Title: Common Foot Problems
1Common Foot Problems
- Garrett Post, MD
- PGY-2
- Emory Family Medicine Residency Program
- March 20, 2008
2Common Foot Problems
3 Anatomy - Bones
4Anatomy - Bones
5 Anatomy - Vascular
6Anatomy -Nervous
7Anatomy -Nervous
8Anatomy - Musculoskelatal
9Anatomy - Musculoskelatal
- Where does the Achilles tendon derives its name?
- Hint
10Greek Mythology
- Thetis tried to immortalize Achilles by dipping
him into the sacred river Styx. - What sign is indicative of an Achilles
- tendon rupture?
11Greek Mythology
- Thetis tried to immortalize Achilles by dipping
him into the sacred river Styx. - What sign is indicative of an Achilles
- tendon rupture? Thompsons sign
12What is wrong with my Foot?!?
- Fungal and Bacterial Conditions
- Corns and calluses
- Warts
- Bunions
- Ingrown toenails
- Hammer toe
- Spurs
- Plantar Fasciitis
- Ankle Sprain
- Mortons Neuroma
- Post-tib Tendinitis
- Sesamoiditis
- Shin Splints
- Tarsal Tunnel Syndrome
- Metatarsalgia
- Excessive Pronation
- Excessive Supination
- Achilles tendinitis
- Gout
13What is wrong with my Foot?!?
- Mortons Neuroma
- Post-tib Tendinitis
- Sesamoiditis
- Shin Splints
- Tarsal Tunnel Syndrome
- Ingrown toenails
- Excessive Pronation
- Excessive Supination
- Achilles tendinitis
- Gout
- Fungal and Bacterial Conditions
- Corns and calluses
- Warts
- Bunions
- Metatarsalgia
- Hammer toe
- Spurs
- Plantar Fasciitis
- Ankle Sprain
14Bunions - Hallux Valgus
15Bunions - Hallux Valgus
Not so much good luck But you can cross them
anyway.
16Bunions - Hallux Valgus
- NOT likely from high heel shoes (Myth)
- High heels may exacerbate the underlying etiology.
17Hallux Valgus
- Affects 1 of adults in the US. (National Health
Interview survey by the National Center for
Health Statistics) - Incidence increased with age
- 3 15-30 years
- 9 31-60 years
- 16 gt 60 years
- Female to Male ratio - 21 to 41
- The role of genetic predisposition has also been
noted, with evidence to suggest familial
tendencies. - Gould et al., 1980 1
18Hallux Valgus - Etiology
- Biomechanical instability
- Most common
- Difficult to understand and evaluate
- Genetically inherited and/or from underlying
conditions
19Hallux Valgus - Etiology
- Arthritic/metabolic conditions
- Gouty arthritis
- Rheumatoid arthritis
- Psoriatic arthritis
- Connective tissue disorders such as Ehlers-Danlos
syndrome, Marfan syndrome, Down syndrome, and
ligamentous laxity
20Hallux Valgus - Etiology
- Neuromuscular disease
- Multiple sclerosis
- Charcot-Marie-Tooth disease
- Cerebral palsy
- Traumatic compromise
- Structural deformity i.e. Abnormal metatarsal
length
21Bunions - Hallux Valgus
22Bunions - Pathophysiology
- Hallux and digits generally remain parallel to
the long axis of the foot. - Medial tension causes the medial collateral
ligaments to pull on the dorsomedial aspect of
the first metatarsal head, causing the bone to
proliferate. - Lateral tension causes the sesamoid apparatus to
fixate in a laterally dislocated position. - Remodeling (bone and cartilage) occurs laterally
and medially. - Without correction of the biomechanical etiology,
excessive pronation continues, with propagation
of the deformity.
23Presentation
- Hallux position
- Medial prominence
- First metatarsophalangeal joint ROM
- First ray ROM
- Plantar keratosis
- Pain location
- Contracture of the extensor hallucis longus
- Associated deformities
24Evaluation Labs and XRay
- Uric acid, ESR, CRP, ANA, RF
- Foot AP, Lat, and Oblique
25Staging
- Stage 1 - excessive pronation causes
hypermobility of the first ray, causing the
tibial sesamoid ligament to be stretched and the
fibular sesamoid ligament to contract, and
lateral subluxation of the proximal phalanx
occurs. - Stage 2 - hallux abduction progresses, with the
flexor hallucis longus and flexor hallucis brevis
gaining lateral mechanical advantage. - Stage 3 - further subluxation occurs at the first
metatarsophalangeal joint, with formation of
metatarsus primus adductus. - Stage 4 - the first metatarsophalangeal joint
finally dislocates.
