Treatment of Infectious Tenosynovitis in the Foot
Prompt diagnosis and treatment of foot infection, including tenosynovitis, is strongly recommended to avoid amputation. 1
Diagnosis
- Signs of infectious tenosynovitis include:
- Local pain or tenderness along tendon sheath
- Periwound erythema
- Edema, induration, or fluctuance
- Purulent discharge
- Foul odor
- Systemic inflammatory response (fever, tachycardia, elevated WBC)
Treatment Algorithm
Step 1: Assess Severity and Need for Surgical Intervention
Urgent surgical consultation is required for:
- Deep abscesses
- Compartment syndrome
- Necrotizing soft tissue infections
- Extensive necrosis or gangrene
- Crepitus or tissue gas on imaging
- Rapid progression of infection
- Pain out of proportion to clinical findings 1
Step 2: Obtain Appropriate Cultures
- Collect tissue specimens (not swabs) from the infected area
- Send specimens promptly to microbiology in sterile containers
- Include clinical information about specimen type and wound location 1
Step 3: Initiate Antimicrobial Therapy
- Start empiric antibiotics based on likely pathogens and infection severity
- For mild to moderate infections:
- Oral antibiotics targeting common pathogens
- Duration: 1-2 weeks 1
- For severe infections:
- Begin with parenteral antibiotics
- Switch to oral therapy when infection responds
- Duration: typically longer based on clinical response 1
Step 4: Surgical Management
- Surgical debridement is essential for most infectious tenosynovitis cases
- Procedures may include:
- Drainage of infected fluid
- Excision of infected and necrotic tissues
- Tendon sheath irrigation
- In severe cases, partial amputation may be necessary 1
Step 5: Post-Surgical Care
- Continue appropriate antibiotics
- Regular wound assessment
- Passive range of motion exercises to minimize adhesions and fibrosis 2
- Off-loading of affected area
Special Considerations
Vascular Assessment
- Assess arterial perfusion early in treatment
- Consider vascular consultation if ischemia complicates the infection
- Urgent vascular intervention for critically ischemic limbs 1
Interdisciplinary Care
For optimal outcomes, involve an interdisciplinary team including:
- Infectious disease specialists
- Surgeons with foot expertise
- Vascular specialists
- Wound care specialists 1
Follow-up and Monitoring
- Monitor for clinical improvement
- Follow inflammatory markers (ESR, CRP)
- For cases involving bone (osteomyelitis), longer follow-up is needed
- Consider remission achieved after 6 months without recurrence 1
Pitfalls and Caveats
- Delay in surgical intervention can lead to irreparable tissue damage
- Diabetes and peripheral arterial disease significantly worsen outcomes
- Presence of both PAD and infection confers nearly 3-fold higher risk of amputation 1
- Unusual pathogens (like mycobacteria) may require specialized cultures and treatment 3
- Bilateral presentation is rare but possible and should not delay treatment 4
Infectious tenosynovitis of the foot requires aggressive management with prompt surgical intervention and appropriate antimicrobial therapy to prevent serious complications including amputation. The combination of early surgical debridement and targeted antibiotics offers the best chance for successful treatment and preservation of foot function.