Disorders of FeetMaria Carmela L. Domocmat, RN, MSNInstructorNorthern Luzon Adventist College
2 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Overview• Part 1: Degenerative & Metabolic bone disorders:• Part 2: Bone infections• Part 3: Muscular disorders• Part 4: Disorders of the hand• Part 5: Spinal column deformities• Part 6 : Disorders of feet• Part 7: Sports Injuries
3 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Disorders of Feet• Hallux valgus (bunions)• Morton’s neuroma (plantar neuroma)• Hammer toe• Tarsal tunnel syndrome• Plantar Fasciitis• Corn• Callus• Ingrown Nail• Hypertrophic Ungual Labium
4 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Disorders of Feet• Hallux valgus (bunions), Morton’s neuroma (plantar neuroma), Hammer toe , Tarsal tunnel syndrome , Plantar Fasciitis, Corn, Callus, Ingrown Nail, Hypertrophic Ungual Labium
5 Maria Carmela L. Domocmat, RN, MSN 3/5/2012http://familyfootcarenj.com/web/images/layout/conditions_map.jpg
8 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hallux valgus• is a condition that affects the joint at the base of the big toe.• The condition is commonly called a bunion. ▫ bunion - refers to the bump that grows on the side of the first metatarsophalangeal (MTP) joint.
9 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hallux valgus (bunion)• The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal.• Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral).http://www.footankleinstitute.com/hallux-valgus-bunion-surgery/
10 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hallux valgus (bunion)• As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground.• this constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot.http://www.footankleinstitute.com/hallux-valgus-bunion-surgery/
11 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hallux valgus (bunion)• The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due to the mal-positioned joint.• A bunion deformity is always progressive. It will always get worse over time.http://www.footankleinstitute.com/hallux-valgus-bunion-surgery/
14 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hallux valgus (bunion)• term hallux valgus actually describes what happens to the big toe. ▫ Hallux - medical term for big toe ▫ Valgus - anatomic term that means the deformity goes in a direction away from the midline of the body.• hallux valgus - big toe begins to point towards the outside of the foot. ▫ As this condition worsens, other changes occur in the foot that increase the problem.
15 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Etiology• Contrary to common belief, ▫ high-heeled shoes with a small toe box or tight- fitting shoes do not cause hallux valgus. ▫ such footwear does keep the hallux in an abducted position if hallux valgus is present, causing mechanical stretch and deviation of the medial soft tissue. ▫ In addition, tight shoes can cause medial bump pain and nerve entrapment.
16 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Etiology• Biomechanical instability• Arthritic/metabolic conditions• Structural deformity• Neuromuscular disease• Traumatic compromise
17 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Etiology• Biomechanical instability ▫ most common yet most difficult to understand etiology ▫ Contributing factors, if present, include gastrocnemius or gastrocsoleus equinus, flexible or rigid pes plano valgus, rigid or flexible forefoot varus, dorsiflexed first ray, hypermobility, or short first metatarsal. Most often, excessive pronation at the midtarsal and subtalar joints compensates for these factors throughout the gait cycle.
18 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Etiology• Biomechanical instability ▫ Some pronation must occur in gait to absorb ground-reactive forces. However, excessive pronation produces too much midfoot mobility, which decreases stability and prevents resupination and creation of a rigid lever arm; these effects make propulsion difficult.
19 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Etiology• Biomechanical instability ▫ During normal propulsion approximately 65° of dorsiflexion is necessary at the first metatarsophalangeal joint, only 20-30° is available from hallux dorsiflexion. Therefore, the first metatarsal must plantarflex at the sesamoid complex to gain the additional 40° of motion needed. Failure to attain the full 65° because of jamming of the joint during pronation subjects the first metatarsophalangeal to intense forces from which hallux valgus develops. ▫ If the foot is sufficiently hypermobile as a result of excessive pronation, the metatarsal tends to drift medially and the hallux drifts laterally, producing hallux valgus. If no hypermobility is present, hallux rigidus develops instead.
Maria Carmela L. Domocmat, RN, MSN 20 3/5/2012EtiologyArthritic/metabolic Structural deformityconditions ▫ Gouty arthritis • Malalignment of articular ▫ Rheumatoid arthritis surface or metatarsal shaft ▫ Psoriatic arthritis • Abnormal metatarsal length ▫ Connective tissue disorders • Metatarsus primus elevatus such as Ehlers-Danlos • External tibial torsion syndrome, Marfan • Genu varum or valgum syndrome, Down syndrome, • Femoral retrotorsion and ligamentous laxity
22 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Symptoms • Symptoms of Hallux valgus depending on the degree of severity: ▫ Aesthetic problem. ▫ Formation of calluses, chronic irritation of the skin and bursa. ▫ Increasing pain under load and when moving. ▫ Progressive arthrosis and stiffening in the base joint of the toe. ▫ Corollary deformities such as hammer and clawhttp://www.hallufix.org/english/hallux_valgus.html toe.
23 3/5/2012Types of Hallux valgusDegree 1 Degree 2• Toe malpositioning below 20 • Malpositioning between 20 degrees. No symptoms. and 30 degrees. Occasional pain.
