Foot Problems Flashcards
what are osme examples of non-operative management?
Analgesia
Shoe wear modification
Activity modification
Weight loss (all foot and ankle condition orse if patient carrying to much weight)
Physiotherapy
Orthotics including insoles and bracing
when do you operate?
The only indication for operative management is failure of non-operative management
Pathological Grouping of Disease can be put in what categories?
(Look at aetiology – any of these underlying problems can be responsible for foot or ankle pain)
- Vascular (ischaemic)
- Infective
- Traumatic
- Autoimmune (rheumatic arthritis and other rheumatoid problems etc
- Metabolic (endocrine /drugs)
- Inflammatory
- Inherited (congenital)
- Neurological
- Neoplastic
- Degenerative
- Idiopathic
Anatomical Grouping of Disease can be put into what groups?
- Forefoot problems – metatarsals and toes
- Midfoot problems - tarsal
- Hindfoot problems – heel, calcaneus and talus
- Other
what are examples of forefoot problems?
- Hallux valgus
- Hallux rigidus
- Lesser toe deformities
- Morton’s neuroma (painful condition on sole of foot)
- Metatarsalgia
- Rheumatoid Forefoot
what is Hallux Valgus?
“Bunions”
a deformity of the big toe. The toe tilts over towards the smaller toes and a bony lump appears on the inside of the foot
Hallux valgus is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected and is often accompanied by significant functional disability and foot pain. This joint is gradually subluxed (lateral deviation of the MTP joint) resulting in an resulting in an abduction of the first metatarsal while the phalanges adduct. This often leads to development of soft tissue and bony prominence on the medial side of what is called a bunion
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 (condition in which the ball of your foot becomes painful and inflamed)
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 (medially) – less weight goes through great toe
As deformity progresses abnormalities of lesser toes occur
how is the diagnosis of hallux valgus made?
Clinical (probably best way, just looking at the foot)
Xrays:
- Determine severity of underlying bony deformity
- Exclude associated degenerate change
what is the non-operative management of hallux valgus?
- Shoe wear modification (wide +/- high toe box)
- Orthotics to offload pressure/correct deformity
- Activity modification (less time standing)
- Analgesia
what is the operative management (if non-operative failed or unacceptable to patient) of hallux valgus?
- Release lateral soft tissues
- Osteotomy 1st metatarsal +/- proximal phalanx
- Generally good outcome but recurrence inevitable
Hallux Valgus – Scarf osteotomy
Bone broken and shifted in the coronal plane
Hallux Valgus – basal osteotomy
what is Hallux Rigidus?
- Latin – Stiff big toe!
- Hallux limitus
- Hallux non-extensus
- Osteoarthritis of 1st MTP joint (causes of these symptoms)
- Bimodal distribution of age
It causes pain and stiffness in the joint, and with time, it gets increasingly harder to bend the toe. Hallux refers to the big toe, while rigidus indicates that the toe is rigid and cannot move
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 (incidental finding on x-ray)
Pain – often at extreme of dorsiflexion
Limitation of range of movement
what is the diagnosis of hallux rigidus?
Clinical (history and examinations)
Radiographs
radiography:
Older patient, osteoarthritis, narrowing and irregularity of the MTP joint, joint space narrowed, osteophyte, sclerosis in margins
Normal angle between 1st and 2nd metatarsals
Big dorsal osteophytes so that’s why extension is sore as rub on the soft tissues and pain impinge on dorsiflexion
what is the management of hllux rigidus?
Non-operative:
- Activity modification (running and up hill as more dorsiflexion causes pain)
- Shoe wear with rigid sole
- Analgesia
Surgery (main ones):
- Cheilectomy
- Arthrodesis
- Arthroplasty
what is Cheilectomy?
remove dorsal impingement
Particular pain when dorsiflexed, remove dorsal osteophytes
what is 1st MTPJ fusion?
