Foot problems

Question 1

What is the only indication for surgery for foot problems?

Answer 1

Failure of non-operative management

Question 2

Problems of the forefoot (6)

Answer 2

• Hallux valgus (bunions)
• Hallux rigidus
• Lesser toe deformities
• Morton’s neuroma
• Metatarsalgia
• Rheumatoid arthritis (in the forefoot)

Question 3

Causes of Hallux valgus (bunions) (3)

Answer 3

• Genetic
• Foot wear
• Gender: female

Question 4

Symptoms associated with bunions

Answer 4

• Pressure symptoms from shoes
• Pain from crossing over of toes
• Metatarsalgia - joint pain

Question 5

Pathogenesis of Hallux Valgus

Answer 5

• Lateral angulation of the great toe
• Tendons pull the toe into a lateral alignment and this worsens the deformity
• Vicious cycle of increased pull (due to deformity) creating increased deformity
• The sesamoid bones in the knuckles of toes sublux/ partially dislocate so then less weight goes through the great toe
• As deformity progresses, abnormalities of the lesser toes occur

Question 6

Non-operative management of Hallux Valgus (4)

Answer 6

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

Question 7

Operative management of Hallux Valgus

Answer 7

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

Question 8

What is Hallux rigidus?

Answer 8

A stiff/ painful big toe

• It is a form of degenerative arthritis - the toe’s range of motion gradually decreases until it potentially reaches the end stage of rigidus, in which the big toe becomes stiff or what is sometimes called a frozen joint.
• This disorder can be very troubling and even disabling since we use the big toe whenever we walk, stoop down, climb up or even stand

Question 9

Causes of Hallux rigidus?

Answer 9

Unknown but possibly genetic or multiple microtrauma

Question 10

Symptoms of Hallux rigidus

Answer 10

• Many asymptomatic
• Pain - often at extreme of dorsiflexion
• Limitation of range of movement

Question 11

Management of Hallux Rigidus: non-operative and surgery

Answer 11

Non-operative

• Activity modification
• Shoe wear with rigid sole
• Analgesia

Surgery

• ‘Gold standard’ = Arthrodesis - joint fusion of the 1st metatarsophalangeal joint - This procedure fuses together the 2 bones and it can lessen your pain. It can also make your joint more stable and help you bear more weight on it.
• Cheilectomy - remove excess bone from the joint of your big toe
• Arthroplasty - joint replacement - 1st MTPJ hemiarthroplasty - good option to maintain range of motion - high failure rate though

Question 12

What are some lesser toe deformities? (3)

Answer 12

• Claw toes
• Hammer toes
• Mallet toes

Question 13

Causes of Hammer toe, claw toe or mallet toe? (5)

Answer 13

• Imbalance between flexors/extensors
• Shoe wear
• Neurological
• Rheumatoid arthritis
• Idiopathic

Question 14

What are the non-operative and operative treatment options for lesser toe deformities?

Answer 14

Non-operative

• Activitiy modification
• Shoe wear - flat shoes with high toe box
• Orthotic insoles - metatarsal bar/dome support

Operative

• Flexor to extensor transfer due to imbalance
• Fusion of interphalangeal joint
• Release MTP joint
• Shortening osteotomy of metatarsal

Question 15

What is Morton’s Neuroma?

Answer 15

A painful condition that affects the ball of your foot, most commonly the area between your third and fourth toes.

Symptoms:

• Inflammation
• Severe neuralgic (short and severe) burning pain into the toes
• Numbness on the ball of the foot

Question 16

Causes of Morton’s Neuroma

Answer 16

• Mechanically induced degenerative neuropathy
• Thickened tissue in your toe puts pressure on the nerve irritating it and causing pain.
• 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

Question 17

How do you diagnose Morton’s neuroma?

Answer 17

Clinical examination

Mulder’s click - clinical test specific to Morton’s Neuroma

USS or MRI

Question 18

What are the management options for Morton’s neuroma?