Maria Carmela L. Domocmat, RN, MSN 3/5/2012Types of Hallux valgusDegree 3 Degree 4• Malpositioning between 30 • Severest form with and 50 degrees. Regular pain. malpositionings over 50 Increasing restraints on degrees and painful restraints activities. Pronounced on the activities of everyday malpositioning! life. Surgical treatment
25 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• Medical Therapy ▫ Adapting footwear ▫ Pharmacologic or physical therapy ▫ Functional orthotic therapy• Surgical Therapy ▫ Capsulotendon balancing or exostectomy ▫ Osteotomy ▫ Resectional arthroplasty ▫ Resectional arthroplasty with implant ▫ First metatarsophalangeal joint arthrodesis ▫ First metatarsocuneiform joint arthrodesis
28 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Bunionectomy• remove the bump that makes up the bunion.• performed through a small incision on the side of the foot immediately over the area of the bunion.• Once the skin is opened the bump is removed using a special surgical saw or chisel.• The bone is smoothed of all rough edges and the skin incision is closed with small stitches.• It is more likely that realignment of the big toe will also be necessary. The major decision that must be made is whether or not the metatarsal bone will need to be cut and realigned as well. The angle made between the first metatarsal and the second metatarsal is used to make this decision. The normal angle is around nine or ten degrees. If the angle is 13 degrees or more, the metatarsal will probably need to be cut and realigned.• When a surgeon cuts and repositions a bone, it is referred to as an osteotomy. There are two basic techniques used to perform an osteotomy to realign the first metatarsal.http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf
29 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Distal Osteotomy• the far end of the bone is cut and moved laterally• This effectively reduces the angle between the first and second metatarsal bones.• usually requires one or two small incisions in the foot.• Once the surgeon is satisfied with the position of the bones, the osteotomy is held in the desired position with one, or several,metal pins.• Once the bone heals, the pin is removed. The metal pins are usually removed between three and six weeks following surgery.http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf
30 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Proximal Osteotomy• the first metatarsal is cut at the near end of the bone• usually requires two or three small incisions in the foot.• Once the skin is opened the surgeon performs the osteotomy. The bone is then realigned and held in place with metal pins until it heals. Again, this reduces the angle between the first and second metatarsal bones.• Realignment of the big toe is then done by releasing the tight structures on the lateral, or outer, side of the first MTP joint. This includes the tight joint capsule and the tendon of the adductor hallucis muscle. This muscle tends to pull the big toe inward. By releasing the tendon, the toe is no longer pulled out of alignment. The toe is realigned and the joint capsule on the side of the big toe closest to the other toe is tightened to keep the toe straight, or balanced.• Once the surgeon is satisfied that the toe is straight and well balanced, the skin incisions are closed with small stitches. A bulky bandage is applied to the foot before you are returned to the recovery room.http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf
31 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Good footwear is often all that isneeded• Wearing good footwear does not cure the deformity but may ease symptoms of pain and discomfort. Ideally, get advice about footwear from a podiatrist or chiropodist. Advice may include:• Wear shoes, trainers or slippers that fit well and are roomy.• Dont wear high-heeled, pointed or tight shoes.• You might find that shoes with laces or straps are best, as they can be adjusted to the width of your foot.• Padding over the bunion may help, as may ice packs.• Devices which help to straighten the toe (orthoses) are still occasionally recommended, although trials investigating their use have not found them much better than no treatment at all. http://www.patient.co.uk/health/Bunions-(Hallux-Valgus).htm
32 Maria Carmela L. Domocmat, RN, MSN 3/5/2012How to Choose Shoes1. Know your foot. Take a look at your old shoes. Look at what areas the most worn out shoes. A well-chosen shoes will help to endure the physical stress well. One way to determine your foots shape is to do a "wet test"--- wet your foot, step on a piece of brown paper and trace your footprint. Or just look at where your last pair of shoes shows the most wear.2. Dont buy uncomfortable shoes even if they are hot!3. Ideally, you should avoid wearing heels4. Dont make shoes multitask. http://hallux-valgus- rigidus.com/index.php?option=com_content&view=article&id=74&Itemid=88
34 Maria Carmela L. Domocmat, RN, MSN 3/5/2012How to Choose Shoes5. Knowing your foots particular quirks is key to selecting the right pair of shoes.6. You must find shoes with well cushioned soles and ideally, some type of soft arch-support.7. 7. Measure your foot frequently. Foot size changes as we get older.8. 8. You should not buy shoes in the morning. The size of our feet at night more than in the morning. Feet swell over the course of the day; they also expand while you run or walk, so shoes should fit your feet when theyre at their largest. http://hallux-valgus- rigidus.com/index.php?option=com_content&view=article&id=74&Itemid=88
36 Maria Carmela L. Domocmat, RN, MSN 3/5/2012How to Choose Shoes9. Always buy shoes to fit the larger or wider foot. Buy well-fitting shoes with a wide toe box.10. Use bunion shields, bunion pads or bunion cushions to protect the bunion when wearing shoes. A bunion sleeve can be especially effective at relieving shoe pressure when walking with a hallux valgus.11. Utilize an orthotic device or insert, such as a bunion splint or bunion brace, to redistribute the pressure along the arch and ball of the foot and control the separation of the bones. These devices help support your foot and reduce the tendency toward hallux valgus formation.12. Use a bunion regulator to stretch tight tendons and toe muscles overnight – especially if you want to avoid surgery. http://hallux-valgus- rigidus.com/index.php?option=com_content&view=article&id=74&Itemid=88
38 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Resectional arthroplasty• is a joint-destructive procedure• most commonly reserved for elderly patients with advanced degenerative joint disease and significant limitation of motion.• The typical resectional arthroplasty that is performed is known as a Keller procedure. http://emedicine.medscape.com/article/1232902-treatment#showall
39 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Resectional arthroplasty• performed when morbidity might be increased with the more aggressive osteotomy that would otherwise be selected.• The procedure includes resection of the base of the proximal phalanx with reapproximation of the abductor and adductor tendon groups.• The technique is inherently unstable and should be used judiciously.• The postoperative course includes limited-to-full weight bearing in a surgical shoe immediately after the procedure. http://emedicine.medscape.com/article/1232902-treatment#showall
40 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Resectional arthroplasty withimplant• is the same procedure as the resectional arthroplasty, with similar indications, but stability is markedly improved with the addition of the total implant.http://emedicine.medscape.com/article/1232902-treatment#showall
41 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Resectional arthroplasty withimplant• Preoperative radiograph shows • Postoperative radiograph degenerative joint disease. obtained after resectional arthroplasty and total joint implant placement.http://emedicine.medscape.com/article/1232902-treatment#showall
42 Maria Carmela L. Domocmat, RN, MSN 3/5/2012First metatarsophalangeal jointarthrodesis• is a joint-destructive procedure that offers a higher degree of stability and functionality.• considered the definitive procedure for degenerative joint disease.• results in complete loss of motion at the first metatarsophalangeal joint and is reserved for patients with high activity levels and functional demands.
