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MSK > Common Foot and Ankle Conditions > Flashcards

Common Foot and Ankle Conditions Flashcards

1
Q

Treatment options

A

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
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2
Q

Forefoot problems

A
  • Hallux valgus
  • Hallux rigidus
  • Lesser toe deformities
  • Morton’s neuroma
  • Metatarsalgia
  • Rheumatoid Forefoot
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3
Q

Hallux valgus

A
  • ‘bunions’
  • aetiology
    • genetic
    • footwear
    • female>male
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4
Q

Hallax valgus symtoms

A
  • Pressure symptoms from shoe wear
  • Pain from crossing over of toes
  • Metatarsalgia
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5
Q

Hallux valgus pathology

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
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6
Q

Hallax valgus diagnosis

A
  • Clinical
  • X-ray
    • Determine severity of underlying bony deformity
    • Exclude associated degenerate change
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7
Q

Hallax valgus non-operative management

A
  • Shoe wear modification
  • Orthotics to offload pressure/correct deformity
  • Activity modification
  • Analgesia
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8
Q

Hallax valgus operative management

A
  • Release lateral soft tissues
  • Osteotomy 1st metatarsal +/- proximal phalanx
    • Generally good outcome but recurrence inevitable
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9
Q

Hallax rigidus

A
  • stiff big toe
  • osteoarthritis of 1st MTP joint
  • aetiology
    • possibly genetic
    • possibly multiple microtrauma
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10
Q

Hallux rigidus symptoms

A
  • Many asymptomatic
  • Pain – often at extreme of dorsiflexion
  • Limitation of range of movement
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11
Q

Hallax rigidus non-operative management

A
  • Activity modification
  • Shoe wear with rigid sole
  • Analgesia
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12
Q

Hallax rigidus operative management

A
  • Cheilectomy - remove dorsal impingement
  • Arthrodesis - 1st MTPJ fusion (gold standard)
  • Arthroplasty - 1st MTPJ hemiarthroplasty
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13
Q

Lesser Toe deformities

A
  • Claw toes
  • Hammer toes
  • Mallet toes
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14
Q

Lesser Toe deformities Aetiology

A
  • Imbalance between flexors/extensors
  • Shoe wear
  • Neurological
  • Rheumatoid arthritis
  • Idiopathic
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15
Q

Lesser toe deformity symptoms

A
  • Deformity
  • Pain from dorsum
  • Pain from plantar side (metatarsalgia)
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16
Q

Lesser toe deformities non-operative treatment

A
  • Activity modification
  • Shoe wear - flat shoes with high toe box to accommodate deformity
  • Orthotic insoles - metatarsal bar/dome support
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17
Q

Lesser toe deformities operative treatment

A
  • Flexor to extensor transfer
  • Fusion of interphalangeal joint
  • Release metatarsophalangeal joint
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18
Q

Morton’s neuroma

A
  • 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
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19
Q

Morton’s neuroma symtoms

A
  • Typically affects 3rd followed by 2nd webspace/toes
  • Neuralgic burning pain into toes
  • Intermittent
  • Altered sensation in webspace

Interdigital Neuralgia = Morton’s Neuroma

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20
Q

Morton’s Neuroma Diagnosis

A
  • Clinical
  • Mulder’s Click
  • Ultrasound best / MRI good
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21
Q

Morton’s Neuroma Management

A
  • 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
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22
Q

Metatarsalgia

A
  • a symptom, not a diagnosis
  • pain in the ball of the foot
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23
Q

Rheumatoid forefoot treatment

A
  • Non-operative
    • shoewear
    • orthotics
    • activity modification
  • Operative
    • 1st MTPJ arthrodesis
    • 2-5th toe excision arthroplasty
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24
Q

Midfoot problems

A
  • Ganglia
  • Osteoarthritis
  • Plantar fibromatosis
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25
Q

Dorsal foot ganglia

A
  • Arise from joint or tendon sheath
  • Aetiology
    • Idiopathic
    • Underlying arthritis
    • Underlying tendon pathology
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26
Q

Dorsal foot ganglia symtoms

A
  • pain from pressure from shoe wear
  • pain from underlying problem
27
Q

Dorsal foot ganglia treatment

A

Non-operative

  • Aspiration

Operative

  • Excision
28
Q

Dorsal foot ganglia prognosis

A

high rate of return - 50%

29
Q

Midfoot arthritis

A
  • Post-traumatic arthritis
  • Osteoarthitis
  • Rheumatoid arthritis
30
Q

Midfoot arthritis treatment

A

Non-operative

  • Activity/shoewear/orthotics etc
  • Injections – X-ray guided

Operative

  • Fusion
31
Q

Plantar fibromatosis

A
  • “Dupuytren’s of the foot”
  • Progressive
  • Usually asymptomatic unless very large or on weightbearing area
32
Q