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27Hallux Valgus - Treatment
- Medical therapy
- Adapting footwear
- Pharmacologic or physical therapy
- Functional orthotic therapy
- Activity
- Weight
- Top cover
- Biomechanical examination
- Modifications - cushions
- Surgical therapy
28Look good and feels good.
29Recovery
- Six months to full activity
- Best to take 2 weeks off and elevate leg
- Ice popliteal fossa for 1 week postoperatively to
reduce swelling - Ambulating in 2 weeks
- Pain free without strenuous exercise at 3-5 weeks
30Heel Pain
31Plantar Fasciitis
- In US5
- 10 of runner-related injuries
- 11-15 of all foot symptoms requiring
professional care - 10 - general population
- Presents bilaterally 1/3 cases
- Race and ethnicity play no role in the incidence
- Peak incidence may occur in women aged 40-60
years.
32Plantar Fasciitis
- A thickened fibrous aponeurosis
- Originates from medial tubercle of the calcaneus
- Runs forward to insert into the deep short
transverse ligaments of the metatarsal heads - Continues forward to form the fibrous flexor
sheathes on the plantar aspect of the toes - Central plantar fascia is the thickest and
strongest section, and most likely to be involved
with plantar fasciitis. - Function - provide static support for the
longitudinal arch of the foot and to assist with
shock absorption during foot strike (2-3 times an
individual's body weight with each step).
33Plantar Fasciitis - Pathophysiology
- Increased risk
- pes planus (low arches or flat feet)
- pes cavus (high arches)
- Pain - collagen degeneration associated with
repetitive microtears of the plantar fascia. - Common h/o increase in weight-bearing activities
causing the microtears exceeding healing
capacity. - Elderly biomechanical (functional and
degenerative factors)
34Plantar Fasciitis - Etiology
- Extrinsic risk factors
- Training errors
- Overuse Most common
- Equipment
- Intrinsic risk factors
- Structural risk factors
- Overpronation, discrepancy in leg length,
excessive lateral tibial torsion and excessive
femoral anteversion - Functional risk factors
- Tightness or weakness of soleus, gastrocnemius,
Achilles tendon and intrinsic foot muscles. - Degenerative risk factors
- Poor intrinsic muscle strength and poor force
attenuation secondary to acquired flat feet and
compounded by a decrease in the body's healing
capacity
35Plantar Fasciitis - Symptoms
- Intense sharp heel pain with the first couple of
steps in the morning. - Pain is anterior aspect of the calcaneus, but may
radiate proximally in more severe cases. - Dull ache in the heel at the end of the day,
especially after extensive walking or standing.
36Plantar Fasciitis - Physical Exam
- Point of maximal tenderness at the anteromedial
region of the calcaneus. - Pain along the proximal plantar fascia.
37Plantar Fasciitis - Physical Exam
- "windlass" test - Passive dorsiflexion of the
toes which elicits Sx pain - Having the patient bear weight during the
windlass test increased the sensitivity of the
test from 13.6 to 31.8 (De Garceau, 2003) 9
38Plantar Fasciitis - Treatment
- Correcting training errors by
- relative rest
- ice after activities
- evaluation of the patient's shoes and activities
- Correction of biomechanical factors by
- stretching and strengthening program (PT)
- Then, consider night splints and orthotics
- Finally, other treatment options are considered.
- NSAIDs are considered throughout the treatment
course for pain control. - Time for resolution - often 6 to 18 months.
39Plantar Fasciitis - Treatment
- Iontophoresis Electric stimulation
- Use of electric impulses from a low-voltage
galvanic current stimulation unit to drive
topical corticosteroids into soft tissue
structures. - Corticosteroid Injections
- Greatest benefit if administered early
- Studies7,8 have found steroid treatments
successful 70 or better - Potential risks
- rupture of the plantar fascia
- fat pad atrophy.
- Autologous blood injections
- Ignites the healing process
- Surgery
- Success rate of surgical release is 70 to 90
- Potential risks
- flattening of the longitudinal arch
- heel hypoesthesia.
40Ankle Sprain
- Common site for acute musculoskeletal injuries.
