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Gavin Heyes and Lyndon Mason
D. Injection into the 2nd MTPJ
E. Orthosis with a metatarsal bar
46. A 25-year-old female presents with diffuse pain
and stiffness in her right foot. She struggles
with walking in the forest when she goes for
hikes.
The radiograph reveals thefollowing (Figure 9.1).
Figure 9.1
Internally rotated
oblique radiograph.
This view is best
used to image the
cubocalcaneal,
cubocuneiform and
cubometatarsal
joints which are
seen in profile
Figure 9.2
Oblique ankle
radiograph
What surgery would be most appropriate?
A. Distal tibial osteotomy
B. Distraction arthrodesis
C. Tibiotalar calcaneal fusion
D. Total ankle fusion
E. Total ankle replacement
What is the initial treatment that should be
offered to the patient?
A. Accommodative orthotics
B. Corrective orthotics
C. Subtalar fusion
D. Talanavicular fusion
E. Tarsal bar resection
47. A 62-year-old male presents with pain in his left
ankle. He is a builder and owns his own business. He says he had an ankle injury many years
ago. The X-ray is as shown in Figure 9.2.He
wants to improve his pain but still wants to
work. He has exhausted conservative management and wants surgery.
48. A 49-year-old woman with chronic plantar
medial pain in the region of the head of the
1st metatarsal. She undergoes corrective surgery
for the same in the form of a medial sesamoidectomy. This relieves her symptoms temporarily but the patient presents back to your clinic
in 2 years with redness and pain over the medial
aspect of the head of the 1st metatarsal and
difficulty in wearing heels.
What is the patient’s most likely aetiology?
A. Bunionnette
B. Hallux valgus
C. Hallux varus
D. Metatarsus adductus
E. Metatarsus varus
49. A 19-year-old patient presents with a painful
pes planus. Jack’s test was abnormal.
Radiographs are shown in Figure 9.3.
The radiograph shows what radiographic
sign?
A. Anteater’s sign
B. C sign
184
Foot and Ankle I Structured SBA
Figure 9.3 Lateral
radiograph left foot.
C. Fleck sign
D. Rocker bottom
E. Too many toes sign
50. A 1.5-month-old baby is brought by a very
concerned mother to your clinic with complaints of toes turned in. Father is unavailable.
Examination – bilateral metatarsus adductus
and heel bisector through the 3rd toe. No
medial crease noted and deformity is correctable at this point.
What should the advice to the mother be?
A. Passive stretching
B. Reverse lateral shoes
C. Serial casting
D. Serial casting as per Ponsetti technique and
then TA tenotomy
E. Tarsometatarsal osteotomy at 1 year of age
52. A 25-year-old male presents to the foot and ankle
clinic and is found to have long-standing pain
localised to a tendon pathology. This tendon
contracts concentrically during terminal stance
and pre-swing phase of the gait cycle. It is also
primarily involved in the pathology that leads to
the ‘too many toes’ sign.
From what structure does the muscle originate?
A. Distal femur and proximal tibia
B. Fibula only
C. Interosseous membrane
D. Tibia and fibula
E. Tibia only
53. A patient presents with an acute onset of pain
under the 2nd metatarsal head 4 weeks ago. The
patient then developed the diffuse callosity under
the metatarsal head as seen in Figure 9.4.
What is the most likely diagnosis?
Figure 9.4 Clinical picture
sole foot
51. A 34-year-old male presents to you with pain on
the lateral aspect of his foot and on clinical
examination you notice he has increased medial
longitudinal arches. He also has a callosity on the
base of the 1st metatarsal head. The patient has
tried non-operative treatment in the form of
shoe modifications and orthotics. You use a
board and ask the patient to rest the lateral board
over it with the hallux and metatarsal head off to
check for hindfoot alignment with the ankle.
The basis of this test lies in?
A. Confirming normal heel varus in toe rise
B. Elevating the medial arch in a cavovarus foot
C. Eliminating the effect of first ray plantar
flexion
D. Locking the transverse tarsal joint to form a
rigid lever
E. Placing the hindfoot into an equinus posture
A. Bursitis
B. Intractable plantar keratosis
C. Mallet toe
D. Morton’s neuroma
E. Plantar plate rupture
54. A 66-year-old patient presents with 2 months of
right ankle pain after having a total ankle
replacement 5 years ago. On workup – his blood
investigations are normal with a marginally
raised ESR. Aspiration reveals a <50% count of
neutrophils and no pus or organisms on culture.
