HISTORY/INTRODUCTION/SCOPE OF THE PROBLEM
Lincoln’s advice is predicated on stout figurative ankles. Indeed, the demands placed on the foot and ankle are extraordinary. Effective load bearing depends on precise biomechanical balance of bones, ligaments, and myotendinous units. The utility of the foot and ankle complex rests in its ability to bear standing weight painlessly and without requiring excessive muscle force to do so. Therefore, a seemingly minor imbalance can result in pathologic loading, and over time imbalanced weight-bearing can result in degenerative arthrosis.
The ankle joint is subject to more weight-bearing force per square centimeter than any other joint in the human body. In addition, the ankle is the most commonly injured articulation of the body. Despite these facts, the prevalence of symptomatic arthritis of the ankle is approximately nine times lower than arthritis of the hip or knee. Various mechanical, biochemical, and anatomic attributes of the ankle account for its apparent resilience to the process of aging and trauma.
Unlike the hip and knee, the ankle joint is less commonly affected by osteoarthritis.
HISTORY AND PHYSICAL EXAMINATION
History
Each patient encounter commences with a detailed history and physical examination. Although a diagnosis may be apparent from the outset, taking a systematic approach with each patient reduces the likelihood of dismissing diagnoses that should have otherwise been considered.
A careful initial history must be elicited for the formulation of an appropriate differential diagnosis and successful treatment options. In addition to gathering information, the history provides the physician an opportunity to become acquainted with the patient and to establish a good rapport.
Answers to some basic questions are needed:
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What are the symptoms?
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Where precisely in the foot and ankle is the pain?
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Anterior ankle joint pain may indicate tibiotalar arthritis.
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Pain anterior to the distal fibula/sinus tarsi may indicate subtalar arthritis.
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Sinus tarsi pain can be associated with lateral ankle impingement from advanced posterior tibial dysfunction or sinus tarsi syndrome.
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Midfoot pain can be associated with talonavicular, naviculocuneiform, or tarsometatarsal arthritis, as well as midfoot coalitions.
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Predominant forefoot symptoms may herald rheumatoid arthritis, fat pad atrophy, or osteoarthritis.
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First metatarsophalangeal (MTP) pain can be associated with gout or hallux rigidus.
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Involvement of a single toe, particularly the second MTP joint, may suggest psoriatic arthritis.
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When do the symptoms occur?
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Pain that worsens on awakening and/or taking the first few steps suggests rheumatoid arthritis.
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Pain relieved by unloading, which is worse at the end of the day, is suggestive of osteoarthrosis.
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How long have symptoms persisted? Have they worsened over time?
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What situations exacerbate the symptoms?
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Plantarflexion/dorsiflexion worsens tibiotalar symptoms.
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Inversion/eversion (uneven surfaces) worsens subtalar symptoms
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What, if anything, provides relief?
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What is the nature/quality of the discomfort (sharp/dull, constant/intermittent)?
Further information specific to the foot and ankle should include:
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Thorough discussion of footwear and whether different types of shoes affect the symptoms.
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Whether there is a history of first MTP joint hyperextension injury.
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Whether there is a history of repeated ankle sprains or osteochondral lesions of the talus.
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Whether there is a history of a fracture or dislocation; if so, what was the mechanism of injury?
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Whether there has ever been swelling, stiffness, loss of sensation, or perceived instability of the ankle joint.
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Whether any prior treatments have been attempted and what were the outcomes.
Prior medical history may contribute to the patient’s current symptoms. Some seemingly unrelated conditions can present with ankle pain.
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Is there a recent or remote history of a serious viral illness? Postviral arthritides can present in the days or weeks following symptoms. Often, multiple joints are involved and the intra-articular inflammation is nonsuppurative in nature. Common infectious causes include human immunodeficiency virus (HIV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and parvovirus B19.
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HIV also has an independent association with both reactive and psoriatic arthritis.
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Also, long-term treatment with potent antiretroviral agents can cause osteopenia, osteonecrosis, and joint degeneration.
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Tick-borne illness can result in several manifestations of arthritis. Both Borrelia burgdorferi (Lyme disease) and Rickettsia rickettsii (Rocky Mountain spotted fever) may result in arthritides.
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Tuberculous arthritis usually appears as a secondary manifestation of disease and is usually slowly progressive with granulomatous inflammation.
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Gout is increasing in incidence, especially in elderly men. It often presents in the foot and ankle in a manner that mimics septic arthritis. Gout also appears to have an association with joints already affected by osteoarthritis. Patients who have received organ transplants and those taking diuretics are at greater risk for the development of gout.
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Neuropathic disorders such as Charçot-Marie-Tooth and radiculopathy can affect gait patterns causing pathologic ankle loading; over time, this can result in degenerative articular changes.
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Systemic inflammatory diseases can manifest in joint inflammation. In addition, chronic treatment with corticosteroids can lead to joint destruction.
