Foot Flashcards
What is tarsal coalition?
Abnormal connection that develops between the talus and calcaneus at the back of the foot
Can be composed of bone, cartilage or fibrous tissue
Can lead to limited motion and pain
Presentation of tarsal coalition
Can present as rigid pronated FLAT foot in the early teens
What can foot pain in children be associated with?
Congenital abnormalities such as equinovarus abnormality (club foot) - these structural abnormalities can reflect underlying neurological disease such as cerebral palsy
What is club foot associated with
Cerebral palsy
Which joints are most commonly affected in JCA
Knee and ankle joints - in all subtypes of JCA
What is metatarsalgia?
Pain in the forefoot
What is another name for Morton’s metatarsalgia?
Interdigital neuroma
What does mortons neuroma affect?
It affects the proximal part of the plantar digital nerve and accompanying plantar digital artery
How does Morton’s neuroma develop?
Trauma to the PD nerve - trapped nerve under transverse ligaments (and artery) leads to inflammatory oedema, microscopic changes, fibrosis and lateral degeneration of the nerve - the pain arrives from entrapment of the interdigital nerve
Symptoms of Morton’s neuroma?
Gradual onset, sudden attacks of neuralgic pain or paraesthesia during walking
Often in 3rd and 4th toe
Investigation findings in Mortons neuroma
May show lesser toe deformities, slight splaying of the forefoot, abnormal pronation and hallux valgus (bunion)
What is a bunion?
It is hallux valgus, medial protrusion and inflammation of the 1st MTP joint
May be present in women who wear court shoes
Management of Mortons neuroma
Advice about suitable footwear and possibly orthoses to control abnormal pronation
Injections of local anaesthetic and hydracortisone around the nerve or surgical excision (leads to loss of sensation)
What are forefoot stress/march fractures ? where?
Fractures associated with increased activity - lesions can affect any of the metatarsal shafts and are often along the line of the surgical neck
Typical history of a patient with a stress fracture in the forefoot?
History of change in amount of activity, occupation or foot wear
Or sudden weight gain
Symptoms of forefoot stress fracture?
Dull ache along the affected metatarsal shaft
This changes to a sharp ache just behind the metatarsal head
Pain exacerbated by exercise - more acute at “toe off”
Signs in forefoot stress fracture?
Tenderness and swelling over dorsal surface of shaft
Pain produced by compression of metatarsal head or traction of the toe
Examination of forefoot stress fracture?
Might not show up on x-ray for 2-4 weeks but if need to confirm a diagnosis then bone scan can be done
Treatment of forefoot stress fracture
Rest and local protective padding with partial immobilisation
What is Freibergs disease?
Avascular necrosis of metatarsal head which commonly affects the first metatarsal
What is acute synovitis in the forefoot
Normally caused by acute trauma - leads to inflammation of the synovial membrane and effusion
Can also be caused by systemic disease such as RA or infection
Who is often affected by acute synovitis in the forefoot
Young adults
Rare in children
Symptoms of forefoot acute synovitis
Sudden onset painful throbbing made worse by movement on the background of a history of trauma
Fusiform swelling may be present and crepitus may be felt
Treatment of forefoot acute synovitis
Rest, immobilisation and US treatment may help in trauma is the cause
Anti-inflammatories can help
What causes acute inflammation of the anterior metatarsal soft tissue
Commonly in middle-aged women, where there is increased shear forces eg. from wearing slip on or high-heeled court shoes
Symptoms of acute inflammation of the anterior metatarsal soft tissue
Burning of throbbing in forefoot anterior to metatarsal heads - usually develops over weeks and is related to wearing a pair of shoes - relieved by rest
Signs of acute inflammation of the anterior metatarsal soft tissue
Tissues are inflamed, warm and congested
Direct palpation, rotation and simulation of shear forces exacerbate pain
Shoes may have a worn insole and depression under metatarsal heads
Details of plantar metatarsal bursitis
Can affect deep or superficial bursae (deep tissues are tight and congested, superficial - signs of acute inflammation)
Can be acute (dancers, squash players or skiiers) or chroniic (inflammatory arthritis)
Throbbing pain usually - persists at rest
Treat with anti-inflammatories, gels and oral drugs - injections may be needed if severe
Rest area - padding
What is osteochondritis/freibergs infarction
Aseptic necrosis or epiphyseal infarction associated with trauma of 2nd/3rd metatarsal head
Who does freibergs infarction affect - presentation
Teenagers, associated with increased sporting activity
Limp + dull pani with movement and “toe off”
Can lead to arthritis
Management of freibergs infarction
Rest and immobilisation at first
May need corrective surgery
4 causes of painful heel
Sever’s disease (calcaneal apophysitis)
Plantar calcaneal bursitis “policemans heel”
Chronic inflammation of heel pad
Achilles tendon affections
Details of sever’s disease
Chronic strain of attachment of post.apophysis of calcaneus to main body of bone, possibly form pull of achilles
Usually in boys age 8-13
Dull ache behind heel, gradual onset
Exacerbated with jumping just before “heel lift”
Tenderness
Rest and reducing activities
Details of plantar calcaneal bursitis
Inflammation of bursa beneath plantar aspect of calcaneal tuberosities
Associated with sheering stress
Increasing burning aching and throbbing pain on plantar surface of heel
Hx of increased activity or weight gain
Rest and antiinflammatoires Stretching exercises
What causes chronic inflammation of heel pad?
