9COMMON FOOT DISORDERS Hallux Valgus and Rigidus Lesser toe deformities Hammer toeMallet toeClaw toeFlat footMetatarsalgia
10GENERAL PROFILE OF DEFORMITIES Commonly seen in females82% of women report having foot pain, while 72% report one or more foot deformities.More than 7 out of 10 women develop a bunion, hammertoe, or other painful foot deformity.Nine out of 10 women’s foot deformities can be attributed to tight shoes.
11HALLUX VALGUS Definition Lateral deviation of great toe Aetiology FamilialInappropriate footwearFlatfeetLong first rayIncongruous 1st MTP joint articular surfaceMetatarsus primus varusRheumatoid arthritis.HVHV + Claw toes
12HALLUX VALGUS CONTD.PathogenesisComplex deformity with angle between 1st & 2nd MT > 9 degrees and valgus angle at MTP joint >20 degrees.Valgus posture of great toe causing hammer toe like deformity of second toe.Splaying of forefoot causing bunion.Incongruence causing osteoarthritis of 1st MTP joint.
13WHEN TO REFER Bunion pain Transfer metatarsalgia SymptomsBunion painTransfer metatarsalgiaSignificant deformity causing:2nd toe deformityShoe wear problemsCosmesis – relative contraindication
14SIGNS Bunion and inflamed overlying bursa and skin Valgus and pronation deformity of hallux.Painful callus on 2nd toeSecond toe is forced into hyperextension by deviated great toeTransfer metatarsalgia/thickened skin over MT heads.Increased valgus angle at first MTP jointValgus angle at first MTP joint >20 degreesAngle between 1st & 2nd MT >9 degrees
15MANAGEMENT Entire foot must be assessed first. X-ray of foot –Standing dorso plantar, oblique & axial sesamoid viewsMedial exostosis (bunion)Lateral displacement proximal phalanxDegenerative changes in 1st MTP/IP JointIntermetatarsal & Hallux Valgus angles
17TREATMENT CONSERVATIVE TREATMENT Aim: Relieve pressure over painful bunion prominenceProperly fitted, low heeled stiff-soled shoesWide, square shaped toe boxToe portion stretched to accommodate bunionExtra-depth shoe to accommodates dorsiflexed second toeSplint separates first and second toeAcute pain managementRestApply moist heatAnalgesics
18SURGICAL MANAGEMENT Indications Refractory to conservative managementSevere deformity or bunion painFactors to be considered before surgeryValgus deviation of great toeVarus deviation of first metatarsalArthritis of MTP and IP jointBunionMetatarso-cuneiform joint instabilityVascularity & sensibilitySurgical ProceduresSoft tissue surgery - rarely indicated in adolescent casesBone/joint procedure remains the gold standard
19HALLUX RIGIDUS/DORSAL BUNION Painful limitation of motion at 1st MTP jointPathogenesis: synovitis, cartilage destruction, osteophyte proliferation, subchondral cysts and sclerosisClinical presentation: pain, limited dorsiflexion and dorsal osteophyte, dorsal tendernessAetiology: Trauma, Repeated microtrauma, osteochondritis dissicans and abnormally long first metatarsal
20TREATMENT Grade I: Mild osteophytes, joint space preserved NSAID, orthosis and injectionGrade II: Moderate osteophyte formation, joint space narrowing & subchondral sclerosisCheilectomy: excision of 20-35% of dorsal metatarsal head aiming for up to 70º of dorsiflexion.Grade III: Severe arthritisArthrodesis/joint replacement
21LESSER TOE DEFORMITIES Hammer, Claw and MalletAssociation with HV, RA, DM and NM disordersPain, corns, ulcers, shoe wear difficultiesFlexible and fixedConservative treatment: manipulation, corn pads, accommodative shoe wearSurgical treatment: tendon release and transfers for flexible deformities; fusion and excision arthroplasties for fixed deformities.
22FLAT FOOT/PES PLANUS Flexible (99%) or Rigid (1%) Distinguished by Jack test and tiptoeingPathology - Loss of normal medial longitudinal arch in combination with valgus posture of heel, mild subluxation of subtalar joint & eversion of calcaneumArch develops till the age of 7-10 years so there is no treatment required15-20% of adults have asymptomatic pes planus
23TREATMENT OF FLEXIBLE PES PLANUS 3-9 years: symptomatic - arch support10-14 years require investigationSymptomatic patient - rule out accessory navicular or incomplete tarsal coalition and treat accordingly.Adults with painful pes planus not responding to conservative management will benefit with surgery
24RIGID PES PLANUSAetiology: Congenital vertical talus & tarsal coalitionTarsal coalition: calcaneo-navicular & talocalcaneal; can be bony, cartilagenous or fibrous.Symptoms: Foot pain, difficulty walking on uneven surfaces, foot fatigue, peroneal spasm.Treatment: 4-6 weeks of cast immobilization; surgical treatment includes resection of connecting bar & soft tissue interposition, subtalar arthrodesis, triple arthrodesis.
