Foot Problems Flashcards
What non-operative management is there for foot problems?
- Shoe wear modification
- Activity modification
- Weight loss
- Physiotherapy
- Orthotics including insoles and bracing
What is the only indication fro operative management of foot problems?
Failure of non-operative management
How can disease be pathologically grouped?
- Vascular (ischaemic)
- Infective
- Traumatic
- Autoimmune
- Metabolic (endocrine /drugs)
- Inflammatory
- Inherited (congenital)
- Neurological
- Neoplastic
- Degenerative
- Idiopathic
How can foot problems be grouped anatomically?
- Forefoot problems
- Midfoot problems
- Hindfoot problems
- Other
What forefoot problems are there?
- Hallux valgus
- Hallux rigidus
- Lesser toe deformities
- Morton’s neuroma
- Metatarsalgia
- Rheumatoid Forefoot
What is the colloquial name for hallux valgus?
Bunions
What is the aetiology of 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
How is hallux valgus diagnosed?
Clinical
X-rays
- Determine severity of underlying bony deformity
- Exclude associated degenerate change
How is hallux valgus managed?
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
What are other names for hallux rigidus?
- Stiff big toe
- Hallux limitus
- Hallux non-extensus
What is hallux rigidus?
Osteoarthritis of the 1st MTP
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 valgus?
- Many asymptomatic
- Pain – often at extreme of dorsiflexion
- Limitation of range of movement
How is hallux rigidus diagnosed?
- Clinical
- Radiographs
How is hallux rigidus managed?
Non-operative
- Activity modification
- Shoe wear with rigid sole
- Analgesia
Surgery
- Cheilectomy
- Arthrodesis
- Arthroplasty
What is a cheilectomy?
Removal of dorsal impingement
What is the gold standard operative treatment for hallux rigidus?
1st MTPJ fusion (arthrodesis), though it’s permanent
What are the features of the 1st MTPJ hemiarthroplasty as operative treatment for hallux rigidus?
- Good option to maintain ROM
- High failure rate
- Probably better for low demand patients
Name dome lesser toes 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 for 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 Morton’s neuroma?
-Idiopathic
Frequently associated with wearing high heeled shoes
What is Morton’s neuroma?
Mechanically induced degenerative neuropathy
Who is usually affected by Morton’s neuroma?
Females aged 40-60
What is the pathogenesis of Morton’s neuroma?
Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
What are the symptoms of Morton’s neuroma?
- Typically affects 3rd followed by 2nd webspace/toes
- Neuralgic burning pain into toes
- Intermittent
- Altered sensation in webspace
How is Morton’s neuroma diagnosed?
- Clinical
- Mulder’s Click
- Ultrasound best / MRI good
How are Morton’s neuromas managed?
- Injection for small lesions
- Surgery – excision of lesion including a section of normal nerve
What are the disadvantages of surgery for Morton’s neuromas?
- Numbness
- Recurrence
- Up to 30% have pain 1 year post surgery
What is metatarsalgia?
- A symptom, not a diagnosis
- Pain and inflammation in the ball of the foot
How can the cause of metatrsalgia be identified?
- Careful examination should localise the cause
- If no obvious cause consider tight gastrocnemius
What can cause metatrsalgia?
- Synovitis
- Bursitis
- Arthritis
- Neuralgia
- Neuromata
- Freiberg’s disease
What is the treatment for rheumatoid foot?
Non-operative
-Shoewear/orthotics/activity etc
Operative
- Many described techniques
- Current gold standard is 1st MTPJ arthrodesis and 2-5th toe excision arthroplasty
Give examples of midfoot problems.
- Ganglia
- Osteoarthritis
- Plantar fibromatosis
What is a dorsal foot ganglia?
A benign cystic lesion which arises 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 the treatment for dorsal foot ganglia?
Non-operative
- Aspiration
- “Family bible”
Operative
-Excision
What is the prognosis for dorsal foot ganglia?
High rate of return (50%)
What types of arthritis can affect the midfoot?
- Post-traumatic arthritis
- Osteoarthritis
- Rheumatoid arthritis
What is the treatment for midfoot arthritis?
Non-operative
- Activity/shoewear/orthotics etc
- Injections – xray guided
Operative
-Fusion
What are other names for plantar fibromatosis?
- Ledderhose disease
- “Dupuytren’s of the foot”
What is the treatment for plantar fibromatosis?
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)
How does plantar fibromatosis present?
