Common Foot and Ankle Conditions Flashcards
Treatment options
Non-operative management
- Analgesia
- Shoe wear modification
- Activity modification
- Weight loss
- Physiotherapy
- Orthotics including insoles and bracing
Operative management
- The only indication for operative management is failure of non-operative management
Forefoot problems
- Hallux valgus
- Hallux rigidus
- Lesser toe deformities
- Morton’s neuroma
- Metatarsalgia
- Rheumatoid Forefoot
Hallux valgus
- ‘bunions’
- aetiology
- genetic
- footwear
- female>male
Hallax valgus symtoms
- Pressure symptoms from shoe wear
- Pain from crossing over of toes
- Metatarsalgia
Hallux valgus pathology
- 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
Hallax valgus diagnosis
- Clinical
- X-ray
- Determine severity of underlying bony deformity
- Exclude associated degenerate change
Hallax valgus non-operative management
- Shoe wear modification
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesia
Hallax valgus operative management
- Release lateral soft tissues
- Osteotomy 1st metatarsal +/- proximal phalanx
- Generally good outcome but recurrence inevitable
Hallax rigidus
- stiff big toe
- osteoarthritis of 1st MTP joint
- aetiology
- possibly genetic
- possibly multiple microtrauma
Hallux rigidus symptoms
- Many asymptomatic
- Pain – often at extreme of dorsiflexion
- Limitation of range of movement
Hallax rigidus non-operative management
- Activity modification
- Shoe wear with rigid sole
- Analgesia
Hallax rigidus operative management
- Cheilectomy - remove dorsal impingement
- Arthrodesis - 1st MTPJ fusion (gold standard)
- Arthroplasty - 1st MTPJ hemiarthroplasty
Lesser Toe deformities
- Claw toes
- Hammer toes
- Mallet toes
Lesser Toe deformities Aetiology
- Imbalance between flexors/extensors
- Shoe wear
- Neurological
- Rheumatoid arthritis
- Idiopathic
Lesser toe deformity symptoms
- Deformity
- Pain from dorsum
- Pain from plantar side (metatarsalgia)
Lesser toe deformities non-operative treatment
- Activity modification
- Shoe wear - flat shoes with high toe box to accommodate deformity
- Orthotic insoles - metatarsal bar/dome support
Lesser toe deformities operative treatment
- Flexor to extensor transfer
- Fusion of interphalangeal joint
- Release metatarsophalangeal joint
Morton’s neuroma
- mechanically induced degenerative neuropathy
- frequently associated with wearing high healed shoes – common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
Morton’s neuroma symtoms
- Typically affects 3rd followed by 2nd webspace/toes
- Neuralgic burning pain into toes
- Intermittent
- Altered sensation in webspace
Interdigital Neuralgia = Morton’s Neuroma
Morton’s Neuroma Diagnosis
- Clinical
- Mulder’s Click
- Ultrasound best / MRI good
Morton’s Neuroma Management
- Injection for small lesions
- Surgery – excision of lesion including a section of normal nerve
- Numbness
- Recurrence
- Up to 30% have pain 1 year post surgery
- Nitrogen freezing
Metatarsalgia
- a symptom, not a diagnosis
- pain in the ball of the foot
Rheumatoid forefoot treatment
- Non-operative
- shoewear
- orthotics
- activity modification
- Operative
- 1st MTPJ arthrodesis
- 2-5th toe excision arthroplasty
Midfoot problems
- Ganglia
- Osteoarthritis
- Plantar fibromatosis
Dorsal foot ganglia
- Arise from joint or tendon sheath
- Aetiology
- Idiopathic
- Underlying arthritis
- Underlying tendon pathology
Dorsal foot ganglia symtoms
- pain from pressure from shoe wear
- pain from underlying problem
Dorsal foot ganglia treatment
Non-operative
- Aspiration
Operative
- Excision
Dorsal foot ganglia prognosis
high rate of return - 50%
Midfoot arthritis
- Post-traumatic arthritis
- Osteoarthitis
- Rheumatoid arthritis
Midfoot arthritis treatment
Non-operative
- Activity/shoewear/orthotics etc
- Injections – X-ray guided
Operative
- Fusion
Plantar fibromatosis
- “Dupuytren’s of the foot”
- Progressive
- Usually asymptomatic unless very large or on weightbearing area
Plantar fibromatosis treatment
- Non-operative - avoid pressure
- shoewear/orthotics
- Operative
- excision (up to 80% risk of recurrence)
- Radiotherapy (similar recurrence as operative)
- Combination radiotherapy/surgery (low risk recurrence/high risk complications)
Hindfoot problems
- Achilles tendonitis/tendinosis
- Plantar fasciitis
