The FootThe Foot

Briant W. Smith, MDBriant W. Smith, MD

Orthopedic SurgeryOrthopedic Surgery

TPMG Santa RosaTPMG Santa Rosa

General ConsiderationsGeneral Considerations

VERY common VERY common problems.problems.

Systemic disease is a Systemic disease is a major player major player (diabetes, vascular (diabetes, vascular and and neurologic diseases, neurologic diseases, inflammatory inflammatory arthritis)arthritis)

Divide the Foot into ThirdsDivide the Foot into Thirds

Hindfoot Midfoot ForefootHindfoot Midfoot Forefoot

Order Standing RadiographsOrder Standing Radiographs

AP and Lateral are StandingAP and Lateral are Standing Oblique is supineOblique is supine

Forefoot ProblemsForefoot Problems

Women far outnumber men because of Women far outnumber men because of shoe choices. Shoe modification is the shoe choices. Shoe modification is the first line of treatment for:first line of treatment for: BunionsBunions NeuromasNeuromas MetatarsalgiaMetatarsalgia SesamoiditisSesamoiditis

Shoewear ProblemsShoewear Problems

Over-PronationOver-Pronation

Many foot problems are due to excessive Many foot problems are due to excessive pronation (flat feet):pronation (flat feet): Plantar fasciitisPlantar fasciitis Achilles and posterior tibial tendinitisAchilles and posterior tibial tendinitis SesamoiditisSesamoiditis BunionsBunions Sinus tarsi and tarsal tunnel syndromesSinus tarsi and tarsal tunnel syndromes MetatarsalgiaMetatarsalgia

PronationPronation

PronationPronation

Midfoot ProblemsMidfoot Problems

Dorsal midfoot pain occurs secondary to Dorsal midfoot pain occurs secondary to arthritis. Bony prominence=‘bossing’arthritis. Bony prominence=‘bossing’

Plantar midfoot pain is rare. Can be plantar Plantar midfoot pain is rare. Can be plantar fasciitis or fibromatosis.fasciitis or fibromatosis.

Midfoot ArthritisMidfoot Arthritis

Hindfoot ProblemsHindfoot Problems

Plantar fasciitis is the most common. Pain Plantar fasciitis is the most common. Pain is plantar/medial.is plantar/medial.

Heel pad pain is usually a ‘stone bruise’ or Heel pad pain is usually a ‘stone bruise’ or due to atrophy of the fat pad.due to atrophy of the fat pad.

Posterior tibial tendon dysfunction is the Posterior tibial tendon dysfunction is the most overlooked problem of the foot.most overlooked problem of the foot.

Plantar FasciitisPlantar Fasciitis

The ForefootThe Forefoot

BunionsBunions Funny toesFunny toes MetatarsalgiaMetatarsalgia Interdigital NeuromaInterdigital Neuroma SesamoiditisSesamoiditis Stress FractureStress Fracture

BunionsBunions

BunionsBunionsHallux ValgusHallux Valgus

The bunion is the enlarged medial The bunion is the enlarged medial prominence of the first MTP joint.prominence of the first MTP joint.

Often there are secondary lesser toe Often there are secondary lesser toe deformities (corns, calluses, hammertoes, deformities (corns, calluses, hammertoes, bunionette)bunionette)

Get xrays if patient is going to be referred.Get xrays if patient is going to be referred. TX: shoe change: TX: shoe change: widen the toe boxwiden the toe box, arch , arch

+ heel support (bunion pads crowd shoe)+ heel support (bunion pads crowd shoe)

Bunion XraysBunion Xrays

11stst MTP Arthritis MTP Arthritis

Hallux rigidus (ortho) or limitus (pod)Hallux rigidus (ortho) or limitus (pod) 11stst MTP can be swollen, spur is dorsal on MTP can be swollen, spur is dorsal on

the xray.the xray. Limited MTP extension (compare to other Limited MTP extension (compare to other

foot), pain is during the toe-off phase of foot), pain is during the toe-off phase of walking.walking.

