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The Foot Briant W. Smith, MD Orthopedic Surgery TPMG Santa Rosa.

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Presentation on theme: "The Foot Briant W. Smith, MD Orthopedic Surgery TPMG Santa Rosa."— Presentation transcript:

1 The Foot Briant W. Smith, MD Orthopedic Surgery TPMG Santa Rosa

2 General Considerations VERY common problems. VERY common problems. Systemic disease is a major player (diabetes, vascular and neurologic diseases, inflammatory arthritis) 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 AP and Lateral are Standing Oblique is supine Oblique is supine

5 Forefoot Problems Women far outnumber men because of shoe choices. Shoe modification is the first line of treatment for: Women far outnumber men because of shoe choices. Shoe modification is the first line of treatment for: Bunions Bunions Neuromas Neuromas Metatarsalgia Metatarsalgia Sesamoiditis Sesamoiditis

6 Shoewear Problems

7 Over-Pronation Many foot problems are due to excessive pronation (flat feet): Many foot problems are due to excessive pronation (flat feet): Plantar fasciitis Plantar fasciitis Achilles and posterior tibial tendinitis Achilles and posterior tibial tendinitis Sesamoiditis Sesamoiditis Bunions Bunions Sinus tarsi and tarsal tunnel syndromes Sinus tarsi and tarsal tunnel syndromes Metatarsalgia Metatarsalgia

8 Pronation

9 Pronation

10 Midfoot Problems Dorsal midfoot pain occurs secondary to arthritis. Bony prominence=bossing Plantar midfoot pain is rare. Can be plantar fasciitis or fibromatosis.

11 Midfoot Arthritis

12 Hindfoot Problems Plantar fasciitis is the most common. Pain is plantar/medial. 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. 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. Posterior tibial tendon dysfunction is the most overlooked problem of the foot.

13 Plantar Fasciitis

14 The Forefoot Bunions Bunions Funny toes Funny toes Metatarsalgia Metatarsalgia Interdigital Neuroma Interdigital Neuroma Sesamoiditis Sesamoiditis Stress Fracture Stress Fracture

15 Bunions

16 Bunions Hallux Valgus The bunion is the enlarged medial prominence of the first MTP joint. The bunion is the enlarged medial prominence of the first MTP joint. Often there are secondary lesser toe deformities (corns, calluses, hammertoes, bunionette) Often there are secondary lesser toe deformities (corns, calluses, hammertoes, bunionette) Get xrays if patient is going to be referred. Get xrays if patient is going to be referred. TX: shoe change: widen the toe box, arch + heel support (bunion pads crowd shoe) TX: shoe change: widen the toe box, arch + heel support (bunion pads crowd shoe)

17 Bunion Xrays

18 1 st MTP Arthritis Hallux rigidus (ortho) or limitus (pod) Hallux rigidus (ortho) or limitus (pod) 1 st MTP can be swollen, spur is dorsal on the xray. 1 st 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. Limited MTP extension (compare to other foot), pain is during the toe-off phase of walking. Tx with stiff soled shoes, NSAIDs Tx with stiff soled shoes, NSAIDs

19 Hallux Rigidus

20

21 Funny Toes Hammer and Claw Toes Usually due to IMPROPER SHOE WEAR 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. 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. Hammertoes have flexion deformities of the PIP joint, and flexible MP and DIP joints. Can develop corns and calluses Can develop corns and calluses Tx with wide shoes and toe straps, pads OK; non-operative treatment as long as it is flexible. Tx with wide shoes and toe straps, pads OK; non-operative treatment as long as it is flexible.

22 Hammertoes

23 Metatarsalgia It just means forefoot pain. It just means forefoot pain. Pain is under a metatarsal head (usually 2 nd ) as opposed to between the heads for neuromas. Pain is under a metatarsal head (usually 2 nd ) as opposed to between the heads for neuromas. Often associated with hammertoes and calluses. Often associated with hammertoes and calluses. Get wider shoes, use metatarsal pads or cut-outs, shave the calluses. Get wider shoes, use metatarsal pads or cut-outs, shave the calluses.

24 Metatarsalgia

25 Sesamoiditis Sesamoids are embedded in the flexor hallucis brevis tendon beneath the first metatarsal head. 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. 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. Very tender, will move with flex/ext of great toe MPJ. Get xrays. Tx: stiff shoe, pads/cut-outs; no heels. Tx: stiff shoe, pads/cut-outs; no heels.

