musculoskeletal disorders part 6 disorders of the feet

Disorders of FeetDisorders of Feet

Maria Carmela L. Domocmat, RN, MSN

Instructor

Northern Luzon Adventist College

Overview

• Part 1: Degenerative & Metabolic bone disorders:

• Part 2: Bone infections

3/5/2012Maria Carmela L. Domocmat, RN, MSN

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• Part 2: Bone infections

• Part 3: Muscular disorders

• Part 4: Disorders of the hand

• Part 5: Spinal column deformities

• Part 6 : Disorders of feet

• Part 7: Sports Injuries

Disorders of Feet

• Hallux valgus (bunions)

• Morton’s neuroma (plantar neuroma)

• Hammer toe


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• Hammer toe

• Tarsal tunnel syndrome

• Plantar Fasciitis

• Corn

• Callus

• Ingrown Nail

• Hypertrophic Ungual Labium

Disorders of Feet

• Hallux valgus (bunions), Morton’s neuroma(plantar neuroma), Hammer toe , Tarsal tunnel syndrome , Plantar Fasciitis, Corn, Callus,


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syndrome , Plantar Fasciitis, Corn, Callus, Ingrown Nail, Hypertrophic Ungual Labium


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http://familyfootcarenj.com/web/images/layout/conditions_map.jpg


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Hallux valgus

• is a condition that affects the joint at the base of the big toe.

• The condition is commonly called a bunion.

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• The condition is commonly called a bunion.

▫ bunion - refers to the bump that grows on the side of the first metatarsophalangeal (MTP) joint.

Hallux valgus (bunion)

• The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal.

• Over time, the 1st metatarsal will begin to move

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• Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral).

http://www.footankleinstitute.com/hallux-valgus-bunion-surgery/


• As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground.

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and the ground.

• this constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot.



• The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due

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Over time arthritis can develop in the joint due to the mal-positioned joint.

• A bunion deformity is always progressive. It will always get worse over time.


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• term hallux valgus actually describes what happens to the big toe.▫ Hallux - medical term for big toe

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▫ Hallux - medical term for big toe▫ Valgus - anatomic term that means the deformity

goes in a direction away from the midline of the body.

• hallux valgus - big toe begins to point towards the outside of the foot. ▫ As this condition worsens, other changes occur in

the foot that increase the problem.

Etiology

• Contrary to common belief,

▫ high-heeled shoes with a small toe box or tight-fitting shoes do not cause hallux valgus.

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fitting shoes do not cause hallux valgus.

▫ such footwear does keep the hallux in an abducted position if hallux valgus is present, causing mechanical stretch and deviation of the medial soft tissue.

▫ In addition, tight shoes can cause medial bump pain and nerve entrapment.

Etiology

• Biomechanical instability

• Arthritic/metabolic conditions

• Structural deformity

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• Structural deformity

• Neuromuscular disease

• Traumatic compromise

Etiology

• Biomechanical instability▫ most common yet most difficult to understand etiology ▫ Contributing factors, if present, include

� gastrocnemius or gastrocsoleus equinus,

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� gastrocnemius or gastrocsoleus equinus,

� flexible or rigid pes plano valgus,

� rigid or flexible forefoot varus,

� dorsiflexed first ray,

� hypermobility, or

� short first metatarsal.

� Most often, excessive pronation at the midtarsal and subtalar joints compensates for these factors throughout the gait cycle.

Etiology

• Biomechanical instability

▫ Some pronation must occur in gait to absorb ground-reactive forces. However, excessive

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ground-reactive forces. However, excessive pronation produces too much midfoot mobility, which decreases stability and prevents resupination and creation of a rigid lever arm; these effects make propulsion difficult.

Etiology

• Biomechanical instability▫ During normal propulsion

� approximately 65° of dorsiflexion is necessary at the first metatarsophalangeal joint,

� only 20-30° is available from hallux dorsiflexion.

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� only 20-30° is available from hallux dorsiflexion. � Therefore, the first metatarsal must plantarflex at the sesamoid

complex to gain the additional 40° of motion needed. � Failure to attain the full 65° because of jamming of the joint

during pronation subjects the first metatarsophalangeal to intense forces from which hallux valgus develops.

▫ If the foot is sufficiently hypermobile as a result of excessive pronation, the metatarsal tends to drift medially and the hallux drifts laterally, producing hallux valgus. If no hypermobility is present, hallux rigidus develops instead.

EtiologyArthritic/metabolic conditions

Structural deformity

▫ Gouty arthritis

▫ Rheumatoid arthritis

• Malalignment of articular surface or metatarsal shaft

• Abnormal metatarsal length


▫ Psoriatic arthritis

▫ Connective tissue disorders such as Ehlers-Danlossyndrome, Marfansyndrome, Down syndrome, and ligamentous laxity

• Abnormal metatarsal length

• Metatarsus primus elevatus

• External tibial torsion

• Genu varum or valgum

• Femoral retrotorsion

Etiology

Neuromuscular disease Traumatic compromise

• Multiple sclerosis

• Charcot-Marie-Tooth disease

• Malunions

• Intra-articular damage

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• Cerebral palsy • Soft-tissue sprains

• Dislocations

Symptoms

• Symptoms of Hallux valgus depending on the degree of severity:

▫ Aesthetic problem.

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▫ Aesthetic problem.

▫ Formation of calluses, chronic irritation of the skin and bursa.

▫ Increasing pain under load and when moving.

▫ Progressive arthrosis and stiffening in the base joint of the toe.

▫ Corollary deformities such as hammer and claw toe.

http://www.hallufix.org/english/hallux_valgus.html

Types of Hallux valgus

Degree 1 Degree 2

• Toe malpositioning below 20 degrees. No symptoms.

• Malpositioning between 20 and 30 degrees. Occasional pain.

