Cortex- Lower Limb: Foot and Ankle Flashcards
what can cause ankle OA
idiopathic, primary or consequence of a previous injury
what are the two surgical options for patients with significant advanced ankle OA
arthrodesis and ankle replacement
what is hallux valgus
deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
in severe cases hallux may override the second toe
who gets hallux valgus
commoner in females (4:1) there a familial tendency
incidence increases with age but can occur in adolescence
what other conditions is hallux valgus commoner in
RA, inflammatory arthropathies, neuromuscular diseases (multiple sclerosis, cerebral palsy)
why is hallux valgus painful
joint incongruence and a wideneing forefoot may cause a bunion
great toe and second toe may rub causing ulceration and skin breakdown
what is a bunion
when rubbing of the foot with shoes causes an inflamed bursa over the medial 1st metatarsal head
what causes hallux valgus
unknown cause but higher in shoe wearing populations
what is the conservative treatment for hallux valgus
wider and deeper shoes to prevent bunions
spacer in the first web space
what is the surgical management for hallux valgus
osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues
what is surgery cautioned in hallux valgus
if doing for cosmesis many will be unhappy with the result
30% will be dissatisfied due to altered biomechanics of the foot
some have pain of metatarsal heads after surgery
what is hallux ridigus
OA of the first MTPJ
can be primary (degenerative) or secondary to osteochondral injury
what is the conservative treatment for hallux ridigus
wearing stiff soled shoes to limit motion at the MTPJ
removal of dorsal osteophytes (cheilectomy) when they impinge during dorsiflexion
what is the gold standard surgical treatment for hallux rigidus
arthrodesis (stabilisation of a joint by fusion of the bones)
should alleviate pain with the small sacrifice of no motion
what might be the problem with women an arthodesis
cant wear high heals
can you do MTP joint replacement in hallux ridigus
yes but failure rates high and once failed salvage surgery is difficult
what is mortons neuroma
plantar interdigital nerves (from the medial and lateral plantar nerves) overlying the intermetatarsal ligaments can be subjected to repeat trauma
irritated nerves can become inflamed and swollen (forming a neuroma)
what are the symptoms of a mortons neuroma
burning pain and tingling radiating into the affected toes
who gets mortons neuroma
women (4 times)
wearing high heals has been implicated as a cause
what is the most common areas to be affected by mortons neuroma
third interspace nerve
what might be seen on clinical examination of mortons neuroma
loss of sensation in the affected web space
mulders click test- compression of the metatarsal heads (squeezing forefoot with your hand) may reproduce symptoms or a characteristic click
what imaging might be useful for the diagnosis of mortons neuroma
ultrasound can demonstrate a swollen nerve
what is the conservative management of mortons neuroma
the use of a metatarsal pad or offloading insole
steroid and local anaesthetic injections may relieve symptoms and aid diagnosis
is surgery for mortons neuroma possible
yes but some continue to experience pain and there is a small risk of recurrence
where in foot do metatarsal stress fractures most commonly occur
in the 2nd metatarsal followed by the 3rd
who get metatarsal stress fractures
runners, soldiers on prolonged marches, dancers, or distance walking in those not used to it
when can x rays show metatarsal stress fractures
after 3 weeks wen resorption at the fracture ends occur or callus begins to appear
what might be useful in diagnosing a metatarsal stress fracture
bone scan
what is the treatment for a metatarsal stress fracture
prolonged rest for 6-12 weeks in a ridgid soled boot
what causes tendonitis of the achilles tendon
repetitive strain (from sports) which leads to a peritendonitis or due to degenerative process with intrasubstance microtears
what can predispose to achilles tendonitis
quinolone antibiotcs (ciprofloxacin), RA, inflammatory arthropathies, gout
what is the treatment for achilles tendonitis
rest, physio, heel raise to offload the tendon, use of a splint or a boot
resistant cases may benefit from tendon decompression and resection of paratendon
condition usually self limiting
where is the pain in achilles tendonitis
main body of achilles, its insertion at the calcaneus
what does tendonitis predispose to
tendon rupture
why do you never administer steroid injection around the achilles tendon
as risks rupture
who get achilles tendon rupture and why
occurs in middle aged or older groups and is usually due to degenerative changes within the tendon or recent tendonitis
