Foot and Ankle Flashcards
Hallux Valgus
Big toe deformity.
Medial deviation of 1st metatarsal and lateral movement of the toe.
Who is most affected by hallux Valgus?
Women 4:1 with some familial tendency.
Seems to be more common in show wearing countries.
What conditions are associated with hallux Valgus?
Rheumatoid arthritis
Inflammatory arthropathies
Multiple sclerosis
Cerebral Palsy
What is main complaint of patients with hallux Valgus?
Pain
Cosmetic appearance
What causes the pain in hallux valgus?
Widened forefoot causes rubbing resulting in an inflamed bursae (bunion) and frequent ulceration.
1st and 2nd toe rub together resulting in skin breakdown.
What is used in the non surgical treatment of hallux Valgus?
Wearing wider accommodating shoes.
Spacer between 1st and 2nd toe to prevent ulcers.
What is the main reason for surgical treatment of hallux Valgus ?
generally for cosmetic reasons, however 30% are dissatisfied with the result due to pain.
What is hallux rigidus?
Osteoarthritis of the 1st Metatarsophalangeal joint
Two types of hallux rigidus
Primary (degenerative)
Secondary (osteochondral injury etc)
What is the conservative treatment of hallux rigidus?
Use of stiff soled shoes to limit movement.
Removal of dorsal osteophytes which can impinge movement.
What is the removal of osteophytes called?
Cheilectomy
What is the gold standard surgical treatment of hallux rigidus?
Arthrodesis, fusion of MTPJ joint.
Benefits of arthrodesis of the MTPJ joint?
Alleviate all pain
MTPJ is a stiff joint anyway no real sacrifice in movement.
More successful than joint replacement.
Drawback of arthrodesis in hallux rigidus?
Unable to wear heals
Mortons neuroma
Irritated and swollen digital nerve leads to degenerative fibroma.
Clinical signs of Mortons neuroma
Burning and tingling pin radiating from affected toes.
Loss if sensation in web space.
What is the Mulder’s click test?
Mortons neuroma
Mediolateral compression of metatarsal ellicits a click
What imaging is used for diagnosis of Mortons neuroma?
Ultrasound
What is the conservative management used in Mortons neuroma?
Injections of local anaesthetic and steroids.
Insoles
What us the surgical management of a Mortons neuroma?
Excision- some patients complain of continued pain.
Small risk of recurrence.
What are some common stories for metatarsal stress fractures?
Runners, soldiers on long marches, dancers, of poorly conditioned people walking long distances.
Which are the most common metatarsals to present with stress fractures?
2nd and 3rd
What is the treatment for a metatarsal stress fracture?
Prolonged rest in rigid soled boot.
On X-ray when are the metatarsal fractures most visible?
3 weeks post injury as resorption of the fracture causes gap to open up or callus forms.
Where on the achilles tendon does tendonitis or rupture originate from?
Hypovascular region 2-6 cm from the origin.
Pathology of achilles tendonitis
Repetitive microtrauma and collagen repair dysfunction resulting in misalignment.
Predisposing factors for achilles tendontitis
Quinolone antibiotics (ciprofloxacin) Over training Rheumatoid arthritis Gout Inflammatory athropathies Steroids CTD
In achilles tendonitis where can the pain occur?
Within the tendon
On its insertion on the calcaneous.
Treatment for achilles tendonitis?
Activity modification (heel raising)
NSAIDs
Physiotherapy
What treatment is last line for achilles tendonitis?
Surgical decompression, wound healing and scars are often problematic.
What treatment is never used in achilles tendonitis?
Steroid injections
Method of injury in achilles rupture?
Sudden deceleration with calf contraction.
Lunging in badminton
What do patients often say with an achilles rupture?
Feel like they’d been kicked in the back of the leg.
What is clinical appearance of an achilles rupture?
Unable to bear weight.
Weak plantar flexion
Palpable painful gap
Predisposing factors for an achilles tendon rupture
Old age (degenerative) Existing tendonitis Steroid injections
Surgical repair of achilles tendon rupture.
Suture damaged tendon to restore tension.
Cast for 8 weeks
Non surgical repair of achilles tendon rupture.
Serial casts with ankle plantar flexed.
Early weightbearing whilst preventing dorsiflexio
Benefits of serial casting over surgery for achilles rupture repair?
Serial casting avoids common wound problems and has as good functional output.
Plantar Facsiits
Self limiting
Repetitive stress/ degenerative condition.
Pain whilst walking
Where is the pain in plantar fasciitis.
Heel of the foot
Origin of plantar aponeurosis on distal plantar aspect of calcaneal tuberosity.
What are some predisposing factors for plantar fasciitis?
Diabetes
Obesity
Frequent walking on hard floor or poorly cushioned shoes.
Treatment for plantar fasciitis
Rest Physiotherapy NSAIDs Steroid injection Night splints Heel cups in shoes.
Is surgery used in plantar faciitis?
Surgical release is used however 50% success rate and risk of damaging plantar nerves.
Tibialis Posterior route and insertion in the foot.
Passes posterior to the medial malleolus.
Inserts onto medial aspect of the navicular , and plantar aspect of medial and middle cuneiform.
What is the function of the tibias posterior?
Raises and stabilises the posterior arch.
Invertor and plantar flexor.
Predisposing factors for developing tibialis posterior dysfunction.
Rheumatoid arthitis Hypertension Diabetes Obesity Seronegative arthropathies
Treatment for tibialis posterior tendonitis
Splinting with medial arch support.
NO steroid injection
Surgical decompression if symptoms unresolving
How does tibias posterior dysfunction present?
Pain posterior to medial malleolus
Diminished balance dislikes uneven surfaces
Flat Feet
Valgus of the heel
What is likely to occur if tibias posterior ruptures?
Osteoarthritis of hind and mid foot.
Surgery if no OA present in tibalis posterior rupture?
Tendon transfer and calcaneal osteotomy
Surgery if OA is present in tibialis posterior rupture?
Arthrodesis
Pes Cavus
Abnormally high arched foot
Often with clawed toes
What is pes cavus often associated with?
Polio unilateral
Cerebral palsy
Hererditary sensory and motor neuropathy
Spina Bifida occulta
What is treatment if pain is present?
Surgical Soft tissue release Tendon transfer Calcaneal osteotomy Arthrodesis (severe)
What is the dysfunction in claw toes?
Hyperextension at MTPJ
Hyperflexion at PIP and DIP
What is the dysfunction in hammer toes?
Hyperextension and MTPJ and DIP
Hyperflexion at PIPJ
Issues with claw and hammer toes?
Painful and often rub against shoes and or each other resulting in ulceration and skin breakdown.
What are the non surgical options in claw or hammer toes?
Toe sleeves and corn plasters can prevent skin issues
Surgical options for claw or hammer toes.
Tenotomy (devotion of overactive tendon)
Tendon transfer
Arthrodesis or amputation in severe cases.