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pain.

Types of Hallux valgus

Degree 3 Degree 4

• Malpositioning between 30 and 50 degrees. Regular pain. Increasing restraints on

• Severest form with malpositionings over 50 degrees and painful restraints


Increasing restraints on activities. Pronounced malpositioning!

degrees and painful restraints on the activities of everyday life.Surgical treatment

Treatment

• Medical Therapy▫ Adapting footwear▫ Pharmacologic or physical therapy▫ Functional orthotic therapy

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▫ Functional orthotic therapy

• Surgical Therapy▫ Capsulotendon balancing or exostectomy▫ Osteotomy▫ Resectional arthroplasty▫ Resectional arthroplasty with implant▫ First metatarsophalangeal joint arthrodesis▫ First metatarsocuneiform joint arthrodesis

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Bunionectomy• remove the bump that makes up the bunion. • performed through a small incision on the side of the foot immediately over

the area of the bunion. • Once the skin is opened the bump is removed using a special surgical saw or

chisel.

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chisel. • The bone is smoothed of all rough edges and the skin incision is closed with

small stitches.• It is more likely that realignment of the big toe will also be necessary. The

major decision that must be made is whether or not the metatarsal bone will need to be cut and realigned as well. The angle made between the first metatarsal and the second metatarsal is used to make this decision. The normal angle is around nine or ten degrees. If the angle is 13 degrees or more, the metatarsal will probably need to be cut and realigned.

• When a surgeon cuts and repositions a bone, it is referred to as an osteotomy. There are two basic techniques used to perform an osteotomy to realign the first metatarsal.

http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf

Distal Osteotomy

• the far end of the bone is cut and moved laterally • This effectively reduces the angle between the first

and second metatarsal bones. • usually requires one or two small incisions in the

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• usually requires one or two small incisions in the foot.

• Once the surgeon is satisfied with the position of the bones, the osteotomy is held in the desired position with one, or several,metal pins.

• Once the bone heals, the pin is removed. The metal pins are usually removed between three and six weeks following surgery.


Proximal Osteotomy• the first metatarsal is cut at the near end of the bone • usually requires two or three small incisions in the foot. • Once the skin is opened the surgeon performs the osteotomy. The bone is

then realigned and held in place with metal pins until it heals. Again, this reduces the angle between the first and second metatarsal bones.

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reduces the angle between the first and second metatarsal bones.• Realignment of the big toe is then done by releasing the tight structures on

the lateral, or outer, side of the first MTP joint. This includes the tight joint capsule and the tendon of the adductor hallucis muscle. This muscle tends to pull the big toe inward. By releasing the tendon, the toe is no longer pulled out of alignment. The toe is realigned and the joint capsule on the side of the big toe closest to the other toe is tightened to keep the toe straight, or balanced.

• Once the surgeon is satisfied that the toe is straight and well balanced, the skin incisions are closed with small stitches. A bulky bandage is applied to the foot before you are returned to the recovery room.


Good footwear is often all that is needed• Wearing good footwear does not cure the deformity but may

ease symptoms of pain and discomfort. Ideally, get advice about footwear from a podiatrist or chiropodist.

Advice may include:

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Advice may include:• Wear shoes, trainers or slippers that fit well and are roomy.• Don't wear high-heeled, pointed or tight shoes.• You might find that shoes with laces or straps are best, as they

can be adjusted to the width of your foot.• Padding over the bunion may help, as may ice packs.• Devices which help to straighten the toe (orthoses) are still

occasionally recommended, although trials investigating their use have not found them much better than no treatment at all.

http://www.patient.co.uk/health/Bunions-(Hallux-Valgus).htm

How to Choose Shoes

1. Know your foot. Take a look at your old shoes. Look at what areas the most worn out shoes. A well-chosen shoes will help to endure the physical stress well. One way to

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to endure the physical stress well. One way to determine your foot's shape is to do a "wet test"---wet your foot, step on a piece of brown paper and trace your footprint. Or just look at where your last pair of shoes shows the most wear.

2. Don't buy uncomfortable shoes even if they are hot!3. Ideally, you should avoid wearing heels4. Don't make shoes multitask.

http://hallux-valgus-rigidus.com/index.php?option=com_content&view=article&id=74&Itemid=88

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How to Choose Shoes

5. Knowing your foot's particular quirks is key to selecting the right pair of shoes.

6. You must find shoes with well cushioned soles and ideally, some type of soft arch-support.

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ideally, some type of soft arch-support.7. 7. Measure your foot frequently. Foot size changes

as we get older.8. 8. You should not buy shoes in the morning. The

size of our feet at night more than in the morning. Feet swell over the course of the day; they also expand while you run or walk, so shoes should fit your feet when they're at their largest.



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How to Choose Shoes

9. Always buy shoes to fit the larger or wider foot.Buy well-fitting shoes with a wide toe box.

10. Use bunion shields, bunion pads or bunion cushions to protect the bunion when wearing shoes. A bunion sleeve can be especially effective at relieving shoe pressure when walking

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protect the bunion when wearing shoes. A bunion sleeve can be especially effective at relieving shoe pressure when walking with a hallux valgus.

11. Utilize an orthotic device or insert, such as a bunion splint or bunion brace, to redistribute the pressure along the arch and ball of the foot and control the separation of the bones. These devices help support your foot and reduce the tendency toward hallux valgus formation.

12. Use a bunion regulator to stretch tight tendons and toe muscles overnight – especially if you want to avoid surgery.



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Resectional arthroplasty

• is a joint-destructive procedure

• most commonly reserved for elderly patients with advanced degenerative joint disease and

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with advanced degenerative joint disease and significant limitation of motion.

• The typical resectional arthroplasty that is performed is known as a Keller procedure.

http://emedicine.medscape.com/article/1232902-treatment#showall

Resectional arthroplasty

• performed when morbidity might be increased with the more aggressive osteotomy that would otherwise be selected.

