Orthopaedic Foot Conditions Flashcards
Describe the general management of foot problems?
General management:
- Non operative management
- Analgesia
- Shoe wear modification
- Activity modification
- Weight loss
- Physiotherapy
- Orthotics including insoles and bracing
- Operative management
- Only indication for this is failure of non-operative management
What are the different pathological groupings of disease based on underlying aetiology?
- Vascular
- Infective
- Traumatic
- Autoimmune
- Metabolic
- Endocrine/drugs
- Inflammatory
- Inherited
- Congenital
- Neurological
- Neoplastic
- Degenerative
- Idiopathic
What are the different anatomical groupings of foot problems?
- Forefoot problems
- Hallux valgus
- Hallux rigidus
- Lesser toe deformities
- Morton’s neuroma
- Metatarsalgia
- Rheumatoid forefoot
- Midfoot problems
- Ganglia
- Osteoarthritis
- Plantar fibromatosis
- Hindfoot problems
- Achilles tendonitis
- Plantar fasciitis
- Ankle osteoarthritis
- Tibialis posterior dysfunction
- Cavovarus foot
- Other foot problems
- Diabetic foot
- Ulceration
- Charcot foot
- Diabetic foot
What are examples of forefoot problems?
- Hallux valgus
- Hallux rigidus
- Lesser toe deformities
- Morton’s neuroma
- Metatarsalgia
- Rheumatoid forefoot
What are examples of midfoot problems?
- Ganglia
- Osteoarthritis
- Plantar fibromatosis
What are examples of hindfoot problems?
- Achilles tendonitis
- Plantar fasciitis
- Ankle osteoarthritis
- Tibialis posterior dysfunction
- Cavovarus foot
What is hallus valgus also called?
Bunions
What is this?
Hallus valgus
What is the aetiology of hallus valgus?
- Genetic
- Footwear
Describe the epidemiology of hallus valgus in terms of sex?
- Predominantly woman
Describe the pathophysiology of hallus valgus?
- Lateral angulation of great toe
- Tendons pull realigned to lateral of centre of rotation of toe worsening deformity
- Vicious cycle of increasing pull increasing deformity
- Sesamoid bones sublux, less weight goes through great tow
- Abnormalities of lesser toes
What is the presentation of hallus valgus?
- Pressure symptoms from shoe wear
- Pain from crossing over of toes
- Metatarsalgia
What investigation is done for hallus valgus?
- X-ray
- Determine severity of underlying bony deformity
- Exclude associated degenerative change
What is the mangement of hallus valgus?
- Non-operative
- Shoe wear modification
- Wide +/- high toe box
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesia
- Shoe wear modification
- Operative
- Indication is failure of non-operative treatment
- Release lateral soft tissues
- Osteotomy of 1st metatarsal +/- proximal phalanx
- Good outcome but recurrence inevitable
What is indication for operative treatment of hallus valgus?
- Indication is failure of non-operative treatment
What is hallux rigidus?
Means stiff big toe, basically osteoarthritis of 1st MTP joint
What is the aetiology of hallux rigidus?
Aetiology:
- Not known
- Possibly genetic
What is the presentation of hallux rigidus?
- Many asymptomatic
- Pain
- Often at extreme of dorsiflexion
- Limitation of range of movement
What investigation is done for hallux rigidus?
X-ray
What is the mangement of hallux rigidus?
- Non-operative
- Activity modification
- Shoe wear with rigid sole
- Analgesia
- Operative
- Cheilectomy
- Remove dorsal osteophytes to stop dorsal impingement
- Arthrodesis
- 1st MTPJ fusion
- Gold standard treatment
- 1st MTPJ hemiarthroplasty
- Good option to maintain ROM
- High failure rate
- 1st MTPJ fusion
- Arthroplasty
- Cheilectomy
What is a cheilectomy?
- Remove dorsal osteophytes to stop dorsal impingement
What are the 3 classic terms of lesser toe deformities?
- Claw toes
- Flexion at proximal and distal interphalangeal joint
- Hammer toes
- Flexion of proximal interphalangeal joint and dorsiflexion at MTP joint
- Mallet toes
- Flexion at distal interphalangeal joint
What is claw toe?
- Flexion at proximal and distal interphalangeal joint
What is hammer toes?
- Flexion of proximal interphalangeal joint and dorsiflexion at MTP joint
What is mallet toes?
