Foot Problems Flashcards
What are some non-operative treatment options for foot and ankle conditions?
- Analgesia
- Shoe-wear / Activity modification
- Weight loss
- Physiotherapy
- Orthotics / bracing
When are surgical measures taken to treat foot and ankle problems?
The only indication for operative measures is the failure of non-operative measures to resolve the issue
- Operation is not desirable due to harsh recovery / side effects of foot / ankle surgery
How are the foot and ankle problems classified?
- Forefoot problems: affecting metatarsals and toes
- Midfoot problems: affecting tarsals
- Hindfoot problems: affecting the heel, calcaneus and talus
List some examples of forefoot problems
- Hallux valgus
- Hallux rigidus
- Lesser toe deformities
- Morton’s Neuroma
- Metatarsalgia
- Rheumatoid forefoot
What is hallux valgus? Pathophysiology?
Bunions - a bony bump that forms at the base of the first MTP joint
- lateral angulation of hallux (big toe) occurs
- Tendons of the toe pull due to slack due to deviation
- Cycle of increased pull leading to increased deformity
- sesamoid bones sublux, less weight through hallux
- Abnormalities of lesser toes develop w increased weight bearing
How does the bony lump often present in hallux valgus occur?
Medial tension causes the medial collateral ligaments to pull on the dorsomedial aspect of the first metatarsal head, causing bony proliferation
Symptoms of hallux valgus?
- pressure symptoms / pain from shoe wear
- Pain from crossing over of toes
- Metatarsalgia (due to increased weight on smaller toes)
Investigations for hallux valgus?
Clinical suspicion usually enough
X-Ray
- Determine severity of injury
- Exclude associated degenerative change
Management of hallux valgus?
Non-operative:
- Shoe wear modification +/- orthotics
- Analgesia / activity modification
Operative (if non-operative failed):
- Release lateral soft tissues
- Osteotomy 1st metatarsal +/- proximal phalanx
What is hallux rigidus? What is it caused by? Symptoms? Investigations?
Stiffness of the big toe
- Caused by osteoarthritis of 1st MTP joint
- Limited ROM of hallux, pain often present on dorsiflexion (osteophytes on MTP impinge)
- Clinical examination / X-Ray
Management of hallux rigidus?
Non-Operative:
- Activity modification / Analgesia
- Shoe wear with rigid sole
Operative:
- Cheilectomy (remove dorsal osteophytes - impingement)
- Arthrodesis (fusion of 1st MTP)
- Arthroplasty
What are the three common lesser toe deformities? Brief description of each?
Claw Toes - flexion at PIP & DIP joints
Hammer toes - flexion of the PIP, dorsiflexion of the MTP and extension of the DIP joint
Mallet toes - flexion at the DIP joint
Possible causes of lesser toe deformities?
- Imbalance between flexors and extensors
- Shoe wear
- Neurological
- Rheumatoid arthritis
- Idiopathic
Symptoms of lesser toe deformities?
- Visible deformity
- Pain from dorsum
- Pain from plantar side (metatarsalgia)
What are some non-operative treatment options for lesser toe deformities?
- Activity modification
- Shoe wear: flat shoes with high toe box to accomodate deformity
- Orthotic insoles: metatarsal bar / dome support
What are some operative treatment options for lesser toe deformities?
- Flexor to extensor transfer
- Fusion of interphalangeal joint
- Release of MTP joint
- Shortening osteotomy of metatarsal
What is Morton’s Neuroma? Where does it tend to occur? Who tends to get it?
- Inflammation around one of the nerves leading to the toes, mechanical interaction between swollen nerve and associated tissues causes symptoms
Tends to occur in 3rd webspace (followed by second)
- Tends to occur to females between 40 & 60, frequently associated with wearing high healed shoes
Symptoms of Morton’s Neuroma?
- Neuralgic burning pain, often radiating into toes
- Pain is intermittent (associated with activity)
- Altered sensation in webspace (numbness / tingling)
Investigations for Morton’s neuroma?
Clinical examination - Mulder’s click
USS / MRI - imaging often not that effective
Management of Morton’s Neuroma?
Steroid injection & shoe wear modification (no more high heels) - resolves around 50%
Surgery
- Excise the lesion and distal nerve
- High chance of recurrence due to nerve growing back
What is metatarsalgia? Possible causes?
