Common foot and ankle conditions Flashcards
1
Q
Non-opertative management of foot and ankle conditions?
A
> Analgesia > Shoe wear modification > Activity modification > Weight loss > Physiotherapy > Orthotics including insoles and bracing
2
Q
When to operate in foot and ankle conditions?
A
The only indication for operative management is failure of non-operative management
3
Q
Common forefoot problems?
A
Hallux valgus Hallux rigidus Lesser toe deformities Morton’s neuroma Metatarsalgia Rheumatoid Forefoot
4
Q
What is another name for hallux valgus?
A
Bunions
5
Q
Aetiology of Hallux valgus?
A
> Genetic
Foot wear
Significant female preponderance
6
Q
Symptoms of hallux valgus?
A
> Pressure symptoms from shoe wear
Pain from crossing over of toes
Metatarsalgia
7
Q
Pathogenesis of hallux valgus?
A
> 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
8
Q
Diagnosis of hallux valgus?
A
> Clinical
Xrays
- Determine severity of underlying bony deformity
- Exclude associated degenerate change (E.g. Arthritis)
9
Q
Management of hallux valgus - Non-operative?
A
> Shoe wear modification (wide +/- high toe box)
Orthotics to offload pressure/correct deformity
Activity modification
Analgesia
10
Q
Management of hallux valgus - Operative?
A
Operative (if non-operative failed or unacceptable to patient):
> Release lateral soft tissues
> Osteotomy 1st metatarsal +/- proximal phalanx
> Generally good outcome but recurrence inevitable
11
Q
What is hallux rigidus?
A
> Stiff big toe
> Osteoarthritis of 1st MTP joint
12
Q
Aetiology of hallux rigidus?
A
> Not known
Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
Possibly multiple microtrauma
Bimodal distribution of age
13
Q
Aetiology of hallux rigidus?
A
> Not known
Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
Possibly multiple microtrauma
Bimodal distribution of age
14
Q
Diagnosis of hallux rigidus?
A
> Clinical
> Radiographs
15
Q
Diagnosis of hallux rigidus?
A
> Clinical
> Radiographs (Often visible osteocytes)
16
Q
Management of hallux rigidus - Operative?
A
Surgery: > Cheilectomy > Arthrodesis > Arthroplasty > 1st MTPJ fusion (Gold standard) > 1st MTPJ hemiarthroplasty
17
Q
What is Cheilectomy?
A
Remove dorsal impingement within hallux rigidus
It allows increase ROM in dorsiflexion
18
Q
Examples of lesser toe deformities?
A
> Claw toes
Hammer toes
Mallet toes
19
Q
Examples of lesser toe deformities?
A
> Claw toes
Hammer toes
Mallet toes
20
Q
Aetiology of lesser toe deformities?
A
> Imbalance between flexors/extensors > Shoe wear > Neurological > Rheumatoid arthritis > Idiopathic
21
Q
Symptoms of lesser toe deformities?
A
> Deformity
Pain from dorsum
Pain from plantar side (metatarsalgia)
22
Q
Management of lesser toe deformities - Non-operative?
A
Non-operative:
> Activity modification
> Shoe wear – flat shoes with high toe box to accommodate deformity
> Orthotic insoles – metatarsal bar/dome support
23
Q
Management of lesser toe deformities - Operative?
A
Operative: > Flexor to extensor transfer > Fusion of interphalangeal joint > Release metatarsophalangeal joint > Shortening osteotomy of metatarsal
24
Q
What is Interdigital Neuralgia – Morton’s Neuroma?
A
Inflammation, sever pain and numbness are the bifurcation of the common digital nerve due to mechanical stress
25
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
26
Management of interdigital neuralgia - Non-operative?
Injection for small lesions
27
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
28
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
29
Interdigital Neuralgia – Morton’s Neuroma what is it usually incorrectly diagnosed as?
Forefoot pain
30
Management of rheumatoid forefoot - Non-operative?
Non-operative – shoewear/orthotics/activity etc
31
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
32
What is Rheumatoid forefoot?
Deformities often with degenerative changes
33
Aetiology of dorsal foot ganglia?
> Idiopathic
> Underlying arthritis
> Underlying tendon pathology
34
Symptoms of dorsal foot ganglia?
> Pain from pressure from shoe wear
> Pain from underlying problem
35
Management of dorsal foot ganglia - Non-operative?
Non-operative:
> Aspiration
> “Family bible”
36
What is Dorsal foot ganglia?
