Musculoskeletal > Foot Problems > Flashcards

Foot Problems Flashcards

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1
Q

What are non-operative managements of foot problems?

A

–Analgesia

–Shoe wear modification

–Activity modification

–Weight loss

–Physiotherapy

–Orthotics including insoles and bracing

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2
Q

When are operations indicated on the foot?

A

The only indication for operative managment is failure of non-operative managment

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3
Q

What are the forefoot problems?

A
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4
Q

What is the aetiology of bunions (hallux valgus)?

A

–Genetic

–Foot wear

–Significant female preponderance)

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5
Q

What are the symptoms of hallux valgus?

A

–Pressure symptoms from shoe wear

–Pain from crossing over of toes

–Metatarsalgia

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6
Q

What is the pathogenesis of hallux valgus?

A

–Lateral angulation of great toe.

–Tendons pull realigned to lateral of centre of rotation of toe worsening deformity

–Vicious cycle of increased pull creating increased deformity

–Sesamoid bones sublux – less weight goes through great toe

–As deformity progresses abnormalities of lesser toes occur

(there is lateral angulation of the great toe, and from here there is now a lateral pull from the tendon which causes progressive worsening of the condition). Lesser toes are eventually involved)

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7
Q

How is diagnosis of hallux valgus achieved?

A

–Clinical

–Xrays

  • Determine severity of underlying bony deformity
  • Exclude associated degenerate change
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8
Q

What is the management of hallux valgus?

A
  • Shoe wear modification (wide +/- high toe box)
  • Orthotics to offload pressure/correct deformity
  • Activity modification
  • Analgesia

–Operative (if non-operative failed or unacceptable to patient)

  • Release lateral soft tissues
  • Osteotomy 1st metatarsal +/- proximal phalanx
  • Generally good outcome but recurrence inevitable

(so wear different shoes, change the shoes, change what you do, painkillers, operate)

Operating involves removing some bone and release of lateral soft tissues. The osteotomy is called a scarf osteotomy)

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9
Q

Which joint does OA affect in hallux rigidus?

A

Osteoarthritis of 1st MTP joint

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10
Q

What is the aetiology of hallux rigidus?

A

–Not known

–Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded

–Possibly multiple microtrauma

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11
Q

What are the symptoms of hallux rigidus?

A

–Many asymptomatic

–Pain – often at extreme of dorsiflexion

–Limitation of range of movement

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12
Q

How is diagnosis of hallux rigidus made?

A

Clinical

Radiographs

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13
Q

What is the management of hallux rigidus?

A

–Non-operative

  • Activity modification
  • Shoe wear with rigid sole
  • Analgesia

Operative

  • Cheilectomy (removing bone spurs from the base of the big toe)
  • Arthrodesis (fusion of the joint) (gold standard - fusion of the 1st MTPJ. Arthrodesis is a good operation if the other operations have failed
  • Arthroplasty (replacing the joint) (hemiarthroplasty is a good option to maintain ROM, high failure rate, probably better for low demand patients, if the operation fails it tends to fail early.)
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14
Q

What are examples of lesser toe deformities?

A
  • Claw toes
  • Hammer toes
  • Mallet toes
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15
Q

What is the aetiology of lesser toe deformities?

A

–Imbalance between flexors/extensors

–Shoe wear

–Neurological

–Rheumatoid arthritis

–Idiopathic

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16
Q

What are the symptoms of lesser toe deformities?

A

–Deformity

–Pain from dorsum

–Pain from plantar side (metatarsalgia)

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17
Q

What is the treatment of lesser toe deformities?

A

–Non-operative

  • Activity modification
  • Shoe wear – flat shoes with high toe box to accommodate deformity
  • Orthotic insoles – metatarsal bar/dome support

–Operative

  • Flexor to extensor transfer
  • Fusion of interphalangeal joint
  • Release metatarsophalangeal joint
  • Shortening osteotomy of metatarsal
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18
Q

What is the aetiology of mortons neuroma?

A

–Mechanically induced degenerative neuropathy

–Tends to affect females aged 40-60

–Frequently associated with wearing high healed shoes

–Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear

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19
Q

What are the symptoms of mortons neuroma?

A

–Typically affects 3rd followed by 2nd webspace/toes

–Neuralgic burning pain into toes

–Intermittent

–Altered sensation in webspace

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20
Q

What is the diagnosis of mortons neuroma?

