Foot problems

Question 1

What is Achilles tendonitis?

Answer 1

Degenerative/overuse condition with little inflammation. (misnomer)
Tendinosis histopathological.
Tendinopathy term to describe symptoms.

Question 2

What are the subtypes of Achilles tendonitis and their associations

Answer 2

Paratendinopathy - common in athletics, age 30-40, M 2:1 F.

Tendinopathy – commonest in non-athletics, aged > 40, obesity, steroids, diabetes.

Question 3

What are the symptoms of Achilles tendonitis?

Answer 3

Pain during exercise.
Pain following exercise.
Recurrent episodes.
Difficulty fitting shoes (insertional).
Rupture – don’t miss.

Question 4

What is the non-operative management for Achilles tendonitis?

Answer 4

Non-operative: activity modification, weight loss, shoe wear modification (slight heel raise), Physiotherapy (eccentric stretching), extra-corporeal shockwave treatment, immobilisation (in below knee cast).

Question 5

What are operative management options for Achilles tendonitis?

Answer 5

Gastrocnemius recession. Release and debridement of tendon.

Question 6

Describe plantar fasciosis?

Answer 6

Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, avascularity. Can’t make extra cellular matrix required for repair and remodelling.

Question 7

What is the aetiology of plantar fasciosis?

Answer 7

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.

Question 8

What are the symptoms of plantar fasciosis?

Answer 8

Pain first thing in morning
Pain on weight bearing after rest - Post-static dyskinesia (impairment of movement)
Pain located at origin of plantar fascia
Frequently long lasting – 2 years or more

Question 9

What is the management for plantar fasciosis?

Answer 9

Rest, change training. 
Stretching – Achilles +/- direct stretching 
Ice 
NSAIDs
Orthoses – heel pads 
Physiotherapy 
Weight loss
Injection – CCS (good in short term but may worsen condition in long term) 
Night splinting.

Question 10

What is the aetiology of ankle OA + the mean age of presentation?

Answer 10

Mean age of presentation is 46 years. Commonly post-traumatic. Idiopathic.

Question 11

What are the symptoms of ankle OA?

Answer 11

Pain, stiffness

Question 12

What non-operative treatments are there for ankle OA?

Answer 12

Weight loss, activity modification, analgesia, physiotherapy, steroid injections.

Question 13

What operative treatment can be used for ankle OA?

Answer 13

• If symptoms are exclusively anterior – arthroscopic anterior debridement
• Arthrodesis – open or arthroscopic: gold standard, good long-term outcome.
• Joint replacement – maintain ROM, questionable long-term outcome esp. in high demand patients, not easy to revise even to fusion.

Question 14

What is tibialis posterior dysfunction?

Answer 14

Acquired adult flat foot planovalgus. Relatively common, under-recognised. Comes in 4 stages.

Question 15

What are the symptoms of tibialis posterior dysfunction and describe the diagnosis?

Answer 15

Symptoms- medial or lateral pain. Largely clinical diagnosis – double & single heel raise (tip toes). Too many toes sign when looking from behind and stood up.

Question 16

How would you treat tibialis posterior dysfunction?

Answer 16

Orthotics – medial arch support.
Reconstruction of tendon (tendon transfer) 
Triple fusion (subtalar, talonavicular and calcaneocuboid)

Question 17

What is hallux valgus also known as?

Answer 17

“bunions”

Question 18

What is the aetiology of hallux valgus?

Answer 18

Genetic, footwear, significant female preponderance.

Question 19

Describe the pathogenesis of hallux valgus

Answer 19

Lateral angulation of great toe, tendons realigned to lateral of central of rotation, vicious cycle of increasing pull creating increasing deformity, sesamoid bone subluxation (partial dislocation) – less weight going through big toe, as deformity progresses, abnormalities of lesser toes occur.

Question 20

What are the treatments of hallux valgus (non-op + op)?

Answer 20

Non-operative: shoe wear modification (wide +/- high toe box); Orthotics to offload pressure/correct deformity; Activity modification; Analgesia.
Operative – release lateral soft tissues; Osteotomy 1st metatarsal +/- proximal phalanx; generally good outcome but recurrence inevitable.

Question 21

What is hallux rigidus?

Answer 21

Latin – stiff big toe. OA of 1st MTP joint.

Question 22

What is the aetiology of hallux rigidus?

