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15 The Foot andAnkle
heeled shoes typically alleviate symptoms,
whereas barefoot walking and wearing at shoes
may increase symptoms. Physical examination
shows point tenderness on the plantar medial
heel. Often, there is a tight Achilles tendon complex with limited ankle dorsiexion. Occasionally,
fat pad or heel pad atrophy is present. Radiographs
include a lateral X-ray which may show a plantar
heel spur (Fig. 15.27). This is often associated
with a exor digitorum brevis origin and can signify a chronic condition. It is important to rule
out a calcaneal stress fracture and tumor via
X-rays and a calcaneus “squeeze test” which
should not generate pain in plantar fasciitis.
Treatment is almost always conservative consisting of rest, anti-inammatory medication,
orthotic devices, and aggressive stretching.
Isolated stretching of the gastrocsoleus complex
and plantar fascia is important. Surgery is typically reserved for chronic conditions that have
lasted over 6months to a year and involves partial release of the plantar fascial origin in addition
to tarsal tunnel decompression.
Arthritic Conditions oftheFoot
andAnkle
387
Fig. 15.27 Bone spurs of the calcaneus. The plantar heel
spur (solid arrow) can be present in cases of plantar fasciitis. This patient also has a Haglund deformity (dashed
arrow)
include ankle arthrodesis (fusion) or a total
ankle replacement (Fig.15.28). While the main
advantage with fusion is permanency, the downside is that stress transference into adjacent
joints leading to osteoarthritis can occur. Ankle
replacement avoids this problem by maintaining
ankle motion; however, longevity of the implant
may require revision surgery over a lifetime.
Recent advances in implants have resulted in
custom implant printing when necessary.
Osteoarthritis
Ankle
The causes of ankle joint degeneration include
primary osteoarthritis, posttraumatic arthritis,
avascular necrosis, osteochondritis dissecans,
synovial chondromatosis, and rheumatologic
conditions. By far, the most common cause of
ankle arthritis is posttraumatic, unlike the hip or
knee joint. Conservative management includes
anti-inammatory medications, bracing, and
intraarticular cortisone injections. Surgical
management is dependent on the extent and
location of the arthrosis. Options are split
between reconstruction and salvage. For early to
intermediate stage or focal involvement, options
include joint debridement either arthroscopically or open, low tibial osteotomy, osteochondral auto or allograft replacement, and
distraction arthroplasty. Salvage procedures
Foot (Hindfoot, Midfoot, andForefoot)
Arthritis of the foot is very common and can
affect all joints. It can be secondary to all the
causes listed above for ankle arthritis. Forefoot
arthritis is very common, with hallux rigidus
being the most frequent subset. This is discussed
in more detail in an earlier section. Isolated
midfoot arthritis is the least common and is
commonly attributed to posttraumatic, inammatory, or neuropathic arthritis. Lisfranc injuries and midfoot fractures are common causes
of posttraumatic arthritis in the midfoot. It is
also worth noting that hindfoot fusion will cause
transfer of stresses to the midfoot joints and
cause secondary osteoarthritis. Hindfoot arthritis is most commonly posttraumatic but can be
secondary to atfoot, cavovarus foot deformities, or inammatory arthropathies. It includes
degeneration of the subtalar, talonavicular, and
calcaneocuboid joints.
388
P. S. Cooper et al.
Fig. 15.28 To p: AP, mortise, and lateral radiographs
demonstrating a total ankle arthroplasty for ankle arthritis.
Bottom: AP, lateral, and oblique foot radiographs of an
Management begins with conservative treatment
as noted above. Surgical options aim to reduce pain
and include osteophyte resection in early stages and
fusion as the gold standard in late stages.
Rheumatoid Arthritis
Rheumatoid arthritis is a systemic disease that
commonly involves the foot as there are many
joints lined with synovium (Fig.15.29). It affects
both the synovial lining of the joint and the surrounding tendons. These problems are less often
encountered in the present day due to advances in
medical management, particularly the newer bio-
ankle fusion. The former allows for retention of ankle
range of motion
logic medications. Physical examination shows an
antalgic gait, generalized swelling, and decreased
motion in the joints of the foot. Weight- bearing
radiographs of the foot and ankle are essential for
showing deformity and often show a valgus angulation of either the ankle or subtalar joint.
Treatment options include conservative management such as patient education, activity modication, intermittent steroid injections,
optimizing medical management, shoe modications, and the use of an ankle–foot orthosis.
