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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

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The foot l.jpg

The Foot

Briant W. Smith, MD

Orthopedic Surgery

TPMG Santa Rosa


General considerations l.jpg
General Considerations

  • VERY common problems.

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


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Divide the Foot into Thirds

Hindfoot Midfoot Forefoot


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Order Standing Radiographs

  • AP and Lateral are Standing

  • Oblique is supine


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Forefoot Problems

  • Women far outnumber men because of shoe choices. Shoe modification is the first line of treatment for:

    • Bunions

    • Neuromas

    • Metatarsalgia

    • Sesamoiditis



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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




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Midfoot Problems

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

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



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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.



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The Forefoot

  • Bunions

  • Funny toes

  • Metatarsalgia

  • Interdigital Neuroma

  • Sesamoiditis

  • Stress Fracture



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BunionsHallux 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)



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1st MTP Arthritis

  • Hallux rigidus (ortho) or limitus (pod)

  • 1st 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




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Funny ToesHammer 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.



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It just means forefoot pain.

Pain is under a metatarsal head (usually 2nd) 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



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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.



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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.



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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.



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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.


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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.



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Plantar Heel Pain

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

  • Add a pad, like Spenco gel heel cushions.



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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.



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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.



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Foot Examination

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


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Vascular Examination

  • Foot color—dependent and on elevation

  • Edema

  • Pulses

  • Capillary Refill

  • Hair distribution


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Neurologic Examination

  • Lumbar dermatomes vs. specific nerves vs systemic disease

  • Light touch for gross testing

  • Semmes-Weinstein 5.07 monofilament for diabetics.


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Range of Motion

  • Should be symmetric

  • Ankle dorsiflexion 10 deg with knees ext.

  • Subtalar joint should be mobile.

  • 1st MTP joint extension should be >60 deg


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Tendons

  • Achilles insertion and body of tendon

  • Posterior tibial tendon

  • Peroneal tendons


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Deformities

  • Pump bump

  • Talar head

  • NWB and WB for pes planus/cavus

  • 1st MTP joint

  • Lesser toes


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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


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Treatment Options

  • Physical therapy

    • Ultrasound

    • Interferential stimulation

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

  • NSAIDS

  • Injections


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