Hindfoot Problems Flashcards
5 types of hindfoot problems
- Achilles tendonitis/tendinosis
- Plantar fasciitis
- Ankle osteoarthritis
- Tibialis posterior dysfunction
- Cavovarus foot
What is Achilles tendonitis/tendinosis
Degenerative/overuse condition with little inflammation
- Tendonitis should be avoided
- Tendinosis histopathological
- Tendinopathy term to describe symptoms
4 types of Achilles tendinopathy
- Insertional tendinopathy
- Non-insertional tendinopathy
- Bursitis
- Paratendinopathy
Define insertional and non-insertional tendinopathy
- Insertional = Within 2cm of insertion
- Non-insertion = 2-7cm of insertion
2 types of bursitis related to Achilles tendinopathy
- Retrocalcaneal
- Superficial calcaneal
Define paratendinopathy
True inflammatory problem showing paratendonitis histologically
Aetiology of paratendinopathy
- Commonest is athletic populations
- Age group 30-40
- Male:Female = 2:1
Aetiology of tendinopathy
- Commonest in non-athletic population
- Aged over 40
- Obesity
- Steroids
- Diabetes
Symptom of Achilles tendinopathy
- Pain during/following exercise
- Recurrent episodes
- Difficulty in fitting shoes
- RUPTURE (don’t miss!)
How to diagnose Achilles tendinopathy
- Clinical (tenderness, test for rupture)
- US
- MRI
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)
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)
Surgical Rx of Achilles tendinopathy
- Gastrocnemius resection
- Release + debridement of tendon
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
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)
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)
