Describe the epidemiology of ankle OA - i.e. who commonly gets it and how does it arise
Can be primary (idiopathic) or secondary to injury
With football players particularly prone to it
What are the signs of ankle OA ?
Pain in the ankle - with inflam markers not raised, X -ray showing appearances of OA (remember loss)
What are the two different options for advanced ankle OA
Arthrodesis and ankle replacement
Compare the benefits of ankle arthrodesis (fusion of the joints) and ankle replacement
Ankle replacement - provides better functional outcome as preserves motion, problem is a substantial comprissive and shearing force is placed across relatively small bones and has higher rates of early loosening, component sinkage and failure than hip or knee replacement. (should be reserved for elderly patients)
Ankle arthrodesis - more reliable, need for further surgery less likely (doesnt preserve the motion as well though)
What deformity is shown here ?
What is one of the complications of hallux valgus which can develop?
Due to widened forefoot - can result in rubbing of foot with shoe resulting in an inflamed bursa called a bunion
What are the treatment options of hallux valgus ?
Conservative treatment - wearing of wider and deeper “accommodating” shoes to prevent painful bunions and the use of a spacer in the first web space to stop rubbing between the great and second toes.
Many patients want surgery but many of them are not happy with the results (30%)
Surgical management - involves osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues.
What is hallux rigidus and what is the characteristic appearance seen ?
OA of the 1st MTPJ (this is in the big toe)
characterisitcally see a lump above where the 1st MTPJ is
What are the treatment options of hallux rigidus ?
Conservative treatment may involve the wearing of stiff soled shoe to limit motion at the MTPJ.
The “gold standard” surgical treatment is arthrodesis (fusion of the joints preventing motion)
What is mortons neuroma ?
It is where plantar interdigital nerves (nerves in the foot) become irritated and inflamed, this results in thickening of tissues around the nerve forming a neuroma
What is the primary complaint of patients with mortons neuroma ?
Burning and tingling pain radiating into the affected toes
What is the most common part of the foot affected by mortons neuroma ?
The third interspace (between the third and fourth toes) as seen in pic
Upon clinical examination what are some of the signs/ tests you would do - when suspecting mortons neuroma ?
Mulders click test - Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic "click"
May also be loss of sensation in the affected web space
Diagnosis of mortons neuroma is usually based on the clinical examination but what investigations could be done to diagnosis it ?
MRI or US to demonstrate swollen nerve
What is the first line management options for mortons neuroma and if symptoms persist what can be done ?
- 1st line - Avoid high heels, and shoes with a constricting toe box or thin soles to reduce pressure on the forefoot and to use a metatarsal pad.
- NSAID's may help
For persistent neuromas:
Refer the person to an orthotist for a metatarsal dome orthotic
Who does metatarsal stress fractures more often occur in ?
Runners and soliders on long marches or people not used to long walks
Where does Metatarsal stress fractures most commonly occur ?
The 2nd metatarsal followed by the 3rd
What are the symptoms of metatarsal stress fractures ?
- Pain that diminishes during rest.
- Pain that occurs and intensifies during normal, daily activities.
- Swelling on the top of the foot or on the outside of the ankle.
- Tenderness to touch at the site of the fracture.
- Possible bruising.
What are the investiagtions done to diagnose metatarsal stress fractures ?
X-ray but may not show until around 3 weeks when callus begins to appear
Bone scan can be done to diagnose if no signs on X-ray
What is the treatment of a metatarsal stress fracture ?
Prolonged rest for 6‐12 weeks in a rigid soled boot
What are the symptoms of achilles tendonitis ?
- Pain and stiffness along the Achilles tendon in the morning
- Pain along the tendon or back of the heel that worsens with activity
- Severe pain the day after exercising
- Thickening of the tendon
- Bone spur (insertional tendinitis)
- Swelling that is present all the time and gets worse throughout the day with activity
What is the treatment of achilles tendoitis ?
Rest, physio conditioning, use of a heel raise to offload the tendon and use of a splint or boot
What is achilles tendon ruputre usually due to ?
Middle aged or older groups and is usually due to degenerative changes within the tendon or recent tendonitis.
Describe the typical mechanism of injury for achilles tendon ruputres
- Sudden deceleration with resisted calf muscle contraction (eg lunging at squash)
- Leads to sudden pain (like being kicked in the back of the leg) and difficulty weight bearing.
Upon clinical examination what is seen in patients with achilles tendon ruptures ?
Weakness of plantar flexion and a palpable gap in the tendon are usually apparent.
Positive simmonds test - no plantarflexion of the foot when squeezing the calf (the foot should plantar-flex)
What is the treatment of achilles tendon ruptures ?
Two options - surgical and non-surgical
- Surgical is where the damaged tendon is sutured together
- Non-surgical is treatment with a series of casts in the equinous position: the ankle platarflexed with the toes pointing down, as this closes the gap in the torn tendon
Most surgeons go for non-operative treatment