43 Maria Carmela L. Domocmat, RN, MSN 3/5/2012First metatarsophalangeal jointarthrodesis• Preoperative radiograph shows • Postoperative radiograph show arthrodesis. arthrodesis.
44 Maria Carmela L. Domocmat, RN, MSN 3/5/2012First metatarsocuneiform jointarthrodesis• Significant and/or hypermobile hallux abductovalgus may be reduced with arthrodesis of the first metatarsocuneiform joint (see images below).• Indications include metatarsus primus varus, hypermobility of the first ray, metatarsalgia of the lesser metatarsals, and degenerative joint disease of the metatarsocuneiform joint.
45 Maria Carmela L. Domocmat, RN, MSN 3/5/2012First metatarsocuneiform jointarthrodesis• Preoperative radiograph shows • Postoperative radiograph a hypermobile first ray. shows arthrodesis of the first metatarsocuneiform.
47 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Marfan syndrome (MFS)• is a spectrum disorder caused by a heritable genetic defect of connective tissue that has an autosomal dominant mode of transmission• The defect itself has been isolated to the FBN1 gene on chromosome 15, which codes for the connective tissue protein fibrillin.• Abnormalities in this protein cause a myriad of distinct clinical problems, of which the musculoskeletal, cardiac, and ocular system problems predominate.
48 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Marfan syndrome (MFS)• The skeleton of patients with MFS typically displays multiple deformities including arachnodactyly (ie, abnormally long and thin digits), dolichostenomelia (ie, long limbs relative to trunk length), pectus deformities (ie, pectus excavatum and pectus carinatum), and thoracolumbar scoliosis
49 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Marfan syndrome (MFS)• In the cardiovascular system, aortic dilatation, aortic regurgitation, and aneurysms are the most worrisome clinical findings. Mitral valve prolapse that requires valve replacement can occur as well. Ocular findings include myopia,cataracts, retinal detachment and superior dislocation of the lens
Maria Carmela L. Domocmat, RN, MSN 50 3/5/2012pectus carinatum pectus excavatum
51 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Genetics of Ehlers-Danlos Syndrome• Ehlers-Danlos family of disorders is a group of related conditions that share a common decrease in the tensile strength and integrity of the skin, joints, and other connective tissues.
52 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Genetics of Ehlers-Danlos Syndrome• The first detailed clinical description of the syndrome is attributed to Tschernogobow in 1892.• The syndrome derives its name from reports by Edward Ehlers, a Danish dermatologist, in 1901 and by Henri-Alexandre Danlos, a French physician with expertise in chemistry of skin disorders, in 1908.• These 2 physicians combined the pertinent features of the condition and accurately delineated the phenotype of this group of disorders.
53 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Ehlers-Danlos syndrome• The amazing, almost unnatural, contortions that some patients with Ehlers-Danlos syndrome can perform often arouse curiosity.• Historically, some patients with Ehlers-Danlos syndrome displayed the maneuvers publically in circuses, shows, and performance tours.
54 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Ehlers-Danlos syndrome• Some achieved modest degrees of fame and bore titles such as "The India Rubber Man," "The Elastic Lady," and "The Human Pretzel."• Such clinical features also raise suspicion of the diagnosis when identified upon physical examination.• Unfortunately, patients often go many years before being diagnosed
55 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Ehlers-Danlos syndrome• Patient with Ehlers-Danlos • Patient with Ehlers-Danlos syndrome mitis. syndrome. Note the abnormal• Joint hypermobility is less ability to elevate the right toe. intense than with other conditions.
56 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Ehlers-Danlos syndrome• Girl with Ehlers-Danlos syndrome.• Dorsiflexion of all the fingers is easy and absolutely painless.
