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Systems: MSK AB > Foot Problems > Flashcards

Foot Problems Flashcards

1
Q

What non-operative management is there for foot problems?

A
  • Shoe wear modification
  • Activity modification
  • Weight loss
  • Physiotherapy
  • Orthotics including insoles and bracing
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2
Q

What is the only indication fro operative management of foot problems?

A

Failure of non-operative management

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3
Q

How can disease be pathologically grouped?

A
  • Vascular (ischaemic)
  • Infective
  • Traumatic
  • Autoimmune
  • Metabolic (endocrine /drugs)
  • Inflammatory
  • Inherited (congenital)
  • Neurological
  • Neoplastic
  • Degenerative
  • Idiopathic
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4
Q

How can foot problems be grouped anatomically?

A
  • Forefoot problems
  • Midfoot problems
  • Hindfoot problems
  • Other
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5
Q

What forefoot problems are there?

A
  • Hallux valgus
  • Hallux rigidus
  • Lesser toe deformities
  • Morton’s neuroma
  • Metatarsalgia
  • Rheumatoid Forefoot
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6
Q

What is the colloquial name for hallux valgus?

A

Bunions

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7
Q

What is the aetiology of hallux valgus?

A
  • Genetic
  • Foot wear
  • Significant female preponderance
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8
Q

What are the symptoms of hallux valgus?

A
  • Pressure symptoms from shoe wear
  • Pain from crossing over of toes
  • Metatarsalgia
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9
Q

What is the pathogenesis of hallux valgus?

A
  • 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
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10
Q

How is hallux valgus diagnosed?

A

Clinical

X-rays

  • Determine severity of underlying bony deformity
  • Exclude associated degenerate change
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11
Q

How is hallux valgus managed?

A

Non-operative

  • 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
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12
Q

What are other names for hallux rigidus?

A
  • Stiff big toe
  • Hallux limitus
  • Hallux non-extensus
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13
Q

What is hallux rigidus?

A

Osteoarthritis of the 1st MTP

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14
Q

What is the aetiology of hallux rigidus?

A
  • Not known
  • Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
  • Possibly multiple microtrauma
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15
Q

What are the symptoms of hallux valgus?

A
  • Many asymptomatic
  • Pain – often at extreme of dorsiflexion
  • Limitation of range of movement
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16
Q

How is hallux rigidus diagnosed?

A
  • Clinical

- Radiographs

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17
Q

How is hallux rigidus managed?

A

Non-operative

  • Activity modification
  • Shoe wear with rigid sole
  • Analgesia

Surgery

  • Cheilectomy
  • Arthrodesis
  • Arthroplasty
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18
Q

What is a cheilectomy?

A

Removal of dorsal impingement

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19
Q

What is the gold standard operative treatment for hallux rigidus?

A

1st MTPJ fusion (arthrodesis), though it’s permanent

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20
Q

What are the features of the 1st MTPJ hemiarthroplasty as operative treatment for hallux rigidus?

A
  • Good option to maintain ROM
  • High failure rate
  • Probably better for low demand patients
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21
Q

Name dome lesser toes deformities.

A
  • Claw toes
  • Hammer toes
  • Mallet toes
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22
Q

What is the aetiology of lesser toe deformities?

A
  • Imbalance between flexors/extensors
  • Shoe wear
  • Neurological
  • Rheumatoid arthritis
  • Idiopathic
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23
Q

What are the symptoms of lesser toe deformities?

A
  • Deformity
  • Pain from dorsum
  • Pain from plantar side (metatarsalgia)
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24
Q

What is the treatment for lesser toe deformities?

A

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
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25
Q

What is the aetiology of Morton’s neuroma?

A

-Idiopathic

Frequently associated with wearing high heeled shoes

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26
Q

What is Morton’s neuroma?

A

Mechanically induced degenerative neuropathy

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27
Q

Who is usually affected by Morton’s neuroma?

A

Females aged 40-60

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28
Q

What is the pathogenesis of Morton’s neuroma?

A

Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear

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29
Q

What are the symptoms of Morton’s neuroma?

A
  • Typically affects 3rd followed by 2nd webspace/toes
  • Neuralgic burning pain into toes
  • Intermittent
  • Altered sensation in webspace
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30
Q

How is Morton’s neuroma diagnosed?

A
  • Clinical
  • Mulder’s Click
  • Ultrasound best / MRI good
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31
Q

How are Morton’s neuromas managed?

A
  • Injection for small lesions

- Surgery – excision of lesion including a section of normal nerve

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32
Q

What are the disadvantages of surgery for Morton’s neuromas?

A
  • Numbness
  • Recurrence
  • Up to 30% have pain 1 year post surgery
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33
Q

What is metatarsalgia?

A
  • A symptom, not a diagnosis

- Pain and inflammation in the ball of the foot

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34
Q

How can the cause of metatrsalgia be identified?

