Foot Pain and Ankle

Anatomie du pied

FOOT OSTEOARTHRITIS:

All joints of the ankle and foot may have a degenerative disease.

Outside of hallux rigidus, primary osteoarthritis is exceptional in the foot. Osteoarthritis is secondary to trauma (fractures, dislocations, sprains with osteochondral fracture) to strain (chronic ankle instability), to primitive static or acquired disorders or destructive arthropathy (inflammatory, infectious, neurological, metabolic, hemophilic, villonodular synovitis).

Talocrural osteoarthritis (tibiotarsal):

She is responsible for the pain circumferential kick or more localized if osteoarthritis is eccentric and is accompanied by a misalignment of the back foot. The pain appears to support implementation. For a long time the talocrural osteoarthritis is well tolerated and is manifested by a feeling of stiffness, from morning stiffness and pain with prolonged walking.

In the decompensated stage the pain can be intense and result in significant functional impairment with a limp from the first steps. The clinic is characterized by slurred ankle, sometimes by a misalignment of the back foot to always seek the patient standing and back, and a limitation roughly equal flexion and extension the ankle. Radiographs show a narrowing of the symmetrically or asymmetrically spaced, periarticular osteophytes, osteosclerosis subchondral geodes intraosseous. A special case is that the ankle footballer who has previous posterior osteophytes and without pinching the talocrural spaced.

Osteoarthritis subtalar (subtalar):

The pain is localized in external sub-ankle, usually at the tarsal sinus and appears when walking on uneven ground.Clinically this Osteoarthritis is characterized by limited mobility valgus and varus of the calcaneus. This mobility limitation may also see if synostose calcanéotalienne or calcaneonavicular, but also in case of post-traumatic foot contractured (the ligament injury in hedge in the tarsal sinus is behind a permanent contracture of muscles peroneal).

The subtalar joint is best explored by the scanner that differentiates a subtalar arthrosis of synostosis.

Osteoarthritis midtarsal:

The pain is localized to the dorsum of the foot and appeared at the place of not, especially on rough ground and running. Clinically pain is accompanied by a limitation of supination movements of the foot. Palpation pain awakens the talonavicular spaced or calcanéocuboïdien. This osteoarthritis is often associated with static foot disorders (piedplat, hollow foot, rearfoot valgus or varus) to be explored on a podoscope and radiographs supported.

Hallux Rigidus:

This is osteoarthritis of the first metatarsophalangeal joint.

It is a primary osteoarthritis without changing deflection axis. The pain appears on the extension of the big toe. The end of the pitch is hampered by pain and limitation of extension of the big toe. The patient adapts by turning the forefoot supination in late with no consequences as the emergence of a callus under the fifth metatarsal head and tightness ligament responsible for radiating pain to the tarsus, neck-depied often and sometimes knee to hip.

Radiographs show a deformed first metatarsophalangeal joint, pinch, sometimes amalgamated. Osteophytes appear at the periphery, especially in its dorsal side may be responsible for a conflict with the shoe.

Treatment:

The treatment of degenerative arthropathy of the foot is primarily medical. It combines medication (simple analgesics, nonsteroidal anti-inflammatory drugs [NSAIDs] short course oral or topical application antiarthrosic slow-acting) to physical measures such as weight loss, maintenance of joint mobility, physiotherapy, the manufacture of insoles, care pedicure and wearing appropriate footwear. Intra-articular injections of corticosteroids have a good analgesic effect but usually transient (not to exceed 3 to 4 injections per year). Surgical treatment is reserved for incapacitating forms.Spinal fusion may be proposed in first intention, in the elderly, if the joint in question is already very enraidie. This fusion is trying to correct the static disorder associated foot and is in a functional position. The ankle prosthesis is reserved for non eccentric talocrurales osteoarthritis in young patients without static disorder of the back foot and without flattening the slope.

In the metatarsophalangeal hallux rigidus silicone prosthesis allows to find good mobility and improve the walking pattern.

PATHOLOGY TENDON:

Achilles Tendinopathy:

The anatomical configuration of the Achilles tendon is responsible for a maximum stresses at a poorly vascularized area between 2 and 6 cm above its insertion. It is the seat of tendinopathy of the body of the tendon.

