Foot disorders/reactive arthritis Flashcards
Anatomy of the Foot
26 bones of the foot are divided into 3 groups:
Tarsals
Metatarsals
Phalanges
Plantar arches function to:
Distribute and absorb the body weight
Provide the foot with elasticity and resilience during locomotion
Adapt to uneven surfaces
Protect the neurovasculature on the plantar surface
Bunion
general
Hallux valgus deformity of the 1st metatarsal phalangeal (MTP) joint
Most common cause of forefootpain
Pain is exacerbated by wearing shoes
Diagnosed clinically based on a history of great toepain and increasing valgusdeformity
Bunion
Tx
Conservative management: wear roomy shoes, bunion pads/cushions, NSAIDs for pain, application of ice
Surgical management: bunionectomy
Morton neuroma
General and sx
Commonly occurs in runners
Mechanism involves a mechanically induced neuropathic degeneration of the interdigital nerves
Patient presents with burningpain and numbness at the third intermetatarsal space
Clicking sensation, tenderness, and crepitus during palpation
Morton neuroma
Tx
Strength exercises
Padded shoes inserts
Glucocorticoid and local anesthetic injection
Surgery for patients that have failed conservative management; rare recurrence after surgery
Corns and calluses
general
Arise from abnormal pressure over theskinand bony prominences from shoes orfootbreakdown
Calluses
Diffuse thickening of thestratum corneum layer on the plantar aspect of the foot
Corns
Central “core” that is hyperkeratotic and often painful
Corns and calluses
Tx
Application of salicylic acid or cryotherapy with liquid nitrogen
Education the patient on proper fitting shoes
Pes cavus & Pes planus
general
Causes in childhood and adulthood
Increased risk of midfootpainin individuals with these conditions
Pes cavus = high-arched feet
Usually caused by neurologic disorders
Foot is supinated
Pes planus = flat feet
Collapse of the longitudinal arches, especially the medial longitudinal arch
Foot is pronated
Normal for infants and young children due to ligamentous laxity
Pes planusin adulthood may be due to a breakdown in supporting structures (posterior tibialis tendon andspring ligament)
Pes cavus & Pes planus
Tx
Orthotic devices or bracing
Shoe modification
Plantar fasciitis
General
MOI
Condition that produces pain at the site of the attachment of the plantar fascia and the calcaneus (calcaneal enthesopathy), with or without accompanying pain along the medial band of the plantar fascia
Commonly due to overuse stress
Problematic for patient with heel spurs, pes cavus, and pes planus
Plantar fasciitis
pain
Medially located on the plantar surface
Most significant with first steps in the morning or after prolonged sitting
Tenderness is elicited by palpating thefasciafrom the heel to the forefoot while dorsiflexing the patient’s toes
Plantar fasciitis
Tx
Stretching exercises for the plantarfascia and calf muscles
Avoid the use of flat shoes and barefoot walking
Use arch supports and/or heel cups
Decrease physical activities (excessive running, dancing, or jumping)
Short-term trial (2–3 weeks) ofNSAIDs
If all previous measures fail, an injection of glucocorticoidsand a local anesthetic by a podiatrist or orthopedist
Lisfranc Injury
general
MOI
Tarsometatarsal fracture-dislocation characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal
Lisfranc ligament
An interosseous ligament between the medial cuneiform and the base of the 2nd metatarsalbone
Critical to stabilizing the 1st and 2nd tarsometatarsal joints and maintenance of the midfoot arch
Commonly occurs when there is indirect loading on a plantar-flexed foot or with acrush injury
Lisfranc injury
clin man
Severe midfoot pain
Swelling or deformity in the midfoot
Ecchymosis
Lisfranc injury
Diagnosis
Plain-film radiograph of the foot (weight-bearing)
Space between the base of the first and second metatarsal bones
Space is > 2 mm, then a Lisfranc ligament injury should be considered
Avulsion fracture (fleck sign) is seen at the base of the second metatarsal or medial cuneiform
MRI
Allow for assessment of the integrity of the ligament
Obtain for patients that cannot bear weight
Lisfranc injury
Tx
Non-operative for non-displaced injuries
6-8 weeks non-weight bearing in a cast
Operative for displaced injuries or significant instability of the midfoot
Reactive Art
general
Aka
Previously known as Reiter’s syndrome
Seronegative autoimmune spondyloarthropathy that occurs in response to a previous gastrointestinal (GI) or genitourinary (GU) infection
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Occurs more frequently in young adults (< 40 years of age)
70%–90% have the HLA-B27 allele
Seronegative arthropathies include:
“PAIR”
Psoriatic arthritis
Ankylosing spondylitis
Inflammatory bowel disease–associated arthritis
Reactive Arthritis
reactive art
etiology
Generally occurs 1–4 weeks after infections:
Genitourinary (GU):
Chlamydia trachomatis(most common)
Neisseria gonorrhoeae
Ureaplasma urealyticum
Gastrointestinal (GI):
Campylobacter jejuni(most common)
Shigella flexneri, S. dysenteriae,andS. sonnei
Salmonella enterica
Yersinia enterocoliticaandYersinia pseudotuberculosis
Escherichia coli
all gram negative.
