Foot and Ankle Problems Flashcards
name the common forefoot problems
hallux valgus hallux rigidus Lesser toe deformities - claw toes, hammer toe, mallet toe morton's neuroma metatarsalgia rheumatoid forefoot
what is hallux valgus also known as?
bunions
aetiology og hallux valgus
genetic
shoes
female
symptoms hallux valgus
pressure symptoms from shoe
pain from crossing over of toes
metatarsalgia
pathogenesis of hallux valgus
lateral angulation of great toe
tendon pull realigned to lateral of centre of rotation of toe, worsening deformity
vicious cycle of increased pull creating increased deformity
sesamoid bones sublux and less weight goes through great toe
as deformity progresses abnormalities of lesser toes occur
diagnosis hallux valgus
clinical
x-rays
management of hallux valgus non operative
shoe wear modification (wide and high toe box)
orthotics to offload pressure/correct deformity
activity modification
analgesia
management of hallux valgus operative
release lateral soft tissues
osteotomy 1st metatarsal +/- prox phalanx
outcome of surgical management og hallux valgus
good but recurrence inevitable
other names for hallux rigidus
stiff big toes
hallux limitus
hallux non-extensus
what causes hallux rigidus?
OA of 1st MTP
aetiology of hallux rigidus
unknown
possibly genetic
possibly multiple microtrauma
hallux rigidus symptoms
many asymptomatic
pain - often at extreme of dorsiflexion
limitation of range of movement
hallux rigidus diagnosis
clinical
radiographs
non-operative management of hallux rigidus
activity modification
shoe wear with rigid sole
analagesia
operative management of hallux rigidus
cheilectomy
arthrodesis
arthroplasty
what joints are affected in: hammer toe
prox IPJ
what joints are affected in: claw toe
prox and distal IPJ
what joints are affected in: mallet toe
distal IPJ
causes of lesser toe deformities
imbalance between flexors/extensors shoewear neurological RA idiopathic
symptoms of lesser toe deformities
deformity
pain from dorsum
pain from plantar side
non-operative treatment of lesser toe deformities
activitiy modification
shoe wear - flat with high toe box
orthotic insoles - metatarsal bar/dome support
operative treatment of lesser toe deformities
flexor to extensor transfer
fusion of interphalangeal joint
release metatarsophalangeal joint
shortening osteotomy of metatarsal
morton’s neuroma causes
mechanically induce degenerative neuropathy
high heeled shoes
common digital nerve relatively teathered to one metatarsal and movement in adjacent metatarsal causing shear
morton’s neuroma gender and age
femaes 40-60
symptoms morton’s neuroma
3rd then 2nd webspace
neuralgic burning in toes
intermittent
altered sensation in webspace
diagnosis morton’s neuroma
clinical
mulder’s click
USS/MRI
management morton’s neuroma
injection for small lesions
surgery - excision of lesion inc section of normal nerve
what may cause metatarsalgia
synovitis bursitis arthritis neuralgia neuromata Freiberg's disease tight gastrocnemius
treatment of rheumatoid forefoot non-operative
shoes
orthotics
activity
treatment of rheumatoid forefoot operative
1st MTPJ arthrodeisis
2nd-5th toe excision arthroplasty
name the common midfoot problems
dorsal foot ganglia
midfoot arthritis
plantar fibromatosis
from where do dorsal foot ganglia arise?
joint or tendon shealth
cause of dorsal foot ganglia
idiopathic
underlying arthritis
underlying tendon pathology
symptoms dorsal foot ganglia
pain from pressure from shoes
pain from underlying problem
treatment of dorsal foot ganglia
nonoperative - aspiration, book
operative - excision
recurrence rate of dorsal foot ganglia
50%
what kind of arthritis may come in the midfoot?
post traumatic arthritis
OA
RA
treatment of midfoot arthritis non operative
acitivty
shoes
orthotics
injection - xray guided
treatment of midfoot arthritis operative
fusion
plantar fibromatosis symptoms
progressive
usually asymptomatic unless very large or weight baring area
treatment plantar fibromatosis
o Non-operative § Avoid pressure – shoes/orthotics o Operative § Excision (up to 80% risk of recurrence) o Radiotherapy (similar recurrence to operative) o Combination radiotherapy and surgery – low risk recurrence/high risk complications
name common hindfoot problems
achilles tendonitis/tendinosis plantar fasciitis ankle OA tibialis posterior dysfunction cavovarus foot
what is achilles tendonitis?
degenerative/overuse condition with little inflammation
what is the only way you can make a diagnosis of achilles tendinosis?
histopathological
what is insertional achilles tendinopathy?
within 2cm of insertion
what is non-insertional/mid-substance achilles tendinopathy?
