Common foot and ankle conditions Flashcards
Non-opertative management of foot and ankle conditions?
> Analgesia > Shoe wear modification > Activity modification > Weight loss > Physiotherapy > Orthotics including insoles and bracing
When to operate in foot and ankle conditions?
The only indication for operative management is failure of non-operative management
Common forefoot problems?
Hallux valgus Hallux rigidus Lesser toe deformities Morton’s neuroma Metatarsalgia Rheumatoid Forefoot
What is another name for hallux valgus?
Bunions
Aetiology of Hallux valgus?
> Genetic
Foot wear
Significant female preponderance
Symptoms of hallux valgus?
> Pressure symptoms from shoe wear
Pain from crossing over of toes
Metatarsalgia
Pathogenesis of hallux valgus?
> Lateral angulation of great toe.
Tendons pull realigned to lateral of centre of rotation of toe worsening deformity
Vicious cycle of increased pull creating increased deformity
Sesamoid bones sublux – less weight goes through great toe
As deformity progresses abnormalities of lesser toes occur
Diagnosis of hallux valgus?
> Clinical
Xrays
- Determine severity of underlying bony deformity
- Exclude associated degenerate change (E.g. Arthritis)
Management of hallux valgus - Non-operative?
> Shoe wear modification (wide +/- high toe box)
Orthotics to offload pressure/correct deformity
Activity modification
Analgesia
Management of hallux valgus - Operative?
Operative (if non-operative failed or unacceptable to patient):
> Release lateral soft tissues
> Osteotomy 1st metatarsal +/- proximal phalanx
> Generally good outcome but recurrence inevitable
What is hallux rigidus?
> Stiff big toe
> Osteoarthritis of 1st MTP joint
Aetiology of hallux rigidus?
> Not known
Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
Possibly multiple microtrauma
Bimodal distribution of age
Aetiology of hallux rigidus?
> Not known
Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
Possibly multiple microtrauma
Bimodal distribution of age
Diagnosis of hallux rigidus?
> Clinical
> Radiographs
Diagnosis of hallux rigidus?
> Clinical
> Radiographs (Often visible osteocytes)
Management of hallux rigidus - Operative?
Surgery: > Cheilectomy > Arthrodesis > Arthroplasty > 1st MTPJ fusion (Gold standard) > 1st MTPJ hemiarthroplasty
What is Cheilectomy?
Remove dorsal impingement within hallux rigidus
It allows increase ROM in dorsiflexion
Examples of lesser toe deformities?
> Claw toes
Hammer toes
Mallet toes
Examples of lesser toe deformities?
> Claw toes
Hammer toes
Mallet toes
Aetiology of lesser toe deformities?
> Imbalance between flexors/extensors > Shoe wear > Neurological > Rheumatoid arthritis > Idiopathic
Symptoms of lesser toe deformities?
> Deformity
Pain from dorsum
Pain from plantar side (metatarsalgia)
Management of lesser toe deformities - Non-operative?
Non-operative:
> Activity modification
> Shoe wear – flat shoes with high toe box to accommodate deformity
> Orthotic insoles – metatarsal bar/dome support
Management of lesser toe deformities - Operative?
Operative: > Flexor to extensor transfer > Fusion of interphalangeal joint > Release metatarsophalangeal joint > Shortening osteotomy of metatarsal
What is Interdigital Neuralgia – Morton’s Neuroma?
Inflammation, sever pain and numbness are the bifurcation of the common digital nerve due to mechanical stress
Aetiology of interdigital neuralgia?
> Mechanically induced degenerative neuropathy
> Tends to affect females aged 40-60
> Frequently associated with wearing high healed shoes
> Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
Management of interdigital neuralgia - Non-operative?
Injection for small lesions
Management of interdigital neuralgia - Operative?
Surgery – excision of lesion including a section of normal nerve
> Numbness
> Recurrence
> Up to 30% have pain 1 year post surgery
Management of interdigital neuralgia - Operative?
Surgery – excision of lesion including a section of normal nerve:
> Numbness occurs
> Recurrence
> Up to 30% have pain 1 year post surgery
Interdigital Neuralgia – Morton’s Neuroma what is it usually incorrectly diagnosed as?
Forefoot pain
Management of rheumatoid forefoot - Non-operative?
Non-operative – shoewear/orthotics/activity etc
What is Metatarsalgia?
> Pain in the ball of your foot
> It is a symptom, not a diagnosis
> Causes include Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease… etc
> If not obvious consider tight gastrocnemius
What is Rheumatoid forefoot?
Deformities often with degenerative changes
Aetiology of dorsal foot ganglia?
