone with the tendon intact is approximately 25°
of plantar exion passive. The second nding is
performing the Thompson test, which is done
with the patient’s foot hanging over the edge of
the examination table in a prone position
(Fig.15.25). The midcalf is squeezed. If the tendon is intact, the ankle passively plantar exes. If
the tendon is ruptured, no plantar exion occurs.
15 The Foot andAnkle
Fig. 15.25 Clinical
exam ndings of an
Achilles tendon rupture.
Top: Example of resting
tension in normal (left)
and injured (right)
extremities. Notice the
slight plantar exion of
the normal foot, while
the injured side is in
neutral to dorsiexed
position. Bottom: The
Thompson squeeze test.
On the normal (left)
side, the Achilles
mechanism is squeezed
which contracts the
mechanism and causes
the foot to plantarex.
The foot does not move
with the Thompson
squeeze on the injured
(right) side since there is
no longer tension of the
heel cord
385
In difcult cases, MRI or ultrasound can conrm
the diagnosis.
Treatment of an acute rupture of the Achilles
tendon can be conservative or surgical.
Nonoperative management includes immobilization in a plantar exed position for 4–6 weeks
followed by progressive weight-bearing and
aggressive physical therapy. Disadvantages of
conservative management include a higher rerupture rate. Some postulate that nonoperative
treatment results in weaker push-off strength, but
this has not been proven. Surgical repair includes
direct repair of the ends of the Achilles tendon.
Potential complications involve wound complications, infection, and sural nerve injury.
Treatment of chronic neglected ruptures includes
bracing with an ankle–foot orthosis or complex
surgical reconstruction including exor hallucis
longus tendon transfer to ll the defect.
Posterior Tibial Tendon
The posterior tibial tendon is the primary
dynamic arch support to the medial arch of the
foot. It functions as a hindfoot inverter and ankle
plantar exor, and when the muscle contracts, it
locks the transverse tarsal joint to allow a rigid
lever arm for the toe-off phase of the gait cycle.
Overuse of the posterior tibial tendon causes
conditions that range from mild tendonitis to
complete rupture and asymmetrical atfoot
deformity. Posterior tibial tendon dysfunction
etiologies include trauma, inammatory arthropathies, or nutritional degenerative conditions.
Predisposing factors include hypertension, obesity, diabetes, steroid exposure, and prior surgery
or trauma. Early stages include pain, swelling,
and fullness localized to the posterior and medial
hindfoot. As the tendon continues to deteriorate
and becomes dysfunctional, a progressive asym-
386
a
P. S. Cooper et al.
metrical atfoot deformity develops with lateral
cb
hindfoot impingement and peroneal tendonitis.
Clinical exam may show tenderness and swelling over the posterior medial hindfoot, a secondary Achilles tendon contracture, and weakness
with resisted plantar exion and inversion.
Patients are unable to perform a single stance
heel rise and often show a “too-many-toes sign”
when visualizing the foot from behind in a stand-
d
ing position. Too- many- toes sign refers to an
advanced collapse of the arch with the heel in
signicant valgus. The toes are abducted more
on the affected foot than the unaffected foot and
show more prominently on exam. Weightbearing X-rays may show uncovering or “sag” of
the talar head by the navicular on both AP and
lateral views (Fig. 15.26); the normal angle is
close to zero. The forefoot and midfoot are
abducted in relation to the hindfoot. MRI can
conrm tenosynovitis versus tendinosis.
Treatment options are determined by the stage of
dysfunction and presentation. Stage I, which is
very mild tendon weakness and pain without
atfoot deformity, can be addressed with orthotics, anti-inammatory medicines, and physical
therapy. A period of immobilization is often
helpful to decrease the inammation. Stage II,
which involves posterior tibial tendon elongation
or partial disruption and the presence of a exible atfoot deformity, can be treated conservatively with orthotics or surgically, which involves
Fig. 15.26 Weight-bearing AP (top) and lateral (bottom)
foot radiographs showing a atfoot deformity, also known
as pes planus. The AP weight-bearing radiograph can
show (a) talonavicular joint uncoverage percentage—the
percentage of the talar articular surface that is uncovered
by the navicular, pes planus values >30% and normal considered <30% coverage, (b) talonavicular coverage
angle—the angle between the articular surface of the
navicular and articular surface of the talus, pes planus is
>7° and normal is 7°, and (c) talo-rst metatarsal angle,
also called the AP Meary’s angle—the angle between the
axis of the rst metatarsal and axis of the talus, pes planus
>16 and normal <16. The lateral weight-bearing radiograph can be used to measure the (d) lateral Meary’s
angle, also called the talo-rst metatarsal angle measured
with a line bisecting the rst metatarsal shaft and the axis
of the talus. Normal is zero degrees and values greater
than 4° indicate pes planus, with <15 mild, 15–30 moderate, and >30 severe pes planus
repair of the posterior tibial tendon. In advanced
cases, reconstruction is accomplished by using
Heel Pain
the adjacent exor digitorum longus tendon as a
transfer. Alone, tendon repair or reconstruction
will yield a 50% failure within 2 years postreconstruction unless a bone procedure is added
to correct the deformity. Options include a
medial displacement calcaneal osteotomy, a lateral column lengthening at the anterior one-third
calcaneus, or a plantar exion osteotomy through
the medial cuneiform. Stage III, which involves
a rigid foot or advanced arthritis, can be treated
conservatively with orthotics or surgically with
the appropriate joint fusions. Typically, a triple
arthrodesis involving fusions of the subtalar,
talonavicular, and calcaneocuboid joints is
recommended.
Plantar heel pain is one of the most common and
most disabling conditions of the foot. There are
many causes including tumors, infection, stress
fractures, inammatory arthropathies, and neuropathies. The most common cause of plantar
heel pain is associated with chronic injury of the
plantar fascial origin. This heel pain syndrome is
also known as heel spur syndrome and plantar
fasciitis. Typical pain occurs at the plantar medial
aspect of the heel. Onset is insidious and often
patients recall no trauma. Classic pain and stiffness occur when arising from bed and taking the
rst step on the oor in the morning. Symptoms
often decrease after prolonged walking. High-