Year 3 - MSK > Foot Problems > Flashcards

Foot Problems Flashcards

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1
Q

what are osme examples of non-operative management?

A

Analgesia

Shoe wear modification

Activity modification

Weight loss (all foot and ankle condition orse if patient carrying to much weight)

Physiotherapy

Orthotics including insoles and bracing

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2
Q

when do you operate?

A

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

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3
Q

Pathological Grouping of Disease can be put in what categories?

(Look at aetiology – any of these underlying problems can be responsible for foot or ankle pain)

A
  • Vascular (ischaemic)
  • Infective
  • Traumatic
  • Autoimmune (rheumatic arthritis and other rheumatoid problems etc
  • Metabolic (endocrine /drugs)
  • Inflammatory
  • Inherited (congenital)
  • Neurological
  • Neoplastic
  • Degenerative
  • Idiopathic
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4
Q

Anatomical Grouping of Disease can be put into what groups?

A
  • Forefoot problems – metatarsals and toes
  • Midfoot problems - tarsal
  • Hindfoot problems – heel, calcaneus and talus
  • Other
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5
Q

what are examples of forefoot problems?

A
  • Hallux valgus
  • Hallux rigidus
  • Lesser toe deformities
  • Morton’s neuroma (painful condition on sole of foot)
  • Metatarsalgia
  • Rheumatoid Forefoot
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6
Q

what is Hallux Valgus?

A

“Bunions”

a deformity of the big toe. The toe tilts over towards the smaller toes and a bony lump appears on the inside of the foot

Hallux valgus is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected and is often accompanied by significant functional disability and foot pain. This joint is gradually subluxed (lateral deviation of the MTP joint) resulting in an resulting in an abduction of the first metatarsal while the phalanges adduct. This often leads to development of soft tissue and bony prominence on the medial side of what is called a bunion

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7
Q

what is the aetiology of hallux valgus?

A

Genetic

Foot wear

Significant female preponderance

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8
Q

what are the symptoms of hallux valgus?

A

Pressure symptoms from shoe wear

Pain from crossing over of toes

Metatarsalgia (condition in which the ball of your foot becomes painful and inflamed)

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9
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 (medially) – less weight goes through great toe

As deformity progresses abnormalities of lesser toes occur

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10
Q

how is the diagnosis of hallux valgus made?

A

Clinical (probably best way, just looking at the foot)

Xrays:

  • Determine severity of underlying bony deformity
  • Exclude associated degenerate change
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11
Q

what is the non-operative management of hallux valgus?

A
  • Shoe wear modification (wide +/- high toe box)
  • Orthotics to offload pressure/correct deformity
  • Activity modification (less time standing)
  • Analgesia
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12
Q

what is the operative management (if non-operative failed or unacceptable to patient) of hallux valgus?

A
  • Release lateral soft tissues
  • Osteotomy 1st metatarsal +/- proximal phalanx
  • Generally good outcome but recurrence inevitable
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13
Q

Hallux Valgus – Scarf osteotomy

Bone broken and shifted in the coronal plane

A

Hallux Valgus – basal osteotomy

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14
Q

what is Hallux Rigidus?

A
  • Latin – Stiff big toe!
  • Hallux limitus
  • Hallux non-extensus
  • Osteoarthritis of 1st MTP joint (causes of these symptoms)
  • Bimodal distribution of age

It causes pain and stiffness in the joint, and with time, it gets increasingly harder to bend the toe. Hallux refers to the big toe, while rigidus indicates that the toe is rigid and cannot move

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15
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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16
Q

what are the symptoms of hallux rigidus?

A

Many asymptomatic (incidental finding on x-ray)

Pain – often at extreme of dorsiflexion

Limitation of range of movement

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17
Q

what is the diagnosis of hallux rigidus?

A

Clinical (history and examinations)

Radiographs

radiography:

Older patient, osteoarthritis, narrowing and irregularity of the MTP joint, joint space narrowed, osteophyte, sclerosis in margins

Normal angle between 1st and 2nd metatarsals

Big dorsal osteophytes so that’s why extension is sore as rub on the soft tissues and pain impinge on dorsiflexion

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18
Q

what is the management of hllux rigidus?

