9/18/2015

1

Common Ailments of the footBettricia Otto DPM, FACFAS

Plantar fasciitisSymptoms: Stabbing sensation in the heel Pain worse in the morning when getting

out of bed or after prolonged seating and decreases after the first several steps.

Limping, tenderness, swelling, stiff sensation

Can be caused by prolonged standing

Plantar fasciitis

9/18/2015

2

Plantar fasciitis One of the most common causes of heel

pain. Caused by inflammation, micro tearing of

the fascia

Plantar fasciitis Risks

Obesity Working long hours on hard surfaces Age Exercise with repetitive stress to the heels Foot mechanics ie. Pes planus, pes cavus

Plantar fasciitis Can get xray but will commonly see a

heel spur. These are common and often blamed for plantar fascial symptoms but can also be seen on xrays in people who do not have plantar fasciitis.

Stress fracture Pinched nerve

9/18/2015

3

Plantar fasciitis Differential diagnosis1. pinched nerve2. Calcaneal stress fracture

Plantar fasciitis treatment

Anti-inflammatories Physical therapy Night splints Orthotics Steroid shots. ECSWT, Tenex, etc Surgery

Plantar fasciitis treatment continued

Weight loss Supportive shoe gear, changing shoes

frequently if a runner Changing exercises Icing Stretching

9/18/2015

4

Freidberg’s Avascular necrosis of the metatarsal

head. Most commonly affects the 2nd

metatarsal head. Can be difficult to diagnose on plain

radiographs Diagnosis primarily made on H& P

Freidberg’s

Freigberg’s symptoms

Swelling Pain upon ROM of the 2nd MPJ Pain with compaction of the MPJ Pain with ambulation

9/18/2015

5

Freiberg’s diagnosis

Xray- may not show anything initially but can eventually see osteopenia in the metatarsal head, flattening of metatarsal head, loose bodies, arthritic changes

MRI- can be used to diagnose in the early stages will show increase signal intensity on T-2 images

Freiberg’s treatment

Conservative: immobilization in boot or cast with or without crutches for 4-6 weeks, or until symptoms resolve then gradual return to normal activity. Orthotics, shoes modifications.

Surgical: cleaning up the joint, cartilage replacement, implants, resection of the metatarsal head.

Hallux limitus definition

Hallux limitus:-A degenerative process of the joint characterized by decreased Range of Motion of the Hallux. Over a period of time this jamming forms a dorsal bump on the head of the 1st Metatarsal and is often referred to as a dorsal bunion. Eventually can lead to joint ankyloses and loss of motion.

9/18/2015

6

Hallux limitus Several etiologies including

Biomechanical, Neuromuscular, Iatrogenic, traumatic, metabolic, anatomic/structural. Four common factors is: 1) Systemic dz (Gout, RA), 2)Injury to the joint (turf toe, jamming etc.) 3)Metatarsus primus elevatus 4) Long 1st

metatarsal

Hallux limitus Stage I – No symptoms to vague joint

pain, decreased dorsiflexion of the 1st

MPJ. X-rays show no changes, can show mild dorsal enlargement. One or more etiologic factors.

Hallux limitus Stage II – Decreased dorsiflexion, pain

with end ROM, increased frequency of pain. x-ray finding such as subchondral sclerosis, mild joint space narrowing with asymmetry, mild dorsal exostosis.

9/18/2015

7

Hallux limitus

Hallux limitus Stage III- Inflammatory arthritis, pain with

activity, Limited ROM which is very noticeable. Impingement with nerve type symptoms with shoe gear. Increased dorsal exostosis, subchondral cyst, irregular narrowing with practical obliteration.

Hallux limitus

9/18/2015

8

Hallux limitus Stage IV- Significant pain with attempted

ROM of the joint to no pain within the joint just with bony protrusions of joint. Joint is enlarged. X-ray findings can show flattening of the joint with surrounding spurring of the joint to ankyloses with no joint space visible.

Hallux limitus

Hallux limitus

9/18/2015

9

Hallux limitus STAGE I- Orthotics with reverse morton’s

extension or padding, rigid rocker bottom type shoes

Hallux limitus/Hallux rigidus

Plantar warts Caused by Human papillomavirus (HPV)

which enters the body via tiny abrasions in the skin. These can cause discomfort and pain.

9/18/2015

10

Plantar warts Black pinpoints which are small clotted

vessels Disrupts normal lines and ridges of the skin

in the foot.

Plantar wartsTreatment: Most clear up on their own but laser therapy,

cryotherapy, acid treatments ( Salicyclic acid, cantharone) surgical excision. No single treatment is 100% effective

Imiquimod 5-Flurouracil Bleomycin sulphate Candida antigen Interferon-alpha

Plantar warts Oral medication (Retinoids, Cimetidine,

Diindolymethane) Laser Surgical excision

9/18/2015

11

Onychomycosis

A fairly common disease of the toenail . The two most common causes of Onychomycosis are Trichophyton mentagrophytes and Trichophyton rubrum. Less commonly it can be caused by molds or yeast as well. Some families have a genetic predisposition for T. rubrum.

Onychomycosis

Onychomycosis Test that can be ordered to confirm

onychomycosis are Periodic acid-Schiff (PAS), KOH, PCR. Fungal cultures are more difficult to obtain, hard to culture and takes weeks to grow cultures.

9/18/2015

12

Onychomycosis Tinea pedis is linked to onychomycosis.

Onychomycosis often starts as Tinea pedis. Important that you treat both of these. If you only treat tinea pedis and patient has onychomycosis, onychomycosis can re-infect the skin.

Onychomycosis is more common in diabetic than those who are non-diabetic.