25METATARSALGIA Pressure from subluxed MTPJs with painful callosities Freiberg’s AVN (treatment: conservative and surgical)Stress FracturesTransfer from first metatarsal insufficiency/HVSesamoiditisMorton’s
26MORTON’S METATARSALGIA Commoner in middle-aged women; 85% unilateralAetiology: trauma, ischaemia, entrapmentPathology: degenerative rather than a true neuroma with perineural fibrosis and demyelination.Diagnosis: symptom of shooting/constant pain on walking, relieved by rest and removal of footwear; clinical sign of third/second cleft tenderness and palpable click on metatarsal squeeze test.Treatment: orthoses, injection and excision
27ANKLE DISORDERS Instability Impingement Osteochondritis Dissecans of talusArthritisPosttraumaticInflammatoryDegenerative
29ANKLE IMPINGEMENT Repeated sporting dorsiflexion injuries Presentation with anterior ankle painDiagnosis: clinical anterior tenderness and ± anterior osteophytes on X-raysTreatmentConservative: activity modification/NSAIDsSurgical: open/arthroscopic decompression
30OSTEOCHONDRITIS DISSECANS Posttraumatic in young patientsPresentation with persistent pain and swelling with stiffnessDiagnosis: clinical tenderness, diffuse swellingImaging: X-rays and MRI scanTreatment: undisplaced lesions treated with rest and cast immobilisation; displaced lesions require arthroscopic removal/drilling
31ANKLE ARTHRITISPosttraumatic: rare in commonly injured joint; associated with displaced intra-articular fractures and significant lateral ligament complex injury.Inflammatory: RA in low-demand patientsDegenerative: relatively uncommonPresentation with pain, swelling, stiffness, limited mobility, limping.
32ANKLE ARTHRITIS (CONTD.) Diagnosis: clinical swelling, tenderness, ↓ROMImaging: X-rays, bone scan to assess surrounding jointsTreatmentConservative: NSAIDs, walking stick, weight reduction and activity modification.Surgical: arthroscopic/open decompression; ankle arthrodesis (up to 25% non-union, 3 month casting); ankle replacement gives satisfactory mid-term results in properly selected low-demand patients (long-term results?)
35TIBIALIS POSTERIOR TENDON Anatomy - posteromedial tendon, origin from posterior surface of tibia & inserts on to the medial cuneiformFunction - plantar flexion, inversion, stabilizes medial longitudinal archImportant tendon in foot, affection of which causes more functional disability than TA ruptureAetiology - trauma, chronic flat foot, inflammatory arthropathy, degenerative tendonopathy, chronic tenosynovitis, abnormal insertion, steroid use.Deformity - collapse of medial longitudinal arch, hindfoot valgus, midfoot abduction, forefoot pronation
36PATHOLOGY/PRESENTATION Pathogenesis: tenosynovitis, incomplete tear, complete disruptionTwo groups of patients:Younger patients with inflammatory arthropathy/traumatic ruptureOlder, typically female patients with degenerative tearsPRESENTATIONFatigue of foot with limited activity, medial and lateral painFlat foot on weight bearingStanding tip toe – heel will go into valgusClinical examination confirms tenderness, weak/ruptured tendon, hindfoot valgus (flexible/fixed) and a lack of heel varus on tiptoeing
37MANAGEMENT Imaging: X-ray (degeneration), MRI Tenosynovitis - rest, NSAIDs, short leg walking cast, orthoses, steroid injection in tendon sheath, synovectomy.Incomplete tear - repair or augmentation with either FDL or FHL.Complete disruption – repair in traumatic young cases; tendon transfer with medial calcaneal displacement osteotomy (mobile hindfoot) and subtalar/triple arthrodesis (fixed hindfoot).Satisfactory results in spite of prolonged rehabilitation
38TIBIALIS ANTERIOR Anatomy: Origin - lateral condyle of tibia, proximal 2/3 of lateral surface of tibia, interosseous membraneInsertion - base of first metatarsal and medial plantar surface of 1st cuneiformAction - dorsiflexes and inverts footDisorders are common in athletes and old age groupDiagnosis- weakness of dorsiflexion of foot, pain, use of toe extensors for dorsiflexion of foot.Treatment- steroid injection or synovectomy . Tendon repair rarely required as deformity is not functionally significant.