- Progressive
- Usually asymptomatic unless very large or on weightbearing area
Name some hindfoot problems?
- Achilles tendonitis/tendinosis
- Plantar fasciitis
- Ankle osteoarthitis
- Tibialis posterior dysfunction
- Cavovarus foot
What is Achilles tendinopathy?
Degenerative/overuse condition with little inflammation
What is the pathogenesis of Achilles tendinopathy?
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
What is the epidemiology of Achilles paratendonopathy?
- Commonest in athletic populations
- Age group 30-40
- M:F = 2:1
What is the epidemiology of Achilles tendonopathy?
- Commonest in non-athletic populations
- Aged over 40
- Obesity
- Steroids
- Diabetes
What are the symptoms of Achilles tendinopathy?
- Pain during exercise
- Pain following exercise
- Recurrent episodes
- Difficulty fitting shoes (insertional)
- RUPTURE – don’t miss!
How is Achilles tendinopathy diagnosed?
Clinical
- Tenderness
- Tests for rupture
Investigations
- Ultrasound
- MRI
What are the Achilles rupture tests?
- Simmonds test
- Angle of Dangle
- Matles
What are the treatment options for Achilles tedinopathy?
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
What is fasciosis?
- 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
What is the aetiology of plantar fasciitis?
- 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
What are the symptoms of plantar fasciitis?
- 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
What is the differential diagnosis for plantar fasciitis?
- Nerve entrapment syndrome
- Arthritis
- Calcaneal pathology
How is plantar fasciitis diagnosed?
- Mainly clinical
- Occasionally x-rays, ultrasound and MRI
What treatment options are there for plantar fasciitis?
- 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
What are the newer 3rd line treatments for plantar fasciitis?
- Extracorporeal Shockwave therapy
- Topaz Plasma Coblation
- Nitric Oxide
- Platelet Rich Plasma
- Endoscopic / Open Surgery
What is the aetiology of ankle arthritis?
- Commonly post-traumatic
- Idiopathic
What is the mean age of presentation for ankle arthritis?
46 years old
What are the symptoms of ankle arthritis?
- Pain
- Stiffness
How is ankle arthritis diagnosed?
- Clinical
- Radiographs
- CT scan – exclude adjacent joint arthritis
What is the non-operative management for ankle arthritis?
- Weight loss
- Activity modification
- Analgesia
- Physiotherapy
- Steroid injections
What is the operative management for ankle arthritis?
- 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
What is tibialis posterior tendon?
- A cause of acquired adult flat foot planovalgus
- Relatively common
- Under recognised
How is tibialis posterior tendon dysfunction diagnosed?
Clinical
-Double and single heel raise (heels should swing from valgus to varus)
MRI to assess tendon
How does tibialis posterior tendon dysfunction present?
- Medial or lateral pain
- 4 stages
What is the management of tibialis poster tendon dysfunction?
- Orthotics: medial arch support
- Reconstruction of tendon (tendon transfer)
- Triple fusion (subtalar, talonavicular and calcaneocuboid)
How can a diabetic foot present?
- Ulceration
- Charcot foot
What is the aetiology of diabetic foot ulcers?
- 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
What is the treatment for diabetic foot ulcer?
Prevention Modify the main detriments to healing -Diabetic control -Smoking -Vascular supply -External pressure (splints/shoes/weight bearing) -Internal pressure (deformity) -Infection -Nutrition
What surgical treatments are available for diabetic foot ulcers?
- Improve Vascular Supply
- Debride ulcers and get deep samples for microbiology
- Correct any deformity to offload area
- Amputation
What is the prognosis for diabetic foot ulcers?
- 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%
What is the aetiology of charcot neuroarthropathy?
- Any cause of neuropathy
- Diabetes commonest cause
- Historically originally described and most common with syphillis
What are the 2 theories for the pathophysiology of charcot neuroarthropathy?
Neurotraumatic
-Lack of proprioception and protective pain sensation
Neurovascular
-Abnormal autonomic nervous system results in increased vascular supply and bone resorption
What is charcot neuroarthropathy characterised by?
Characterised by rapid bone destruction occurring in 3 stages
- Fragmentation
- Coalescence
- Remodelling
How is charcot neuroarthropathy diagnosed?
- 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
How is charcot neuroarthropathy managed?
- Prevention
- Immobilisation / non-weight bearing until acute fragmentation resolved
- Correct deformity: deformity leads to ulceration leads to infection leads to amputation.
