Kategoriarkiv: Foot, ankle

Nerve entrapment behind inne ankle knuckle

NERVE ENTRAPMENT BEHIND INNER ANKLE KNUCKLE

Diagnosis: NERVE ENTRAPMENT BEHIND INNER 
ANKLE KNUCKLE

(Tarsal tunnel syndrome)


Anatomy:
Behind the inner ankle knuckle (mediale malleol), one of the lower leg’s large nerves (Nervus tibialis) runs down to the foot.

  1. N. ischiadicus
  2. N. tibialis
  3. N. tibialis
  4. Tendo calcaneus (Achillis)

LOWER LEG FROM THE REAR

Cause: The nerve (N tibialis) behind the inner ankle knuckle (mediale malleol) can become jammed against the bone, whereby nerve damage can occur. A great many causes of nerve entrapment have been described (article).

Symptoms: A burning, prickling sensation is felt in the sole of the foot and the toes, often localised to the inward side of the foot. There can be symptoms from the calf. The pain is aggravated when walking and running. The heel is not affected.

Examination: Medical examination is usually sufficient to make the diagnosis, as the symptoms can be provoked by applying pressure to the nerve behind the inner ankle knuckle (mediale malleol) (article). The pain will diminish with use of a local anaesthetic above the nerve (diagnostic blockade). If the physician has doubts about the diagnosis, it can be confirmed by use of an EMG examination (ElectroMyoGraphy)

Treatment: Treatment primarily comprises relief from the pain inducing activities (running). Use of shoes with a high heel often alleviates the pain. If smooth progress is not achieved by relief and rehabilitation, the treatment can be supplemented by medicinal treatment in the form of rheumatic medicine (NSAID) or injection of corticosteroid in the tarsal tunnel. If the desired effect is not forthcoming, surgery can be attempted to release the nerve, however, the results are often disappointing (article).

Complications: If there is not a steady improvement in the condition, medical assistance should be sought to determine whether the diagnosis is correct or whether complications have arisen, with consideration being given to:

Degenerative arthritis

SLIDGIGT

Diagnosis: DEGENERATIVE ARTHRITIS
(Osteoarthritis)


Anatomy:
The surfaces of the joints are lined with a cartilage covering of a few millimetre’s thickness which serves to reduce the load or strain on the joint surfaces.

  1. Phalanx media
  2. Tuberositas ossis metatarsalis V
  3. Os cuboideum
  4. Calcaneus
  5. Talus
  6. Os naviculare
  7. Os cuneiforme laterale
  8. Os cuneiforme intermedium
  9. Os cuneiforme mediale
  10. Os metatarsalei
  11. Os sesamoideum
  12. Phalanx proximalis
  13. Phalanx distalis


THE FOOT FROM ABOVE

Cause: Degenerative arthritis occurs with repeated (over) load when first the cartilage takes damage, and then the bone under the cartilage. Degenerative arthritis can in some instances cause an irritation of the synovial membrane which will result in concentration of fluid, swelling, reduction in mobility and pain in the joints. Degenerative arthritis in the ankle joint is often seen after repeated ligament injuries (outer ankle joint ligaments, inner ankle joint ligaments), where cartilage lesions in the ankle joint have occurred at the same time.

Symptoms: Pain in the joint with movement under load. Occasionally swelling in the joint.

Examination: Normal clinical examination is often sufficient. However, it is also often necessary to perform an x-ray (or ultrasound scan or MRI examination) to make the diagnosis. Ultrasound scanning will often reveal inflammation surrounding new bone development at the joint surfaces.

