Foot & Ankle Flashcards
hallux valgus
a deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself.
The aetiology is poorly understood.
hallux valgus risk factors
commoner in females (by up to 4:1) and there is often a familial tendency (but no direct genetic link).
incidence increases with age however it can occur in adolescence.
wearing of footwear has been implicated (the incidence is lower in populations who don’t wear shoes) but no evidence exists that tight shoes or high heels are to blame.
commoner in rheumatoid arthritis and other inflammatory arthropathies as well as some neuromuscular diseases (multiple sclerosis, cerebral palsy).
hallux valgus symptoms
may be painful due to joint incongruence and a widened forefoot may cause rubbing of the foot with shoes resulting in an inflamed bursa over the medial 1st metatarsal head known as a bunion.
The great toe and second toe may rub causing ulceration and skin breakdown.
In severe cases, the hallux may override the second toe.
hallux valgus treatment conservative
Conservative treatment includes the wearing of wider and deeper “accommodating” shoes to prevent painful bunions and the use of a spacer in the first web space to stop rubbing between the great and second toes.
hallux valgus treatment surgery
Surgical management involves osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues.
Any surgery may alter the complex biomechanics of the foot and overall around 30% of patients are dissatisfied with their surgery.
Some patients complain of pain in the metatarsal heads (metatarsalgia) after surgery.
Numerous surgical techniques have been described with no single procedure proving ideal for all cases.
Hallux rigidus: 1st MTPJ OA
It can be primary (degenerative) or secondary to osteochondral injury.
Hallux rigidus: 1st MTPJ OA treatment
Conservative treatment wearing of stiff soled shoe to limit motion at the MTPJ.
metal bar can be inserted into the sole of a shoe.
early cases where dorsal osteophytes impinge during dorsiflexion, removal of osteophytes (cheilectomy) may help.
“gold standard” surgical treatment is arthrodesis.
Successful fusion should alleviate pain with the small sacrifice of no motion (the toe is usually pretty stiff anyway).
Arthrodesis prevents women wearing high heels.
1st MTP joint replacements including ceramic total joint replacements and metal hemi‐arthroplasties are in use but the failure rates are quite high and once failure occurs, salvage surgery is difficult and results are usually disappointing.
Morton’s neuroma
Plantar interdigital nerves (from the medial and lateral plantar nerves) overlying the intermetatarsal ligaments can be subjected to repeated trauma.
Irritated nerves can become inflamed and swollen (forming a neuroma).
The third interspace nerve is most commonly involved followed by the second.
mortons neuroma risk factors
Women are four times more commonly affected and the wearing of high heels has been implicated as a cause.
mortons neuroma symptoms
Patients complain of a burning pain and tingling radiating into the affected toes.
Clinical examination may reveal loss of sensation in the affected web space.
Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic “click”; this is Mulder’s click test.
mortons neuroma investigation
mulders click test
Ultrasound may be used for diagnosis by demonstrating a swollen nerve.
mortons neuroma management
Conservative management involves the use of a metatarsal pad or offloading insole.
Steroid and local anaesthetic injections may relieve symptoms and aid diagnosis.
A neuroma can be excised.
However, some patients continue to experience pain and there is a small risk of recurrence.
Metatarsal stress fractures & who gets them
most commonly occur in the 2nd metatarsal followed by the 3rd.
They may occur in runners, in soldiers on prolonged marches, in dancers or during distance walking in people not conditioned or used to prolonged walks.
Metatarsal stress fractures investigation/ diagnosis
Xrays may not demonstrate a fracture for around 3 weeks until resorption at the fracture ends occurs or callus begins to appear.
Bone scan may be useful to confirm the diagnosis.
Metatarsal stress fractures treatment
Prolonged rest for 6‐12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms.
Tendonitis of the Achilles tendon
can occur due to repetitive strain (from sports) which leads to a peritendonitis or due to degenerative process with intrasubstance microtears
other causes of achilles tendonitis
Quinolone antibiotics (ciprofloxacin etc)
rheumatoid arthritis
other inflammatory arthropaties
gout may also predispose to tendonitis.
achilles tendonitis symptoms
Pain can be in the main substance of the Achilles tendo or at its insertion in the calcaneus.
achilles tendonitis treatment
rest, physiotherapy conditioning, use of a heel raise to offload the tendon and use of a splint or boot.
resistant cases may benefit from tendon decompression and resection of paratenon however scars in this area can be problematic and the condition is usually self‐ limiting.