The wound is well healed, no redness and no
fever or chills.
185
Gavin Heyes and Lyndon Mason
What is the next step in the management in
this patient?
A. Arthrodesis of the ankle
B. CT scan with metal reduction artefact
C. MRI of the ankle joint
D. Repeat aspiration
E. Revision TAR
55. A 52-year-old woman presents with an acute
onset posi tional change to her foot where the
foot has become supinated and adducted
(Figure 9.5a). She has a history of complex
regional pain syndrome. She complains of pain
along the medial arch. An examination under
anaesthetic as per images, shows a complete
Figure 9.5 Clinical picture foot and
ankle. (a) Supinated and adducted right
foot. (b) Examination under anaesthetic
Figure 9.6 (a) Anteroposterior (AP) and (b) lateral radiographs
186
Foot and Ankle I Structured SBA
correction of her deformity on giving muscle
relaxation (Figure 9.5b).
What is the most likely diagnosis?
A. Dystonia
B. L5 nerve root palsy
C. Peroneus brevis rupture
D. Tibial posterior tendon entrapment
E. Tibialis anterior rupture
56. A 35-year-old female presents with medial arch
pain and has noted her foot has become flat.
On examination, the patient is unable to do a
single leg heel raise on the affected side.
The posture of the foot is of a flattened medial
longitudinal arch, which is passively correctable.
The patient has ‘too many toes sign’ when viewed
from behind. She exhausts conservative measures and wants surgery.
What is the most appropriate surgical
intervention?
A. Talanavicular and subtalar joint fusion
B. Tibialis posterior reconstruction and gastro-
cnemius slide
C. Tibialis posterior reconstruction and media-
lising calcaneal osteotomy
D. Tibialis posterior reconstruction, medialising
calcaneal osteotomy, gastrocnemius slide,
Cotton osteotomy
E. Tibialis posterior reconstruction, medialising
calcaneal osteotomy, gastrocnemius slide,
spring ligament reconstruction
187
Gavin Heyes and Lyndon Mason
FOOT AND ANKLE I STRUCTURED SBA
ANSWERS
Anatomy and Biomechanics
1. Answer E. Originates on the sustentaculum tali
and inserts onto the navicular
Otherwise known as the plantar calcaneonavicular
ligamentous complex, it is a broad and thick band
with three constituent ligaments that connect the
anterior margin of the sustentaculum tali of the
calcaneus to the plantar surface of the navicular.
Its individual components are the superomedial,
intermedial (medioplantar) and lateral (inferoplantar) ligaments, which fan out and attach to
the navicular bone at three separate locations. The
ligament combines with the superficial and deep
deltoid to provide the ligamentous support to the
proximal aspect of the medial longitudinal arch.
The distal aspect of the medial longitudinal arch is
supported by the navicularcuneiform ligament.
Campbell KJ et al. The ligament anatomy of
the deltoid complex of the ankle: a qualitative and
quantitative anatomical study. J Bone Joint Surg
Am. 2014;96:e62.
Swanton E, Fisher L, Fisher A, Molloy A,
Mason L. An anatomic study of the naviculocu-
neiform ligament and its possible role maintaining
the medial longitudinal arch. Foot Ankle Int.
2019;40:352–355.
Taniguchi A, Tanaka Y, Takakura Y.
Anatomy of the spring ligament. J Bone Joint
Surg Am. 2003; 85:2174–2178.
2. Answer B. Adductor hallucis
First layer: three short muscles. Flexor
digitorum brevis is central; abductor digiti
minimi laterally and abductor hallucis medially.
Second layer contains two muscles and the two
longus tendons: flexor hallucis longus and flexor
digitorum longus. The four lumbrical muscles
arise from the tendons of flexor digitorum longus.
The second muscle is the quadratus plantae.
Third layer: three muscles, with two acting on
the great toe and one on the little. Flexor
hallucis brevis, adductor hallucis and flexor
digiti minimi brevis.