Treatment: Treatment comprises relief from the painful activities until the swelling has gone down, after which training can commence with the primary aim to strengthen the muscles surrounding the joint and retain joint mobility. There is no treatment which can restore the damaged cartilage (and bone). Cartilage transplants are, as yet, not suitable for general degenerative arthritis. In cases of swelling in the joint, and with inflamed new bone development at the joint surfaces, inflammation of the synovial membrane can be attempted subdued by using rheumatic medicine (NSAID), or by draining the fluid and injecting corticosteroid. The injections can be performed to advantage by utilising an ultrasound guided method. Pain without swelling of the joints is best treated with paracetamol. In severe cases of degenerative arthritis where there is pain when resting (at night), it may be necessary to fix the joint by operation.

Rehabilitation: Rehabilitation is completely dependent upon the degree of the degenerative arthritis and in which joints it is located.
Also read rehabilitation, general.

Bandage: A supportive tape (Hollywood bandage) can be attempted to aid degenerative arthritis in small joints (toes) (tape-instruction). Tape provides no help to attacks in the ankle joint.

Complications: Degenerative arthritis which sits on the weight bearing parts of the joint is one of the most serious sports injuries, and often results in a termination of active sport. It is usually possible to continue sport activities with light strain on the joints (cycling, swimming), whereas it is advisable to participate in activities with great strains on the joint (running, ball games) with restraint. The diagnostic considerations in connection with degenerative arthritis include:

Special: Shoes with shock absorbing inlays will reduce the discomfort of degenerative arthritis.

Inflammation of the bursa

Diagnosis: INFLAMMATION OF THE BURSA
(Bursitis)


Anatomy:
There are numerous bursas around the foot for the purpose of reducing the pressure on the muscles, tendons and ligaments which lie close to bone projections. The bursas at the achilles tendon are those which most often give rise to symptoms.

Cause: The bursas can become inflamed, produce fluid, swell and become painful with repeated over-load or due to blows.

Symptoms: Pain when applying pressure to the bursa, which sometimes, but far from always, can give the impression of being swollen.

Acute treatment: Click here.

Examination: Medical examination is usually not required in light cases with only minimal tenderness. With more pronounced pain, or lack of improvement, medical examination should always be performed for confirm the diagnosis and commencement of treatment if required. The diagnosis is best made using ultrasound examination.

Treatment: Treatment is primarily concentrated on providing rest. If the provoking factor is known (i.e. tight shoes), this should naturally be corrected. Treatment can be supplemented with rheumatic medicine (NSAID) or injection of corticosteroid in the bursa preceded by draining, which can be best performed if ultrasound-guided.

Rehabilitation: Treatment is completely dependent upon which bursa is inflamed, but the sports activity can be cautiously resumed when the pain has diminished, especially if the provoking factor has been identified and removed.
Also read rehabilitation, general.

Bandage: In some cases a ring of felt (for example) can be taped around the tender bursa which will reduce the pressure from shoes. It is naturally important that the hole in the ring is positioned directly above the bursa.

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

In rare cases, the bursa can be infected with bacteria. This is a serious condition if the bursa becomes red, warm and increasingly swollen and tender. This condition requires immediate examination and treatment.

Metatarsus ligament rupture

 

Diagnosis: METATARSUS LIGAMENT RUPTURE
(Ruptura traumatica ligamenti pedis)


Anatomy:
The foot bones comprise the 7 tarsal bones (ossa tarsi), the 5 metatarsal bones (ossa metatarsi) and the 14 bones in the toes (phalanx). Large or small ligaments (metarsus ligaments) run between all the bones, which stabilise the joints if twisted and running with directional change.

OUTER ANKLE JOINT

  1. Lig. tibiofibulare anterius
  2. Lig. talofibulare anterius
  3. Lig. talonaviculare
  4. Lig. calcaneocuboideum (Lig. bifurcatum)
  5. Lig. calcaneonaviculare (Lig. bifurcatum)
  6. Ligg. tarsi dorsalia
  7. Lig. cuneocuboideum interosseum
  8. Lig. calcaneocuboideum
  9. Lig. talocalcaneum interosseum
  10. Retinaculum mm. peroneorum inferius
  11. Lig. calcaneofibulare
  12. Lig. talocalcaneum laterale
  13. Lig. talofibulare posterius
  14. Lig. tibiofibulare posterius
  15. Fibula

