Transcript Treatment

Pes cavus (increased or high medial
arch of the foot):
The medial arch is higher than normal with varus foot and finger clawing
the main Causes are:
 Primary idiopathic, usually familial and bilateral.
 Neuromuscular conditions like cerebral palsy, peroneal muscle dystrophy or friedreich’s ataxia
 This deformity of the foot with the clawing of the toes puts the body weight on the metatarsal
heads that projects down into the sole of the foot and usually there is an overlying skin
callosities due to friction with the shoe.
 In the mobile flexible early deformity the foot shape can be restored if the metatarsal heads
pushed up by the examiner’s finger, as the arch gets normal and the clawing of the toes
corrected. Later the deformity if untreated gets fixed and painful.
Treatment:
 In cases of painless mobile deformity no treatment is needed apart from special shoe wear.
 In severe deformities which is still mobile the foot shape can be improved and weight bearing
on metatarsal heads can be decreased by rebalancing surgery correcting the clawing by tendon
transfer so the long toe flexors are released and transferred from the planter to the dorsal
aspect of the toes and fixed on the extensor expansion so it will correct the hyperextension and
put the toes straight.
 For fixed deformities no much can be done, if special shoe wear is not enough complex bone
surgeries and arthrodesis can be done, operations must always delayed after the age of 16 years.
Hallux valgus:
 It’s the commonest foot and musculoskletal
deformity seen in practice.
 There is valgus deviation of the big toe with mild
medial rotation where the nail facing slightly to
the medial side, there is also overcrowding of the
other toes with the 2nd. Toe usually develops the
deformity known as hammer toe (extension of the
metatarsophalangial joint, flexion of the proximal
interphalangial and extension of the distal
interphalangial joint).
 Predisposing factors:
The shoe wears: In people who do not wear shoes the
forefoot is fan-shaped (splaying) with the big toe in line with
the lst. Metatarsal bone (i.e. varus position which is rather
normal). While in those who uses the shoes the hallux get
deviated laterally at the metatarsophalangial joint especially
in females who wear high shoes that are narrow anteriorly.
 Metatarsus primus varus: there is forefoot splaying with
excessive primary varus position of the 1st. metatarsal bone
that predispose for lateral deviation of the big toe during shoe
wear.
 Tight and prolonged shoe wear by itself play part in
predisposition to the same deformity
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Inter metatarsal angle
less than 9 digree
&metatarsophal angel
angle less than 15
digree
 Soft tissue changes that act to maintain and
gradually worsen the deformity such as:
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The adductor hallucis get tight on the lateral side of the hallux.
There is lateral capsular contracture and shortening.
Lax redundant capsule medially.
The long extensors of the hallux gradually subluxate laterally
and act to maintain and worsen the deformity by its bowstring effect.
 Secondary changes occurs usually like:
 To start with the deformity is mild, with time it get more
severe, immobile and cannot be corrected manually, later
osteoarthritis occurs with stiff and painful first
metatarsophalangial joint.
 The lst. metatarsal head looks thick and widened, and
because of rubbing with shoe wear on its medial side
there will be the formation of thick bony exostosis and
over it there is a protective synovial bursa (the bunion)
that may get swollen, inflamed or infected.
 Both of the above changes can be a cause of pain.
 Causes of hallux valgus:
 Commonest type is the primary idiopathic one that
mostly affects older females (above 40) and usually
bilateral.
 It can occur secondary to muscle imbalance in
neuromuscular disorders or in older people.
 It’s very common in cases of rheumatoid arthritis.
 An uncommon type is the congenital type that affect
young adolescent girls due to congenital metatarsus
primus varus, this type usually present early because the
mother is anxious and afraid that here daughter may get
the severer deformity later in life like herself.
 Clinical features:
 There is obvious deformity with exostosis and bunion, in the
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beginning it’s mild and can be corrected manually, later it
gets more severe, less mobile and osteoarthritis may develop.
The bunion may get swollen infected or inflamed.
Pain at the 1st. metatarsophalangial joint may due to:
Inflamed or infected bunion.
Hammer toe.
Secondary osteoarthritis.
Painful metatarsal heads on the planter aspect of the foot
(painful metatarsalgia) due to forefoot splaying and
downward projection of metatarsal heads and abnormality in
weight bearing.
 X-ray:
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Taken with the patient standing to show the degree of
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metatarsal and hallux angulations.
Also it shows the state of the joint being normal, arthritic or
subluxated.
Treatment:
1.
Adolescent congenital deformity always need surgical
correction of the varus position of the 1st. metatarsal by osteotomy
to put it more straight so the big toe will assume more straight
position.
2.
For adults:
a.
If the deformity is mild and mobile in a patient below
40 years most of the cases respond well for special attention for
footwear, which should be wide anteriorly and soft with special
padding for the bunion, hammer toe and metatarsal heads.
b.
If this is not enough we may use surgical soft tissue
procedure where we release the adductor hallucis laterally and do
lateral capsulotomy, on the medial side, we excise the bunion and
remove the exostosis and tighten the capsule. Postoperatively we
may use special pad between the 1st. and 2nd. toes to prevent
recurrence.
