Foot Problems Flashcards
What is the common word for hallux valgus?
Bunions
What is the aetiology of hallux valgus?
Genetic (foot shape runs in families)
Footwear (high heels push the forefoot into wedge)
Most common in females
What symptoms are caused by hallux valgus?
Pressure symptoms from shoe wear
Painful lump
Pain from toes crossing over
Metatarsalgia
What is the pathogenesis of hallux valgus?
Lump is from swollen bursa and osseous anomaly on MT head
Lateral angulation of big toe
Tendon pull reaiigned to lateral of central rotation of toe worsening deformity
Viscous cycle –> inc. pull –> inc. deformity
Sesmoid bones sublux
As deformity progresses –> abnormalities of lesser toes
What is used to diagnose hallux valgus?
Clinical diagnosis and Xray used (look for appropriate signs, e.g. inc. MT angle, sublux sesmoids etc.)
Exclude assoc. Degen. change
How do you treat hallux valgus non-operatively?
Orthotics, shoe wear, activity modification, analgesia
How do you treat hallux valgus operatively?
Release lateral soft tissue
Osteotomy 1st MT +/- proximal phalanx (recurrence inevitable)
What is hallux rigidus?
Stiff big toe
OA of 1st toe
In which groups of people does it occur?
Peak in young people and 70-80s
What is the aetiology of hallux ridigus?
?multiple episodes of microtrauma –> OA
?Genetic (typical shape of metatarsal head slightly pointed rather than rounded)
What are the symptoms of hallux rigidus?
May be asymptomatic
Pain (esp. on extreme dorsiflexion as this is when osteophytes rub against each other)
Restricted RoM
How is hallux rigidus diagnosed?
Clinical
Xray - look for features of OA (subchondral cysts, loss of joint space etc.)
How do you manage hallux rigidus non-operatively?
Orthotics, shoe wear, analgesia, activity modification
How do you manage hallux rigidus operatively?
Gold standard is arthrodesis
May also do arthroplasty or cheilectomy
What is cheilectomy?
Removal of osteophytes
What is the appearance of claw toes?
Hyperextended MTPJ, flexed DIP and PIP
What is the appearance of hammer toes?
Flexed PIP, straight/hyperextended PIP
What is the appearance of mallet toe?
Flexed DIP
What symptoms can occur from lesser toe deformities?
Pain (metatarsalgia) on plantar side
Deformity
How can you manage lesser toe deformities non-operatively?
Orthotics, activity modification, shoe wear, analgesia
How can you manage lesser toe deformities operatively?
Flexor –> extensor transfer
Fusion of IP joint
Release of MTP joint
Shortening osteotomy of metatarsal
What is Morton Neuroma?
Mechanically induced degenerative neuropathy (e.g. freq. wearing of heels) leading to common digital nerve becoming relatively tethered to one metatarsal and movement of the adjacent metatarsal causes mechanical shearing
IT IS A THICKENING OF THE NERVE
Where does the common plantar digital nerve run and what is its function?
Runs between MTs and supplies sensation to the skin
Where does Morton neuroma most commonly occur?
2nd and 3rd webspace (as these are the smallest gaps)
What symptoms are caused by Morton neuroma?
Intermittent burning sensation in interdigital space (that spreads into the toes)
Altered sensation in webspace
How do you diagnose Morton neuroma?
Clinical - can use Mulder’s click
USS
What is Mulder’s click?
Pressing the two MT heads together and putting pressure on webspace should lead to clicking noise and ilict pain/paraesthesia radiating tot eh affected toes
How do you treat Morton neuroma?
If small - injection (blind or with USS guidance)
If bigger - excision of neuroma and section of healthy tissue (SE: numbness and recurrence is 30%)
What is metatarsalgia?
A group of symptoms including burning/aching pain on the balls of the feet spreading to the toes
What can cause metatarsalgia?
Arthritis, bursitis, neuralgia, Freiberg disease, neuromata, synovitis, tight gastrocn
How can you non-operatively manage rheumatoid forefoot?
Footwear, orthotics, analgesia, activity modification
How can you operatively manage rheumatoid forefoot?
Gold standard - 1t MTPJ arthrodesis and 2-5th toe excision arthroplasty (joint surface and bones removed, surfaces remodelled and left to scar together)
What are dorsal foot ganglia?
Benign transilluminating liquid filled nodules that arise from the joint/tendon sheath
What are the aetiology of dorsal foot ganglia?
Idiopathic
Underlying arthritis/other tendon pathology
What symptoms can be experienced in dorsal foot ganglia?
Pain from pressure (shoewear)
How can you manage dorsal foot ganglia?
Non-op: aspiration/hit with the bible (hit it hard enough that it pops)
Op - excision (recurrence 50% (not worth it))
What are the types of midfoot arthritis?
Post-traumatic OA, RA, OA
How do you manage midfoot arthritis?
Non-op: activity modifications, shoewear, orthotics etc.
Injections (XRay guided)
Fusion
What is plantar fibromatosis otherwise known as?
Duputyrens of the foot
What is plantar fibromatosis?
Thickening of the plantar fascia (initial stages involve development of nodules in the plantar fascia)
What symptoms are associated with plantar fibromatosis?
Rubbing of nodules causes pain
Contracture of toes in later stages (usually nearest the highest part of the arch of the foot)
Usually asymptomatic unless v. large or on weight bearing area
What is the prognosis of plantar fibromatosis?
It is progressive
How do you manage plantar fibromatosis?