INNER ANKLE JOINT

  1. Ligamentum mediale/deltoideum
  2. Pars tibiotalaris posterior
  3. Pars tibiocalcanearis
  4. Retinaculum mm. flexorum (m. flexor hallucis longus)
  5. Lig. talocalcaneum mediale
  6. Lig plantare longum
  7. Lig. calcaneonaviculare plantare
  8. Lig. cuneonaviculare plantare
  9. Os naviculare
  10. Os cuneiforme mediale
  11. Ligg. cuneonavicularia dorsalia
  12. Lig talonaviculare
  13. Pars tibionavicularis
    (lig. deltoidei)
  14. Talus
  15. Pars tibiotalaris anterior
  16. Tibia
Cause: A violent twist of the joint can in light cases result in a strain or sprain of the ligament, whereas sever cases can result in full or partial rupture or tear.

Symptoms: Pain in the ligament also occuring with load (twist) on the joint which the ligament stabilises.

Acute treatment: Click here.

Examination: Clinical examination is normally not required in light cases (strain/sprain) with only minimal tenderness, and no discomfort when walking. More pronounced pain will demand examination to exclude bone fracture, bone membrane tear (periosteal avulsion), inflammation of the tendon sheath, concentration of fluid in the joint (traumatic arthritis/synovitis). A normal medical (evt. clinical) examination is usually sufficient in order to make the diagnosis. X-ray will confirm or exclude any suspicion of fracture. Small bone membrane tears are best seen under ultrasound scanning.

Treatment: Treatment of uncomplicated metatarsus ligament rupture will normally be conservative (rehabilitation).

Bandage: In the rehabilitation phase, tape can be used when running on uneven surfaces or running with rapid directional change begins. The tape has, however, not the same important purpose as for ligament injuries on the large outer or inner ligaments in the ankle, (tape-instruction).

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

 

Cartilage damage in the foot

CARTILAGE DAMAGE IN THE FOOT

Diagnosis: CARTILAGE DAMAGE IN THE FOOT


Anatomy:
The surfaces of the joints are lined with a cartilage covering of a few millimetre’s thickness which serves to reduce the load or strain on the joint surfaces.

  1. Phalanx media
  2. Tuberositas ossis metatarsalis V
  3. Os cuboideum
  4. Calcaneus
  5. Talus
  6. Os naviculare
  7. Os cuneiforme laterale
  8. Os cuneiforme intermedium
  9. Os cuneiforme mediale
  10. Os metatarsalei
  11. Os sesamoideum
  12. Phalanx proximalis
  13. Phalanx distalis

THE FOOT FROM ABOVE

Cause: Localised cartilage injuries in the joint surfaces can occur after a vigorous twisting of the joint, where the joint surfaces impact on each other and cause cartilage damage. In some cases a piece of cartilage can be shed which can wander in the joint (joint mouse) and become jammed.

Symptoms: Pain in the joint when under load or strain. Occasional inflammation of the synovial membrane which causes concentration of fluid in the joint.

Examination: Normal medical examination is often not sufficient. To make the diagnosis correctly it is therefore necessary to perform an arthroscopic examination or an MR-scan.

Treatment: Treatment comprises relief from the painful activities until the pain is no longer experienced, after which gradual training can be commenced. There is no treatment that can restore the damaged cartilage, which has itself poor restorative ability. Different procedures to enhance the healing can be attempted using arthroscopic examination, however, the results are generally unsatisfactory (article-1) (article-2). Results from experimental cartilage transplants are still not successful enough to warrant introduction as a routine treatment in the near future. Joint mouse which provokes the symptoms must be surgically removed.

Rehabilitation: Rehabilitation is completely dependent upon the type of cartilage damage (size and position in the joint) and treatment (conservative or surgical).
Also read rehabilitation, general.