Usually from trauma or heavy heel strike
Sometimes in elderly as fat pads atrophy
Features of inflammation of heel pad
Warm, dull throbbing pain over weight-bearing area of heel
Develops over months
Worse when first rising
Will normally improve with time, soft heel cuchions can help
Where does OA most commonly affect the foot?
First MTP joint and tarsus joints - first MTP is one of the most commonly affected joints in OA
What contributes to degenerative joint changes with OA x4
Compensatory foot pronation etc
Trauma
Recurrent gout
Inappropriate footwear
Where does RA affect in the foot?
MTP joints (typically where RA starts) In early disease hind foot especially subtalar joint can be painful
Foot pain in seronegative spondyloarthritides
Achilles tendon especially affected
Sausage toe can be common
Can have psoriatic skin and nail changes in psoriatic arthritis
What are callosities? - what other similar things are there
Pressure lesions which can develop from joint deformity with arthritides
Corns or ulceration can also occur with joint deformity
Features of club foot x4
Inversion
Adduction of forefoot related to hindfoot
Varus hindfoot
Equinus (plantarflexion) deformity
Foot cannot be passively everted and dorsiflexed through the normal range
Treatment of club foot?
Ponseti method
Foot is manipulated and placed in long leg plaster cast on repeated occasions
Correction must be gradual
What is pes planus
Flat feet - medial longitudinal arch collapses
When is flat feet normal?
In a child learning to walk - and then the medial arch develops over the next few years
What is flat feet in adults associated with?
Dysfunction of the posterior tibialis tendon
Consequences of flat feet
Most it is asymptomatic and does not need intervention if the arch restores itself when standing on tiptoes
May get pain if condition progresses but consequences with surgery therefore not recommended lightly
What is pes cavus?
Accentuated longitudinal arch which does not flatten on weight-bearing
May be idiopathic or associated with underlying neurological condition
What is hammer toes?
Extended at MTP joint, hyperflexed at PIP joint and extended at DIP joint - typically as a result of footwear that doesnt fit properly - 2nd toe most commonly affected
What are claw toes
Extended at MTP joint but flexed at both PIP and DIP joints - often as a result of nerve damage aka alcoholism or DM
Difference between hammer and claw toe
Hammer flattens out at DIP joint but claw toe remains curved
Treatment of hammer and claw toe
Either metatarsal shortening or PIP joint arthrodesis (fixing)
What are mallet toes?
Flexion deformity of DIP joint in isolation
Treatment of mallet toe
Surgical flexor tenotomy or DIP joint arthrodesis
Which digit does ingrowing toenail commonly affect
Big toe
Why do you get ingrowing toenail
Usually due to incorrect cutting and then too tight shoes
What is bunion
Hallux valgus
What happens to bones in bunion?
There are two sesamoid bones in the tendon of flexor hallus longus - these are needed for stability - when metatarsal moves medially, the sesamoid bones fall down into the first web space
Functional problems with bunion
Normally toe - first mtp joint - takes a lot of weight with toe off and therefore with hallus valgus - it can no longer take the weight and this causes stress damage -leads to arthritic changes or stress fractures
When do you get pain in bunion
Due to very advanced deformity and development of painful arthritis and stress fractures
Recovery after bunion surgery
Back on feet 6-8 weeks after
What is cheilectomy and when is it used?
Removal of bony Spurs - eg in OA on MTP
What is Achilles’ tendon tendonitis?
Not inflammatory!!! It’s degenerative changes of the tendon - fibroblasts deposits random collagen - leads to thickening and disorganisation
What is plantar fasciitis
Degenerative tendinosis of the tendon - treated by physiotherapy and stretching (95% of treatment)
Alternative treatment of achilles tendonosis
Shockwave therapy - exceedingly painful - but effectively damages the tendon and induces reparative changes and makes it better
What do you need to think of if high arch foot and varus hind foot
Neurological - eg.spina bifida, Charcot Marie tooth etc - need to go for whole spine MRI
Can present at any age
