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Common Foot Problems

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Hallux Valgus - Treatment Medical therapy Adapting footwear Pharmacologic or physical therapy Functional orthotic therapy Activity Weight Top cover Biomechanical ... – PowerPoint PPT presentation

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Title: Common Foot Problems


1
Common Foot Problems
  • Garrett Post, MD
  • PGY-2
  • Emory Family Medicine Residency Program
  • March 20, 2008

2
Common Foot Problems
  • Anatomy
  • Bones

3
Anatomy - Bones
4
Anatomy - Bones
5
Anatomy - Vascular
6
Anatomy -Nervous
7
Anatomy -Nervous
8
Anatomy - Musculoskelatal
9
Anatomy - Musculoskelatal
  • Where does the Achilles tendon derives its name?
  • Hint

10
Greek Mythology
  • Thetis tried to immortalize Achilles by dipping
    him into the sacred river Styx.
  • What sign is indicative of an Achilles
  • tendon rupture?

11
Greek 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

12
What 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

13
What 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

14
Bunions - Hallux Valgus
15
Bunions - Hallux Valgus
Not so much good luck But you can cross them
anyway.
16
Bunions - Hallux Valgus
  • NOT likely from high heel shoes (Myth)
  • High heels may exacerbate the underlying etiology.

17
Hallux 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

18
Hallux Valgus - Etiology
  • Biomechanical instability
  • Most common
  • Difficult to understand and evaluate
  • Genetically inherited and/or from underlying
    conditions

19
Hallux 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

20
Hallux Valgus - Etiology
  • Neuromuscular disease
  • Multiple sclerosis
  • Charcot-Marie-Tooth disease
  • Cerebral palsy
  • Traumatic compromise
  • Structural deformity i.e. Abnormal metatarsal
    length

21
Bunions - Hallux Valgus
22
Bunions - 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.

23
Presentation
  • Hallux position
  • Medial prominence
  • First metatarsophalangeal joint ROM
  • First ray ROM
  • Plantar keratosis
  • Pain location
  • Contracture of the extensor hallucis longus
  • Associated deformities

24
Evaluation Labs and XRay
  • Uric acid, ESR, CRP, ANA, RF
  • Foot AP, Lat, and Oblique

25
Staging
  • 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.

26
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27
Hallux Valgus - Treatment
  • Medical therapy
  • Adapting footwear
  • Pharmacologic or physical therapy
  • Functional orthotic therapy
  • Activity
  • Weight
  • Top cover
  • Biomechanical examination
  • Modifications - cushions
  • Surgical therapy

28
Look good and feels good.
29
Recovery
  • 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

30
Heel Pain
31
Plantar 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.

32
Plantar 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).

33
Plantar 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)

34
Plantar 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

35
Plantar 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.

36
Plantar Fasciitis - Physical Exam
  • Point of maximal tenderness at the anteromedial
    region of the calcaneus.
  • Pain along the proximal plantar fascia.

37
Plantar 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

38
Plantar 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.

39
Plantar 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.

40
Ankle 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

41
Ankle Sprain
42
Ankle Sprain
43
Ankle Sprain
  • Anterior drawer test - assess the integrity of
    the anterior talofibular ligament
  • Inversion stress test - assess the integrity of
    the calcaneofibular ligament

44
Ankle 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)

45
Ankle 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

46
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47
Ottawa 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

48
Ankle Sprain
  • Sx more than six weeks CT or MRI to rule out
    talar dome lesions

49
Ingrown 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

50
Ingrown toenails
  • Stage 1
  • erythema,
  • slight edema, and
  • pain with pressure to the lateral nail fold.

51
Ingrown toenails
  • Stage 2
  • increased symptoms,
  • drainage, and
  • infection.

52
Ingrown toenails
  • Stage 3
  • magnified symptoms,
  • granulation tissue, and
  • lateral nail-fold hypertrophy.

53
Ingrown 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)

54
Ingrown 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

55
References
  1. Gould N, Schneider W, Ashikaga T Epidemiological
    survey of foot problems in the continental United
    States. 1978-1979. Foot Ankle 18, 1980
  2. Zuber T. Ingrown Toenail Removal. American Family
    Physician. June 15, 2002.
  3. Cole C, Seto C, and Gazewood J. Plantar
    Fasciitis Evidence-Based Review of Diagnosis and
    Therapy. American Family Physician. December 1,
    2005.
  4. Noronha PA, Zubkov B. Nails and nail disorders in
    children and adults. Am Fam Physician. May 1
    199755(6)2129-40.
  5. Young C, Rutherford D, Niedfeldt M. Treatment of
    Plantar Fasciitis. American Family Physician.
    February 1, 2001.
  6. Stiell IG, McKnight RD, Greenberg GH, McDowell I,
    Nair RC, Wells GA, et al. Implementation of the
    Ottawa ankle rules. JAMA 1994271827-32.
  7. Kane D, Greaney T, Bresnihan B, Gibney R,
    FitzGerald O. Ultrasound guided injection of
    recalcitrant plantar fasciitis. Ann Rheum Dis
    199857383-4.
  8. Furey JG. Plantar fasciitis. The painful heel
    syndrome. J Bone Joint Surg 197557672-3.
  9. 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.
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