Common Foot and Ankle Pathology DOTS 17th April Nick Savva Orthopaedic Foot and Ankle Surgeon. Monday, 29 April 13

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1 Common Foot and Ankle Pathology DOTS 17th April 2013 Nick Savva Orthopaedic Foot and Ankle Surgeon Monday, 29 April 13

2 Topics Forefoot pain Hindfoot/Ankle pain Hallux rigidus Bunions Toe deformity Mortons inter-digital neuroma Metatarsalgia Plantar fasciitis Arthritis Fusions Total Ankle Replacement (TAR) Red Flags + Post Op Problems Sundries Charcot Ulceration Counselling patients for surgery Good footwear Information Monday, 29 April 13

3 Treatment Algorithm Live with problem Change lifestyle/job Lose weight Change shoes Modify shoes Inserts/Orthotics (Ray MacIntosh) Physiotherapy NSAIDs/Analgesia Injections Surgery Monday, 29 April 13

4 Hallux Rigidus Presenting complaints Lumps that rubs on foot wear Painful stiff joint Monday, 29 April 13

5 Hallux Rigidus Monday, 29 April 13

6 Hallux Rigidus

7 Hallux Rigidus Treatment Footwear adjustments MUA and injection Cheilectomy Fusion/Arthodesis Replacement Monday, 29 April 13

8 Cheilectomy Monday, 29 April 13

9 Cheilectomy

10 Cheilectomy

11 Cheilectomy

12 Fusion

13 Replacement

14 Replacement

15 Bunions

16 Scarf and Akin Osteotomies

17 Lesser Toes Presenting complaints Rubbing on shoes Painful corns Metatarsalgia Monday, 29 April 13

18 Lesser Toes Treatment Silicon sleeves Bigger shoes Chiropody Surgery Monday, 29 April 13

19 Lesser Toes Treatment Silicon sleeves Bigger shoes Chiropody Surgery Monday, 29 April 13

20 Percutaneous Flexor Tenotomy

21 Percutaneous Flexor Tenotomy

22

23 Surgical fusion

24 Lesser Toes

25 Metatarsalgia Aetiology Idiopathic Tight Achilles tendon Transfer metatarsalgia Inflammatory arthropathy High arch feet (Cavus) Morton s intrerdigital neuroma Exacerbating Factors Over weight Over use Poor foot wear Tight Achilles tendon Monday, 29 April 13

26 Disorders of First Ray

27 Cavus Foot Monday, 29 April 13

28 Natural Progression

29 Natural Progression

30 Metatarsalgia Treatment Lose weight Gastrocnemius stretches Metatarsal dome orthotics Injections/NSAIDS Surgery Monday, 29 April 13

31 Tight Gastrocnemius

32 Tight Gastrocnemius

33 Weil s Osteotomy

34 Morton s Inter-Digital Neuroma Sharp electric pain in forefoot Radiates into 3rd and 4th toes Intermittent Worse in tight shoes Numbness in 3rd web space History is usually diagnostic Monday, 29 April 13

35 Morton s Inter-Digital Neuroma Tenderness between 3/4 metatarsal heads Mulder s click Reproduction of pain Altered sensation Metatarsophalangeal joints not sore Can occur in other web spaces Occasionally bilateral Often asymptomatic Monday, 29 April 13

36 Morton s Inter-Digital Neuroma Differential Diagnosis Joint pain (Metatarsalgia) Stress fracture Freibergs infraction Monday, 29 April 13

37 Investigations Radiographs Ultrasound Bone Scan MRI Monday, 29 April 13

38 Treatment Wide well padded shoes Metatarsal dome orthotics Image guided injection Radio-frequency ablation Alcohol ablation Image guided injection Monday, 29 April 13

39 Surgery

40 Ankle Osteoarthritis Aetiology Primary osteoarthritis Post trauma Rheumatoid Monday, 29 April 13

41 Treatment Aetiology Footwear Braces Injections Arthroscopic debridement Fusion/Arthrodesis (Gold standard) Replacement/Arthroplasty Monday, 29 April 13

42 Arthroscopic Debridement

43 Arthrodesis Fusion Monday, 29 April 13

44 Hindfoot Arthrodesis Nail (HAN)

45 Hindfoot Arthrodesis Nail (HAN)

46 Total Ankle Replacement (TAR)

47 TAR

48 Replacament versus Fusion

49 Plantar Fasciitis Policeman s heel Start up pain Obesity Standing occupation Insidious onset New shoes Monday, 29 April 13

50 Differential Diagnosis Plantar Fasciitis Plantar fasciosis (fasciitis) Infracalcaneal fat pad atrophy Medical calcaneal nerve entrapment Tarsal tunnel syndrome Rheumatoid arthritis Reiter s syndrome Ankylosing spondylitis Psoriatic arthritis Gout Posterior enthesopathies Behet s syndrome Systemic lupus erythematosus Fibromyalgia Sciatica Lateral plantar nerve branch to abductor digiti quinti Calcaneal stress fracture Calcaneal tumors/cysts Intraosseous edema of calcaneus Monday, 29 April 13

51 Plantar Fasciitis

52 Plantar Fasciitis

53 Plantar Fasciitis Treatment Resolves within 18 months Heat/cold NSAIDs Stretches Monday, 29 April 13

54 Plantar Fasciitis Treatment Heel cups Night splints Monday, 29 April 13

55 Plantar Fasciitis Shockwave Lithotripsy 3 6 sessions at least 1 week apart Approved by NICE Reduces length of symptoms by 80% Monday, 29 April 13

56 Plantar Fasciitis

57 Nerve Entrapments

58 Nerve Entrapments Monday, 29 April 13

59 Nerve Entrapments

60 Charcot and the Diabetic Foot

61 Take Home Messages Non-Operative Lose weight NSAIDs Footwear Orthotics Image guided injections Monday, 29 April 13

62 Take Home Messages Weight bearing xrays Elevate elevate elevate Try everything else first Monday, 29 April 13

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