Adult food and ankle disorders Flashcards
What are forefoot, midfoot and hindfoot?
3 main things in F&A examination?
Look
Feel
Move
what is hallux valgus?
Deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
what is the aetiology of hallux valgus?
- Exact aetiology unknown
- more in females
- genetic predisposition
- age related
- common in RA
Clinical presentation of hallux valgus?
- usually bilateral
- May be painful due to joint incongruence ناهماهنگی
- May be unable to wear closed shoes - bursa and/or nerve damage
- A widened forefoot may cause rubbing of the foot with shoes resulting in an inflamed bursa over the medial 1st metatarsal head → bunion
- Joint pain indicates OA
- Transfer metatarsalgia or poor balance indicates defunctioned 1st ray (segment of the foot composed of the first metatarsal and first cuneiform bones)
what is the conservative Mx for hallux valgus?
- Analgesia
- wearing wider, low heel and deeper shoes to prevent bunions
- the use of a spacer in the first web space to stop rubbing between the great and second toes,
- physiotherapy for the tight one
Surgical Mx for hallux valgus?
Osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues.
Nb=patients complain about pain and alteration in biomechanic of the foot.
*This managemeant is for only when these indications are present:
failure of conservative management, lesser toe deformities, lifestyle limitation, overlapping, functional limitation, ulceration *
what is Hallux Rigidus?
OA of the 1st MTPJ; can be primary (degenerative) or secondary to osteochondral injury
What is the clinical presentation for Hallux Rigidus?
- Painful 1st MTP joint
- Stiffness
- Pain increases with activity/aggrevated by shoes
- bone spur (bone lumps)
- The interphalangeal joints (IPJ) hyperextension
Investigations for Hallux rigidus?
X-ray (AP/Lat and oblique)
Mx (both surgical and conservative) of hallux rigidus?
Conservative:
Analgesia, NSAIDs, activity modification, interarticular injection, orthotics (kafie kafsh k mamano man dasram that limit the MTPJ motion)
Surgery:
Fusion (arthrodesis)–gold standard
Replacement of the 1st MTP joint
About Rheumatoid foot?
- Occurs early in Rh disease process
- Surgery if affects the forefoot
- Multi-joint disease
- Systemic effect
- Psychosocial
- Often require multiple joint fusion
- All three fore,hind, midfoot can get affected
About Pes Planus/Flat foot?
- Familial
- Associated ligamentous laxity
- No treatment
- Form an arch on tip toe
What is Tibialis Posterior Tendon Dysfunction?
Caused by attenuation and tenosynovitis of posterior tibialis tendon leading to media arch collapse
What is the aetiology of Tibalis posterior tendon dysfunction?
- unknown
- females
- the most common cause of acquired flat foot in adults
Pahophysiology of Tibialis Posterior dysfunction?
- The tendon is under repeated stress and particularly with degeneration can develop tendonitis, elongation and eventually rupture
- Usually present for years prior to diagnosis
- Elongation or rupture leads to loss of the medial arch with resulting valgus of the heel and flattening of the medial arch of the foot
Clinical presentation of Tibialis Posterior dysfunction?
- Pain and/or swelling posterior to medial malleolus - very specific
- Change in foot shape
- Diminished walking ability/balance
- Dislike of uneven surfaces
- More noticable hallux valgus
- Lateral wall ‘impingement’ pain
- Midfoot and ankle pain
TPD Examination/classifications?
Stage 1– swelling, tenderness, slightly weak muscle power
Stage 2 – flatfoot, midfoot abduction (planovalgus), “too many toes” sign, deformity is passively correctable
Stage 3-flatfoot and rigid forefoot and hindfoot deformities
Stage 4 – Fixity and mortise signs
What does TBD’s classification look like in xray?
Xrays:
stage1-normal
stage 2-arch collapsed
stage 3-arch collapsed+subtalar arthritis
stage 4-arch collapse+subtalar and talar tilt in ankle mortise
What is TBD Mx?
- Physiotherapy
- Insole to support medial longitudinal arch
- Orthoses to accommodate foot shape, Orthoses footwear
- If this fails to settle symptoms, surgical decompression and tenosynovectomy may prevent rupture
- DO NOT use steriod injections
What is Pes Cavus?
Abnormally high arch of the foot
-Often combined with other deformities: hindfoot varus, Forefoot adduction, clawing of toes
Aetiology of Pes Cavus?
idiopathic but is often related to neuromuscular conditions including Hereditary Senory and Motor Neuropathy (HSMN), cerebral palsy, polio(unilateral) and spinal cord tethering from spina bifida occulta
Pes Cavus Mx?
- Soft tissue releases and tendon transfer if supple, or calcaneal osteotomy if more rigid
- Severe cases may require arthrodesis
Planter Fasciitis?
Degenerative condition and inflammation of the plantar fascia (plantar aponeurosis) at its origin on the calcaneus. this causes sharp pain on the bottom of the foot pain
Aetiology and risk factors of plantar fasciitis?
- Repetitive stress/overload or degenerative condition
Risk factors
- Physical overload - excessive exercise, excessive weight (obesity)
- Diabetes
- Age - the cushioning heel fat pad atrophies with age
- Abnormal foot shape - splanovalgus or cavovarus
- Frequent walking on hard floors with poor cushioning in shoes
Clinical presentation of Plantar fasciitis?
Start-up pain after rest
Can be worse after exercise
Fullness or swelling plantarmedial aspect of heel
Tenderness over plantar aspect of heel and/or plantarmedial aspect of heel
Mx of plantar fasciitis?
- Rest, NSAIDs
- Night splints, taping, heel cups or medial arch supports
- Physiotherapy - achilles and plantar fascia stretching exercises
- Corticosteroid injection may alleviate symptoms
- Surgical release of the plantar fascia risks injury to the plantar nerves and it is unclear whether there is an actual benefit
- ECSWL*- not supported by NICE guidelines
Extracorporeal Shock Wave Lithotripsy–ECSWL
What is Morton’s Neuroma?
Degenerative fibrosis of digital nerve near its bifurcation. Most common in 2nd and 3rd space.
What is the aetiology of Morton’s Neuroma?
- Mean age 45-50
- F>M
- Obesity
Clinical presentation of Morton’s Neuroma?
- Burning and tingling in toes
- Loss of sensation in the affected webspace
Investigation of Morton’s Neuroma?
- X-ray (AP/LAT/oblique WB) to rule out MSK pathology
- Diagnostic US - swollen nerve (poor specificity if <6mm in diameter - risk of false positive)
Mx of Morton’s Neuroma?
Non-op:
-insoles
-Steroid and local anaesthetic injections
Operative:
-neuromas* can be excised
neuroma a disorganized growth of nerve cells where is a nerve injury
