Top 10 Foot & Ankle Conditions

What you need to know

By Patrick A. DeHeer,

DPMHoosier Foot &

Ankle317-346-7722

Top 10 Foot & Ankle Conditions

• Equinus• Heel Pain• Onychocryptosis• Onychomycosis• Verrucae

Plantaris

• Hallux Abducto Valgus

• Hammer Digit Syndrome

• Hallux Rigidus• Morton’s Neuroma• Insertional

Achilles Tendonitis

Equinus

• Definition – no standard– < 5° AJ DF with KE– STJ NP & MTJ

Locked• Types –

– Uncompensated– Partially

Compensated– Compensated

Equinus

• Biomechanics– Balanced

standing– Equinus effect

on CoP– STJ axis

relationship– Pressure

changes

Equinus & Abnormal STJ Axis

Equinus Related Conditions

80-85% Foot & Ankle Pathologies● Heel Spur Syndrome/Plantar Fasciitis● Achilles Tendinopathy● Posterior Tibial Tendon Dysfunction● Diabetic Foot Ulcers● Charcot Neuropathy ● Metatarsalgia● Morton’s Neuroma● Lesser MPJ pathologies – PDS, Capsulitis● Hallux Valgus● Hammer Digit Syndrome● Ankle Fracture/Sprains● Sever’s Disease● Pediatric Flatfoot Deformity● Osteoarthritis Forefoot/Midfoot● 1st Ray Hypermobility● Pes Plano Valgus● Hallux Limitus● Sesamoiditis● Lateral Column Syndrome● Freiberg’s Infarction ● Forefoot Callus

Equinus Conservative Management

• Ineffective Conservative Care– Manual

stretching– Casting– Night splints

• Effective Conservative Care– EQ/IQ Brace

Equinus Surgical Management

Heel Pain

• 2,000,000 cases per year in US

• Diagnosis– History– Physical– Radiology – MRI– Ultrasound

Heel Pain Treatment

• Short term acute treatment– Treat symptoms

and etiology– Symptoms –

• MDP• Steroid injection• RICE• PT

– Etiology –• Equinus

– Pronates foot– Twice pressure

on PF as body weight

– Bracing superior

• Strapping – 3 to 4 times

• Plantar Fascia Brace

• Immobilzation

Heel Pain Treatment

• Long term treatment – 80 to 90% improved– Stretching

• 2 to 3 months• Maintenance

therapy– Long-term arch

support• Custom Orthoses

• Resistant Cases – 10 to 15%– Baxter’s Neuritis –

entrapment of 1st branch of LPN• Clinical SSX• MRI – ABH muscle

belly• Dx injection• Release of nerve

entrapment and plantar fasciectomy

Heel Pain Treatment

• EWST – high amplitude, fast rising, asymmetrical, low frequency sound energy– 80 to 90% effective in

literature– 3 treatments spaced

weekly– 2 to 3 bars, 11 to 13

Hz, 2000 to 3000 pulses

– No NSAIDs for 8 weeks

Heel Pain Surgical Treatment

• Plantar fascia release – 80 to 85%

effective– Heel spur is not

addressed– Biomechanical

considerations– Gastroc

Recession +/- PF relase

Onychocryptosis

• Dx – +/- paronychia– Incurvated nail plate– HNF– Granulation– POP– Erythema– Drainage

• Phenol & alcohol procedure – 95% effective

Onychocryptosis

Onychomycosis

• Dx – 6.5 to 8.7%– History – other

skin conditions?• Immune system

compromise?• Age?• Injury?

– Physical Exam –• Thick, yellow,

dystrophic, discolored, onycholysis, odor, subungal debris

– PAS stain –• False negatives

– Poor specimens• Fungal elements

– T. Rubrum– T.

Epidermophyton

– T. Microsporum • Histological

examination• Mixed results?

Onychomycosis

Onychomycosis Treatment

• Topical – 10 to 30 % effective – Best combined with

other treatments– Formula 3

• Jojba oil• Tolnafatate

– Chronic Tinea Pedis treatment?

– Hyperhidrosis treatment?

