Common Foot and Ankle Problems Flashcards
What is the other term commonly used for Hallux Valgus
Bunions
What are the risk factors for Hallux Valgus
Genetics, specific footwear, significant female preponderance
Symptoms of Hallux Valgus
Pressure symptoms from shoe wear, pain from crossing over of toes, metatarsalgia
Pathogenesis of Hallux Valgus
Occurs from lateral angulation of the great toe, the tendons then pull to lateral of centre of rotation of toes which then worsens the deformity. The sesamoid bones then sublux and less weight goes through the great toe.
Diagnosis of Hallux Valgus
Clinical, Xrays
Management of Hallux Valgus (non operative)
Foot wear modification, orthotics to offload the pressure and correct the deformity, activity modification, analgesia
Management of Hallux Valgus (non-operative)
Release lateral soft tissues
Osteotomy 1st metatarsal and the proximal phalanx
What is Hallux Rigidus
A stiff big toe, osteoarthritis of the 1st MTP joint, bimodal distribution of age
Aetiology of Hallux Rigidus
Possibly genetic, possibly multiple microtrauma
Symptoms of Hallux Rigidus
Pain at extreme dorsiflexion, limitation of range of movement
Diagnosis of Hallux Rigidus
Clinical or Xray
Hallux Rigidus Xray
complete loss of joint space bilaterally or dorsal osteophyte
Non operative management of hallux rigidus
Activity modification, shoe wear with rigid sole, analgesia
Surgery Hallux Rigidus
Cheilectomy, arthrodesis, arthroplasty
Cheilectomy
Removal of the dorsal impingement
Gold standard treatment of Hallux Rigidus
1st MTPJ fusion
Aetiology of Lesser Toe Deformities
Imbalance between flexors/extensors Shoe wear Neurological Rheumatoid arthritis Idiopathic
Symptoms of lesser toe deformities
Deformity, pain from the dorsum, pain from the plantar side
Different lesser toes deformities
Hammer Toe, Claw Toe, Mallet Toe
Non-operative management of lesser toe deformities
Activity modification
Shoe wear – flat shoes with high toe box to accommodate deformity
Orthotic insoles – metatarsal bar/dome support
Operative Treatment of lesser toe deformities
Flexor to extensor transfer
Fusion of interphalangeal joint
Release of metatarsophalangeal joint
Shortening osteotomy of metatarsal
What is Mortons Neuroma
Thickening of the tissue around the nerves at the base of the toes (usually the 3rd and 4th)
Causes of Mortons Neuroma
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
Symptoms of Mortons Neuroma
Neuralgic burning pain into the toes and altered sensation in webspace
What webspace does Mortons Neuroma commonly effect
3rd followed by 2nd
Diagnosis of Mortons Neuroma
Clinical, Mulders Click, Ultrasound/MRI
Treatment of small Mortons Neuroma
Steroid Injection
Treatment of larger Mortons Neuroma
Excision of lesion including a section of normal nerve
Common effects of surgery of mortons neuroms
Numbness, recurrence, 30% have pain 1 year post surgery
Metatarsalgia
Pain and inflammation on the base and balls of the foot
Causes of Metatarsalgia
Synovitis, bursitits, arthritis, neuralgia, neuromata, Freiberg’s disease
Non operative treatment of rheumatoid forefoot
Shoewear, orthotics, activity modification
Operative management of rheumatoid forefoot
1st MTPJ arthrodesis and 2-5th toe excision arthroplasty
Ganglia
These tend to occur from arthritis of underlying tendon pathology
Symptoms of ganglia
Pain from pressure
Treatment of ganglia
Aspiration or excision (high rate of return (50%))
Plantar Fibromatosis
Ledderhose disease, thickening of the foots deep connective tissue
Symptoms of plantar fibromatosis
Usually asymptomatic unless very large on weightbearing area
Non-operative management of plantar fibromatosis
Avoid pressure by changing foot wear or adding orthotics
Other treatments of plantar fibromatosis
Operative excision, radiotherapy, combination radiotherapy/surgery
Achilles Tendinosis
Degenerative overuse condition with little inflammation
Insertional Achilles Tendinopathy
Within 2cm of insertion
Non-insertional/ Mid-substance tendinopathy
2-7cm
Bursitis achilles tendinopathy
Retrocalcaneal or superficial calcaneal
Paratendinopathy
True inflammatroy problem showing paratendonitis histologically
Aetiology of paratendonopathy
Common in athletic populations aged around 30-40 and occurs in males more than females (2:1)