Tendonitis predisposes to tendon rupture.
Steroid injection should not be administered around the Achilles tendon due to risk of rupture.
Tendon rupture
usually occurs in middle aged or older groups and is usually due to degenerative changes within the tendon or recent tendonitis.
Tendon rupture symptoms & investigation
sudden deceleration with resisted calf muscle contraction (eg lunging at squash) leads to sudden pain (like being kicked in the back of the leg) and difficulty weight bearing.
Weakness of plantar flexion and a palpable gap in the tendon are usually apparent.
No plantarflexion of the foot is seen when squeezing the calf (Simmonds test).
Tendon rupture treatment
surgery-
suture repair of the damaged tendon to restore the tension of the tendon more accurately and repair may have a slightly lower re‐ rupture rate.
repair is protected by around 8 weeks in a series of casts. Wound problems can occur with surgery and can be very problematic if healing does not occur.
non-surgical-
a series of casts in the equinous position: the ankle platarflexed with the toes pointing down, as this closes the gap in the torn tendon (again over 8 weeks or so).
this avoids the potential for wound problems and good functional outcome can usually be expected.
Plantar fasciitis & causes
self‐limiting repetitive stress / overload or degenerative condition of the foot
Diabetes, obesity and frequent walking on hard floors with poor cushioning in shoes may be causative factors.
the cushioning heel fat pad atrophies with age.
Plantar fasciitis symptoms
pain with walking is felt on the instep of the foot (at the origin of the plantar aponeurosis on the distal plantar aspect of the calcaneal tuberosity) with localized tenderness on palpation of this site.
Plantar fasciitis treatment
Rest, Achilles and plantar fascia stretching exercises and a gel filled heel pad may help.
Corticosteroid injection may also alleviate symptoms.
Symptoms can take up to two years to resolve.
Surgical release of the plantar fascia is of dubious value and risks injury to the plantar nerves.
Flat foot (pes planus)
a normal variation affecting up to 20% of the population where the medial arch does not develop in childhood.
may have a familial tendency.
Patients with generalized ligamentous laxity are more likely to have flat feet.
Developmental flat feet do not usually result in any problems and do not require any specific treatment.
Flat footed people may be at higher risk of tendonitis of the tibialis posterior tendon.
Acquired flat foot may be due to tibialis posterior tendon stretch or rupture, rheumatoid arthritis or diabetes with Charcot foot (neuropathic joint destruction).
Tibialis posterior tendon disfunction
tibialis posterior tendon inserts predominantly onto the medial navicular and serves to support the medial arch of the foot (as well as being a plantarflexor and invertor of the foot)
the tendon is under repeated stress and particularly with degeneration can develop tendonitis, elongation and eventually rupture.
synovitis form RA can also result in tendon rupture.
Tibialis posterior tendon disfunction treatment
Tendonitis should be treated with a splint with a medial arch support to avoid rupture.
If this fails to settle symptoms, surgical decompression and tenosynovectomy may prevent rupture.
Elongation or rupture leads to loss of the medial arch with resulting valgus of the heel and flattening of the medial arch of the foot.
Subsequent degenerative OA of the hindfoot and midfoot may occur.
If the foot remains supple with no OA present, a tendon transfer may be performed to try to prevent secondary OA with a calcaneal osteotomy to reduce stress often performed.
Once OA ensues, the most appropriate surgical treatment if symptoms are severe is arthrodesis.
Pes cavus
abnormally high arch of the foot. It can be idiopathic but is often related to neuromuscular conditions including Hereditary Senory and Motor Neuropathy, cerebral palsy, polio(unilateral) and spinal cord tethering from spina bifida occulta
Pes cavus treatment
Claw toes often accompany pes cavus. Its development is poorly understood.
Pain from pes cavus may be treated with soft tissue releases and tendon transfer (lateral transfer of tibialis anterior) if supple, or calcaneal osteotomy if more rigid. Severe cases may require arthrodesis.
Claw & hammer toes
occur due to acquired imbalance between the flexor and extensor tendons.
Claw toes have hyperextension at the MTPJ with hyperflexion at the PIPJ and DIP.
Hammer toes are similar but have hyperextension at the DIPJ.
Claw & hammer toes symptoms & treatment
can be painful and can rub on footwear causing corns and skin breakdown.
Toe “sleeves” and corn plasters can prevent skin problems.
Surgical solutions include tenotomy (division of an overactive tendon), tendon transfer, arthrodesis (PIPJ) or toe amputation.