The Achilles tendon inserts on the middle third of the posterior aspect of the calcaneus. Before insertion, the scholarship subachillea separated from the posterior aspect of the calcaneus. rétrocalcanéennes sliding scholarships separate the greater tuberosity of the calcaneus of the skin. The insertion tendinopathy should not be confused with bursitis subachillea or retrocalcaneal bursitis (conflict with the shoe), although these conditions can coexist especially if disease Haglund (exaggerated projection of the postérosupérieur angle of the calcaneus) .

Diagnostic:

The pain is felt in the posterior aspect of the ankle. The diagnosis is clinical.

The interrogation must specify the topography of pain, the date and mode of appearance, aggravating and relieving factors, the functional impact (scale Nirschl for sports, Box 1). The usual or unusual activity (professional, sporting or leisure), drugs recently consumed are data to be collected systematically.

Box 1. Scale Nirschl
Stage 1. stiffness or pain after moderate physical activity which resolved within 24 hours
Stage 2. stiffness or pain before moderate physical activity that goes to heating: no pain during physical activity; Cold pain recurrence; duration 48 hours
Stage 3. stiffness or pain before moderate physical activity partially yield to warming; minimal pain during physical activity without impact on this activity
Stage 4. Stage 3 + more intense pain with effects on physical activity: moderate pain with life without repercussion
Stage 5. Severe pain before, during and after physical activity need to stop with this activity: everyday pain without great repercussion
Stage 6. Stage 5 + persistent pain despite complete rest: impact on activities of daily living
Stage 7. Stage 6 + nocturnal pain

Examination standing research of static disorders of the lower extremities. Supine, we appreciate the passive dorsiflexion compared to the opposite side. It may be normal, reduced during suroachilléo stiffness of the plantar complex or short Achilles. Passive stretching of the Achilles tendon is often more painful in charge when squatting in shock. The manual resistance is generally insufficient to trigger pain. While standing, it is necessary to perform tests of increasing difficulty to trigger pain (mounted on the tips of two and one foot, jumping jacks). Palpation is an important time. It is done in ventral ulna dice and differentiates the different clinical forms (nodular tendinopathy, paratendinite, insertion tendinitis).

Radiographs looking tendon calcification, ossification of the enthesis or illness of Haglund. Ultrasound and MRI are of interest in case of failure of medical management.

Treatment:

The treatment combines deep transverse massage, stretching the ankle-Achilleo-foot complex, rehabilitation training tendon with particularly eccentric exercises using the methodology of Stanish (Box 2), orthotics, and always correction factors predisposing intrinsic and extrinsic (Boxes 3 and 4).

corticoid infiltrations are against inappropriate.

Mesotherapy which can deliver locally anti-inflammatory is useful in the paratendinite and tendinopathy insertion.Shock waves are a new treatment, the results are still being evaluated. Surgery is indicated in cases of failure of medical management and good conduct sufficiently long (one year). Treatment involves combing allowing excising lesions tendinosis and promote tendon healing with global thickening of the tendon. For low forms, a number of actions can be associated: excision subachillea purse angle resection postérosupérieur calcaneal sickness of Haglund.

Box 2. Functional treatment of tendinopathy by the method of Stanish
Its principle is based on the finding that pulls used to guide tissue healing and stimulate the fibroblasts that synthesize collagen
The eccentric work resulting in more stress on the muscle-tendon-bone unit, the Stanish rehabilitation program is intended to strengthen the tendon so it can withstand the stresses generated by this eccentric work.
Program based on three parameters
stretching
Charge
Speed
Three-part program
Static stretching. Time 15 to 30 seconds. Repeat 3 to 5 times.
eccentric work:
– Increase in speed: slow, days 1 and 2; mean, days 3 to 5; Quick, days 6 and 7
– Increase in load with repetition of progression in speed over a week, 3 sets of 10 exercises per session. Icing late in the session for 10 minutes.
Pain can control the progression of eccentric strengthening:
– If there is no pain caused by eccentric work, there will be no benefit to the tendon
– If the pain is present during the three series, the work is too important to the tendon
– If the program is done correctly, the pain should appear in the latest round of repetition of the exercise

Box 3. Factors predisposing intrinsic tendinopathy
morphological and static disorders: hyperpronation foot, varus foot, flat-foot, valgus / varus, rotational disorder of the lower limbs, lower limbs inequalities
Dyssynergy muscle agonist / antagonist
muscle stiffness
muscle weakness (strength, endurance)
Laxity and joint instability
Overweight
Age, physical condition
metabolic disorders
Drugs (fluoroquinolones, corticosteroids, statins, doping)

Box 4. Factors predisposing extrinsic tendinopathy
Hardware error (old or unsuitable footwear)
technical error (technopathies)
driving errors (progress too fast, too high intensity, excessive distance)
Soil or unsuitable land
Environment

Tendinopathy with fluoroquinolones:

The Achilles tendon is the tendon preferential localization of fluoroquinolones.