Complications: Greater cartilage injuries which are positioned on the weight-bearing parts of the joint are some of the most serious sports injuries, and often results in an end to the sporting career.

Special: As there is a risk that the injury can be permanent, all cases should be reported to your insurance company.

Concentration af fluid in the joint

Diagnosis: CONCENTRATION OF FLUID IN THE JOINT
(Traumatic arthritis / synovitis)


Anatomy:
The joints in the foot comprise the large ankle joint (between the shin and the foot, articulatio talocruralis), as well as many smaller joints between the tarsal bones (ossa tarsi) and the metatarsal bones (ossa metatarsi), and the toe joints.

 

  1. Phalanx media
  2. Tuberositas ossis metatarsalis V
  3. Os cuboideum
  4. Calcaneus
  5. Talus
  6. Os naviculare
  7. Os cuneiforme laterale
  8. Os cuneiforme intermedium
  9. Os cuneiforme mediale
  10. Os metatarsalei
  11. Os sesamoideum
  12. Phalanx proximalis
  13. Phalanx distalis

THE FOOT FROM ABOVE

Cause: Inflammation of the synovial membrane can occur after a violent twist of a joint, which can cause the membrane to thicken and produce fluids resulting in the joint swelling up. The concentration of fluid in the joint (traumatic arthritis/synovitis) is often seen in connection with ligament injuries in the ankle joint area, Associated injuries in chronic lateral ankle instability, but is often overlooked.

Symptoms: Swelling of the joint. Pain with pressure on the joint lines, as well as with passive and active movement of the joint.

Acute treatment: Click here.

Examination: In pronounced cases the diagnosis is made from a normal medical examination, however, experience has shown that diagnosis is difficult and is often overlooked. Ultrasound scanning enables the diagnosis to be made from minor swelling, and swelling in joints that are otherwise difficult to examine.
(article), (Ultrasonic image-1), (Ultrasonic image-2).

Treatment: Treatment is primarily based on relieving the affected area (and treatment of other possible injuries that have developed at the same time). If swelling of the joint persists despite relieving the area as much as possible, a supplement of medicinal treatment in the form of rheumatic medicine (NSAID) can be administered. Alternatively, draining and evaluating the fluid can be performed, and injection of corticosteroid into the joint. Injection into the joint is best performed if ultrasound guided (article).

Rehabilitation: Rehabilitation is completely dependent upon which joint is injured, and which treatment has been administered. Until the swelling and the pain has subsided, the guidelines under rehabilitation, general should be followed.

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

Inflammation of the tendon sheath

Diagnosis: INFLAMMATION OF THE TENDON SHEATH
(Tenosynovitis)


Anatomy:
Tendons from the shin bone to the foot pass both inwardly, outwardly, in front and behind the ankle joint, and continue on the back of the foot and the sole to the toes. The tendons are during part of the course deposited in synovial sheaths.

 

  1. M. flexor digitorum longus
  2. Vagina synovialis tendinis m. tibialis posterioris
  3. Vagina synovialis tendinis m. flexoris hallucis longi
  4. Vagina tendinum m. flexoris digitorum pedis longi
  5. Tendo m. tibialis anterioris
  6. Vagina tendinis m. tibialis anterioris

INNER FOOT

 

  1. M. extensor digitorum longus
  2. M. peroneus brevis
  3. M. peroneus longus
  4. Vagina tendinum m. extensoris digitorum pedis longi
  5. M. peroneus tertius
  6. Tendines m. extensoris digitorum longi
  7. Vagina synovilis mm. peroneorum communis

OUTER FOOT

Cause: Inflammation of the tendon sheath (tenosynovitis) occurs either due to a mechanical irritation (e.g. a shoe tied too tightly, or from a kick), or often from a straining of the ligaments in the ankle joint. In some cases, a prolonged inflammation of the tendon sheath can cause a weakening, and in worst cases a rupture of the tendon. Inflammation of the tendon sheath is often seen as a result of ligament injuries (article), but is often unfortunately overlooked, (article). The tendon sheaths surrounding the ankle often communicate with the ankle joint itself, and accumulation of fluid in the tendon sheaths can therefore be a consequence of increased fluid in the ankle joint itself, concentration of fluid in the joint (traumatic arthritis / synovitis).

