Foot and Ankle Problems Flashcards by Laura I

name the common forefoot problems

hallux valgus
hallux rigidus
Lesser toe deformities - claw toes, hammer toe, mallet toe 
morton's neuroma
metatarsalgia 
rheumatoid forefoot

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what is hallux valgus also known as?

bunions

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aetiology og hallux valgus

genetic
shoes
female

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symptoms hallux valgus

pressure symptoms from shoe
pain from crossing over of toes
metatarsalgia

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pathogenesis of hallux valgus

lateral angulation of great toe
tendon pull realigned to lateral of centre of rotation of toe, worsening deformity
vicious cycle of increased pull creating increased deformity
sesamoid bones sublux and less weight goes through great toe
as deformity progresses abnormalities of lesser toes occur

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diagnosis hallux valgus

clinical

x-rays

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management of hallux valgus non operative

shoe wear modification (wide and high toe box)
orthotics to offload pressure/correct deformity
activity modification
analgesia

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management of hallux valgus operative

release lateral soft tissues

osteotomy 1st metatarsal +/- prox phalanx

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outcome of surgical management og hallux valgus

good but recurrence inevitable

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other names for hallux rigidus

stiff big toes
hallux limitus
hallux non-extensus

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what causes hallux rigidus?

OA of 1st MTP

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aetiology of hallux rigidus

unknown
possibly genetic
possibly multiple microtrauma

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hallux rigidus symptoms

many asymptomatic
pain - often at extreme of dorsiflexion
limitation of range of movement

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hallux rigidus diagnosis

clinical

radiographs

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non-operative management of hallux rigidus

activity modification
shoe wear with rigid sole
analagesia

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operative management of hallux rigidus

cheilectomy
arthrodesis
arthroplasty

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what joints are affected in: hammer toe

prox IPJ

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what joints are affected in: claw toe

prox and distal IPJ

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what joints are affected in: mallet toe

distal IPJ

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causes of lesser toe deformities

imbalance between flexors/extensors
shoewear
neurological
RA
idiopathic

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symptoms of lesser toe deformities

deformity
pain from dorsum
pain from plantar side

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non-operative treatment of lesser toe deformities

activitiy modification
shoe wear - flat with high toe box
orthotic insoles - metatarsal bar/dome support

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operative treatment of lesser toe deformities

flexor to extensor transfer
fusion of interphalangeal joint
release metatarsophalangeal joint
shortening osteotomy of metatarsal

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morton’s neuroma causes

mechanically induce degenerative neuropathy
high heeled shoes
common digital nerve relatively teathered to one metatarsal and movement in adjacent metatarsal causing shear

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morton's neuroma gender and age

femaes 40-60

symptoms morton's neuroma

3rd then 2nd webspace neuralgic burning in toes intermittent altered sensation in webspace

diagnosis morton's neuroma

clinical mulder's click USS/MRI

management morton's neuroma

injection for small lesions | surgery - excision of lesion inc section of normal nerve

what may cause metatarsalgia

``` synovitis bursitis arthritis neuralgia neuromata Freiberg's disease tight gastrocnemius ```

treatment of rheumatoid forefoot non-operative

shoes orthotics activity

treatment of rheumatoid forefoot operative

1st MTPJ arthrodeisis | 2nd-5th toe excision arthroplasty

name the common midfoot problems

dorsal foot ganglia midfoot arthritis plantar fibromatosis

from where do dorsal foot ganglia arise?

joint or tendon shealth

cause of dorsal foot ganglia

idiopathic underlying arthritis underlying tendon pathology

symptoms dorsal foot ganglia

pain from pressure from shoes | pain from underlying problem

treatment of dorsal foot ganglia

nonoperative - aspiration, book | operative - excision

recurrence rate of dorsal foot ganglia

50%

what kind of arthritis may come in the midfoot?

post traumatic arthritis OA RA

treatment of midfoot arthritis non operative

acitivty shoes orthotics injection - xray guided

treatment of midfoot arthritis operative

fusion

plantar fibromatosis symptoms

progressive | usually asymptomatic unless very large or weight baring area

treatment plantar fibromatosis

``` o Non-operative § Avoid pressure – shoes/orthotics o Operative § Excision (up to 80% risk of recurrence) o Radiotherapy (similar recurrence to operative) o Combination radiotherapy and surgery – low risk recurrence/high risk complications ```

name common hindfoot problems

``` achilles tendonitis/tendinosis plantar fasciitis ankle OA tibialis posterior dysfunction cavovarus foot ```

what is achilles tendonitis?

degenerative/overuse condition with little inflammation

what is the only way you can make a diagnosis of achilles tendinosis?

histopathological

what is insertional achilles tendinopathy?

within 2cm of insertion

what is non-insertional/mid-substance achilles tendinopathy?

2-7cm of insertion

where may bursitis occur around the achilles?

retrocalcaneal | superficial calcaneal

what is paratendinopathy achilles?

true inflammatory problem showing paratendonitis histologically

who gets achilles paratendonopathy?

athletes age 30-40 M:F 2:1

who gets achilles tendinopathy?