A

Non-operative:

  • Activity modification (running and up hill as more dorsiflexion causes pain)
  • Shoe wear with rigid sole
  • Analgesia

Surgery (main ones):

  • Cheilectomy
  • Arthrodesis
  • Arthroplasty
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19
Q

what is Cheilectomy?

A

remove dorsal impingement

Particular pain when dorsiflexed, remove dorsal osteophytes

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20
Q

what is 1st MTPJ fusion?

A
  • Gold standard treatment
  • Permanent
  • “Bail out operation”

Most reliable consistent treatment

Surface of the joint is debrided, fixation so bone crosses of the joint

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21
Q

what is 1st MTPJ hemiarthroplasty?

A
  • Good option to maintain ROM
  • High failure rate
  • Probably better for low demand patients
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22
Q

whata re some lesser toe deformities?

A
  • Claw toes - Flexion at the proximal and distal interphalangeal joint, may have underlying neurological problem
  • Hammer toes - Flexion of the proximal interphalangeal joint and dorsiflexion at MTP joint, distal interphalangeal joint extended
  • Mallet toes - Not as common, flexion at distal interphalangeal joint, get pain form nail impinging on the sole of their shoe
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23
Q

Lesser Toe deformities - how bone is effected

A
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24
Q

what is the aetiology of lesser toe deformities?