- Flexion at distal interphalangeal joint
What is the aetiology of lesser toe deformities?
- Imbalance between flexors/extensors
- Shoe wear
- Neurological
- Rheumatoid arthritis
- Idiopathic
What is the presentation of lesser toe deformties?
- Deformity
- Pain from dorsum and plantar side
What is the treatment of lesser toe deformities?
- Non-operative
- Activity modification
- Shoe wear
- Flatter shoes with high toe box
- Orthotic insoles
- Operative
- Flexor to extensor transger
- Fusion of interphalangeal joint
- Release MTP joint
- Shortening osteotomy of metatarsal
What is the aetiology of Morton’s neuroma?
- Mechanically induced degenerative neuropathy
- High heeled shoes
Describe the epidemiology of Morton’s neuroma in terms of age and sex?
- Females aged 40-60
What is the presentation of Morton’s neuroma?
- Typically affects 3rd, followed by 2nd webspace/toes
- Neuralgic burning pain into toes
- Intermittent
- Altered sensation in webspace
- Metatarsalgia
- Symptom, not a diagnosis
Which toe is most commonly affected by Morton’s neuroma?
- Typically affects 3rd, followed by 2nd webspace/toes
How is Morton’s neuroma diagnosed?
- Mulder’s click
- Best clinical test
- USS best, MRI good
What is the management of Morton’s neuroma?
- Injection for small lesions
- Surgery for excision of lesion and section of normal nerve
What is the treatment of rheumatoid forefoot?
- Non operative
- Shoe wear
- Orthotics
- Activity
- Operative
- 1st MTPJ arthrodesis is gold standard
- 2-5 toe excision arthroplasty
What does dorsal foot ganglia arise from?
Arise from joint or tendon sheath
What is the aetiology of dorsal foot ganglia?
- Idiopathic
- Underlying arthritis
- Underlying tendon pathology
What is the presentation of dorsal foot ganglia?
- Pain from pressure shoe wear or underling problem
What is the treatment of dorsal foot ganglia?
- Non-operative
- Aspiration
- Operative
- Excision
What is the prognosis of dorsal foot ganglia?
- High rate of return, 50%
What is the aetiology of midfoot arthritis?
- Post-traumatic arthritis
- Osteoarthritis
- Rheumatoid arthritis
What is the treatment of midfoot arthritis?
- Non-operative
- Activity
- Shoe wear
- Orthotics
- Injections
- X-ray guided
- Operative
- Fusion
What is plantar fibromatosis also known as?
Also known as Ledderhose disease
What is the presentation of plantar fibromatosis?
- Similar to duputrens of hand
- Progressive
- Usually asymptomatic unless very large or on weight bearing area
What is the treatment of plantar fibromatosis?
- Non-operative
- Avoid pressure
- Shoe wear
- Orthotics
- Operative
- Excision
- 80% risk of recurrence
- Excision
What is achilles tendonitis/tendonosis?
Degenerative/overuse condition with little inflammation
What conditions are associated with achilles tendonitis/tendonosis?
- Insertional tendinopathy
- Within 2cm of insertion
- Non-insertional tendinopathy
- 2-7cm of insertion
- Bursitis
- Paratendinopathy
What is the difference between insertional and non-insertional tendinopathy?
- Insertional tendinopathy
- Within 2cm of insertion
- Non-insertional tendinopathy
- 2-7cm of insertion
Describe the epidemiology of paratendonopathy in terms of age and sex?
- Common in athletic population
- Age group 30-40
- M:F 2:1
Describe the epidemiology of tendonopathy in terms of age?
- Age >40
What are risk factors for paratendonopathy and tendonopathy?
- Paratendonopathy
- Common in athletic population
- Age group 30-40
- M:F 2:1
- Tendonopathy
- Commonest in non-athletic population
- Age >40
- Obesity
- Steroids
- Diabetes
What is the presentation of achilles tendonitis/tendinosis?
Presentation:
- Pain during exercise and following
- Recurrent episodes
- Difficulty fitting shoes
- Rupture
What investigations are done for achilles tendonitis/tendonosis?
- USS
- MRI
- Achilles rupture test
- Simmonds calf squeeze test
What is the treatment for achilles tendonitis/tenodonosis?