> Idiopathic
Underlying arthritis
Underlying tendon pathology
Symptoms of dorsal foot ganglia?
> Pain from pressure from shoe wear
> Pain from underlying problem
Management of dorsal foot ganglia - Non-operative?
Non-operative:
> Aspiration
> “Family bible”
What is Dorsal foot ganglia?
Build up of pseudocaspsule overlying a joint
Management of dorsal foot ganglia - Operative?
Excision
Prognosis f dorsal foot ganglia after treatment?
High rate of return - 50%
Management of mid foot arthritis- Non-operative?
> Activity/shoewear/orthotics etc
> Injections – Xray guided
Management of mid foot arthritis- Operative?
Fusion
Prognosis of dorsal foot ganglia after treatment?
High rate of return - 50%
Natural course of planter fibromatosis?
Progressive
Management of mid foot arthritis- Non-operative?
> Activity /shoewear/orthotics etc
> Injections (steroid) – Xray guided
Management of mid foot arthritis- Operative?
Fusion - Not the best but if extremely painful can to increase function (Even though there is a loss of function) due to decrease pain
Management of planter fibromatosis - Operative?
> Operative – excision (up to 80% risk of recurrence)
> Combination radiotherapy/surgery (low risk recurrence/high risk complications)
Common hind foot problems?
> Achilles tendonitis/tendinosis > Plantar fasciitis > Ankle osteoarthitis > Tibialis posterior dysfunction > Cavovarus foot – already discussed by Mr Forrest
What is Achilles tendinosis/tendinopathy?
Degenerative / overuse condition with little inflammation of the achilles tendon
More than one clinical condition:
> Insertional tendinopathy - within 2cm of insertion
> Non-insertional / mid-substance tendinopathy- 2-7cm of insertion
> Bursitis
- Retrocalcaneal
- Superficial calcaneal
> Paratendinopathy is a true inflammatory problem showing paratendonitis histologically
Aetiology of Achilles paratendinopathy?
Paratendonopathy:
> Commonest in athletic populations
> Age group 30-40
> Male:Female = 2:1
Management of planter fibromatosis - Operative?
> Operative – excision (up to 80% risk of recurrence)
Combination radiotherapy/surgery (low risk recurrence/high risk complications - wound healing, increase risk of cancer etc)
Symtoms of Achilles tendinosis/tendinopathy?
Symptoms > Pain during exercise > Pain following exercise > Recurrent episodes > Difficuly fitting shoes (insertional) > RUPTURE – don’t miss!
What is Achilles tendinosis/tendinopathy?
Degenerative / overuse condition with little inflammation of the achilles tendon
More than one clinical condition:
> Insertional tendinopathy - within 2cm of insertion
> Non-insertional / mid-substance tendinopathy- 2-7cm of insertion
> Bursitis
- Retrocalcaneal
- Superficial calcaneal
> Paratendinopathy is a true inflammatory problem showing paratendonitis histologically (Sheath and first layer of tendon effected)
Management of Achilles tendinosis/tendinopathy - Non-operative?
Non-operative Treatment > Activity modification > Weight loss > Shoe wear modification – slight heel > Physiotherapy - Eccentric stretching > Extra-corporeal shockwave treatment > Immobilisation (in below knee cast)
Achilles Rupture Tests?
1) Simmonds
2) “Angle of the Dangle” & Matles
Symtoms of Achilles tendinosis/tendinopathy?
Symptoms > Pain during exercise > Pain following exercise > Recurrent episodes > Difficuly fitting shoes (insertional) > RUPTURE – don’t miss!
What is Plantar Fasciitis?
> Fasciitis is incorrect fasciosis better term
> Fasciosis - Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity
> Cant make Extra Cellular Matrix required for repair and re-modelling
What is Plantar Fasciitis?
> Fasciitis is incorrect fasciosis better term
> Fasciosis - Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity
> Cant make Extra Cellular Matrix required for repair and re-modelling
Achilles Rupture Tests?
1) Simmonds
2) “Angle of the Dangle” & Matles
Symptoms of Plantar fasciitis?
> Pain first thing in morning
Pain on weight bearing after rest
Post-static dyskinesia
Pain located at origin of plantar fascia
Frequently long lasting – 2 years or more
Achilles Rupture Tests - Simmonds?
Squeeze calf should plantarflex, if it doesn’t can indicate rupture
Achilles Rupture Tests - “Angle of the Dangle” & Matles?
Feet hanging of side of bed, foot is dropped versus other foot
Differential diagnosis of Plantar fasciitis?