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c.
For those above 40 years with failure of the previous
methods we add to the surgery above an osteotomy of the 1st.
metatarsal to correct its alignment. There are different types of
osteotomies as Basal osteotomy, Mitchell’s osteotomy and Willson’s
osteotomy.
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d.
For elderly or osteoarthritic joint we do excisional
arthroplasty by excising the proximal part of the proximal phalanx
(Keller’s operation), this will relieve pain and improve shape and
movement.
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Hallux rigidus
 This is a case of painful rigid stiff 1st. metatarsophalangial
joint due to osteoarthritis secondary to one of the followings:
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Trauma.
Ostoechondritis dissicans of the lst. metatarsal head.
Gout or pseudogout.
The deformity is most common in males in contrast to
hallux valgus.
 Clinically:
 Patient have painful tender joint that is stiff on examination
and disturb the normal walking of the patient because of the
lack of hallux extension.
 The joint is thick and tender with limitation of movement
specially extension.
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 X-ray:
 Show signs of osteoarthritis with narrowing of the joint
space and sclerosis with big osteophytes.
 Treatment:
 To help walking and make it painless we may use a
special (rocker-soled shoe i.e. convex planter aspect of
the shoe) where walking can be completed without the
need for hallux extension.
 If the above is not useful or uncomfortable for the
patient, we can do surgery that is either by replacement
arthroplasty or arthrodesis of the joint in mild extension.
In normal walking, the
big toe dorsiflexes
(extends) considerably.
With rigidusThe usual
cause is OA of the first
MTP joint.
Rheumatoid arthritis of the ankle
and foot:
 The foot is affected as common as the hand and the disease
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pass in its three stages,
1st. stage of synovitis that affects ankle, intertarsal and other
small joints, also affects synovial tendon sheath of different
tendons mainly the tibialis posterior and the peronei.
2nd.stage of erosion of the articular cartilage and
tendons that can be torn.
3rd. stage of severe deformity and dysfunction with the
characteristic deformities of foot valgus, forefoot splaying,
hallux valgus and toe clawing.
There will be lot of planter callosities and dorsal corns that
may get inflamed or infected and sometimes ulcerate.
 Clinically:
 Patient having progressive pain and discomfort with difficulties in shoe
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wear and walking. There is limitation of movements and gradual
development of deformities, callosities and corns.
X-ray: May show the joint erosions and foot deformities.
Treatment:
Special care for shoe wear, rest, and limitation of weight bearing sometimes
by special weight relieving calipers.
Drug treatment according to the stage of the disease like NSAID,
painkillers, disease modifying drugs.. .etc.
Local steroid injection of joints or around tendon sheaths whenever
indicated.
Synovectomy of joints or tendon sheaths.
For seriously deformed foot replacement arthroplasty or joint
arthrodesis.
Ruptured tendo Achillis
 Probably rupture occurs only if the tendon is degenerated.
Consequently most patients are over 40. While pushing off
(running or jumping), the calf muscle contracts; but the
contraction is resisted by body weight and the tendon
ruptures.
 The patient feels as if he has been struck just above the heel,
and he is unable to tiptoe.
 Soon after the tear occurs, a gap can he seen and felt 5 cm
above the insertion of the tendon. Plantar flexion of the foot is
weak and is not accompanied by tautening of the tendon.
 Where doubt exists, Simmonds’ test is helpful: with the
patient prone and foot free out of bed, the calf is squeezed; if
the tendon is intact, the foot is seen to go into planti-flexion; if
the tendon is ruptured the foot is still without any movement.
 Treatment:
 If the patient is seen early, the ends of the tendon
may be approximate when the foot is passively
plantiflexed. If so, plaster is applied with the foot in
equinus and is worn for 8 weeks. A shoe with a
raised heel is worn for a further 6 weeks.
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Operative repair is probably safer, but an
equinus plaster for 8 weeks and a heel raise for a
further 6 weeks are still needed.
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The diabetic foot
 Foot disorders are common in diabetes and result from:
 Peripheral vascular disease causing claudication, trophic changes,
ulceration and even gangrene.
 Neuropathy with sensory and/or motor impairment causing various foot
deformities and possibly charcot joints.
 Osteoporosis, which may be severe enough to lead to fractures.
 Infection, which is an ever-present danger in diabetes.
 Treatment
 The principles of treatment are:
 Proper control of the diabetes.
 Constant and careful attention to the skin and toenails to prevent infection.
 Dry gangrene of the toe can be left to demarcate before amputation; wet
gangrene and infection may call for immediate amputation.
 Charcot joints causing instability may need splintage.
Osteoporotic fractures should be immobilized only until pain subsides. 
Gout arthritis:
 Swelling, redness, heat and exquisite tenderness of
the metatarsophalangial joint of the big toe
(‘podagra’) is characteristic of gout.
 The condition may closely resemble septic arthritis,
but the systemic features of infection are absent. The
serum uric acid level may be raised.
 Treatment with anti-inflammatory drugs will abort
the attack; until the pain subsides the foot should be
rested and protected from injury.
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