Surgical options include simple synovectomy,
arthrodesis, and total ankle arthroplasty.
ab
15 The Foot andAnkle
389
c
Fig. 15.29 The rheumatoid foot. (a) Plain radiograph of
severe forefoot deformity in rheumatoid arthritis. (b) The
clinical appearance of the typical forefoot deformity. (c)
Prominent plantar bursae in established rheumatoid arthri-
Infections
tis. (Reprinted from Neale’s Disorders of the Foot and
Ankle, 9th ed., Burrow JG, Rome K & Padhiar N,
Rheumatic Diseases, Rome K & Stewart S, p.222–260,
Copyright Elsevier (2020), with permission from Elsevier)
Paronychia
A paronychia is an infection of the medial or lat-
Both the bones and joints of the foot can be
involved in musculoskeletal septic processes
such as osteomyelitis and septic arthritis.
eral nail fold, often seen in the great toe
(Fig. 15.30). Paronychiae are often seen in an
abnormally growing nail or “in-grown toenail,”
which penetrates the skin of the lateral nail fold,
Puncture Wounds
Puncture wounds in the foot can be caused by
many objects including glass, nail, and plant
and animal parts. Typically, the puncture
occurs through the sole of the sneaker and
enters the foot. Since the insole of a sneaker
can be colonized with the Pseudomonas organism, care should be taken to treat the patient
introducing bacteria.
A soft tissue abscess forms and a paronychia
develops. Decompression of the abscess is done
under local anesthesia and removing the lateral
portion of the nail often allows temporary relief.
With more chronic paronychial infections, more
aggressive nail procedures including either partial or total nail ablation may be required.
with an infection from a puncture wound for
this organism. Patients frequently present late
with a swollen cellulitic foot. Standard radiographs and a bone scan can conrm the diagnosis. When bone or joint involvement is
extensive, aggressive surgical debridement is
mandatory for satisfactory resolution. Appropriate antibiotic coverage is required until the
infection has resolved.
Diabetic Foot Infections
People with diabetes can develop a sensory neuropathy which prevents them from protective sensation. Because of abnormal pressures unremitting
for 20min or more, ulcerations which allow bacterial inoculation and infection to develop may
result. Typical scenarios in which this can happen
is after a pedicure or from the abrasions of a poorly
390
P. S. Cooper et al.
a
b
Fig. 15.31 This diabetic patient had recently obtained
new shoes. The two small, dorsal ulcers were exquisitely
painful. Note the blanching of the toes distal to the ulcers.
(Reprinted from Orthopedic Clinics of North America,
20(4), Harrelson JM, Management of the diabetic foot,
p.606, Copyright Saunders (1989), with permission from
Elsevier)
Fig. 15.30 (a) Bilateral infected ingrowing of both edges
of the big toenails. The toenail of the right big toe was
practically completely separated from its bed and was
avulsed. The operation, which was performed under a
local anesthetic, consisted of bilateral resection of all onychogenic tissue in the longitudinal grooves. (b) Sixteen
months after surgery. (Reprinted from Disorders of the
Foot, Vol II, Jahss MH, The toenails, Lapidus PW, p.1589,
Copyright Saunders (1991), with permission from
Elsevier)
tting shoe (Figs.15.31 and 15.32). With abscesses
and ulcers, both acute and chronic septic arthritis
and osteomyelitis are frequently the end result.
Aggressive treatment of any infection in the diabetic foot is mandatory for salvage. Medical management of diabetes is crucial and the patient must
be under strict diabetic control. Intravenous antibiotics are almost always necessary in the acute scenario. Antibiotics are often broad spectrum due to
the polymicrobial nature of these infections. It is
important to distinguish between infection and
Charcot arthropathy, discussed below.
Charcot Arthropathy
Charcot arthropathy, a noninfectious degradation of joints, can be confused with infection or
inammatory arthropathies. It was named by
Fig. 15.32 One day of new shoe wear produced the
ulcers seen over the fth metatarsal head and lateral sides
of the fourth and fth toes. (Reprinted from Orthopedic
Clinics of North America, 20(4), Harrelson JM,
Management of the diabetic foot, p. 606, Copyright
Saunders (1989), with permission from Elsevier)
15 The Foot andAnkle
391
Jean-Martin Charcot for joint destruction
associated with tertiary syphilis, but other
causes include neuropathies caused by diabetes,
Charcot-Marie-tooth, alcoholic peripheral neuropathy, leprosy, Caisson’s disease (the bends).
