John Angel

Fortnightly review: Plantar fasciitis

Plantar fasciitis is the most common cause of inferior heel pain (fig 1). Its aetiology is poorly understood by many, which has led to a confusion in terminology.1 It is said to affect patients between the ages of 8 and 80, but is most common in middle aged women and younger, predominantly male, runners.2 Fig 1 Causes of inferior heel pain The role of the doctor in the management of plantar fasciitis is to make an appropriate diagnosis and to allow enough time for the condition to run its course, with the aid of supportive measures. If treatment is begun soon after the onset of symptoms, most patients can be cured within six weeks.3 This article is based largely on our experience and recent concepts that have changed our management of inferior heel pain. Reviews written by experts have been supplemented by selected original articles cited in Medline between 1976 and 1995 and published in high quality journals. We used the following keywords for the Medline search: plantar fasciitis, inferior heel pain, heel spur, calcaneodynia. The plantar fascia is a strong band of white glistening fibres which has an important function in maintaining the medial longitudinal arch: spontaneous rupture or surgical division of the plantar fascia will lead to a flat foot.4 5 The plantar fascia arises predominantly from the medial calcaneal tuberosity on the undersurface of the calcaneus, and its main structure fans out to be inserted through several slips into the plantar plates of the metatarso-phalangeal joints, the bases of the proximal phalanges of the toes and the flexor tendon sheaths. Just after heel strike during the first half of the stance phase of the gait cycle, the tibia turns inward and the foot pronates to allow flattening of the foot. This stretches the plantar fascia. …

Tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot

Adults with an acquired flatfoot deformity may present not with foot deformity but almost uniformly with medial foot pain and decreased function of the affected foot (for a list of causes of an acquired flatfoot deformity in adults, see box 1).1 Patients whose acquired flatfoot is associated with a more generalised medical problem tend to receive their diagnosis and are referred appropriately. However, in patients whose “adult acquired flatfoot deformity” is a result of damage to the structures supporting the medial longitudinal arch, the diagnosis is often not made early.2 These patients are often otherwise healthier and tend to be relatively more affected by the loss of function resulting from an acquired flatfoot deformity. The most common cause of an acquired flatfoot deformity in an otherwise healthy adult is dysfunction of the tibialis posterior tendon, and this review provides an outline to its diagnosis and treatment. We seached PubMed for publications by using the keywords “flatfoot” and “tibialis posterior dysfunction”. ### Tibialis posterior dysfunction: a common condition Tibialis posterior dysfunction is well recognised by orthopaedic surgeons specialising in foot and ankle surgery and by podiatrists. However, greater general awareness of this condition is required,2 as most patients presenting to a general practitioner receive a diagnosis of ankle sprain or arthritis. By the time most patients present to a specialist foot and ankle clinic they have had the condition for several years and have consulted numerous doctors.3 Even general orthopaedic surgeons and physiotherapists often miss the diagnosis.3 However, tibialis posterior dysfunction need not remain a “specialist diagnosis” as it is usually diagnosed without any investigations, from a history and physical examination.2 Many patients benefit from relatively simple treatment, such as orthotic devices.4 Population based studies to identify the prevalence of tibialis posterior dysfunction are under way. In elderly people the condition …

Treatment of Morton's Neuroma by Neurolysis

Thirty-five patients who had undergone neurolysis for Mortons neuroma were reviewed at a mean of 21.4 months. Those patients who had received diagnostic lidocaine (local anesthetic) injections as an evaluation tool before the operation did extremely well after this operation. Overall patient satisfaction was found to be extremely high, with 17 of 35 patients enjoying complete relief of their pain and 12 of 35 reporting minimal discomfort with activity. The likelihood of persistent symptoms seemed to be related to the presence of associated foot disorders.

The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England

BACKGROUND To investigate the prevalence of posterior tibial tendon dysfunction (PTTD) in women over the age of 40. METHODS A validated survey was posted to a random sample of 1000 women (over 40 years) from a GP group practice in Hertfordshire, England. Survey positive women were telephoned and when indicated, a detailed examination was performed. RESULTS There were 582 usable responses. The majority indicated they had minor forefoot or no problems. Telephone contact was made with 116 women and of those 79 required examination. The diagnosis of symptomatic flatfeet was made in 9 patients, 7 patients had stage I PTTD, 12 patients had stage II PTTD and 9 patients had an adult acquired flatfoot deformity. CONCLUSIONS This is the first report of the prevalence of stage I and II PTTD in women (over 40 years). The prevalence is 3.3% and all patients were undiagnosed despite characteristic and prolonged symptoms.

Fixation of an Akin osteotomy with a tension suture: Our results

An Akin osteotomy is a closing wedge varus osteotomy of the proximal phalanx, usually performed as part of a hallux valgus correction surgery to complement the metatarsal correction. Numerous fixation techniques have been described; most provide good and stable fixation, but involve permanent and sometimes protruding hardware. A retrospective cohort study has been carried out of 115 feet in 109 patients using a technique with an absorbable suture fixation of the medial cortex of the proximal phalanx while preserving the lateral cortex. All the osteotomies united completely with no loss of position. HV angles and IM angles were within acceptable parameters. In comparison to others methods, the technique presented in this study is technically simple, provides good results, requires no specialized instrumentation, is cost effective and has a very low complication rate.

Clinical tip: revision first metatarsophalangeal joint arthrodesis for sagittal plane malunion with an opening wedge osteotomy using a small fragment block plate.

Arthrodesis of the first metatarsophalangeal (MTP) joint is commonly used in the treatment of severe hallux rigidus,4 and recurrent hallux valgus,3,5 providing good results.1 It is important to position the proximal phalanx properly when performing an arthrodesis. Too much plantarflexion leads to overloading of the great toe, ulceration, interphalangeal joint osteoarthritis and difficulty executing the toe-off phase of stance. Patients tolerate excessive dorsiflexion poorly because of dorsal impingement and difficulty with footwear. Both, however, are recognized complications of first MTP joint arthrodesis. Techniques that can be used for revision of an excessively dorsiflexed arthrodesis include a dorsal opening wedge osteotomy packed with bone graft before fixation with a small fragment plate or crossed screws, a plantar closing wedge osteotomy, a crescentic osteotomy,2 or trapezoid osteotomy. All of these techniques require technical expertise to attain an appropriate MTP joint dorsiflexion angle. Dorsal opening wedge osteotomy fixed with a small fragment block plate is a technically less demanding procedure than other common techniques and reliably allows accurate reduction and stable fixation for revision of first MTP joint arthrodesis.

Tibialis posterior insufficiency occurring in a patient without peronei: A mechanical etiology

A patient presented with a painful flatfoot deformity, which developed after the onset of a drop-foot secondary to a herniated lumbar disk. On examination, the only functioning muscles were her gastrocnemiussoleus complex and her intrinsic toe flexors. Her affected foot had taken the classic deformity seen with tibialis posterior dysfunction—a valgus heel, midfoot collapse and an abducted forefoot. Peroneus brevis was not functioning and therefore could not be implicated as part of the etiology of this patients acquired flatfoot deformity. The mechanism in which the ground reaction force produces the foot deformity in a tibialis posterior insufficient foot will be presented.