They are characterized by their speed of installation, bilateral involvement, and severity of lesions intratendinous with a very high risk of chronicity and tendon rupture even after treatment, short course. Statins may have a toxicity even after a longer exposure time (an average of 4 months).

Rupture of the Achilles Tendon:

The rupture of the Achilles tendon is a therapeutic emergency.

Diagnostic:

The diagnosis is clinical. The inaugural accident is characteristic and allows strongly evoke the diagnosis. The initial violent pain is located in the posterior aspect of the ankle and radiates to the calf. It gives the impression to receive a stone on the tendon or putting a hole in the heel. It can be accompa nied by the perception of a snap or crack by the patient or his entourage. The fall is fickle. Initially functional impairment is total, but quickly the supporting recovery is possible and walking foot is flat with a slight limp due to pain and especially the lack of progress of the posterior half step.

The rise on tiptoes is kept shifting weight the healthy side. The monopod mounted on the injured side is impossible.

Supine, active plantar flexion is retained against strong manual resistance even in case of total rupture (action of the toe flexors, tibialis posterior and longus peroneus), passive dorsiflexion is increased when the injured person is seen early so that it can be reduced by pain later.

Prone feet outside the table, we see two pathognomonic signs:

– A verticalization of the foot side of the break while the healthy side foot has a slight equinus related physiological tone the triceps; the pressure of the muscle of the calf causes no response from the broken hand and a net plantar flexion of the healthy side (sign Thomson).

Palpation allows palpation of a notch in the body of the tendon but which is quickly hidden by edema retromalleolar.

Ultrasound Achilles tendon is useless for the diagnosis of rupture. Its prescription delaying treatment initiation and often wanders the diagnosis speaking of partial rupture as rupture is total.

Treatment:

* Orthopedic treatment:

The protocol of J. Rodineau includes:

– Immobilization in a resin boot foot in varus for 6 weeks without support;

– At the end of the 6th week, making another boot resin: the hindfoot is repositioned at the right angle and less important equine.

Support is authorized under cover of crutches;

– The patient is reviewed every 10 days in order to gradually decrease the equine by successive casts that maintain a certain tension to the tendon. At the end of the tenth week, the boot is removed. The patient walks with raised heels for 2 months and is informed of the risk of recurrent rupture during this period;

– Rehabilitation is started at 12 weeks.

Anticoagulant therapy should be routinely prescribed for the duration of the asset.

Orthopedic treatment avoids hospitalization, anesthesia and local complications of surgical treatment at the cost of longer standstill. It has the major disadvantage that a significant failure rate itérativeplus although strict compliance J. Rodineau protocol has very significantly reduced the frequency. The functional outcome at one year of conservative treatment is comparable to that of surgical treatment.

* Surgical treatment:

It allows a repair under direct vision, a solid mounting and cast immobilization 4 weeks with support. It has the major disadvantage that its local complications (skin necrosis and / or tendon, infection, nerve injury, skin scar).

* Percutaneous Ténorraphie:

The suture is done percutaneously under local anesthesia with appropriate equipment (Tenolig®). Hospitalization is short of two to three days. Sunrise is early without support. At week 2, the progressive support under two canes permitted under control of a physiotherapist with initiation of an assisted active rehabilitation. Full support is authorized to 6 weeks, at which the material is removed.

The ideal indication is the recent breakdown where percutaneous ténorraphie may preferably be chosen, reserving the non-operative treatment to cases where any surgical procedure is disqualified, either by the patient or for special reasons context, local or general. However, any break beyond the 15th day, all iterative rupture or avulsion heel, is an indication of surgical treatment.

Tibialis Posterior tendinopathy (tibialis posterior):

Diagnostic:

The tibialis posterior is the main internal active stabilizer element of the back foot and arch. Its tendon injuries are favored by the constitutional valgus hindfoot, overweight and hyperutilisation.

