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
What are the management options for Morton’s neuroma?
Injection for small lesions
Surgery - excision of lesion including a section of normal nerve - this can sometimes result in numbness or recurrence.
What is Metatarsalgia?
- A symptom (joint pain), not a diagnosis
- Careful examination should localise cause
- Many causes but if no obvious cause consider tight gastrocnemius
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

Midfoot problems (3)
- Ganglia
- Osteoarthritis
- Plantar fibromatosis
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.

Treatment of dorsal foot ganglia
Non-operative
- Aspiration
Surgery
- Excision
Poor prognosis + high rate of return (50%)
Midfoot arthritis
Types: post traumatic, osteoarthritis, rheumatoid
Treatment:
- Activity, footwear, orthotics
- Injections
- Operative - fusion
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)

Hindfoot problems (5)
- Achilles tendonitis/tendinosis
- Plantar fasciitis
- Ankle osteoarthritis
- Tibialis posterior dysfunction
- Cavovarus foot - high foot arch, because of this, an excessive amount of weight is placed on the ball and heel of the foot when walking or standing
Achilles tendinopathy (collective term describing achilles problems)
Tendinopathy occurs when a tendon is unable to adapt to the strain being place upon it. This causes microtrauma to the tendon fibres and results in the tendon trying to heal itself. Also called Achilles tendinits or tendinosis but these terms mean the same as achilles tendinopathy.
Achilles tendinopathy: tendinopathy vs paratendinopathy
- Paratendinopathy - inflammation of the paratenon (areolar tissue filling the space between a tendon and its sheath) - commonest in athletic populations, age 30-40
- Tendinopathy - commonest in non-athletic populations - aged over 40. RF: obesity, steroids, diabetes
Symptoms of achilles tendinopathy
- Pain during or following exercise
- Recurrent episodes
- Difficulty fitting shoes - back of the shoe rubs on the area - this suggests insertional tendinopathy
- Rupture - some tendinopathies progress to rupture because it weakens the tendon. Early treatment is better so needs to be picked up quickly.
How do you diagnose achilles tendinopathy?
Clinical
- Tenderness
- Test for tendon rupture
Investigations
- USS
- MRI
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

Treatment of tendinopathy - operative and non-operative
Non-operative
- Weight loss
- Activity modification and immobilisation of ankle - sometimes a below the knee cast is used for a few weeks at a time to try and help things heal
- Slight heel raise - takes pressure off achilles tendon
- Physio - Stretching
- Extra-corporeal shockwave treatment - applying something similar to USS that vibrates the tissues and stimulates fibirous tissue to form and healing
Operative treatment
- Gastrocnemius recession - release of the gastrocnemius tendon and subsequent lengthening of the calf muscle
- Release and debridement of tendon and remove paratenon
What is plantar fasciitis/plantar fasciosis?
Fasciosis is a better term as there isn’t actually inflammation involved in this condition. Plantar fasciitis is where you have pain on the bottom of your foot, around your heel and arch.
- Chronic degenerative changes
- Hypertrophy of fibroblasts
- Absence of inflammatory cells
- Disorganised and dysfunctional blood vessels and collagen
- Avascularity
Basically the matrix that is required for repair isn’t there
Causes of plantar fasciitis/fasciosis?
- Unknown
- In athletes - associated with high intensity or rapid increase in training
- Running with poorly padded shoes or hard surfaces
- Obesity
- Occupation - if involves prolonged standing
- Foot/lower limb rotational deformities
Symptoms of plantar fasciitis
- Pain first thing in the morning
- Pain on weight bearing after rest
- Pain located at origin of plantar fascia
- Frequently long lasting - 2 years or more
Treatment of plantar fasciitis
- Rest, change training
- Stretching - achilles +/- direct stretching
- Ice
- NSAIDs
- Orthoses - heel pads
- Physio
- Weight loss
- Injections - corticosteroid (good in short term but may make condition worse in long term)
- Night splinting
Newer/3rd line treatments - extracorporeal shockwave therapy, topaz plasma coblation, nitric oxide
Ankle arthritis
Commonly post-traumatic
Diagnosis - clinical, radiographs, CT scan
Treatment:
- Non operative - weight loss, activity modification, analgesia, physio, steroid injection
- Operative
- If symptoms are exclusively anterior - arthroscopic anterior debridement
- Arthrodesis - open or athroscopic (gold standard)
- Joint replacement - questionable long term outcome
Posterior tibial tendon dysfunction
- Relatively common but under-recognised
- 4 stages. Diagnosis is clinical + MRI to assess tendon
- Double & single heel raise - to go with both feet from a flatfoot stance to standing on the toes. Double heel raise: Stage 1 can do this but it is painful. Stage 2, 3 and 4 cannot do this. Patients cannot do a single heel raise on the affected foot.
- Medial or lateral pain
- Management - orthotics, reconstruction of tendon, triple fusion
Diabetic foot ulcer: causes, treatment
Causes
- diabetic neuropathy - patient uanware of trauma to foot
- diabetic autonomic neuropathy - lack of sweating - dry cracked skin, skin more sensitive to minor trauma
- Poor vascular supply
- Lack of patient education
Treatment is prevention
- Also modify the main detriments to healing i.e diabetic control, smoking, vascular supply, external pressure etc
- Surgery - improve vascular supply, debridement (samples for microbiology too), correct any deformity to offload area, amputation
What is Charcot Neuroarthropathy?
Can be caused by any cause of neuropathy but is commonly a complication of diabetes mellitus - progressive degeneration of the joints in the foot. It is characterised by rapid bone destruction occuring in 3 stages: fragmentation, coalescence and remodelling.
Pathophysiology:
- Neurotraumatic - Lack of proprioception and protective pain sensation
- Neurovascular - Abnormal autonomic nervous system results in increased vascular supply and bone resorption
Diagnosis and management of Charcot’s foot
- High index of suspicion
- Consider in any diabetic patient with swollen erythematous foot especially with neuropathy
- Frequently not painful
- MRI
- Radiographs
Management:
- Prevention
- Immobilisation/non-weight bearing until acute fragmentation resolved
- Correct deformity as this leads to ulceration which leads to infection and then amputation.