Top 10 Foot & Ankle Conditions What you need to know

By Patrick A. DeHeer, DPM Hoosier Foot & Ankle

Top 10 Foot & Ankle Conditions Equinus Heel Pain Onychocryptosis Onychomycosis Verrucae Plantaris Hallux Abducto Valgus Hammer Digit Syndrome Hallux Rigidus Morton’s Neuroma Insertional Achilles Tendonitis

Equinus Definition – no standard –< 5° AJ DF with KE –STJ NP & MTJ Locked Types – –Uncompensated –Partially Compensated –Compensated

Equinus Biomechanics –Balanced standing –Equinus effect on CoP –STJ axis relationship –Pressure changes

Equinus & Abnormal STJ Axis

Equinus Related Conditions 80-85% Foot & Ankle Pathologies ● Heel Spur Syndrome/Plantar Fasciitis ● Achilles Tendinopathy ● Posterior Tibial Tendon Dysfunction ● Diabetic Foot Ulcers ● Charcot Neuropathy ● Metatarsalgia ● Morton’s Neuroma ● Lesser MPJ pathologies – PDS, Capsulitis ● Hallux Valgus ● Hammer Digit Syndrome ● Ankle Fracture/Sprains ● Sever’s Disease ● Pediatric Flatfoot Deformity ● Osteoarthritis Forefoot/Midfoot ● 1st Ray Hypermobility ● Pes Plano Valgus ● Hallux Limitus ● Sesamoiditis ● Lateral Column Syndrome ● Freiberg’s Infarction ● Forefoot Callus

Equinus Conservative Management Ineffective Conservative Care –Manual stretching –Casting –Night splints Effective Conservative Care –EQ/IQ Brace

Equinus Surgical Management

Heel Pain 2,000,000 cases per year in US Diagnosis –History –Physical –Radiology –MRI –Ultrasound

Heel Pain Treatment Short term acute treatment –Treat symptoms and etiology –Symptoms – MDP Steroid injection RICE PT –Etiology – Equinus –Pronates foot –Twice pressure on PF as body weight –Bracing superior Strapping – 3 to 4 times Plantar Fascia Brace Immobilzation

Heel Pain Treatment Long term treatment – 80 to 90% improved –Stretching 2 to 3 months Maintenance therapy –Long-term arch support Custom Orthoses Resistant Cases – 10 to 15% –Baxter’s Neuritis – entrapment of 1 st branch of LPN Clinical SSX MRI – ABH muscle belly Dx injection Release of nerve entrapment and plantar fasciectomy

Heel Pain Treatment EWST – high amplitude, fast rising, asymmetrical, low frequency sound energy –80 to 90% effective in literature –3 treatments spaced weekly –2 to 3 bars, 11 to 13 Hz, 2000 to 3000 pulses –No NSAIDs for 8 weeks

Heel Pain Surgical Treatment Plantar fascia release –80 to 85% effective –Heel spur is not addressed –Biomechanical considerations –Gastroc Recession +/- PF relase

Onychocryptosis Dx – +/- paronychia –Incurvated nail plate –HNF –Granulation –POP –Erythema –Drainage Phenol & alcohol procedure –95% effective

Onychocryptosis

Onychomycosis Dx – 6.5 to 8.7% –History – other skin conditions? Immune system compromise? Age? Injury? –Physical Exam – Thick, yellow, dystrophic, discolored, onycholysis, odor, subungal debris –PAS stain – False negatives –Poor specimens Fungal elements –T. Rubrum –T. Epidermophyton –T. Microsporum Histological examination Mixed results?

