16.3. Foot Problems - Hindfoot Problems Flashcards
What are the main Hindfoot Problems?
- Achilles Tendonitis / Tendinosis
- Plantar Fasciitis
- Ankle Arthritis
- Tibialis Posterior Tendon Dysfunction
- Diabetic Foot Ulcer
- Charcots Foot
What is Achilles Tendonitis / Tendinosis?
A Degenerative / Overuse condition with little inflammation
What is the definition of:
- Tendinosis?
- Tendinopathy?
- Histopathological Disease
- Term used to describe symptoms
Note - “Tendonitis” Should be avoided
What can Achillies Tendinopathy refer to?
More than 1 Clinical Condition:
- Insertional Tendinopathy - within 2cm of insertion
- Non-Insertional / Mid-Substance Tendinopathy - 2-7cm of insertion
- Bursitis - Retrocalcaneal / Superficial Calcaneal
- Paratendinopathy - a true inflammatory problem
What is the Aetiology of Achilles Tendinopathy, caused by Paratendonopathy?
- Commonest in Athletic Populations
- Male (2:1)
- Ages 30-40
What is the Aetiology of Achilles Tendinopathy, caused by Tendonopathy?
- Commonest in Non-Athletic Populations
- Aged 40+
- Common in those with Obesity / Diabetes / Take Steroids
What symptoms occur in Achilles Tendinopathy?
- Pain During / Following Exercise
- Recurrent Episodes
- Difficulty Fitting Shoes (Insertional)
- Rupture - Don’t Miss This
How is Achilles Tendinopathy diagnosed?
- Clinically:
- a) Tenderness
- b) Tests for Rupture
- Investigations:
- a) Ultrasound
- b) MRI
What is the Achilles Rupture Test?
- Squeeze the Calf (Soleus) Muscle Gently
- If the Calf Squeeze Moves the foot then the Achilles Tendon is not fully Ruptured
- If the Calf Squeeze does not move the foot, then there is a Full Achilles Tendon Rupture
What is the Non-Operative Treatment for Achilles Tendinopathy?
- Activity Modification
- Weight Loss
- Shoe-Wear Modification - Slight Heel
- Physiotherapy - Eccentric Stretching
- Extra-Corporeal Shockwave Treatment
- Immobilisation (below the Knee Cast)
What is the Operative Treatment for Achilles Tendinopathy?
- Gastrocnemius Recession
2. Release and Debridement of Tendon
What is a better term for Fasciitis, in relation to Plantar Fasciitis?
Fasciosis
What is Fasciosis?
Chronic degenerative change, in which the patient can’t make the Extra-Cellular Matrix required for Repair / Remodelling, leading to:
- Fibroblast Hypertrophy
- Absence of Inflammatory Cells
- Disorganised and Dysfunctional Blood Vessels
- Disorganised and Dysfunctional Collagen
- Avascularity
What is the Aetiology of Plantar Fasciitis (Fasciosis)?
- Unknown
- Anything which puts increased pressure on the Foot
- Foot / Lower Limb Rotational Deformities
- Tight Gastro-Soleus Complex
What are the Symptoms of Plantar Fasciitis (Fasciosis)?
- Pain first thing in the Morning
- Post-Static Dyskinesia - Pain on weight bearing and after rest
- Pain located at origin of Plantar Fascia
- Frequently long-lasting (2 years +)
What is the Differential Diagnosis for Plantar Fasciitis (Fasciosis)?
- Nerve Entrapment Syndrome
- Arthritis
- Calcaneal Pathology
How is Plantar Fasciitis (Fasciosis) Diagnosed?
- Clinically (Mainly)
2. Radiology - X-Rays / Ultrasound / MRI (Occasionally)
What are the standard treatments of Plantar Fasciitis (Fasciosis)?
- Rest / Change Training
- Stretching
- Ice
- NSAID’s
- Orthoses - Heel Pads
- Physiotherapy
- Weight Loss
- Corticosteroid Injections
- Night Splinting
What are the new treatments of Plantar Fasciitis (Fasciosis)?
- Extracorporeal Shockwave Therapy
- Topaz Plasma Coblation
- Nitric Oxide
- Platelet Rich Plasma
- Endoscopic / Open Surgery
What is the Aetiology of Ankle Arthritis?
- Mean age of presentation is 46 years old
- Commonly Post-traumatic
- Idiopathic
What are the Symptoms of Ankle Arthritis?
- Pain
2. Stiffness
How is Ankle Arthritis diagnosed?
- Clinically
2. Radiographs - CT Scan to exclude adjacent Joint Arthritis
What is the Non-Operative Management of Ankle Arthritis?
- Weight Loss
- Activity Modification
- Analgesia
- Physiotherapy
- Steroid Injections
What is the Operative Management of Ankle Arthritis?
- Open / Arthroscopic Arthrodesis
- Joint Replacement
- Arhtroscopic Anterior Debridement - If symptoms are exclusively anterior
What is Tibialis Posterior Tendon Dysfunction?
Acquired Adult Flat Foot Planovalgus.
It is relitively common but under-recognised.
What are the Symptoms of Tibialis Posterior Tendon Dysfunction?
Medial / Lateral Pain
Note - There are 4 stages
How is Tibialis Posterior Tendon Dysfunction Diagnosed?
- Clinically - Double & Single Limb Heel Raise
2. MRI to Assess Tendon
How is Tibialis Posterior Tendon Dysfunction managed?
- Orthotics - Medial Arch Support
- Reconstruction of Tendon (Tendon Transfer)
- Triple Fusion (Subtalar, Talonavicular, and Calcaneocuboid)
What is the Aetiology of Diabetic Foot Ulcers?
- Diabetic Neruopathy
- Diabetic Autonomic Neuropathy
- Poor Vascular Supply
- Lack of Patient Education
What are the Non-Operative treatments of Diabetic Foot Ulcers?
- Prevention
- Modifying the main detriments to Healing:
- a) Diabetic Control / Nutrition
- b) Smoking
- c) Vascular Supply
- d) External Pressure (Splints / Shoes / Weight Bearing)
- e) Internal Pressure (Deformity)
- f) Infection
What are the Surgical treatments of Diabetic Foot Ulcers?
- Improve Vascular Supply
- Debride Ulcers and get Deep Samples for Microbiology
- Correct and Deformity to Offload Area
- Amputation
What is the prognosis of Diabetic Foot Ulcers?
- 15% of Diabetics will develop Ulceration
- 85% of amputations for Diabetes are preceded by ulceration
- 25% with Diabetic Ulcers go onto amputation
What is the aetiology of Charcot Neuropathy?
Any cause of Neuropathy:
- Diabetes
- Syphillis
What are the 2 Theories of the Pathophysiology of Charcot Neuropathy?
- Neurotraumatic - Lack of Proprioception and Protective Pain Sensation
- Neurovascular - Abnormal Autonomic Nerve System results in Increased Vascular Supply and Bone Resorption
What is Charcot Neuropathy characterised by?
Rapid Bone Destruction in 3 stages:
- Fragmentation
- Coalescence
- Remodelling
How is Charcot Neuropathy diagnosed?
- Clinically - Consider any diabetic with an acutely swollen erythematous foot
- Radiologically - X-Rays / MRI Scnas
How is Charcot Neuropathy managed?
- Prevention
- Immobilisation / Non-Weight Bearing until acute Fragmentation Resolved
- Correct Deformity = Deformity - Ulceration - Infection - Amputation