Plantar fibromatosis treatment

A
  • 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)
33
Q

Hindfoot problems

A
  • Achilles tendonitis/tendinosis
  • Plantar fasciitis
  • Ankle osteoarthitis
  • Tibialis posterior dysfunction
  • Cavovarus foot
34
Q

Achilles tendonitis/tendinosis

A

Degenerative condition with little inflammation

35
Q

Achilles tendinopathy aetiology

A

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
36
Q

Achilles Tendinopathy Symptoms

A
  • Pain during exercise
  • Pain following exercise
  • Recurrent episodes
  • Difficuly fitting shoes (insertional)
  • Rupture
37
Q

Achilles tendinopathy diagnosis

A
  • Clinical
    • Tenderness
    • Tests for rupture (Simmonds)
  • Investigations
    • Ultrasound
    • MRI
38
Q

Achilles Tendinopathy Non-operative Treatment

A
  • 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)
39
Q

Achilles tendinopathy operative treatment

A
  • Gastrocnemius recession
  • Release and debridement of tendon
40
Q

Plantar fasciitis

A
  • 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
41
Q

Plantar fasciitis symptoms

A
  • heel pain (stabbing)
  • pain relieved with rest
  • post-static dyskinesia
42
Q

Plantar fasciitis differential diagnosis

A
  • Nerve entrapment syndrome
  • Arthritis
  • Calcaneal pathology
43
Q

Plantar fasciitis diagnosis

A
  • mainly clinical
  • occasionally
    • X-Ray
    • ultrasound
    • MRI
44
Q

Plantar fasciitis treatment

A
  • 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
45
Q

Plantar fasciitis newer/third line treatment

A
  • Extracorporeal Shockwave therapy
  • Nitric Oxide
  • Platelet Rich Plasma injections
46
Q

Ankle arthritis aetiology

A
  • Mean age of presentation is 46 years
  • Idiopathic
  • Commonly post-traumatic
47
Q

Ankle arthritis symtoms

A
  • pain
  • stiffness
48
Q

Ankle Arthritis Diagnosis

A
  • clinical
  • X-Ray
  • CT - exclude adjacent joint arthritis
49
Q

Ankle arthritis non-operative management

A
  • weight loss
  • activity modification
  • analgesia
  • physiotherapy
  • steroid injections
50
Q

Ankle arthritis operative management

A
  • 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
51
Q

Tibialis posterior tendon dysfunction

A

acquired adult flat foot - planovalgus

52
Q

Double and single limb heel raise

A

heels should swing from valgus to varus as heel rises

53
Q

Tibialis posterior tendon dysfunction diagnosis

A
  • clinical
  • MRI to assess tendon
54
Q

Tibialis posterior tendon dysfunction management

A
  • Orthotics – medial arch support
  • Reconstruction of tendon (tendon transfer)
  • Triple fusion (subtalar, talonavicular and calcaneocuboid)
55
Q

Diabetic foot problems

A
  • Ulceration
  • Charcot foot
56
Q

Diabetic foot ulcer aetiology

A
  • 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
57
Q

Diabetic foot ulcer - modify the main detriments to healing

A
  • Diabetic control
  • Smoking
  • Vascular supply
  • External pressure (splints/shoes/weight bearing)
  • Internal pressure (deformity)
  • Infection
  • Nutrition
58
Q

Diabetic foot ulcer surgical treatment

A
  • Improve Vascular Supply
  • Debride ulcers and get deep samples for microbiology
  • Correct any deformity to offload area
  • Amputation
59
Q

Diabetic foot ulcer Prognosis

A
  • 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%
60
Q

Charcot Neuroarthropathy

A
  • Characterised by rapid bone destruction occurring in 3 stages
    • Fragmentation
    • Coalescence
    • Remodelling
61
Q

Charcot Neuroarthropathy pathophysiology

A
  • Neurotraumatic
    • Lack of proprioception and protective pain sensation
  • Neurovascular
    • Abnormal autonomic nervous system results in increased vascular supply and bone resorption
62
Q

Charcot neuroarthropathy diagnosis

A
  • 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
63
Q

Charcot neuropathy management

A
  • Prevention
  • Immobilisation / non-weight bearing until acute fragmentation resolved
  • Correct deformity

MSK (24 decks)

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