Symptoms: Inflammation of the tendon sheath causes pain along the tendon sheath itself, which is aggravated by stretching and activation of the muscle tendon.

Examination: In obvious cases the diagnosis can be established from a normal medical examination. The diagnosis is, however, easily determinable by use of ultrasound scanning, which can also be advantageously used in cases where steady improvement is not noticeable from relieving the affected area (Ultrasonic image).

Treatment: Treatment is primarily based on relieving the affected area and removal of the provoking factor, if such a factor is in evidence (i.e. tightly bound shoes). If satisfactory progress is not made, the treatment can be supplemented by medicinal treatment in the form of rheumatic medicine (NSAID) Alternatively, draining and evaluating fluid form the tendon sheath can be performed, and injection of corticosteroid into the tendon sheath. Injection into the tendon sheath is best performed if ultrasound guided.

Rehabilitation: Rehabilitation is completely dependent upon which tendon is involved, and whether the inflammation of the tendon sheath is a part of another injury (ligament rupture). The guidelines above (rehabilitation, general) should be followed. Strenuous exercises can be gradually resumed when the pain has decreased.

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

Special: Shock absorbing shoes or inner inlays will reduce the risk of various forms of inflammation of the tendon sheath. In the event of unsatisfactory progress, or relapse after successful rehabilitation, consideration must be given to performing an analysis of the patient’s running style to establish whether a correction of the running style should be recommended.

Tendon luxation, outer ankle knuckle

Diagnosis: TENDON LUXATION – OUTER ANKLE KNUCKLE
(Peroneus luxation)


Anatomy:
The tendons surrounding the ankle joint are connected to the bones in several places by connective tissue strings (retinaculum). Two peroneus muscles are positioned behind the outer ankle knuckle, which are used to stabilise and flex the ankle joint.

 

  1. M. peroneus brevis
  2. M. peroneus longus
  3. Tendo calcaneus (Achillis)
  4. Bursa subcutanea malleoli lateralis
  5. Retinaculum mm. peroneorum inferius
  6. Vagina synovialis mm. peroneorum communis
  7. Retinaculum mm. peroneorum superius

OUTER FOOT

Cause: Discomfort can be produced if a rupture of the connective tissue (retinaculum musculorum peroneorum superius & inferius) behind the outer ankle knuckle (malleolus lateralis) occurs. A rupture of the connective tissue (retinaculum) is relatively often combined with outer ligament injuries in the ankle joint.

Symptoms: Pain at the outer ankle knuckle (malleolus lateralis), where certain movements of the ankle joint can give rise to a painful sense of “slipping”.

Acute treatment: Click here.

Examination: When the painful movement of the ankle joint is performed, normal examination can detect the tendon slip over the outer ankle knuckle. A normal medical examination is usually sufficient in order
to make the diagnosis, however, if there is any doubt concerning the
diagnosis it can be made with certainty by use of ultrasound scanning while the ankle joint is in motion (dynamic ultrasound scanning). Ultrasound scanning will reveal whether there is bleeding in the acute stage. Inflammation of the tendon sheath can develop at a later stage.

Treatment: Treatment is primarily concentrated on providing rest from the painful activities (running). If steady progress from rest and rehabilitation is not achieved, and ultrasound scanning reveals inflammation of the tendon sheath, the treatment can be supplemented by medicinal treatment in the form of rheumatic medicine (NSAID) Alternatively, draining and evaluating fluid can be performed, and injection of corticosteroid into the tendon sheath. Injection into the tendon sheath is best performed if ultrasound guided. Surgical intervention can be attempted in certain cases, if resting, rehabilitation and medicinal treatment do not provide the desired result (article).

