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Common Foot and Ankle Conditions Flashcards

1
Q

What are some forefoot problems?

A

Hallux valgus, hallux rigidus, lesser toe deformities, Morton’s neuroma, Metatarsalgia, and rheumatoid forefoot

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2
Q

What is the aetiology of hallux valgus (bunions)?

A

Genetics, foot wear and significant female preponderance

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3
Q

What are the symptoms of hallux valgus?

A

Pressure symptoms from shoe wear, pain from crossing over of toes and metatarsalgia

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4
Q

What is the pathogenesis of hallux valgus?

A

Lateral angulation of great toe
Tendons pull realigned lateral to centre of toe worsening deformity
Vicious cycle of increased pull causing deformity
Sesamoid bones sublux medially
Then abnormalities of lesser toes occur as less pressure on big toe

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5
Q

What angles are changed in hallux valgus?

A

First metatarsophalangeal angle and intermetatarsal angle

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6
Q

How is hallux valgus diagnosed?

A

Clinical
X-ray - determine severity and exclude degenerative change

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7
Q

What is the non-operative management of hallux valgus?

A

Shoe wear modification
Orthotics to offload pressure and correct deformity
Activity modification
Analgesia

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8
Q

What is the operative management for hallux valgus?

A

Release lateral soft tissues
Osteotomy 1st metatarsal and possible proximal phalanx
Generally good outcome but recurrence is inevitable
Scarf and basal osteotomy

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9
Q

What is hallux rigidus?

A

Stiff big toe
OA of 1st metatarsal-phalangeal joint
Bimodal distribution of age

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10
Q

What is the aetiology of hallux rigidus?

A

Not known
Possibly genetic
Possible multiple micro-trauma

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11
Q

What is the symptoms and diagnosis for hallux rigidus?

A

Many asymptomatic, pain often at extreme dorsiflexion and limitation of range of movement
Diagnosis - clinical and radiographs

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12
Q

What are the features of hallux rigidus on radiographs?

A

Features of OA
Narrowing and irregularity at MTP joint
Osteophytes seen
Sclerosis of margins
Angle is normal

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13
Q

What is the management of hallux rigidus?

A

Non-operative - activity modification, shoe wear with rigid insole and analgesia
Surgery - cheilectomy (remove dorsal impingement), arthrodesis, and arthroplasty

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14
Q

What is the gold standard treatment for hallux rigidus?

A

1st MTPJ fusion
Is permanent

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15
Q

Describe 1st MTPJ hemiarthroplasty

A

Good option to maintain range of movement
High failure rate
Probably better for low demand patients

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16
Q

What are some lesser toe deformities?

A

Claw toes
Hammer toes
Mallet toes

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17
Q

What is the differences between claw, hammer and mallet toes?

A

Claw - flexion at proximal and distal interphalangeal joints
Hammer - flexion of proximal interphalangeal joints and dorsiflexion at MTP joint
Mallet - flexion at distal interphalangeal joint

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18
Q

What is the aetiology of lesser toes deformities?

A

Imbalance between flexors/ extensors, shoe wear, neurological, RA and idiopathic

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19
Q

What are the symptoms of lesser toes deformities?

A

Deformity, pain from dorsum and pain from planter side (metatarsalgia)

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20
Q

What is the non-operative treatment for lesser toe deformities?

A

Activity modification, shoe wear (flat shoes with high toe box), and orthotic insoles (metatarsal bar/ dome support)

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21
Q

What is the operative treatment for lesser toe deformities?

A

Flexor to extensor transfer
Fusion of interphalangeal joint
Release metatarsophalangeal joint
Shortening osteotomy of metatarsal

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22
Q

What is Morton’s neuroma?

A

Inflammation with severe pain and numbness on plantar side of foot
Interdigital neuroma

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23
Q

What is the aetiology of Morton’s neuroma?

A

Mechanically induced degenerative neuropathy
Tends to affect females aged 40-60
Associated with wearing high heels
Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical tear

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24
Q

What are the symptoms of Morton’s neuroma?

A

Typically affects 3rd followed by 2nd web spaces
Neuralgic burning pain into toes
Intermittent
Altered sensation in web space

