1
Q
Posterior tibial tendon dysfunction (insufficiency)
A
- Most common cause of adult acquired pes planus
- More common in females over 40
- Caused by degeneration of the tibialis posterior tendong
2
Q
Tibialis posterior
A
- Primary foot inverter
- Primary dynamic stabilizer of the medial longitudinal
3
Q
Tibialis posterior contraction
A
- Elevates the arch and causes the midfoot/hindfoot to become more rigid
- Increases efficiency of triceps surae during gait
4
Q
Tibialis posterior pathway
A
- Passes in groove on posterior aspect of medial malleolus
- Poor blood supply in this area
- Tendon splits into 3 components
5
Q
3 components of tibialis posterior tendon
A
- Main
- Plantar
- Recurrent
6
Q
Main component of tibialis posterior tendon
A
- Inserts on navicular tuberosity and medial cuneiform
7
Q
Plantar component of tibialis posterior tendon
A
- Inserts on the base of the 2nd-4th metatarsal, intermediate and lateral cuneiforms, cuboid
8
Q
Recurrent component of tibialis posterior tendon
A
- Inserts on sustentaculum tali
9
Q
Degeneration of tibialis posterior may result from
A
- Acute/traumatic rupture (less common)
- Tendinosis from repeated microtrauma (more common)
10
Q
Degeneration of TP leads to
A
- Loss of medial longitudinal arch
11
Q
Overstress of TP leads to
A
- Spring ligament failure (most important static stabilizer)
- Longer term can cause failure of deltoid
12
Q
Long term TP degeneration can cause
A
- Long term can cause collapse of the medial longitudinal arch
- Joint degeneration
13
Q
TP degeneration presentation
A
- Pain in the medial hindfoot area (behind medial malleolus and along medial arc)
- Changes foot appearance (arch height/positioning)
- Too many toes sign and inability to stand on tip-toes
14
Q
2 trabecular orientations from tibia
A
- Posteriorly through talar body to the posterior calcaneus
- Anteriorly through talar body through the neck and head of talus
15
Q
Trabeculae through talar body are oriented vertically
A
- Through the neck/head transition to horizontal
16
Q
Metatarsal bases, cuneiforms, cuboid, navicular trabeculae are oriented
A
- Horizontally and transversely
17
Q
Calcaneus trabeculae are oriented
A
- Along lines of compression and tension
- Most dense inferior to posterior facet and posterior to calcaneocuboid joint
- Calcaneus is designed for bipedalism (balance and propulsion)
18
Q
Neutral triangle of calcaneus
A
- Visible area that contains fewer trabeculae
- Inferior to lateral talar process
- Reflects weight distribution
- Cortical bone superior to the neutral triangle is dense
19
Q
Neutral triangle of calcaneus is susceptible to
A
- Fracture from axial loading
20
Q
Bohler’s angle
A
- Angle between 2 lines tangential to anterior and posterior calcaneus
- Normal is 20-40⁰
- < 20⁰ could indicate calcaneal fracture
21
Q
Bohler’s angle boundaries
A
- Anterior process to highest part of posterior facet
- Superior aspect of posterior calcaneal tuberosity to highest part of posterior facet
22
Q
Angle of Gissane (“critical angle”)
A
- Formed by the slopes of the calcaneal superior articular surface
- Normal is 120-145⁰ (different normal)
- > 145 could indicate fracture
23
Q
Calcaneus intra-articular fracture (through posterior facet)
A
- Intra-articular fracture line passes through neutral triangle
- These occur due to axial loading (fall from height, MVA)
- Lateral talar process acts like a wedge
24
Q
Hallux sesamoid bones are paired ossicles located
A
- Within the tendon of the medial and lateral heads of the FHB
25
Medial (tibial) sesamoid is usually larger than lateral (fibular)
- Greater weight bearing
| - More commonly injuried
26
Hallux sesamoid bones function
- Fulcrums that increase leverage of flexor hallucis brevis
- Weight bearing structures
Protect metatarsal head and FHL tendon
27
Hallux sesamoid bones begin ossification between years
- 7 and 8
28
Multipartite hallux sesamoid
- Mostly medial sesamoid
- Normal variant from multiple ossification centers
- Bipartite is most common variant
- When present, common to be bilateral
29
Hallux abducto valgus (bunion)
- Foot deformity that affects the 1st MTP joint
| - Medial deviation of metatarsal (varus) and lateral deviation of hallux (valgus)
30
Deformity of MTP joint in hallux abducto valgus allows the flexor/extensor tendons to
- Bowstring, exerting a deforming force
- Medial capsule/ligaments become stretched
- Lateral capsule/lig become contracted
31
Hallux abducto valgus (bunion) characteristics
- Not just a transverse plane deformity
- Met head produces the characteristic prominence
- Less effective Windlass leads to metatarsalgia of lesser digits
- F > M
32
Weightbearing AP x-rays for hallux abducto valgus
- Intermetatarsal angle
- Hallux abductus angle (1st metatarsophalangeal angle)
- Other x-rays exist
33
Intermetatarsal angle
- Angle between the lines through the shafts of the 1st and 2nd metatarsals on AP foot x-ray
- Normal is less than 10ᵒ
34
Hallux abductus angle (1st metatarsophalangeal angle)
- Angle formed by a longitudinal bisecting line through the 1st met shaft and a longitudinal bisecting line through the proximal phalanx
- Normal is less than 15⁰
35
Morton’s neuroma (interdigital neuroma, interdigital neuritis, etc.)