- Gold standard treatment
- Permanent
- “Bail out operation”
Most reliable consistent treatment
Surface of the joint is debrided, fixation so bone crosses of the joint
what is 1st MTPJ hemiarthroplasty?
- Good option to maintain ROM
- High failure rate
- Probably better for low demand patients
whata re some lesser toe deformities?
- Claw toes - Flexion at the proximal and distal interphalangeal joint, may have underlying neurological problem
- Hammer toes - Flexion of the proximal interphalangeal joint and dorsiflexion at MTP joint, distal interphalangeal joint extended
- Mallet toes - Not as common, flexion at distal interphalangeal joint, get pain form nail impinging on the sole of their shoe
Lesser Toe deformities - how bone is effected
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 non-operative treatment for Lesser Toe deformities?
(best treamtnet for most)
- Activity modification
- Shoe wear – flat shoes with high toe box to accommodate deformity
- Orthotic insoles – metatarsal bar/dome support
what is the operative treatment for Lesser Toe deformities?
(a lot of morbidity associated with these)
- Flexor to extensor transfer (dividing flexor tendon and moving it to the extensor)
- Fusion of interphalangeal joint
- Release metatarsophalangeal joint
- Shortening osteotomy of metatarsal
Interdigital Neuralgia – Morton’s Neuroma
what is it?
Interdigital nerve irritation (neuralgia) or persistent benign enlargement of the perineurium (neuroma) can cause pain, which may be nonspecific, burning, or lancinating, or a foreign body sensation. Diagnosis is usually clinical
Medial and lateral plantar nerve
Painful lump
Interdigital Neuroma – Morton’s Neuroma
what is the aetiology?
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
Interdigital Neuroma – Morton’s Neuroma
what are the symptoms?
Typically affects 3rd followed by 2nd webspace/toes (Unknown in the 1st web space)
Neuralgic burning pain into toes
Intermittent
Altered sensation in webspace
Interdigital Neuralgia – Morton’s Neuroma
how is a diagnosis made?
Clinical
Mulder’s Click (best test clinically) - Mulder’s clinical test is a well-known maneuver in which compression of the metatarsal heads produces a palpable click due to displace- ment of an intermetatarsal mass
Ultrasound best/MRI good
Interdigital Neuralgia – Morton’s Neuroma
what is the management?
Advice on no high heels and padded shoes
Injection (steroid) for small lesions
Surgery – excision of lesion including a section of normal nerve:
- Numbness
- Recurrence (end of nerve regrow)
- Up to 30% have pain 1 year post surgery
Interdigital Neuralgia – Morton’s Neuroma
would ou more likely operate from the dorsla or plantar side?
Easier to access nerve but leaves painful scar so recommended going form the dorsal side instead of plantar
Interdigital Neuralgia – Morton’s Neuroma
what mistake is often made?
•Frequently incorrectly diagnosed for any forefoot pain
what is Metatarsalgia?
Any pain coming from forefoot, symptoms form Morton’s neuroma is one cause of this
a condition in which the ball of your foot becomes painful and inflamed
- A symptom, not a diagnosis.
- Careful examination should localise cause
- Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease………
- If no obvious cause consider tight gastrocnemius
- Sometime difficult problem to treat
Rheumatoid forefoot - what is the treatment?
Non-operative (this is best) - shoewear/orthotics/activity etc
Operative:
- Many described techniques
- Current gold standard
- 1st MTPJ arthrodesis (surgical immobilization of a joint by fusion of the bones)
- 2-5th toe excision arthroplasty (Remove metatarsal phalangeal joints of the lesser toes)
(Picture - Heads of metatarsals removed and MTP joint of first ray has been fused)
what ar eosme examples of midfoot problems?
- Ganglia
- Osteoarthritis
- Plantar fibromatosis (uncommon non-malignant thickening of the feet’s deep connective tissue, or fascia)
what are Dorsal Foot Ganglia?