They are found in athletes (hyperpronateur runner), but also in adults aged sedentary and obese. We distinguish a sliding pathology osteofibrous sheath on the medial malleolus (tenosynovitis), tendinopathy tendon body in its sub malleolar portion and an insertional tendinopathy on the navicular (scaphoid).

The pain is felt on the inner side of the ankle to walking or running. The review on the research podoscope unilateral calcaneal valgus and flat foot for a break-tearing of the tendon. The usual pain was found by passive dorsiflexion valgus and contraction resisted adduction of the foot. Palpation found a swelling on the medial malleolus in case of tenosynovitis and pain below the medial malleolus in case of tendinitis.

Treatment:

The medical care is based on wearing orthotics, deep transverse massage and physiotherapy. The infiltration in the synovial sheath is indicated in cases of tenosynovitis.

We must not infiltrate the tendon in his ankle sub-portion or its insertion.

In case of failure of taking into prolonged medical care well conducted, a tenolysis tendon may be associated proposed, depending on tendinosis lesions, a combing. In case of recent rupture, the tendon must be surgically sutured, while a soustalienne arthrodesis may be proposed in the old forms poorly tolerated.

Crackling tenosynovitis of the anterior surface of the anchor:

Diagnostic:

It affects the tendons of the tibialis anterior (tibialis anterior), the extensor hallucis longus (extensor hallucis longus) and more rarely of the extensor digitorum (extensor digitorum longus) and results in the front of pain ankle walking and climbing stairs. On examination, there is an exquisite pain on palpation of the tendons in the lower third of the leg with the tactile sensation of crepitus during active movements of flexion-extension of the foot. It is caused by repeated dorsal flexion movement of the ankle and is favored by a too tight shoe kick.

Treatment:

It quickly heals with injection into the tendon sheath of one to two mL of prednisolone acetate. Sometimes changes can be made to a tenosynovitis may require surgical release of the tendon.

Syndrome Peroneal:

Diagnostic:

Responsible for pain in the outside of the ankle, the syndrome may be due to an adhesive tenosynovitis, dislocation of the peroneal, longitudinal cracking tendon short or long peroneal, an anatomical abnormality (additional fibers of peroneus brevis , supernumerary muscles or accessories).

Depending on the pathology, pain or sub-retro ankle is accompanied by swelling, a feeling of instability or external snap or most often a combination of these symptoms. Clinical examination shows tenderness and contraction of the peroneal upset, swelling of their sheath, permanent or intermittent luxation, a tactile and audible sensation to jump when they upset contraction. Ultrasound confirms the synovial effusion, highlights thickening or longitudinal cracking, anatomical abnormalities and allows you to view or projection tendon subluxation during dynamic maneuvers.

Treatment:

Treatment of tenosynovitis is medical.

The treatment of recurrent dislocation, cracking and anatomical abnormalities is surgical.

Plantar Fasciitis:

Diagnostic:

It is a micro-traumatic enthesopathy insertion of the plantar fascia of the posterior medial tuberosity of the calcaneus.

With postural disorders of the foot, we must remember as intrinsic predisposing factors, a short Achilles and overweight.

The pain is mostly felt at the sole of the heel in its posteromedial part and more rarely at the arch. It is most often gradual onset. An apparition or sudden worsening associated with cracking or tearing sensation must look for a ruptured plantar fascia. The pain appears standing start. It is aggravated by prolonged walking and running. In the acute phase it may be permanent. Passive tensioning the plantar fascia is rarely painful. The pain is caused by the increasing difficulty of testing (mounted on tiptoe, then a foot, hopping on two, then on one foot). Palpation finds an exquisite point at the posteromedial tuberosity of the calcaneus or just ahead, rarely at the arch.

Plain radiographs are normal or show a heel spur.

The ultrasound, CT or MRI especially clearly show the plantar fasciitis injury but are not required for diagnosis.

Treatment:

The medical care includes a support brace eviction at the posteromedial tuberosity of the calcaneus, deep transverse massage with a wooden stopper, corticosteroid injections, and exercises easing suroachilléo-calcaneus-plantar system. The indication for surgery is rare. It is reserved for aponévrosites plantar rebels continued medical treatment for over a year and breaks the superficial plantar fascia.