Avoid pressure, orthotics
Excision
RT
Combination RT and excision (higher complications vs lower recurrence rate)
Define tendonitis
Inflammation of the tendon
Define tendinosis
Non-inflammatory degeneration of the tendon (usually from repetitive microtrauma)
Define paratenonitis
Inflammation of the surrounding tendon sheath (the paratenon)
Define insertional tendinopathy
Tendinopathy within 2cm of the insertion of the tendon
Define non-insertional tendinopathy
Tendinopathy 2cm-7cm away from the insertion of the tendon
What kind of bursitis may cause posterior ankle pain?
Retrocalcaneal or superficial calcaneal
How do you diagnose paratenopathy?
Requires a biopsy for diagnosis
Who is achilles paratenonitis more common in?
Younger, athletic populations (30s-40s)
Who is achilles tendonosis more common in?
Non-athletic populations, >40yo
RF include DM, obesity and steroid use
What symptoms are associated with achilles tendinopathy?
During on posterior aspect of ankle following exercise/during exercise
Difficulty with plantarflexion
Difficulty fitting shoes
Tenderness over tendon
What must you always check for in achilles tendinopathy?
For rupture - using Matle’s/angle of the dangle or Simmonds test
What is a positive Matle’s test?
Dorsiflexion of affected foot
What is a positive Simmonds test?
Failed plantarflexion of foot on squeezing the calf (this can be very sore!!)
What imaging can you use for suspected achilles tendinopathy?
USS/MRI
What is management for achilles tendinopathy?
Non-op: activity modification, wt loss, shoe wear modification, orthotics, physioterhapy (eccentric stretching), ECSW treatment, immobilisation (in knee cast)
Op: gastrocn. recession, release and debridement of tendon
What is plantar fasciitis?
Disorder of the connective tissue supporting the arch of the foot (chronic degenerative change with fibroblast hypertrophy - not inflammatory!)
What is the aetiology of plantar fasciitis?
Unable to make ECM Microtears Athletes: increase in training/running on hard ground/improper footwear Obesity Occupations with prolonged standing Lower limb/foot rotational deformities Tight gastro-soleus complex
What symptoms are associated with plantar fasciits?
Pain at origin of plantar fascia first thing in the morning/after rest
Pain long lasting (>2y+)
What are differential diagnoses for plantar fasciits?
Nerve entrapment, arthritis, calcaneal pathology
How do you diagnose plantar fasciitis?
Mainly clinical
Occassionally use XRay, MRI or USS
What is first line treatment for plantar fasciitis?
Rest, changing training, ice, NSAIDs, orthoses, physio, wt loss, night splinting
What is 2nd line treatment for plantar fasciitis?
Corticosteroid injections (only for short term, may make worse long term?)
What is 3rd line treatment for plantar fasciitis?
ECSW therapy, topaz plasma coblation, nitric oxide, platelet rich plasma, endoscopic/open surgery
What is the mean age of presentation of ankle arthritis?
46yo
How common is ankle arthritis?
Relatively uncommon (esp compared to knee and hip)
What symptoms are associated with ankle arthritis?
Pain and stiffness
How do you diagnose ankle arthritis?
Clinical
Xray
CTS - to exclude adjacent joint arthiritis
How do you treat ankle arthritis?
Non-op: wt loss, activity modification, analgesia, physiotherapy, steroid injections
Op: gold standard is arthrodesis, if symptoms purely ant. can do arthroscopic ant. debridement
Arthroplasty
What results from posterior tibial tendon dysfunction?
Lowering of the longitudinal arch of the foot (i.e. planovalgus or acquired adult flatfoot)
How many clinical stages are there of planovalgus?
4
How do you diagnose posterior tibial tendon dysfunction?
Mostly clinical - single and double heel raise
MRI to assess tendon
What is involved in a single and double heel raise?
Heels should swing from valgus to varus as heel raises
What are signs and symptoms of posterior tibial tendon dysfunction?
Asymptomatic or medial/lateral pain
Heel is valgus - can impinge on medial malleolus –> pain
How do you treat posterior tibial tendon dysfunction?
Orthotics - medical arch support Reconstruction of the tendon (tendon transfer) Triple fusion (subtalar, talonavicular, calcaneocuboid)
What is the aetiology of diabetic food ulceration?
Diabetic neuropathy - patient is unaware of the trauma
Diabetic autonomic neuropathy - lack of sweating/normal sebum production (–> dry, cracked skin that is more sensitive to minor trauma)
Poor vascular supply
Lack of patient education
How do you manage diabetic foot ulcerations?
Prevention is key
Modify main determinants to healing: diabetic control, smoking, vascular supply, external factors (e.g. splints, shoes, wt bearing), internal pressure (deformity), infection and nutrition
Op: improve vascular supply, debride ulcers, get deep samples for microbiology, correct deformity to offload area, amputation
What is charcot neuropathy?
Deformation of joints and bones of foot, typically PAINLESS
What is the cause of charcot neuropathy?
Any cause of neuropathy (DM most common)
Historically most common with syphilis
What is the pathophysiology of charcot neuropathy?
Neurotraumatic - loss of proprioception and protective pain sensation
Neurovascular - abnormal autonomic nervous system results in increased vascular supply and bone resorption
What is charcot neuropathy characterised by?
Rapid bone destruction occurring in 3 stages:
Fragmentation
Coalscence
Remodelling
What complications can arise from charcot neuropathy?
Prominent areas –> high risk of ulceration
Deformity –> ulceration –> infection –> amputation
How do you diagnose charcot neuropathy?
High index suspicion
Consider in any diabetic with acutely swollen, erythematous foot, esp. w. neuropathy
Greater than 3 degree difference between limbs
Radiographs and MRI
How do you manage charcot neuropathy?
Prevention!!
Immobilisation/non-wt bearing until acute fragmentation resolved
Correct deformity
