Foot and Ankle Conditions Flashcards
What is hallux valgus?
“BUNION”
Deformity of the great toe, whereby the hallux moves towards the second toe - can overly the second toe
Tendons pull the toe laterally, seamoid bones sublux
What sex does hallux valgus more commonly occur in?
Female
What risk factors contribute to the development of hallux valgus?
- Age
- Family history
- Hypermobility
- Footwear
- Neuromuscular disease
What is the following deformity?
Hallux valgus - abducted hallux, adducted metatarsal, MTPJ angle >14.5o
What other features, beside the classic deformity, are associated with hallux valgus?
- Pain - Pressure symptoms from wearing shoes
- Evidence of hypermobility
How would you investigate hallux valgus?
- Clinical diagnosis
- Imaging - X-ray
What non-operative measures could you take to help manage someone with hallux valgus?
- Shoe wear modification (wide +/- high toe box)
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesia
What surgical options are available for the treatment of hallux valgus?
Only indicated in painful bunions, not for aesthetic purposes
- Lateral soft tissue release
- Osteotomy - 1st metatarsal +/- proximal phalanx
What is hallux rigidus?
Osteoarthritis of the 1st MTPJ
How does hallux rigidus present?
- Asymptomatic
- Pain - dorsiflexion, on walking
- Limited ROM - dorsiflexion
What general measures can be taken to manage someone with hallux rigidus?
- Activity modification
- Shoewear with rigid sole
- Analgesia
What surgical options are available for someone with hallux rigidus?
- Arthrodesis - MTPJ fusion - GOLD STANDARD
- Chielectomy - remove dorsal impingement
- Arthroplasty - good option to maintain range of motion, high failure rate
What is a cheilectomy?
Surgical procedure involving the removal of osteophytes from around a degenerate joint to regain further function and ROM. It is most commonly performed on those with hallux rigidus to remove dorsal impingement
What are the main lesser toe deformities?
- Hammer toe
- Mallet Toe
- Claw toe
What toe deformity can be seen here?
Claw toe - extended MTPJ, Flexed PIP and DIP
What toe deformity can be seen here?
Mallet toe - Normal MTPJ, Neutral PIP, Flexed DIP
What toe deformity can be seen here?
Hammer toe - Extended MTPJ, Flexed PIP, Extended/neutral DIP
What can cause lesser toe deformities?
Imbalance between flexors/extensors
Trauma
- Shoewear
Degenerative
- Neurological
- Rheumatoid arthritis
Besides actual deformity, what other features can be present in lesser toe deformities?
- Pain - Dorsum/Plantar side
- Calluses
- Hallux valgus
- Progression to fixed deformity
What should always be inestigated for in the presence of lesser toe deformities?
- Presence of diabetic foot
- Neurological status
- Musculature
What non-operative measures could you employ to manage lesser toe deformities?
- Activity modification
- Shoewear – flat hoes with high toe box to accommodate deformity
- Orthotic insoles – metatarsal bar/dome support
What surgical options are available to manage lesser toe deformities?
- Flexor to extensor transfer
- Fusion of IP joint
- MTPJ release
- Shortening osteotomy of metatarsal
What is interdigital neuralgia?
“Morton’s Neuroma”
Perineural Fibrosis of an intermetatarsal nerve
Where is the most common location for a Morton’s neuroma to develop?
3rd/4th webspace
What percentage of morton’s neuroma occur in the 2nd/3rd webspace of the foot?
35%
Which sex does Morton’s neuroma more commonly occur in?
Females
How does Morton’s Neuroma present?
-
Pain - Metatarsalgia
- Usually radiates to lateral side of one toe, and medial side of it’s neighbour
What is metatarsalgia?
Aching pain in the metatarsal bones of the foot. Usually arises from beneath the metatarsal heads in the transverse plantar arch
What are risk factors for the development of metatarsalgia?
- Increased BMI
- High heels
- Toe deformities
- High-impact sports
- Inflammatory arthritis
- Morton’s Neuroma
What clinical test would increase your suspicion of a morton’s neuroma?
Compressing the affected webspace elicits pain
(mulder’s click)
How would you investigate a suspected morton’s neuroma?
Imaging
- US
- MRI
What non-operative measures could you use to treat a Morton’s Neuroma?
Injection therapy
What surgical options are available for Morton’s neuroma?
Surgical Excision - Neuroma and Nerve
How would you treat a Rheumatoid forefoot, both operatively and non-operatively?