57 Maria Carmela L. Domocmat, RN, MSN 3/5/2012• All forms of Ehlers-Danlos syndrome share the following primary features to varying degrees: ▫ Skin hyperextensibility ▫ Joint hypermobility and excessive dislocations ▫ Tissue fragility ▫ Poor wound healing, leading to wide thin scars: The classic description of abnormal scar formation in Ehlers-Danlos syndrome is "cigarette paper scars." ▫ Easy bruising
58Type Inheritan PreviousMaria Carmela L. Domocmat, RN, MSN 3/5/2012 Major Minor Diagnostic ce Nomencla Diagnostic Criteria ture CriteriaKypho- Auto- Type VI – Joint laxity, Tissue fragility,scoliosis somal lysyl severe easy bruising, recessive hydroxyla hypotonia at arterial rupture, se birth, scoliosis, marfanoid, deficiency progressive microcornea, scleral fragility osteopenia, or rupture of positive family globe history (affected sibling)
59Type Inheritance Previous Major Diagnostic Minor Diagnostic Nomenclatur Criteria Criteria eArthro Autosomal Type VII A, B Congenital Skinchalasi dominant bilateral hyperextensibility,a dislocated hips, tissue fragility with severe joint atrophic scars, muscle hypermobility, hypotonia, recurrent easy bruising, subluxations kyphoscoliosis, mild osteopeniaDerma Autosomal Type VII C Severe skin Soft, doughy skin;tospara recessive fragility; saggy, easy bruising;xis redundant skin premature rupture of membranes; hernias (umbilical and inguinal)
60Type Inheritan Previous Major Diagnostic Criteria Minor Diagnostic Criteria ce Nomenclatu reClassic Autoso Types I and Skin Smooth, velvety skin; mal II hyperextensibility, easy bruising; domina molluscoid nt pseudotumors; subcutaneous wide atrophic scars, spheroids; joint joint hypermobility hypermobility; muscle hypotonia; postoperative complication (eg, hernia); positive family history; manifestations of tissue fragility (eg, hernia, prolapse)
61Type Inherita Previous Major Diagnostic Minor Diagnostic nce Nomenclat Criteria Criteria ureHyperm Autoso Type III Skin involvement (soft, Recurrent jointobility mal smooth and velvety), dislocation; chronic domina joint hypermobility joint pain, limb pain, nt or both; positive family historyVascular Autoso Type IV Thin, translucent skin; Acrogeria, mal arterial/intestinal hypermobile small domina fragility or rupture; joints; tendon/muscle nt extensive bruising; rupture; clubfoot; early characteristic facial onset varicose veins; appearance arteriovenous, carotid- cavernous sinus fistula; pneumothorax; gingival recession; positive family history; sudden death in close relative
62 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Down syndrome• Down syndrome is by far the most common and best known chromosomal disorder in humans and the most common cause of intellectual disability.• Mental retardation, dysmorphic facial features, and other distinctive phenotypic traits characterize the syndrome
64 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Corn• induration and thickening of skin caused by friction and pressure, painful conical mass • appear as a horny thickening of the skin on the toes. • this thickening appears as a cone shaped mass pointing down into the skin.
66 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Types of Corno Hard corns most common are concentrated areas of dry, hardened skin about the size of a pea usually located on the outer surface of the little toe or on the upper surface of the other toes, but can occur between the toes may develop within a broader area of callused skin sometimes called digital corns
67 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Types of Corno Soft corns are white and rubbery can be extremely painful and tend to develop between toes are like hard corns that have been softened by continual exposure to moisture, usually because you don’t dry between toes properly or from sweat. may form opposite one another and are known as ‘kissing lesions’. Sometimes, soft corns can become infected by bacteria or fungi.
68 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Other, rarer types of corn include:• seed corns ▫ may appear as one corn or as clusters of small corns on the bottom foot; they are usually painless• vascular corns ▫ occur in blood vessels and bleed if cut• fibrous corns ▫ are corns that have been around for a long time and have become attached to the deeper layers of your skin, sometimes causing pain
69 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes of cornso Corns are caused by constant pressure on a bony area of foot. This can happen for a number of different reasons. These include: poorly fitting footwear – for example, shoes that are too small, cramp toes or have uneven soles; this is the most common cause of corns being very active – doing lots of exercise can put pressure on feet prominent bones – these can press against shoes
70 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes of cornso Corns are caused by constant pressure on a bony area of foot. This can happen for a number of different reasons. These include: a misshapen foot because foot or toes have developed unusually –may have a toe that is overly curved or a particular bone that is too short poorly healed fractures – if have broken a toe or another bone in foot, it may have set out of place causing foot to press against shoe
71 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Corn• Treatment: • surgical removal by podiatrist
72 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Prevention of cornso wearing sensible, low-heeled footwear (maximum 4cm heel) with a rounded toeo not wearing slip-on shoes because these cause feet to move forward and squash toeso not wearing court shoes because they don’t support feet and can cramp toes
73 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Corn pad
74 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Prevention of cornso drying properly between toeso losing excess weight – this will help to reduce pressure on feeto If already have a corn, apply an antifungal or antibacterial powder after washing foot to help prevent it becoming infected.
77 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Callus• flat, poorly defined mass on the sole over a bony prominence caused by pressure • When skin is exposed to lots of pressure or friction, the keratin layer thickens to protect it, and develops into a callus. • Although calluses can cover a wide area, they arent usually painful.
78 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Callus• Treatment: o padding and lanolin creams o overall good skin hygiene
79 Maria Carmela L. Domocmat, RN, MSN 3/5/2012• Self treatment or management of corns and callus includes: ▫ following the advice of a Podiatrist ▫ proper fitting of footwear ▫ proper foot hygiene and the use of emollients to keep the skin in good condition
81 Maria Carmela L. Domocmat, RN, MSN 3/5/2012• Neuromas ▫ are non-cancerous growths of the nerve tissue that develop in different parts of the body.
82 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Mortons Neuroma• affects a nerve in the foot, often times the nerve between the third and fourth toe.• thickens the tissue around the nerves that lead to the toes, causing sharp, burning sensations in the ball of the foot, as well as a numbing or stinging feeling.• AKA: plantar neuroma or intermetatarsal neuroma.
