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The Foot


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The Foot

  1. 1. The Foot Briant W. Smith, MD Orthopedic Surgery TPMG Santa Rosa
  2. 2. General Considerations <ul><li>VERY common problems. </li></ul><ul><li>Systemic disease is a major player (diabetes, vascular and neurologic diseases, inflammatory arthritis) </li></ul>
  3. 3. Divide the Foot into Thirds <ul><ul><li>Hindfoot Midfoot Forefoot </li></ul></ul>
  4. 4. Order Standing Radiographs <ul><li>AP and Lateral are Standing </li></ul><ul><li>Oblique is supine </li></ul>
  5. 5. Forefoot Problems <ul><li>Women far outnumber men because of shoe choices. Shoe modification is the first line of treatment for: </li></ul><ul><ul><li>Bunions </li></ul></ul><ul><ul><li>Neuromas </li></ul></ul><ul><ul><li>Metatarsalgia </li></ul></ul><ul><ul><li>Sesamoiditis </li></ul></ul>
  6. 6. Shoewear Problems
  7. 7. Over-Pronation <ul><li>Many foot problems are due to excessive pronation (flat feet): </li></ul><ul><ul><li>Plantar fasciitis </li></ul></ul><ul><ul><li>Achilles and posterior tibial tendinitis </li></ul></ul><ul><ul><li>Sesamoiditis </li></ul></ul><ul><ul><li>Bunions </li></ul></ul><ul><ul><li>Sinus tarsi and tarsal tunnel syndromes </li></ul></ul><ul><ul><li>Metatarsalgia </li></ul></ul>
  8. 8. Pronation
  9. 9. Pronation
  10. 10. Midfoot Problems <ul><li>Dorsal midfoot pain occurs secondary to arthritis. Bony prominence=‘bossing’ </li></ul><ul><li>Plantar midfoot pain is rare. Can be plantar fasciitis or fibromatosis. </li></ul>
  11. 11. Midfoot Arthritis
  12. 12. Hindfoot Problems <ul><li>Plantar fasciitis is the most common. Pain is plantar/medial. </li></ul><ul><li>Heel pad pain is usually a ‘stone bruise’ or due to atrophy of the fat pad. </li></ul><ul><li>Posterior tibial tendon dysfunction is the most overlooked problem of the foot. </li></ul>
  13. 13. Plantar Fasciitis
  14. 14. The Forefoot <ul><li>Bunions </li></ul><ul><li>Funny toes </li></ul><ul><li>Metatarsalgia </li></ul><ul><li>Interdigital Neuroma </li></ul><ul><li>Sesamoiditis </li></ul><ul><li>Stress Fracture </li></ul>
  15. 15. Bunions
  16. 16. Bunions Hallux Valgus <ul><li>The bunion is the enlarged medial prominence of the first MTP joint. </li></ul><ul><li>Often there are secondary lesser toe deformities (corns, calluses, hammertoes, bunionette) </li></ul><ul><li>Get xrays if patient is going to be referred. </li></ul><ul><li>TX: shoe change: widen the toe box , arch + heel support (bunion pads crowd shoe) </li></ul>
  17. 17. Bunion Xrays
  18. 18. 1 st MTP Arthritis <ul><li>Hallux rigidus (ortho) or limitus (pod) </li></ul><ul><li>1 st MTP can be swollen, spur is dorsal on the xray. </li></ul><ul><li>Limited MTP extension (compare to other foot), pain is during the toe-off phase of walking. </li></ul><ul><li>Tx with stiff soled shoes, NSAIDs </li></ul>
  19. 19. Hallux Rigidus
  20. 20. Hallux Rigidus
  21. 21. Funny Toes Hammer and Claw Toes <ul><li>Usually due to IMPROPER SHOE WEAR </li></ul><ul><li>Claws are usually seen in diabetics. These are fixed extension of MPJ, and flexion of PIP and DIP joints. </li></ul><ul><li>Hammertoes have flexion deformities of the PIP joint, and flexible MP and DIP joints. </li></ul><ul><li>Can develop corns and calluses </li></ul><ul><li>Tx with wide shoes and toe straps, pads OK; non-operative treatment as long as it is flexible . </li></ul>
  22. 22. Hammertoes
  23. 23. Metatarsalgia <ul><li>It just means forefoot pain. </li></ul><ul><li>Pain is under a metatarsal head (usually 2 nd ) as opposed to between the heads for neuromas. </li></ul><ul><li>Often associated with hammertoes and calluses. </li></ul><ul><li>Get wider shoes, use metatarsal pads or cut-outs, shave the calluses. </li></ul>
  24. 24. Metatarsalgia
  25. 25. Sesamoiditis <ul><li>Sesamoids are embedded in the flexor hallucis brevis tendon beneath the first metatarsal head. </li></ul><ul><li>Caused by repeated stress, and can be inflamed, fracture, or even get arthritic. </li></ul><ul><li>Very tender, will move with flex/ext of great toe MPJ. Get xrays. </li></ul><ul><li>Tx: stiff shoe, pads/cut-outs; no heels. </li></ul>
  26. 26. Sesamoiditis