A
  • Careful examination should localise the cause

- If no obvious cause consider tight gastrocnemius

35
Q

What can cause metatrsalgia?

A
  • Synovitis
  • Bursitis
  • Arthritis
  • Neuralgia
  • Neuromata
  • Freiberg’s disease
36
Q

What is the treatment for rheumatoid foot?

A

Non-operative
-Shoewear/orthotics/activity etc

Operative

  • Many described techniques
  • Current gold standard is 1st MTPJ arthrodesis and 2-5th toe excision arthroplasty
37
Q

Give examples of midfoot problems.

A
  • Ganglia
  • Osteoarthritis
  • Plantar fibromatosis
38
Q

What is a dorsal foot ganglia?

A

A benign cystic lesion which arises from the joint or tendon sheath

39
Q

What is the aetiology of dorsal foot ganglia?

A
  • Idiopathic
  • Underlying arthritis
  • Underlying tendon pathology
40
Q

What are the symptoms of dorsal foot ganglia?

A
  • Pain from pressure from shoe wear

- Pain from underlying problem

41
Q

What is the treatment for dorsal foot ganglia?

A

Non-operative

  • Aspiration
  • “Family bible”

Operative
-Excision

42
Q

What is the prognosis for dorsal foot ganglia?

A

High rate of return (50%)

43
Q

What types of arthritis can affect the midfoot?

A
  • Post-traumatic arthritis
  • Osteoarthritis
  • Rheumatoid arthritis
44
Q

What is the treatment for midfoot arthritis?

A

Non-operative

  • Activity/shoewear/orthotics etc
  • Injections – xray guided

Operative
-Fusion

45
Q

What are other names for plantar fibromatosis?

A
  • Ledderhose disease

- “Dupuytren’s of the foot”

46
Q

What is the treatment for plantar fibromatosis?

A

Non-operative

  • Avoid pressure: shoewear/orthotics
  • Radiotherapy (similar recurrence as operative)

Operative

  • Excision (up to 80% risk of recurrence)
  • Combination radiotherapy/surgery (low risk recurrence/high risk complications)
47
Q

How does plantar fibromatosis present?

A
  • Progressive

- Usually asymptomatic unless very large or on weightbearing area

48
Q

Name some hindfoot problems?

A
  • Achilles tendonitis/tendinosis
  • Plantar fasciitis
  • Ankle osteoarthitis
  • Tibialis posterior dysfunction
  • Cavovarus foot
49
Q

What is Achilles tendinopathy?

A

Degenerative/overuse condition with little inflammation

50
Q

What is the pathogenesis of Achilles tendinopathy?

A

More than one clinical condition

  • Insertional tendinopathy within 2cm of insertion
  • Non-insertional / mid-substance tendinopathy, 2-7cm of insertion
  • Bursitis, either retrocalcaneal or superficial calcaneal
  • Paratendinopathy is a true inflammatory problem showing paratendonitis histologically
51
Q

What is the epidemiology of Achilles paratendonopathy?

A
  • Commonest in athletic populations
  • Age group 30-40
  • M:F = 2:1
52
Q

What is the epidemiology of Achilles tendonopathy?

A
  • Commonest in non-athletic populations
  • Aged over 40
  • Obesity
  • Steroids
  • Diabetes
53
Q

What are the symptoms of Achilles tendinopathy?

A
  • Pain during exercise
  • Pain following exercise
  • Recurrent episodes
  • Difficulty fitting shoes (insertional)
  • RUPTURE – don’t miss!
54
Q

How is Achilles tendinopathy diagnosed?

A

Clinical

  • Tenderness
  • Tests for rupture

Investigations

  • Ultrasound
  • MRI
55
Q

What are the Achilles rupture tests?

A
  • Simmonds test
  • Angle of Dangle
  • Matles
56
Q

What are the treatment options for Achilles tedinopathy?

A

Non-operative Treatment

  • Activity modification
  • Weight loss
  • Shoe wear modification – slight heel
  • Physiotherapy – Eccentric stretching
  • Extra-corporeal shockwave treatment
  • Immobilisation (in below knee cast)

Operative Treatment

  • Gastrocnemius recession
  • Release and debridement of tendon
57
Q

What is fasciosis?

A
  • Chronic and degenerative change
  • Fbroblast hypertrophy
  • Absence of inflammatory cells
  • Disorganised and dysfunction blood vessels and collagen
  • Avascularity
  • Can’t make extra cellular matrix required for repair and re-modellign
58
Q

What is the aetiology of plantar fasciitis?

A
  • Not known
  • In athletes associated with high intensity or rapid increase in training
  • Running with poorly padded shoes or hard surfaces
  • Obesity
  • Occupations involving prolonged standing
  • Foot/lower limb rotational deformities
  • Tight gastro-soleus complex
59
Q

What are the symptoms of plantar fasciitis?

