Pathologies Related to the Foot and Ankle Flashcards
What is diabetes mellitus?
Chronic systemic disorder characterized by hyperglycemia and abnormal metabolism
What is type I diabetes?
- Auto-immunity affecting the pancreas that produces insulin
- Deficiency of insulin production and secretion
What is type II diabetes?
- Excessive dietary sugar and other simple carbohydrates limits effect of insulin
- May be influenced by auto-immunity
What is insulin?
- Released from the Pancreas
- Lowers blood sugar
- Stores fats
How many americans are prediabetic?
1/3 of Americans are pre-diabetic; a huge number… (US pop. > 330 million)
How many americans have diabetes?
~ 1/10 Americans with diabetes
Diabetes is the MOST common __________/__________ disorder
Endocrine/metabolic
Is type I diabetes or type II more common?
type II MORE common (> 90%) than type I
What is happening with the population that diabetes is occuring in?
Occurring in younger and younger individuals
- MORE sedentary lifestyles
- Increasing obesity
What are type I diabetes risk factors?
- family hx
What are type II diabetes risk factors?
- family hx
- ethnic origin
- obesity
- increasing age
- habitual physical inactivity
- previous hx of gestational diabetes or babies over 9 lbs
- presence of other clinical conditions with insulin resistance
- hx of vascular disease
- previously identified impaired fasting glucose or glucose intolerance
- hypertension
- HDL cholesterol level
- cigarette smoking
What ar other contributors to diabetes mellitus?
- SAD- layered with sugars and simple carbohydrates
- ≥ 2 hrs. of screen time/day as a part of a sedentary lifestyle
- Daily carbonated beverage- MORE sugar
- Fast food > 2x/wk.- MORE sugar
Why can unmanaged stress and lack of regular sleep cause diabetes?
- Inhibits insulin production
- Increased cortisol production that produces MORE sugars
What is the pathogenesis of type I diabetes?
inability to produce and secrete adequate insulin to use glucose
What is the pathogenesis of type II diabetes?
inadequate response of insulin receptors to insulin
What can inadequate response to insulin such as with type II diabetes cause?
- Excessive carbohydrate (CHO)/sugar intake
- increasing insulin production
- increasing fat storage and SYSTEMIC INFLAMMATION
- As the cycle continues you limit the effect of insulin, so the body makes even MORE insulin
- MORE fat storage and SYSTEMIC INFLAMMATION
- Insulin production finally stops or nearly stops bc Pancreatic cells that make insulin are exhausted
- Obesity and diabetes develop
What are cardinal S&S with diabetes?
- Frequent urination (polyuria)
- Dry mouth
- Extreme thirst (polydipsia)
- Decreased skin turgor
- Blurry vision due to sugar damaging blood vessels
- Weakness/fatigue
What are the 3 types of nneuropathies that diabetes can progress to?
1, sensory
2. motor
3. autonomic
What are the qualities of senosry neuropathy with diabetes?
- Large ill-defined areas of non-segmental paresthesia and hyposensitivity or numbness of involved terminal nn
- Joint destruction because repeated microtrauma is not felt- Charcot foot- see next slide
- Less aware of a heart attack they are already MORE prone to
What are qualities of a motor neuropathy with diabetes?
weakness of mm. innervated by the involved terminal nn.
What are qualities of an autonomic neuropathy with diabetes?
- Diminished pulses
- Necrosis, especially distally, i.e., wounds, amputations
- Poor healing
- Stroke
- Cardiac dz
- Excess hunger because cells can’t use glucose with ineffective insulin… so more eating… obesity
What are some other severe complications for all types of diabetes?
- Leading cause of kidney dz and blindness
- Cognitive dysfunction leading to Alzheimer’s, referred to as type III diabetes
What will we find with observation with diabetes?
Charcot foot
Dry mouth
Cognitive decline
Fruity and long deep breaths with type 1
What will we find in our scan and biomechanical exam with diabetes?
- Age-related Joint Change S&S in ½ of diabetics
- Resisted/MMT- possible weaknesses
> Neuro
- Diminished sensation
- Terminal n. pattern
- Also assess 2 pt. discrimination and monofilament sensation
- + Dural mobility tests
- Weaknesses of involved terminal nn.
- Myotomes WNL
What can we palpate for with diabetes?
diminished pulses
What kind of referral is diabetes?
Urgent referral to MD
What other PT conditions can diabetes make more likely due to the systemic inflammation and impaired circulation?
- HIGHER prevalence of Carpal Tunnel Syndrome, Dupuytren’s contracture, Trigger finger, and Adhesive Capsulitis
- HIGHEST prevalence of DISH (enthesis ossification) in those with Diabetes
- Delayed healing
- Disorganized and excessive scar tissue
- Nociplastic pain
- SYSTEMIC INFLAMMATION
Systemic inflammation with diabetes is the primary contributor to:
- Diabetes
- HTN
- High triglycerides
- Low HDL
- Being overweight
>2/5 = metabolic syndrome
Why are there contraindications to grade V JMs with diabetes?
- Due to increase in osteoclastic activity, Osteoporosis develops in first 5 years of dx
- Hardening of aa and their walls associated with Diabetes
Can type II diabetes be controlled/reversed?
yes, with proper diet, exercise, and/or medications
What should we know about exercising with diabetes?
