Foot and Ankle Problems Flashcards
Non-operative management of foot and ankle problems
Analgesia Shoe wear modification Activity modification weight loss physio orthotics including insoles and bracing
Only indication for operative management in foot and ankle problems
Failure of non-operative management
Definition of achilles tendonitis/tedinosis
Degeneration/overuse condition of the achilles tendon with little inflammation
Definition of paratendinopathy
True inflammatory problem showing paratendoitis histologically
What is tendinopathy?
A term used to describe symptoms
Who gets paratendinopathy in achilles tendonitis?
Athletic populations
30-40 y/os
M > F
Who gets tendinopathy in achilles tendonitis?
Non-athletic populations > 40 y/os Obesity Steriods Diabetes
Symptoms of achilles tendonitis
Pain during exercise Pain following exercise Recurrent episodes Difficulty fitting shoes (insertional) RUPTURE tenderness
Investigations for achilles tendonitis
tenderness Simmonds test angle of dangle and matles USS MRI
Tests for rupture of achilles tendon
Simmonds test
Angle of dangle and matles
how does Simmonds test work?
Feet hanging off the bed lying face down
calf is squeexed
IF MOVES FOOT - then tendon not fully ruptured between the soleus mucle and heel bone
IF DOESNT MOVE FOOT - then full rupture of the tendon
Treatment of achilles tendonitis
activity modification weight loss shoe wear modification - > slight heel Extracorpeal shockwave treatment Physio-eccentric stretching Immbolilisation (below knee cast) operative - gastrocnemius resection - release and debridement of tendon
Definition of plantar fasciitis
inflammation of the plantar fascia that runs along the bottom of the foot and connects the heel bone to the toes
Pathology of plantar fasciitis
Chronic degenerative change fibroblast hypertrophy absence of inflammatory cells disorganised and dysfunctional vessels and collagen avascularity
Who is plantar fasciitis seen in?
Athletes with high intensity or rapid increase in training
Running in poorly padded shoes or on hard surfaces
Obesity
occupations with prolonged standing
foot/lower limb rotational deformities
tight gastro-soleus complex
Symptoms 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 long lasting > 2 + years
Differential diagnosis of plantar fasciitis
nerve entrapement syndrome
arthritis
calcaneal pathology
Investigations of plantar fasciitis
Mainly clinical
Xrays
USS
MRI
Treatment of plantar fasciitis
Rest, change training Stretching = achilles +/- direct stretching Ice NSAIDs Arthoses - heel pads physio weight loss injections - corticosteriods extracorpoel shockwave therapy nitric oxide endoplasmic/open surgery platlet rich plasma topaz plasma coblation
What is hallux valgus?
Bunions
Which gender is hallux valgus most seen in?
Females
Causes of hallux valgus
Genetic
footwear
Symptoms of hallux valgus
deformed foot shape pressure
pressure symptoms from shoewear
pain from crossing over toes
metatarsalgia
What is metatarsalgia?
Pain and inflammation in the ball of the foot
Pathology of hallux valgus
Lateral angulation of great toe
Tendon pull realigned to centre of rotation of worsening deformity
Viscous cycle of increased pull creating increased deformity
Sesamoid bones sublex - less weight goes through the great toe
As deformity progresses, abnormality of the lesser toes occur
Investigations of hallux valgus
clinical
x-ray
- severity of deformity
- exclude associated degenerative change
Treatment of hallux valgus
shoe wear modification (wide +/- high toe box)
orthotics to offload pressure/correct deformity
activity modification
analgesia
operative
- release lateral soft tissues
- osteotomy 1st metatarsal +/- proximal phalanx
What is hallux rigidus?
Osteoarthritis of 1st MTP joint - stiff big toe
Causes of hallux rigidus
unknown
genetic
multiple microtrauma
Symptoms of hallux rigidus
mainly asymptomatic
extreme pain on dorsiflexion
limited ROM
Investigations of hallux rigidus
clinical
radiographs
Treatment of hallux rigidus
activity modification shoe wear with rigid sole (limited bending of toe) analgesia Surgery - cheilectomy - arthrodesis - arthroplasty - 1st MTPJ fusion - GOLD STANDARD - 1st MTPJ hemiarthropalsty
Pathology of claw toes
MTP hyperextended
Distal and proximal ITP flexed
Pathology of hammer toe
MTP can be extended but sometimes not
Distal ITP is straight or hyperextended
Causes of mallet toe
Imbalance between flexors/extensors Shoe wear (long 2nd toe being pushed down in shoe) neurological RA idiopathic
Symptoms of mallet toe
Deformity Pain from dorsum - from joint - from where toe sticks up rubbing on shoe Pain from plantar side - metatarsalgia
Treatment of mallet toe
activity modification shoe wear - flat shoes with high toe box to accommodate deformity orthotic insoles operative - flexor to extensor transfer - fusion of interphalangeal joint - release of metatarsophalangeal joint - shortening of osteotomy of metatarsal
What is mortons neuroma?
common digital nerve branches become individual nerves in between the metatarsal heads - interdigital neuralgia
symptoms of Mortons neuroma
Typically affects 3rd and 2nd webspaces pain - neuralgic burning pain - pain in between metatarsal heads - pain on the plantar side Inflammation and swelling severe numbness intermittent - especially if barefooted altered sensation in webspace
Who does mortons neuropathy tend to affect?
females aged 40-60
What is mortons neuroma frequently associated with?
