Foot Problems

Question 1

What are the treatment options for common foot and ankle problems?

Answer 1

Non operative assessment - 
analgesia
Shoe modification
Activity modification
Weight loss
Physio
Orthotics including insoles/bracing

Operative management if failure of non-operative.

Question 2

What are some common forefoot problems?

Answer 2

Hallux valgus
Hallus rigidus
Lesser toe deformities
Morton's neuroma
Metatarsalgia
Rheumatoid forefoot

Question 3

What is Hallux Valgus?

Answer 3

Bunions
Bony lump appears on side of big toe that is now turning towards other toes.
Increased pull of tendons increases deformity, eventually progresses to abnormalities of lesser toes.
Symptoms - pressure sores from footwear, pain from crossing over of toes, metatarsalgia (ball of foot becomes painful and inflamed).

Question 4

What is Hallux rigidus?

Answer 4

Disorder of joint located at base of big toe, causing it to become stiff and painful.
OA of 1st MTP joint.

Question 5

What are some examples of lesser toe deformities?

Answer 5

Claw toes
Hammer toes
Mallet toes

Question 6

What is Morton’s Neuroma?

Answer 6

Interdigital neuralgia usually between 3rd and 4th toes.
Inflammation, severe pain and numbness.
tends to affect females aged 40-60yrs. Associated with wearing high heels.
Nerve tethered to 1 metatarsal and movement in others causes shear.

Question 7

How is Morton’s neuroma diagnosed?

Answer 7

Clinically
Mulder’s click
Ultrasound (best)
MRI

Question 8

What is the management for Morton’s neuroma?

Answer 8

Injection for small lesions

Surgery - excision of lesion including small section of normal nerve.

Question 9

What are some common mid foot problems?

Answer 9

Ganglia
Osteoarthritis
Plantar fibromatosis

Question 10

What are dorsal foot ganglia?

Answer 10

Benign cystic lesion arising from joint or tendon sheath.
Symptoms include pain from pressure of shoe wear, pain from underlying problem.
Aspiration, or excision can be used to treat.

Question 11

What is plantar fibromatosis?

Answer 11

Non-malignant thickening of the feet’s deep connective tissue, or fascia.
Dupuytren’s of the foot.
Also known as Ledderhose disease.
Usually asymptomatic unless very large or on weight bearing area.
Avoid pressure, excision, radiotherapy and combination therapy are all treatment options.

Question 12

What are some common hindfoot problems?

Answer 12

Achilles tendonitis/tendinosis
Plantar fasciitis
Ankle osteoarthritis
Tibialis posterior dysfunction
Cavovarus foot

Question 13

What is achilles tendonitis/tendonosis?

Answer 13

Degenerative/overuse condition of the achilles tendon. Little inflammation. 
Pain, tenderness, nodules, swelling. 
Pain during/after exercise
Recurrent episodes
Difficulty fitting shoes. 
MRI/ultrasound to investigate. 
Simmonds rupture test (squeeze calf). 
Angle of the dangle test.

Question 14

What is the treatment for achilles tendinopathy?

Answer 14

Activity modification 
Weight loss
Slight heel in shoe
Eccentric stretching
Extra-corporeal shockwave treatment
Immobilsation
Gastrocnemius recession
Release and debridement of tendon.

Question 15

What is plantar fasciitis?

Answer 15

Strong band on bottom of foot becomes irritated.
Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessel and collagen, avascularity.
Can’t make extracellular matrix required to fix it.

Question 16

What are the symptoms of plantar fasciitis?

Answer 16

Pain first thing in morning
Pain on weight bearing after rest - post static dyskinesia
Pain located at origin of plantar fascia.
Frequently long lasting - 2years or more.

Question 17

What is the treatment for plantar fasciitis?

Answer 17

Rest and change in training
Stretching - achilles
Ice
NSAIDs
Orthoses - heel pads
Physio
Weight loss
Injections - corticosteroid
Night splinting. 
3rd line treatments - extracorporeal shockwave therapy, topaz plasma coblation, nitric oxide, platelet rich plasma, endoscopic/open surgery.

Question 18

What is tibialis posterior tendon dysfunction?

Answer 18

Changes within the tendon causing inability to support the arch. Results in flattening of the foot.
4 stages
largely clinical diagnosis with double and single heel raise.
Medial or lateral pain

Question 19

What is the management of tibias posterior tendon dysfunction?

Answer 19

Orthotics - medial arch support. 
Reconstruction of tendon
triple fusion (subtalar, talonavicular and calcaneocuboid)

Question 20

What is diabetic foot ulcer?

Answer 20

Open sore or wound on foot due to diabetic neuropathy.
Usually lack of sweating/ normal sebum production creating dry cracked skin that is more sensitive to minor trauma.
Poor vascular supply.

Question 21

What is the treatment for diabetic foot ulcers?

Answer 21

Prevention
diabetic control
Smoking cessation
Improve vascular supply
Ease external pressure through splints, shoes, weight bearing. 
Improve risk of infection and nutrition. 
Debride ulcers
Surgical correction of deformity.
Amputation

Question 22

What is Charcot neuroarthropathy?

Answer 22

Condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage.
With continued walking foot changes shape.
Characterised by rapid bone destruction occurring in 3 stages: fragmentation, coalescence and remodelling.

Question 23

How is Charcot’s neuroarthropathy diagnosed?

Answer 23

Consider in any diabetic with acute swollen erythematous foot.
Greater than 3 degree difference between limbs.
Frequently not painful.
Radiographs
MRI

Question 24

What is the management for Charcot’s neuroarthropathy?

Answer 24

Prevention
Immobilsation until acute fragmentation resolved.
Correct deformity to avoid ulceration and amputation.

Question 25

What are tarsal coalitions?

Answer 25

Abnormal connection that develops between two bones in the back of the foot (the tarsal bones). This abnormal connection, which can be composed of bone, cartilage or fibrous tissue, may lead to limited motion and pain in one or both feet.

Question 26

What are some features of ankle arthritis?

Answer 26

Commonly post traumatic
Consider haemochromatosis if non known trauma and under 50yrs.
Mean onset age 46yrs compared to 51 yrs in hip arthritis.

Question 27

What 2 tendons form the achilles tendon?

Answer 27

Gastrocnemius and Soleus

Question 28

What is a cavovarus foot?

Answer 28

Foot deformity characterised by an abnormally high arch and an inverted heel.
Excessive weight is placed on the ball and heel of the foot when standing or walking.
Weakness of intrinsic muscles also results in clawing of toes.
Overpull of tibialis posterior resulting in adduction of forefoot.

Question 29

What are the clinical manifestations of cavovarus foot?

Answer 29

Plantar callosities due to plantarflexion of metatarsals and clawing of toes.
Ankle instability due to hind foot varus.
Altered gait due to equinus (weakness of tibias anterior)
Stress fractures of lateral metatarsals due to overpull of tibialis posterior.

Question 30

What 5 questions would you ask someone with suspected cavovarus foot?

Answer 30

Progressive?
Family history?
Muscle pain or weakness?
Elevated creatinine kinase?
Altered sensation?

Question 31

What investigative test is used in Cavovarus foot?

Answer 31

Coleman Block test.
Differentiates between forefoot driven hindfoot varus and hindfoot driven varus.

Patient stands with 1st ray hanging over the edge of the block
If hindfoot varus corrects, then it is compensating for a rigidly plantarflexed 1st ray.