Foot problems Flashcards
What is the only indication for surgery for foot problems?
Failure of non-operative management
Problems of the forefoot (6)
- Hallux valgus (bunions)
- Hallux rigidus
- Lesser toe deformities
- Morton’s neuroma
- Metatarsalgia
- Rheumatoid arthritis (in the forefoot)
Causes of Hallux valgus (bunions) (3)
- Genetic
- Foot wear
- Gender: female
Symptoms associated with bunions
- Pressure symptoms from shoes
- Pain from crossing over of toes
- Metatarsalgia - joint pain
Pathogenesis of Hallux Valgus
- Lateral angulation of the great toe
- Tendons pull the toe into a lateral alignment and this worsens the deformity
- Vicious cycle of increased pull (due to deformity) creating increased deformity
- The sesamoid bones in the knuckles of toes sublux/ partially dislocate so then less weight goes through the great toe
- As deformity progresses, abnormalities of the lesser toes occur
Non-operative management of Hallux Valgus (4)
- Shoe wear modification (wide +/- high toe bod=x)
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesia
Operative management of Hallux Valgus
- Release lateral soft tissues - muscle dissections and muscle/tendon lengthening
- Osteotomy 1st metatarsal +/- proximal phalanx
- Generally good outcome but recurrence inevitable
What is Hallux rigidus?
A stiff/ painful big toe
- It is a form of degenerative arthritis - the toe’s range of motion gradually decreases until it potentially reaches the end stage of rigidus, in which the big toe becomes stiff or what is sometimes called a frozen joint.
- This disorder can be very troubling and even disabling since we use the big toe whenever we walk, stoop down, climb up or even stand
Causes of Hallux rigidus?
Unknown but possibly genetic or multiple microtrauma
Symptoms of Hallux rigidus
- Many asymptomatic
- Pain - often at extreme of dorsiflexion
- Limitation of range of movement
Management of Hallux Rigidus: non-operative and surgery
Non-operative
- Activity modification
- Shoe wear with rigid sole
- Analgesia
Surgery
- ‘Gold standard’ = Arthrodesis - joint fusion of the 1st metatarsophalangeal joint - This procedure fuses together the 2 bones and it can lessen your pain. It can also make your joint more stable and help you bear more weight on it.
- Cheilectomy - remove excess bone from the joint of your big toe
- Arthroplasty - joint replacement - 1st MTPJ hemiarthroplasty - good option to maintain range of motion - high failure rate though
What are some lesser toe deformities? (3)
- Claw toes
- Hammer toes
- Mallet toes
Causes of Hammer toe, claw toe or mallet toe? (5)
- Imbalance between flexors/extensors
- Shoe wear
- Neurological
- Rheumatoid arthritis
- Idiopathic
What are the non-operative and operative treatment options for lesser toe deformities?
Non-operative
- Activitiy modification
- Shoe wear - flat shoes with high toe box
- Orthotic insoles - metatarsal bar/dome support
Operative
- Flexor to extensor transfer due to imbalance
- Fusion of interphalangeal joint
- Release MTP joint
- Shortening osteotomy of metatarsal
What is Morton’s Neuroma?
A painful condition that affects the ball of your foot, most commonly the area between your third and fourth toes.
Symptoms:
- Inflammation
- Severe neuralgic (short and severe) burning pain into the toes
- Numbness on the ball of the foot
Causes of Morton’s Neuroma
- Mechanically induced degenerative neuropathy
- Thickened tissue in your toe puts pressure on the nerve irritating it and causing pain.
- 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
How do you diagnose Morton’s neuroma?
Clinical examination
Mulder’s click - clinical test specific to Morton’s Neuroma
USS or MRI
Rheumatoid forefoot
Rheumatoid arthritis in the forefoot
Non-operative treatment = shoes, orthotics, activity etc
Operative treatment = 1st MTPJ arthrodesis or 2-5th toe excision arthroplasty
What is dorsal foot ganglia?
- A benign cyst in the foot that arises from joint or tendon sheath
- Appears as a lump
- Causes: idiopathic, underlying arthritis or underlying tendon pathology
- A dorsal foot ganglion is typically painful. Especially when wearing incorrect footwear.
What is Plantar fibromatosis (otherwise known as Ledderhose disease)?
A rare, benign, hyperproliferative fibrous tissue disorder resulting in the formation of nodules along the plantar fascia.
- It is generally seen in middle-aged and elderly people,
- M>F 10:1
- It is progressive
- Usually asymptomatic unless very large or on weight-bearing area
Treatment:
- 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 is the Simmonds test?
Achilles rupture test
Patient usually lies on their stomach and dangles their foot over the end of the bed. Squeeze the calf gently:
- If the calf squeeze moves the foot up (plantarflexion) then the achilles tendon is not fully ruptured between the soleus muscle and the heel bone
- If the calf squeeze does not move the foot up then there is a full achilles tendon rupture between the soleus muscle and the heel
Ruptured Achilles tendon
Right side - very well defined. Foot is slightly plantarflexed
Left side - diffuse swelling, margins of achilles tendon are not clear