- Sprains 75 of ankle injuries
- Acute ankle trauma 10 to 30 of sports-related
injuries in young athletes - Estimated 1 million persons present with acute
ankle injuries - gt40 ankle sprains have potential to cause
chronic problems
41Ankle Sprain
42Ankle Sprain
43Ankle Sprain
- Anterior drawer test - assess the integrity of
the anterior talofibular ligament - Inversion stress test - assess the integrity of
the calcaneofibular ligament
44Ankle Sprain
- Grade I partial tear of a ligament
- Mild tenderness and swelling
- Slight or no functional loss (i.e., patient is
able to bear weight and ambulate with minimal
pain) - No mechanical instability (negative clinical
stress examination) - Grade II incomplete tear of a ligament, with
moderate functional impairment - Moderate pain and swelling
- Mild to moderate ecchymosis
- Tenderness over involved structures
- Some loss of motion and function (i.e., patient
has pain with weight-bearing and ambulation) - Mild to moderate instability (mild unilateral
positivity of clinical stress examination) - Grade III complete tear and loss of integrity of
a ligament - Severe swelling (more than 4 cm about the fibula)
- Severe ecchymosis
- Loss of function and motion (i.e., patient is
unable to bear weight or ambulate) - Mechanical instability (moderate to severe
positivity of clinical stress examination)
45Ankle Sprain
- Grades I or II sprains
- Accurate early diagnosis
- RICE (rest, ice, compression and elevation)
- Maintenance of ROM - Functional Rehabilitation
- Ankle support
- Grade III
- Early motion and mobility are recommended
- Ligamentous strength returns months after injury
delayed functional rehab - May require surgical intervention
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47Ottawa ankle and foot rules
- XR ankle indicated if
- pain in the malleolar zone and
- any of these findings
- bone tenderness at A,
- bone tenderness at B or
- inability to bear weight immediately and in the
emergency department. - pain in the midfoot zone and
- any of these findings
- bone tenderness at C,
- bone tenderness at D or
- inability to bear weight immediately and in the
emergency department. - Sensitivity 100 for malleolar fractures (95
percent confidence interval CI range 82 to
100) - Sensitivity 100 for midfoot fractures (95
percent CI range 95 to 100) 6
48Ankle Sprain
- Sx more than six weeks CT or MRI to rule out
talar dome lesions
49Ingrown toenails
- Etiology4
- Inheritance - genetically predisposed inwardly
curved nails with distortion of one or both nail
margins - Underlying bony pathology causing deformation of
the nail - Obesity fat feet - deepening of the nail groove
- HIV antiviral therapy - increased incidence of
ingrown nails - Prior trauma - irregularly shaped nail
50Ingrown toenails
- Stage 1
- erythema,
- slight edema, and
- pain with pressure to the lateral nail fold.
51Ingrown toenails
- Stage 2
- increased symptoms,
- drainage, and
- infection.
52Ingrown toenails
- Stage 3
- magnified symptoms,
- granulation tissue, and
- lateral nail-fold hypertrophy.
53Ingrown toenails - Management
- Stage I
- Warm soaks
- Cotton-wick elevation of the affected nail corner
- Antibiotic therapy in the presence of infection
- Taping
- Stage II
- Partial nail avulsion (successful rate 30 per
Zuber 2)
54Ingrown toenails - Management
- Stage III (Remove and Debride)
- Debridement (debulking) of the lateral nail
groove - Silver nitrate cautery to the hypertrophied
lateral nail - Complete nail avulsion
- Wedge resection of the distal nail edge
- Partial nail avulsion with
- Phenol (inaccurate), Sodium hydroxide, Laser
(expensive), or Electrosurgical (new)
matricectomy - Surgical excision of nail plate, nail bed, and
matrix
55References
- Gould N, Schneider W, Ashikaga T Epidemiological
survey of foot problems in the continental United
States. 1978-1979. Foot Ankle 18, 1980 - Zuber T. Ingrown Toenail Removal. American Family
Physician. June 15, 2002. - Cole C, Seto C, and Gazewood J. Plantar
Fasciitis Evidence-Based Review of Diagnosis and
Therapy. American Family Physician. December 1,
2005. - Noronha PA, Zubkov B. Nails and nail disorders in
children and adults. Am Fam Physician. May 1
199755(6)2129-40. - Young C, Rutherford D, Niedfeldt M. Treatment of
Plantar Fasciitis. American Family Physician.
February 1, 2001. - Stiell IG, McKnight RD, Greenberg GH, McDowell I,
Nair RC, Wells GA, et al. Implementation of the
Ottawa ankle rules. JAMA 1994271827-32. - Kane D, Greaney T, Bresnihan B, Gibney R,
FitzGerald O. Ultrasound guided injection of
recalcitrant plantar fasciitis. Ann Rheum Dis
199857383-4. - Furey JG. Plantar fasciitis. The painful heel
syndrome. J Bone Joint Surg 197557672-3. - De Garceau D, Dean D, Requejo SM, Thordarson DB.
The association between diagnosis of plantar
fasciitis and Windlass test results. Foot Ankle
Int. Mar 200324(3)251-5.