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The Foot

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Systemic disease is a major player (diabetes, ... 1st MTP can be swollen, spur is dorsal on the xray. ... Initial xray often normal. Bone scan positive early. ... – PowerPoint PPT presentation

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Title: The Foot


1
The Foot
  • Briant W. Smith, MD
  • Orthopedic Surgery
  • TPMG Santa Rosa

2
General Considerations
  • VERY common problems.
  • Systemic disease is a major player (diabetes,
    vascular and neurologic
    diseases, inflammatory arthritis)

3
Divide the Foot into Thirds
  • Hindfoot Midfoot Forefoot

4
Order Standing Radiographs
  • AP and Lateral are Standing
  • Oblique is supine

5
Forefoot Problems
  • Women far outnumber men because of shoe choices.
    Shoe modification is the first line of treatment
    for
  • Bunions
  • Neuromas
  • Metatarsalgia
  • Sesamoiditis

6
Shoewear Problems

7
Over-Pronation
  • Many foot problems are due to excessive pronation
    (flat feet)
  • Plantar fasciitis
  • Achilles and posterior tibial tendinitis
  • Sesamoiditis
  • Bunions
  • Sinus tarsi and tarsal tunnel syndromes
  • Metatarsalgia

8
Pronation
9
Pronation
10
Midfoot Problems
  • Dorsal midfoot pain occurs secondary to
    arthritis. Bony prominencebossing
  • Plantar midfoot pain is rare. Can be plantar
    fasciitis or fibromatosis.

11
Midfoot Arthritis
12
Hindfoot Problems
  • Plantar fasciitis is the most common. Pain is
    plantar/medial.
  • Heel pad pain is usually a stone bruise or due
    to atrophy of the fat pad.
  • Posterior tibial tendon dysfunction is the most
    overlooked problem of the foot.

13
Plantar Fasciitis
14
The Forefoot
  • Bunions
  • Funny toes
  • Metatarsalgia
  • Interdigital Neuroma
  • Sesamoiditis
  • Stress Fracture

15
Bunions
16
Bunions Hallux Valgus
  • The bunion is the enlarged medial prominence of
    the first MTP joint.
  • Often there are secondary lesser toe deformities
    (corns, calluses, hammertoes, bunionette)
  • Get xrays if patient is going to be referred.
  • TX shoe change widen the toe box, arch heel
    support (bunion pads crowd shoe)

17
Bunion Xrays
18
1st MTP Arthritis
  • Hallux rigidus (ortho) or limitus (pod)
  • 1st MTP can be swollen, spur is dorsal on the
    xray.
  • Limited MTP extension (compare to other foot),
    pain is during the toe-off phase of walking.
  • Tx with stiff soled shoes, NSAIDs

19
Hallux Rigidus
20
Hallux Rigidus
21
Funny Toes Hammer and Claw Toes
  • Usually due to IMPROPER SHOE WEAR
  • Claws are usually seen in diabetics. These are
    fixed extension of MPJ, and flexion of PIP and
    DIP joints.
  • Hammertoes have flexion deformities of the PIP
    joint, and flexible MP and DIP joints.
  • Can develop corns and calluses
  • Tx with wide shoes and toe straps, pads OK
    non-operative treatment as long as it is flexible.

22
Hammertoes
23
Metatarsalgia
  • It just means forefoot pain.
  • Pain is under a metatarsal head (usually 2nd) as
    opposed to between the heads for neuromas.
  • Often associated with hammertoes and calluses.
  • Get wider shoes, use metatarsal pads or cut-outs,
    shave the calluses.

24
Metatarsalgia
25
Sesamoiditis
  • Sesamoids are embedded in the flexor hallucis
    brevis tendon beneath the first metatarsal head.
  • Caused by repeated stress, and can be inflamed,
    fracture, or even get arthritic.
  • Very tender, will move with flex/ext of great toe
    MPJ. Get xrays.
  • Tx stiff shoe, pads/cut-outs no heels.

26
Sesamoiditis
27
Interdigital Neuroma
  • Really perineural fibrosis secondary to
    repetitive irritation (from tight shoes!)
  • 90 are in the third interspace rest in 2nd
  • Feels like walking on a pebble. Feels better out
    of shoes.
  • squeeze test. Pain is between MT heads.
  • Tx wide shoes, MT pads/cut-outs, inject.

28
Interdigital Neuroma
29
Stress Fracture
  • Pain directly over a metatarsal, usually more
    proximal than MT heads.
  • Change in activities, worse with wt bearing
  • Initial xray often normal. Bone scan positive
    early.
  • Tx with modified activity, stiff soled shoe or
    boot/cast, time.

30
Stress Fracture
31
Midfoot Arthritis
  • Dorsal bossing or spurs over the involved
    joint(s).
  • XR and/or bone scan will show changes.
  • Tx with stiff soled shoes, firm arch support,
    NSAIDs, activity modification.

32
Plantar Fasciits
  • Pain with arising, especially first AM steps
  • Almost always at plantar-medial origin.
  • Inflammation and chronic degeneration.
  • Worse with obesity, overpronation.
  • Not due to spurs
  • Tx Arch support, elevate heel. NO barefeet, flat
    shoes NSAIDs, injections, PT for ultrasound.

33
Plantar Fasciitis
34
Plantar Heel Pain
  • Can be traumatic (stone bruise) or common in
    elderly as fat pad atrophies.
  • Add a pad, like Spenco gel heel cushions.

35
Heel Pad Pain
36
Posterior Tibial Tendinitis (PTT)
  • Most missed problem of the foot.
  • Pain/aching between navicular and medial
    malleolus. Looks swollen
  • Flatfeet. Heel should invert with rising on toes.
  • Tx arch supports, slight heel. NSAIDs and PT for
    u/s.

37
Posterior Tibial Tendinitis
38
Tarsal Tunnel Syndrome
  • Post Tib nerve gets entrapped near med malleolus.
    Plantar tingling/burning as opposed to
    pain/swelling of PTT. Not whole foot like with
    diabetes.
  • Tinel test can be loss of PP sensation, can be
    toe clawing.
  • Tx arch support if overpronated. Consider NCV
    tests.

39
Tarsal Tunnel Syndrome
40
Foot Examination
  • Become comfortable with apparent deformities,
    joint mobility, tendon insertions, vascular and
    neurologic examinations.

41
Vascular Examination
  • Foot colordependent and on elevation
  • Edema
  • Pulses
  • Capillary Refill
  • Hair distribution

42
Neurologic Examination
  • Lumbar dermatomes vs. specific nerves vs systemic
    disease
  • Light touch for gross testing
  • Semmes-Weinstein 5.07 monofilament for diabetics.

43
Range of Motion
  • Should be symmetric
  • Ankle dorsiflexion 10 deg with knees ext.
  • Subtalar joint should be mobile.
  • 1st MTP joint extension should be gt60 deg

44
Tendons
  • Achilles insertion and body of tendon
  • Posterior tibial tendon
  • Peroneal tendons

45
Deformities
  • Pump bump
  • Talar head
  • NWB and WB for pes planus/cavus
  • 1st MTP joint
  • Lesser toes

46
Treatment Arsenal
  • Change shoes
  • OTC arch supports and insoles, pads
  • Custom Orthotics
  • Calf stretching/toe rises
  • Activity modification (swimming/biking)
  • Weight loss
  • Night splints/boots/casts

47
Treatment Options
  • Physical therapy
  • Ultrasound
  • Interferential stimulation
  • Contrast soaks (10 mins warm, 30 secs ice cold,
    repeat x2, end with cold)
  • NSAIDS
  • Injections
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