Podiatric Update, 2005

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Podiatric Update, 2005

• William N. McCann, DPM
• Concord, New Hampshire

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Common Foot Deformities

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

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Orthopedic Conditions

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

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Hammertoe

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

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Hammertoe Treatment

• Debridement
• Padding
• Shoe gear change
• Surgery as a last option

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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

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Osteoarthritis

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

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Osteoarthritis Treatment

• Cortisone injection
• Physical therapy
• NSAIDS
• Orthotics
• Surgery

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Ankle - Foot Orthosis

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

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Ankle Foot Orthosis

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

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Time wounds all heels!
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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

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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

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Heel Pain Etiologies
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Plantar Fasciitis Risk Factors

• High body mass index
• Tight Achilles tendon
• Inappropriate footwear
• Biomechanical abnormalities
• Work Surface
• Minor Trauma

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Plantar Fasciitis Symptoms

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

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Plantar Fasciitis Diagnosis

• Pain on palpation
• Antalgic gait
• Pes planus
• X-ray
• Ultrasound

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Plantar Fasciitis Treatment

• Gastrocsoleas Stretching
• RICE
• Change shoes
• OTC inserts
• Nocturnal Anti-contracture Devices

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Plantar Fasciitis Treatment

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

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Extracorporeal Shock Wave Therapy ESWT

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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

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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

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Types Of Shockwave Emitters
Disposable costs No
Disposable Crystals Anesthesia
Local
Multi-treatments Mid - High Energy
Low - High Energy Low Energy
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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

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Shock Wave Focus
Level 1
Level 5
Level 9
As Power Levels Increase Length of Focus
Decreases Width Increases
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Ultrasound Targeting Shockwave Focus
Ultrasound Transducer
Shock head coupled to medial aspect of foot
Focus Diameter Focus Length
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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
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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
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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

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ESWT Plantar Fasciitis Protocol
Energy Level Frequency of ShocksLevel 1
60 50Level 2 90
50Level 3 120 50Level 4 150
50Level 5 180 50Level 6 210
50Level 7 240 3,500 Total 3,800 or
1,300mJ/mm2
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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
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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

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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

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Neurologic Conditions

• Neuroma
• Cutaneous Nerve Entrapment
• Neuropathy
• Tarsal Tunnel Syndrome

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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

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Mortons Neuroma Differential Diagnosis

• Stress fracture
• Callus
• Freiberg's infraction
• Capsulitis
• Bone tumor
• Local manifestation of systemic disease

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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

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Dermatologic Conditions

• Onychomycosis
• Paronychia
• Verucca
• Tinea Pedis

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Onychomycosis

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

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Onychomycosis Treatment

• Debridement
• Topical
• Oral antifungals
• PAS Stain for differential diagnosis
• Matrixectomy

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Paronychia

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

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Paronychia Treatment

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

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Verruca?
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Verruca!

• Human Papilloma Virus (HPV)
• Contagious
• Usually plantar on foot

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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

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Diabetes Related Foot and Ankle Conditions

• Neurotrophic Ulcers
• Neuropathy
• Charcot Foot

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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

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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.

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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

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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

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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

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