26 Sesamoiditis

27 Interdigital Neuroma Really perineural fibrosis secondary to repetitive irritation (from tight shoes!) Really perineural fibrosis secondary to repetitive irritation (from tight shoes!) 90% are in the third interspace; rest in 2nd 90% are in the third interspace; rest in 2nd Feels like walking on a pebble. Feels better out of shoes. Feels like walking on a pebble. Feels better out of shoes. + squeeze test. Pain is between MT heads. + squeeze test. Pain is between MT heads. Tx: wide shoes, MT pads/cut-outs, inject. Tx: wide shoes, MT pads/cut-outs, inject.

28 Interdigital Neuroma

29 Stress Fracture Pain directly over a metatarsal, usually more proximal than MT heads. Pain directly over a metatarsal, usually more proximal than MT heads. Change in activities, worse with wt bearing Change in activities, worse with wt bearing Initial xray often normal. Bone scan positive early. Initial xray often normal. Bone scan positive early. Tx with modified activity, stiff soled shoe or boot/cast, time. Tx with modified activity, stiff soled shoe or boot/cast, time.

30 Stress Fracture

31 Midfoot Arthritis Dorsal bossing or spurs over the involved joint(s). Dorsal bossing or spurs over the involved joint(s). XR and/or bone scan will show changes. XR and/or bone scan will show changes. Tx with stiff soled shoes, firm arch support, NSAIDs, activity modification. Tx with stiff soled shoes, firm arch support, NSAIDs, activity modification.

32 Plantar Fasciits Pain with arising, especially first AM steps Pain with arising, especially first AM steps Almost always at plantar-medial origin. Almost always at plantar-medial origin. Inflammation and chronic degeneration. Inflammation and chronic degeneration. Worse with obesity, overpronation. Worse with obesity, overpronation. Not due to spurs Not due to spurs Tx: Arch support, elevate heel. NO barefeet, flat shoes; NSAIDs, injections, PT for ultrasound. Tx: Arch support, elevate heel. NO barefeet, flat shoes; NSAIDs, injections, PT for ultrasound.

33 Plantar Fasciitis

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

35 Heel Pad Pain

36 Posterior Tibial Tendinitis (PTT) Most missed problem of the foot. Most missed problem of the foot. Pain/aching between navicular and medial malleolus. Looks swollen Pain/aching between navicular and medial malleolus. Looks swollen Flatfeet. Heel should invert with rising on toes. Flatfeet. Heel should invert with rising on toes. Tx: arch supports, slight heel. NSAIDs and PT for u/s. Tx: arch supports, slight heel. NSAIDs and PT for u/s.

37 Posterior Tibial Tendinitis

38 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. 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. + Tinel test; can be loss of PP sensation, can be toe clawing. Tx: arch support if overpronated. Consider NCV tests. Tx: arch support if overpronated. Consider NCV tests.

39 Tarsal Tunnel Syndrome

40 Foot Examination Become comfortable with apparent deformities, joint mobility, tendon insertions, vascular and neurologic examinations. Become comfortable with apparent deformities, joint mobility, tendon insertions, vascular and neurologic examinations.

41 Vascular Examination Foot colordependent and on elevation Foot colordependent and on elevation Edema Edema Pulses Pulses Capillary Refill Capillary Refill Hair distribution Hair distribution

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

43 Range of Motion Should be symmetric Should be symmetric Ankle dorsiflexion 10 deg with knees ext. Ankle dorsiflexion 10 deg with knees ext. Subtalar joint should be mobile. Subtalar joint should be mobile. 1 st MTP joint extension should be >60 deg 1 st MTP joint extension should be >60 deg

44 Tendons Achilles insertion and body of tendon Achilles insertion and body of tendon Posterior tibial tendon Posterior tibial tendon Peroneal tendons Peroneal tendons

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

46 Treatment Arsenal Change shoes Change shoes OTC arch supports and insoles, pads OTC arch supports and insoles, pads Custom Orthotics Custom Orthotics Calf stretching/toe rises Calf stretching/toe rises Activity modification (swimming/biking) Activity modification (swimming/biking) Weight loss Weight loss Night splints/boots/casts Night splints/boots/casts

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


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