Wearing high heeled shoes
investigations of mortons neuroma
clinical
mulders click
USS - BEST CHOICE
MRI
What is mulder’s click?
squeeze the metatarsal heads together and you will feel a CLICK
Treatment of mortons neuroma
injections for small lesions
exicision of lesion including a section of normal nerve
- ALWAYS leads to NUMBNESS
Mean presentation of ankle arthritis
46 y/o
Causes of ankle arthritis
Commonly post traumatic
idiopathic
Symptoms of ankle arthritis
Pain
stiffness
Diagnosis of ankle arthritis
clinical
radiographs
CT scan - to exclude other adjacent joint arthritis
treatment of ankle arthritis
weight loss activity modification analgesia physio steroid injections arthrodesis - GOLD STANDARD joint replacement
What is posterior tibial tendon dysfunction?
Acquired adult flat foot planovalgus
Diagnosis of posterior tibial tendon dysfunction?
Clinical = double or single heel rise MRI = to assess tendon
Presentation of posterior tibial dysfunction
flat foot planovalgus
medial or lateral pain
In double/single heel rise, what should happen to the heels?
Should swing from valgus to varus as heal rises
Treatment of posterior tibial tendon dysfunction
orthotics - medial arch support
reconstruction of tendon
triple fusion
- subtalar, talonavicular, calcaneouboid
Treatment of rheumatoid forefoot
shoewear orthotics activity modification gold standard - MTPJ arthrodesis - 2-5th toe excision arthroplasty
Where do dorsal foot ganglion arise from?
Joint
tendon sheath
Causes of dorsal foot ganglia
Idiopathic
underlying arthritis
underlying tendon pathology
Symptoms of dorsal foot ganglia
condition itself doesn’t present with pain but can get pain from
- pressure of shoewear
- underlying problem
Treatment of dorsal foot ganglia
Aspiration
operative excision
Recurrence rate of dorsal foot ganglia
high - 50%
What is plantar fibromatosis also known as?
Ledderhose disease and
Dupytrens of the foot
Pathology of plantar fibromatosis
progressive thickening if the foots deep connective tissue (fascia)
Presentation of plantar fibromatosis
Usually asymptomatic unless
- very large
- weight bearing area
Treatment of plantar fibromatosis
Avoid pressure - shoewear/orthotics
Operative excision
radiotherapy
Recurrence rate of plantar fibromatosis
very high - up to 80%
Causes of diabetic foot ulcer
diabetic neuropathy (unaware of trauma) diabetic autonomic neuropathy - lack of sweating/normal sebum production leading to dry cracked skin and skin being more sensitive to minor trauma poor vascular supply lack of patient education
Treatment of diabetic foot ulcer
prevention modify detriments to healing - diabetic control - smoking - vascular supply - external pressure (splints/shoe/weight bearing) - internal pressure (deformity) - infection - nutrition surgery - improve vascular supply - debride ulcers - correct any deformity to offload area - amputation
How many diabetic patients will develop ulceration?
15%
How many diabetic patients with ulcers will go onto amputation?
25%
5 year mortality of diabetic patients with ulcers
50%
Pathology of charcot’s neuroathropathy
Neurotraumatic
- lack of proprioception and protective pain sensation
Neurovascular
- abnormal autonomic nervous system results in increased vascular supply and bone resorption
Rapid bone destruction occurring in 3 stages
1. fragmentation
2. coalescence
3. remodelling
Causes of charcot’s neuroarthropathy
any cause of neuropathy
diabetes
syphillius
Presentation of charcots neuroarhropathy
not painful swelling erythematous foot neuropathy fractures/dislocations from minimal or no known trauma
Diagnosis of charcots neuroarthropathy
clinical
radiographs
MRI
Treatment of charcot’s neuroarthropathy
prevention
immobilisation/non weight bearing until acute fragmentation resolved
correct deformity
What is used to look for evidence of achilles tendon rupture?
Simmonds triad
- Palpation
- Examining the angle of declination at rest
- Calf squeeze test
What drug can have S/Es of new onset achilles tendon disorders?
Ciprofloxacin