Check with MD initially - “balancing act”
- No restrictions if glucose levels monitored and managed well
- 3 10-minute bouts of cardiovascular activity better for sugar levels than 1 30-minute bout
- Wait to exercise 1-2 hrs. after a meal
- May need to decrease insulin prior to exercise
- May need extra carbs to build glucose “stores” after exercise
- Keep snacks handy in case of hypoglycemia
What are S&S of hypoglycemia?
- rapid onset
- labile, irritable, nervous mood
- difficulty concentrating. speaking, focusing
- shake, hungry, HA, dizziness,
- palor, sweating
- normal mucous membrane
- shallow respirations
- tachycardia
- tremor, dialated pupils, convulsions
What are S&S of hyperglycemia?
- gradual onset
- lethargic
- dulled sensorium, confused
- thirst, weakness. N&V, abdominal pain
- flushed, signs of dehydration
- dry and crusty mucous membranes
- deep rapid breaths
- fruity and acetone breath odor
- diminished reflexes, paresthesias
What is our patient education with diabetes?
- Wear accommodating shoes and socks
- Examine feet regularly for skin breakdown
- Avoid alcohol and cortisone shots, high sugars in both
What is gout?
metabolic disorder with elevated levels of uric acid and deposition of urate crystals
Where is gout most common?
1st MTP is MOST common site
What is gout the most common disorder of in the US?
MOST common crystallopathy in the US
What population is gout most common in?
Primarily in middle-aged biological males
What are risk factors for gout?
- Family hx
- Decreased renal function with aging
- Conditions increasing uric acid production, i.e., leukemia, lymphoma, psoriasis, or RBC disorder
- Conditions limiting excretion of uric acid, i.e., alcoholism, HTN, obesity, and renal and thyroid disorders
- High fructose of SAD
- High nitrogen in organ meats, trout, shellfish, sardines, etc.
What is the etiology of gout? (primary and secondary)
Primary- Genetic
Secondary to another disorder
Idiopathic or unknown
What is the pathogenesis of gout?
- Uric acid typically forms from breaking down cellular waste in the bloodstream
- Kidneys unable to process higher amount of uric acid
So MORE uric acid remains in circulation and migrates, primarily to joints - Sparks an inflammatory response leading to tissue changes
- Necrosis of original tissue
- Proliferation of fibrous secondary tissue
What are clinical manifestations of gout?
*** Symptoms develop after ~ 10-20 yrs. of hyperuricemia… so it’s been going on for a while…
* Typically, monoarticular
* Rather sudden onset of severe joint pain, often at night or morning
* Episodic with increasing frequency and severity based pm risk factors
* May develop cellulitis or infection
* May have constitutional symptoms if multiple joints involved
What can we tell out patients about gout?
- Education on causes and risk factors
- Patients often develop subsequent orthopedic conditions in and around gouty area
What will we find in observaiton with gout?
Redness
Swelling
What will we find with temperature with gout?
warmth, possibly fever
What generality will we find in our scan and biomechanical exam with gout?
findings like age-related joint changes
What kind of referral is gout?
Urgent referral to MD
What is osteomyelitis?
Inflammation of bone due to microorganism
Destructive infection
What is the incidence/prevalence of osteomyelitis?
- Uncommon in wealthier countries… but resurgence with longevity and IV drug use
- MOST common in tarsal and metatarsal bones (43%) followed by tibia and femur
- Also, may occur in vertebra- see thoracic notes
What are risk factors for osteomyelitis?
- Immunosuppression
- Chronic illness like Diabetes
- IV drug use
- Joint replacement
What is the etiology and pathogenesis of osteomyelitis?
- Complex and poorly understood
- Microorganisms, typically Staphylococcus aureus
- Preferentially binds to cartilage
- Metaphysis of bone is very porous… spreads quickly
What are clinical manifestations and S&S of osteomyelitis?
- Gradual onset of deep and achy P!/stiffness is MOST common presenting symptom
- Infection S&S
- Localized and PROGRESSIVE P! that limits motion and WBing, may become constant
- May develop constitutional symptoms
What will we observe with osteomyelitis?
Asymmetrical gait, Red and swollen
What will we find with temperature with osteomyelitis?
warmth, possibly fever
What will we find with our scan and biomechanical exam with osteomyelitis?
findings like age-related joint changes
What kind of referral is osteomyelitis?
Urgent referral to MD
Where is osteochondritis dissecans MOST common?
MOST common in medial femoral condyle and talus
What are clinical manifestations / S&S of osteochondritis dissecans in the foot/ankle?
S&S of hypermobility/instability of involved ligament but with persistent age-related joint like changes
What will we find in our scan with osteochondritis dissecans of the foot/ankle?
- ROM- limited and painful, particularly with DF
- Resisted/MMT- may be weak and painful, particular at end range DF
- Compression likely (+) and distraction relieving
What will we find in our biomechanical exam with osteochondritis dissecans of the foot/ankle?
Stability tests (+)
TTP over talar dome
What kind of referral is osteochondritis dissecans?
Urgent referral to MD