Fourth layer consists of two muscle groups
and two tendons: the plantar and dorsal
interossei, and the tendons of peroneus longus
and tibialis posterior.
3. Answer C. Peroneus longus
Peroneus longus – The peroneus longus inserts
onto the 1st metatarsal base and to a lesser extent
the medial cuneiform, traversing the plantar
aspect of the foot from lateral to medial. The
action is to plantar flex the 1st metatarsal, and
participate in the eversion of the foot. In nonbipedal apes, the peroneus longus lateralised the
first ray, which was used for grasping.
Flexor hallucis longus – This muscle inserts
onto the base of the distal phalanx of the hallux. It
acts to flex all joints of the hallux and, to a lesser
extent, plantar flex the ankle joint.
Flexor hallucis brevis – This muscle inserts on
the medial and lateral sides of the proximal phalanx, comprising a component of the hallucal sesamoid complex. It flexes the hallux along with the
flexor hallucis longus muscle.
Tibialis anterior – This muscle inserts onto
the dorsal and medial aspect of the medial cuneiform and 1st metatarsal. Its function is to dorsiflex
and invert the foot.
Tibialis posterior – This muscle inserts onto
the navicular and medial cuneiform, and in a variable nature onto the other cuneiforms. It acts to
invert the foot and plantar flex the foot at the ankle.
4. Answer B. Interosseous ligament between the
medial cuneiform and the 2nd metatarsal
The ligaments at the 2nd metatarsal base have a
unique arrangement in that there is no intermetatarsal ligament between the 1st and 2nd
metatarsals. Instead, in addition to the dorsal ligaments, there are two ligaments between the medial
cuneiform and 2nd metatarsal base. These two
large ligaments maintain the relationship of the
2nd metatarsal base to the medial cuneiform. The
interosseous ligament, also called the Lisfranc ligament, attaches to the lateral aspect of the medial
cuneiform and the medial aspect of the 2nd metatarsal base. The plantar ligament attaches to the
lateral aspect of the me dial cuneiform and the
plantar aspect of the base of the 2nd and 3rd
metatarsals.
There are three dorsal ligaments attached to
the 2nd metatarsal base, one from each of the first
three cuneiforms.
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Foot and Ankle I Structured SBA
Solan et al. (2001) showed that onbiomechanical
testing the plantar and Lisfranc ligaments were significantly stiffer and stronger than the dorsal ligament, and the Lisfranc ligament was significantly
stronger and stiffer than the plantar ligament.
Panchbhavi VK, Molina D 4th, Villarreal J,
Curry MC, Andersen CR. Three-dimensional,
digital, and gross anatomy of the Lisfranc ligament. Foot Ankle Int. 2013;34:876– 880.
Solan MC, Moorman CT 3rd, Miyamoto RG,
Jasper LE, Belkoff SM. Ligamentous restraints of
the second tarsometatarsal joint: a biomechanical
evaluation. Foot Ankle Int. 2001;22:637–641.
5. Answer C. Flexor hallucis brevis
The sesamoids are closely connected with the
fibrous layer of the joint capsule as well as with
the medial and lateral sesamoid ligaments that are
blended with the capsule. Sharpey’s fibres from
the sesamoid ligaments penetrate the sesamoids
on their capsular side. Anterior to the medial
and lateral sesamoid ligaments are the collateral
ligaments that fan out distally and plantarward,
connecting to the base of the proximal phalanx.
The dense, fibrous plantar pad enshrouds the
plantar aspect of the sesamoids and anchors the
sesamoid complex to the base of the proximal
phalanx. The tendons of the flexor hallucis brevis
are attached to the plantar surface of the sesamoids. However, the tendons of the adductor
and abductor hallucis mainly bypass the sesamoids. The intersesamoid ligament connects the
sesamoids. The flexor hallucis longus nestles on
the plantar aspect between the sesamoids with the
inter-sesamoid ligament, blending with its synovial tendon.
6. Answer E. Posterior tibial artery
The talus is 60% covered by articular cartilage.
Blood vessels enter the talus via capsular and ligamentous attachments, limiting the arterial entry
sites to the talar neck, the medial surface of the
body below the medial malleolus, the sinus tarsi
and the posterior tubercle.