83Maria Carmela L. Domocmat, RN, MSN 3/5/2012 http://www.footdoc.ca/www.FootDoc.ca/ Website_Neuroma.gif
84 Maria Carmela L. Domocmat, RN, MSN 3/5/2012 • Sex ▫ The female-to-male ratio for Mortons neuroma is 5:1. • Age ▫ The highest prevalence of Mortons neuroma is found in patients aged 15-50 years, but the condition may occur in any ambulatory patient.http://emedicine.medscape.com/article/308284-clinical#showall
85 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes• Various factors have been implicated in the precipitation of Mortons neuroma.• Mortons neuroma is known to develop as a result of chronic nerve stress and irritation, particularly with excessive toe dorsiflexion.• Poorly fitting and constricting shoes (ie, small toe box) or shoes with heel lifts often contribute to Mortons neuroma. Women who wear high-heeled shoes for a number of years or men who are required to wear constrictive shoe gear are at risk. http://emedicine.medscape.com/article/308284-clinical#showall
86 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes• A biomechanical theory of causation involves the mechanics of the foot and ankle. For instance, individuals with tight gastrocnemius-soleus muscles or who excessively pronate the foot may compensate by dorsiflexion of the metatarsals subsequently irritating of the interdigital nerve.• Certain activities carry increased risk of excessive toe dorsiflexion, such as prolonged walking, running, squatting, and demi-pointe position in ballet. http://emedicine.medscape.com/article/308284-clinical#showall
87 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Manifestations• Obtaining an accurate history is important to making the diagnosis of Mortons neuroma. Possible reported findings provided by the patient with Mortons neuroma include the following:• The most common presenting complaints include pain and dysesthesias in the forefoot and corresponding toes adjacent to the neuroma.• Pain is described as sharp and burning, and it may be associated with cramping. http://emedicine.medscape.com/article/308284-clinical#showall
89 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Manifestations• Numbness often is observed in the toes adjacent to the neuroma and seems to occur along with episodes of pain.• Pain typically is intermittent, as episodes often occur for minutes to hours at a time and have long intervals (ie, weeks to months) between a single or small group of multiple attacks.• Some patients describe the sensation as "walking on a marble."• Massage of the affected area offers significant relief.• Narrow tight high-heeled shoes aggravate the symptoms.• Night pain is reported but is rare. http://emedicine.medscape.com/article/308284-clinical#showall
90 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Dx tests• palpable mass or a "click" between the bones.• Doctor put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain.• Range of motion tests will rule out arthritis or joint inflammations.• X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot.http://emedicine.medscape.com/article/308284-clinical#showall
91 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• Rehabilitation Program: Physical Therapy• Treatment strategies range from conservative to surgical management.• The conservative approach may benefit from the involvement of a PT. ▫ Recommend soft-soled shoes with a wide toe box and low heel (eg, an athletic shoe). ▫ High-heeled, narrow, nonpadded shoes should not be worn, because they aggravate the condition.http://emedicine.medscape.com/article/308284-clinical#showall
92 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment • Rehabilitation Program: PT • conservative management ▫ to alter alignment of the metatarsal heads. ▫ One recommended action is to elevate the metatarsal head medial and adjacent to the neuroma, thereby preventing compression and irritation of the digital nerve. ▫ A plantar pad is used most often for elevation. Have the patient insert a felt or gel pad into the shoe to achieve the desired elevation of the above metatarsal head.http://emedicine.medscape.com/article/308284-clinical#showall
93 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• Rehabilitation Program: PT• Cryotherapy• Ultrasonography• deep tissue massage• stretching exercises. http://emedicine.medscape.com/article/308284-clinical#showall
94 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• Rehabilitation Program: PT• Ice is beneficial to decrease the associated inflammation.• Phonophoresis also can be used, rather than just ultrasonography, to further decrease pain and inflammation. http://emedicine.medscape.com/article/308284-clinical#showall
95 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Phonophoresis
96 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Phonophoresis
97 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment • Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal. • Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.http://orthoinfo.aaos.org/topic.cfm?topic=a00158
98 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.• Combination ▫ Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Mortons Neuroma.http://orthoinfo.aaos.org/topic.cfm?topic=a00158
99 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Surgical Intervention• When conservative measures for Mortons neuroma are unsuccessful, surgical excision of the area of fibrosis in the common digital nerve may be curative.• Common adverse outcomes include ▫ dysesthesias radiating from a painful nerve stump. Dysesthesias may be treated as any other dysesthetic pain.• Surgical options include the following: ▫ Neurectomy with nerve burial ▫ Transverse intermetatarsal ligament release, with or without neurolysis ▫ Endoscopic decompression of the transverse metatarsal ligamenthttp://emedicine.medscape.com/article/308284-clinical#showall
100 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Other Treatment• Perform injection into the dorsal aspect of the foot, 1-2 cm proximal to the webspace, in line with the MTP joints.• Advance the needle through the midwebspace into the plantar aspect of the foot until the needle gently tents the skin. Then withdraw it about 1 cm to where the tip of the neuroma is located.
101 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Other Treatment• Inject a corticosteroid/anesthetic mix. A reasonable volume is 1 mL of corticosteroid and 2 mL of anesthetic. T• the anesthetic used should not contain epinephrine, as necrosis may result. Care also should be taken not to inject into the plantar pad.
102 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Other Treatment• Adverse outcomes include plantar fat pad necrosis. Transient numbness of the toes also may occur. Although many practitioners use multiple injections, the likelihood of benefit from subsequent injections, after failure to achieve relief from the initial injection, is negligible.
103 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Other Treatment• An Australian investigation using a single, ultrasonographically guided corticosteroid injection for Mortons neuroma found that 9 months after treatment, complete pain relief had occurred in 11 of the 39 neuromas studied.