• The procedure includes resection of the base of the

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• The procedure includes resection of the base of the proximal phalanx with reapproximation of the abductor and adductor tendon groups.

• The technique is inherently unstable and should be used judiciously.

• The postoperative course includes limited-to-full weight bearing in a surgical shoe immediately after the procedure.


Resectional arthroplasty with implant • is the same procedure as the resectional

arthroplasty, with similar indications, but stability is markedly improved with the addition

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stability is markedly improved with the addition of the total implant.


Resectional arthroplasty with implant • Preoperative radiograph shows

degenerative joint disease.• Postoperative radiograph

obtained after resectionalarthroplasty and total joint implant placement.


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implant placement.


First metatarsophalangeal joint arthrodesis• is a joint-destructive procedure that offers a

higher degree of stability and functionality.

• considered the definitive procedure for

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• considered the definitive procedure for degenerative joint disease.

• results in complete loss of motion at the first metatarsophalangeal joint and is reserved for patients with high activity levels and functional demands.

First metatarsophalangeal joint arthrodesis• Preoperative radiograph shows

arthrodesis.• Postoperative radiograph show

arthrodesis.


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First metatarsocuneiform joint arthrodesis• Significant and/or hypermobile hallux

abductovalgus may be reduced with arthrodesisof the first metatarsocuneiform joint (see images

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of the first metatarsocuneiform joint (see images below).

• Indications include metatarsus primus varus, hypermobility of the first ray, metatarsalgia of the lesser metatarsals, and degenerative joint disease of the metatarsocuneiform joint.

First metatarsocuneiform joint arthrodesis• Preoperative radiograph shows

a hypermobile first ray.• Postoperative radiograph

shows arthrodesis of the first metatarsocuneiform.


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Marfan syndrome (MFS)

• is a spectrum disorder caused by a heritable genetic defect of connective tissue that has an autosomal dominant mode of transmission

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autosomal dominant mode of transmission• The defect itself has been isolated to

the FBN1 gene on chromosome 15, which codes for the connective tissue protein fibrillin.

• Abnormalities in this protein cause a myriad of distinct clinical problems, of which the musculoskeletal, cardiac, and ocular system problems predominate.


• The skeleton of patients with MFS typically displays multiple deformities including arachnodactyly (ie, abnormally long and thin

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arachnodactyly (ie, abnormally long and thin digits), dolichostenomelia (ie, long limbs relative to trunk length), pectus deformities (ie, pectusexcavatum and pectus carinatum), and thoracolumbar scoliosis


• In the cardiovascular system, aortic dilatation, aortic regurgitation, and aneurysmsare the most worrisome clinical findings. Mitral

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are the most worrisome clinical findings. Mitral valve prolapse that requires valve replacement can occur as well. Ocular findings include myopia,cataracts, retinal detachment and superior dislocation of the lens

pectus carinatum pectus excavatum

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Genetics of Ehlers-Danlos Syndrome

• Ehlers-Danlos family of disorders is a group of related conditions that share a common decrease in the tensile strength and integrity of the skin,

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in the tensile strength and integrity of the skin, joints, and other connective tissues.

Genetics of Ehlers-Danlos Syndrome

• The first detailed clinical description of the syndrome is attributed to Tschernogobow in 1892.

• The syndrome derives its name from reports by

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• The syndrome derives its name from reports by Edward Ehlers, a Danish dermatologist, in 1901 and by Henri-Alexandre Danlos, a French physician with expertise in chemistry of skin disorders, in 1908.

• These 2 physicians combined the pertinent features of the condition and accurately delineated the phenotype of this group of disorders.

Ehlers-Danlos syndrome

• The amazing, almost unnatural, contortions that some patients with Ehlers-Danlos syndrome can perform often arouse curiosity.

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perform often arouse curiosity.

• Historically, some patients with Ehlers-Danlossyndrome displayed the maneuvers publically in circuses, shows, and performance tours.


• Some achieved modest degrees of fame and bore titles such as "The India Rubber Man," "The Elastic Lady," and "The Human Pretzel."

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Elastic Lady," and "The Human Pretzel."

• Such clinical features also raise suspicion of the diagnosis when identified upon physical examination.

• Unfortunately, patients often go many years before being diagnosed


• Patient with Ehlers-Danlossyndrome mitis.

• Joint hypermobility is less intense than with other


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• Patient with Ehlers-Danlossyndrome. Note the abnormal ability to elevate the right toe.

intense than with other conditions.


• Girl with Ehlers-Danlossyndrome.

• Dorsiflexion of all the fingers is easy and absolutely painless.


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is easy and absolutely painless.

• All forms of Ehlers-Danlos syndrome share the following primary features to varying degrees:

▫ Skin hyperextensibility

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▫ Skin hyperextensibility

▫ Joint hypermobility and excessive dislocations

▫ Tissue fragility

▫ Poor wound healing, leading to wide thin scars: The classic description of abnormal scar formation in Ehlers-Danlos syndrome is "cigarette paper scars."