Earlier studies (Phemister 1940) seemed to
confirm that the main blood supply was from the
anterior tibial artery, providing branches to the
superior surface of the body and neck of the talus.
Gelberman and Mortensen’s work (1938)
changed the consensus to the posterior tibial
artery as the main blood supply, along with its
anastomotic network to the sinus tarsi artery,
allowing only retrograde blood flow to the talar
body from the talar neck.
Miller et al. (2011) used a gadoliniumenhanced MRI study and found the posterior
tibial artery to be the main contributor, like
Gelberman and Mortensen’s initial findings.
However, they found an entry point not only at
the talar neck but also an antegrade flow entry
point at the posterior tubercle .
Gelberman RH, Mortensen WW. The arterial
anatomy of the talus. Foot Ankle 1983;4:64–72.
Miller AN, Prasarn ML, Dyke JP, Helfet DL,
Lorich DG. Quantitative assessment of the vascu-
larity of the talus with gadolinium-enhanced magnetic resonance imaging. J Bone Joint Surg Am.
2011;93:1116–1121.
Phemister DB. Changes in bones and joints
resulting from interruption of circulation: I.
General consider ations and changes resulting
from injuries. Arch Surg. 1940;41:436–472.
7. Answer D. Tibialis anterior
The tibialis anterior contracts eccentrically during
heel strike; thus, it acts to help control the lowering
of the foot onto the ground. Injury to the tibialis
anterior or to the motor nerve supply (deep peroneal nerve) will mean that the foot will slap onto
the ground during initial contact. The tibialis anterior will contract concentrically during the initial
and mid-swing phases of the gait cycle. If the tibialis anterior is weak during these phases, then clearance of the foot becomes a problem, which can lead
to a compensatory high-stepping gait.
Bland DC, Prosser LA, Bellini LA, Alter KE,
Damiano DL. Tibialis anterior architecture,
strength, and gait in individuals with cerebral
palsy. Muscle Nerve 2011;44:509–517.
Brunner R, Rutz E.
function during gait. JChildOrthop.2013;7:367–371.
8. Answer C. Lateral plantar nerve
Five main nerves innervate the foot (Table 9.1).
Biomechanics and muscle
Achilles and Heel
9. Answer A. Calf tightness
Individuals with calf tightness, defined as less than
0° of ankle dorsiflexion, are 23 times more likely
189
Gavin Heyes and Lyndon Mason
Table 9.1 Nerve anatomy of the foot
Nerve Motor function in the foot Sensory function
Lateral plantar nerve Adductor hallucis Plantar foot + lateral 1½ digits
Quadratus plantae
Lumbricals 4–5
Interossei
Medial plantar nerve Flexor hallucis brevis Plantar foot + medial 3½ digits
Flexor digitorum brevis
Lumbricals 2–3
Abductor hallucis
Baxter’s nerve (first branch of
lateral plantar)
Deep peroneal nerve Extensor hallucis brevis Extensor
Superficial peroneal nerve - Medial branch – dorsomedial hallux
Abductor digiti minimus
1st web space (dorsal)
digitorum brevis
Lateral branch – dorsum foot
to have plantar heel pain. Obesity (BMI greater
than 30) are 2.9 times more likely to have plantar
heel pain. Those with jobs involving standing are
3.6 times more likely to have plantar heel pain if
they stand for long periods throughout the day.
This is because peak forces for walking and running occur at 60% of stance, with the plantar fascia
taking 1.8 body weight during walking and 3.7
body weight during running.
Obesity does not only affect the plantarfascia due
to weight. Tenocyte inhibition, weaker collagen and
cytokines occur with obesity. Hypercholesterolaemia
is also associated with Achilles tendon ruptures.
For every 1 unit increase in depression, anxiety
or stress (in the DASS subscales), the odds ratios
for having plantar heel pain are increased by 1.3.
10. Answer C. Increased production of large pro-
teoglycans, which bind with large amounts of
water
It is important to understand the pathophysiology and ‘patient-specific’ risk factors to individualise tendinopa thy treatment and develop sound
treatment theory where evidence is lacking.
