Common foot problems Flashcards
what are the non-operative managements for foot problems?
orthotics i.e. insoles & bracing shoe wear modification analgesia weight loss physiotherapy
what are common forefoot problems?
hallux valgus hallux rigidus lesser toe deformities (claw, hammer and mallet toes) mortons neuroma metatarsalgia rheumatoid forefoot
what is the aetiology of hallux valgus?
genetic
female predisposition
foot wear can precipitate hallux vallus in a susceptible individual
describe the pathogenesis of hallux valgus.
lateral angulation of the big toe
the tendons pulls lateral to the centre of rotation to realign the toe but this worsens the deformity
the sesamoid bone sublux - therefore less weight is put on the big toe
as it progresses abnormalities of the lesser toes occur
what are the treatment options for hallux valgus?
non-operative
surgery: osteotomy of 1st metatarsal +/- proximal phalanx
what is hallux rigidus and what age groups is is most common?
stiff big toe
bimodal age distribution: 20s/30s and 40s
what is the presentation of hallux rigidus?
stiff big toe
often pain at the extremes of dorsiflexion
what are the treatment options for hallux rigidus?
non-operative surgery: - cheilectomy (remove osteophyte to relive nerve impingement) - arthrodesis (gold standard) - arthroplasty
what are the 3 lesser toe deformities?
claw toes:
- hyperextension of MTP joint
- flexion at the distal and proximal interphalangeal joints
hammer toe:
- hyperextension of the MTP joint
mallet toe:
- fixed extension of the distal interphalangeal joint
what is the aetiology of lesser toe deformities?
imbalance between flexors and extensors shoe wear neurological rheumatoid arthritis idiopathic
what is morton’s neuroma?
interdigital neuralgia caused by inflammation at the site where the common digital nerve splits to supply adjacent toes
the common digital nerve is tethered to one metatarsal but is also involved in movement in adjacent metatarsal causing mechanical shear
what is the aetiology of mortons neuroma?
mechanically induced degenerative neuropathy
commonly associated with wearing high heels
what is the presentation of morton’s neuroma?
neuralgic burning pain into toes
intermittent
altered sensation in webspace
how is morton’s neuroma diagnosed?
clinical
examination: Mulder’s click
USS
what is the treatment for Morton’s neuroma/ interdigital neuralgia?
steroid injection
surgery: excision of lesion (not usually done)
what is metatarsalgia?
pain and inflammation in the forefoot - metatarsal head/ the ball of the foot
it is a symptom rather than a diagnosis
what could be the cause of metatarsalgia if there is no identifiable cause?
a high gastrocnemius muscle
what deformity is found in rheumatoid forefoot?
hallux valgus with degenerative change
what is the treatment for rheumatoid forefoot?
non-operative
1st MTP joint arthrodesis (union)
2nd to 5th toe excision arthroplasty
what are common conditions of the mid foot?
ganglion
osteoarthritis
plantar fibromatosis
where does a dorsal foot ganglion arise from and what causes it?
arises from the joint or tendon sheath
idiopathic
may have underlying arthritis or tendon pathology
what is the treatment for a dorsal foot ganglion?
aspiration
excision
what are the aetiologies of mid foot arthritis?
post trauma
rheumatoid arthritis
osteoarthritis
what is the management of mid foot arthritis?
non-operative
steroid injections
surgery: fusion
what is plantar fibromatosis?
thickening of the deep connective tissue or fascia
what is the presentation of fibromatosis?
usually asymptomatic unless very heavy large or at a weight bearing area
what are the treatment options for planet fibromatosis?
non-operative
excision
radiotherapy
combination of radiotherapy & surgery
what are examples of hind foot problems?
chillies tendonosis plantar fasciitis ankle osteoarthritis tibialis posterior dysfunctiion cavovarus foot
what is achillies tendinosis?
degenerative / overuse condition with little inflammation
what is the difference in the prevalence of achillies paratendinopathy and tendinopathy?
paratendinopathy occurs in athletic populations
- 30s & 40s
- male: female 2:1
tendinopathy commonest in non-athletic populations:
- diabetics
- age > 40 yrs
- obesity
- steroids
paratendinopathy is inflammation of a thin membrane that surrounds the chillies tendon whereas tendinopathy is inflammation of the tendon itself
what is the presentation of achillies tendinopathy?
pain on exercise pain after exercise recurrent episodes difficulty fitting shoes rupture
how would you diagnose achillies tendonopathy?
history pattern
clinical: tenderness, tests for rupture
investigations: MRI, USS
what clinical tests is used to diagnose an achillies tendon rupture?
Simmonds test;
- Lie patient on their front and let feet hand from the bed
squeeze the calf and it the foot doesn’t move then their is a full rupture
Angle of dangle / Matles;
- Lie patient supine on their front and ask to bend their knees. if their is a tear then there will be excessive dorsiflexion in the ruptured side
also can do it by asking them to dangle feet from edge of the bed whilst lying on their frontand observe from their
what is the management for achillies tendinopathy?
non-operative:
- activity modification
- weight loss
- physiotherapy
- shoe wear modification
- extracorporeal shock wave therapy
- immobilisation with cast
surgery:
- gastrocnemius recession
- release and debridement of tendon
what is plantar fasciitis?
chronic degenerative change with fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, vascularity
can’t make extracellular matrix required for repair and remodelling
what is the aetiology of plantar fasciitis?
idiopathic athletes - high intensiting, rapid increase in training exercise with poorly padded shoes obesity foot/lower limb rotational deformities tight gastro-soleus complex
what is the presentation of plantar fasciitis?
pain first thing in the morning
pain on weight bearing after rest (post static dyskinesia)
pain located at origin of plantar fascia
frequently lasting 2 years or more
how is plantar fasciitis diagnosed?
clinical diagnosis
MRI, x-rays, USS may be useful
what are the treatments for plantar fasciitis?
rest stretching NSAIDS ice orthotics i.e. heel pads, insoles weight loss steroid injections night splinting
3rd line:
- extracorporeal shockwave therapy
- endoscopic open surgery
what is the presentation of ankle arthritis and at what age does it common present?
mean age is 46 yrs
commonly post traumatic or idiopathic
symptoms: pain and stiffness
what is the treatment for ankle arthritis?
non-operative
surgery: arthrodesis, arthroplasty
if symptoms are exclusively anterior then treat with arthroscopic anterior debridement
what is tibialis posterior tendon dysfunction?
acquired adult flat foot planovalgus
what does tibialis posterior tendon dysfunction present with?
medial or lateral pain
acquired flat feet (in adults)
how can you diagnose tibialis posterior tendon dysfunction?
double and single limb heel raise test:
they can rise on their heels if they do both at a time but they can’t do a heel rise on one foot
MRI to assess tendon
what is the treatment for tibialis posterior tendon dysfunction?
orthotics to support arch
reconstruction of tendon (tendon transfer)
tripple fusion
how does charcot’s foot develop? (neuroarthropathy)
neurotraumatic:
- lack of proprioception and protective pain sensation
neurovascular:
- abnormal autonomic nervous system results in increased vascular supply and bone resorption
what are the 3 stages involved in bone destruction in charcots foot?
fragmentation
coalescence
remodelling
