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

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 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.

22. Hammertoes

23. 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.

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