Answer 18

Injection for small lesions

Surgery - excision of lesion including a section of normal nerve - this can sometimes result in numbness or recurrence.

Question 19

What is Metatarsalgia?

Answer 19

• A symptom (joint pain), not a diagnosis
• Careful examination should localise cause
• Many causes but if no obvious cause consider tight gastrocnemius

Question 20

Rheumatoid forefoot

Answer 20

Rheumatoid arthritis in the forefoot

Non-operative treatment = shoes, orthotics, activity etc

Operative treatment = 1st MTPJ arthrodesis or 2-5th toe excision arthroplasty

Question 21

Midfoot problems (3)

Answer 21

• Ganglia
• Osteoarthritis
• Plantar fibromatosis

Question 22

What is dorsal foot ganglia?

Answer 22

• A benign cyst in the foot that arises from joint or tendon sheath
• Appears as a lump
• Causes: idiopathic, underlying arthritis or underlying tendon pathology
• A dorsal foot ganglion is typically painful. Especially when wearing incorrect footwear.

Question 23

Treatment of dorsal foot ganglia

Answer 23

Non-operative

• Aspiration

Surgery

• Excision

Poor prognosis + high rate of return (50%)

Question 24

Midfoot arthritis

Answer 24

Types: post traumatic, osteoarthritis, rheumatoid

Treatment:

• Activity, footwear, orthotics
• Injections
• Operative - fusion

Question 25

What is Plantar fibromatosis (otherwise known as Ledderhose disease)?

Answer 25

A rare, benign, hyperproliferative fibrous tissue disorder resulting in the formation of nodules along the plantar fascia. * It is generally seen in middle-aged and elderly people, * M\>F 10:1 * It is progressive * Usually asymptomatic unless very large or on weight-bearing area Treatment: * 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)

Question 27

Hindfoot problems (5)

Answer 27

* Achilles tendonitis/tendinosis * Plantar fasciitis * Ankle osteoarthritis * Tibialis posterior dysfunction * Cavovarus foot - high foot arch, because of this, an excessive amount of weight is placed on the ball and heel of the foot when walking or standing

Question 28

Achilles tendinopathy (collective term describing achilles problems)

Answer 28

Tendinopathy occurs when a tendon is unable to adapt to the strain being place upon it. This causes microtrauma to the tendon fibres and results in the tendon trying to heal itself. Also called Achilles tendinits or tendinosis but these terms mean the same as achilles tendinopathy.

Question 29

Achilles tendinopathy: tendinopathy vs paratendinopathy

Answer 29

* Paratendinopathy - inflammation of the paratenon (areolar tissue filling the space between a tendon and its sheath) - commonest in athletic populations, age 30-40 * Tendinopathy - commonest in non-athletic populations - aged over 40. RF: obesity, steroids, diabetes

Question 30

Symptoms of achilles tendinopathy

Answer 30

* Pain during or following exercise * Recurrent episodes * Difficulty fitting shoes - back of the shoe rubs on the area - this suggests insertional tendinopathy * Rupture - some tendinopathies progress to rupture because it weakens the tendon. Early treatment is better so needs to be picked up quickly.

Question 31

How do you diagnose achilles tendinopathy?

Answer 31

Clinical * Tenderness * Test for tendon rupture Investigations * USS * MRI

Question 32

What is the Simmonds test?

Answer 32

**Achilles rupture test** Patient usually lies on their stomach and dangles their foot over the end of the bed. Squeeze the calf gently: * If the calf squeeze moves the foot up (plantarflexion) then the achilles tendon is not fully ruptured between the soleus muscle and the heel bone * If the calf squeeze does not move the foot up then there is a full achilles tendon rupture between the soleus muscle and the heel

Question 33

Ruptured Achilles tendon

Answer 33

Right side - very well defined. Foot is slightly plantarflexed Left side - diffuse swelling, margins of achilles tendon are not clear

Question 34

Treatment of tendinopathy - operative and non-operative

Answer 34

Non-operative * Weight loss * Activity modification and **immobilisation of ankle** - sometimes a below the knee cast is used for a few weeks at a time to try and help things heal * Slight heel raise - takes pressure off achilles tendon * Physio - Stretching * Extra-corporeal shockwave treatment - applying something similar to USS that vibrates the tissues and stimulates fibirous tissue to form and healing Operative treatment * Gastrocnemius recession - release of the gastrocnemius tendon and subsequent lengthening of the calf muscle * Release and debridement of tendon and remove paratenon

Question 35

What is plantar fasciitis/plantar fasciosis?