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

Possibly supplement with further examinations (x-ray, ultrasound scanning).

Bone membrane tear

Diagnosis: BONE MEMBRANE TEAR
(Perisotael avulsion)


Anatomy:
The foot bones comprise the 7 tarsal bones (ossa tarsi), the 5 metatarsal bones (ossa metatarsi) and the 14 bones in the toes (phalanx). Muscles or ligaments are attached or anchored to all the bones. The outer surface of the bone is called bone membrane (periosteum), (Ultrasonic image).

Cause: A violent twist can stretch the ligaments and tear a small piece of bone membrane (periosteum) from the ligament anchor point. In other cases, bone membrane tears can occur when the bones impact upon each other (for example if the foot is bent or flexed backwards with great force so that one of the tarsal bones (talus) impacts against the front edge of the shin bone). Bone membrane tears in the ankle joint area are common, and can be seen in most cases where the person has played football for many years (“football-ankle”). Bone membrane tears can occur on all the bones of the foot where tendons or ligaments are anchored.

Symptoms: Pain when applying pressure, and when stretching the tendon or ligament which is attached to the bone.

Acute treatment: Click here.

Examination: Normal clinical examination is often sufficient. Larger tears can be seen on an x-ray. Many lesser tears can be best seen via an ultrasound scan or MRI examination, (article).

Treatment: Relief from the pain inducing activities. Larger tears can require surgical operation. Lesser tears do not require treatment. Some cases can cause prolonged discomfort with pain which does not recede despite relief. This can be due to the tear causing inflammation in the tissue. In such cases, rheumatic medicine (NSAID) or injection of corticosteroid in the area surrounding the tear can be recommended.

Rehabilitation: Rehabilitation is totally dependent upon the type of tear, and the treatment (conservative or surgical).
Also read rehabilitation, general.

Complications: If there is not a steady improvement in the condition consideration must be given as to whether the diagnosis is correct, or if complications have arisen:

Stress fracture

STRESS FRACTURE

Diagnosis: STRESS (FATIGUE) FRACTURE


Anatomy:
The foot bones comprise the 7 tarsal bones (ossa tarsi), the 5 metatarsal bones (ossa metatarsi) and the 14 bones in the toes (phalanx).

  1. Phalanx media
  2. Tuberositas ossis metatarsalis V
  3. Os cuboideum
  4. Calcaneus
  5. Talus
  6. Os naviculare
  7. Os cuneiforme laterale
  8. Os cuneiforme intermedium
  9. Os cuneiforme mediale
  10. Os metatarsalei
  11. Os sesamoideum
  12. Phalanx proximalis
  13. Phalanx distalis

THE FOOT FROM ABOVE

Cause: Repeated load or strain (walking or running) can in some cases entail the load exceeding the strength of the bone tissue, thus resulting in a stress (or fatigue) fracture. Stress fractures are most often seen in the metatarsal bones, (article) (article).

Symptoms: Pain when applying pressure (direct or indirect tenderness), and when applying load or strain.

Examination: X-ray examination will usually, but not always, reveal a stress fracture. The x-ray examination can be repeated after a few weeks as a number of stress fracture are not easily discernible in the early stages. Bone scintigraphy, ultrasound scanning and MRI examination can often diagnose a stress fracture much earlier than x-ray examination (Ultrasonic image), (Scintigraphy-image).

Treatment: Treatment is primarily relief and rest, and possible bandaging. Surgical intervention is only required in very special cases. It is imperative that shoes are equipped with impact absorbing soles (article).

Rehabilitation:
Rehabilitation is totally dependent upon the type of fracture, and the treatment (conservative or surgical). Until the pain has subsided, the guidelines under rehabilitation, general should be followed.

Complications: If there is not a steady improvement in the condition a medical examination should be performed once more to ensure that the fracture is healing according to plan. In some cases, a false joint can develop which will require surgical treatment.