Foot & Ankle Problems Flashcards
what surgical options exist for advanced ankle OA
arthrodesis (more reliable) ankle replacement (reserved for older patients as can get major malalignment)
what ligaments typically involved in ankle sprain
ATFL (anterior talofibular ligament) CFL (calcaneofibular ligament)
what symptoms of ankle sprain
pain, bruising and tenderness
how is ankle sprain severity measured
grade 1-3, 3 is complete tear of ligament
what is non-operative management of ankle sprain
RICE = rest, ice, compression and elevation physiotherapy = strength, stability, proprioception
what is operative management of ankle sprain
brostrum gould chrisman snook
what are the the different classification of ankle fractures
Weber classification
what is a stable ankle fracture
distal fibula fracture with no medial malleolus fracture or deltoid ligament rupture
what is an unstable ankle fracture
distal fibula fracture with medial malleolus fracture or deltoid ligament rupture
what is hallux valgus
deformity of great toe due to medial deviation of 1st metatarsal and lateral deviation of toe itself bunion
who is it more common in
females incidence increases with age commoner inflammatory arthropathies and some neuromuscular diseases (MS, cerebral palsy)
what are consequences of hallux valgus
painful due to joint incongruence inflamed bursa due to rubbing on shoes (this is the bunion) great toe and second toe may rub causing ulceration severe cases = hallux may override second toe
what is conservative treatment of hallux valgus
wearing of more accommodating shoes to prevent painful bunions and use of spacer in first web to stop rubbing between toes
what is surgical management of hallux valgus but why should caution be applied with this
osteotomies to realign bones and soft tissue procedures to tighten slack tissues and release tight tissue caution as often unhappy cosmetically and some complain of metatarsalgia (pain) after surgery
what is hallux rigidus
OA of first MTPJ
what are conservative treatments of hallux rigidus
wearing stiff soled shoe to limit motion to MTPJ, a metal bar can be inserted into sole of shoe
what surgery can take place in early cases of hallux rigidus where dorsal osteophytes impinge during dorsiflexion
removal of osteophytes (cheilectomy)
what is the gold standard surgical treatment of hallux rigidus
arthrodesis (alleviate pain with small sacrifice of no motion) SE: prevents women wearing heels 1st MTP joint replacement is in place but failure rate quite high n when it does fail salvage surgery is difficult
what is morton’s neuroma
plantar interdigital nerves (from medial and lateral plantar nerves) overlying the intermetatarsal ligaments can be subject to repeated trauma and irritated nerves can become inflamed and swollen forming a neuroma
who is mortons neuroma more common in
women 4x more common since wearing of high heels been implicated as cause
what nerve is most commonly involved in mortons neuroma
third interspace nerve followed by second
what are symptoms of mortons neuroma
burning pain and tingling radiating into affected toes
what may clinical examination reveal in mortons neuroma
loss of sensation in affected web space Mulder’s test = medio-lateral compression of the metatarsal heads (squeezing forefoot with your hand) may reproduce symptoms or produce click
how is morton’s neuroma
ultrasound = demonstrates swollen nerve
what is treatment of morton’s neuroma
conservative = metatarsal pad or offloading insole. Steroid and local anaesthetic injections may relieve symptoms and aid diagnosis A neuroma can be excited but some patients still get pain etc
in which metatarsal does stress fracture most commonly occur and in which conditions do they commonly occur
2nd, followed by 3rd occur in runners, in solders on prolonged marches, in dancers or distance walking in people not used to it
how is metatarsal stress fracture diagnosed
xray may not demonstrate fracture for about 3 weeks until reabsorption at fracture end occurs or callus begins to appear, bone scan may be useful to confirm diagnosis
how is metatarsal stress fracture treated
prolonged rest for 6-12 weeks in a rigid soled boot
what causes tendonitis of achilles tendon
repetitive strain (from sports) which leads to a peritendonitis or due to degenerative process with intrasubstance microtears
what are risk factors for achilles tendonitis
quinolone antibiotics (ciprofloxacin etc), RA, other inflammatory arthropathies and gout
what are the symptoms of achilles tendonitis
pain either in achilles tendon or its insertion in calcaneus also lost outline of achilles tendon
how is achilles tendonitis treated
