Foot Problems Flashcards
What are non-operative managements of foot problems?
–Analgesia
–Shoe wear modification
–Activity modification
–Weight loss
–Physiotherapy
–Orthotics including insoles and bracing
When are operations indicated on the foot?
The only indication for operative managment is failure of non-operative managment
What are the forefoot problems?
What is the aetiology of bunions (hallux valgus)?
–Genetic
–Foot wear
–Significant female preponderance)
What are the symptoms of hallux valgus?
–Pressure symptoms from shoe wear
–Pain from crossing over of toes
–Metatarsalgia
What is the pathogenesis of hallux valgus?
–Lateral angulation of great toe.
–Tendons pull realigned to lateral of centre of rotation of toe worsening deformity
–Vicious cycle of increased pull creating increased deformity
–Sesamoid bones sublux – less weight goes through great toe
–As deformity progresses abnormalities of lesser toes occur
(there is lateral angulation of the great toe, and from here there is now a lateral pull from the tendon which causes progressive worsening of the condition). Lesser toes are eventually involved)
How is diagnosis of hallux valgus achieved?
–Clinical
–Xrays
- Determine severity of underlying bony deformity
- Exclude associated degenerate change
What is the management of hallux valgus?
- Shoe wear modification (wide +/- high toe box)
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesia
–Operative (if non-operative failed or unacceptable to patient)
- Release lateral soft tissues
- Osteotomy 1st metatarsal +/- proximal phalanx
- Generally good outcome but recurrence inevitable
(so wear different shoes, change the shoes, change what you do, painkillers, operate)
Operating involves removing some bone and release of lateral soft tissues. The osteotomy is called a scarf osteotomy)
Which joint does OA affect in hallux rigidus?
Osteoarthritis of 1st MTP joint
What is the aetiology of hallux rigidus?
–Not known
–Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
–Possibly multiple microtrauma
What are the symptoms of hallux rigidus?
–Many asymptomatic
–Pain – often at extreme of dorsiflexion
–Limitation of range of movement
How is diagnosis of hallux rigidus made?
Clinical
Radiographs
What is the management of hallux rigidus?
–Non-operative
- Activity modification
- Shoe wear with rigid sole
- Analgesia
Operative
- Cheilectomy (removing bone spurs from the base of the big toe)
- Arthrodesis (fusion of the joint) (gold standard - fusion of the 1st MTPJ. Arthrodesis is a good operation if the other operations have failed
- Arthroplasty (replacing the joint) (hemiarthroplasty is a good option to maintain ROM, high failure rate, probably better for low demand patients, if the operation fails it tends to fail early.)
What are examples of lesser toe deformities?
- Claw toes
- Hammer toes
- Mallet toes
What is the aetiology of lesser toe deformities?
–Imbalance between flexors/extensors
–Shoe wear
–Neurological
–Rheumatoid arthritis
–Idiopathic
What are the symptoms of lesser toe deformities?
–Deformity
–Pain from dorsum
–Pain from plantar side (metatarsalgia)
What is the treatment of lesser toe deformities?
–Non-operative
- Activity modification
- Shoe wear – flat shoes with high toe box to accommodate deformity
- Orthotic insoles – metatarsal bar/dome support
–Operative
- Flexor to extensor transfer
- Fusion of interphalangeal joint
- Release metatarsophalangeal joint
- Shortening osteotomy of metatarsal
What is the aetiology of mortons neuroma?
–Mechanically induced degenerative neuropathy
–Tends to affect females aged 40-60
–Frequently associated with wearing high healed shoes
–Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
What are the symptoms of mortons neuroma?
–Typically affects 3rd followed by 2nd webspace/toes
–Neuralgic burning pain into toes
–Intermittent
–Altered sensation in webspace
What is the diagnosis of mortons neuroma?
–Clinical
–Mulder’s Click
–Ultrasound best / MRI good
What is the management of interdigital neuroma?
–Injection for small lesions (steroidal medication or alcohol solutions)
–Surgery – excision of lesion including a section of normal nerve
- Numbness
- Recurrence
- Up to 30% have pain 1 year post surgery
Define metatarsalgia
Metatarsalgia is a general term used to denote a painful foot condition in the metatarsal region of the foot (the area just before the toes, more commonly referred to as the ball-of-the-foot). This is a common foot disorder that can affect the bones and joints at the ball-of-the-foot. It is a symptom and not a diagnosis.
What are the causes of metatarsalgia?
Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease - a neuroma is a tumour formed on the nerve cell sheath
What is the treatment for rheumatoid forefoot?
–Non-operative – shoewear/orthotics/activity etc
–Operative
- Many described techniques
- Current gold standard
–1st MTPJ arthrodesis
–2-5th toe excision arthroplasty
What are mid foot problems?
Ganglia
OA
Plantar fibromatosis
Where do dorsal foot ganglia arise from?
Arise from the joint or tendon sheath
What is the aetiology of dorsal foot ganglia?
–Idiopathic
–Underlying arthritis
–Underlying tendon pathology
What are the symptoms of dorsal foot ganglia?
–pain from pressure from shoe wear
–Pain from underlying problem
What is it called when the foot begins to tip inwards?
Flat foot planovalgus
How does a valgus heel swing when the heel rises off the ground?
Should swing from valgus to varus