A

–Clinical

–Mulder’s Click

–Ultrasound best / MRI good

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21
Q

What is the management of interdigital neuroma?

A

–Injection for small lesions (steroidal medication or alcohol solutions)

–Surgery – excision of lesion including a section of normal nerve

  • Numbness
  • Recurrence
  • Up to 30% have pain 1 year post surgery
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22
Q

Define metatarsalgia

A

Metatarsalgia is a general term used to denote a painful foot condition in the metatarsal region of the foot (the area just before the toes, more commonly referred to as the ball-of-the-foot). This is a common foot disorder that can affect the bones and joints at the ball-of-the-foot. It is a symptom and not a diagnosis.

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23
Q

What are the causes of metatarsalgia?

A

Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease - a neuroma is a tumour formed on the nerve cell sheath

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24
Q

What is the treatment for rheumatoid forefoot?

A

–Non-operative – shoewear/orthotics/activity etc

–Operative

  • Many described techniques
  • Current gold standard

–1st MTPJ arthrodesis

–2-5th toe excision arthroplasty

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25
What are mid foot problems?
Ganglia OA Plantar fibromatosis
26
Where do dorsal foot ganglia arise from?
Arise from the joint or tendon sheath
27
What is the aetiology of dorsal foot ganglia?
–Idiopathic –Underlying arthritis –Underlying tendon pathology
28
What are the symptoms of dorsal foot ganglia?
–pain from pressure from shoe wear –Pain from underlying problem
29
What is the treatment for dorsal foot ganglia?
•Treatment –Non-operative * Aspiration * “Family bible” –Operative * Excision * Prognosis –High rate of return – 50%
30
What are the types of mid foot arthritis?
Post-traumatic, OA, rheumatoid arthritis
31
What is the treatment for mid foot arthritis?
–Non-operative – Activity/shoewear/orthotics etc –Injections – xray guided –Operative - fusion
32
What feature of plantar fibromatosis makes the history distinct?
It is a progressive disease
33
What are the clinical features of plantar fibromatosis?
Usually asymptomatic unless very large or on weightbearing area
34
What is the treatment of plantar fibromatosis?
–Non-operative – avoid pressure – shoewear/orthotics –Operative – excision (up to 80% risk of recurrence) –Radiotherapy (similar recurrence as operative) –Combination radiotherapy/surgery (low risk recurrence/high risk complications)
35
What are the hindfootproblems?
Achilles tendonitis. tendonosis Plantar fasciitis Ankle osteoarthritis Tbialis posterior dysfunction Cavovarus foot
36
What is the description of achilles tendonitis/tendonosis?
Degenerative / overuse condition with little inflammation
37
What is the difference between insertional tendinopathy and non-insertional/midsubstance tendonopathy?
Insertional - within 2 cm of insertion Non-insertional/midsubstance - 2-7 cm of insertion
38
What are the other achilles tendonopathies?
Bursitis Paratendinopathy
39
What are the types of bursitis of the achilles?
Retrocalcaneal Superficial calcaneal
40
What is paratendonitis?
–Paratendinopathy is a true inflammatory problem showing paratendonitis histologically (inflamamtion or degeneration of the thin membrane around the achilles tendon)
41
What are the aetiologies of tendonopathy?
–Paratendonopathy * Commonest in athletic populations * Age group 30-40 * Male:Female = 2:1 –Tendonopathy * Commonest in non-athletic populations * Aged over 40 * Obesity * Steroids * Diabetes
42
What are the symptoms of achilles tendonopathy?
–Pain during exercise –Pain following exercise –Recurrent episodes –Difficuly fitting shoes (insertional) –RUPTURE – don’t miss!
43
What is the diagnosis of achilles tendinopathy?
Clinical - tenderness, tests for rupture Investigations - Ultrasounds, MRI Rupture - altered angle of dangle, simmonds squeeze test, visible gap
44
What is non-operative treatment of achilles tondinopathy?
–Activity modification –Weight loss –Shoe wear modification – slight heel –Physiotherapy – Eccentric stretching –Extra-corporeal shockwave treatment –Immobilisation (in below knee cast)
45
What is operative treatment of achilles tendinopathy?
–Gastrocnemius recession –Release and debridement of tendon
46
What are the stages of pathogenesis of plantar fasciitis?
•Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity **You can't make the extracellular matrix needed for repair and remodelling** Micro-tears