▫ Easy bruising

Type Inheritance

Previous Nomenclature

Major Diagnostic Criteria

Minor Diagnostic Criteria

Kypho-scoliosis

Auto-somalrecessive

Type VI –lysylhydroxylase

Joint laxity, severe hypotonia at birth, scoliosis,

Tissue fragility,easy bruising, arterial rupture,marfanoid,

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sedeficiency

birth, scoliosis, progressive scleral fragility or rupture of globe

marfanoid,microcornea,osteopenia,positive familyhistory (affected sibling)

Type Inheritance Previous Nomenclature



Arthrochalasia

Autosomal dominant

Type VII A, B Congenital bilateral dislocated hips,severe joint hypermobility,recurrent

Skin hyperextensibility,tissue fragility with atrophic scars, muscle hypotonia,easy bruising,

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recurrent subluxations

easy bruising,kyphoscoliosis, mild osteopenia

Dermatosparaxis

Autosomal recessive

Type VII C Severe skin fragility; saggy, redundant skin

Soft, doughy skin;easy bruising; premature rupture of membranes; hernias (umbilical and inguinal)

Type Inheritance


Major Diagnostic Criteria Minor Diagnostic Criteria

Classic Autosomal dominant

Types I and II

Skin hyperextensibility,

wide atrophic scars, joint hypermobility

Smooth, velvety skin; easy bruising; molluscoidpseudotumors; subcutaneous spheroids; joint hypermobility; muscle hypotonia;

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hypotonia; postoperative complication (eg, hernia); positive family history; manifestations of tissue fragility (eg, hernia, prolapse)

Type Inheritance




Hypermobility

Autosomaldominant

Type III Skin involvement (soft, smooth and velvety), joint hypermobility

Recurrent joint dislocation; chronic joint pain, limb pain, or both; positive family history

Vascular Autosomal

Type IV Thin, translucent skin; arterial/intestinal

Acrogeria,hypermobile small

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mal dominant

arterial/intestinal fragility or rupture; extensive bruising; characteristic facial appearance

hypermobile small joints; tendon/muscle rupture; clubfoot; early onset varicose veins; arteriovenous, carotid-cavernous sinus fistula;pneumothorax;gingival recession; positive family history; sudden death in close relative

Down syndrome

• Down syndrome is by far the most common and best known chromosomal disorder in humans and the most common cause of

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humans and the most common cause of intellectual disability.

• Mental retardation, dysmorphic facial features, and other distinctive phenotypic traits characterize the syndrome


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Corn

• induration and thickening of skin

caused by friction and pressure,

painful conical mass


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painful conical mass

• appear as a horny thickening of the

skin on the toes.

• this thickening appears as a cone

shaped mass pointing down into

the skin.


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Types of Corn

oHard corns� most common

� are concentrated areas of dry, hardened skin


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� are concentrated areas of dry, hardened skin

about the size of a pea

� usually located on the outer surface of the little

toe or on the upper surface of the other toes,

but can occur between the toes

� may develop within a broader area of callused

skin

� sometimes called digital corns

Types of Corn

o Soft corns� are white and rubbery� can be extremely painful and tend to develop

between toes


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between toes� are like hard corns that have been softened by

continual exposure to moisture, usually because you don’t dry between toes properly or from sweat.

� may form opposite one another and are known as ‘kissing lesions’.

� Sometimes, soft corns can become infected by bacteria or fungi.

Other, rarer types of corn include:

• seed corns ▫ may appear as one corn or as clusters of small

corns on the bottom foot; they are usually painless


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painless

• vascular corns ▫ occur in blood vessels and bleed if cut

• fibrous corns ▫ are corns that have been around for a long time

and have become attached to the deeper layers of your skin, sometimes causing pain

Causes of corns

oCorns are caused by constant pressure on a

bony area of foot. This can happen for a

number of different reasons. These include:


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� poorly fitting footwear – for example, shoes that

are too small, cramp toes or have uneven soles;

this is the most common cause of corns

� being very active – doing lots of exercise can put

pressure on feet

� prominent bones – these can press against shoes

Causes of corns

oCorns are caused by constant pressure on a

bony area of foot. This can happen for a



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� a misshapen foot because foot or toes have

developed unusually –may have a toe that is

overly curved or a particular bone that is too short

� poorly healed fractures – if have broken a toe or

another bone in foot, it may have set out of place

causing foot to press against shoe

Corn

• Treatment:

• surgical removal by podiatrist


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Prevention of corns

owearing sensible, low-heeled footwear

(maximum 4cm heel) with a rounded toe

not wearing slip-on shoes because these


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onot wearing slip-on shoes because these

cause feet to move forward and squash

toes

onot wearing court shoes because they

don’t support feet and can cramp toes

Corn pad


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Prevention of corns

odrying properly between toes

o losing excess weight – this will help to

reduce pressure on feet


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reduce pressure on feet

o If already have a corn, apply an antifungal

or antibacterial powder after washing foot

to help prevent it becoming infected.


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Callus

• flat, poorly defined mass on the sole over a

bony prominence caused by pressure

• When skin is exposed to lots of pressure or


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• When skin is exposed to lots of pressure or

friction, the keratin layer thickens to protect it,

and develops into a callus.

• Although calluses can cover a wide area, they

aren't usually painful.

Callus

• Treatment:

o padding and lanolin creams

o overall good skin hygiene


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o overall good skin hygiene

• Self treatment or management of corns and

callus includes:

▫ following the advice of a Podiatrist


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▫ following the advice of a Podiatrist

▫ proper fitting of footwear

▫ proper foot hygiene and the use of emollients to

keep the skin in good condition

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• Neuromas

▫ are non-cancerous growths of the nerve tissue that develop in different parts of the body.

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develop in different parts of the body.

Mortons Neuroma

• affects a nerve in the foot, often times the nerve between the third and fourth toe.

• thickens the tissue around the nerves that lead

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• thickens the tissue around the nerves that lead to the toes, causing sharp, burning sensations in the ball of the foot, as well as a numbing or stinging feeling.

• AKA: plantar neuroma or intermetatarsalneuroma.

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http://www.footdoc.ca/www.FootDoc.ca/Website_Neuroma.gif

• Sex

▫ The female-to-male ratio for Morton's neuroma is 5:1.

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5:1.

• Age

▫ The highest prevalence of Morton's neuroma is found in patients aged 15-50 years, but the condition may occur in any ambulatory patient.

http://emedicine.medscape.com/article/308284-clinical#showall

Causes

• Various factors have been implicated in the precipitation of Morton's neuroma.