• Oral – 70 to 75% effective– Lamisil 250 mg

qd– LFTs pre and

midway– 3 month therapy– 9 to 12 months

to evaluate success• Chronic Tinea

resolution at 1 month

Onychomycosis Treatment

• Laser Therapy– Cool Touch CT3

CoolBreeze– 1320 nm– Nd:Yag laser– 5 mm spot size– 6 joules– 40° to 45° C– 80% Effective

Onychomcosis Treatment

Verrucae Plantaris

• Human Papilloma Virus – 46 strains

• 10% incidence in children and young adults

• Can resolve spontaneously

• Transmitted by contact

• Sites of trauma or irritation

• Contracted from other individuals in public traffic areas

• Located in epidermal layer – no scarring

• Clinically –– No skin lines– Encapsulated– PSTSP– Rete-pegs– HPK overlying

Verrucae Plantaris

Verrucae Plantaris

• VP treatment – not penetrate dermis– Oral vitamin A

10,000 IU with 15 mg zinc BID x 2 months

– Oral Tagamet 1600 mg per day in divided doses• Teens and

younger• 90% effective

• Keratolytic therapy – 20%, 40%, 60% Salicylic acid– Must debride HPK– Occlusion helpful– Changed dialy– Pumice stone to remove

mascerated tissue and HPK

• Chemotherapy – similar to Keratolytic– Monochloroacetic acid – Bichloroacetic acid– Cantharidin 0.7% to 1.0%

- green blister beetle

Verrucae Plantaris

• Cyrosurgery – carbon dioxide, liquefied nitrous oxide or liquid nitrogen– Freeze-thaw cycles – Ice formation,

cellular dehydration, vascular stasis

– Multiple treatments• Candida injections• Laser therapy

Verrucae Plantaris

Hallux Abducto Valgus

• Laterally deviated hallux with valgus rotation

• History –– Injury– Arthritis – OA, RA– Shoe gear– Activity level– Pain

• Physical exam –– Mild, moderate, severe– Hypermobile 1st ray– Erythema 1st MTH

medially– POP– PROM– Tracking – Crepitus– Reducible– Equinus factor– Foot structure -

pronated

Hallux Abducto Valgus

Hallux Abucto Valgus

• Radiologic Exam –– AP, Lateral, LO

WB • IM <• HA <• TSP• PASA• MPE• Joint alignment

• Treatment –– Watchful neglect– Shoe gear change– Custom orthoses– Equinus

management– Surgical

• Distal Procedures -Austin/Akin

• Proximal Procedures – Lapidus/Akin

Hallux Abucto Valgus

Hammer Digit Syndrome

• Etiology – – Flexor stabalization– Extensor substituion– Flexor substitution

• Types –– Hammer toe– Mallet toe– Claw toe

• Associated conditions – PDS– Cross-over toe

Hammer Digit Syndrome

• Symptoms –– Erythema– Helloma Durum– Helloma Molle– Pain– Edema– Arthrosis

• Physical Exam –– Rigid vs. Flexible– Level of deformity– MPJ involvement– Associated deformity –

hypermobile 1st ray

• Treatment –– Watchful neglect– Splinting– Toe spreader– Orthoses– Equinus

management– Surgery

• Flexible – FDL Transfer

• Rigid – arthrodesis vs. arthroplasty

Hammer Digit Syndrome

Hammer Digit Syndrome

Hammer Digit Syndrome

Hallux Rigidus

• Normal 1st MPJ DF - 60° to 70°

• Normal gait requires 35° DF 1st MPJ

• Etiologies –– MPE due hypermobile

1st ray– FF supinatus– Long 1st MT– DJD– HAV– Systemtic arthritis

• SSx –– Pain– Swelling– Stiffness– Crepitus– Dorsal bony

prominence– Sub hallux IPJ HPK– Sub 2nd MTH HPK– Lateral

metatarsalgia

Hallux Rigidus

• Radiologic Exam –– Subchondral

sclerosis– Joint space

narrowing – Flattening of

MTH– Osteophytes

Hallux Rigidus

• Non Surgical Tx –– Rocker sole shoes– Custom orthoses– Equinus management– PT– Anti-inflammatory

medication– Activity modification– Steroid injection

• Surgical Tx –– Joint

preservation –• Chielectomy• Austin osteotomy• Lapidus

procedure– Joint destructive

–• 1st MPJ

arthrodesis• Implant

arthroplasty

Hallux Rigidus

Morton’s Neuroma

• Definition – perineural fibrosis

• Not a true neoplasm

• 3rd IMS – Morton– MPN and LPN– Associated with

IM Bursae• Mulder’s Test

• SSx –– Pain b/w 3rd & 4th MTH– Burning– Shooting pain– Aggravated by WB– Aggravated by shoegear– Alleviated by rest – Alleviated by massage