Answer 35

Fasciosis is a better term as there isn't actually inflammation involved in this condition. Plantar fasciitis is where you have pain on the bottom of your foot, around your heel and arch. * Chronic degenerative changes * Hypertrophy of fibroblasts * Absence of inflammatory cells * Disorganised and dysfunctional blood vessels and collagen * Avascularity Basically the matrix that is required for repair isn't there

Question 36

Causes of plantar fasciitis/fasciosis?

Answer 36

* Unknown * In athletes - associated with high intensity or rapid increase in training * Running with poorly padded shoes or hard surfaces * Obesity * Occupation - if involves prolonged standing * Foot/lower limb rotational deformities

Question 37

Symptoms of plantar fasciitis

Answer 37

* Pain first thing in the morning * Pain on weight bearing after rest * Pain located at origin of plantar fascia * Frequently long lasting - 2 years or more

Question 38

Treatment of plantar fasciitis

Answer 38

* Rest, change training * Stretching - achilles +/- direct stretching * Ice * NSAIDs * Orthoses - heel pads * Physio * Weight loss * Injections - corticosteroid (good in short term but may make condition worse in long term) * Night splinting Newer/3rd line treatments - extracorporeal shockwave therapy, topaz plasma coblation, nitric oxide

Question 39

Ankle arthritis

Answer 39

Commonly post-traumatic Diagnosis - clinical, radiographs, CT scan Treatment: * Non operative - weight loss, activity modification, analgesia, physio, steroid injection * Operative * If symptoms are exclusively anterior - arthroscopic anterior debridement * Arthrodesis - open or athroscopic (gold standard) * Joint replacement - questionable long term outcome

Question 40

Posterior tibial tendon dysfunction

Answer 40

* Relatively common but under-recognised * 4 stages. Diagnosis is clinical + MRI to assess tendon * Double & single heel raise - to go with both feet from a flatfoot stance to standing on the toes. Double heel raise: Stage 1 can do this but it is painful. Stage 2, 3 and 4 cannot do this. Patients cannot do a single heel raise on the affected foot. * Medial or lateral pain * Management - orthotics, reconstruction of tendon, triple fusion

Question 41

Diabetic foot ulcer: causes, treatment

Answer 41

Causes * diabetic neuropathy - patient uanware of trauma to foot * diabetic autonomic neuropathy - lack of sweating - dry cracked skin, skin more sensitive to minor trauma * Poor vascular supply * Lack of patient education Treatment is prevention * Also modify the main detriments to healing i.e diabetic control, smoking, vascular supply, external pressure etc * Surgery - improve vascular supply, debridement (samples for microbiology too), correct any deformity to offload area, amputation

Question 42

What is Charcot Neuroarthropathy?

Answer 42

Can be caused by any cause of neuropathy but is commonly a complication of diabetes mellitus - progressive degeneration of the joints in the foot. It is characterised by rapid bone destruction occuring in 3 stages: fragmentation, coalescence and remodelling. Pathophysiology: * Neurotraumatic - Lack of proprioception and protective pain sensation * Neurovascular - Abnormal autonomic nervous system results in increased vascular supply and bone resorption

Question 43

Diagnosis and management of Charcot's foot

Answer 43

* High index of suspicion * Consider in any diabetic patient with swollen erythematous foot especially with neuropathy * Frequently not painful * MRI * Radiographs Management: * Prevention * Immobilisation/non-weight bearing until acute fragmentation resolved * Correct deformity as this leads to ulceration which leads to infection and then amputation.