A

Imbalance between flexors/extensors

Shoe wear

Neurological

Rheumatoid arthritis

Idiopathic

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25
what are the symptoms of lesser toe deformities?
Deformity Pain from dorsum Pain from plantar side (metatarsalgia)
26
what is the non-operative treatment for Lesser Toe deformities? (best treamtnet for most)
* Activity modification * Shoe wear – flat shoes with high toe box to accommodate deformity * Orthotic insoles – metatarsal bar/dome support
27
what is the operative treatment for Lesser Toe deformities? (a lot of morbidity associated with these)
* Flexor to extensor transfer (dividing flexor tendon and moving it to the extensor) * Fusion of interphalangeal joint * Release metatarsophalangeal joint * Shortening osteotomy of metatarsal
28
Interdigital Neuralgia – Morton’s Neuroma what is it?
Interdigital nerve irritation (neuralgia) or persistent benign enlargement of the perineurium (neuroma) can cause pain, which may be nonspecific, burning, or lancinating, or a foreign body sensation. Diagnosis is usually clinical Medial and lateral plantar nerve Painful lump
29
Interdigital Neuroma – Morton’s Neuroma what is the aetiology?
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
30
Interdigital Neuroma – Morton’s Neuroma what are the symptoms?
Typically affects 3rd followed by 2nd webspace/toes (Unknown in the 1st web space) Neuralgic burning pain into toes Intermittent Altered sensation in webspace
31
Interdigital Neuralgia – Morton’s Neuroma how is a diagnosis made?
Clinical Mulder’s Click (best test clinically) - Mulder's clinical test is a well-known maneuver in which compression of the metatarsal heads produces a palpable click due to displace- ment of an intermetatarsal mass Ultrasound best/MRI good
32
Interdigital Neuralgia – Morton’s Neuroma what is the management?
Advice on no high heels and padded shoes Injection (steroid) for small lesions Surgery – excision of lesion including a section of normal nerve: * Numbness * Recurrence (end of nerve regrow) * Up to 30% have pain 1 year post surgery
33
Interdigital Neuralgia – Morton’s Neuroma would ou more likely operate from the dorsla or plantar side?
Easier to access nerve but leaves painful scar so recommended going form the dorsal side instead of plantar
34
Interdigital Neuralgia – Morton’s Neuroma what mistake is often made?
•Frequently incorrectly diagnosed for any forefoot pain
35
what is Metatarsalgia?
Any pain coming from forefoot, symptoms form Morton's neuroma is one cause of this a condition in which the ball of your foot becomes painful and inflamed * A symptom, not a diagnosis. * Careful examination should localise cause * Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease……… * If no obvious cause consider tight gastrocnemius * Sometime difficult problem to treat
36
Rheumatoid forefoot - what is the treatment?
Non-operative (this is best) - shoewear/orthotics/activity etc Operative: * Many described techniques * Current gold standard - 1st MTPJ arthrodesis (surgical immobilization of a joint by fusion of the bones) - 2-5th toe excision arthroplasty (Remove metatarsal phalangeal joints of the lesser toes) (Picture - Heads of metatarsals removed and MTP joint of first ray has been fused)
37
what ar eosme examples of midfoot problems?
* Ganglia * Osteoarthritis * Plantar fibromatosis (uncommon non-malignant thickening of the feet's deep connective tissue, or fascia)
38
what are Dorsal Foot Ganglia?
Ganglia are most commonly asymptomatic, except for a lump, but symptoms depend on the location. A dorsal foot ganglion is typically painful. On the dorsal foot, the dorsalis pedis artery and the medial branch of the deep peroneal nerve are located under the fascia •Arise from joint or tendon sheath
39
what is the aetiology of dorsal foot ganglia?
Idiopathic Underlying arthritis Underlying tendon pathology
40
what are the symptoms of dorsal foot ganglia?
pain from pressure from shoe wear Pain from underlying problem
41
what is the treatment of dorsal foot ganglia?
Non-operative: * Aspiration * “Family bible” Operative: •Excision
42
what is the prognosis of dorsal foot ganglia?
High rate of return – 50%
43
Midfoot Arthritis may be in what forms?
* Post-traumatic arthritis * Osteoarthitis * Rheumatoid arthritis
44
what is the treatment of midfoot arthritis?
Non-operative – Activity/shoewear/orthotics etc Injections – xray guided Operative – fusion (of joint)
45
what is Plantar Fibromatosis?
Plantar fascial fibromatosis, also known as Ledderhose's disease, is a relatively uncommon non-malignant thickening of the feet's deep connective tissue, or fascia. In the beginning, where nodules start growing in the fascia of the foot the disease is minor * Ledderhose disease * “Dupuytren’s of the foot”
46
how does plantar fibromatosis present?
* Progressive * Usually asymptomatic unless very large or on weightbearing area Just get lumpy areas in the sole of the foot unlike in hands you get contraction of the fingers
47
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)
48
what are examples of hindfoot problems?
* Achilles tendonitis/tendinosis * Plantar fasciitis * Ankle osteoarthitis * Tibialis posterior dysfunction * Cavovarus foot – already discussed by Mr Forrest
49
what is Achilles tendonitis/tendinosis?
Achilles tendinosis is a condition in which the Achilles tendon degenerates and becomes inflamed. Sometimes, it may also be called Achilles tendinitis. If you have Achilles tendinosis, your tendon can swell and become painful. This condition is common in athletes, runners, and people who have calf tightness • Degenerative / overuse condition with little inflammation - “Tendonitis” should be avoided – suggest inflammation that may not be there - Tendinosis histopathological - Tendinopathy term to describe symptoms
50
Achilles tendinopathy is more than one lcinical conditoin, what are the different types?
Insertional tendinopathy - within 2cm of insertion Non-insertional/mid-substance tendinopathy - 2-7cm of insertion Bursitis - Retrocalcaneal, Superficial calcaneal Paratendinopathy is a true inflammatory problem showing paratendonitis histologically
