Practical Management of Common Foot Problems Putting Your Best Diagnostic Foot Forward

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Practical Management of Common Foot
ProblemsPutting Your Best DiagnosticFoot Forward

• Hassan El Shahaly, MD
• Professor of Rheumatology and Rehabilitation
• Suez Canal University

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Bones of the Foot
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OA 1st MTP with hallux valgus andbunion
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Early OA of 1st MTP joint

• Non-uniform
• narrowing
• Subchondral
• sclerosis
• Osteophytes

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Moderate OA of 1st MTP joint

• Soft tissue swelling
• Non-uniform
• narrowing
• Subchondral
• sclerosis
• Osteophytes
• Hallux valgus

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Advanced OA of 1st MTP joint

• Non-uniform
• narrowing
• Subchondral
• sclerosis
• Large
• osteophytes
• Hallux rigidus

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Acute Gout 1st MTPsodium urate

• Radiological pattern

• Clinical spectrum

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Gout
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Acute Pseudogout 1st MTPcalcium pyrophosphate
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Acute Calcific Periarthritis 1st
MTP(Hydroxyapatite)
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Tophaceous Gout 1st MTP
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Gout tophi, ear
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Septic Bone Disease of Big Toein Diabetes
Mellitus
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RA Synovitis MTPs
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METATARSALGIA
H.shahaly
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RA MTP joints
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RA MTP Joints
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RA X-ray MTPs -1997
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RA X-ray MTPs -2003
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RA X-ray MTPs -2007
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X-ray MTPs in 2009
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Psoriatic arthritis feet (radiograph)

• Erosions
• Osteolysis
• DIP joints
• to lesser
• extent PIP
• joints

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Psoriatic arthritis progressive joint changes
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Arthritis mutilans
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SEVERE EROSIONS AND CYSTS OF DIP
JOINTS
MARGINAL EROSIONS
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Reactive arthritis foot at end stage
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CUTANEOUS MANIFESTATIONS

• CIRCINATE BALANITIS
• KERATODERMA BLENORHAGICA
• Severe keratotic lesions

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Freibergs disease (osteochondritis)infarction
3rd MT head
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Dactylitis
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Psoriatic Arthritis Dactylitis
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SAUSAGE SHAPE TOES DACTYLITIS
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RA Deformities of midfoot

• Ankle valgus
• Insufficient post tib on RT side
• Pes planus
• H valgus
• Rt midfoot ext rotation
• Forefoot midfoot
• valgus on R
• R hammer toes L cockup toes

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MRI Foot (T2 Sagittal)Ganglion
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X-ray Foot Diabetic neuropathicarthropathy
(Charcot joints) infected ulcer
Mixture between severe destruction and new bone
formation with joint degeneration
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Heel examination

• examination of insertion of planter fascia
• Insertion of tendo achilles
• Body of tendo achilles

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Achilles tendinitis
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Tuberculous peri-tendinitis
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Achilles tendon thickened due torepetitive
microtrauma of sport
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RA nodules in Achilles tendon
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Tophus in tendo-achilles
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Hyperlipidemia type 4 xanthomataAchilles tendons
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Reactive arthritis enthesitisorigin of plantar
fascia
Erosion New
bone formation
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ENTHESOPATHY OF RS
RETROCALCANEAN EROSION
PERIOSTEAL Rx CALCANEAN SPUR
ACHILLES TENDINITIS
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Ankylosing Spondylitis enthesitis at Achilles
insertion and at plantar fascia origin
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Swelling and pain

• Ankle

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CT Scan Normal Ankle
Coronal Bones Joints
Coronal Tendons
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RA Synovitis ankle, midfoot andposterior tibial
tendon
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RA Posterior Tibialis Tenosynovitis
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RA Anterior tibialis tenosynovitis
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Deformity in RA
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Crescent sign rupture poplitealcyst in RA
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POPLITEAL CYST (BACKERS CYST)
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Septic arthritis ankle (Gonococcal)
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Acute Sarcoidosis
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Difference between edema and synovitis

• Synovitis

• edema

• Warmth, erythema, tenderness
• Pain at extremes of joint range of Movement

• Pitting without tenderness
• Swelling over the medial and/or lateral malleolus

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Edema
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Synovial rupture ankle joint
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Hypertrophic osteoarthropathy

• Periostitis of
• metatarsals and proximal phalanges
• Clubbing
• Arthritis
• Bronchogenic carcinoma

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Migratory regional osteoporosis ofthe foot
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Reflex sympathetic dystrophyof foot

• Painful, tender,swollen, purplish, cool foot
  after Surgery of the foot

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Diffusely painful-not swollenfoot

• Vasculopathy
• Neuropathy
• Tarsal tunnel syndrome
• Referred pain
• Osteomalacia

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Conclusion

• Foot is a major source of challenging clinical
  problems
• Anatomical diagnosis is the easiest way to catch
  the diagnosis
• Foot syndromes can be isolated or part of
  clinical syndrome.
• Based on proper diagnosis teamwork management
  is mandatory to solve foot problems.

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THANK YOU
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Welcome to EGYRAR 200930th of septmber till 3rd
of October, 2009
Mediterranean Azure Hotel- Alexandria
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EGYRAR 2009