reactive arthritis
Articular manifestations
Onset is acute, within 1–4 weeks of an inciting infection
Peripheral arthritis
Joint involvement is generally asymmetric
Can be oligoarticular or polyarticular
Predominantly of the large weight-bearing joints of the lower extremities:
Knees
Ankles
Other common joints:
Shoulders, wrists, elbows, small joints of hands and feet
Back pain – severe disease
reactive arthritis
On exam, joints will be:
Tender, warm, and swollen
reactive arthritis
Enthesopathy:
Inflammation at the site of ligament, tendon, fascia, or joint capsule insertion to bone
Tenderness and swelling
Common insertion sites:
Achilles tendon
Plantar fascia (insertion site on the calcaneus)
Ischial tuberosities
Iliac crests
Tibial tuberosities
Ribs
reactive arthritis
Hand and back S/Sx
Dactylitis:
Swollen fingers and toes (“sausage digits”)
Sacroiliitis:
Inflammation of the sacroiliac joints
Low back pain
Decreased lumbar flexion
reactive arthritis
ocular and GU Sx
Ocular: visual acuity is fine
Conjunctivitis (most common)
Anterior uveitis
Episcleritis
Keratitis
Genitourinary:
Urethritis 7-14 days after sexual contact
Cervicitis
Prostatitis
Cystitis
Salpingo-oophoritis
reactive arthritis
cutaneous & GI Sx
Mucocutaneous:
Keratoderma blennorrhagicum
Vesicles of the palms, soles, and around nails
Become hyperkeratotic and form crusts
Appears similar to pustular psoriasis
Balanitis circinata
Shallow, painless ulcers of the glans penis
Painless oral ulcers
Nail dystrophy
Gastrointestinal:
Intermittent diarrhea
reactive arthritis
Classic Triad
This classic triad of symptoms is found in only about 30% of patients:
Conjunctivitis
Urethritis
Post-infectious arthritis
reactive arthritis
reactive arthritis
Dx
Reactive arthritis is a clinical diagnosis based on:
Acute oligoarthritis and typical articular manifestations
Preceding GI or genitourinary (GU) infection
Presence of ≥ 1 extra-articular manifestation
Exclusion of other diagnoses
Supporting work-up:
Synovial fluid analysis
Laboratory findings:
Inflammatory markers (ESR and/or CRP) normal or ↑
Stool cultures → evaluate for causative organisms if the patient is having diarrhea
Urine or genital swab → evaluate forC. trachomatis and N. gonorrhoeae
HLA-B27 testing
Antigens of the organisms causing infection are frequently isolated, but no bacterial growth occurs on culture
reactive arthritis
Acute Tx
Symptoms of ReA typically resolve in 3‒4 months, but prolonged or recurrent symptoms can occur in up to 50% of patients
Acute presentation (duration < 6 months):
Nonsteroidal anti-inflammatory drugs (NSAIDs)are the mainstay of therapy
Naproxen, Diclofenac, Indomethacin
Intra-articular or systemic glucocorticoids
Reserved for those with an inadequate response to NSAIDs
Disease-modifying antirheumatic drugs (DMARDs)
Indicated if a patient fails the above treatments
reactive arthritis
Chronic ReA
Tx
(duration > 6 months):
DMARDs – methotrexate or sulfasalazine
Tumor necrosis factor (TNF) inhibitors
Considered in patients who do not respond to DMARDs
ReA
Management of underlying infections
GI infection
Antibiotics are generally not indicated
Exceptions:
Severe disease, elderly or immunocompromised patients
GU infection
C. trachomatistreatment
First-line therapy with either:
Doxycycline 100 mg twice daily for 7 days
Azithromycin 1 g PO once
N.gonorrhoeae treatment
Single-agent therapy with ceftriaxone (Rocephin) is the preferred regimen:
500 mg IM once (individuals who weigh < 150 kg)
1,000 mg IM once (individuals who weigh ≥150 kg
