33: Orthopaedic Foot Conditions Flashcards
list some conditions that affect the forefoot
- hallux valgus
- hallux rigidus
- lesser toe deformities
- Morton’s neuroma
- Metatarsalgia
- rheumatoid forefoot
what is another name for hallux valgus?
bunions
bunions aetiology
- genetic
- foot wear
- significant female preponderance
Hallux valgus symptoms
- pressure symptoms from shoe wear
- pain from crossing over of toes
- metatarsalgia (ball of foot becomes painful and inflamed
Hallux valgus pathogenesis
- lateral angulation of great toe
- tendons pull realigned to lateral of centre of rotation of toe, worsening the deformity
- vicious cycle of increased pull creating increased deformity
- sesamoid bones sublux - less weight goes through big toe
- as deformity progresses abnormalities of lesser toes occur
Hallux Valgus non-operative management
- shoe wear modification (wide +/- high toe box)
- orthotics to offload pressure/correct deformity
- activity modification
- analgesia
Hallux Valgus operative management
if non-operative failed or unacceptable to patient
- release lateral soft tissues
- osteotomy 1st metatarsal +/- proximal phalanx
- generally good outcome but recurrence inevitable
describe Hallux rigidus
- stiff big toe
- osteoarthritis of 1st MTP joint
Hallux rigidus symptoms
- many asymptomatic
- pain, often at extreme of dorsiflexion
- limited range of movement
Hallux Rigidus non-operative and operative management
non-operative:
- activity modification
- shoe wear with rigid sole
- analgesia
operative:
- cheilectomy
- arthrodesis
- arthroplasty
list some lesser toe deformities
- claw toes
- hammer toes
- mallet toe
lesser toe deformities symptoms
- deformity
- pain from dorsum
- pain from plantar side (metatarsalgia)
lesser toe deformities treatment
non-operative:
- activity modification
- shoe wear - flat shoes with high toe box to accommodate deformity
- orthotic insoles - metatarsal bar/dome support
operative:
- flexor to extensor transfer
- fusion of interphalangeal joint
- release metatarsophalangeal joint
- shortening osteotomy of metatarsal
what is Morton’s neuroma?
- interdigital neuralgia of the foot
Morton’s neuroma aetiology
- mechanically induced degenerative neuropathy
- tends to affect females aged 40-60
- frequently associated with wearing high-heeled shoes
- common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
Morton’s neuroma symptoms
- typically affects 3rd followed by 2nd webspace/toes
- neuralgic burning pain into toes
- intermittent
- altered sensation in webspace
Morton’s neuroma investigations
- clinical
- Mulder’s click
- US best/ MRI good
Morton’s neuroma management
- injection for small lesions
- surgery: excision of lesion including a section of normal nerve, can cause numbness, recurrence.
what is the treatment for rheumatoid forefoot?
- non-operative: shoewear, orthotics, activity modification etc.
- operative: current gold standard is 1st MTPJ arthrodesis and 2-5th toe excision arthroplasty
list some conditions affecting the midfoot
-
- ganglia (cyst)
- osteoarthritis
- planar fibromatosis
Dorsal foot ganglia treatment
- aspiration
- ‘family bible’
- excision, though high rate of return (50%)
describe plantar fibromatosis
A plantar fibroma is a rare benign growth on your plantar fascia, the rubber band-like ligament that stretches from your heel to your toes.
- also called Ledderhose disease
- progressive
plantar fibromatosis treatment
- Non-operative – avoid pressure – shoewear/orthotics
- Operative – excision (up to 80% risk of recurrence)
- Radiotherapy (similar recurrence as operative)
- Combination radiotherapy/surgery (low risk recurrence/high risk complications)
list some problems affecting the hindfoot
- achilles tendonitis/tendinosis
- plantar fasciitis
- ankle osteoarthritis
- tibialis posterior dysfunction
- cavovarus foot
achilles tendinopathy aetiology
Paratendonopathy:
- commonest in athletic populations
- age group 30-40 years
- male:female = 2:1
Tendonopathy:
- commonest in non athletic populations
- aged over 40
- obesity
- steroids
- diabetes
achilles tendinopathy symptoms
- pain during exercise
- pain following exercise
- recurrent episodes
- difficulty fitting shoes (insertional)
- RUPTURE
achilles tendinopathy diagnostic investigations
clinical:
- tenderness
- tests for rupture
investigations:
- US
- MRI
achilles tendinopathy treatment
non-operative:
- activity modification
- weight loss
- shoe wear modification - slight heel
- physio - eccentric stretching
- extra-corporeal shockwave treatment
- immobilisation (in below knee cast)
operative:
- gastrocnemius recession
- release and debridement of tendon
plantar fasciitis symptoms
- pain first thing in the morning
- pain on weight bearing after rest: post-static dyskinesia
- pain located at origin of plantar fascia
- frequently long-lasting > 2 years or more
plantar fasciits treatment
- Conservative measures including rest, ice, and avoidance of activities that exacerbate pain
- Use of non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief
- Supportive footwear and orthotics to reduce strain on the plantar fascia
- Physical therapy involving stretching exercises for the plantar fascia and Achilles tendon
- Corticosteroid injections for severe cases
- Surgery is considered as a last resort when all conservative measures have failed
what are the surgical management options for ankle arthritis?
- if symptoms are exclusively anterior then arthroscopic anterior debridement
- arthrodesis (open or arthroscopic), gold-standard, good long-term outcome
- joint replacement
which clinical tests are used to help diagnose tibialis posterior tendon dysfunction?
a cause for acquired adult flat foot
tibialis posterior tendon dysfunction treatment
- Orthotics – medial arch support
- Reconstruction of tendon (tendon transfer)
- Triple fusion (subtalar, talonavicular and calcaneocuboid)
Charcot neuroarthropathy aetiology
- any cause of neurpathy
- diabetes is commonset cause
- historically originally described and most common with syphillis
Charcot neuroarthropathy pathophysiology: two theories.
- neurotraumatic: lack of proprioception and protective pain sensation
- neurovascular: abnormal autonomic nervous system results in increased vascular supply and bone resorption
Charcot neuroarthropathy is characterised by rapid bone destruction occuring in which three stages?
- fragmentation
- coalescence
- remodelling
charcot neuroarthropathy management
- prevention
- immobilisation/non-weight bearing until acute fragmentation resolves
- correct deformity as leads to ulceration to infection to amputation
