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

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

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

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

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

Hallux Rigidus Monday, 29 April 13

Hallux Rigidus

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

Cheilectomy Monday, 29 April 13

Cheilectomy

Cheilectomy

Cheilectomy

Fusion

Replacement

Replacement

Bunions

Scarf and Akin Osteotomies

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

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

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

Percutaneous Flexor Tenotomy

Percutaneous Flexor Tenotomy

Surgical fusion

Lesser Toes

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

Disorders of First Ray

Cavus Foot Monday, 29 April 13

Natural Progression

Natural Progression

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

Tight Gastrocnemius

Tight Gastrocnemius

Weil s Osteotomy

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

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

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

Investigations Radiographs Ultrasound Bone Scan MRI Monday, 29 April 13

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

Surgery

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

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

Arthroscopic Debridement

Arthrodesis Fusion Monday, 29 April 13

Hindfoot Arthrodesis Nail (HAN)

Hindfoot Arthrodesis Nail (HAN)

Total Ankle Replacement (TAR)

TAR

Replacament versus Fusion

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

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

Plantar Fasciitis

Plantar Fasciitis

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

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

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

Plantar Fasciitis

Nerve Entrapments

Nerve Entrapments Monday, 29 April 13

Nerve Entrapments

Charcot and the Diabetic Foot

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

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