Non-operative
- Shoewear, orthotics, activity
Operative
- Current gold standard - fuse 1st MTP joints - arthrodesis
- 2-5th metatarsal head excision arthroplasty
What is a dorsal foot ganglia?
- Tumor or swelling on top of a joint or the covering of a tendon (tissue that connects muscle to bone) - dorsum of the foot
- Thick, sticky, clear, colorless, jellylike material within the sac.
- Depending on the size, cysts may feel firm or spongy
How would you treat a dorsal foot ganglia?
- Leave it be
- Aspiration
- Surgical excision
What can cause midfoot arthritis?
- Post-trauma
- Osteoarthritis
- Rheumatoid Arthritis
How would you treat midfoot arthritis?
Non-operative
- Activity/shoewear/orthotics etc
- Injections – xray guided
Operative
- Fusion
What is plantar fibromatosis?
Non-malignant thickening of the feet’s deep connective tissue, or fascia
What is the following?
Plantar Fibromatosis
How would you manage someone with plantar fibromatosis?
Non-operative
- Avoid pressure – shoewear/orthotocs
Operative
- Excision - high risk of recurrence - causes more
What is plantar fasciitis?
Inflammationof the point of attachment of the fascia in the sole of the foot to the calcaneus, causing pain and localised tenerness of the heel
Self-limiting probelm
What can cause plantar fasciitis?
Weight bearing
- PROLONGED STANDING
- Overweight/obesity
- Running
- Equinus
- Pes Planus/Pes cavus
How does plantar fasciitis occur?
Degenerative changes from microtrauma, leading to microtears in the fascia
What are the symptoms of plantar fasciitis?
-
Heel Pain
- Stabbing, knife-like
- Radiates to lateral heel, plantar medial arch
- When taking first few steps in morning/from sitting position (post static dyskinesia)
- Worse with barefoot walking
On examination, what would suggest plantar fasciitis as the diagnosis?
- Focal, pin point tenderness - palpation of plantar medial/central calcaneal tuberosity (a lot of pain!), and potentially proximal third of the plantar fascia
- Lateral squeeze - rule out stress fracture
- Dorsiflexion-eversion test - positive
How would you diagnose plantar fasciitis?
Clinical diagnosis of exculsion
Occassionally imaging - US, MRI, X-Ray
How would you treat plantar fasciitis?
- WEIGHT LOSS!!!!!
- Rest, cross training
- Stretching – Achilles +/- direct stretching
- Ice
- NSAIDs
- Orthoses
- Physiotherapy
- Corticosteroid
- Night Splinting
What is tibialis posterior dysfunction?
Adult Acquired flat foot
Process of tendinosis (degeneration) - posterior tibialis tendon becomes fibrotic through a process of repeated microtrauma
What can cause tibialis posterior dysfunction?
- Charcots foot
- Any degenerative process
- Trauma
What are the symptoms of tibialis posterior dysfunction?
- Pain - behind medial malleolus, along the instep
- Swelling - behing medial malleolus
- Change in walking ability
On examination, what would indijcate tibialis posterior dysfunction?
- Swelling and tenderness - behind medial malleolus
- Pain and Weakness- with foot inversion
- Acquired flatfoot deformity - too many toes sign (due to abduction of forefoot)
- Valgus heel deformity Flattened medial longitudinal arch
- Unable to perform Single Heel Raise - Normal is 8-10 times single heel rise, >/= stage 2 - unable to perform 1
- Double Heel Raise (tip toe test) - flexible deformity resolves
If, on examination, you observed the following, what would you suspect?
Tibialis posterior dysfunction
If, on examination, you observed the following, what clinical tests could you do to help make the diagnosis?
- Single/Double Heal Raise
- Achilles Tendon Examination
What classification system is used to classify the severity of tibialis posterior dysfunction?
Johnson and Strom classification
What are the different grades of tibialis posterior dysfunction in the Johnson and Strom classification system?
- Stage 1 - Medial pain, no deformity, can single heel raise
- Stage 2 - Flat foot, flexible deformity, cannot heel raise
- Stage 3 - Flat foot, fixed deformity
- Stage 4 - Ankle involvement
What non-operative interventions can be used in tibialis posterior dysfunction?
Stage 1/2: physiotherapy, orthotics (medial arch support), analgesia
What surgical options are available for those with stage 1 tibialis posterior dysfunction?
Surgical decompression of the tendon
What surgical options are available for those with stage 2 tibialis posterior dysfunction?
Surgical reconstruction (flexor digitorum longus transfer + calcaneal osteotomy)
What surgical options are available for those with stage 3 tibialis posterior dysfunction?