- Non-operative
- Activity modification
- Weight loss
- Shoe wear modification
- Slight heel
- Physiotherapy
- Extra-corporeal shockwave treatment
- Immobilisation (in below knee cast)
- Operative treatment
- Gastrocnemius recession
- Release and debridement of tendon
What is the correct term for plantar fasciitis?
Fasciitis is incorrect term, fasciosis is better term
What is fasciosis?
Fasciosis = chronic degernerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity
What is the aetiology of plantar fasciitis?
- Not known
- Seen more in athletes, running, obesity, occupation involving prolonged standing, foot deformities
What are risk factors for plantar fasciitis?
- Seen more in athletes, running, obesity, occupation involving prolonged standing, foot deformities
What is the presentation of plantar fasciitis?
- Pain
- Worse in the morning
- Pain on weight bearing after rest
- Located at origin of plantar fascia
What is the differential diagnosis of plantar fasciitis?
Differential diagnosis:
- Nerve entrapment syndrome
- Arthritis
- Calcaneal pathology
Describe the diagnosis of plantar fasciitis?
- Mainly clinical
- Occasionally x-rays, USS and MRI
What is the treatment of plantar fasciitis?
- Rest
- Stretching
- Ice
- NSAIDs
- Orthoses
- Physiotherapy
- Weight loss
- Injections
- Corticosteroid
- Good in short term but makes condition worse in long term
- Corticosteroid
- Night splinting
- Newer/3rd line treatments
- Extracorporeal shockwave therapy
- Topaz plasma coblation
- Nitric oxide
- Platelet rich plasma
- Endoscopic/open surgery
What is the aetiology of ankle arthritis?
- Idiopathic
- Post-traumatic
Describe the epidemiology of ankle arthritis in terms of age?
- Presents in 40s
What is the presentation of ankle arthritis?
- Pain
- Stiffness
Describe the diagnosis of ankle arthritis?
- Clinical
- Radiographs
- CT scan
- Exclude adjacent joint arthritis
What is the management of ankle arthritis?
- Non operative
- Weight loss, activity modification, analgesia, physiotherapy, steroid injections
- Operative
- Arthrodesis
- Gold standard treatment
- Good long term outcome
- Joint replacement
- Maintain ROM
- Arthrodesis
What is posterior tibial tendon dysfunction?
Acquired adult flat foot planovalgus
What is the presentation of posterior tibial tendon dysfunction?
- Pain medial or lateral
Describe the diagnosis of posterior tibial tendon dysfunction?
- Double and single heel raise
- In normal, heels should swing from valgus to varus as heel rises
- Cant do this with posterior tibial tendon dysfunction
- MRI
- Assess tendon
What is the treatment of posterior tibial tendon dysfunction?
- Orthosis in early stages
- Surgery in later stages
- Reconstruction of tendon (tendon transfer)
- Triple fusion (subtalar, talonavicular and calcaneocuboid)
Describe the aetiology of diabetic foot ulcer?
- Diabetic neuropathy
- Patient unaware of trauma to foot
- Diabetic autonomic neuropathy
- Lack of sweating/normal serum production
- Dry cracked skin
- Skin more sensitive to minor trauma
- Lack of sweating/normal serum production
- Poor vascular supply
- Lack of patient education
What is the treatment of diabetic foot ulcer?
- Prevention
- Modify main treatment detriments to healing
- Diabetic control
- Smoking
- Vascular supply
- External pressure
- Splints, shoes, weight bearing
- Internal pressure
- Deformity
- Infection
- Nutrition
- Surgical treatment
- Improve vascular supply
- Debride ulcers and get deep samples for microbiology
- Correct any deformity to offload area
- Amputation
Describe the aetiology of charcot neuroarthropathy?
- Any cause of neuropathy
- Diabetes commonest cause
Describe the pathophysiology of charcot neuroarthropathy?
- Neurotraumatic
- Lack of proprioception and protective pain sensation
- Neurovascular
- Abnormal autonomic nervous system results in increased vascular supply and bone resorption
- Characterised by rapid bone destruction in 3 stages
- Fragmentation
- Coalescence
- Remodelling
Describe the diagnosis of charcot neuroarthropathy?
- High index of suspicion
- Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy
- Radiographs
- MRI scan
Describe the management of charcot neuroarthropathy?
- Prevention
- Immobilisation/non-weight bearing
- Correct deformity
- Deformity leads to ulceration leads to infection leads to amputation