A symptom - pain in the forefoot
- Synovitis, bursitis, arthritis, neuralgia, neuroma, Freiberg’s disease, tight gastrocnemius
How can rheumatoid arthritis present in the forefoot?
As a wide range of deformities, including hallux valgus and lesser toe deformities
How is rheumatoid forefoot treated?
Non-operative:
- shoewear / orthotics / activity modification
Operative:
- 1st MTP joint arthrodesis (fusion)
- 2-5th toe excision arthroplasty (excision of MTP joints)
What is a dorsal foot ganglia? Symptoms? Treatment?
Swelling (lump) on the dorsum of the foot - they arise from the joint / tendon sheath
Pain from shoewear / pain from associated underlying problem
- Aspiration / excision / bible
What is plantar fibromatosis? Symptoms? Treatment?
- Basically Duputren’s of the foot, except lumps don’t pull on the toes as in the fingers of the hand
- Usually painless / asymptomatic, unless lesion is in a weight bearing area
- shoe wear modification / excision (high rate of recurrence - 80%)
What are some of the causes of achilles tendinopathies?
- Bursitis (retrocalcaneal / superficial calcaneal)
- Paratendinopathy (inflammatory condition - most common in younger patients)
(insertional tendinopathy: tendinopathy within 2cm of the insertion, non-insertional: further than 2cm)
Symptoms of achilles tendinopathy?
- Pain during exercise
- Pain following exercise
- Difficulty fitting shoes (if back of shoe rubs on sore area - suggests insertional problem)
- Rupture of the tendon
Investigations for achilles tendinopathy?
- Test for rupture: Simmond’s test (patient lying on stomach w feet off bed, squeeze calf - if no plantar flexion then it’s ruptured)
- USS
- MRI
Non-operative treatment for achilles tendinopathy?
- Activity modification / weight loss / Physiotherapy
- Shoe wear modification (slight heel)
- Extra-corporeal shockwave treatment
- Immobilization (below knee cast)
Operative treatment for achilles tendinopathy?
- Gastrocnemius recession (lengthen the muscle)
- Release and debridement of tendon & removal of paratenon
What is plantar fasciitis?
Plantar fasciitis inflammation of the plantar fascia, the CT on the bottom of the foot that helps to support the arch & connect heel to toes
It occurs when the fascia is overloaded or overstretched, causing small tears in the fibres of the fascia, especially where the fascia meets the heel bone
- Doesn’t always involve inflammation, can just be a degenerative change
What are some risk factors for plantar fasciitis?
- Athletic activity / overuse
- Obesity
- Foot / lower limb rotational deformity
- Tight gastro-soleus complex
Symptoms of plantar fasciitis?
- Pain first thing in morning (ankle)
- Pain on weight bearing after rest
- Pain gets better after activity, but then reappears after resting
Treatment of plantar fasciitis?
- Stretching / NSAIDs / weight loss / physio
- Corticosteroid injection (don’t help in long term)
- Night splinting
- Shockwave therapy / topaz plasma coblation / nitric oxide / platelet rich plasma
- Endoscopic / open surgery
Symptoms of ankle arthritis? Non-operative management?
- Pain and stiffness of the joint
Non-operative:
- weight loss, orthotics, analgesia, steroid injections
Operative management of ankle arthritis?
- Arthrodesis (fusion): gold standard
- Joint replacement
What is tibialis posterior tendon dysfunction? How is it diagnosed? Treatment?
- Acquired adult flat foot planovalgus (inner ankle bent towards midline)
- Usually clinical diagnosis. Can person go on their tip toes? (bc ankle goes from valgus to varus to accomplish this)
- Orthotics or surgery to treat
Treatment of diabetic foot ulcers?
- Debridement
- Weight loss / smoking cessation
- Restore blood supply to foot (vascvular surgery)
- Orthotics (pressure off affected area)
- Amputation
What is charcots foot?
Deformity that occurs in diabetics - lose feeling of foot and then damage occurs to foot bones but isn’t felt
Results in remodelling of the foot of the patient and loss of foot arch
Presentation of Charcot’s foot?
- Visible deformity of foot / ulceration on foot
- Swollen, erythematous foot