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Hemophilia and blood dyscrasias can lead to joint degeneration. Repeated hemarthroses can lead to chronic joint destruction. Sickle cell disease predisposes the patient to many types of arthritis, including gout, septic, and autoimmune; also, periarticular bone infarction can result in joint degeneration.
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Rheumatoid arthritis involves synovial cell proliferation/fibrosis, pannus formation, and cartilage and bone erosion.
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Diabetic neuropathy that impairs proprioceptive sensibility can result in repetitive traumatic loading of the weight-bearing joints.
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Chronic, extensive alcoholism can also result in metaphyseal osteonecrosis and consequent joint collapse.
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The presence of peripheral vascular disease is critical in the consideration of any patient who is a candidate for lower extremity elective surgery.
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Was there prior surgery on the affected foot? When possible, operative reports should be obtained.
The patient’s medication list contains valuable information. Some additional specific questions to ask include:
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Any history of systemic corticosteroid intake. If so, what is the dosage and duration of treatment?
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Any history of chemotherapy?
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Does the patient take glucosamine and/or chondroitin?
Regarding hypersensitivity and adverse reactions to medications, it is important to document each instance and include a description of the associated effect.
A detailed social history is helpful regarding goals of treatment, as well as a guide to patient expectations regarding outcome. Age, gender, occupation, activity level, and recreational pursuits may illustrate how the patient’s life has been affected by his or her condition. Information on alcohol consumption and tobacco use should be noted. Consider the presence of other social factors such as family responsibilities, work stressors, pending personal injury, or work-related claims.
Physical Examination
Focused physical examination enhances the knowledge gained from the patient history. A systematic approach can correctly identify individual joint dysfunction and also will catalogue pertinent phenomena that may be related or possibly unrelated to the present condition.
Weight
A body mass index over 25 kg/m 2 is associated with load-related ankle dysfunction and a greater prevalence of ankle arthritis. Consider the comparison of a 70-kg patient with one who weighs 100 kg; the difference in ground impact forces is proportional to body weight:
If a 70-kg person hops vertically 10 cm off of the ground, the landing impact force will be 686 N compared with 980 N in the case of a 100-kg individual.
Shoes
Provided that shoes are relatively well worn, inspection of footwear can supply information about gait patterns. Uneven wear may suggest a pathologic gait. Some examples are as follows:
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Lateral mid/foresole wear can reflect varus foot alignment. Conversely, medial wear suggests valgus alignment.
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Lateral sole wear may also be caused by in-toeing or crossover gait.
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Significant wear on the posterolateral heel is often normal since the hindfoot is slightly inverted at foot-strike.
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Asymmetric heel wear can indicate leg length discrepancy.
Gait and Stance
Before the formal office visit begins, one can observe a patient’s gait while they are being placed into the room. Such information may provide insight into the patient’s underlying problem. Observation of gait while a patient enters or walks through the office may provide a more authentic portrait of ambulatory impairment than when the patient senses the scrutiny of a physician’s focused attention.
Formal observation of gait can reveal a great deal about the mechanics of a patient’s pathology and can also give insight into their functional status. Thorough examination involves having the patient roll up the pant legs at least to the mid calf; barefoot ambulation affords the best view of mechanics but may not always be possible. Also, separately observe the patient in an upright stance from both anterior and posterior aspects.
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Observe for gait pattern that may narrow determination of the cause (neurologic, musculoskeletal, or combined).
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Confirm normal stance phase with foot-strike, smooth transition from foot-flat to heel-rise, and then toe-off ( Fig. 1-1 ).
FIGURE 1-1
Phases of gait.
(From Coughlin MJ, Mann RA, Saltzman CL [eds]: Surgery of the Foot and Ankle, 2nd ed. Philadelphia, Elsevier, 2007.)
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In-toeing versus out-toeing—A cadaver study found that both internal and external tibial malrotation decreased joint contact area and increased peak pressures across the tibiotalar joint.
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Early stages of ankle arthritis do not uniformly alter gait patterns. In advanced ankle arthritis, the stance phase in the affected ankle is shorter in an effort to reduce load transmitted by that joint.
Evaluation of alignment from both anterior and posterior inspection can assess for pronation or supination, varus or valgus hindfoot deformities, and a leg length discrepancy.
Inspection
The patient should sit upon the table with both lower extremities exposed and at a comfortable working level of a seated examiner. Careful observation will reveal the presence of callosities, lesions, wounds, scars, edema, swelling, discoloration, nail abnormalities, and morphologic deformities.
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A callus on the plantar medial surface of the medial arch is a good indication of pes planus caused by tibialis posterior dysfunction.
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A callus beneath the plantar surface of the second metatarsal head may suggest imbalanced load distribution and possible hypermobility of the first ray or lengthened second metatarsal.
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Surgical scars and skin-grafted sites are common in patients who have undergone treatment for high-energy fractures of the ankle.
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Osteophytes may be visualized subcutaneously in the areas of the talonavicular, tarsometatarsal, and MTP joints.
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Edema may be noticeable over individual joints.
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Note the presence of hammer, claw, and mallet toes; hallux valgus/varus; crossover toes; and pes planus/cavus deformities.