- Compression neuropathy of the common plantar digital nerve
- Not a true neuroma
- F > M
36
Morton's neuroma is most commonly located
- Between 3rds and 4th metatarsal (3rd webspace)
37
Neuropathic pain in the distribution of a common digital nerve (Morton's neuroma)
- Intermittent pain most commonly on the plantar forefoot, also in plantar toes and dorsal webspace
- Pain free intervals
- Sharp burning pain, sometimes numbness
38
Morton's neuroma may be caused by
- Repetitive irritation of the nerve that leads to perineural fibrosis
- This is believed to disrupt the nerves and arteries
39
Nerve irritation associated with Morton's neuroma may be caused by
- Compressed or stretched against the deep transverse metatarsal ligament
- Repetitive toe dorsiflexion, tight narrow shoes, tight gastro-soleus complex
40
Morton's neuroma presentation
- Patients describe abnormal forefoot sensations (burning or an ache)
- Feels like they are walking on a pebble
- Sensory abnormalities in affected nerve distribution
- Pain with passive/active toe dorsiflexion
41
Squeeze test (used for Morton's neuroma)
- Squeezing of the metatarsal heads while palpating the interspace may elicit pain
- Also may elicit a click (Mulder’s click) with the pain
42
Morton's neuroma dx made clinically
- US or MRI can confirm if needed
43
Morton's neuroma conservative treatment
- Change footwear
- Metatarsal padding
- Mobilization/manipulation
- Injections
- Etc.
44
Surgical treatment for Morton's neuroma required if
- Conservative treatment fails
- Neurectomy
- Cut through deep transverse metatarsal ligament
45
Plantar skin thickness
- Thick overall
| - Thickest at the heel, lateral plantar margin, met heads
46
Plantar epidermis
- Keratinzed stratified squamous epithelium
47
Keratinocyte
- Major cell type of plantar epidermis
48
Melanocytes
- Not numerous on plantar skin
| - Produce little melanin
49
Langerhan’s cells
- Immunological function
50
Merkel’s cells
- Mechanorecteptors
51
Plantar dermis contains
- Fibroblasts
- Collagen
- Nerves
- Arteries & veins
- Lymph vessels
52
Plantar dermis vasculature
- Nourishes the avascular epidermis
53
Plantar dermis layers
- More superficial papillary layer of loose connective tissue
- Deeper reticular layer of denser connective tissue
54
Plantar skin color
- Yellow-golden from carotene in the subcutaneous fat
| - Pink color from oxygemoglobin found in the highly vascular plantar dermis
55
Plantar vs. dorsal skin
- More fixed than dorsal (dorsal is more mobile)
- Dorsal doesn’t require as big as an incision
- Plantar is more resistant to abrasion
- Plantar lacks hair follicles and sebaceous glands
- Plantar has large amounts of eccrine sweat glands
- Plantar has numerous flexion creases
- Cleavage lines (Langer lines)
56
Cleavage lines (Langer lines)
- Run longitudinal in a proximal to distal orientation
57
Arterial supply to the plantar skin
- Found within the subdermal plexus
| - Vessels to the skin perforate through the deep fascia from deeper branches
58
Plantar subcutaneous tissue characteristics
- Thin in the arch area
- Fat pads
- Shock absorption, energy dissipation and dispersion
protect from stress generated during locomotion
59
Fat pads located
- Heel: ~ 2cm thick
- MTP joint (ball of foot)
- Distal phalanges
60
Heel fat pad
- Specialized adipose-based structure formed by fibrous septa and connective tissue
- Creates chambers that retain adipose tissue
- Globules of fat encapsulated by fibroelastic strands of tissue
61
Fat pad at ball of foot
- Subcutaneous tissue at the ball of the foot is maintained by a system of intersecting ligaments and bands
- Also provide protection and cushion to neurovascular structures between metatarsals
62
Fat pads can undergo atrophy (thinning) or loss of anchorage
- Descreased ability to disperse forces leading to pain
| - Heel fat pad atrophy is a common cause of heel pain
63
Calcaneofibular ligament with anterior talofibular ligament
- Forms 105ᵒ angle
Lower Extremity Anatomy II
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