The continuum model proposed by Cook and
Purdam is well established. They proposed that
the cell response is the initial trigger in tendinopathy and not collagen breakdown. The
continuum contains three phases: reactive, dysrepair and degeneration.
Tenocytes manufacture components of extra-
cellular matrix. The extracellular matrix’s main
component is tightly packed collagen.
Proteoglycans in tendons are typically small.
Phases
Reactive – The tenocyte responds to acute
overload by increasing the production of large
proteoglycans, which bind with large amounts of
water. The tendon therefore swells
homogeneously (fusiform), which serves to
increase cross-sectional area. This increase in
cross-sectional area reduces strain. The response
takes minutes to a few days. No collagen damage
or neovessels occur. The goal of treatment in this
phase is to reduce tenocyte activation/response.
So, the swelling associated with the reactive phase
is not inflammation.
Dysrepair – The ongoing reaction to
inappropriate loading leads eventually to collagen
fibre dysrepair, increased chondrocytic cellularity
and proteins with the production of weak type III
collagen. Disorganisation leads to early ingrowth
of neovessels. Clinically, it can be difficult to
distinguish this stage, but it can be picked up on
imaging. Changes remain reversible.
190
Foot and Ankle I Structured SBA
Degeneration – This is typified by areas of cell
death, minimal fibrillar collagen and the
ingrowth of neovessels. In tendon matrix
heterogeneity, the tendon becomes knobbly due
to fibrotic thickening. Irreversible changes occur
within those areas, but this does not necessarily
mean clinical benefit cannot be achieved.
Treatment requires stimulation of cell response.
Cook JL, Purdam CR. Is tendon pathology a
continuum? A pathology model to explain the
clinical presentation of load-induced
tendinopathy. Br J Sports Med. 2009;43:409–416.
11. Answer A. Calcaneal fracture
The following tests are described for the diagnosis of the cause of heel pain:
Heel squeeze test – Calcaneal stress fracture is
typically painful by squeezing the calcaneum
from both sides.
Silfverskiöld test – Passive ankle dorsiflexion
with the knee flexed to 90°. Abn ormal if when
going from extension to flexion, there is an
increase in passive dorsiflexion of the ankle.
This diagnoses a tight gastrocnemius complex.
Passive toe dorsiflexion (plantar fasciopathy)
– Tightens the windlass mechanism and exacerbates pain.
Dorsiflexion-eversion test (tarsal tunnel syn-
drome) – Tibial nerve is compressed.
Table 9.2 Effectiveness of treatment options for plantar
fasciopathy compared with placebo
Intervention Improvement
as compared
with placebo
Ultrasoundguided pulsed
radiofrequency
Low-level laser
therapy
Dry needling Moderate No
Calcaneal
taping
Shockwave
therapy
Orthotic Low No
Calf muscle
stretching
Plantar fascia
stretching
Low-dye taping No No
Pulsed No No
radiofrequency
electromagnetic
field
High No
Moderate No
Moderate No
Low No
No No
No No
Improvement
VAS clinically
better than
placebo
12. Answer C. Physiotherapy
In the majority of cases, plantar fasciopathy is a
self-limiting problem. If you do nothing, then
90% will resolve by 10 months. Mechanical overload reduction includes focused calf stretches,
weight loss and activity modification amongs t
other measures. Until recently this was the preferred first-line treatment for plantar fasciopathy. New up to date evidence suggests that
physiotherapy is now the preferred option in
the initial phase of the condition. All other conservative measures have been investigated quite
extensively with level 1 evidence. A summary of
the conclusions from a level 1 meta-analysis by
Savioli et al. (2017) showed no intervention had a
clinical improvement compared with placebo on
the visual analogue scale (VAS) (Table 9.2).
Salvioli S, Guidi M, Marcotulli G. The effect-
iveness of conservative, non-pharmacological
treatment, of plantar heel pain: a systematic
review with meta-analysis. Foot 2017;33:57–67.