The pathophysiology is unclear at this time but
leading theories are (1) autonomic dysregulation from the underlying neuropathy leading to
alterations in vascularity and (2) repetitive
microtrauma in an insane extremity triggering
an inammatory cascade resulting in the collapse of the joint. There are three clinical stages
classied by Eikenholz: (1) development, (2)
coalescence, and (3) reconstruction and reconstitution. Physical exam is characterized by erythema, edema, and elevated temperature that is
resolved with elevation of the affected joint,
termed “dependent rubor.” Plain radiographs
demonstrate complete destruction of the joint,
extreme to that of other inammatory arthropathies or infections. Nonoperative treatment with
total contact casting is rst line treatment.
Surgical therapies are utilized when nonoperative management has failed or is not feasible in
a patient, with the goal to ofoad the affected
part of the foot to prevent ulceration and allow
for weight- bearing through fusions and tendon
releases.
Tumors
A complete discussion of soft tissue and bone
tumors is beyond the scope of this chapter;
however, a few specic lesions are mentioned
here.
Soft Tissue Lesions
The anterolateral ankle is the common site for
the development of a ganglion cyst as well as
soft tissue lipomas. These are both benign
lesions and excision can be performed if symptoms warrant. Thickening of the plantar fascia
on the plantar surface of the foot can be palpated
on some patients. Sometimes these thickenings
are large, rm nodules known as plantar bromas. They are benign and should be treated conservatively at all costs.
Bone Tumors
Common bone tumors include enchondroma, a
benign cartilage tumor that can occur in the short
tubular bones such as the phalanges. The chondromyxoid broma (Fig. 15.33) is another
benign cartilage tumor that can affect the bones
of the foot. It is usually managed by curettage of
the lesion. Occasionally, a bone cyst can form in
the calcaneus. Pathologic fracture through this
can occur and may, in fact, be the chief complaint at a patient’s presentation. Treatment usually requires curettage and bone grafting. It is
uncommon to have metastatic disease to the
small bones of the foot. When seen, one should
suspect the lung as the primary site of the
patient’s disease.
Complex Regional Pain Syndrome
This disabling disorder of unknown pathophysiology has a variable symptom complex with
many hypothesized causes and mechanisms.
Renamed from the limited descriptive term reex
sympathetic dystrophy, complex regional pain
syndrome (CRPS) is more common in women
than men, and more common in adults than children. It can occur after a minor injury or surgery
with no nerve involvement, or after a signicant
injury with nerve involvement. Patients present
with disproportionate extremity pain, swelling,
autonomic symptoms (i.e., changes in sweating,
skin discoloration), and motor symptoms (i.e.,
weakness). Diagnosis of any obvious, treatable
causes of pain should be done prior to denitively
selecting CRPS as the diagnosis. Treatment
involves extensive therapy and pain relief with
desensitization through medication or nerve
blockade.
392
P. S. Cooper et al.
Fig. 15.33 Chondromyxoid broma of the
rst metatarsal. (a)
Preoperative radiograph
revealing rst metatarsal
lesion; (b) radiograph
3months after treatment
with curettage and bone
grafting. (Reprinted
from International
Orthopedics, 30(3),
Sharma H, Jane M &
Reid R, Chondromyxoid
broma of the foot and
ankle: 40years’ Scottish
bone tumour registry
experience, p.206,
Copyright Springer
Nature (2006), with
permission from
Springer Nature)
ab
Summary andConclusions
Numerous conditions affect the foot and ankle,
and foot pain remains a very common presenting complaint. A knowledge of anatomy and
common foot and ankle problems can provide
the diagnostician adequate tools to treat patients.
