Briant W. Smith, MD Orthopedic Surgery TPMG Santa Rosa 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 Hindfoot Midfoot Forefoot

Order Standing Radiographs AP and Lateral are Standing Oblique is supine

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

Shoewear Problems

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

Pronation

Pronation

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

Midfoot Arthritis

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.

Plantar Fasciitis

The Forefoot Bunions Funny toes Metatarsalgia Interdigital Neuroma Sesamoiditis Stress Fracture

Bunions

Bunions Hallux 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)

Bunion Xrays

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

Hallux Rigidus

Hallux Rigidus

Funny Toes Hammer 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.

Hammertoes

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.

Metatarsalgia

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.

Sesamoiditis

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.

Interdigital Neuroma

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.

Stress Fracture

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.

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.

Plantar Fasciitis

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

Heel Pad Pain

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.

Posterior Tibial Tendinitis

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.

Tarsal Tunnel Syndrome

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

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

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

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

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

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

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

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