Foot problems Flashcards
What are some possible causes of hallux valgus (bunions)?
Genetic
Foot wear
Significant female preponderance
What are some symptoms of hallux valgus?
Pressure symptoms from shoe wear
Pain from crossing over of toes
Metatarsalgia
What causes hallux valgus?
Lateral angulation of toe
Tendons pull realigned to lateral of centre
Increased pull creates increased deformity
How is hallux valgus diagnosed?
Clinical
X-ray
What is x-ray used for in hallux valgus?
Assess severity of bone deformity
Exclude associated degenerative change
What are some non-operative treatment options for hallux valgus?
Shoe wear modification
Orthotics to offload pressure/correct deformity
Activity modification
Analgesia
What are some operative treatment options for hallux valgus?
Release lateral soft tissues
Osteotomy 1st metatarsal +/- proximal phalanx
Generally good outcome but recurrence inevitable
What is hallux rigidus?
Stiff big toe
Osteoarthritis of 1st MTP joint
How does hallux rigidus present?
Limited range of movement
Pain mostly on dorsiflexion
Many asymptomatic
What are some non-operative treatment options for hallux rigidus?
Activity modification
Shoe wear with rigid sole
Analgesia
What are the operative treatment options for hallux rigidus?
Cheilectomy
Arthrodesis
Arthroplasty
1st MTPJ fusion (gold standard)
What is cheilectomy?
Remove dorsal impingement
What are some lesser toe deformities?
Claw toes
Hammer toes
Mallet toes
What are some causes of lesser toe deformities?
Imbalance between flexors/extensors Shoe wear Neurological Rheumatoid arthritis Idiopathic
What are some symptoms of lesser toe deformities?
Deformity
Pain on dorsum of foot
Pain from plantar side
What are some operative treatment options for lesser toe deformities?
Flexor to extensor transfer
Fusion of interphalangeal joint
Release metatarsophalangeal joint
Shortening osteotomy of metatarsal
What are some non-operative treatment options for lesser toe deformities?
Activity modification
Shoe wear – flat shoes with high toe box to accommodate deformity
Orthotic insoles to support metatarsal bar/dome
What is interdigital neuroma?
Morton’s neuroma
Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
What are some possible causes of Morton’s neuroma?
Mechanically induced degenerative neuropathy
Tends to affect females aged 40-60
Frequently associated with wearing high healed shoes
How does Morton’s neuroma present?
Typically affects 3rd followed by 2nd webspace/toes
Neuralgic burning pain into toes
Intermittent
Altered sensation in webspace
How is Morton’s neuroma diagnosed?
Clinical
Mulder’s click
USS best test
MRI
How are Morton’s neuromas managed?
Injection for small lesions
Excision of lesion including section of normal nerve
What are some possible causes of metatarsalgia?
Synovitis Bursitis Arthritis Neuralgia Neuromata Freiberg's disease Tight gastrocnemius
What are some non-operative treatment options for rheumatoid forefoot?
Shoewear
Orthotics
Activity modification
What are some operative treatment options for rheumatoid forefoot?
1st MTJP arthrodesis
2-5th tow excision arthroplasty
Where do dorsal foot ganglia come from?
Joint or tendon sheath
What causes dorsal foot ganglia?
Idiopathic
Underlying arthritis
Underlying tendon pathology
What are some symptoms of dorsal foot ganglia?
Pain from pressure from shoe wear
Pain from underlying problem
How are dorsal foot ganglia treated?
Immobilisation to stop growth
Aspiration
Excision
What is ledderhose disease?
Plantar fibromatosis
“Dupuytrens of the foot”
How does plantar fibromatosis present?
Usually asymptomatic unless very large or over weightbearing area
Progressive
How is plantar fibromatosis treated?
Orthotics
Excision
Radiotherapy
What is the difference between paratendonopathy and tendonopathy?
Tendonopathy more common in non-athletic populations rather than athletic
Tendonopathy also often associated with obesity, steroids, diabetes
How does achilles tendonopathy present?
Pain during exercise
Pain following exercise
Recurrent episodes
Difficulty fitting shoes
Can achilles tendonopathy cause rupture?
Yes
How is achilles tednonopathy diagnosed?
Tenderness
Test for rupture
USS
MRI
What are some tests used to check for achilles rupture?
Simmonds test
Matles (“angle of the dangle”)
What are some non-operative treatment options for achilles tendonopathy?
Activity modification Weight loss Shoe wear modification – slight heel Physiotherapy – Eccentric stretching Extra-corporeal shockwave treatment Immobilisation
What are the operative treatment options for achilles tendonopathy?
Gastrocnemius recession
Release and debridement of tendon
What is plantar fasciitis?
Chronic degenerative change
Fibroblast hypertrophy
Disorganised and dysfunctional blood vessels and collagen
What are some possible causes of plantar fasciitis?
High intensity or rapid increase in training
Running with poorly padded shoes or hard surfaces
Obesity
Job with prolonged standing
Foot/lower limb rotational deformities
Tight gastro-soleus complex
How does plantar fasciitis present?
Pain first thing in the morning
Pain on weight bearing after rest
What are some possible differential diagnoses with plantar fasciitis?
Nerve entrapment syndrome
Arthritis
Calcaneal pathology
How is plantar fasciitis diagnosed?
Mainly clinical
Sometimes x-rays, USS, MRI
How can plantar fasciitis be treated?
Rest Stretching Ice NSAIDs Orthoses Physio Weight loss Corticosteroid injections Night splinting
What is tibialis posterior tendon dysfunction?
Acquired adult flat foot planovalgus
Where does pain occur in tibialis posterior tendon dysfunction?
Medial or lateral
How is tibialis posterior tendon dysfunction managed?
Orthoses or surgery
How is tibialis posterior tendon dysfunction diagnosed?
Largely clinical diagnoses
Single and double heel raise (heels should normally swing from varus to valgus)
How does surgery resolve diabetic foot ulcers?
Improve Vascular Supply
Debride ulcers and get deep samples for microbiology
Correct any deformity to offload area
Amputation
What is neurovascular charcot neuropathy?
Abnormal autonomic nervous system results in increased vascular supply and bone resorption
What is neurotraumatic charcot neuropathy?
Lack of proprioception and protective pain sensation
When should charcot neuropathy be considered?
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
Which tests are used for charcot neuropathy?
Radiographs
MRI
How is charcot neuropathy managed?
Prevention
Immobilisation
Correct deformity causing neuropathy
