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Podiatric Update, 2005

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Title: Podiatric Update, 2005


1
Podiatric Update, 2005
  • William N. McCann, DPM
  • Concord, New Hampshire

2
Common Foot Deformities
  • Orthopedic
  • Heel Pain ESWT (Heel Lithotripsy)
  • Neurologic
  • Dermatologic
  • Diabetes-related foot and ankle ailments

3
Orthopedic Conditions
  • Hammertoe
  • Hallux valgus (bunion)
  • Hallux limitus/rigidus (osteoarthritis)
  • Sports medicine related injuries
  • Plantar Fasciitis

4
Hammertoe
  • Digital Contracture
  • Usually PIPJ
  • May have MPJ dorsiflexion
  • May have clavus
  • Pre-ulcerative in patients with diabetes

5
Hammertoe Treatment
  • Debridement
  • Padding
  • Shoe gear change
  • Surgery as a last option

6
Hallux Valgus
  • Painful bump secondary to increase IM angle
  • Poor biomechanics
  • Hurts in shoes
  • Usually bump pain vs. joint pain
  • Wider shoes help
  • Orthotics may slow or stop progression and pain

7
Osteoarthritis
  • Usually at first MPJ
  • Hallux limitus/rigidus
  • Poor biomechanics
  • Painful to walk

8
Osteoarthritis Treatment
  • Cortisone injection
  • Physical therapy
  • NSAIDS
  • Orthotics
  • Surgery

9
Ankle - Foot Orthosis
  • Articulated hinge device
  • Used when functional orthotic fails or will fail
  • For active patient that can tolerate motion
  • Excellent for sports

10
Ankle Foot Orthosis
  • Gauntlet (Arizona) style for total control
  • For patients that cannot tolerate motion
  • Good for severe DJD and Charcot foot

11
Time wounds all heels!
12
Plantar Fasciitis
  • Inflammation and pain of the plantar fascia,
    usually at its insertion at the plantar medial
    tubercle of the calcaneous
  • Becomes chronic in 5-10 of all patients
  • Is not necessarily associated with a heel spur

13
Plantar Fasciitis Incidence
  • 14 of foot disorders due to heel pain each year,
    (2.5 million pts)
  • Up to 20 of population presenting to healthcare
    providers specializing in foot and ankle
    disorders

14
Heel Pain Etiologies
15
Plantar Fasciitis Risk Factors
  • High body mass index
  • Tight Achilles tendon
  • Inappropriate footwear
  • Biomechanical abnormalities
  • Work Surface
  • Minor Trauma

16
Plantar Fasciitis Symptoms
  • Weight-bearing pain on arising
  • Pain subsides, returns with activity
  • Footwear related to pain?

17
Plantar Fasciitis Diagnosis
  • Pain on palpation
  • Antalgic gait
  • Pes planus
  • X-ray
  • Ultrasound

18
Plantar Fasciitis Treatment
  • Gastrocsoleas Stretching
  • RICE
  • Change shoes
  • OTC inserts
  • Nocturnal Anti-contracture Devices

19
Plantar Fasciitis Treatment
  • Low Dye Strap
  • Custom fabricated orthotics
  • NSAIDS
  • Cortisone shot(s)
  • Physical Therapy
  • Plantar Fasciectomy

20
Extracorporeal Shock Wave Therapy ESWT

21
ESWT
  • Heel Lithotripsy
  • Surgical alternative
  • 48-81 effective in preliminary studies
  • 3 months until significant relief in most
    patients
  • Few complications
  • Theodore G, et.al Extracorporeal Shock
    Wave Therapy for the Treatment of Plantar
    Fasciitis, Foot and Ankle International 25290,
    2004

22
Theories Of Action
  • Shock causes release of neuro enzyme effecting
    nociceptor
  • Analgesic Affect
  • Multiple micro trauma promotes neo-vascularization
  • Action is similar to tenderizing meat

23
Types Of Shockwave Emitters
Disposable costs No
Disposable Crystals Anesthesia
Local
Multi-treatments Mid - High Energy
Low - High Energy Low Energy
24
Electro-Magnetic Shock Wave Emitter
  • Highest U.S. available shock wave intensity
  • Versatile power range
  • Consistent energy shock to shock
  • Ultrasound targeting
  • Multi-positional shock head
  • Easily transportable

25
Shock Wave Focus
Level 1
Level 5
Level 9
As Power Levels Increase Length of Focus
Decreases Width Increases
26
Ultrasound Targeting Shockwave Focus
Ultrasound Transducer
Shock head coupled to medial aspect of foot
Focus Diameter Focus Length
27
Ultrasound Targeting Shockwave Focus
Ultrasound Transducer
Direction of Sound Beam
Ultrasound Image Display
The ultrasound transducer is placed on the
plantar aspect of the foot. The sound waves
penetrate the foot directly off the surface of
the transducer, almost like shining a flash light
beam
28
Ultrasound Targeting Shockwave Focus
The plantar fascia is displayed as a band on dark
echoes with a white reflector on each side,
wrapping over the calcaneus to the point of
insertion.
Calcaneus
29
ESWT Single Treatment Overview Plantar Fasciitis
  • Local Anesthesia block - Posterior Tibial/Sural
  • Total therapy - 3,800 shockwaves
  • Total energy delivered - 1,300 mJ/mm2
  • Average treatment duration - 21 minutes
  • Return to normal activity - 24 hours