``` non-athletic >40 obesity steroids diabetes ```

symptoms of achilles tendonitis

``` pain during exercise pain following exercise recurrent episodes difficulty fitting shoes (insertional) rupture ```

diagnosis of achilles tendonitis

clinical - tenderness, rupture

investigations for achilles tendonitis

USS | MRI

non-operative treatment of achilles tendonitis

``` activity modification weight loss shoe modification - slight heel physio - eccentric extra-corporeal shockwave treatment immobilisation ```

operative treatment of achilles tendonitis

gastrocnemius recession | release and debridement of tendon

what is plantar fasciosis?

Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, avascularity

what causes plantar fasciosis?

``` can't make ECM required for repair and remodelling microtears not know athletes - high intensity/rapid increase running with poorly padded shoes/hard surfaces obesity occupations with long standing foot/LL rotational deformities tight gastro-soleus complex ```

symptoms plantar fasciosis

pain in morning pain on weight bearing after rest pain at origin of plantar fascia long lasting > 2 years

plantar fasciosis DDx

nerve entrapment syndrome arthritis calcaneal pathology

plantar fasciosis diagnosis

mainly clinical | occassionally xray, USS, MRI

plantar fasciosis treatment

``` o Rest, change training o Stretching – Achilles +/- direct stretching o Ice o NSAIDs o Heel pads o Physio o Weight loss o Injections – corticosteroid (may make worse in long term) o Night splinting o Newer/3rd line § Extracorporeal shockwave therapy § Topaz plasma coblation § Nitric oxide § Platelet rich plasma § Endoscopic surgery ```

cause of ankle OA

commonly post traumatic | idiopathic

mean age of presentatio with ankle OA?

symptoms of ankle OA

pain | stiffness

diagnosis of ankle OA

clinical radiographs CT - exclude adjacent joint arthritis

non-operative management of ankle OA

``` weight loss activity modification analgesia PT steroid injections ```

operative management of ankle OA

``` If symptoms are exclusively anterior, then arthroscopic anterior debridement § Arthrodesis • Open or arthroscopic • Gold standard • Good long-term outcome § Joint replacement • Maintain range of movement • Questionable long-term outcome especially in high demand patients • Not easy to revise even to fusion ```

discuss tibialis posterior dysfunction

``` • Acquired adult flat foot planovalgus • Relatively common • Under-recognised • 4 stages • Largely clinical diagnosis – double and single heel raise • Medial or lateral pain • Diagnosis o Clinical o MRI to assess tendon • Management o Orthotics – medial arch support o Reconstruction of tendon (tendon transfer) ```

diabetic foot: aetiology

diabetic neuropathy diabetic autonomic neuropathy poor vascular supply lack of patient education

diabetic foot: treatment

``` o Prevention o Modify the main detriments to healing § Diabetic control § Smoking § Vascular supply § External pressure (splints/shoes/weight bearing) § Internal pressure (deformity) § Infection § Nutrition o Operative § Improve vascular supply § Debride ulcers and get deep samples for microbiology § Correct any deformity to offload area ```

diabetic foot: prognosis

o 15% of all diabetics will develop ulceration o 85% of all amputations for diabetics are preceded by foot ulceration o 25% of patients with diabetic ulcers go on to amputation o 5-year patient mortality 50%

charcot neuroarthropathy: aetiology

o Any cause of neuropathy o Diabetes commonest cause o Historically originally described and most common with syphilis

charcot neuroarthropathy: pathophysiology 2 theories

o Neurotraumatic § Lack of proprioception and protective pain sensation o Neurovascular § Abnormal autonomic NS results in increased vascular supply and bone resorption

charcot neuroarthropathy: is characterised by rapid bone destruction occuring in 3 stages

fragmentation coalescence remodelling

charcot neuroarthropathy: diagnosis

o High index of suspicion o Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy o Greater than 3-degree difference between limbs o Frequently not painful o Radiographs o MRI

charcot neuroarthropathy: management

o Prevention o Immobilisation/non-weight bearing until acute fragmentation resolved o Correct deformity § Deformity leads to ulceration à infection à amputation

Foot and Ankle Problems Flashcards

(77 cards)