104 Maria Carmela 3/5/2012 L. Domocmat, RN, MSNNeurectomy: typical incision location. Neurectomy: superficial exposure.Neurectomy: deeper dissection. Neuroma and adherent fibrofatty tissue. http://emedicine.medscape.com/article/308284-clinical#showall
105 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Medication Summary• Dysesthesias may be treated as any other dysesthetic pain.• Tricyclic antidepressants, such as amitriptyline at 10-25 mg PO qhs, may be tried.• If this approach is unsuccessful, anticonvulsants (eg, gabapentin, carbamazepine) often are effective.
106 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Tricyclic Antidepressants• A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission, and they block the active re- uptake of norepinephrine and serotonin.• Amitriptyline (Elavil) ▫ Analgesic for certain chronic and neuropathic pain. Low doses, 10-25 mg qhs, may provide pain relief from burning and tingling occurring at rest but function only as an adjunct to definitive treatment.
107 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Anticonvulsants• Use of certain antiepileptic drugs (AEDs), such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Thus, although unstudied, a trial of such an agent might conceivably provide analgesia for symptomatic neuropathy. Used for dysesthesias not controlled with definitive treatment plus tricyclic antidepressants (or in patients unable to take tricyclic antidepressants).• Gabapentin (Neurontin) ▫ Neuromembrane stabilizer useful in pain reduction with dysesthetic pain. Has antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA, but does not interact with GABA receptors.
108 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Anticonvulsants• Pregabalin (Lyrica) ▫ Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.
109 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Serotonin-Norepinephrine ReuptakeInhibitors• These agents inhibit neuronal serotonin and norepinephrine reuptake.• Duloxetine (Cymbalta) ▫ Description Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake
110Maria Carmela L. Domocmat, RN, MSN 3/5/2012
111 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hammer toe• is a deformity of the toe, in which the end of the toe is bent downward.• usually affects the second toe. However, it may also affect the other toes. The toe moves into a claw-like position.
112 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hammer toe
113 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes, incidence, and risk factors• most common cause of hammer toe is wearing short, narrow shoes that are too tight. The toe is forced into a bent position. Muscles and tendons in the toe tighten and become shorter.
114 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes, incidence, and risk factors• Hammer toe is more likely to occur in: ▫ Women who wear shoes that do not fit well or have high heels ▫ Children who keep wearing shoes they have outgrown• The condition may be present at birth (congenital) or develop over time.• In rare cases, all of the toes are affected. This may be caused by a problem with the nerves or spinal cord.
115 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes, incidence, and risk factors• may be present at birth (congenital) or develop over time.• In rare cases, all of the toes are affected. This may be caused by a problem with the nerves or spinal cord.
116 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Symptoms• The middle joint of the toe is bent. The end part of the toe bends down into a claw-like deformity. At first, you may be able to move and straighten the toe. Over time, you will no longer be able to move the toe.• A corn often forms on the top of the toe. A callus is found on the sole of the foot.• Walking or wearing shoes can be painful.
117 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hammer toe
118 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Dx tests • physical examination of the foot • decreased and painful movement in the toes.http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9360.jpg
119 Maria Carmela L. Domocmat, RN, MSN 3/5/2012http://www.myfootshop.com/images/medical/ortho/hammer_toe_differences_mod.jpg
120 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• Mild hammer toe in children can be treated by manipulating and splinting the affected toe. http://www.family-foot.com/images/hammer_toe_whatis.jpg
121 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• The following changes in footwear may help relieve symptoms: ▫ Wear the right size shoes or shoes with wide toe boxes for comfort, and to avoid making hammer toe worse. ▫ Avoid high heels as much as possible. ▫ Wear soft insoles to relieve pressure on the toe. ▫ Protect the joint that is sticking out with corn pads or felt pads
122 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• A foot doctor can make foot devices called hammer toe regulators or straighteners for you, or you can buy them at the store.• Exercises may be helpful. ▫ You can try gentle stretching exercises if the toe is not already in a fixed position. ▫ Picking up a towel with your toes can help stretch and straighten the small muscles in the foot.
123 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• For severe hammer toe, you will need an operation to straighten the joint.• The surgery often involves cutting or moving tendons and ligaments.• Sometimes the bones on each side of the joint need to be connected (fussed) together.• Most of the time, you will go home on the same day as the surgery. The toe may still be stiff afterward, and it may be shorter.
124 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Prevention and Cure of Hammer Toeswith Products• Hammer Toe • Yoga Toes Toe Regulator Stretcher• Hammer Toe Cushion • Toe Rings• Foam Toe Tubes • Toe Brace• Gel Toe Cap • Toe Alignment Splint• Toe Spreader • Toe Trainers• Silicone Toe Crest • Hammer Toe• Toe Spacer Cushion Straightener• Digital Toe Pad
125Maria Carmela L. Domocmat, RN, MSN 3/5/2012
126 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hammer Toe Correction Bandage• Price $14.95
127 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hammer Toe Regulator• Toe regulator efficiently integrates the middle joint of toe with other joints.• It reduces the pressure and irritation at toe tips and region over the toes.• The toe regulator straightens the joint of hammer toes (or) claw toes with a slight and smooth pressure.• Toe regulator is effective for pain relief and proper alignment of hammer toes.
128 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hammer Toe Regulator
129 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hammer Toe Cushion• provides ease feel over the contracted part and comforts Hammer toe with enough support.• assists for a stress free movement and aid in lifting the toe to normal position.• minimizes pressure at the top and tip of toes with a spongy effect.• is provided with an adjustable toe loop for comfortable and secure fit.