Ganglia are most commonly asymptomatic, except for a lump, but symptoms depend on the location. A dorsal foot ganglion is typically painful. On the dorsal foot, the dorsalis pedis artery and the medial branch of the deep peroneal nerve are located under the fascia
•Arise from 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 of dorsal foot ganglia?
Non-operative:
- Aspiration
- “Family bible”
Operative:
•Excision
what is the prognosis of dorsal foot ganglia?
High rate of return – 50%
Midfoot Arthritis may be in what forms?
- Post-traumatic arthritis
- Osteoarthitis
- Rheumatoid arthritis
what is the treatment of midfoot arthritis?
Non-operative – Activity/shoewear/orthotics etc
Injections – xray guided
Operative – fusion (of joint)
what is Plantar Fibromatosis?
Plantar fascial fibromatosis, also known as Ledderhose’s disease, is a relatively uncommon non-malignant thickening of the feet’s deep connective tissue, or fascia. In the beginning, where nodules start growing in the fascia of the foot the disease is minor
- Ledderhose disease
- “Dupuytren’s of the foot”
how does plantar fibromatosis present?
- Progressive
- Usually asymptomatic unless very large or on weightbearing area
Just get lumpy areas in the sole of the foot unlike in hands you get contraction of the fingers
what is the treatment of Plantar Fibromatosis?
Non-operative – avoid pressure – shoewear/orthotics
Operative – excision (up to 80% risk of recurrence)
Radiotherapy (similar recurrence as operative)
Combination radiotherapy/surgery (low risk recurrence/high risk complications)
what are examples of hindfoot problems?
- Achilles tendonitis/tendinosis
- Plantar fasciitis
- Ankle osteoarthitis
- Tibialis posterior dysfunction
- Cavovarus foot – already discussed by Mr Forrest
what is Achilles tendonitis/tendinosis?
Achilles tendinosis is a condition in which the Achilles tendon degenerates and becomes inflamed. Sometimes, it may also be called Achilles tendinitis. If you have Achilles tendinosis, your tendon can swell and become painful. This condition is common in athletes, runners, and people who have calf tightness
• Degenerative / overuse condition with little inflammation
- “Tendonitis” should be avoided – suggest inflammation that may not be there
- Tendinosis histopathological
- Tendinopathy term to describe symptoms
Achilles tendinopathy is more than one lcinical conditoin, what are the different types?
Insertional tendinopathy - within 2cm of insertion
Non-insertional/mid-substance tendinopathy - 2-7cm of insertion
Bursitis - Retrocalcaneal, Superficial calcaneal
Paratendinopathy is a true inflammatory problem showing paratendonitis histologically
what is the aetiology of Achilles Tendinopathy?
Paratendonopathy:
- Commonest in athletic populations
- Age group 30-40
- Male:Female = 2:1
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
Difficuly fitting shoes (insertional type)
RUPTURE – don’t miss! – lots of complications if picked up late
how is the diagnosis of Achilles Tendinopathy made?
Clinical:
- Tenderness
- Tests for rupture
Investigations:
- Ultrasound
- MRI
Achilles Rupture Tests - Simmonds
Foot and ankle over edge of couch
Achilles Rupture Tests – “Angle of the Dangle” & Matles
Left picture – right foot is normal and the left foot there is a diffuse swelling and margins of achilies tendon not clear
what is the non-operative treatment of Achilles Tendinopathy?
Activity modification
Weight loss
Shoe wear modification – slight heel
Physiotherapy – Eccentric stretching
Extra-corporeal shockwave treatment (vibrates tissues and stimulates fibrous tissue to form and healing)
Immobilisation (in below knee cast)
what is the operative treatment of Achilles Tendinopathy?
Gastrocnemius recession (involves release of the gastrocnemius tendon and subsequent lengthening of the calf muscle)
Release and debridement of tendon
what is Plantar Fasciitis?