30
ESWT Plantar Fasciitis Protocol
Energy Level Frequency of Shocks Level 1
60 50 Level 2 90
50 Level 3 120 50 Level 4 150
50 Level 5 180 50 Level 6 210
50 Level 7 240 3,500 Total 3,800 or
1,300mJ/mm2
31
Clinical Outcomes
Plantar Fasciitis 70 - 80 Success Europe 60 -
65 Initial Success, FDA Trials Complication
rate lt1 Most commonly reported 1. Minor
Bruising 2. Transient Numbness
32
Clinical Outcomes
  • 150 patients enrolled in a multicenter,
    randomized, placebo-controlled, prospective,
    double-blinded study on ESWT effectiveness
  • Electromagnetic shock wave emitter
  • 2 years mean symptom duration
  • Multiple evaluation methods

33
Clinical Outcomes
  • Active group reported 56 success at 3 months
    posttreatment and 94 at 12 months posttreatment
  • Control group reported 47 success at 3 months
    posttreatment
  • Control group was unblinded at 3 months and
    offered treatment
  • Theodore G, et.al Extracorporeal Shock Wave
    Therapy for the Treatment of Plantar Fasciitis,
    Foot and Ankle International 25290, 2004

34
Neurologic Conditions
  • Neuroma
  • Cutaneous Nerve Entrapment
  • Neuropathy
  • Tarsal Tunnel Syndrome

35
Mortons Neuroma
  • Painful swelling of the interdigital nerve
  • Most commonly seen in third web space
  • Patients can feel numbness of adjacent digits and
    plantar pain
  • Etiology is abnormal stretching of the nerve

36
Mortons Neuroma Differential Diagnosis
  • Stress fracture
  • Callus
  • Freiberg's infraction
  • Capsulitis
  • Bone tumor
  • Local manifestation of systemic disease

37
Mortons Neuroma Treatment
  • Change shoe gear
  • Padding
  • Orthotic
  • Cortisone injection
  • 4 dehydrated alcohol injection for neurolysis
  • Surgical excision
  • Dockery G The Treatment of Intermetatarsal
    Neuromas with 4 Alcohol Sclerosing Injections, J
    Foot Ankle Surg 38(6) 403, 1999

38
Dermatologic Conditions
  • Onychomycosis
  • Paronychia
  • Verucca
  • Tinea Pedis

39
Onychomycosis
  • Dermatophyte
  • Often seen with skin manifestations
  • Usually acquired but may be inherited
  • More treatable than in the past
  • Differentiate from Melanoma

40
Onychomycosis Treatment
  • Debridement
  • Topical
  • Oral antifungals
  • PAS Stain for differential diagnosis
  • Matrixectomy

41
Paronychia
  • Erythema and edema of the ungual labia
  • Wide or incurvated nail plate
  • May drain serous to purulent exudate
  • Hallux most effected

42
Paronychia Treatment
  • Incision and Drainage
  • Oral antibiotics usually not necessary
  • Longstanding infection may require X-ray
  • Chemical matrixectomy, partial or total

43
Verruca?
44
Verruca!
  • Human Papilloma Virus (HPV)
  • Contagious
  • Usually plantar on foot

45
Verruca Treatment
  • Debridement is diagnostic and therapeutic
  • Chemocautery
  • Imiquimod 5 cream hs
  • Oral Cimetidine for pediatric usage (30-40Mg/Kg
    in 3 divided doses)
  • Curretage

46
Diabetes Related Foot and Ankle Conditions
  • Neurotrophic Ulcers
  • Neuropathy
  • Charcot Foot

47
Diabetic Ulcer
  • Etiology is usually traumatic caused by shoes
  • Bony promonence is usually involved (hammertoe,
    bunion, plantarflexed metatarsal, bone spur)
  • Often start as a blister, corn or callous

48
Diabetic Ulcer
  • Focal pressure keratosis with accompanying risk
    factors are the major cause of ulcer.
  • Patients who have regular, frequent foot clinic
    visits that include risk evaluation, debridement
    of lesions, prescription of appropriate shoes and
    patient education are less likely to ulcerate. 1
  • 1 Sage RA, Webster JK, Fisher SG Outpatient Care
    and Morbidity Reduction in Diabetic Foot Ulcers
    Associated with Chronic Pressure Callus. JAPMA
    91275, 2001.

49
Diabetic Ulcer Treatment
  • Always obtain serial X-rays to rule out
    osteomyelitis
  • Debride the wound to granular bed
  • Remove hyperkeratosis
  • Gently probe wound for deep sinus
  • Dress initially with sulfur silvadiazene cream or
    saline wet-to-dry dressings
  • Consider other wound products
  • Consider offloading

50
Charcot Joint
  • Diabetic Neuroarthropathy
  • Often involves both pathologic dislocation and
    fracture
  • Usually effects midfoot, but all lower extremity
    joints are susceptible
  • Foot is acutely edematous and warm
  • Deformity is common

51
Charcot Joint Treatment
  • Non-weight bearing for 12 weeks
  • Patient education is critical to outcome
  • Serial X-rays to document deformity
  • Molded shoe often needed after coalescence

52
Thank You! wnminnh_at_comcast.net
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