51
what is the aetiology of Achilles Tendinopathy?
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
52
what are the symptoms of Achilles Tendinopathy?
Pain during exercise Pain following exercise Recurrent episodes Difficuly fitting shoes (insertional type) RUPTURE – don’t miss! – lots of complications if picked up late
53
how is the diagnosis of Achilles Tendinopathy made?
Clinical: * Tenderness * Tests for rupture Investigations: * Ultrasound * MRI
54
Achilles Rupture Tests - Simmonds Foot and ankle over edge of couch
Achilles Rupture Tests – “Angle of the Dangle” & Matles Left picture – right foot is normal and the left foot there is a diffuse swelling and margins of achilies tendon not clear
55
what is the non-operative treatment of Achilles Tendinopathy?
Activity modification Weight loss Shoe wear modification – slight heel Physiotherapy – Eccentric stretching Extra-corporeal shockwave treatment (vibrates tissues and stimulates fibrous tissue to form and healing) Immobilisation (in below knee cast)
56
what is the operative treatment of Achilles Tendinopathy?
Gastrocnemius recession (involves release of the gastrocnemius tendon and subsequent lengthening of the calf muscle) Release and debridement of tendon
57
what is Plantar Fasciitis?
Plantar fasciitis is inflammation of the plantar fascia, a part of your foot that connects your heel bone to your toes * Fasciitis is incorrect fasciosis better term * Fasciosis - Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity * Cant make Extra Cellular Matrix required for repair and re-modelling * Microtears?
58
what. is the aetiology of plantar faciitis?
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
59
what are the ysmptoms of Plantar Fasciitis?
Pain first thing in morning Pain on weight bearing after rest - Post-static dyskinesia (a medical term referring to pain that occurs after a period of rest) Pain located at origin of plantar fascia Frequently long lasting – 2 years or more
60
what are some differential diagnosis of plantar fasciitis?
Nerve entrapment syndrome Arthritis Calcaneal pathology
61
how is the diagnosis of plantar fasciitis made?
Mainly clinical Occasionally x-rays, ultrasound and MRI
62
what is the treatment of 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
63
what are some Newer / Third Line Treatments of plantar fasciitis?
1. Extracorporeal Shockwave therapy 2. Topaz Plasma Coblation 3. Nitric Oxide 4. Platelet Rich Plasma 5. Endoscopic / Open Surgery
64
what is the aetiology of ankle arthritis?
Mean age of presentation is 46 years Commonly post-traumatic Idiopathic (Lots of people that present you don’t know the cause)
65
what are the symptoms of ankle arthritis?
Pain Stiffness
66
what is the diagnosis of ankle arthritis?
Clinical Radiographs CT scan – exclude adjacent joint arthritis
67
what is the non-operative management of ankle arthritis?
Weight loss, activity modification, analgesia, physiotherapy, steroid injections
68
what is the operative management of ankle arthritis?
If symptoms are exclusively anterior (front of ankle) 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
69
what is Posterior Tibial Tendon Dysfunction?
Posterior tibial tendon dysfunction is one of the most common problems of the foot and ankle. It occurs when the posterior tibial tendon becomes inflamed or torn. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot * Relatively Common * Under-recognised * 4 stages * Largely clinical diagnosis – double & single heel raise. * Medial or lateral pain * Orthoses or surgery
70
how is the diagnosis of Tibialis posterior tendon dysfunction made?
Clinical MRI to assess tendon Double & Single Limb Heel Raise - Heel(s) should swing from valgus to varus as heel rises. If they have tibialis posterior dysfunction they cant do this
71
what is the management of tibialis posterior tendon dysfunction?
Orthotics – medial arch support Reconstruction of tendon (tendon transfer) Triple fusion (subtalar, talonavicular and calcaneocuboid – joints fused in better position)
72
what are some other foot problems?
• Diabetic foot - Ulceration –Charcot foot
73
what is the aetiology of Diabetic foot ulcer?
Diabetic neuropathy – patient unaware of trauma to foot Diabetic autonomic neuropathy - Lack of sweating/normal sebum production: - Dry cracked skin - Skin more sensitive to minor trauma Poor vascular supply Lack of patient education
74
what is the treatment of 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
75
what surgical treatment is avalible for diabetic foot ulcer?
Improve Vascular Supply Debride ulcers and get deep samples for microbiology Correct any deformity to offload area Amputation
76
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%
77
what is Charcot Neuroarthropathy?
Charcot neuroarthropathy, also known as Charcot foot, is a complication of diabetes mellitus where there is progressive degeneration of the joints, but it potentially is devastating in its consequences
78
what is aetiology of charcot foot?
Any cause of neuropathy Diabetes commonest cause Historically originally described and most common with syphillis
79
what is the pathophysiology of Charcot Neuroarthropathy?
Neurotraumatic - Lack of proprioception and protective pain sensation Neurovascular - Abnormal autonomic nervous system results in increased vascular supply and bone resorption
80
Charcot Neuroarthropathy characterised by rapid bone destruction occurring in 3 stages, what are they?
- Fragmentation - Coalescence - Remodelling
81
how is a diagnosis of Charcot Neuroarthropathy 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 (so often present late) Radiographs MRI scan (bone scan may also be useful)
82
what is the management of Charcot Neuroarthropathy?
Prevention Immobilisation / non-weight bearing until acute fragmentation resolved Correct deformity - Deformity leads to ulceration leads to infection leads to amputation
83
Majority of conditions treated \_\_\_\_\_\_\_\_\_\_\_\_
non-operatively
Year 3 - MSK
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