  27. 27. Interdigital Neuroma <ul><li>Really ‘perineural fibrosis’ secondary to repetitive irritation (from tight shoes!) </li></ul><ul><li>90% are in the third interspace; rest in 2nd </li></ul><ul><li>Feels like walking on a pebble. Feels better out of shoes. </li></ul><ul><li>+ squeeze test. Pain is between MT heads. </li></ul><ul><li>Tx: wide shoes, MT pads/cut-outs, inject. </li></ul>
  28. 28. Interdigital Neuroma
  29. 29. Stress Fracture <ul><li>Pain directly over a metatarsal, usually more proximal than MT heads. </li></ul><ul><li>Change in activities, worse with wt bearing </li></ul><ul><li>Initial xray often normal. Bone scan positive early. </li></ul><ul><li>Tx with modified activity, stiff soled shoe or boot/cast, time. </li></ul>
  30. 30. Stress Fracture
  31. 31. Midfoot Arthritis <ul><li>Dorsal bossing or spurs over the involved joint(s). </li></ul><ul><li>XR and/or bone scan will show changes. </li></ul><ul><li>Tx with stiff soled shoes, firm arch support, NSAIDs, activity modification. </li></ul>
  32. 32. Plantar Fasciits <ul><li>Pain with arising, especially first AM steps </li></ul><ul><li>Almost always at plantar-medial origin. </li></ul><ul><li>Inflammation and chronic degeneration. </li></ul><ul><li>Worse with obesity, overpronation. </li></ul><ul><li>Not due to spurs </li></ul><ul><li>Tx: Arch support, elevate heel . NO barefeet, flat shoes; NSAIDs, injections, PT for ultrasound. </li></ul>
  33. 33. Plantar Fasciitis
  34. 34. Plantar Heel Pain <ul><li>Can be traumatic (stone bruise) or common in elderly as fat pad atrophies. </li></ul><ul><li>Add a pad, like Spenco gel heel cushions. </li></ul>
  35. 35. Heel Pad Pain
  36. 36. Posterior Tibial Tendinitis (PTT) <ul><li>Most missed problem of the foot. </li></ul><ul><li>Pain/aching between navicular and medial malleolus. Looks swollen </li></ul><ul><li>Flatfeet. Heel should invert with rising on toes. </li></ul><ul><li>Tx: arch supports, slight heel. NSAIDs and PT for u/s. </li></ul>
  37. 37. Posterior Tibial Tendinitis
  38. 38. Tarsal Tunnel Syndrome <ul><li>Post Tib nerve gets entrapped near med malleolus. Plantar tingling/burning as opposed to pain/swelling of PTT. Not whole foot like with diabetes. </li></ul><ul><li>+ Tinel test; can be loss of PP sensation, can be toe clawing. </li></ul><ul><li>Tx: arch support if overpronated. Consider NCV tests. </li></ul>
  39. 39. Tarsal Tunnel Syndrome
  40. 40. Foot Examination <ul><li>Become comfortable with apparent deformities, joint mobility, tendon insertions, vascular and neurologic examinations. </li></ul>
  41. 41. Vascular Examination <ul><li>Foot color—dependent and on elevation </li></ul><ul><li>Edema </li></ul><ul><li>Pulses </li></ul><ul><li>Capillary Refill </li></ul><ul><li>Hair distribution </li></ul>
  42. 42. Neurologic Examination <ul><li>Lumbar dermatomes vs. specific nerves vs systemic disease </li></ul><ul><li>Light touch for gross testing </li></ul><ul><li>Semmes-Weinstein 5.07 monofilament for diabetics. </li></ul>
  43. 43. Range of Motion <ul><li>Should be symmetric </li></ul><ul><li>Ankle dorsiflexion 10 deg with knees ext. </li></ul><ul><li>Subtalar joint should be mobile. </li></ul><ul><li>1 st MTP joint extension should be >60 deg </li></ul>
  44. 44. Tendons <ul><li>Achilles insertion and body of tendon </li></ul><ul><li>Posterior tibial tendon </li></ul><ul><li>Peroneal tendons </li></ul>
  45. 45. Deformities <ul><li>Pump bump </li></ul><ul><li>Talar head </li></ul><ul><li>NWB and WB for pes planus/cavus </li></ul><ul><li>1 st MTP joint </li></ul><ul><li>Lesser toes </li></ul>
  46. 46. Treatment Arsenal <ul><li>Change shoes </li></ul><ul><li>OTC arch supports and insoles, pads </li></ul><ul><li>Custom Orthotics </li></ul><ul><li>Calf stretching/toe rises </li></ul><ul><li>Activity modification (swimming/biking) </li></ul><ul><li>Weight loss </li></ul><ul><li>Night splints/boots/casts </li></ul>
  47. 47. Treatment Options <ul><li>Physical therapy </li></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>Interferential stimulation </li></ul></ul><ul><li>Contrast soaks (10 mins warm, 30 secs ice cold, repeat x2, end with cold) </li></ul><ul><li>NSAIDS </li></ul><ul><li>Injections </li></ul>