Common foot and ankle conditions Flashcards
List some non operative treatments
analgesia/shoewear modifications/weight loss/activity modification/physiotherapy/orthotics eg insoles
6 forefoot problems
hallux valgus hallux rigidus lesser toe deformities mortons neuroma metatarsalgia rheumatoid forefoot
Aetiology of hallux valgus
genetic. female, footwear
Symptoms of hallux valgus
pressure symptoms from shoe wear
pain from toes crossing over
metatarsalgia
Metatarsalgia
pain in ball of foot
describe in 5 steps the pathogenesis of hallux valgus
lateral angulation of great toe
tendon pull realigned to lateral of toe
vicious cycle of increase pull and deformity
sesamoid bone sublux - less weight through big toe
deformities of lesser toes occur
Diagnosis of hallux valgus
clinical
x-rays show severity of bone deformity
non operative - hallux valgus
shoes - wide and increase toe box
orthotics to offload pressure and correct deformity
activity modification and analgesia
Operative - hallux valgus
release lateral soft tissue
osteotomy - 1st MT +/- proximal phalanx`
What is hallux rigidus
OA of 1st MTP joint
Aetiology of hallux rigidus
unknown, genetic, multiple microtrauma
Symptoms of hallux rigidus
many asymptomatic
can be decreased ROM and pain at extreme dorsiflexion
Diagnosis of hallux rigidus
clinical and radiographs
non op - hallux rigidus
activity/shoe with rigid sole/analgesia
op - hallux rigidus
cheilectomy, arthrodesis and arthroplasty
Gold standard of for hallux rigidus
1st MTP joint fusion
When is 1st MTPJ hemiarthroplasty a good option for hallux rigidus?
retain ROM and in low demand patients
3 lesser toe deformities and briefly describe appearance
claw - flexed PIP and DIP
hammer - flexed PIP and extended DIP
mallet - DIP flexion
Aetiology of lesser toe deformities
imbalance between flexors/extensors shoe wear RA neurological idiopathic
symptoms of lesser toe deformities
deformity, pain from dorsum and plantar side
3 non op - lesser toe deformities
activity
shoe wear - flat with high toe box
orthotic insoles
4 op - lesser toe deformities
flexor –> extensor transfer
IPJ fusion
release metatarsophalangeal joint
shortening osteotomy of metatarsal
aetiology of mortons neuroma
mechanically induced degenerative neuropathy
females age 40-60
high heeled shoes
mortons neuroma symptoms
3rd followed by 2nd webspace with burning pain
intermittent and sensation in webspace altered
Diagnosis of mortons neuroma - name of clinical sign
mulders click
USS/MRI
Management of mortons neuroma
injection for small lesions
excise lesion and some of normal nerve
If no known cause of metatarsalgia what should you consider?
tight gastrocnemius
non op management of RA forefoot
shoewear, orthotics and activity
op - RA forefoot
1st MTPJ arthrodesis is gold standard
2-5th toe excision arthroplasty
3 midfoot problems
ganglia
OA and plantar fibromatosis
Where do dorsal foot ganglia arise from?
tendon sheath or joint
aetiology of dorsal foot ganglia
idiopathic
underlying arthritis
underlying tendon pathology
symptoms of ganglia
pain from shoe wear pressure or underlying problem
Treatment of ganglia
aspirate or family bible
excise
% return rate of ganglia excision
50
3 types of midfoot arthritis
post traumatic, OA, RA
3 treatments of arthritis in midfoot
non op = activity/shoes/orthotics
x-ray guided injections
fusion
When is plantar fibromatosis symptomatic?
very large or weightbearing area
non op - plantar fibromatosis
avoid pressure - shoes/orthotics
other treatments of pantar fibromatosis
excise
radiotherapy
radiotherapy and surgery
5 hindfoot problems
ankle osteoarthritis cavovarus foot achilles tendinosis plantar fasciitis tibialis posterior dysfunction
Describe achilles tendinosis
degenerative/overuse condition with little inflammation
Who does paratendonopathy affect?
athletes, 30-40, males
Who does tendonopathy affect?
non athlete, obese, over 40, steroids, DM
Symptoms of achilles tendinopathy
pain on exercise or after exercise
recurrent and difficulty fitting shoes
Diagnosis of achilles tendinopathy and the name of tests
clinical = Simmonds squeeze test and matles angle of dangle
USS/MRI
non op - achilles tendinopathy
activity/weight loss/shoes - slight heel/physio/ECST/immobilise
op - achilles tendinopathy
gastrocnemius recession
release and debridement of tendon
Describe fasciosis
chronic degenerative change with disorganised blood vessels, no inflammatory cells and fibroblast hypertrophy
cannot make ECM needed for remodelling
Aetiology of plantar fasciitis
unknown/obese/athletes/standing/poorly padded shoes/foot and lower limb deformities/tight gastrosoleus
4 symptoms of plantar fasciitis
pain in morning or after rest
pain at origin of plantar fascia
2 years + duration
differential diagnosis of plantar fasciitis
arthritis
calcaneal pathology
nerve entrapment syndrome
Diagnosis of plantar fasciitis
mainly clinical
x-rays, USS, MRI
9 treatments of plantar fasciitis
NSAIDS ice physiotherapy CCS injections orthoses - heel pads stretching rest night splinting weight loss
5 newer treatments for plantar fasciitis
extracorpeal shockwave therapy Nitric oxide endoscopic/open surgery platelet rich plasma topaz plasma coblation
aetiology of ankle arthritis
46 years, post trauma, idiopathic
Symptoms of ankle arthritis
pain and stiffness
diagnosis of ankle arthritis
clinical, radiographs and CT
non op - ankle arthritis
weight loss/activity/analgesia/physio/steroid injections
op - ankle arthritis
anterior symptoms - arthroscopic anterior debridement
arthrodesis is the gold standard
joint replacement
Clinical diagnosis of posterior tibial tendon dysfunction
double and single heel raise
What Is posterior tibial tendon dysfunction a common cause of?
acquired flat feet
3 managements of posterior tibial tendon dysfunction
orthotics - medial arch support
reconstruct tendon
triple fusion
Diagnosing posterior tibial tendon dysfunction
clinical or MRI
Why does diabetic foot ulcers occur?
peripheral neuropathy
lack of patient education
poor blood supply
ANS dysfunction - less sweating - dry cracked skin
Treatment of diabetic foot ulcer
prevention
modify –> smoking, DM control, vascular supply, shoes, deformity, infection, nutrition
Surgery for diabetic foot ulcer
improve vascular supply
amputate
debride ulcers
correct deformity
prognosis for diabetic foot ulcer statistics
15% diabetics develop
50% 5ys
85% diabetic amputations due to this
25% –> amputation
aetiology of charcot neuropathy
neuropathy causes
diabetes
syphilis
2 types of charcot foot
neurotraumatic - lack of proprioception and protective pain sensation
neurovascular - abnormal ANS leads to increased blood supply and bone resorption
3 stages of charcots foot
fragmentation
coalescence
remodelling
diagnosing charcots foot
acute erythematous foot in DM and neuropathy
more than 3 degrees difference in limbs
non painful
radiograph, MRI
Managing charcots foot
prevention
immobilisation
correct deformity before amputation