130 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Foam Toe Tubes• The soft foam present in the tube safeguard toes from rash rubbing against footwear.• Foam toe tube is easy to wear for getting effective pain relief from hammer toes.• It reduce the pressure and swelling over Hammer toes for trouble free walks.
131 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Gel Toe Cap• Gel Toe Cap softens the Hammer toes giving excellent cushioning to the painful deformed toes.• It also relieves extreme pain at the top and tip of toes effectively.• Gel maintains the spongy comfort and reduces pressure all over the hammer toe.
132 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Silicone Toe Crest• The reinforced loop with elastic fabric of the toe crest holds the toe perfectly straight.• The toe crest provides soft feel under three toes excluding the big and little toe.• It relieves the pain caused by hammer toe.• It adds strength to the toe and gives extra smoothness to the affected spot.• Silicone soothes the toe for ease feel.• Toe crest is durable and can be worn comfortably with a snug fit.
133 Maria Carmela L. Domocmat, RN, MSN 3/5/2012 Toe Alignment Splint• Toe alignment splint reduces the pressure and pain caused by Hammer toes and Bunions.• specifically aligns the toe placing it in correct position.• The smooth cotton band with elastic property gives secure fit around the foot.• Its thin straps can be placed over affected toes and the rigidity is adjustable using hook-and loop strap.• Unique T-strap of the splint reduces the pain of bunion and prevents the big toe to slant over hammer toes (or) crooked toes.• Toe alignment splint is comfortable to wear with casual shoes.
134 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Toe Toe trainer comforts • Trainers flexible hammer toes. It gives better relief against the pain and irritation. Toe trainer separates the toes and aligns them to look straight. It is an effective item to cure slightly movable Hammer toes. • The cotton-covered foam provides secure feel to the crooked toes. • Toe trainer is easy to wear and fits snugly for efficient correction of hammer toes.
135 Maria Carmela L. Domocmat, RN, MSN 3/5/2012HammerStraightener perfectly aligns • The toe Toe Straightener Hammer toes with little pressure. Its cotton-covered loop with elasticity holds the toe firmly in proper place and it can be easily adjusted for stress free movements. The smooth foam pad molds accordingly with the foot shape and renders superior cushioning at the bottom of the feet. It also stops the pain caused by hammer toes. The hook closure present in the toe straightener pulls down and aligns the deformed toes to keep you always smiling. • Hammer toe Straightener assists for healthy feet by strengthening the toes and forefoot muscles.
136 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Prevention• Avoid wearing shoes that are too short or narrow.• Check childrens shoe sizes often, especially during periods of fast growth.
137 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Expectations (prognosis)• If the condition is treated early, you can often avoid surgery.• Treatment will reduce pain and walking difficulty.
138 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Complications• Foot deformity• Posture changes caused by difficulty in walking
139Maria Carmela L. Domocmat, RN, MSN 3/5/2012
140Maria Carmela L. Domocmat, RN, MSN 3/5/2012
141 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Tarsal tunnel syndrome• the ankle version of carpal tunnel syndrome (CTS)• posterior tibial nerve in the ankle becomes compressed, resulting in loss of sensation and pain in a portion of the foot
142Maria Carmela L. Domocmat, RN, MSN 3/5/2012
143 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Tarsal tunnel syndrome• median and lateral plantar branches, which supply the sole of the and distal phalanges, are affected by nerve compression• dx and treatment: same with CTS
144Maria Carmela L. Domocmat, RN, MSN 3/5/2012
145 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Plantar fasciitis• an inflammation of the plantar fascia, which is located in the area of the arch of the foot• common: middle-aged and older adults, athletes esp runners
146 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Plantar fasciitis http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg
147 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Plantar fascia• A very thick band of tissue that covers the bones on the bottom of the foot.• extends from the heel to the bones of the ball of the foot and acts like a rubber band to create tension which maintains the arch of the foot.• If the band is long it allows the arch of the foot to be low, which is most commonly known as having a flat foot.• A short band of tissue causes a high arch.• This fascia can become inflamed and painful in some people, making walking more difficult.
148 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Plantar fascia http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg
149 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Risk factorso Foot arch problems (both flat feet and high arches)o Obesity or sudden weight gaino Long-distance running, especially running downhill or on uneven surfaceso Sudden weight gaino Tight Achilles tendon (the tendon connecting the calf muscles to the heel)o Shoes with poor arch support or soft soles
150 Maria Carmela L. Domocmat, RN, MSN 3/5/2012s/s:• The most common complaint is pain and stiffness in the bottom of the heel. The heel pain may be dull or sharp. The bottom of the foot may also ache or burn.
151 Maria Carmela L. Domocmat, RN, MSN 3/5/2012s/so The pain is usually worse: In the morning when you take r first steps After standing or sitting for a while When climbing stairs After intense activityo The pain may develop slowly over time, or suddenly after intense activity.
152 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatmento conservative treatment: rest ice - at least twice a day for 10 - 15 minutes, more often in the first couple of days. stretching exercises strapping of foot to maintain arch orthotics
153 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatmento conservative treatment: heel stretching exercises resting as much as possible for at least a week shoes with good support and cushions wear heel cup, felt pads in the heel area, or shoe inserts use night splints to stretch the injured fascia and allow it to heal.
154 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatmento If these treatments do not work, doctor may recommend: Wearing a boot cast, which looks like a ski boot, for 3-6 weeks. It can be removed for bathing. Custom-made shoe inserts (orthotics) Steroid shots or injections into the heel NSAIDs or steroids endoscopic surgery – to remove inflamed tissue may be required
155 Maria Carmela 3/5/2012 L. Domocmat, RN, MSNBoot cast
156 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Orthotics
157 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Orthotic devices
158 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Expectations (prognosis)o Nonsurgical treatments almost always improve the pain.• Treatment can last from several months to 2 years before symptoms get better. Most patients feel better in 9 months. Some people need surgery to relieve the pain.