Onychomycosis

Onychomycosis Treatment Topical – 10 to 30 % effective –Best combined with other treatments –Formula 3 Jojba oil Tolnafatate –Chronic Tinea Pedis treatment? –Hyperhidrosis treatment? Oral – 70 to 75% effective –Lamisil 250 mg qd –LFTs pre and midway –3 month therapy –9 to 12 months to evaluate success Chronic Tinea resolution at 1 month

Onychomycosis Treatment Laser Therapy –Cool Touch CT3 CoolBreeze –1320 nm –Nd:Yag laser –5 mm spot size –6 joules –40° to 45° C –80% Effective

Onychomcosis Treatment

Verrucae Plantaris Human Papilloma Virus – 46 strains 10% incidence in children and young adults Can resolve spontaneously Transmitted by contact Sites of trauma or irritation Contracted from other individuals in public traffic areas Located in epidermal layer – no scarring Clinically – –No skin lines –Encapsulated –PSTSP –Rete-pegs –HPK overlying

Verrucae Plantaris

VP treatment – not penetrate dermis –Oral vitamin A 10,000 IU with 15 mg zinc BID x 2 months –Oral Tagamet 1600 mg per day in divided doses Teens and younger 90% effective Keratolytic therapy – 20%, 40%, 60% Salicylic acid –Must debride HPK –Occlusion helpful –Changed dialy –Pumice stone to remove mascerated tissue and HPK Chemotherapy – similar to Keratolytic –Monochloroacetic acid –Bichloroacetic acid –Cantharidin 0.7% to 1.0% - green blister beetle

Verrucae Plantaris Cyrosurgery – carbon dioxide, liquefied nitrous oxide or liquid nitrogen –Freeze-thaw cycles –Ice formation, cellular dehydration, vascular stasis –Multiple treatments Candida injections Laser therapy

Verrucae Plantaris

Hallux Abducto Valgus Laterally deviated hallux with valgus rotation History – –Injury –Arthritis – OA, RA –Shoe gear –Activity level –Pain Physical exam – –Mild, moderate, severe –Hypermobile 1 st ray –Erythema 1 st MTH medially –POP –PROM –Tracking –Crepitus –Reducible –Equinus factor –Foot structure - pronated

Hallux Abducto Valgus

Hallux Abucto Valgus Radiologic Exam – –AP, Lateral, LO WB IM < HA < TSP PASA MPE Joint alignment Treatment – –Watchful neglect –Shoe gear change –Custom orthoses –Equinus management –Surgical Distal Procedures - Austin/Akin Proximal Procedures – Lapidus/Akin

Hallux Abucto Valgus

Hammer Digit Syndrome Etiology – –Flexor stabalization –Extensor substituion –Flexor substitution Types – –Hammer toe –Mallet toe –Claw toe Associated conditions –PDS –Cross-over toe

Hammer Digit Syndrome Symptoms – –Erythema –Helloma Durum –Helloma Molle –Pain –Edema –Arthrosis Physical Exam – –Rigid vs. Flexible –Level of deformity –MPJ involvement –Associated deformity – hypermobile 1 st ray Treatment – –Watchful neglect –Splinting –Toe spreader –Orthoses –Equinus management –Surgery Flexible – FDL Transfer Rigid – arthrodesis vs. arthroplasty

Hammer Digit Syndrome

Hallux Rigidus Normal 1 st MPJ DF - 60° to 70° Normal gait requires 35° DF 1 st MPJ Etiologies – –MPE due hypermobile 1 st ray –FF supinatus –Long 1 st MT –DJD –HAV –Systemtic arthritis SSx – –Pain –Swelling –Stiffness –Crepitus –Dorsal bony prominence –Sub hallux IPJ HPK –Sub 2 nd MTH HPK –Lateral metatarsalgia

Hallux Rigidus Radiologic Exam – –Subchondral sclerosis –Joint space narrowing –Flattening of MTH –Osteophytes

Hallux Rigidus Non Surgical Tx – –Rocker sole shoes –Custom orthoses –Equinus management –PT –Anti-inflammatory medication –Activity modification –Steroid injection Surgical Tx – –Joint preservation – Chielectomy Austin osteotomy Lapidus procedure –Joint destructive – 1 st MPJ arthrodesis Implant arthroplasty