Build up of pseudocaspsule overlying a joint
37
Management of dorsal foot ganglia - Operative?
Excision
38
Prognosis f dorsal foot ganglia after treatment?
High rate of return - 50%
39
Management of mid foot arthritis- Non-operative?
> Activity/shoewear/orthotics etc
| > Injections – Xray guided
40
Management of mid foot arthritis- Operative?
Fusion
41
Prognosis of dorsal foot ganglia after treatment?
High rate of return - 50%
42
Natural course of planter fibromatosis?
Progressive
43
Management of mid foot arthritis- Non-operative?
> Activity /shoewear/orthotics etc
> Injections (steroid) – Xray guided
44
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
45
Management of planter fibromatosis - Operative?
> Operative – excision (up to 80% risk of recurrence)
| > Combination radiotherapy/surgery (low risk recurrence/high risk complications)
46
Common hind foot problems?
```
> Achilles tendonitis/tendinosis
> Plantar fasciitis
> Ankle osteoarthitis
> Tibialis posterior dysfunction
> Cavovarus foot – already discussed by Mr Forrest
```
47
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
48
Aetiology of Achilles paratendinopathy?
Paratendonopathy:
> Commonest in athletic populations
> Age group 30-40
> Male:Female = 2:1
49
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)
50
Symtoms of Achilles tendinosis/tendinopathy?
```
Symptoms
> Pain during exercise
> Pain following exercise
> Recurrent episodes
> Difficuly fitting shoes (insertional)
> RUPTURE – don’t miss!
```
51
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)
52
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)
```
53
Achilles Rupture Tests?
1) Simmonds
| 2) “Angle of the Dangle” & Matles
54
Symtoms of Achilles tendinosis/tendinopathy?
```
Symptoms
> Pain during exercise
> Pain following exercise
> Recurrent episodes
> Difficuly fitting shoes (insertional)
> RUPTURE – don’t miss!
```
55
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
56
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
57
Achilles Rupture Tests?
1) Simmonds
| 2) “Angle of the Dangle” & Matles
58
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
59
Achilles Rupture Tests - Simmonds?
Squeeze calf should plantarflex, if it doesn't can indicate rupture
60
Achilles Rupture Tests - “Angle of the Dangle” & Matles?
Feet hanging of side of bed, foot is dropped versus other foot
61
Differential diagnosis of Plantar fasciitis?
> Nerve entrapment syndrome
> Arthritis
> Calcaneal pathology
62
Management of Plantar fasciitis - third line treatment?
```
> Extracorporeal
> Shockwave therapy
> Topaz Plasma Coblation
> Nitric Oxide
> Platelet Rich Plasma
> Endoscopic / Open Surgery
```
63
Aetiology of Ankle Arthritis?
> Mean age of presentation is 46 years
> Commonly post-traumatic
> Idiopathic
64
Symptoms of Ankle Arthritis?
> Pain
| > Stiffness
65
Diagnosis of Ankle Arthritis?
> Clinical
> Radiographs
> CT scan – exclude adjacent joint arthritis
66
Management of Ankle Arthritis - Non-operative?
```
Weight loss
> Activity modification
> Analgesia
> Physiotherapy
> Steroid injections
```
67
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
68
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
69
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
70
Presentation of Posterior Tibial Tendon Dysfunction?
> Acquired adult flat foot planovalgus
> Largely clinical diagnosis – double & single heel raise.
> Medial or lateral pain
71
Diagnosis of Posterior Tibial Tendon Dysfunction?
Clinical
| MRI to assess tendon
72
Management of Posterior Tibial Tendon Dysfunction?
> Orthotics – medial arch support
> Reconstruction of tendon (tendon transfer)
> Triple fusion (subtalar, talonavicular and calcaneocuboid)
73
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
74
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
75
Treatment of Diabetic foot ulcer - Operative?
> Improve Vascular Supply
> Debride ulcers and get deep samples for microbiology
> Correct any deformity to offload area
> Amputation
76
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%
77
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%
78
Aetiology of Charcot Neuroarthropathy?
> Any cause of neuropathy
> Diabetes commonest cause
> Historically originally described and most common with syphillis
79
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
80
Characteristics (Stages) of bone destruction of Charcot Neuroarthropathy?
Characterised by rapid bone destruction occurring in 3 stages:
1) Fragmentation
2) Coalescence
3) Remodelling
81
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
82
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.
83
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