STATIC DISORDERS FOREFOOT:

Metatarsalgia:

This is pain in the anterior metatarsal region associated with support Disorders forefoot plantar causing excess stress.When upright, the body weight is distributed evenly in the heel and forefoot. The previous stresses a good spread all metatarsal heads with greater intensity on the first metatarsal which supports a force double that of other heads. A modification of this pressure distribution determines metatarsalgia. This overload of the forefoot may be related to excessive verticalization of the metatarsals relative to the ground as in the hollow foot. The imbalance can be the result of a lack of support at a radius. Most often this is insufficient length of the first metatarsal whether congenital or due to geometric metatarsus varus in cases of Hallux valgus example. This overload causes a loss of flexibility of the footpad when the skin reacts by hyperkeratosis. Secondly the capital fall causes hyperextension of the metatarsophalangeal joint with formation of a toe claw itself generates a dorsal conflict with the shoe.

Diagnostic:

Static metatarsalgia affects mostly women. The chief complaint is the anterior plantar pain occurred gradually mechanical rhythm, aggravated by walking and trampling. The clinical examination involves standing on a study of the progress of morphotype, plantar imprints (podoscope) and laid a search for areas of hyperkeratosis and a study of reducibility deformations. Support foot x-rays are needed to identify problems and to eliminate static differential diagnoses such as osteonecrosis of Freiberg and stress fractures.

Ultrasound research a Morton’s neuroma, bursitis, injury to the plantar plate, joint effusion, flexor tenosynovitis.

Differential diagnosis:

Osteonecrosis of Freiberg:

It is located in a metatarsal head.

It goes very quickly from joint limitation. The X-ray can diagnose formally except at the initial stage where scintigraphy and MRI are essential for diagnosis. The disease progresses to a deformation of the metatarsal head, the release of a foreign body in the joint and ultimately results in a metatarsophalangeal osteoarthritis.

Treatment is usually surgical.

Disease Morton:

It represents the most difficult differential diagnosis of metatarsalgia. Indeed the capitométatarsienne hypertension can cause irritation of the nerve intermetatarsal and deceive for Morton disease.

it frequently is associated with a static disorder of the forefoot. The existence of a Lasegue toe (obtained by traction in the axis of dorsiflexion adjacent toes), hypoesthesia in a “book of sheet” of the two corresponding faces within the space and a vertical pressure-pain space while Intercapital rebound tenderness of the head itself is painless are very suggestive of Morton’s disease and should be investigated by the neuroma ultrasound or MRI. It is more accurate to speak of a pseudonévrome since the injury intermetatarsal nerve is not primitive, it forms part of the ductal pathology.

Treatment:

The treatment of metatarsalgia is primarily medical: behavioral and hygienic measures (weight reduction and abandonment of high-heeled shoes), wearing a foot orthosis fitted with a retrocapital bar, physiotherapy fight against contracture and atrophy plant, tendon and ligament retractions aggravating claws. We can also advise the patient to walk home barefoot exercising gripping toe movements. Podiatry Care on hyperkeratosis zones can help. In the presence of pain intermétatarsiennes by bursitis or pseudonévrome Morton, local corticosteroid infiltration is effective though often temporary. Surgical treatment is indicated in case of failure of good medical management and extended for at least one year. Metatarsalgia surgery involves gestures of soft tissue and bone osteotomy gestures. Neurolysis of intermetatarsal nerve is essential when Morton disease.

Hallux Valgus :

Diagnostic:

It is a misalignment of the first ray characterized by a permanent abduction of the big toe usually coexisting with the permanent supply of the first metatarsal (metatarsus varus). The hallux valgus deformity can be congenital and occur in childhood but in 90% of cases hallux valgus starts between 40 and 50 years and more particularly women (1 man 30 to 40 women) . The acquired form is multifactorial: genetic factors (wide front foot first long toe characteristic of Egyptian foot), wearing certain types of shoes (high heels, pointed toe), menopause that promotes the relaxation of fibrous structures favoring the widening of the forefoot. The hallux valgus can long remain asymptomatic and to form one aesthetic suffering. Then the disease evolves by episodes of pain related to bone projection ( “onion”) or the consequences of the loss of function of the big toe on static forefoot.

Treatment:

Hallux valgus should not be operated preventively.

boot councils, pedicure care, of stretching and massage exercises should be given preventively or to relieve pain debutantes. The insoles port is useful in cases of metatarsalgia.

Surgery is the only treatment that can permanently solve the problem and avoid complications. It is indicated when pain and functional impairment are significant and / or when the deformation is significant.