Aetiology of tendonopathy
Common in non-athletic populations, usually aged over 40
Risk factors for tendonopathy
Obesity, steroids and diabetes
Symptoms of Achilles Tendinopathy
Pain during exercise
Pain following exercise
Recurrent episodes
Difficulty fitting shoes
How is achilles tendinopathy usually diagnosed
Tenderness, tests for rupture, ultrasound scan or MRI
Simmonds Test
If the calf squeeze does not move the foot then the achilles tendon is ruptured
Non-operative treatment of achilles tendinopathy
Activity modification Weight loss Shoe wear modification Physiotherapy - eccentric stretching Extra-corporeal shockwave treatment Immobilisation in below the knee cast
Operative treatment of achilles tendinopathy
Gastrocnemius recession
Release and debridement of tendon
Plantar Fasciitis/Fasciosis
Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen and avasularity
Causes of Plantar Fasciitis
Athletes associated with high intensity or marked increase in training
Running with poorly padded shoes
Obesity
Occupations involving long periods of standing
Foot/lower limb rotational deformities
Tight gastro-soleus compex
Symptoms of plantar fasciitis
Pain first think in the morning, pain on weight bearing after rest (post-static dyskinesia), pain located at the origin of plantar fascia, frequently long lasting - 2 years or more
Differential diagnosis plantar fasciitis
Nerve entrapment syndrome
Arthritis
Calcaneal Pathology
Diagnosis of Plantar Fasciits
Mainly clinical, can use X-rays, Ultrasounds and MRI
Treatments of plantar fasciitis
Rest Stretching Ice NSAIDs Orthoses Physiotherapy Weight loss Corticosteroid injections Night spinting
Newer treatments of plantar fasciitis
Extracorporeal Shockwave therapy Topaz Plasma Coblation Nitric Oxide Platelet Rich Plasma Endoscopic / Open Surgery
Ankle Arthritis mean age of presentation
46
Symptoms of Ankle arthritis
Pain and stiffness in the ankle joint
Diagnosis of Ankle Arthritis
Clinical, X-ray, CT scan - exclude adjacent joint arthritis
Non-operative management of Ankle Arthritis
Weight loss, activity modification, analgesia, physiotherapy, steroid injections
Operative Managment of Ankle Arthritis (exclusively anterior symptoms)
Arthroscopic anterior debridement
Operative management of ankle arthritis
Arthrodesis, joint replacement
Gold standard treatment for ankle arthritis
Arthrodesis
Tibialis posterior tendon dysfunction
Acquired adult flat foot planovalgus
Diagnosis of tibialis posterior tendon dysfunction
Double and single heel raise test (valgus to varus)
Symptoms of tibialis posterior tendon dysfunction
Medial or lateral pain
Treatment of tibialis posterior tendon dysfunction
Orthoses (medial arch support) or surgery (reconstruction of tendon or triple fusion of subtalar, talnoavicular and calcaneocuboid)
Aetiology of diabetic foot ulcer
Occurs due to diabetic neuropathy resulting in the patient being unaware of the trauma occuring to their foot.
There is also autonomic neuropathy resulting in a alack of sweating and normal sebum production, therefore there is dry cracked skin and it is more sensitive to trauma
Poor vascular supply
Treatment of diabetic foot ulcer (modification the main detriments to healing)
Diabetic control Smoking Vascular supply External pressure (splints/shoes/weight bearing) Internal pressure (deformity) Infection Nutrition
Surgical treatment of diabetic foot ulcer
Improvement of vascular supply
Debridement of ulcers and get deep samples for microbiology
Amputation
Percentage of diabetic patients who get foot ulcers
15%
Percentage of patients with diabetic foot ulcers that go on to have amputation
25%
5 year mortality of diabetic foot ulcers
50%
Aetiology of Charcot Neuroarthropathy
Any cause of neuropathy to the foot, mostly diabetic neuropathy
Neurotraumatic theory of the pathophysiology of Charcot Neuroarthropathy
Lack of proprioception and protective pain sensation
Neurovascular pathophysiology of Charcot
Abnormal autonomic nervous system results in increased vascular supply and bone resorption
3 stages of bone destruction in Charcot
Fragmentation
Coalescence
Remodelling
Diagnosis of Charcot
Consider in any diabetic with acutely swollen erythematous foot
X-ray
MRI scan
Management of Charcot
Prevention
Immobilisation
Correction of the deformity