• Morton's neuroma is known to develop as a result of

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• Morton's neuroma is known to develop as a result of chronic nerve stress and irritation, particularly with excessive toe dorsiflexion.

• Poorly fitting and constricting shoes (ie, small toe box) or shoes with heel lifts often contribute to Morton's neuroma. Women who wear high-heeled shoes for a number of years or men who are required to wear constrictive shoe gear are at risk.


Causes

• A biomechanical theory of causation involves the mechanics of the foot and ankle. For instance, individuals with tight gastrocnemius-soleusmuscles or who excessively pronate the foot may

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individuals with tight gastrocnemius-soleusmuscles or who excessively pronate the foot may compensate by dorsiflexion of the metatarsals subsequently irritating of the interdigital nerve.

• Certain activities carry increased risk of excessive toe dorsiflexion, such as prolonged walking, running, squatting, and demi-pointeposition in ballet.


Manifestations

• Obtaining an accurate history is important to making the diagnosis of Morton's neuroma. Possible reported findings provided by the patient with Morton's neuroma include the

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Possible reported findings provided by the patient with Morton's neuroma include the following:

• The most common presenting complaints include pain and dysesthesias in the forefoot and corresponding toes adjacent to the neuroma.

• Pain is described as sharp and burning, and it may be associated with cramping.


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Manifestations

• Numbness often is observed in the toes adjacent to the neuroma and seems to occur along with episodes of pain.

• Pain typically is intermittent, as episodes often occur for minutes to hours at a time and have long intervals (ie,

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minutes to hours at a time and have long intervals (ie, weeks to months) between a single or small group of multiple attacks.

• Some patients describe the sensation as "walking on a marble."

• Massage of the affected area offers significant relief.• Narrow tight high-heeled shoes aggravate the symptoms.• Night pain is reported but is rare.


Dx tests

• palpable mass or a "click" between the bones. • Doctor put pressure on the spaces between the

toe bones to try to replicate the pain and look for

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toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain.

• Range of motion tests will rule out arthritis or joint inflammations.

• X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot.


Treatment

• Rehabilitation Program: Physical Therapy

• Treatment strategies range from conservative to

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• Treatment strategies range from conservative to surgical management.

• The conservative approach may benefit from the involvement of a PT. ▫ Recommend soft-soled shoes with a wide toe box

and low heel (eg, an athletic shoe). ▫ High-heeled, narrow, nonpadded shoes should not

be worn, because they aggravate the condition.


Treatment

• Rehabilitation Program: PT• conservative management

▫ to alter alignment of the metatarsal heads.

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▫ One recommended action is to elevate the metatarsal head medial and adjacent to the neuroma, thereby preventing compression and irritation of the digital nerve.

▫ A plantar pad is used most often for elevation. Have the patient insert a felt or gel pad into the shoe to achieve the desired elevation of the above metatarsal head.


Treatment

• Rehabilitation Program: PT

• Cryotherapy

• Ultrasonography

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• Ultrasonography

• deep tissue massage

• stretching exercises.


Treatment

• Rehabilitation Program: PT

• Ice is beneficial to decrease the associated inflammation.

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inflammation.

• Phonophoresis also can be used, rather than just ultrasonography, to further decrease pain and inflammation.


Phonophoresis


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Phonophoresis


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Treatment

• Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to

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heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.

• Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.

http://orthoinfo.aaos.org/topic.cfm?topic=a00158

Treatment

• Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.

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swelling and inflammation of the nerve, bringing some relief.

• Combination ▫ Several studies have shown that a combination

of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton's Neuroma. http://orthoinfo.aaos.org/topic.cfm?topic=a00158

Surgical Intervention

• When conservative measures for Morton's neuroma are unsuccessful, surgical excision of the area of fibrosis in the common digital nerve may be curative.

• Common adverse outcomes include

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• Common adverse outcomes include ▫ dysesthesias radiating from a painful nerve stump.

Dysesthesias may be treated as any other dysesthetic pain.

• Surgical options include the following:▫ Neurectomy with nerve burial

▫ Transverse intermetatarsal ligament release, with or without neurolysis

▫ Endoscopic decompression of the transverse metatarsal ligament


Other Treatment

• Perform injection into the dorsal aspect of the foot, 1-2 cm proximal to the webspace, in line with the MTP joints.

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with the MTP joints.

• Advance the needle through the midwebspaceinto the plantar aspect of the foot until the needle gently tents the skin. Then withdraw it about 1 cm to where the tip of the neuroma is located.

Other Treatment

• Inject a corticosteroid/anesthetic mix. A reasonable volume is 1 mL of corticosteroid and 2 mL of anesthetic. T

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2 mL of anesthetic. T

• the anesthetic used should not contain epinephrine, as necrosis may result. Care also should be taken not to inject into the plantar pad.

Other Treatment

• Adverse outcomes include plantar fat pad necrosis. Transient numbness of the toes also may occur. Although many practitioners use

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may occur. Although many practitioners use multiple injections, the likelihood of benefit from subsequent injections, after failure to achieve relief from the initial injection, is negligible.

Other Treatment

• An Australian investigation using a single, ultrasonographically guided corticosteroid injection for Morton's

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corticosteroid injection for Morton's neuroma found that 9 months after treatment, complete pain relief had occurred in 11 of the 39 neuromas studied.

Neurectomy: typical incision location. Neurectomy: superficial exposure.

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Maria Carmela L. Domocmat,

RN, MSN

Neurectomy: typical incision location. Neurectomy: superficial exposure.

Neurectomy: deeper dissection. Neuroma and adherent fibrofatty tissue.http://emedicine.medscape.com/article/308284-clinical#showall

Medication Summary

• Dysesthesias may be treated as any other dysesthetic pain.