Palpation
Placing hands directly on the foot yields information about skin temperature, edema, presence of pulses, severity of callosities, forefoot/heel pad fat bulk, and pain sensitivity. Full assessment should include palpation in a methodical manner for pain and osteophytes around the joints of the foot and ankle.
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Beginning with checking pulses provides a neutral touch and helps avoid patient anxiety about the potential of pain.
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A systematic assessment includes feeling for painful bony prominences
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Tenderness in the lateral hindfoot may arise from the sinus tarsi and indicate subtalar joint pathology.
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Patients with diabetes require vigilant foot assessment including inspection of callosities and checking web spaces for skin breakdown.
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Noting skin temperature may lend insight into vascular insufficiency, cellulitis, Charçot changes, and inflammatory conditions. Hyperemic skin lacking cellulitic boundaries may indicate Charçot arthropathy.
Motion and Stability
The foot’s efficacy as a load-bearing structure depends on flexibility and coordination through numerous joints. Motion occurs in multiple planes during the stance phase of gait. Assessing individual joints for range of motion reveals information about function including the presence of contractures, hypermobility, and pain. Loss of motion in a given joint should be noted.
The talus deserves particular attention, as it is critical in transitioning motion between the foot and the ankle. The talus permits the foot to be positioned in space in multiple weight-bearing planes. This bone can transmit many times the body’s weight to high-demand athletic maneuvers such as sprinting, jumping, and cutting. It is subject to exceedingly large axial and sheer forces even during normal weight-bearing. Talar articulations account for the vast majority of the foot’s ability to dorsiflex, plantarflex, invert, and evert. To function properly, the talus depends on the physical constraints of ligamentous structures in addition to the mortise.
The tibiotalar joint motion is difficult to isolate because other joints account for significant movement in the sagittal plane. Tibiotalar motion ranges from 25 degrees of dorsiflexion to 40 degrees plantarflexion. Notably, dorsiflexion and plantarflexion do not occur in the same planes. To accurately assess the degree of motion at this joint, one can obtain lateral radiographs in maximum plantarflexion and dorsiflexion. Assessment is required with the knee in both flexion and extension. If there is restriction of dorsiflexion when the knee is extended only, a gastrocnemius contracture is likely present.
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The subtalar joint permits much of the inversion and eversion of the foot. Typical motion ranges from 15 degrees inversion to 15 degrees of eversion. However, other studies have suggested that motion depends on the integrity of stabilizing ligamentous structures. When these structures have been damaged, inversion can range 50 degrees, and eversion, 26 degrees.
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The talonavicular and calcaneocuboid joints form Chopart’s joint. Of the two, the talonavicular joint allows greater motion and, when subjected to arthrodesis, up to 90% pronation and supination arc may be lost.
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The talonavicular joint allows the midfoot to flex, adduct, and supinate about the hindfoot. This motion locks Chopart’s joint and prevents dorsiflexion.
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First ray mobility may be quantified with either a Glasoe or Klaue device or, alternatively, by grasping the first and second metatarsal heads and observing significant dorsal translation of the first.
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A normal first MTP may plantarflex to 15 degrees and may dorsiflex to 70 degrees from the weight-bearing surface of the foot and should be compared with the contralateral side. Note that when the foot is dorsiflexed, great toe extension becomes more difficult and increases the load across the MTP joint due to the windlass mechanism. If hallux valgus is present, passive correctability is assessed.
Specific ligamentous structures merit individual attention:
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The spring ligament spans from the sustentaculum tali to the base of the talar head; along with the posterior tibialis motor function, it provides support against medial displacement of the talar head and arch collapse. In the presence of advanced posterior tibialis tendon dysfunction, the spring ligament can become attenuated.
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The deltoid ligament provides medial stabilization of the ankle joint. There is biomechanical evidence that incompetence of the superficial portion of the ligament results in a decrease in tibiotalar contact and consequently an increase in peak pressures. Chronic incompetence may contribute to joint degeneration.
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The anterior talofibular ligament (ATFL) spans from the tip of the lateral malleolus to the lateral base of the talar neck ( Fig. 1-2 ). The ATFL is the most frequently injured ligament in ankle sprains, and it provides restraint against inversion, internal rotation, and anterior translation. To assess ATFL stability, the distal anterior tibia is stabilized with one hand while using the other hand to cup the heel and draw the foot forward in an anterior drawer test ( Fig. 1-2 B ). This test is done with the foot in slight plantarflexion.
Related posts:
Distraction Arthroplasty for the Treatment of Ankle Arthritis
The Challenging Total Ankle Arthroplasty: Management of Associated Foot Pathology
Conversion of a Failed Total Ankle Replacement to an Ankle Fusion: Indications and Technique
Diagnosis and Classification of Bone Defects: The Effect on Total Ankle Arthroplasty
Tendon Transfers for Acquired Posterior Tibial Tendon Deficiency
Midfoot Arthritis: Nonoperative Treatment and Arthrodesis
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