After an accurate analysis of deformations and their causes, the surgeon adapts individually intervention if necessary by combining several surgical procedures bone or soft tissue.

BONE DISEASE:

Stress fractures predominate in the lower limbs and especially the foot where all the bones can be achieved. The most common sites are in descending order: the calcaneus, metatarsal, navicular bone, the talus, cuboid, sesamoid, cuneiform.

Stress fractures occur in young subjects, in good condition, mostly sportsmen. They are due to repetitive stresses applied to a normal bone. This mechanical overwork leads to osteoclast hyperactivity responsible for bone resorption with a delay of osteoblast reconstruction.

This disorder of bone remodeling temporarily weakens the bone. If the stress continues, microfractures may occur to resorption sites, and develop into macroscopic fractures. This explains the delay pathophysiology radios signs (2 to 3 weeks or longer for the calcaneus and the tarsal bones) and sometimes their negativity when excessive mechanical stress were stopped early.

Diagnostic:

Bone scintigraphy and MRI are sensitive to bone metabolism changes allow early diagnosis stage préfracturaire.

The topography of the pain depends on the bone involved. The onset is gradual and corresponds to an intense physical activity, unusual and repeated. This is a moderate pain, yielding to rest and reappearing at the resumption of the activity. When she continued, the pain increases and appears functional impairment with lameness. The clinical examination is often very poor. It comes down to palpatory signs and sometimes the finding of localized edema in a bone site. Calcaneal pain is caused by the pressure bidigitale of its lateral faces as palpation of the insertion of the plantar fascia is painless as the insertion area of the Achilles tendon (differential diagnosis fasciitis plantar and the insertion tendinitis of the Achilles tendon).

In this location, the stress fracture occurs with spongy tissue on the radio the late appearance of a condensed linear area perpendicular to the trabecular bone. In other locations, the stress fracture interested cortical bone with the radios, the appearance of fine continuity, and a periosteal reaction, a condensation périfracturaire and finally the callus usually hypertrophic during the consolidation phase.

Treatment:

The treatment of foot stress fractures is simple and consists of a landfill respecting indolence for 6 weeks. The resumption of sport depends on the locations but it is rarely possible before 3 months. The prognosis of stress fractures is good except for two locations: the navicular bone and the fifth metatarsal diaphysométaphysaire junction (Jones fracture) where consolidation delays and nonunion are frequent. These stress fractures requiring cast immobilization without support for 6 weeks with a compression screw when moving or among top athletes. Stress fractures should not be confused with insufficiency fractures or pathologic fractures, neighbor mechanism, but which occur on a bone weakened by rarefying osteopathy (osteoporosis, osteomalacia), or malignancy. The insufficiency fractures mainly concern the calcaneus and the central metatarsals. Treatment is the same as stress fractures by involving treatment of osteopathy.

CANAL SYNDROME TARSAL:

It is rare. Its frequency can be compared with that of his counterpart in the upper limb, the carpal tunnel syndrome.

Diagnostic:

Patients consult for pain and paresthesias in the territory of the plantar nerves, usually limited to 2 or 3 toes.

Sometimes there is an upward irradiation. Symptoms are often nocturnal and exacerbated by efforts (walking, prolonged standing, sports). Sometimes found sensory disorders objectives for the exam, but the motor signs are exceptional. Palpation search swelling and internal retromalleolar a sign of Tinel. The electromyogram is essential to confirm the diagnosis.

Compression of the tibialis nerve in the tarsal tunnel may fall under several etiologies: tumor (cyst, neuroma, lipoma), tenosynovitis, muscle supernumerary, static foot disorders, or idiopathic dilated veins.

Treatment:

The treatment is surgical outset for tumor compressions. In all other cases the surgical treatment will be considered after failure of medical treatment (correction of static disorders, corticosteroid infiltration).

DIABETIC FOOT:

One gathers under the name “diabetic foot”, vascular and neurological manifestations complicating diabetes and affecting the foot. The perforating is the most usual form. This is a painless chronic skin lesion, favored by external causes (inadequate footwear, pedicure gestures, or inappropriate hygiene behavior). An estimated 60% of amputations could be avoided by better information for diabetics.

Prevention is essential, both to avoid the appearance of a wound, only to limit the amputation when unfortunately necessary: prevention of many even minimal trauma (especially with shoes), training for effective daily hygiene , quick reference even for small signs of benign appearance and glycemic control.