• Tricyclic antidepressants, such as amitriptyline

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• Tricyclic antidepressants, such as amitriptylineat 10-25 mg PO qhs, may be tried.

• If this approach is unsuccessful, anticonvulsants (eg, gabapentin, carbamazepine) often are effective.

Tricyclic Antidepressants

• A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission, and they block the active re-

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sedative effects. They have central effects on pain transmission, and they block the active re-uptake of norepinephrine and serotonin.

• Amitriptyline (Elavil)▫ Analgesic for certain chronic and neuropathic

pain. Low doses, 10-25 mg qhs, may provide pain relief from burning and tingling occurring at rest but function only as an adjunct to definitive treatment.

Anticonvulsants

• Use of certain antiepileptic drugs (AEDs), such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Thus, although unstudied, a trial of such an agent might conceivably provide analgesia for symptomatic

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although unstudied, a trial of such an agent might conceivably provide analgesia for symptomatic neuropathy. Used for dysesthesias not controlled with definitive treatment plus tricyclic antidepressants (or in patients unable to take tricyclic antidepressants).

• Gabapentin (Neurontin)▫ Neuromembrane stabilizer useful in pain reduction with

dysesthetic pain. Has antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA, but does not interact with GABA receptors.

Anticonvulsants

• Pregabalin (Lyrica)▫ Structural derivative of GABA. Mechanism of

action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In

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alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.

Serotonin-Norepinephrine Reuptake Inhibitors• These agents inhibit neuronal serotonin and

norepinephrine reuptake.

• Duloxetine (Cymbalta)

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• Duloxetine (Cymbalta)

▫ Description Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake


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Hammer toe

• is a deformity of the toe, in which the end of the toe is bent downward.

• usually affects the second toe. However, it may

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• usually affects the second toe. However, it may also affect the other toes. The toe moves into a claw-like position.

Hammer toe


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Causes, incidence, and risk factors

• most common cause of hammer toe is wearing short, narrow shoes that are too tight. The toe is forced into a bent position. Muscles and tendons

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forced into a bent position. Muscles and tendons in the toe tighten and become shorter.


• Hammer toe is more likely to occur in:▫ Women who wear shoes that do not fit well or

have high heels

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▫ Children who keep wearing shoes they have outgrown

• The condition may be present at birth (congenital) or develop over time.

• In rare cases, all of the toes are affected. This may be caused by a problem with the nerves or spinal cord.


• may be present at birth (congenital) or develop over time.

• In rare cases, all of the toes are affected. This

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• In rare cases, all of the toes are affected. This may be caused by a problem with the nerves or spinal cord.

Symptoms

• The middle joint of the toe is bent. The end part of the toe bends down into a claw-like deformity. At first, you may be able to move and straighten

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At first, you may be able to move and straighten the toe. Over time, you will no longer be able to move the toe.

• A corn often forms on the top of the toe. A callus is found on the sole of the foot.

• Walking or wearing shoes can be painful.

Hammer toe


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Dx tests

• physical examination of the foot

• decreased and painful movement in the toes.

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http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9360.jpg

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http://www.myfootshop.com/images/medical/ortho/hammer_toe_differences_mod.jpg

Treatment

• Mild hammer toe in children can be treated by manipulating and splinting the affected toe.

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http://www.family-foot.com/images/hammer_toe_whatis.jpg

Treatment

• The following changes in footwear may help relieve symptoms:

▫ Wear the right size shoes or shoes with wide toe

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▫ Wear the right size shoes or shoes with wide toe boxes for comfort, and to avoid making hammer toe worse.

▫ Avoid high heels as much as possible.

▫ Wear soft insoles to relieve pressure on the toe.

▫ Protect the joint that is sticking out with corn pads or felt pads

Treatment

• A foot doctor can make foot devices called hammer toe regulators or straighteners for you, or you can buy them at the store.

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or you can buy them at the store.

• Exercises may be helpful.

▫ You can try gentle stretching exercises if the toe is not already in a fixed position.

▫ Picking up a towel with your toes can help stretch and straighten the small muscles in the foot.

Treatment

• For severe hammer toe, you will need an operation to straighten the joint.

• The surgery often involves cutting or moving

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• The surgery often involves cutting or moving tendons and ligaments.

• Sometimes the bones on each side of the joint need to be connected (fussed) together.

• Most of the time, you will go home on the same day as the surgery. The toe may still be stiff afterward, and it may be shorter.

Prevention and Cure of Hammer Toes with Products• Hammer Toe

Regulator

• Hammer Toe Cushion

• Yoga Toes Toe Stretcher

• Toe Rings

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• Hammer Toe Cushion

• Foam Toe Tubes

• Gel Toe Cap

• Toe Spreader

• Silicone Toe Crest

• Toe Spacer Cushion

• Digital Toe Pad

• Toe Rings

• Toe Brace

• Toe Alignment Splint

• Toe Trainers

• Hammer Toe Straightener

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Hammer Toe Correction Bandage

• Price $14.95

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Hammer Toe Regulator

• Toe regulator efficiently integrates the middle joint of toe with other joints.

• It reduces the pressure and


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• It reduces the pressure and irritation at toe tips and region over the toes.

• The toe regulator straightens the joint of hammer toes (or) claw toes with a slight and smooth pressure.

• Toe regulator is effective for pain relief and proper alignment of hammer toes.

Hammer Toe Regulator


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Hammer Toe Cushion

• provides ease feel over the contracted part and comforts Hammer toe with enough support.


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support.

• assists for a stress free movement and aid in lifting the toe to normal position.

• minimizes pressure at the top and tip of toes with a spongy effect.

• is provided with an adjustable toe loop for comfortable and secure fit.

Foam Toe Tubes

• The soft foam present in the tube safeguard toes from rash rubbing against footwear.