Tx with stiff soled shoes, NSAIDsTx with stiff soled shoes, NSAIDs

Hallux RigidusHallux Rigidus

Hallux RigidusHallux Rigidus

Funny ToesFunny ToesHammer and Claw ToesHammer and Claw Toes

Usually due to IMPROPER SHOE WEARUsually due to IMPROPER SHOE WEAR Claws are usually seen in diabetics. These are Claws are usually seen in diabetics. These are

fixed extension of MPJ, and flexion of PIP and fixed extension of MPJ, and flexion of PIP and DIP joints.DIP joints.

Hammertoes have flexion deformities of the PIP Hammertoes have flexion deformities of the PIP joint, and flexible MP and DIP joints.joint, and flexible MP and DIP joints.

Can develop corns and callusesCan develop corns and calluses Tx with wide shoes and toe straps, pads OK; Tx with wide shoes and toe straps, pads OK;

non-operative treatment as long as it is non-operative treatment as long as it is flexibleflexible..

HammertoesHammertoes

MetatarsalgiaMetatarsalgia

It just means forefoot pain.It just means forefoot pain. Pain is Pain is underunder a metatarsal head (usually a metatarsal head (usually

22ndnd) as opposed to between the heads ) as opposed to between the heads for neuromas.for neuromas.

Often associated with hammertoes and Often associated with hammertoes and calluses.calluses.

Get wider shoes, use metatarsal pads Get wider shoes, use metatarsal pads or cut-outs, shave the calluses.or cut-outs, shave the calluses.

MetatarsalgiaMetatarsalgia

SesamoiditisSesamoiditis

Sesamoids are embedded in the flexor Sesamoids are embedded in the flexor hallucis brevis tendon beneath the first hallucis brevis tendon beneath the first metatarsal head.metatarsal head.

Caused by repeated stress, and can be Caused by repeated stress, and can be inflamed, fracture, or even get arthritic. inflamed, fracture, or even get arthritic.

Very tender, will move with flex/ext of Very tender, will move with flex/ext of great toe MPJ. Get xrays.great toe MPJ. Get xrays.

Tx: stiff shoe, pads/cut-outs; no heels.Tx: stiff shoe, pads/cut-outs; no heels.

SesamoiditisSesamoiditis

Interdigital NeuromaInterdigital Neuroma

Really ‘perineural fibrosis’ secondary to Really ‘perineural fibrosis’ secondary to repetitive irritation (from tight shoes!) repetitive irritation (from tight shoes!)

90% are in the third interspace; rest in 2nd90% are in the third interspace; rest in 2nd Feels like walking on a pebble. Feels Feels like walking on a pebble. Feels

better out of shoes.better out of shoes. + squeeze test. Pain is between MT + squeeze test. Pain is between MT

heads.heads. Tx: wide shoes, MT pads/cut-outs, inject.Tx: wide shoes, MT pads/cut-outs, inject.

Interdigital NeuromaInterdigital Neuroma

Stress FractureStress Fracture

Pain directly over a metatarsal, usually Pain directly over a metatarsal, usually more proximal than MT heads.more proximal than MT heads.

Change in activities, worse with wt bearingChange in activities, worse with wt bearing Initial xray often normal. Bone scan Initial xray often normal. Bone scan

positive early.positive early. Tx with modified activity, stiff soled shoe or Tx with modified activity, stiff soled shoe or

boot/cast, time.boot/cast, time.

Stress FractureStress Fracture

Midfoot ArthritisMidfoot Arthritis

Dorsal bossing or spurs over the involved Dorsal bossing or spurs over the involved joint(s). joint(s).

XR and/or bone scan will show changes.XR and/or bone scan will show changes. Tx with stiff soled shoes, firm arch support, Tx with stiff soled shoes, firm arch support,

NSAIDs, activity modification.NSAIDs, activity modification.

Plantar FasciitsPlantar Fasciits

Pain with arising, especially first AM stepsPain with arising, especially first AM steps Almost always at plantar-medial origin.Almost always at plantar-medial origin. Inflammation and chronic degeneration.Inflammation and chronic degeneration. Worse with obesity, overpronation.Worse with obesity, overpronation. Not due to spursNot due to spurs Tx: Arch support, Tx: Arch support, elevate heelelevate heel. NO . NO

barefeet, flat shoes; NSAIDs, injections, barefeet, flat shoes; NSAIDs, injections, PT for ultrasound.PT for ultrasound.