INFLAMMATORY FOOT:

Main causes:

Psoriatic arthritis has a predilection for the foot with both lesions that destroy and others who build, affecting as much the forefoot the back foot.

In rheumatoid arthritis, the achievement of the foot is early and predominates to the forefoot.

The lesions are bilateral and symmetrical.

A heel pain the young man who is more bilaterally symmetrical, is a guidance element to a spondyloarthropathy.

Medical treatment of these disorders is covered in Chapter polyarthralgia.

Drop:

Gout is the articular disease caused by uric acid overload of the body.

Acute gout starts in 65% of cases of acute arthritis of the metatarsophalangeal joint of the big toe and more rarely, an arthritis médiotarse or by Achilles tendinitis.

Diagnostic:

It holds for the diagnosis: often nocturnal sudden onset, intense local inflammatory phenomena, evolutionary mode (unprocessed access evolves by a succession of nocturnal exacerbations and diurnal partial sedation with complete healing in 6 to 10 days ), the dramatic effectiveness of colchicine especially since it is administered early, the context (obese male subject, and good living, family history of gout or uric stones in the primitive drop of adults the existence of renal failure, hematological malignancy or diuretics taken in secondary drops) and the results of laboratory tests (blood inflammatory syndrome without specificity, synovial fluid containing leukocytes, over 50 000 / mL, with over 90% neutrophils, the presence in the microcrystals of liquid sodium urate). The normal serum uric acid may be in or near the crisis makes it essential renewal of the assay.

Treatment:

Treatment of acute attacks of gout:

He understands :

– Immobilization of the joint and glazing;

– Evacuation of the effusion when possible;

– Anti-inflammatory drugs administered as early as possible.

Colchicine (Colchicine®; Colchimax® combines colchicine antidiarrheal) is dosage:

– 3 mg on day 1 in 3 doses at 8 hours apart;

– 2 mg on days 2 and 3, in 2 doses, 12 hours apart;

– 1 mg / d the following days, until recovery from the crisis.

Diarrhea, nausea and vomiting are the early signs of overdose and require reducing the dose or stopping treatment sometimes. Allergic accidents are rare, exceptional haematological accidents.

Severe kidney or liver failure are cons-indications to colchicine.

The Colchimax® is against-indicated in cases of BPH and glaucoma

NSAIDs should only be used in case of intolerance to colchicine.

Glucocorticoids are not indicated.

Treatment of hyperuricemia:

In the absence of an effective treatment hypouricaemic, settled insidiously chronic gouty arthropathy and subcutaneous tophi. Plain radiographs show destructive lesions characteristic (or epiphyseal geodes notches image halberd) and builders (spiky appearance of the back of the foot). Achieving cartilage is late.

Tophi form swellings sub-cutaneous that localize to the Achilles tendon and the dorsal surface of the toes.

We must first limit any risk factors of hyperuricemia: overweight, dietary intake of purines, the protein hyperalimentation, alcohol and all hyperuricémiants drugs (thiazide diuretics, salicylates, ethambutol, pyrazinamide, cyclosporine) should be removed.

Diuresis cure (daily intake of two liters of water) aims to promote the urinary excretion of uric acid.

The urate-lowering drugs used are:

– Allopurinol (Zyloric®), a uricofreinateur by inhibiting xanthine oxidase. The starting dose is 300 mg per day to maintain serum uric acid below 300 micromoles (50 mg) per liter. It can be used in cases of kidney failure, but the dosage should be adjusted to the clearance of creatinine.

Adverse effects are sometimes of serious cutaneous hypersensitivity syndrome, aplastic anemia, acute gout, hepatitis.

Some drug combinations should be avoided: azathioprine (hematological toxicity), ampicillin and amoxicillin (allergic dermatitis), vidarabine (neurological disorders), vitamin K (coagulation disorders);

– Rasburicase, recombinant urate oxidase, uricolytic extremely powerful indicated for the treatment of hyperuricemia induced by chemotherapy. It is administered at a dosage of 0.2 mg / kg / d for 5 to 7 days;

– Note: uricosuric are no longer available.

The urate-lowering therapy should be started after at least 2-3 articular crises and 2 to 3 weeks after recovery of gout.Prophylactic treatment with colchicine, at 1 mg / day, is maintained for 2 to 3 months.