13. Answer A. Functional rehabilitation is equal to
surgical treatment regarding the incidence of
re-rupture
In the initial phase of tendon healing, collagen
type III is the initial collagen layered down. After
3 days, type I collagen production increases from
15- to 22-fold. After 2 weeks, a fibrous bridge
consisting of fibroblasts and collagen fibres fuses
the tendon. Between 3 and 4 weeks, the collagen
fibres begin to organise longitudinally, a process
that continues for a number of months. Collagen
fibril crosslinking improves with applied stress.
Healing tendons undergoing passive motion
will undergo intrinsic healing from tendon cells
from the epitenon. If immobilised, the tendon
heals predominately by granulation tissue from
191
Gavin Heyes and Lyndon Mason
the endotenon. Prolonged immobilisation causes
decreased fibrillogenesis, and collagen and elastic
fibres are less organised. Protective passive mobilisation has been shown to increase load to failure
significantly when compared with immobilisation.
The most recent meta-analysis by Zhang et al.
(2015) included a total of nine meta-analyses.
When functional rehabilitation was used, conservative intervention was equal to surgical treatment
regarding the incidence of re-rupture, range of
motion, calf circumference and functional outcomes while reducing the incidence of other complications. Wherefunctional rehabilitation was not
performed, conservativeintervention could significantly increase re-rupture rate. Critical to using a
functional walking orthosis for an Achilles tendon
rupture is ensuring the orthosis achieves the
required equinus. Ellison et al. (2017) showed that
using heel wedges causes the foot to flex at the
midfoot and the Achilles does not shorten.
Ellison P, Molloy A, Mason LW. Early protected weightbearing for acute ruptures of the
Achilles tendon: do commonly used orthoses
produce the required equinus? J Foot Ankle
Surg. 2017;56:960–963.
Zhang H et al. Surgical versus conservative
intervention for acute Achilles tendon rupture: a
PRISMA-compliant systematic review of overlapping meta-analyses. Medicine (Balt.) 2015;94:e1951.
Ahmed S, Bolt B, McBryde A. Comparison
of standard screw fixation versus sutu re button
fixation in Lisfranc ligament injuries. Foot Ankle
Int. 2010;31:892–896.
Alberta FG et al. Li gamentous Lisfranc joint
injuries: a biomechanical comparison of dorsal
plate and transarticular screw fixation. Foot
Ankle Int. 2005 ;26 :462–473.
Smith N, Stone C, Furey A. Does open
reduction and internal fixation versus primary
arthrodesis improve patient outcomes for
Lisfranc trauma? A systematic review and metaanalysis. Clin Orthop Relat Res.
2016;474:1445–1452.
15. Answer E. Stage IIB tibialis posterior tendon
dysfunction
This sign is indicative of forefoot abduction. This
may be seen following clinical examination and
would most likely be seen in stage IIB tibialis
posterior tendon dysfunction. This sign is caused
by forefoot abduction; it would be seen in association with talonavicular uncoverage >40%.
Stage IIA does not have significant talonavicular
uncoverage and thus no ‘too many toes’ sign
(Table 9.3). Fibular hemimelia is associated with
Table 9.3 Myerson modification of Johnson and Strom
classification of adult acquired flat foot deformity
Midfoot
14. Answer D. Quality of anatomical reduction is
the best predictor of functional outcomes
Most studies agree that the quality of anatomical
reduction is the best predictor of functional outcomes. Smith et al. (2018) performed a metaanalysis on fixation vs fusion, where three trials
met criteria for inclusion. There was no difference
in PROMs or alignment; the only difference was
hardware removal. In a biomechanical study,
transarticular screws and dorsal plates showed
similar ability to reduce the first and second TMT
joints after TMT and Lisfranc ligament transection
and to resist TMT joint displacement with weight
bearing load (Alberta et al. 2005). In regard to the
use of tightrope, biomechanical studies have
shown this can control translation, but there is no
axial control;therefore, this is often combinedwith
bridge plating (Ahmed et al. 2010).