159 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Complicationso Pain may continue despite treatment.o Some may need surgery.
160Maria Carmela L. Domocmat, RN, MSN 3/5/2012
161 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Ingrown Nail• nail silver penetration of the skin, causing inflammation• occurs when the edge of the nail grows down and into the skin of the toe. There may be pain, redness, and swelling around the nail.
162 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Anatomy of a toenail
163 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Ingrown Nail• AKA: ▫ Onychocryptosis ▫ Unguis incarnatus ▫ Nail avlusion ▫ Matrix excision
164 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes, incidence, and risk factors• An ingrown toenail can result from a number of things,• but poorly fitting shoes and toenails that are not trimmed properly are the most common causes.• The skin along the edge of a toenail may become red and infected.• The great toe is usually affected, but any toenail can become ingrown.
165Maria Carmela L. Domocmat, RN, MSN 3/5/2012
166 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes, incidence, and risk factors• Ingrown toenails may occur when extra pressure is placed on toe.• Most commonly, this pressure is caused by shoes that are too tight or too loose.• If walk often or participate in athletics, a shoe that is even a little tight can cause this problem.• Some deformities of the foot or toes can also place extra pressure on the toe.
167 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Infected ingrown toenail
168 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes, incidence, and risk factorso Nails that are not trimmed properly can also cause ingrown toenails. When toenails are trimmed too short or the edges are rounded rather than cut straight across, the nail may curl downward and grow into the skin. Poor eyesight and physical inability to reach the toe easily, as well as having thick nails, can make improper trimming of the nails more likely. Picking or tearing at the corners of the nails can also cause an ingrown toenail.
169 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Causes, incidence, and risk factors• Some people are born with nails that are curved and tend to grow downward. Others have toenails that are too large for their toes. Stubbing your toe or other injuries can also lead to an ingrown toenail.
170 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment• If have diabetes, nerve damage in the leg or foot, poor blood circulation to foot, or an infection around the nail, go to the doctor right away.• Do NOT try to treat this problem at home (Bathroom treatment)
171 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatmento To treat an ingrown nail at home: Soak the foot in warm water 3 to 4 times a day if possible. Keep the toe dry, otherwise. Gently massage over the inflamed skin. Place a small piece of cotton or dental floss under the nail. Wet the cotton with water or antiseptic.
172 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment may trim the toenail one time, if needed. When trimming toenails: Consider briefly soaking your foot in warm water to soften the nail. Use a clean, sharp trimmer. Trim toenails straight across the top. Do not taper or round the corners or trim too short. Do not try to cut out the ingrown portion of the nail. This will only make the problem worse. Consider wearing sandals until the problem has gone away. Over-the-counter medications that are placed over the ingrown toenail may help some with the pain but do not treat the problem.
173 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Proper and improper toenail trimming.
174 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Treatment If this does not work and the ingrown nail gets worse, see family doctor, a foot specialist (podiatrist) or a skin specialist (dermatologist). removal of silver by podiatrist
175 Maria Carmela L. Domocmat, RN, MSN 3/5/2012partial nail avulsion o If ingrown nail does not heal or keeps coming back, doctor may remove part of the nail. o Numbing medicine is first injected into the toe. o Using scissors, your doctor then cuts along the edge of the nail where the skin is growing over. This portion of the nail is then removed. This is called a partial nail avulsion. o It will take 2 to 4 months for the nail to regrow
176 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Sometimes doctor will use a chemical,electrical current, or another small surgical cutto destroy or remove the area from which a newnail may grow.antibiotic ointment - If the toe is infected
177 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Prevention• Wear shoes that fit properly.• Shoes worn every day should have plenty of room around toes.• Shoes that wear for walking briskly or for running should have plenty of room also, but not be too loose.
178 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Preventiono When trimming toenails: Considering briefly soaking foot in warm water to soften the nail. Use a clean, sharp nail trimmer. Trim toenails straight across the top. Do not taper or round the corners or trim too short. Do not pick or tear at the nails. Keep the feet clean and dry. People with diabetes should have routine foot exams and nail care.
179Maria Carmela L. Domocmat, RN, MSN 3/5/2012
180Maria Carmela L. Domocmat, RN, MSN 3/5/2012
181 Maria Carmela L. Domocmat, RN, MSN 3/5/2012Hypertrophic Ungual Labium• chronic hypertrophy of nail lip• caused by improper nail trimming• results from untreated ingrown toenail• treatment: o surgical removal of necrotic nail and skin o treatment of secondary infection
182Maria Carmela L. Domocmat, RN, MSN 3/5/2012
183 Maria Carmela L. Domocmat, RN, MSN 3/5/2012References• Krug RJ, Lee EH, Dugan S, Mashey K. Hammer toe. In: Frontera WR, Silver JK, Rizzo TD Jr., eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 82.• http://www.ncbi.nlm.nih.gov/pubmedhealth/P MH0002215/
184 Maria Carmela L. Domocmat, RN, MSN 3/5/2012References• Ignatavicius and Workman (2006). Medical surgical nursing [5th ed]. Singapore: Elsevier.• http://www.epodiatry.com/corns-callus.htm• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 0004438/• http://www.bupa.co.uk/individuals/health- information/directory/c/corns• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 0002217/• http://orthoinfo.aaos.org/topic.cfm?topic=a00154