The last gures in this chapter provide algorithms that can assist in the diagnosis and treatment of foot and ankle pain. Figure15.34 can
assist in the diagnosis and treatment of patients
with foot and ankle complaints resulting from
an acute injury. Figure15.35 provides steps to
evaluate and treat patients that have foot and
ankle pain without a history of an acute injury
but with radiographic evidence of deformity or
pathology. Figure 15.36 should provide some
structure to the diagnosis and treatment of
patients with foot and ankle complaints without
injury and no radiographic evidence of deformity or pathology. These are not comprehensive
algorithms but should provide some guidance
when encountering patients with foot and ankle
complaints.
y
15 The Foot andAnkle
393
Acute
Foot/Ankle
Injury
X-Ray
+
Fracture
Dislocation
Foreign Body
Appropriate
Treatment
Occult
Fracture
Immobilize
– –
Edema
Ecchymoses
+
activity
+
Rest +/-
Full
Splint
TC99
Scan
RSD
Sympathetic
Block
–
Continue
Splinting
–
Achilles
Long Flexor
or Extensor
Surgery
Te ndon
Rupture
Rehabilitation
Return to
Normal Activity
Loss of Active Motion
Good Passive Motion
Flexor or
Extensor
–
Short
Splint
+
Nerve
Palsy
EMG
Splint
Rehab
–
Surgery
+
Return to
Normal Activit
Fig. 15.34 Algorithm for diagnosis and treatment of foot and ankle pain with acute injury
394
Activity
to
No Foot/Ankle
Injury, Xray
+
P. S. Cooper et al.
–
Modified
Activity
Normal
Activity
–
Rest
Bunion
Bunionette
Hammertoe
Shoewear
Modification
Corrective
Surgery
No Foot/Ankle
Injury, Xray
–
Pes Planus or Cavus
Wart, Callus, Com
+
Normal
Activity
–
–
Deformity
Skin Lesion
Shoeware
Modification
–
Corrective
Surgery
Surgery
Heel Pain
with Spur
Plantar
Fasciitis
Injection +/-
Orthosis
–
Return to
Normal
Heat Edema
Sed Rate,
Bone Scan
Aspiration
Uric
Acid
Crystals
Gout
NSAIDs
Rest
Normal
Activity
+
Erythema
CBC,
Septic Arthritis
Osteomyelitis
Decompress
Antibiotics
+
–
Corrective
Surgery
Culture
Rest
Arthritis
Osteoarthritis
Rheumatoid
Neuropathic
NSAIDS
Orthotics
Injections
Rest
Paresthesia
Dysesthesia
Neurologic
Lesion
Neuroma
Ta rsal Tunnel
Treat
Neurologic
Lesions
Painful
Bony Lesion
Bone Tumor
Biopsy
Appropriate
Treatment
Osteochondritis
Dessicans
Arthroscopic
Excision
Return to
Normal Activity
+
Return to
Fig. 15.35 Algorithm for diagnosis and treatment of foot and ankle pain with no injury and positive radiograph
+
Full
Activity
Palpable
Mass
Ganglion
Injection
Excision
–
TC99
Scan
Local Tenderness
and Edema
Overuse
Syndrome
NSAIDS
Rest
Splint
+
Stress
Fracture
Immobilize
EMG
GTT
+
Peripheral
Neuropathy
Return
Modified
Activity
+
Treat
Neuropathy
Fig. 15.36 Algorithm for diagnosis and treatment of foot and ankle pain with no injury and negative radiograph
15 The Foot andAnkle
395
Further Reading
Adelaar RS. The treatment of complex fractures of
the talus. Orthop Clin N Am. 1989;20(4):692–3,
991–1200.
Harrelson JM.Management of the diabetic foot. Orthop
Clin N Am. 1989;20(4):606.
Hawkins LG.Fractures of the neck of the talus. J Bone
Joint Surg. 1970;52A:991–1002.
Lapidus PW.Chapter 53: the toenails. In: Jahss MH, edi-
tor. Disorders of the foot, vol. 2. Philadelphia, PA:
Saunders; 1991. p.1589.
Linklater JM, Read JW, Sofka CM, Hayter CL, Dimmick
SJ. Chapter 3: Imaging of the foot and ankle. In:
Haskell A, Coughlin MJ, editors. Coughlin and Mann’s
surgery of the foot and ankle. 10th ed. Amsterdam:
Elsevier; 2024. p.62.
Mann RA. The great toe. Orthop Clin N Am.
1989;20(4):524.
Montgomery HC, Davies MB. Common disorders
of the adult foot and ankle. Surgery (Oxford).
2016;34(9):477.
Myerson MS, Kadakia AR.Chapter 11. Arthrodesis of the
hallux metatarsophalangeal and interphalangeal joints.
In: Myerson MS, Kadakia AR, editors. Reconstructive
foot and ankle surgery: management of complications.
3rd ed. Amsterdam: Elsevier; 2019. p.142.