Plantar FasciitisPlantar Fasciitis

Plantar Heel PainPlantar Heel Pain

Can be traumatic (stone bruise) or Can be traumatic (stone bruise) or common in elderly as fat pad atrophies.common in elderly as fat pad atrophies.

Add a pad, like Spenco gel heel cushions.Add a pad, like Spenco gel heel cushions.

Heel Pad PainHeel Pad Pain

Posterior Tibial Tendinitis (PTT)Posterior Tibial Tendinitis (PTT)

Most missed problem of the foot.Most missed problem of the foot. Pain/aching between navicular and medial Pain/aching between navicular and medial

malleolus. Looks swollenmalleolus. Looks swollen Flatfeet. Heel should invert with rising on Flatfeet. Heel should invert with rising on

toes.toes. Tx: arch supports, slight heel. NSAIDs and Tx: arch supports, slight heel. NSAIDs and

PT for u/s.PT for u/s.

Posterior Tibial TendinitisPosterior Tibial Tendinitis

Tarsal Tunnel SyndromeTarsal Tunnel Syndrome

Post Tib nerve gets entrapped near med Post Tib nerve gets entrapped near med malleolus. Plantar tingling/burning as malleolus. Plantar tingling/burning as opposed to pain/swelling of PTT. Not opposed to pain/swelling of PTT. Not whole foot like with diabetes.whole foot like with diabetes.

+ Tinel test; can be loss of PP sensation, + Tinel test; can be loss of PP sensation, can be toe clawing.can be toe clawing.

Tx: arch support if overpronated. Consider Tx: arch support if overpronated. Consider NCV tests.NCV tests.

Tarsal Tunnel SyndromeTarsal Tunnel Syndrome

Foot ExaminationFoot Examination

Become comfortable with apparent Become comfortable with apparent deformities, joint mobility, tendon deformities, joint mobility, tendon insertions, vascular and neurologic insertions, vascular and neurologic examinations.examinations.

Vascular ExaminationVascular Examination

Foot color—dependent and on elevationFoot color—dependent and on elevation EdemaEdema PulsesPulses Capillary RefillCapillary Refill Hair distributionHair distribution

Neurologic ExaminationNeurologic Examination

Lumbar dermatomes vs. specific nerves vs Lumbar dermatomes vs. specific nerves vs systemic diseasesystemic disease

Light touch for gross testingLight touch for gross testing Semmes-Weinstein 5.07 monofilament for Semmes-Weinstein 5.07 monofilament for

diabetics.diabetics.

Range of MotionRange of Motion

Should be symmetricShould be symmetric Ankle dorsiflexion 10 deg with knees ext.Ankle dorsiflexion 10 deg with knees ext. Subtalar joint should be mobile.Subtalar joint should be mobile. 11stst MTP joint extension should be >60 deg MTP joint extension should be >60 deg

TendonsTendons

Achilles insertion and body of tendonAchilles insertion and body of tendon Posterior tibial tendonPosterior tibial tendon Peroneal tendonsPeroneal tendons

DeformitiesDeformities

Pump bumpPump bump Talar headTalar head NWB and WB for pes planus/cavusNWB and WB for pes planus/cavus 11stst MTP joint MTP joint Lesser toesLesser toes

Treatment ArsenalTreatment Arsenal

Change shoesChange shoes OTC arch supports and insoles, padsOTC arch supports and insoles, pads Custom OrthoticsCustom Orthotics Calf stretching/toe risesCalf stretching/toe rises Activity modification (swimming/biking)Activity modification (swimming/biking) Weight lossWeight loss Night splints/boots/castsNight splints/boots/casts

Treatment OptionsTreatment Options

Physical therapyPhysical therapy UltrasoundUltrasound Interferential stimulationInterferential stimulation

Contrast soaks (10 mins warm, 30 secs Contrast soaks (10 mins warm, 30 secs ice cold, repeat x2, end with cold)ice cold, repeat x2, end with cold)

NSAIDSNSAIDS InjectionsInjections