192
Stage Description
I Mild medial pain and swelling with no
deformity, can perform heel-rise test but
demonstrates weakness on repetition,
tenosynovitis on pathology with normal
tendon length
II Moderate pain with or without lateral pain,
flexible deformity, unable to perform heel-rise
test, elongated tendon with longitudinal tears
IIA <30% talar head uncoverage
IIB >30% talar head uncoverage
III Severe pain, fixed deformity, unable to
perform heel-rise test, visible tears on
pathology
IV Lateral talar tilt
IVA Flexible ankle valgus without severe arthritis
IVB Fixed ankle valgus with or without arthritis
Foot and Ankle I Structured SBA
a ball and socket ankle and tarsal coalition. In
more severe cases, the lateral rays are also deficient, and therefore will not have ‘too many toes’.
Charcot–Marie–Tooth disease would be associated with pes cavus and forefoot adductus.
Iselin’s disease is an apophysitis of the base of
the 5th metatarsal.
Johnson KA, Strom DE. Tibialis posterior
tendon dysfunction. Clin Orthop Relat Res.
1989;239:196–206.
Myerson MS. Adult acquired flatfoot
deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect.
1997;46:393–405.
16. Answer C. Flexor hallucis longus
Flexor hallucis longus (FHL) runs with flexor
digitorum longus (FDL) and intersects at the
knot of Henry. Dista l to the knot of Henry there
are often multiple other connections between the
two tendons, allowing the harvesting of the
tendon with minimal functional loss. Baxter’s
nerve, the first branch of the lateral plantar
nerve, turns medially around the calcaneus to
travel laterally, sending the branch to the
abductor digiti quinti (ADQ). The plantar fascia
is plantar and superficial to FDL. Adductor hallucis is deeper and more laterally located and
does not become accessible until further distal.
Lumbricals are further deep and dorsal.
17. Answer E. Supination deformity
The deformity most commonly encountered is a
supination deformity. It develops as part of an
adaptive mechanism to re-establish the columns
of the foot while in pes planus. The forefoot
abnormalities will require derotation through
the Chopart joints. It may also require a Cotton
osteotomy to plantar flex the first ray. Prior to
reduction of the hindfoot, the forefoot would be
expected to show an abduction deformity. With
coverage of the talar head, the abduction deformity should be corrected; however, the rotation
may not have been fully appreciated. This would
typically manifest itself as a persistent supination
deformity of the forefoot.
18. Answer C. Ledderhose disease
Ledderhose disease, or plantar fibromatosis, is
the correct diagnosis. The disease is named after
Dr Georg Ledderhose, a German surgeon who
described the condition in 1894. It is a similar
disease to Dupuytren’s disease. As in most forms
of fibromatosis, it is usually benign. The nodules
are typically slow growing and most often found
in the central and medial portions of the plantar
fascia. Options for intervention include radiation
therapy, cryosurgery, treatment with collagenase
clostridium histolyticum or surgical removal
only if discomfort hinders walking.
In synovial sarcoma, histopathology would
show a high histologicalgrade, includingcell atypia
and the presence of poorly differentiated epithelial
and spindle cells. For a lipoma, histological analysis
demonstrates acellular stroma and lack of atypia.
Fibromyxomas typically occur in the sub or periungual region, and histological analysis would
show poor margins, spindle- and stellate-shaped
cells, eosinophilic cytoplasm, fibrous and myxoid
stroma and infrequent mitotic and minimal atypia.
Gardner’s syndrome is a variant of familial adeno-
matous polyposis and is associated with multiple
tumours of soft tissue, skin and osteomas.
Forefoot
19. Answer B. Distal chevron osteotomy
The patient has acquired hallux valgus deformity,
and on radiographs this has been described as
mild (Table 9.4 ). Therefore, a basal osteotomy
would be too powerful for this correction. The
examination shows no instability of the first ray,
ruling out the Lapidus fusion (fusion of the 1st
tarsometatarsal joint), and no arthritis (negative
grind test), ruling out the 1st metatarsal phalangeal joint fusion. The Moberg osteotomy is a
dorsiflexion osteotomy usually preserved for
arthritis to allow range of motion. The proximal
phalanx osteotomy is prim arily used to correct a
hallux interphalangeus deformity (delta phalanx)
or to supplement a 1st metatarsal osteotomy. The
Table 9.4 Classification of severity of hallux valgus based on the
hallux valgus and intermetatarsal angles
Hallux valgus angle Intermetatarsal angle
Mild <30° <13°
Moderate 30–40° 13–20°
Severe >40° >20°
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