Hindfoot Problems Flashcards by Calum Gibson-Smith

5 types of hindfoot problems

Achilles tendonitis/tendinosis
Plantar fasciitis
Ankle osteoarthritis
Tibialis posterior dysfunction
Cavovarus foot

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What is Achilles tendonitis/tendinosis

Degenerative/overuse condition with little inflammation

Tendonitis should be avoided
Tendinosis histopathological
Tendinopathy term to describe symptoms

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4 types of Achilles tendinopathy

Insertional tendinopathy
Non-insertional tendinopathy
Bursitis
Paratendinopathy

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Define insertional and non-insertional tendinopathy

Insertional = Within 2cm of insertion

- Non-insertion = 2-7cm of insertion

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2 types of bursitis related to Achilles tendinopathy

Retrocalcaneal

- Superficial calcaneal

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Define paratendinopathy

True inflammatory problem showing paratendonitis histologically

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Aetiology of paratendinopathy

Commonest is athletic populations
Age group 30-40
Male:Female = 2:1

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Aetiology of tendinopathy

Commonest in non-athletic population
Aged over 40
Obesity
Steroids
Diabetes

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Symptom of Achilles tendinopathy

Pain during/following exercise
Recurrent episodes
Difficulty in fitting shoes
RUPTURE (don’t miss!)

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How to diagnose Achilles tendinopathy

Clinical (tenderness, test for rupture)
US
MRI

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How to test for rupture of Achilles tendon

Gently squeeze calf (soleus muscle)
If the squeeze makes the foot move then the Achilles is not fully ruptured
If no movement after squeeze then there is a complete rupture of the tendon

(Angle of the dangle + Matles)

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Non-surgical Rx of Achilles tendinopathy

Activity modification/shoe with a slight heel
Physiotherapy (eccentric stretching)
Weight loss
Extra-corporeal shockwave treatment
Immobilisation (below knee cast)

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Surgical Rx of Achilles tendinopathy

Gastrocnemius resection

- Release + debridement of tendon

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Aetiology of plantar fasciitis

Unknown
Associated with high intensity or rapid increase in training
Running in poorly padded shoes or hard surfaces
Obesity
Occupations involving prolonged standing
Tight gastrocnemius muscle
Foot/lower limb rotational deformities

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Symptoms of plantar fasciitis

Pain 1st thing in the morning
Pain on weight bearing after rest (post-static dyskinesia
Pain located at origin of fascia
Frequently long lasting (2 or more years)

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DDx for plantar fasciitis

Nerve entrapment syndrome
Arthritis
Calcaneal pathology

How to diagnose plantar fasciitis

Mainly clinical

- Occasionally X-ray, US and MRI

Non-pharmacological Rx for plantar fasciitis

Rest/change training, ice
Orthoses
Physiotherapy
Weight loss
Night splinting
Stretching
Endoscopic/open surgery

Pharmacological Rx for plantar fasciitis

NSAIDs
Corticosteroid injection (good short term but long term may make condition worse)
Nitric oxide
Extracorporeal shockwave therapy
Platelet rich plasma
Topaz plasma coblation

Aetiology of ankle arthritis

46 is the mean age of presentation
Commonly post-traumatic
Idiopathic

Symptoms of ankle arthritis

Pain

- Stiffness

How to diagnose ankle arthritis

Clinical
Radiographs
CT (exclude adjacent joint arthritis)

Non-surgical Rx for ankle arthritis

Weight loss, activity modification
Physiotherapy
Analgesia
IA Steroids

Surgical Rx for ankle arthritis

Arthrodesis, open/closed (Gold standard + good long term outcome)
Joint replacement

Pros + cons of joint replacement in ankle arthritis

Pros -Maintains ROM Cons - Questionable long-term outcome, especially in high demand patients - Not easy to revise even to fusion

How to diagnose tibialis posterior tendon dysfunction

- Clinical | - MRI to assess tendon

Rx of tibialis posterior tendon dysfunction

- Orthotic (medial arch support) - Reconstruction of tendon (tendon transfer) - Triple fusion (subtalar, talonavicular and calcaneocuboid)

Aetiology of diabetic foot ulcer

- Diabetic neuropathy, patient unaware of trauma - Diabetic autonomic neuropathy (lack of sweating, dry/cracked skin, skin more sensitive to trauma) - Poor vascular supply - Lack of patient education

Non-surgical Rx for diabetic foot ulcer

Prevention - Smoking - Diabetic control - Vascular supply - External pressure (shoes/splints) - Internal pressure (deformity)

Surgical Rx for diabetic foot ulcer

- Debride ulcers + get deep samples for microbiology - Correct any deformities to reduce pressure - Improve vascular supply - Amputation

Prognosis of diabetic foot ulcer

- 25% get amputation | - 5 year mortality is 50%

Aetiology of Charcot neuroarthropathy

- Any cause of neuropathy | - Diabetes is commonest cause

Pathophysiology of Charcot neuroarthropathy

Neurotraumatic -Lack of proprioception + protective pain sensation Neurovascular -Abnormal autonomic nervous system results in increase vascular supply + bone resorption

Charcot neuroarthropathy is characterised by rapid bone destruction occurring in 3 stages. What are those stages

- Fragmentation - Coalescence - Remodelling

How to diagnose Charcot neuroarthropathy

- High index of suspicion - Consider any diabetic with a swollen foot (esp. w/ neuropathy) - Radiographs - MRI

Symptoms of Charcot neuroarthropathy

Often painless

Rx for Charcot neuroarthropathy

-Immobilise/non-weight bearing until acute fragmentation resolves -Correct deformity (deformity leads to ulceration=>infection=>amputation)