- Ankle osteoarthitis
- Tibialis posterior dysfunction
- Cavovarus foot
Achilles tendonitis/tendinosis
Degenerative condition with little inflammation
Achilles tendinopathy aetiology
Paratendonopathy
- Commonest in athletic populations
- Age group 30-40
- Male:Female = 2:1
- Tendonopathy
- Commonest in non-athletic populations
- Aged over 40
- Obesity
- Steroids
- Diabetes
Achilles Tendinopathy Symptoms
- Pain during exercise
- Pain following exercise
- Recurrent episodes
- Difficuly fitting shoes (insertional)
- Rupture
Achilles tendinopathy diagnosis
- Clinical
- Tenderness
- Tests for rupture (Simmonds)
- Investigations
- Ultrasound
- MRI
Achilles Tendinopathy Non-operative Treatment
- Activity modification
- Weight loss
- Shoe wear modification – slight heel
- Physiotherapy – Eccentric stretching
- Extra-corporeal shockwave treatment
- Ultrasound guided injection of platelet rich plasma
- Immobilisation (in below knee cast)
Achilles tendinopathy operative treatment
- Gastrocnemius recession
- Release and debridement of tendon
Plantar fasciitis
- an acute or chronic pain in the inferior heel at the attachment of the medial band of the plantar fascia to the median calcaneal tubercle
- chronic inflammatory process and may be an overuse injury
- pain is self limiting and usually resolves after between 6 to 18 months without treatment
Plantar fasciitis symptoms
- heel pain (stabbing)
- pain relieved with rest
- post-static dyskinesia
Plantar fasciitis differential diagnosis
- Nerve entrapment syndrome
- Arthritis
- Calcaneal pathology
Plantar fasciitis diagnosis
- mainly clinical
- occasionally
- X-Ray
- ultrasound
- MRI
Plantar fasciitis treatment
- Rest, change training
- Stretching – Achilles +/- direct stretching
- Ice
- NSAIDs
- Orthoses – Heel pads
- Physiotherapy
- Weight loss
- Injections – corticosteroid (good in short term but may make condition worse long term)
- Night Splinting
Plantar fasciitis newer/third line treatment
- Extracorporeal Shockwave therapy
- Nitric Oxide
- Platelet Rich Plasma injections
Ankle arthritis aetiology
- Mean age of presentation is 46 years
- Idiopathic
- Commonly post-traumatic
Ankle arthritis symtoms
- pain
- stiffness
Ankle Arthritis Diagnosis
- clinical
- X-Ray
- CT - exclude adjacent joint arthritis
Ankle arthritis non-operative management
- weight loss
- activity modification
- analgesia
- physiotherapy
- steroid injections
Ankle arthritis operative management
- 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
Tibialis posterior tendon dysfunction
acquired adult flat foot - planovalgus
Double and single limb heel raise
heels should swing from valgus to varus as heel rises
Tibialis posterior tendon dysfunction diagnosis
- clinical
- MRI to assess tendon
Tibialis posterior tendon dysfunction management
- Orthotics – medial arch support
- Reconstruction of tendon (tendon transfer)
- Triple fusion (subtalar, talonavicular and calcaneocuboid)
Diabetic foot problems
- Ulceration
- Charcot foot
Diabetic foot ulcer aetiology
- Diabetic neuropathy
- Patient unaware of trauma to foot
- Diabetic autonomic neuropathy
- Lack of sweating / normal sebum production
- Dry cracked skin
- Skin more sensitive to minor trauma
- Poor vascular supply
Diabetic foot ulcer - modify the main detriments to healing
- Diabetic control
- Smoking
- Vascular supply
- External pressure (splints/shoes/weight bearing)
- Internal pressure (deformity)
- Infection
- Nutrition
Diabetic foot ulcer surgical treatment
- Improve Vascular Supply
- Debride ulcers and get deep samples for microbiology
- Correct any deformity to offload area
- Amputation
Diabetic foot ulcer Prognosis
- 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%
Charcot Neuroarthropathy
- Characterised by rapid bone destruction occurring in 3 stages
- Fragmentation
- Coalescence
- Remodelling
Charcot Neuroarthropathy pathophysiology
- Neurotraumatic
- Lack of proprioception and protective pain sensation
- Neurovascular
- Abnormal autonomic nervous system results in increased vascular supply and bone resorption
Charcot neuroarthropathy diagnosis
- 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
Charcot neuropathy management
- Prevention
- Immobilisation / non-weight bearing until acute fragmentation resolved
- Correct deformity