Joint fusion (subtalar, calcaneal cuboid, talonavicular)
What surgical options are available for those with stage 4 tibialis posterior dysfunction?
Joint and ankle fusion
What is a cavovarus foot deformity?
Pes Cavus
Excessively arched foot, giving an unnaturally high instep which does not flatten on weight-bearing
Can be located in the forefoot, midfoot or hind foot
What are the causes of pes cavus?
- Freidrich’s Ataxia
- Charcot-Marie-Tooth Disease
- Trauma
- Family history
What symptoms can accompany pes cavus deformity?
- Difficulty finding shoes that fit
- Pain - Metatarsalgia, Plantar fasciitis, Ankle arthritis, Achilles tendonitis
On examination, what would you see that would indicate cavovarus foot deformity?
- Fixed Deformity - Varus Hindfoot, high instep on weight bearing
- Neurological signs - Progressive deformity, Muscle pain or weakness, Elevated creatine kinase
- Claw Toes
What is the following foot deformity?
Cavovarus foot/Pes cavus
How would you treat someone with pes cavus?
- Orthoses/footwear adaptation
- Surgery - soft tissue, bone, tendon transfer
How would you treat someone with ankle arthritis?
- Non-operative management - othoses
- Surgery - osteotomy, arthrodesis (fusion), arthroplasty
How do diabetic foot ulcer’s occur?
- Diabetic neuropathy - patient unaware of trauma + dry cracked skin due to lack of sweat
- Skin more sensitive to minor trauma
- Poor vascular supply - impairs healing process
What percentage of diabetics will develop ulceration?
15%
What are the modifiable determinants of healing of a diabetic foot ulcer?
- Diabetic control
- Smoking
- Vascular supply
- External pressure modification
- Internal pressure (deformity)
- Infection
- Nutrition
What is the 5 year mortality for those who develop diabetic foot ulcers?
50%
What percentage of those that develop diabetic foot ulcers go on to have the foot amputated?
25%
What is Charcot’s arthropathy?
Progressive degeneration of a weight bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity.
What are thought to be the processes behind the development of Charcot’s Arthropathy?
- Neurotrauma: Loss of peripheral sensation and proprioception ⇒ repetitive microtrauma ⇒ resultant inflammatory resorption of traumatized bone leaves region weak and susceptible to further trauma.
- Neurovascular: Dysregulated autonomic nervous system reflexes, and de-sensitized joints receive significantly greater blood flow ⇒ Resultant hyperemia leads to increased osteoclast resorption. This, in addition to mechanical stress, leads to bony destruction.
What is the following?
Diabetic Foot Ulcer - Complication of diabetes
The following deformity was found in someone with diabetes. What is the name of this deformity?
Charcot’s Foot
What can Charcot’s foot lead to?
Osteomyelitis - Chronic deformation may lead to repetitive trauma of the mid-foot (arch) during walking, leading to ulceration in this area
In those with Rheumatoid arhtritis of the foot, when is surgery indicated?
- Pain in spite of conservative treatment
- Deformity development
- Need to stop medication for some reason
What surgical procedures are available for those with rheumatoid arthritis in the forefoot?
- Hallux - Osteotomy, Fusion, Joint excision
- Forefoot arthroplasty - hallux fused, with lesser MTPJ joint excsion
What surgical procedures are available for those with rheumatoid arthritis in the midfoot?
Joint Fusion
What surgical procedures are available for those with rheumatoid arthritis in the hindfoot?
Generally fusion or joint replacement
- Ankle joint: Fusion or replacement
- Subtalar joint: Fusion
- Talo-navicular joint: Fusion
- Calcaneo-cuboid joint: Fusion
What is the following?
Dorsal foot ganglion
What classifies someone as having stage 1 tibialis posterior dysfunction?
- Medial pain
- No deformity
- Can single heel raise
What classifies someone as having Stage 2 tibialis posterior dysfunction?
- Flat foot
- Flexible deformity
- Cannot heel raise
What classifies someone as having Stage 3 tibialis posterior dysfunction?
- Flat foot
- Fixed deformity
What classifies someone as having Stage 4 tibialis posterior dysfunction?
Ankle Involvement
What is lisfrancs injury?
Fracture-dislocation at the 1st tarsometatarsal joint
What can be a complication of lisfrancs injury?
COmpartment syndrome of medial foot +/- later artritis
What can be seen in the following radiograph?
Lisfrancs injury
How would you manage lisfrancs injury?
Precise anatomic reduction with screw fixation acros 2nd tarsometatarsal joint (lisfranc joint)