Plantar fasciitis is inflammation of the plantar fascia, a part of your foot that connects your heel bone to your toes
- Fasciitis is incorrect fasciosis better term
- Fasciosis - Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity
- Cant make Extra Cellular Matrix required for repair and re-modelling
- Microtears?
what. is the aetiology of plantar faciitis?
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 ysmptoms of Plantar Fasciitis?
Pain first thing in morning
Pain on weight bearing after rest - Post-static dyskinesia (a medical term referring to pain that occurs after a period of rest)
Pain located at origin of plantar fascia
Frequently long lasting – 2 years or more
what are some differential diagnosis of plantar fasciitis?
Nerve entrapment syndrome
Arthritis
Calcaneal pathology
how is the diagnosis of plantar fasciitis made?
Mainly clinical
Occasionally x-rays, ultrasound and MRI
what is the treatment of 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 some Newer / Third Line Treatments of plantar fasciitis?
- Extracorporeal Shockwave therapy
- Topaz Plasma Coblation
- Nitric Oxide
- Platelet Rich Plasma
- Endoscopic / Open Surgery
what is the aetiology of ankle arthritis?
Mean age of presentation is 46 years
Commonly post-traumatic
Idiopathic (Lots of people that present you don’t know the cause)
what are the symptoms of ankle arthritis?
Pain
Stiffness
what is the diagnosis of ankle arthritis?
Clinical
Radiographs
CT scan – exclude adjacent joint arthritis
what is the non-operative management of ankle arthritis?
Weight loss, activity modification, analgesia, physiotherapy, steroid injections
what is the operative management of ankle arthritis?
If symptoms are exclusively anterior (front of ankle) 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 Posterior Tibial Tendon Dysfunction?
Posterior tibial tendon dysfunction is one of the most common problems of the foot and ankle. It occurs when the posterior tibial tendon becomes inflamed or torn. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot
- Relatively Common
- Under-recognised
- 4 stages
- Largely clinical diagnosis – double & single heel raise.
- Medial or lateral pain
- Orthoses or surgery
how is the diagnosis of Tibialis posterior tendon dysfunction made?
Clinical
MRI to assess tendon
Double & Single Limb Heel Raise - Heel(s) should swing from valgus to varus as heel rises. If they have tibialis posterior dysfunction they cant do this
what is the management of tibialis posterior tendon dysfunction?
Orthotics – medial arch support
Reconstruction of tendon (tendon transfer)
Triple fusion (subtalar, talonavicular and calcaneocuboid – joints fused in better position)
what are some other foot problems?
• Diabetic foot
- Ulceration
–Charcot foot
what is the aetiology of Diabetic foot ulcer?
Diabetic neuropathy – patient unaware of trauma to foot
Diabetic autonomic neuropathy - Lack of sweating/normal sebum production:
- Dry cracked skin
- Skin more sensitive to minor trauma
Poor vascular supply
Lack of patient education
what is the treatment of 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 treatment is avalible for diabetic foot ulcer?
Improve Vascular Supply
Debride ulcers and get deep samples for microbiology
Correct any deformity to offload area
Amputation
what is the prognosis of diabetic foot ulcer?
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 Charcot Neuroarthropathy?
Charcot neuroarthropathy, also known as Charcot foot, is a complication of diabetes mellitus where there is progressive degeneration of the joints, but it potentially is devastating in its consequences
what is aetiology of charcot foot?
Any cause of neuropathy
Diabetes commonest cause
Historically originally described and most common with syphillis
what is 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
Charcot Neuroarthropathy characterised by rapid bone destruction occurring in 3 stages, what are they?
- Fragmentation
- Coalescence
- Remodelling
how is a diagnosis of Charcot Neuroarthropathy made?
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 (so often present late)
Radiographs
MRI scan
(bone scan may also be useful)
what is the management of Charcot Neuroarthropathy?
Prevention
Immobilisation / non-weight bearing until acute fragmentation resolved
Correct deformity - Deformity leads to ulceration leads to infection leads to amputation
Majority of conditions treated ____________
non-operatively
