common foot and ankle conditions

Question 1

treatment options

Answer 1

Non-operative management
Analgesia
Shoe wear modification
Activity modification
Weight loss
Physiotherapy
Orthotics including insoles and bracing
operate only if failure of non operative

Question 2

pathological grouping

Answer 2

Vascular (ischaemic)
Infective
Traumatic
Autoimmune
Metabolic (endocrine /drugs)
Inflammatory
Inherited (congenital)
Neurological
Neoplastic
Degenerative
Idiopathic

Question 3

forefoot problems

Answer 3

hallux valgus
Hallux rigidus
Lesser toe deformities
Morton’s neuroma
Metatarsalgia
Rheumatoid Forefoot

Question 4

hallux valgus

Answer 4

bunions
genetic
increased in footwear
female
symptoms: pressure symptoms from shoe wear
pain crossing over toes
metatarsalgia

Question 5

pathogenesis

Answer 5

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

Question 6

hallux valgus

Answer 6

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

Question 7

hallux rigidus

Answer 7

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

Question 8

management

Answer 8

Activity modification
Shoe wear with rigid sole
Analgesia

Cheilectomy (remove dorsal impingement) (remember)
Arthrodesis 1st MTPJ fusion
Arthroplasty

Question 9

lesser toe deformities

Answer 9

Claw toes
Hammer toes
Mallet toes

Question 10

Aetiology

pain from plantar side

Answer 10

metatarsalgia

imbalance of flexors and extensors

Question 11

treatment

Answer 11

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

Question 12

morton’s neuroma

plantar digit nerves

Answer 12

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

Question 13

diagnosis and management

Answer 13

mulder’s click
Steroid injection for small lesions
Surgery – excision of lesion including a section of normal nerve

Question 14

metatarsalgia

Answer 14

symptom not a diagnosis
Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease
tight gastrocnemius if not obvious

Question 15

rheumatoid forefoot

Answer 15

Non-operative – shoewear/orthotics/activity etc
Operative
Many described techniques
Current gold standard
1st MTPJ arthrodesis
2-5th toe excision arthroplasty

Question 16

Midfoot problems

Answer 16

Ganglia
Osteoarthritis
Plantar fibromatosis

Question 17

dorsal foot ganglia

Answer 17

arise from joint or tendon sheath

• idiopathic
• underlying arthritis/ tendon pathology

symptoms-pain from pressure from shoe wear

Question 18

treatment

Answer 18

aspiration
excision
high rate of return

Question 19

midfoot arthritis

Answer 19

post traumatic arthritis
osteoarthritis
rheumatoid arthritis

Question 20

plantar fibromatosis

Answer 20

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)

Question 21

hindfoot problems

Answer 21

Achilles tendonitis/tendinosis
Plantar fasciitis
Ankle osteoarthitis
Tibialis posterior dysfunction
Cavovarus foot (inverted heel high arch)

Question 22

achilles tendonitis

Answer 22

Degenerative / overuse condition with little inflammation

Question 23

achilles tendinopathy

Answer 23

1. insertional tendinopathy
2. Non insertional
3. Bursitis- retrocalcaneal and superficial calcaneal
4. Paratendinopathy

Question 24

aetiology

Answer 24

paratendonopathy-commonedt in athletic populations
tendonopathy
-commonest in non atheltic populations, obesity, steroids

Question 25

symptoms

Answer 25

Pain during exercise 
Pain following exercise
Recurrent episodes
Difficulty fitting shoes (insertional)
RUPTURE – don’t miss!

Question 26

clinical

Answer 26

tenderness, test for rupture

achilles rupture tests-simmonds (calf squeeze test)

Question 27

treatment

Answer 27

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

Question 28

Plantar fasciitis

Answer 28

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

Question 29

symptoms

Answer 29

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

Question 30

treatments

Answer 30

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

Question 31

ankle arthritis

Answer 31

post traumatic
idiopathic
operative management
-arthroscopic anterior debridement
-Arthrodesis
-Joint replacement

Question 32

posterior tibial tendon dysfunction

Answer 32

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

Question 33

management

Answer 33

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

Question 34

diabetic foot ulcer

Answer 34

Lack of sweating / normal sebum production
Dry cracked skin
Skin more sensitive to minor trauma
Poor vascular supply

Question 35

Treatment

Answer 35

modify main detriments to healing
Diabetic control
Smoking
Vascular supply
External pressure (splints/shoes/weight bearing)
Internal pressure (deformity)
Infection
Nutrition

Question 36

Charcot neuarthropathy

Answer 36

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

Question 37

characterised

Answer 37

• fragmentation
• coalescence
• remodelling

Question 38

diagnosis

Answer 38

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

Question 39

managemet

Answer 39

Prevention
Immobilisation / non-weight bearing until acute fragmentation resolved
Correct deformity
Deformity leads to ulceration leads to infection leads to amputation.

Question 40

summary

Answer 40

know non operative treatments
BOA syllabus
anatomical knowledge