Common Foot Problems

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Common Foot Problems

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

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Common Foot Problems

• Anatomy
• Bones

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Anatomy - Bones
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Anatomy - Bones
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Anatomy - Vascular
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Anatomy -Nervous
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Anatomy -Nervous
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Anatomy - Musculoskelatal
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Anatomy - Musculoskelatal

• Where does the Achilles tendon derives its name?
• Hint

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Greek Mythology

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

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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

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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

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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

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Bunions - Hallux Valgus
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Bunions - Hallux Valgus
Not so much good luck But you can cross them
anyway.
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Bunions - Hallux Valgus

• NOT likely from high heel shoes (Myth)
• High heels may exacerbate the underlying etiology.

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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

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Hallux Valgus - Etiology

• Biomechanical instability
• Most common
• Difficult to understand and evaluate
• Genetically inherited and/or from underlying
  conditions

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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

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Hallux Valgus - Etiology

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

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Bunions - Hallux Valgus
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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.

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Presentation

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

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Evaluation Labs and XRay

• Uric acid, ESR, CRP, ANA, RF
• Foot AP, Lat, and Oblique

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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.

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Hallux Valgus - Treatment

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

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Look good and feels good.
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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

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Heel Pain
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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.

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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).

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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)

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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

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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.

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Plantar Fasciitis - Physical Exam

• Point of maximal tenderness at the anteromedial
  region of the calcaneus.
• Pain along the proximal plantar fascia.

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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

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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.

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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.

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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

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Ankle Sprain
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Ankle Sprain
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Ankle Sprain

• Anterior drawer test - assess the integrity of
  the anterior talofibular ligament
• Inversion stress test - assess the integrity of
  the calcaneofibular ligament

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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)

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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

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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

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Ankle Sprain

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

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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

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Ingrown toenails

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

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Ingrown toenails

• Stage 2
• increased symptoms,
• drainage, and
• infection.

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Ingrown toenails

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

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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)

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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

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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.