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 operate only if failure of non operative
pathological grouping
Vascular (ischaemic) Infective Traumatic Autoimmune Metabolic (endocrine /drugs) Inflammatory Inherited (congenital) Neurological Neoplastic Degenerative Idiopathic
forefoot problems
hallux valgus Hallux rigidus Lesser toe deformities Morton’s neuroma Metatarsalgia Rheumatoid Forefoot
hallux valgus
bunions genetic increased in footwear female symptoms: pressure symptoms from shoe wear pain crossing over toes metatarsalgia
pathogenesis
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-> abnormalities of lesser toes
hallux valgus
Shoe wear modification (wide +/- high toe box)
Orthotics to offload pressure/correct deformity
Activity modification
Analgesia
Operative
-release lateral soft tissues
osteotomy 1st metatarsal +/- proximal phalanx
scarf osteotomy
hallux rigidus
osteoarthritis of 1st MTP joint Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded Possibly multiple microtrauma Pain on dorsiflexion Limited movement
management
Activity modification
Shoe wear with rigid sole
Analgesia
Cheilectomy (remove dorsal impingement) (remember)
Arthrodesis 1st MTPJ fusion
Arthroplasty
lesser toe deformities
Claw toes
Hammer toes
Mallet toes
Aetiology
pain from plantar side
metatarsalgia
imbalance of flexors and extensors
treatment
Activity modification
Shoe wear – flat shoes with high toe box to accommodate deformity
Orthotic insoles – metatarsal bar/dome support
Operative Flexor to extensor transfer Fusion of interphalangeal joint Release metatarsophalangeal joint Shortening osteotomy of metatarsal
morton’s neuroma
plantar digit nerves
Mechanically induced degenerative neuropathy
females 40-60
Frequently associated with wearing high heeled shoes
Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
Symptoms
Typically affects 3rd followed by 2nd webspace/toes
Neuralgic burning pain into toes
Intermittent
Altered sensation in webspace
diagnosis and management
mulder’s click
Steroid injection for small lesions
Surgery – excision of lesion including a section of normal nerve
metatarsalgia
symptom not a diagnosis
Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease
tight gastrocnemius if not obvious
rheumatoid forefoot
Non-operative – shoewear/orthotics/activity etc Operative Many described techniques Current gold standard 1st MTPJ arthrodesis 2-5th toe excision arthroplasty
Midfoot problems
Ganglia
Osteoarthritis
Plantar fibromatosis
dorsal foot ganglia
arise from joint or tendon sheath
- idiopathic
- underlying arthritis/ tendon pathology
symptoms-pain from pressure from shoe wear
treatment
aspiration
excision
high rate of return
midfoot arthritis
post traumatic arthritis
osteoarthritis
rheumatoid arthritis
plantar fibromatosis
ledderhose disease "dupuytren's of the foot" progressive usually asymptomatic Treatment Non-operative – avoid pressure – shoewear/orthotics Operative – excision high recurrence) Radiotherapy (similar recurrence) Combination radiotherapy/surgery (low risk recurrence/high risk complications – wound healing problems)
hindfoot problems
Achilles tendonitis/tendinosis Plantar fasciitis Ankle osteoarthitis Tibialis posterior dysfunction Cavovarus foot (inverted heel high arch)
achilles tendonitis
Degenerative / overuse condition with little inflammation
achilles tendinopathy
- insertional tendinopathy
- Non insertional
- Bursitis- retrocalcaneal and superficial calcaneal
- Paratendinopathy
aetiology
paratendonopathy-commonedt in athletic populations
tendonopathy
-commonest in non atheltic populations, obesity, steroids
symptoms
Pain during exercise Pain following exercise Recurrent episodes Difficulty fitting shoes (insertional) RUPTURE – don’t miss!
clinical
tenderness, test for rupture
achilles rupture tests-simmonds (calf squeeze test)
treatment
Activity modification Weight loss Shoe wear modification – slight heel Physiotherapy – Eccentric stretching Extra-corporeal shockwave treatment Immobilisation Operative- 1. gastrocnemius recession 2. release and debridement of tendon
Plantar fasciitis
Fasciosis - Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity
Cant make ECMatrix required for repair and re-modelling
In athletes with high intensity training
Running with poorly padded shoes
Obesity
Occupations involving prolonged standing
Foot/lower limb rotational deformities
Tight gastro-soleus complex
symptoms
Pain first thing in morning Pain on weight bearing after rest Post-static dyskinesia Pain located at origin of plantar fascia long lasting – 2 years or more
treatments
Rest, change training Stretching – Ice NSAIDs Orthoses – Heel pads Physiotherapy Weight loss Injections – corticosteroid (good in short term but may make condition worse long term) Night Splinting extracorporel shockwave therapy nitric oxide
ankle arthritis
post traumatic idiopathic operative management -arthroscopic anterior debridement -Arthrodesis -Joint replacement
posterior tibial tendon dysfunction
acquired adult flat foot planovalgus
clinical diagnosis (double and single heel raise)
-heels swing from valgus to varus as heel rise
medial or lateral pain
management
Orthotics – medial arch support Reconstruction of tendon (tendon transfer) Triple fusion (subtalar, talonavicular and calcaneocuboid
diabetic foot ulcer
Lack of sweating / normal sebum production
Dry cracked skin
Skin more sensitive to minor trauma
Poor vascular supply
Treatment
modify main detriments to healing Diabetic control Smoking Vascular supply External pressure (splints/shoes/weight bearing) Internal pressure (deformity) Infection Nutrition
Charcot neuarthropathy
any cause of neuropathy
commonly diabetes
Neurotraumatic
Lack of proprioception and protective pain sensation
Neurovascular
Abnormal autonomic nervous system results in increased vascular supply and bone resorption
characterised
- fragmentation
- coalescence
- remodelling
diagnosis
High index of suspicion Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy Frequently not painful Radiographs may be useful MRI scan
managemet
Prevention
Immobilisation / non-weight bearing until acute fragmentation resolved
Correct deformity
Deformity leads to ulceration leads to infection leads to amputation.
summary
know non operative treatments
BOA syllabus
anatomical knowledge