self limiting = rest, physiotherapy, use of heel raise to offload tendon and use of splint or boot resistant causes may benefit from tendon decompression and resection of paratenon
why should steroids NOT be administered around achilles tendon
risk of rupture
who does achilles tendon rupture usually occur in
middle aged or older groups as it is usually due to degenerative changes within tendon or recent tendonitis
what is symptoms of an achilles tendon rupture
sudden deceleration with resisted calf muscle contraction (eg lunging at squash) leads to sudden pain (like kick in back of leg) and difficult weight bearing
what clinical signs are seen i achilles tendon rupture
weakness of plantar flexion and a palpable gap in tendon simmond’s test = no plantarflexion of foot is seen when squeezing calf
some surgeons recommend surgical treatment of achilles tendon rupture, what does this entail
repair of damaged tendon to restore tension of tendon more accurately and reduce risk of re-rupture repair is protected by around 8 weeks in a series of casts
other surgeons recommend non-operative management, what does this entail
a series of casts in equinous position (ankle plantarflexed with toes pointing down as this closes gap in torn tendon - again 8 weeks or so) this avoids potential for wound problems and good functional outcome can be expected
what is process of tibialis posterior dysfunction
tenosynovitis -> progressive elongation -> rupture complication - OA of hindfoot and midfoot may occur
what is type 1 tibialis posterior dysfunction
swelling, tenderness, slightly weak power
what is type 2 tibialis posterior dysfunction
planovalgus, midfoot abduction, passively correctable
what is type 3 and 4 tibialis posterior dysfunction
fixity and mortise signs
what are symptoms of tibialis posterior dysfunction
progressive flat foot and valgus hindfoot
how is tibialis posterior dysfunction treated
NSAIDS, insole / splints with a medial arch support to avoid rupture if this fails = surgical decompression and tenosynovectomy may prevent rupture NO STEROID INJECTION
what are risk factors for tibialis posterior dysfunction
obese middle aged female, flat foot, hypertension, diabetes, steroid injection, seronegative arthropathies, idiopathic tendonosis
what is plantar fasciitis
another self limiting repetitive stress or degenerative condition of foot
what are risk factors for plantar fasciitis
diabetes, obesity and frequent walking on hard floors with poor cushioning in shoes (more frequent as older since cushioning heel fat pad atrophies with age)
what are the symptoms of plantar fasciitis
pain with walking is felt on the instep of foot (at origin of plantar aponeurosis on the distal plantar aspect of calcaneal tuberosity) with localised tenderness on palpation of this site pain also felt on heel pad
how is plantar fasciitis diagnosed
tinel’s test positive for baxters nerve
how is plantar fasciitis treated
NSAIDs, rest, gel filled heel pad, night splint, corticosteroid injection, achilles and plantar fascia stretching exercises
how long can plantar fasciitis take to resolve
2 years surgical release of plantar fascia not of any value
what is pes planus
flat feet - can be a normal variation affecting up to 20% of population where medial arch does not develop in childhood
what is risk factors of flat foot
familial tendency and patients with generalised ligamentous laxity are more likely to have flat feet
are flat feet treated
no, dont really result in any problems
what are complications of flat foot
higher risk of tendonitis of tibialis posterior tendon
what may cause acquired flat foot
tibialis posterior tendon stretch or rupture, RA or diabetes with charcot foot (neuropathic joint destruction)
what is pes cavus
abnormally high arch of foot
what causes pes cavus
can be idiopathic but often related to neuromuscular conditions including hereditary sensory and motor neuropathy, cerebal palsy, polio (unilateral) and spinal cord tethering from spinal bifida occults
what are symptoms of pes cavus
obvious high arch, claw toes often accompany pes cavus
what is treatment of pes cavus
often dont need it 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
why do claw toes and hammer toes occur
imbalance between flexor and extensor tendons
what are symptoms of claw and hammer toes
claw toes = hyperextension at MTPJ with hyperflexion at PIPJ and DIPJ
hammer toes = similar but have hyperextension at DIPJ
how are claw and hammer toes treated
toe sleeves and corn plasters can prevent skin problems (toes rubbing on footwear causing corns and skin breakdown) surgical solution = tenotomy, tendon transfer, arthrodesis (PIPJ) or amputation