39PERONEAL TENDONS Anatomy: Peroneus longus & brevis are posteolateral tendons originating from fibula and interosseous membrane and are inserted at base of I & V MT respectively.
40PERONEAL TENDONS (CONTD.) Pathology:Tenosynovitis - common in high arch foot because of increase in excursion.Sprain/ subluxation - inversion ankle injuries.Symptoms: pain in the outer part of the ankle or just behind the lateral malleolus. This pain commonly worsens with activity and eases with rest.Diagnosis:Examination - tenderness/subluxationX-rays to exclude fractureMRI
41PERONEAL TENDONS (CONTD.) TreatmentNon-surgicalRest, short-leg walking cast/brace, lateral heel wedge, physical therapy, NSAIDs and Cortisone injectionSurgicalTenosynovectomy and repair of splitStabilisation of dislocating tendons by groove deepening, peroneal retinaculum reconstruction and bone block procedures
42ACHILLES TENDINITIS/TENDINOSIS Tendinosis - there will be clinical inflammation, but objective pathologic evidence for cellular inflammation is lackingTendinitis - there will be a peritendinous inflammationSeen in adults in their 30s and 40sMost commonly affects runnersHeel cord contracture can exacerbate symptomsTwo types:Non-insertionalOccurs proximal to retrocalcaneal bursaGenerally responds well to non-operative treatmentInsertionalTenderness is localized to calcaneal tendon insertionMore difficult to treat
43TREATMENT Conservative Rest, ice, NSAIDs, physical therapy, orthoses OperativeAchilles tendon decompression and debridement if unrelieved by 6 months of conservative measures90% will have significant relief of symptoms; 10% will have some symptom improvementComplete symptomatic cure not guaranteed
44ACHILLES TENDON RUPTURE Common sporting incidence affecting the young to middle-agedMechanism usually involves loading on a dorsiflexed ankle with the knee extended (soleus and gastroc on maximal stretch) or repeated microtraumaConsider systemic conditions such as gout or hyperparathyroidism (esp. with pure avulsion injury); previous steroid injectionsDisabling condition requires approx. 6 months to recover when treated adequately
45ACHILLES TENDON RUPTURE (CONTD.) Diagnosis (suspect in all ankle injury cases):Characteristic historyClassical signs:Local tenderness and gapHyper-dorsiflexion at ankleThompson/Simmonds testImaging:Ultrasound and MRI scan in doubtful cases
46TREATMENT Consider DVT prophylaxis Non-operative treatment is indicated in older patients and minimally displaced ruptures and involves serial casting over weeks (complete equinus, mid equinus, neutral walking).Operative repair is indicated in younger patients with clinically displaced ruptures, delayed presentation (48-72 hours) and neglected ruptures followed by similar casting regime.Complications: wound healing and sural nerve injuryConsider DVT prophylaxis
47NON-OPERATIVE VS. OPERATIVE Return to the preinjury level of activityPatient satisfactionRe-ruptureNon-operative69%66%Up to 33%Operative83%93%2-3%
48HEEL PAIN Commonly caused by plantar fasciitis. Heel spurs often associated.Pain is worst on waking up.Causes - obesity, excessive walking/sporting activity, tight plantar fascia & flattening of the arch.Treatment – orthoses, physical therapy, injection, NSAIDs and (rarely) surgical release in resistant cases.
49RETROCALCANEAL BURSITIS Two bursae: retrocalcaneal (subtendinous) bursa & subcutaneous calcaneal bursaCausesRepetitive trauma from shoe wear and sportsGout, RA and ankylosing spondyloarthropathiesBursal impingement between the Achilles tendon and an excessively prominent posterior-superior aspect of the calcaneus (Haglund deformity).Symptoms: pain, swelling, shoe wear difficultySigns: tenderness, lump, inflammation
50MANAGEMENT Imaging: X-rays for calcification and Haglund deformity. Conservative: physical therapy, appropriate shoe wear, injection (risk of tendon rupture).Surgical Intervention includes resection of Haglund deformity (removal of the calcaneal superoposterior prominence), excision of the painful bursa and debridement of tendon insertion