A
  • Pain first thing in morning
  • Pain on weight bearing after rest (Post-static dyskinesia)
  • Pain located at origin of plantar fascia
  • Frequently long lasting – 2 years or more
60
Q

What is the differential diagnosis for plantar fasciitis?

A
  • Nerve entrapment syndrome
  • Arthritis
  • Calcaneal pathology
61
Q

How is plantar fasciitis diagnosed?

A
  • Mainly clinical

- Occasionally x-rays, ultrasound and MRI

62
Q

What treatment options are there for plantar fasciitis?

A
  • Rest, change training
  • Stretching – Achilles +/- direct stretching
  • Ice
  • NSAIDs
  • Orthoses – Heel pads
  • Physiotherapy
  • Weight loss
  • Injections – corticosteroid (good in short term but may make condition worse long term)
  • Night Splinting
63
Q

What are the newer 3rd line treatments for plantar fasciitis?

A
  • Extracorporeal Shockwave therapy
  • Topaz Plasma Coblation
  • Nitric Oxide
  • Platelet Rich Plasma
  • Endoscopic / Open Surgery
64
Q

What is the aetiology of ankle arthritis?

A
  • Commonly post-traumatic

- Idiopathic

65
Q

What is the mean age of presentation for ankle arthritis?

A

46 years old

66
Q

What are the symptoms of ankle arthritis?

A
  • Pain

- Stiffness

67
Q

How is ankle arthritis diagnosed?

A
  • Clinical
  • Radiographs
  • CT scan – exclude adjacent joint arthritis
68
Q

What is the non-operative management for ankle arthritis?

A
  • Weight loss
  • Activity modification
  • Analgesia
  • Physiotherapy
  • Steroid injections
69
Q

What is the operative management for ankle arthritis?

A
  • If symptoms are exclusively anterior then arthroscopic anterior debridement
  • Arthrodesis – open or arthroscopic, gold standard, good long term outcome
  • Joint replacement: maintain range of movement, questionable long-term outcome especially in high demand patients, not easy to revise even to fusion
70
Q

What is tibialis posterior tendon?

A
  • A cause of acquired adult flat foot planovalgus
  • Relatively common
  • Under recognised
71
Q

How is tibialis posterior tendon dysfunction diagnosed?

A

Clinical
-Double and single heel raise (heels should swing from valgus to varus)

MRI to assess tendon

72
Q

How does tibialis posterior tendon dysfunction present?

A
  • Medial or lateral pain

- 4 stages

73
Q

What is the management of tibialis poster tendon dysfunction?

A
  • Orthotics: medial arch support
  • Reconstruction of tendon (tendon transfer)
  • Triple fusion (subtalar, talonavicular and calcaneocuboid)
74
Q

How can a diabetic foot present?

A
  • Ulceration

- Charcot foot

75
Q

What is the aetiology of diabetic foot ulcers?

A
  • Diabetic neuropathy – patient unaware of trauma to foot
  • Diabetic autonomic neuropathy, lack of sweating / normal sebum production leads to dry cracked skin which is more sensitive to minor trauma
  • Poor vascular supply
  • Lack of patient education
76
Q

What is the treatment for diabetic foot ulcer?

A 
Prevention
 Modify the main detriments to healing
-Diabetic control
-Smoking
-Vascular supply
-External pressure (splints/shoes/weight bearing)
-Internal pressure (deformity)
-Infection
-Nutrition
77
Q

What surgical treatments are available for diabetic foot ulcers?

A
  • Improve Vascular Supply
  • Debride ulcers and get deep samples for microbiology
  • Correct any deformity to offload area
  • Amputation
78
Q

What is the prognosis for diabetic foot ulcers?

A
  • 15% of all diabetics will develop ulceration
  • 85% of all amputations for diabetes are preceded by foot ulceration
  • 25% of patients with diabetic ulcers go on to amputation
  • 5 year patient mortality 50%
79
Q

What is the aetiology of charcot neuroarthropathy?

A
  • Any cause of neuropathy
  • Diabetes commonest cause
  • Historically originally described and most common with syphillis
80
Q

What are the 2 theories for the pathophysiology of charcot neuroarthropathy?

A

Neurotraumatic
-Lack of proprioception and protective pain sensation

Neurovascular
-Abnormal autonomic nervous system results in increased vascular supply and bone resorption

81
Q

What is charcot neuroarthropathy characterised by?

A

Characterised by rapid bone destruction occurring in 3 stages

  • Fragmentation
  • Coalescence
  • Remodelling
82
Q

How is charcot neuroarthropathy diagnosed?

A
  • High index of suspicion
  • Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy
  • Greater than 3 degree difference between limbs
  • Frequently not painful
  • Radiographs
  • MRI scan
83
Q

How is charcot neuroarthropathy managed?

A
  • Prevention
  • Immobilisation / non-weight bearing until acute fragmentation resolved
  • Correct deformity: deformity leads to ulceration leads to infection leads to amputation.

Systems: MSK AB (43 decks)

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