Onychomycosis Lasers: has become quite popular very

little data to determine if this is effective . The FDA approved it because it can cause “temporary improvement of the appearance of the toenail” and not actually labelled for treatment of Onychomycosis.

Onychomycosis controlling recurrence

Use maintenance regimens of antifungal agents (Limits growth of fungi on nails)

Discard old shoes (removes fungal reservoir) Alternate wearing different pairs of shoes

(allows shoes to dry, reduces fungal load in footwear.

Wash feet regularly ( minimizes fungal presence on the feet.

Alert provider at first sign of infection (minimizes progression of infection)

9/18/2015

13

Onychomycosis (treatment) Topical (Efinaconazole- 53-55% effective) Oral (Itraconazole 54% , Terbinafine 70%)

% of Mycologic cure

Stress fractures Overuse injury of bone. The more the load

the more calcium will be placed at the site . Increased overloads can overwhelm repair and small cracks can occur within the bone structure.

Stress fracture

9/18/2015

14

Stress fracture -Symptoms Pain Swelling Inability to bear weight

Stress fracture diagnosis Plain film may not initially show fracture

should plan to treat as a fracture and see patient back in 2 weeks to repeat xrays.

MRI CT Scan

Stress fracture (treatment) Rest, Ice , compression, elevation Immobilize (cast or boot) sometimes for at

least 6-8 weeks depending on bone fractured.

PT once healing has occurred and in athletes to try and prevent future injury.

9/18/2015

15

Plantar plate injury Common in over pronators and in middle

aged women. Plantar plate is a thick ligament which

inserts into the base of the phalanges plantarly. It protects the head of the metatarsal from pressure and prevents over extension of our toes also spreading or splaying.

Plantar plate injury

Plantar plate symptoms Swelling under the ball of the foot

extending into the toes seen commonly in the 2nd MPJ and sometimes on the dorsum of the foot.

Sensation of walking on bones Positive Lachman’s test Splaying of toes and clawing

9/18/2015

16

Plantar plate injury diagnosis Careful history Xrays Diagnostic ultrasound MRI

Plantar plate injury treatment Conservative (anti-inflammatories,

strapping of toe, offloading padding, altering activity, changing shoe gear, determining biomechanical cause, orthotics)

Surgical ( plantar plate repair, osteotomy)

Can take 3-4 months to improve symptoms in some cases.

Intermetatarsal neuroma Commonly occurring between the 3rd

and 4th metatarsals called “Morton’s neuroma”

Thickening/enlargement of the nerve as a result of irritation of the nerve

9/18/2015

17

Intermetatarsal neuroma

Intermetatarsal Neuroma Causes:1. Compression from shoe gear2. Activities such as running, court sports,

any activity that involve repetitive irritation to the ball of the foot.

Intermetatarsal neuroma Symptoms:1. Pain2. Feeling of “bunched up sock”3. Feeling of a “pea”4. Burning numbness, tingling sensation

9/18/2015

18

Intermetataral neuroma Treatment:1. Activity modifications2. Padding3. Anti-inflammatories, icing4. Orthotics5. Wide toe box shoes6. Injection therapy –cortisone, injections,

alcohol sclerosing injection therapy

References:

Dananberg HJ. Sagittal plane biomechanics. In: Subotnick SI, ed. Sports Medicine of the lower extremity. New York: Churchill Livingstone; 1999: 137-156

Hetherington VJ, Carnett J, Patterson BA. Motion of the first metatarsophalangeal joint. J Foot Surgery 1989;28(1):13-19.

Clough JG. Functional hallux limitus and lesser metatarsal overload. J Am Podiatric Med Assoc2005;95(6):593-601

Photos: Myfootshop.com, fdafac.com Video: www.drglass.org

http://www.youtube.com/watch?v=1gPcoRVuF9I

References: Levy LA. Epidemiology of onychomycosis in special risk

populations. J AM Podiatr Med Assoc. 1997: 87 (12):546-50 Bodman, M. Keys to managing severe Onychomycosis.

Podiatry today. Volume 25-Issue 5-May 2013 Gupta AK. Simpson FC. New therapeutic options for

onychomycosis. Expert Opin Pharmacothera. 2012 Jun;13 (8):1131-42

Weber C, Hoffman K. How to treat recalcitrant plantar warts. Podiatry today. Volume 26- issuey- July 2013

Leung L. Recalcitrant nongenital warts. Aust Family Physician. 2011;40(1-2):40-2.

9/18/2015

19

References Jacobs, A. An Evidence-Based Medicine approach

to plantar fasciitis. Podiatry Today. Volume 26-Issue11-Nov 2013

Mahowald S, LeggeBS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J AM PodiatrMed Assoc. 2011;101(5):385-9

Cerrato RA. Freiberg’s disease. Foot Ankle Clin N AM. 2011; 16(4):647-58.

Joseph. W. Onychomycosis and the Role of Topical Antifungals. (table1:Preventative strategies to control recurrence of Onychomycosis). Podiatry today: Nov 2013

References: Leung L. Recalcitrant nongenital warts. Aust Family

Physician. 2011: 40 (1-2):40-2 James WD, Berger TG, et al. Andrews’ Diseases of the

Skin:Clinical Dermatology. Saunders Elsevier, Philadelphia, 2006.

Fullem, B. Managing Stress Fractures in Athletes. Podiatry Today. Volume 25-Issue 1- January 2012.

Cruveilhier J. The Anatomy of the Human Body Harper& Bros, New York, 1844, pp.176

Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle. 1993;14:309-319.

DeHeer, P. A Practical approach to Morton’s Neuroma. Podiatry today. Sept 2010.