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25
How is Morton's neuroma diagnosed?
Clinical Mulder's click - if press on lump and squeeze on metatarsal heads, it causes painful click US best and MRI good
26
What is the management of Morton's neuroma?
Injection for small lesions - steroids Surgery - excision of lesion including a section of normal nerve (can cause numbness and recurrence)
27
What is metatarsalgia?
A symptom Any pain coming from forefoot Careful examination should localise pain If no obvious cause then consider tight gastrocnemius
28
What is the treatment for rheumatoid forefoot?
Non-operative - shoe wear, orthotics and activity Operative - many techniques Current gold standard is 1st MTPJ arthrodesis and 2-5th toe excision arthroplasty
29
What are some midfoot problems?
Ganglia, OA and plantar fibromatosis
30
What is the aetiology of dorsal foot ganglia?
Arises from joint or tendon sheath Idiopathic, underlying arthritis and underlying tendon pathology
31
What are the symptoms of dorsal foot ganglia?
Pain from pressure from shoe wear Pain from underlying problem
32
What is the treatment and prognosis of dorsal foot ganglia?
Non-operative - aspiration and 'family bible' Operative - excision High rate of return - 50%
33
What can cause midfoot arthritis?
Post-traumatic arthritis, osteoarthritis and rheumatoid arthritis
34
What is the treatment for midfoot arthritis?
Non-operative - activity/ shoe wear/ orthotics Injections - X-ray guided Operative - fusion
35
Describe plantar fibromatosis
Ledderhose disease Dupuytren's of the foot Progressive Usually asymptomatic unless very large or on weight bearing area Lumps on sole of foot
36
What is the treatment of plantar fibromatosis?
Non-operative - avoid pressure (shoe wear and orthotics) Operative - excision (80% risk of recurrence) RT - similar recurrence as operation Combination RT and surgery (low risk of recurrence but high risk complications)
37
What are some hindfoot problems?
Achilles tendonitis/ tendinosis Plantar fasciitis Ankle OA Tibialis posterior dysfunction Cavovarus foot
38
What is Achilles tendonitis/ tendinosis?
Degenerative/ overuse condition with little inflammation Tendinosis histopathological Tendinopathy term to describe symptoms
39
What are the types of Achilles tendinopathy?
Insertional tendinopathy - within 2cm of insertion Non-insertional - 2-7cm of insertion Bursitis - retrocalcaneal and superficial calcaneal Para tendinopathy is true inflammatory problem - para-tendonitis histologically
40
What is the aetiology of Achilles tendinopathy?
Para-tendinopathy - commonest in athletic population, age 30-40 and more males (2:1) Tendinopathy - commonest in non-athletes, aged over 40, obesity, steroids and diabetes
41
What are the symptoms of Achilles tendinopathy?
Pain during exercise, pain following exercise, recurrent episodes, difficulty fitting shoes (insertional) and rupture
42
How is Achilles tendinopathy diagnosed?
Clinical - tenderness and tests for rupture Simmonds test - squeeze calf gently and if foot moves then not fully ruptured Angle of the Dangle and Matles Investigations - US and MRI
43
What is the non-operative treatment for Achilles tendinopathy?
Activity modification, weight loss, shoe wear, physio, extra-corporeal shockwave treatment and immobilisation
44
What is the operative treatment for Achilles tendinopathy?
Gastrocnemius recession Release and debridement of tendon
45
Describe plantar fasciitis
Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen - fasciosis Cant make extracellular matric required for repair and remodelling
46
What is aetiology of plantar fasciitis?
Not known, athletes associated with high intensity, running with poorly padded shoes/ hard surfaces, obesity, occupations of long standing, foot/ limb rotational deformities and tight gastro-soleus complex
47
What are the symptoms of plantar fasciitis?
Pain first thing in morning, pain on weight bearing after rest, pain localised at origin of plantar fascia and frequently long lasting (2 years or more)
48
What is the differential diagnosis for plantar fasciitis?
Nerve entrapment syndrome, arthritis and calcaneal pathology
49
How is plantar fasciitis diagnosed?
Mainly clinical Occasionally x-rays, US and MRI
50
What is the treatments for plantar fasciitis?
Rest, change training, stretching, ice, NSAIDs, orthoses, physio, weight loss, injection (corticosteroids) and night splinting
51
What are newer/ 3rd line treatments for plantar fasciitis?
Extracorporeal shockwave therapy Topaz plasma coblation Nitric oxide Platelet rich plasma Endoscopic/ open surgery
52
What is the aetiology of ankle arthritis?
Mean age is 46 years Commonly post-traumatic Idiopathic
53
What are the symptoms and diagnosis of ankle arthritis?
Pain and stiffness Clinical, radiographs and CT scan
54
What is the non-operative management of ankle arthritis?
Weight loss, activity modification, analgesia, physio and steroid injections
55
What is the operative management for ankle arthritis?
If anterior symptoms - arthroscopic anterior debridement Arthrodesis - open or arthroscopic (gold standard) - fusion Joint replacement
56
Describe tibialis posterior tendon dysfunction
Acquired adult flat foot planovalgus (heels are valgus and medial arch collapse) Relatively common and under-recognised 4 stages Clinical diagnosis - double and single heel raise Medial or lateral pain
57
What is the treatment for tibialis posterior tendon dysfunction?
Orthoses or surgery
58
What is the normal double and single limb heel raise?
Heels should swing from valgus to varus as heel rises
59
What is the diagnosis and management of tibialis posterior tendon dysfunction?
Diagnosis - clinical and MRI to assess tendon Management - orthotics, reconstruction of tendon and triple fusion
60
What is aetiology of diabetic foot ulcer?
Diabetic neurology and autonomic neuropathy (lack of sweating, dry skin and sensitive to trauma) Poor vascular supply Lack of patient education
61
What is the treatment for diabetic foot ulcer?
Prevention and modify main detriments to healing (control of diabetes, smoking, vascular supply and external pressure) Surgical - vascular supply, debride ulcers, correct deformity and amputation
62
What is the aetiology and pathophysiology of Charcot neuroarthropathy?
Any cause of neuropathy - diabetes most commo Can be lack of proprioception and protective pain sensation Abnormal autonomic nervous system so increased vascular supply and bone resorption
63
What are the 3 stages of Charcot neuroarthropathy?
Fragmentation Coalescence Remodelling
64
How is Charcot neuroarthropathy diagnosed?
High index of suspicion Greater than 3 degrees difference between limbs Frequently not painful Radiographs MRI scan
65
What is the management of Charcot neuroarthropathy?
Prevention, immobilisation and correct deformity - as leads to infection then amputation

MSK (39 decks)

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