2-7cm of insertion
where may bursitis occur around the achilles?
retrocalcaneal
superficial calcaneal
what is paratendinopathy achilles?
true inflammatory problem showing paratendonitis histologically
who gets achilles paratendonopathy?
athletes
age 30-40
M:F 2:1
who gets achilles tendinopathy?
non-athletic >40 obesity steroids diabetes
symptoms of achilles tendonitis
pain during exercise pain following exercise recurrent episodes difficulty fitting shoes (insertional) rupture
diagnosis of achilles tendonitis
clinical - tenderness, rupture
investigations for achilles tendonitis
USS
MRI
non-operative treatment of achilles tendonitis
activity modification weight loss shoe modification - slight heel physio - eccentric extra-corporeal shockwave treatment immobilisation
operative treatment of achilles tendonitis
gastrocnemius recession
release and debridement of tendon
what is plantar fasciosis?
Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, avascularity
what causes plantar fasciosis?
can't make ECM required for repair and remodelling microtears not know athletes - high intensity/rapid increase running with poorly padded shoes/hard surfaces obesity occupations with long standing foot/LL rotational deformities tight gastro-soleus complex
symptoms plantar fasciosis
pain in morning
pain on weight bearing after rest
pain at origin of plantar fascia
long lasting > 2 years
plantar fasciosis DDx
nerve entrapment syndrome
arthritis
calcaneal pathology
plantar fasciosis diagnosis
mainly clinical
occassionally xray, USS, MRI
plantar fasciosis treatment
o Rest, change training o Stretching – Achilles +/- direct stretching o Ice o NSAIDs o Heel pads o Physio o Weight loss o Injections – corticosteroid (may make worse in long term) o Night splinting o Newer/3rd line § Extracorporeal shockwave therapy § Topaz plasma coblation § Nitric oxide § Platelet rich plasma § Endoscopic surgery
cause of ankle OA
commonly post traumatic
idiopathic
mean age of presentatio with ankle OA?
46
symptoms of ankle OA
pain
stiffness
diagnosis of ankle OA
clinical
radiographs
CT - exclude adjacent joint arthritis
non-operative management of ankle OA
weight loss activity modification analgesia PT steroid injections
operative management of ankle OA
If symptoms are exclusively anterior, then arthroscopic anterior debridement § Arthrodesis • Open or arthroscopic • Gold standard • Good long-term outcome § Joint replacement • Maintain range of movement • Questionable long-term outcome especially in high demand patients • Not easy to revise even to fusion
discuss tibialis posterior dysfunction
• Acquired adult flat foot planovalgus • Relatively common • Under-recognised • 4 stages • Largely clinical diagnosis – double and single heel raise • Medial or lateral pain • Diagnosis o Clinical o MRI to assess tendon • Management o Orthotics – medial arch support o Reconstruction of tendon (tendon transfer)
diabetic foot: aetiology
diabetic neuropathy
diabetic autonomic neuropathy
poor vascular supply
lack of patient education
diabetic foot: treatment
o Prevention o Modify the main detriments to healing § Diabetic control § Smoking § Vascular supply § External pressure (splints/shoes/weight bearing) § Internal pressure (deformity) § Infection § Nutrition o Operative § Improve vascular supply § Debride ulcers and get deep samples for microbiology § Correct any deformity to offload area
diabetic foot: prognosis
o 15% of all diabetics will develop ulceration
o 85% of all amputations for diabetics are preceded by foot ulceration
o 25% of patients with diabetic ulcers go on to amputation
o 5-year patient mortality 50%
charcot neuroarthropathy: aetiology
o Any cause of neuropathy
o Diabetes commonest cause
o Historically originally described and most common with syphilis
charcot neuroarthropathy: pathophysiology 2 theories
o Neurotraumatic
§ Lack of proprioception and protective pain sensation
o Neurovascular
§ Abnormal autonomic NS results in increased vascular supply and bone resorption
charcot neuroarthropathy: is characterised by rapid bone destruction occuring in 3 stages
fragmentation
coalescence
remodelling
charcot neuroarthropathy: diagnosis
o High index of suspicion
o Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy
o Greater than 3-degree difference between limbs
o Frequently not painful
o Radiographs
o MRI
charcot neuroarthropathy: management
o Prevention
o Immobilisation/non-weight bearing until acute fragmentation resolved
o Correct deformity
§ Deformity leads to ulceration à infection à amputation
