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

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Pronation
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Pronation
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Midfoot Problems

• Dorsal midfoot pain occurs secondary to
  arthritis. Bony prominencebossing
• Plantar midfoot pain is rare. Can be plantar
  fasciitis or fibromatosis.

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Midfoot Arthritis
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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.

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Plantar Fasciitis
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The Forefoot

• Bunions
• Funny toes
• Metatarsalgia
• Interdigital Neuroma
• Sesamoiditis
• Stress Fracture

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Bunions
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BunionsHallux 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)

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Bunion Xrays
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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

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Hallux Rigidus
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Hallux Rigidus
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Funny ToesHammer 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.

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Hammertoes
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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.

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Metatarsalgia
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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.

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Sesamoiditis
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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.

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Interdigital Neuroma
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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.

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Stress Fracture
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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.

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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.

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Plantar Fasciitis
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Plantar Heel Pain

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

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Heel Pad Pain
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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.

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Posterior Tibial Tendinitis
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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.

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Tarsal Tunnel Syndrome
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Foot Examination

• Become comfortable with apparent deformities,
  joint mobility, tendon insertions, vascular and
  neurologic examinations.

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Vascular Examination

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

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Neurologic Examination

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

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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

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Tendons

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

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Deformities

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

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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

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Treatment Options

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