Myerson MS, Kadakia AR.Chapter 27. Arthrodesis of the
hallux metatarsophalangeal and interphalangeal joints.
In: Myerson MS, Kadakia AR, editors. Reconstructive
foot and ankle surgery: management of complications.
3rd ed. Amsterdam: Elsevier; 2019. p.417.
Rome K, Stewart S.Chapter 9. Rheumatic diseases. In:
Burrow JG, Rome K, Padhiar N, editors. Neale’s
disorders of the foot and ankle. 9th ed. Amsterdam:
Elsevier; 2020. p.222–60.
Rothenberg P, Swanton E, Molloy A, Aiyer AA, Kaplan
JR. Chapter 117. Ligamentous injuries of the foot
and ankle. In: Miller MD, Thompson SR, editors.
DeLee, Drez & Miller’s orthopaedic sports medicine.
Amsterdam: Elsevier; 2020. p.1445.
Sharma H, Jane M, Reid R.Chondromyxoid broma of
the foot and ankle: 40 years’ Scottish bone tumour
registry experience. Int Orthop. 2006;30(3):206.
Waldrop NE III.Chapter 36. Athletic soft tissue injuries
of the foot and ankle. In: Haskell A, Coughlin MJ,
editors. Coughlin and Mann’s surgery of the foot and
ankle. 10th ed. Amsterdam: Elsevier; 2024. p.1463.
Weissman BNW, Sledge CB.Chapter 10. The ankle. In:
Weissman BNW, Sledge CB, editors. Orthopedic radiology. Philadelphia, PA: Saunders; 1985.
Weissman BNW, Sledge CB.Chapter 11. The foot. In:
Weissman BNW, Sledge CB, editors. Orthopedic radiology. Philadelphia, PA: Saunders; 1985.
Index
A
Abduction external rotation (ABER), 223
Abductor digiti minimi (ADM), 370
Acetabular fractures, 76
Achilles tendon disorders, 383–385
Achondroplasia, 155
Acromioclavicular (AC) joint, 204
Acromioclavicular separation, 71
Acute herniated disc, 235
Acute traumatic injuries, 269
Adhesive capsulitis, 220, 221
Adult osteomyelitis, 94–96
Adult septic arthritis, 96
Advanced trauma life support (ATLS), 53
Alumina, 39
Amputation, 113
Aneurysmal bone cysts (ABC), 123
Ankle
acquired deformities, 380, 382
arthritic conditions, 387
charcot arthropathy, 391
diabetic foot infections, 390
diseases, 374
history and physical examination, 372, 373
injuries, 383
radiology, 373
sprains, 378
Ankle–foot orthosis (AFO), 383
Anterior cruciate ligament (ACL), 187, 198–200, 352
Anterior humeral line (AHL), 271
Anterior interosseous nerve (AIN), 268
Anterior-posterior compression I injury (APC-I), 74
Anterior talobular ligament (ATFL), 190
Anteroposterior (AP), 271
Arthritis, 21, 277, 303
Arthrodesis, 341
Arthroplasty, 325, 328–330, 332–337, 339–340,
352–357, 359–361
Arthroscopy, 195, 298, 340
Arthrotomy, 340
Articular cartilage, 187
Atlantoaxial instability, 239
Avascular necrosis (AVN), 24, 281, 333, 336
Axillary view, 42
B
Basilar invagination, 239
Benign bone tumors, 121
Biceps tendon, 209
Biomaterials, 33, 35, 38
Biomechanics, 33–36, 329
Bone(s), 37
arthritis, 21, 22
cartilage, 9
circulation, 8
development, 11
disease, 11–13
embryology, 1–4
growth, 1, 8
metabolism, 7
neurodevelopmental disorders, 27–29
organization, 6
postnatal development, 5
sick cell syndromes, 17, 18
tissue, 5
tumors, 391
vascular disease, 24, 25
Bone morphogenic proteins (BMPs), 8
Brachial artery, 268
Brachial plexus, 205
Broden view, 45
C
Calcaneus fractures, 377
Calcic tendinitis, 221, 222
Calcitonin, 14
Carpal tunnel view, 43
Cartilage, 1, 3, 4
Cavovarus foot deformity, 383
Ceramic, 38
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
W. F. Postma et al. (eds.), Essentials of Orthopedic Surgery,
https://doi.org/10.1007/978-3-031-66215-7
397