> Nerve entrapment syndrome
Arthritis
Calcaneal pathology
Management of Plantar fasciitis - third line treatment?
> Extracorporeal > Shockwave therapy > Topaz Plasma Coblation > Nitric Oxide > Platelet Rich Plasma > Endoscopic / Open Surgery
Aetiology of Ankle Arthritis?
> Mean age of presentation is 46 years
Commonly post-traumatic
Idiopathic
Symptoms of Ankle Arthritis?
> Pain
> Stiffness
Diagnosis of Ankle Arthritis?
> Clinical
Radiographs
CT scan – exclude adjacent joint arthritis
Management of Ankle Arthritis - Non-operative?
Weight loss > Activity modification > Analgesia > Physiotherapy > Steroid injections
Management of Ankle Arthritis - Operative?
> If symptoms are exclusively anterior then arthroscopic anterior debridement
> Arthrodesis – open or arthroscopic
- Gold standard
- Good long term outcome
> Joint replacement
- Maintain range of movement
- Questionable long-term outcome especially in high demand patients
- Not easy to revise even to fusion
Management of Ankle Arthritis - Operative?
> If symptoms are exclusively anterior then arthroscopic anterior debridement
> Arthrodesis – open or arthroscopic
- Gold standard
- Good long term outcome
> Joint replacement:
- Maintain range of movement
- Questionable long-term outcome especially in high demand patients
- Not easy to revise even to fusion
Management of Ankle Arthritis - Operative?
> If symptoms are exclusively anterior then arthroscopic anterior debridement
> Arthrodesis – open or arthroscopic
- Gold standard
- Good long term outcome
> Joint replacement:
- Maintain range of movement
- Questionable long-term outcome especially in high demand patients
- Not easy to revise even to fusion
Presentation of Posterior Tibial Tendon Dysfunction?
> Acquired adult flat foot planovalgus
Largely clinical diagnosis – double & single heel raise.
Medial or lateral pain
Diagnosis of Posterior Tibial Tendon Dysfunction?
Clinical
MRI to assess tendon
Management of Posterior Tibial Tendon Dysfunction?
> Orthotics – medial arch support
> Reconstruction of tendon (tendon transfer)
> Triple fusion (subtalar, talonavicular and calcaneocuboid)
Presentation of Posterior Tibial Tendon Dysfunction?
> Acquired adult flat foot planovalgus
Largely clinical diagnosis – double & single heel raise Valgus to varus does not occur.
Medial or lateral pain
Treatment of Diabetic foot ulcer - Non-operative?
> Prevention
> Modify the main detriments to healing:
- Diabetic control
- Smoking
- Vascular supply
- External pressure (splints/shoes/weight bearing)
- Internal pressure (deformity)
- Infection
- Nutrition
Treatment of Diabetic foot ulcer - Operative?
> Improve Vascular Supply
> Debride ulcers and get deep samples for microbiology
> Correct any deformity to offload area
> Amputation
Prognosis of Diabetic foot ulcer?
> 15% of all diabetics will develop ulceration
> 85% of all amputations for diabetes are preceded by foot ulceration
> 25% of patients with diabetic ulcers go on to amputation
> 5 year patient mortality 50%
Prognosis of Diabetic foot ulcer?
> 15% of all diabetics will develop ulceration
> 85% of all amputations for diabetes are preceded by foot ulceration
> 25% of patients with diabetic ulcers go on to amputation
> 5 year patient mortality 50%
Aetiology of Charcot Neuroarthropathy?
> Any cause of neuropathy
> Diabetes commonest cause
> Historically originally described and most common with syphillis
Pathophysiology of Charcot Neuroarthropathy?
Pathophysiology – two theories:
1) Neurotraumatic
> Lack of proprioception and protective pain sensation
2) Neurovascular
> Abnormal autonomic nervous system results in increased vascular supply and bone resorption
Characteristics (Stages) of bone destruction of Charcot Neuroarthropathy?
Characterised by rapid bone destruction occurring in 3 stages:
1) Fragmentation
2) Coalescence
3) Remodelling
Diagnosis of Charcot Neuroarthropathy?
High index of suspicion
Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy
Greater than 3 degree difference between limbs
Frequently not painful
Radiographs
MRI scan
Management of Charcot Neuroarthropathy?
> Prevention
> Immobilisation / non-weight bearing until acute fragmentation resolved
> Correct deformity
- Deformity leads to ulceration leads to infection leads to amputation.
What often causes the initial cause of a diabetic foot ulcer?
Decreased sweating can lead to increased risk of cracking of skin.
Decreased healing can lead to ulceration
