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

1 st MTP Arthritis  Hallux rigidus (ortho) or limitus (pod)  1 st 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 2 nd ) 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.

 1 st 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  1 st 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