Hallux Rigidus

Morton’s Neuroma Definition – perineural fibrosis Not a true neoplasm 3 rd IMS – Morton –MPN and LPN –Associated with IM Bursae Mulder’s Test SSx – –Pain b/w 3 rd & 4 th MTH –Burning –Shooting pain –Aggravated by WB –Aggravated by shoegear –Alleviated by rest –Alleviated by massage Diagnostic Examination –X-ray –MRI –Ultrasound –L/S injection

Morton’s Neuroma

Treatment – –Steroid injection –Oral steroids –Strapping –Orthoses –Change of shoe gear –EtOH injections –ESWT? –Surgery

Insertional Achilles Tendonitis Patient Type - –Older, less athletic, overweight and sedentary pts. –Young adult males - seronegative spondyloarthropathies SSX – –Posterior heel pain – dull aching pain Increased with standing, walking or running Aggravated by either active or passive ROM Patient Type - –Older, less athletic, overweight and sedentary pts. –Young adult males - seronegative spondyloarthropathies SSX – –Posterior heel pain – dull aching pain Increased with standing, walking or running Aggravated by either active or passive ROM Clinical Exam – –Localized tenderness near achilles insertion –May have localized edema –Achilles tendonitis and retrocalcaneal bursitis often seen with insertional posterior heel pain –Tendon thicken at insertion –Ankle equinus often associated finding Clinical Exam – –Localized tenderness near achilles insertion –May have localized edema –Achilles tendonitis and retrocalcaneal bursitis often seen with insertional posterior heel pain –Tendon thicken at insertion –Ankle equinus often associated finding

Insertional Achilles Tendonitis Radiographic Exam – –Ossification in the most proximal extent of the achilles insertion –Spurs may be incidental findings on x- rays and not be associated with any SSX - usually chronic inflammation is required for pain Radiographic Exam – –Ossification in the most proximal extent of the achilles insertion –Spurs may be incidental findings on x- rays and not be associated with any SSX - usually chronic inflammation is required for pain

Treatment Conservative TX – may be helpful initially –Training modification in athlete –NSAIDs –Heel lifts –Stretching and strengthening –Widening and deepening heel counter on shoes –Padding of the posterior heel –Night splint for more aggressive stretching –Immobilization x 6 weeks Conservative TX – may be helpful initially –Training modification in athlete –NSAIDs –Heel lifts –Stretching and strengthening –Widening and deepening heel counter on shoes –Padding of the posterior heel –Night splint for more aggressive stretching –Immobilization x 6 weeks Surgical TX – when conservative TX fails and SSX persist –Approach – Medial Lateral Posterior – linear or curvilinear Medial and lateral combined –Tendon reflection – Longitudinal midline incision of the achilles tendon Lateral to medial reflection of the achilles tendon Minimal reflection if spur is primarily posterior to tendon Surgical TX – when conservative TX fails and SSX persist –Approach – Medial Lateral Posterior – linear or curvilinear Medial and lateral combined –Tendon reflection – Longitudinal midline incision of the achilles tendon Lateral to medial reflection of the achilles tendon Minimal reflection if spur is primarily posterior to tendon

Treatment Resection of inflamed calcaneal bursa as needed Spur reduction and posterior calcaneal remodeling Achilles reattachment – AJ in NP –Soft Tissue anchors – 1 to 3 (inverted triangle) –Bone wax to prevent osseous activity due to exposed bleeding cancellous bone –Repair any soft tissue attachments to the tendon at this point with 2-0 absorbable suture Resection of inflamed calcaneal bursa as needed Spur reduction and posterior calcaneal remodeling Achilles reattachment – AJ in NP –Soft Tissue anchors – 1 to 3 (inverted triangle) –Bone wax to prevent osseous activity due to exposed bleeding cancellous bone –Repair any soft tissue attachments to the tendon at this point with 2-0 absorbable suture

Treatment

Questions???????????? Patrick A. DeHeer, DPM Shirley M. Catoire, DPM IU North – Johnson Memorial Hospital – Greenwood –Columbus – Shelbyville – Johnson Memorial Wound Healing Center Tel: Hoosierfootandankle.co m t