• Diagnostic Examination – X-ray– MRI– Ultrasound– L/S injection

Morton’s Neuroma

Morton’s Neuroma

• Treatment –– Steroid injection– Oral steroids– Strapping – Orthoses– Change of shoe

gear– EtOH injections– ESWT?– Surgery

Insertional Achilles TendonitisInsertional Achilles Tendonitis

• Patient Type -– Older, less athletic, overweight and sedentary pts.– Young adult males -seronegative

spondyloarthropathies • SSX –

– Posterior heel pain – dull aching pain• Increased with standing, walking or running• Aggravated by either active or passive ROM

• Patient Type -– Older, less athletic, overweight and sedentary pts.– Young adult males -seronegative

spondyloarthropathies • SSX –

– Posterior heel pain – dull aching pain• Increased with standing, walking or running• Aggravated by either active or passive ROM

• Clinical Exam –– Localized tenderness near achilles insertion– May have localized edema– Achilles tendonitis and retrocalcaneal bursitis often

seen with insertional posterior heel pain– Tendon thicken at insertion– Ankle equinus often associated finding

• Clinical Exam –– Localized tenderness near achilles insertion– May have localized edema– Achilles tendonitis and retrocalcaneal bursitis often

seen with insertional posterior heel pain– Tendon thicken at insertion– Ankle equinus often associated finding

Insertional Achilles TendonitisInsertional Achilles Tendonitis

• Radiographic Exam –– Ossification in the most proximal extent of the

achilles insertion– Spurs may be incidental findings on x-rays and

not be associated with any SSX - usually chronic inflammation is required for pain

• Radiographic Exam –– Ossification in the most proximal extent of the

achilles insertion– Spurs may be incidental findings on x-rays and

not be associated with any SSX - usually chronic inflammation is required for pain

TreatmentTreatment

• Conservative TX – may be helpful initially– Training modification in athlete– NSAIDs– Heel lifts– Stretching and strengthening – Widening and deepening heel counter on shoes– Padding of the posterior heel– Night splint for more aggressive stretching– Immobilization x 6 weeks

• Conservative TX – may be helpful initially– Training modification in athlete– NSAIDs– Heel lifts– Stretching and strengthening – Widening and deepening heel counter on shoes– Padding of the posterior heel– Night splint for more aggressive stretching– Immobilization x 6 weeks

• Surgical TX – when conservative TX fails and SSX persist– Approach –

• Medial• Lateral • Posterior – linear or curvilinear • Medial and lateral combined

– Tendon reflection –• Longitudinal midline incision of the achilles tendon • Lateral to medial reflection of the achilles tendon• Minimal reflection if spur is primarily posterior to tendon

• Surgical TX – when conservative TX fails and SSX persist– Approach –

• Medial• Lateral • Posterior – linear or curvilinear • Medial and lateral combined

– Tendon reflection –• Longitudinal midline incision of the achilles tendon • Lateral to medial reflection of the achilles tendon• Minimal reflection if spur is primarily posterior to tendon

TreatmentTreatment

• Resection of inflamed calcaneal bursa as needed• Spur reduction and posterior calcaneal remodeling• Achilles reattachment – AJ in NP

– Soft Tissue anchors – 1 to 3 (inverted triangle)– Bone wax to prevent osseous activity due to exposed

bleeding cancellous bone – Repair any soft tissue attachments to the tendon at

this point with 2-0 absorbable suture

• Resection of inflamed calcaneal bursa as needed• Spur reduction and posterior calcaneal remodeling• Achilles reattachment – AJ in NP

– Soft Tissue anchors – 1 to 3 (inverted triangle)– Bone wax to prevent osseous activity due to exposed

bleeding cancellous bone – Repair any soft tissue attachments to the tendon at

this point with 2-0 absorbable suture

TreatmentTreatment

Questions????????????

• Patrick A. DeHeer, DPM Shirley M. Catoire, DPM

• IU North – Johnson Memorial Hospital – Greenwood –Columbus – Shelbyville – Johnson Memorial Wound Healing Center

• Tel: 800-615-1363• Hoosierfootandankle.com• padeheer@sbcglobal.net