• Foam toe tube is easy to wear


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• Foam toe tube is easy to wear for getting effective pain relief from hammer toes.

• It reduce the pressure and swelling over Hammer toes for trouble free walks.

Gel Toe Cap

• Gel Toe Cap softens the Hammer toes giving excellent cushioning to the painful deformed toes.


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deformed toes.

• It also relieves extreme pain at the top and tip of toes effectively.

• Gel maintains the spongy comfort and reduces pressure all over the hammer toe.

Silicone Toe Crest

• The reinforced loop with elastic fabric of the toe crest holds the toe perfectly straight.

• The toe crest provides soft feel under three toes excluding the


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under three toes excluding the big and little toe.

• It relieves the pain caused by hammer toe.

• It adds strength to the toe and gives extra smoothness to the affected spot.

• Silicone soothes the toe for ease feel.

• Toe crest is durable and can be worn comfortably with a snug fit.

Toe Alignment Splint• Toe alignment splint reduces the pressure and

pain caused by Hammer toes and Bunions.

• specifically aligns the toe placing it in correct position.

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position.

• The smooth cotton band with elastic property gives secure fit around the foot.

• Its thin straps can be placed over affected toes and the rigidity is adjustable using hook-and loop strap.

• Unique T-strap of the splint reduces the pain of bunion and prevents the big toe to slant over hammer toes (or) crooked toes.

• Toe alignment splint is comfortable to wear with casual shoes.

Toe Trainers• Toe trainer comforts flexible hammer toes. It gives better relief against the pain and irritation. Toe trainer separates the toes and aligns them to look straight. It is an effective item to cure slightly movable Hammer toes.

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slightly movable Hammer toes.

• The cotton-covered foam provides secure feel to the crooked toes.

• Toe trainer is easy to wear and fits snugly for efficient correction of hammer toes.

Hammer Toe Straightener• The toe Straightener perfectly aligns Hammer toes with little pressure. Its cotton-covered loop with elasticity holds the toe firmly in proper place and it can be easily adjusted for stress free movements. The smooth foam pad molds accordingly with the foot shape and renders superior cushioning at the bottom of the feet. It also stops the

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and renders superior cushioning at the bottom of the feet. It also stops the pain caused by hammer toes. The hook closure present in the toe straightenerpulls down and aligns the deformed toes to keep you always smiling.

• Hammer toe Straightener assists for healthy feet by strengthening the toes and forefoot muscles.

Prevention

• Avoid wearing shoes that are too short or narrow.

• Check children's shoe sizes often, especially

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• Check children's shoe sizes often, especially during periods of fast growth.

Expectations (prognosis)

• If the condition is treated early, you can often avoid surgery.

• Treatment will reduce pain and walking

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• Treatment will reduce pain and walking difficulty.

Complications

• Foot deformity

• Posture changes caused by difficulty in walking

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Tarsal tunnel syndrome

• the ankle version of carpal tunnel syndrome

(CTS)

• posterior tibial nerve in the ankle becomes


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• posterior tibial nerve in the ankle becomes

compressed, resulting in loss of sensation and

pain in a portion of the foot


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Tarsal tunnel syndrome

• median and lateral plantar branches, which

supply the sole of the and distal phalanges, are

affected by nerve compression


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affected by nerve compression

• dx and treatment: same with CTS


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Plantar fasciitis

• an inflammation of the plantar fascia, which is

located in the area of the arch of the foot

• common: middle-aged and older adults,


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• common: middle-aged and older adults,

athletes esp runners

Plantar fasciitis

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Maria Carmela L. Domocmat, RN, MSN 3/5/2012

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg

Plantar fascia

• A very thick band of tissue that covers the bones on the bottom of the foot.

• extends from the heel to the bones of the ball of the foot and acts like a rubber band to create tension

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foot and acts like a rubber band to create tension which maintains the arch of the foot.

• If the band is long it allows the arch of the foot to be low, which is most commonly known as having a flat foot.

• A short band of tissue causes a high arch.• This fascia can become inflamed and painful in

some people, making walking more difficult.

Plantar fascia

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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg

Risk factors

o Foot arch problems (both flat feet and high

arches)

oObesity or sudden weight gain


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oObesity or sudden weight gain

o Long-distance running, especially running

downhill or on uneven surfaces

o Sudden weight gain

o Tight Achilles tendon (the tendon connecting

the calf muscles to the heel)

o Shoes with poor arch support or soft soles

s/s:

• The most common complaint is pain and

stiffness in the bottom of the heel. The heel

pain may be dull or sharp. The bottom of the


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pain may be dull or sharp. The bottom of the

foot may also ache or burn.

s/s

oThe pain is usually worse:

� In the morning when you take r first steps

� After standing or sitting for a while


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� After standing or sitting for a while

� When climbing stairs

� After intense activity

oThe pain may develop slowly over time, or

suddenly after intense activity.

Treatment

oconservative treatment:

� rest

� ice - at least twice a day for 10 - 15 minutes,


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� ice - at least twice a day for 10 - 15 minutes,

more often in the first couple of days.

� stretching exercises

� strapping of foot to maintain arch

� orthotics

Treatment

oconservative treatment:

� heel stretching exercises

� resting as much as possible for at least a week


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� resting as much as possible for at least a week

� shoes with good support and cushions

� wear heel cup, felt pads in the heel area, or

shoe inserts

� use night splints to stretch the injured fascia

and allow it to heal.

Treatment

o If these treatments do not work, doctor may

recommend:

� Wearing a boot cast, which looks like a ski boot,


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� Wearing a boot cast, which looks like a ski boot,

for 3-6 weeks. It can be removed for bathing.

