Hindfoot Problems

Question 1

5 types of hindfoot problems

Answer 1

• Achilles tendonitis/tendinosis
• Plantar fasciitis
• Ankle osteoarthritis
• Tibialis posterior dysfunction
• Cavovarus foot

Question 2

What is Achilles tendonitis/tendinosis

Answer 2

Degenerative/overuse condition with little inflammation

• Tendonitis should be avoided
• Tendinosis histopathological
• Tendinopathy term to describe symptoms

Question 3

4 types of Achilles tendinopathy

Answer 3

• Insertional tendinopathy
• Non-insertional tendinopathy
• Bursitis
• Paratendinopathy

Question 4

Define insertional and non-insertional tendinopathy

Answer 4

• Insertional = Within 2cm of insertion

- Non-insertion = 2-7cm of insertion

Question 5

2 types of bursitis related to Achilles tendinopathy

Answer 5

• Retrocalcaneal

- Superficial calcaneal

Question 6

Define paratendinopathy

Answer 6

True inflammatory problem showing paratendonitis histologically

Question 7

Aetiology of paratendinopathy

Answer 7

• Commonest is athletic populations
• Age group 30-40
• Male:Female = 2:1

Question 8

Aetiology of tendinopathy

Answer 8

• Commonest in non-athletic population
• Aged over 40
• Obesity
• Steroids
• Diabetes

Question 9

Symptom of Achilles tendinopathy

Answer 9

• Pain during/following exercise
• Recurrent episodes
• Difficulty in fitting shoes
• RUPTURE (don’t miss!)

Question 10

How to diagnose Achilles tendinopathy

Answer 10

• Clinical (tenderness, test for rupture)
• US
• MRI

Question 11

How to test for rupture of Achilles tendon

Answer 11

• Gently squeeze calf (soleus muscle)
• If the squeeze makes the foot move then the Achilles is not fully ruptured
• If no movement after squeeze then there is a complete rupture of the tendon

(Angle of the dangle + Matles)

Question 12

Non-surgical Rx of Achilles tendinopathy

Answer 12

• Activity modification/shoe with a slight heel
• Physiotherapy (eccentric stretching)
• Weight loss
• Extra-corporeal shockwave treatment
• Immobilisation (below knee cast)

Question 13

Surgical Rx of Achilles tendinopathy

Answer 13

• Gastrocnemius resection

- Release + debridement of tendon

Question 14

Aetiology of plantar fasciitis

Answer 14

• Unknown
• Associated with high intensity or rapid increase in training
• Running in poorly padded shoes or hard surfaces
• Obesity
• Occupations involving prolonged standing
• Tight gastrocnemius muscle
• Foot/lower limb rotational deformities

Question 15

Symptoms of plantar fasciitis

Answer 15

• Pain 1st thing in the morning
• Pain on weight bearing after rest (post-static dyskinesia
• Pain located at origin of fascia
• Frequently long lasting (2 or more years)

Question 16

DDx for plantar fasciitis

Answer 16

• Nerve entrapment syndrome
• Arthritis
• Calcaneal pathology

Question 17

How to diagnose plantar fasciitis

Answer 17

• Mainly clinical

- Occasionally X-ray, US and MRI

Question 18

Non-pharmacological Rx for plantar fasciitis

Answer 18

• Rest/change training, ice
• Orthoses
• Physiotherapy
• Weight loss
• Night splinting
• Stretching
• Endoscopic/open surgery

Question 19

Pharmacological Rx for plantar fasciitis

Answer 19

• NSAIDs
• Corticosteroid injection (good short term but long term may make condition worse)
• Nitric oxide
• Extracorporeal shockwave therapy
• Platelet rich plasma
• Topaz plasma coblation

Question 20

Aetiology of ankle arthritis

Answer 20

• 46 is the mean age of presentation
• Commonly post-traumatic
• Idiopathic

Question 21

Symptoms of ankle arthritis

Answer 21

• Pain

- Stiffness

Question 22

How to diagnose ankle arthritis

Answer 22

• Clinical
• Radiographs
• CT (exclude adjacent joint arthritis)

Question 23

Non-surgical Rx for ankle arthritis

Answer 23

• Weight loss, activity modification
• Physiotherapy
• Analgesia
• IA Steroids

Question 24

Surgical Rx for ankle arthritis

Answer 24

• Arthrodesis, open/closed (Gold standard + good long term outcome)
• Joint replacement

Question 25

Pros + cons of joint replacement in ankle arthritis

Answer 25

Pros -Maintains ROM Cons - Questionable long-term outcome, especially in high demand patients - Not easy to revise even to fusion

Question 26

How to diagnose tibialis posterior tendon dysfunction

Answer 26

- Clinical | - MRI to assess tendon

Question 27

Rx of tibialis posterior tendon dysfunction

Answer 27

- Orthotic (medial arch support) - Reconstruction of tendon (tendon transfer) - Triple fusion (subtalar, talonavicular and calcaneocuboid)

Question 28

Aetiology of diabetic foot ulcer

Answer 28

- Diabetic neuropathy, patient unaware of trauma - Diabetic autonomic neuropathy (lack of sweating, dry/cracked skin, skin more sensitive to trauma) - Poor vascular supply - Lack of patient education

Question 29

Non-surgical Rx for diabetic foot ulcer

Answer 29

Prevention - Smoking - Diabetic control - Vascular supply - External pressure (shoes/splints) - Internal pressure (deformity)

Question 30

Surgical Rx for diabetic foot ulcer

Answer 30

- Debride ulcers + get deep samples for microbiology - Correct any deformities to reduce pressure - Improve vascular supply - Amputation

Question 31

Prognosis of diabetic foot ulcer

Answer 31

- 25% get amputation | - 5 year mortality is 50%

Question 32

Aetiology of Charcot neuroarthropathy

Answer 32

- Any cause of neuropathy | - Diabetes is commonest cause

Question 33

Pathophysiology of Charcot neuroarthropathy

Answer 33

Neurotraumatic -Lack of proprioception + protective pain sensation Neurovascular -Abnormal autonomic nervous system results in increase vascular supply + bone resorption

Question 34

Charcot neuroarthropathy is characterised by rapid bone destruction occurring in 3 stages. What are those stages

Answer 34

- Fragmentation - Coalescence - Remodelling

Question 35

How to diagnose Charcot neuroarthropathy

Answer 35

- High index of suspicion - Consider any diabetic with a swollen foot (esp. w/ neuropathy) - Radiographs - MRI

Question 36

Symptoms of Charcot neuroarthropathy

Answer 36

Often painless

Question 37

Rx for Charcot neuroarthropathy

Answer 37

-Immobilise/non-weight bearing until acute fragmentation resolves -Correct deformity (deformity leads to ulceration=>infection=>amputation)