What are the two major options for patients with significant pain from advanced ankle OA?
- Ankle replacement
What does ankle arthrodesis involve?
Fusion of affected joints
Which of the treatments for ankle OA can offer bettwen functional outcome?
What is the major downfall for ankle replacement?
Substantial compressive and shearing force is placed across the small bones of the foot leading to high rates of loosening and failure
Ankle replacements are generally reserved for which patients and why?
When failure occurs fusion is required which can shorten the affected limb
Why is ankle arthrodesis more reliable than ankle replacement?
The need for further surgery is much less and re-operation lates are lower
What is hallux valgus?
A deformity of the great toe involving:
- Medial deviation of the 1st metatarsal
- Lateral deviation of the toe itself
Hallux valgus is more common in which sex?
What may cause an increase or predispose to hallux valgus?
- Wearing footwear
- Inflammatory arthropathies
- Neuromuscular disease e.g. MS and CP
Hallux valgus can be painful due to rubbing of the deformity within footwear causing an inflamed bursa at the base of the big toe, what is the term given to this?
What are the treatment options for hallux valgus?
- Wider and deeper footwear
- Use of a spacer in the first web space
- Osteotomies to realign bones
- Soft tissue procedures to tighten slack tissues and release tigh tissues
What is one of the main reasons patients are unhappy with surgery for hallux valgus?
- The repair is not always cosmetically pleasing
- Patients may have metatarsalgia (pain in the metatarsal head) after surgery
What is the term given to OA of the first MTP joint?
What is the treatment for hallux rigidus?
- Wearing stiff soled shoes to limit movement of the MTP joint
- Cheilectomy (surgical removal of osteophytes)
- Arthrodesis - GOLD standard
What is Morton's neuroma?
Thickening of nerve tissue due to repeated trauma which causes inflammation and swelling leading to formation of a neuroma
Morton's neuroma is most commonly found between the 3rd and 4th metatarsals
Which nerves are affected in Morton's neuroma?
Plantar interdigital nerves
(from medial and plantar nerves)
Which gender is more at risk for Morton's neuroma and what is a potential reason why?
Wearing high heels
What is the type of sensation felt in Morton's neuroma?
- Burning pain
- Tingling radiating to affected toe
What may clinical examination show for a patient with Morton's neuroma?
- Loss of sensation in affected web space
- Postive Mulder's click test
What is Mulder's click test?
Medio-lateral compression achieved by compression metatarsal heads by squeezing the fore foot with your hand will produce a characteristic click in a positive test
What may be used to diagnose swollen nerves?
What are the treatment options for Morton's neuroma?
- Use of metatarsal pad or offloading insole
- Steroid and local anaesthetic injections
- Excision (pain may remain and recurrence is relatively common)
Where do metatarsal stress fractures most commonly occur?
2nd metatarsal (followed by the 3rd)
(generally occur with prolonged activity in runners, dancers, soldiers etc)
What is the best test for diagnosing a metatarsal stress fracture and why?
(x-rays may not shwo a fracture for up to 3 weeks until resorption and callus formation occurs)
What is the treatment for a metatarsal stress fracture?
Prolonged rest (6-12 weeks) in a rigid-soled boot
What are some predisposing factors for achilles tendonitis?
- Repetitive strain
- Quinolone antibiotics
- Other inflammatory arthropathies
What is the treatment for Achilles tendonitis?
- Heel raise to offload the tendon
- Use of splint/boot
- Tendon decompression and resection of paratendon
Tendon rupture of the Achilles occurs in which age groups?
Middle aged or older
Which type of action may result in an Achilles tendon rupture?
Sudden deceleration with resisted calf muscle
How do patients with an Achilles tendon rupture present?
- Sudden pain like they have been kicked in the back of the leg
- Weakness of plantar flexion
- Palpable gap in the tendon
- Postive Simmond's test (no planterflexion of the foot when squeezing the calf)
Why is surgery for an Achilles tendon rupture controversial?
It can be very problematic if wound healing does not occur
What is the non-operative management of Achilles tendon rupture?
A series of casts in the equinous position (to close gap in torn tendon)
(this takes around 8 weeks)
What is plantar fasciitis?
A stress/overload or degenerative condition involving inflammation of the plantar fascia with the distal plantar aspect of the fascia at the calcaneal tuberosity being most commonly affected
What may be causative factors for plantar fasciitis?
- Frequent walking on hard floors without adequate footwear
What are the treatment options for plantar fasciitis?
- Achilles and plantar fascia strengthening exercises
- Gel heel pad
- Corticosteroid injections
- Surgical release of plantar fascia
Why is surgical release of plantar fascia controversial?
- It isn't proven to aid recovery
- It risks injury to plantar nerves
Flat foot is known by which other name?
Patients with what other trait are more likely to develop pes planus?
Generalised ligamentous laxity
Flat footed people may be at a higher risk of what?
Tendonitis of the tibialis posterior tendon
Acquired flat foot may be due to which factors?
- Tibialis posterior tendon stretch or rupture
- Diabetes with Charcot foot (a neuropathic joint destruction)
Where does the tibialis posterior tendon predominantly insert and what are its main functions?
Attaches to medial navicular
- Support the medial arch of the foot
- Plantarflexion of foot
- Inversion of the foot
What are the factors which may lead to tibialis posterior tendon rupture?
- Repeated stress, degeneration and tendonitis
- Synovitis from RA
How can tibialis posterior tendonitis be treated?
- Splint with media arch support
- Surgical decompression with tenosynovectomy
- Tendon transfer with calcaneal osteotomy (if OA is not present (aims to prevent OA by reducing stress))
- Arthrodesis (if OA is present)
Why may OA occur in the mid/hindfoot with tendonitis of the tibialis posterior tendon?
- The tendon may rupture or elongate which causes loss of the medial arch
- This causes valgus of the heel
- This process may cause OA
What is the term given to abnormally high arching of the foot?
What can cause/be related to pes cavus?
- Hereditory Sensory and Motor Neuropathy
- Cerebral palsy
- Spinal cord tethering (due to spina bifida occulta)
Which deformity involving the toes often accompanies pes cavus?
How can pain from pes cavus be treated?
- Soft tissue releases
- Tendon transfer
- Calcaneal osteotomy
- Arthrodesis (severe cases)
What is a tendon transfer?
The insertion of a tendon is moved yet the origin remains fixed
What is the cause of claw toes?
- Hyperextension at the MTP joints
- Hyperflexion at the PIP and DIP joints
Why do hammer toes occur?
- Hyperextension at the MTP joints
- Hyperflexion at the PIP joints
- Hyperextension at the DIP joints
What are the surgical solutions to claw and hammer toes?