� Custom-made shoe inserts (orthotics)

� Steroid shots or injections into the heel

� NSAIDs or steroids

� endoscopic surgery – to remove inflamed tissue

may be required

Boot cast

3/5/2012Maria Carmela L. Domocmat,

RN, MSN

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Orthotics


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Orthotic devices


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Expectations (prognosis)

oNonsurgical treatments almost always

improve the pain.

• Treatment can last from several months to 2


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• Treatment can last from several months to 2

years before symptoms get better. Most

patients feel better in 9 months. Some people

need surgery to relieve the pain.

Complications

oPain may continue despite treatment.

oSome may need surgery.


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Ingrown Nail

• nail silver penetration of the skin, causing

inflammation

• occurs when the edge of the nail grows down


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• occurs when the edge of the nail grows down

and into the skin of the toe. There may be pain,

redness, and swelling around the nail.

Anatomy of a toenail


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Ingrown Nail

• AKA:

▫ Onychocryptosis

▫ Unguis incarnatus


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▫ Unguis incarnatus

▫ Nail avlusion

▫ Matrix excision


• An ingrown toenail can result from a number of

things,

• but poorly fitting shoes and toenails that are


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• but poorly fitting shoes and toenails that are

not trimmed properly are the most common

causes.

• The skin along the edge of a toenail may

become red and infected.

• The great toe is usually affected, but any

toenail can become ingrown.


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• Ingrown toenails may occur when extra

pressure is placed on toe.

• Most commonly, this pressure is caused by


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• Most commonly, this pressure is caused by

shoes that are too tight or too loose.

• If walk often or participate in athletics, a shoe

that is even a little tight can cause this

problem.

• Some deformities of the foot or toes can also

place extra pressure on the toe.

Infected ingrown toenail


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oNails that are not trimmed properly can also

cause ingrown toenails.� When toenails are trimmed too short or the edges


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� When toenails are trimmed too short or the edges

are rounded rather than cut straight across, the

nail may curl downward and grow into the skin.

� Poor eyesight and physical inability to reach the

toe easily, as well as having thick nails, can make

improper trimming of the nails more likely.

� Picking or tearing at the corners of the nails can

also cause an ingrown toenail.


• Some people are born with nails that are

curved and tend to grow downward. Others

have toenails that are too large for their toes.


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have toenails that are too large for their toes.

Stubbing your toe or other injuries can also

lead to an ingrown toenail.

Treatment

• If have diabetes, nerve damage in the leg or

foot, poor blood circulation to foot, or an

infection around the nail, go to the doctor right


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infection around the nail, go to the doctor right

away.

• Do NOT try to treat this problem at home

(Bathroom treatment)

Treatment

oTo treat an ingrown nail at home:

� Soak the foot in warm water 3 to 4 times a day

if possible. Keep the toe dry, otherwise.


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if possible. Keep the toe dry, otherwise.

� Gently massage over the inflamed skin.

� Place a small piece of cotton or dental floss

under the nail. Wet the cotton with water or

antiseptic.

Treatment

� may trim the toenail one time, if needed. When trimming toenails:� Consider briefly soaking your foot in warm water to

soften the nail.


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soften the nail.� Use a clean, sharp trimmer.� Trim toenails straight across the top. Do not taper or

round the corners or trim too short. Do not try to cut out the ingrown portion of the nail. This will only make the problem worse.

� Consider wearing sandals until the problem has gone away. Over-the-counter medications that are placed over the ingrown toenail may help some with the pain but do not treat the problem.

Proper and improper toenail trimming.


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Treatment

� If this does not work and the ingrown nail gets

worse, see family doctor, a foot specialist

(podiatrist) or a skin specialist (dermatologist).


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(podiatrist) or a skin specialist (dermatologist).

� removal of silver by podiatrist

� partial nail avulsion

o If ingrown nail does not heal or keeps coming

back, doctor may remove part of the nail.


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back, doctor may remove part of the nail.

o Numbing medicine is first injected into the toe.

o Using scissors, your doctor then cuts along the

edge of the nail where the skin is growing over.

This portion of the nail is then removed. This is

called a partial nail avulsion.

o It will take 2 to 4 months for the nail to regrow

� Sometimes doctor will use a chemical,

electrical current, or another small surgical cut

to destroy or remove the area from which a new


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to destroy or remove the area from which a new

nail may grow.

� antibiotic ointment - If the toe is infected

Prevention

• Wear shoes that fit properly.

• Shoes worn every day should have plenty of

room around toes.


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room around toes.

• Shoes that wear for walking briskly or for

running should have plenty of room also, but

not be too loose.

Prevention

oWhen trimming toenails:� Considering briefly soaking foot in warm

water to soften the nail.


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water to soften the nail.

� Use a clean, sharp nail trimmer.

� Trim toenails straight across the top. Do not

taper or round the corners or trim too short.

� Do not pick or tear at the nails.

� Keep the feet clean and dry. People with

diabetes should have routine foot exams and

nail care.


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Hypertrophic Ungual Labium

• chronic hypertrophy of nail lip

• caused by improper nail trimming

• results from untreated ingrown toenail


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• results from untreated ingrown toenail

• treatment:

o surgical removal of necrotic nail and skin

o treatment of secondary infection


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References

• Krug RJ, Lee EH, Dugan S, Mashey K. Hammer toe. In: Frontera WR, Silver JK, Rizzo TD Jr., eds. Essentials of Physical Medicine and

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eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 82.

• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002215/

References

• Ignatavicius and Workman (2006). Medical surgical nursing [5th ed]. Singapore: Elsevier.

• http://www.epodiatry.com/corns-callus.htm


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• http://www.epodiatry.com/corns-callus.htm


• http://www.bupa.co.uk/individuals/health-information/directory/c/corns


• http://orthoinfo.aaos.org/topic.cfm?topic=a00154

musculoskeletal disorders part 6 disorders of the feet

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