1 / 47

The Foot

The Foot Briant W. Smith, MD Orthopedic Surgery TPMG Santa Rosa General Considerations VERY common problems. Systemic disease is a major player (diabetes, vascular and neurologic diseases, inflammatory arthritis) Divide the Foot into Thirds

benjamin
Download Presentation

The Foot

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

  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. • 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.

  13. Plantar Fasciitis

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

  15. Bunions

  16. 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)

  17. Bunion Xrays

  18. 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

  19. Hallux Rigidus

  20. Hallux Rigidus

  21. 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.

  22. Hammertoes

  23. 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. Metatarsalgia

  24. Metatarsalgia

  25. 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.

  26. Sesamoiditis

  27. 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.

  28. Interdigital Neuroma

  29. 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.

  30. Stress Fracture

  31. 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.

  32. 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.

  33. Plantar Fasciitis

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

  35. Heel Pad Pain

  36. 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.

  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. • + Tinel test; can be loss of PP sensation, can be toe clawing. • 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.

  41. Vascular Examination • Foot color—dependent and on elevation • Edema • Pulses • Capillary Refill • Hair distribution

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

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

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

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

  46. 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

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

More Related