what is the usual history of an achilles tendon rupture
sudden deceleration with resisted calf muscle contraction (lunging at squash) leads to sudden pain (like being kicked in back of leg) and difficulty weight bearing
weakness of plantar flexion and a palpable gap in the tendon are usually apparent
what is simmonds test
positive in a torn achilles when no plantarflexion of the foot is seen when squeezing the calf
what is the treatment for a ruptured achilles tendon
controversial: operative and non operative
suture repair of the damaged tendon to restore to tension of the tendon
followed by 8 weeks of casts
non operative- series of casts in the equinous position (ankle plantar flexed with the toes pointing down (closes gap in torn tendon) for 8 weeks
what is plantar fasciitis
self limiting repetitive stress/ overload or degenerative condition of the foot causing inflammation of the plantar fascia
what are the symptoms of plantar fasciitis
pain with walking is felt on the instep of the foot, localised tenderness on palpation of this site
where specifically is pain felt in plantar fasciitis
at the origin of the plantar aponeurosis on the distal plantar aspect of the calcaneal tuberosity
what are causative factors of plantar fasciitis
diabetes, obesity, frequent walking on hard floors with poor cushioning floors
cushioning heel fat pad atrophies with age
what is the treatment for plantar fasciitis
rest, achilles and plantar fascia stretching exercises
gel filled heel pad
corticosteroid injection
symptoms may take up to 2 years to resolve
surgery avoided due to risk of plantar nerve damage
what is pes panus
flat feet
what causes normal flat feet in adults
failure of medial arch development in childhood
who is more likely to have pen panus
people with ligamentous laxity
has familial tendency
does developmental pes panus need treatment
no
what are people with developmental pes panus more likely to develop
tendonitis of the tibialis posterior tendon
what can cause acquired flat feet
tibialis posterior tendon stretch or rupture, RA, diabetes with charcot foot
what is charcot foot
neuropathic joint destruction
weakening of bones due to nerve damage
where does the tibialis posterior tendon insert
onto the medial navicular
what does the tibial posterior tendon do
supports the medial arch of the foot
platarflexor
invertor of the foot
the tibialis posterior tendon is under repeated stress and can degenerate, what can this cause?
tendonitis, elongation, rupture
what else can cause tibialis posterior tendon
synovitis from RA
how should tibialis posterior tendonitis be treated
splint and medial arch support to prevent rupture
physio
if this fails to settle symptoms, surgical decompression and tenosynovectomy may prevent rupture
what happens if the tibialise posterior tendon elongates or ruptures
medial arch is lost causing valgus of the heel and flattening of the medial arch of the foot
subsequent degenerative OA of the hindfoot and midfoot may occur
what surgery can be done in a tibialis posterior tendon dysfunction when the foot is supple with no OA
tendon transfer with a calcaneal osteotomy to reduce stress
prevents secondary OA
what is type of surgery can be done in tibialis posterior tendon rupture once OA ensues
arthrodesis
what is pes cavus
abnormally high arch of the foot
what causes pes cavus
idiopathic
related to neuromuscular conditions: hereditary sensory and motor neuropathy, cerebral palsy, polio (unilateral), spinal cord tethering from spina bifida occulta
what toe feature often accompanies pes cavus
claw toes
what is the treatment for pes cavus
pain- if supple:soft tissue releases, tendon transfer (lateral transfer of tibialis anterior
if more rigid: calcaneal osteotomy
severe cases may require arthodesis
what causes claw and hammer toes
an acquired imbalance between the flexor and extensor tendons
describe claw toes
hyperextension at the MTPJ with hyperflexion at the PIPJ and DIP
describe hammer toes
hyperextension at the MTPJ with hyperextension at the DIPJ
claw and hammer toes can be painful and rub on footwear causing corns and skin breakdown. what are the treatment options
toe ‘sleeves’
corn plasters
surgery: tenotomy (division of an overactive tendon), tendon transfer, athrodesis (PIPJ), toe amputation
what prediposes to tibialis posterior dysfunction
obesity middle aged females flat foot hypertension diabetes steroid injection seronegative arthropathies idiopathic tenonosis
what nerve reacts in the tinels test in plantar fasciitis
lateral plantar nerve
when in tibialis posterior tendon rupture can a tendon transfer be performed and how and why is it done
if the foot remains supple with no OA
to prevent secondary OA
done with calcaneal osteotomy to reduce stress