Answer 22

Not known. Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded. Possibly multiple microtrauma.

Question 23

What are the symptoms of hallux rigidus?

Answer 23

Many asymptomatic. Pain – often at extreme dorsiflexion. Limitation of ROM.

Question 24

How do you treat hallux rigidus? (op + non-op)

Answer 24

Non-operative – activity modification, shoe wear with rigid sole, analgesia.
Operative – Cheilectomy (remove dorsal impingement); Arthrodesis; Arthroplasty.

Question 25

What is rheumatoid forefoot?

Answer 25

RA of the forefoot

Question 26

What is the management of rheumatoid forefoot?

Answer 26

Non-operative – shoe wear/orthotics/activity etc. Operative – current gold standard: - 1st MTPJ arthrodesis - 2-5th toe excision arthroplasty

Question 27

Describe metatarsalgia

Answer 27

Symptom, not diagnosis; careful examination should localise the cause. Synovitis, bursitis, arthritis, neuralgia, (Morton’s) neuromata, Freiberg’s disease. If no obvious cause, consider tight gastrocnemius. Sometime difficult problem to treat.

Question 28

Describe the aetiology of hammer and claw toe (lesser toe deformities)

Answer 28

Imbalance between flexors/extensors. Shoe wear. Neurological. RA. Idiopathic.

Question 29

What are the symptoms of hammer/claw toe?

Answer 29

Deformity. Pain from dorsum. Pain from plantar side (metatarsalgia).

Question 30

What are the non-operative treatments for hammer + claw toe (lesser toe deformities)?

Answer 30

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

Question 31

What are the operative treatments for hammer + claw toes (lesser toe deformities)?

Answer 31

Flexor to extensor transfer Fusion of IPJ Release of MTPJ Shortening osteotomy of metatarsal

Question 32

What is the origin of dorsal foot ganglia?

Answer 32

Arises from joint or tendon sheath.

Question 33

What may be aetiological factors for dorsal foot ganglion?

Answer 33

Idiopathic. Underlying arthritis. Underlying tendon pathology.

Question 34

What are the symptoms of dorsal foot ganglia?

Answer 34

Pain from pressure from shoe wear. Pain from underlying problem.

Question 35

How may you treat dorsal foot ganglia?

Answer 35

Non-operative – aspiration. Operative – excision.

Question 36

What may midfoot arthritis be a result of?

Answer 36

Post-traumatic arthritis. OA. RA.

Question 37

How do you treat midfoot arthritis?

Answer 37

Non-op: activity/shoe wear/orthotics etc. Injections – x-ray guided Operative – fusion

Question 38

Describe plantar fibromatosis

Answer 38

AKA Ledderhose disease, characterised by growth of hard and round or flattened nodules on soles of feet. Progressive. Usually asymptomatic unless very large or on WB area.

Question 39

How would you treat plantar fibromatosis?

Answer 39

Non-operative – avoid pressure, shoe wear/orthotics Operative – excision (up to 80% risk of recurrence) Radiotherapy (similar recurrence as operative) Combination radiotherapy/surgery (low risk recurrence/high risk complications)

Question 40

What is the aetiology of diabetic foot ulcer?

Answer 40

Diabetic neuropathy – patient unaware to 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

Question 41

Describe the management of diabetic foot ulcers

Answer 41

Prevention. Modify main detriments to healing – Diabetic control, smoking, vascular supply, external pressure (splints/shoes/WB), internal pressure (deformity), infection, nutrition. Surgical treatment – improve vascular supply; debride ulcers + get samples for microbiology; correct any deformity; amputation.

Question 42

Describe the prognosis of diabetic foot ulcers

Answer 42

15% of diabetics --> foot ulcers. 85% of amputations preceded by foot ulcers; 25% of diabetic foot ulcer get amputated 5-year mortality 50%

Question 43

Describe the aetiology of Chargot’s neuroarthropathy

Answer 43

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

Question 44

Describe the pathology of Chargot’s neuroarthropathy?

Answer 44

Characterised by rapid bone destruction occurring in 3 stages: fragmentation, coalescence, remodelling.

Question 45

Describe the management of Chargot’s neuroarthropathy?

Answer 45

Prevention, immobilisation/non weight bearing until acute fragmentation resolved. Correct deformity – deformity leads to ulceration leads to infection leads to amputation.