47
What is the aetiology of plantar fasciits?
–Not known –In athletes associated with high intensity or rapid increase in training –Running with poorly padded shoes or hard surfaces –Obesity –Occupations involving prolonged standing –Foot/lower limb rotational deformities –Tight gastro-soleus complex
48
What are the symptoms of plantar fasciitis?
**–Pain first thing in morning** –Pain on weight bearing after rest •Post-static dyskinesia –Pain located at origin of plantar fascia –Frequently long lasting – 2 years or more
49
What are the differentials for plantar fasciitis?
Nerve entrapment synreoms Arthritis Calcaneal pathology
50
How is diagnosis of plantar fasciitis made?
Mainly clinical Occasionally x-rays ultrasound and MRI
51
What are the treatments for plantar fasciitis?
–Rest, change training –Stretching – Achilles +/- direct stretching –Ice –NSAIDs –Orthoses – Heel pads –Physiotherapy –Weight loss –Injections – corticosteroid (good in short term but may make condition worse long term) –Night Splinting
52
What are newer/third line treatments for plantar fasciitis (fasciosis)
1. Extracorporeal Shockwave therapy 2. Topaz Plasma Coblation 3. Nitric Oxide 4. Platelet Rich Plasma 5. Endoscopic / Open Surgery
53
What is the aetiology of ankle arthritis?
Mean age is 46 years old Commonly post traumatic Idiopathic
54
What are the symptoms of ankle arthritis?
Pain Stiffness
55
What is the diagnosis of ankle arthritis?
Clinical Radiographs CT scan - exclude adjacent joint arthritis
56
What is non-operative treatment of ankle arthritis?
Weight loss, activity modification, analgesia, physiotherapy, steroid injections
57
What is operative management of ankle arthritis
–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
58
What is it called when the foot begins to tip inwards?
Flat foot planovalgus
59
How does a valgus heel swing when the heel rises off the ground?
Should swing from valgus to varus
60
How is tibialis posterior tendon dysfunction diagnosed - flat foor planovalgus?
Clinical MRI to assess the tendon
61
What is the managment of tibialis posterior tendon dysfunction?
–Orthotics – medial arch support –Reconstruction of tendon (tendon transfer) –Triple fusion (subtalar, talonavicular and calcaneocuboid)
62
What is the pathogenesis of diabetic foot ulcer?
Patient is unaware of trauma to the foot Autonomic neuropathy makes the patient more susceptible to minor foot trauma - lack of sweating or normal sebum production makes the skin on the foot dry and cracked. Poor vascular supply Lack of patient education
63
What is the treatment for diabetic foot ulcer?
–Prevention –Modify the main detriments to healing * Diabetic control * Smoking * Vascular supply * External pressure (splints/shoes/weight bearing) * Internal pressure (deformity) * Infection * Nutrition
64
What is the surgical treatment for diabetic foot ulcer?
–Improve Vascular Supply –Debride ulcers and get deep samples for microbiology –Correct any deformity to offload area –Amputation (so improve the blood supply, debride the ulcers and collect a sample to be sent to microbiology, correct deformities, amputate)
65
What is the prognosis of diabetic foot ulcer?
–15% of all diabetics will develop ulceration –85% of all amputations for diabetes are preceded by foot ulceration –25% of patients with diabetic ulcers go on to amputation –5 year patient mortality 50%
66
What is the aetiology of charcot neuropathy?
Any cause of neuropathy (diabetes, syphillis)
67
What is the pathophysiology of charcot neuropathy?
Neurotraumatic - lack of proprioception and protective pain sensation (can't feel where your feet are or pain) Neurovascular - abnormal autonomic nervous system results in increased blood supply and bone resorption (more blood, more resporption of bone)
68
What are the three stages of charcot neurpathy?
Fragmentation Coalescence Remodelling
69
How is the diagnosis of charcot neurpathy made?
–High index of suspicion –Consider in any diabetic with acutely **swollen** **erythematous** foot especially with neuropathy –Greater than 3 degree difference between limbs –Frequently not painful –**Radiographs** –**MRI scan** So the foot looks red and swollen and often the patient will not be complaining of pain - Then you should order radiographs and MRI
70
What is the management of charcot neuropathy?
–Prevention –Immobilisation / non-weight bearing until acute fragmentation resolved –Correct deformity •Deformity leads to ulceration leads to infection leads to amputation.
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