Foot Problems

Question 1

What are the common causes and presentation of soft tissue disorders? Eg painful heel, tibialis posterior dysfunction

Answer 1

Achilles Tendinopathy: pain during exercise, following exercise, recurrent, difficulty fitting shoes, rupture

• non operative: activity modification, weight loss, shoe wear modification, physiotherapy, ECST, immobilisation
• operative: gastrocnemius recession, release and debridement of tendon

Plantar fasciitis: pain in morning, pain weight bearing after rest, pain at plantar fascia, frequently long lasting

• 1st line = rest, change training, stretching, ice, NSAIDs, orthoses, physiotherapy, weight loss, injections, night splinting
• newer = ECST, topaz plasma coblation, nitric oxide, platelet rich plasma, endoscopic/open surgery

ankle arthritis

• non operative: weight loss, activity modification, analagesia, physiotherapy, steroid injections
• operative: arthroscopic anterior debridement, arthrodesis (gold standard), joint replacement

Posterior tibial tendon dysfunction
- orthotics, reconstruction of tendon, triple fusion

Question 2

What are the common disorders and management of disorders of the first ray? Eg hallux rigidus, hallux valgus

Answer 2

Hallux valgus eg bunions

• lateral angulation of great toe, leading to abnormalities of the lesser toes
• non operative: shoe wear modification, orthotics, activity mod, analgesia
• operative: release lateral soft tissues, osteotomy, recurrence inevitable

Hallux rigidus

• OA of 1st MTP joint
• non operative: activity modification, shoe wear with rigid sole, analgesia
• operative: cheilectomy, arthrodesis, arthroplasty

Question 3

What are the common disorders of the toes and forefoot?

Answer 3

Lesser toes

• claw toes, hammer toes, mallet toes
• non operative: activity modification, shoe wear, orthotic insoles
• operative: flexor to extensor transfer, fusion of IP joint, release of MTP joint, shortening osteotomy of metatarsal

Morton’s neuroma: 3rd-2nd webspace/toes, neuralgic burning pain, intermittent, altered sensation, mulder’s click

• injection for small lesions
• excise larger lesions

Rheumatoid forefoot

• non operative: shoe wear, orthotics, activity modification
• operative: gold standard is 1st MTPJ arthrodesis, 2-5th toe excision arthroplasty

Question 4

What are the features of the foot in diabetes and rheumatoid arthritis?

Answer 4

Diabetes

• ulceration: occurs due to neuropathy and poor vascular supply. Treat by modifying the main detriments to healing eg diabetic control, vascular supply, external pressure, internal pressure, infection, nutrition. Surgical treatment include improving vascular supply, debriefing ulcers, correcting deformity and amputation.
• Charcot foot: occurs with any neuropathy. Characterised by rapid bone destruction in 3 stages - fragmentation, coalescence, remodelling. Radiograph, MRI, frequently not painful. Manage by prevention, immobilisation and correcting the deformity.