The foot
1 / 47

The Foot - PowerPoint PPT Presentation

  • Updated On :

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

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'The Foot' - benjamin

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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)

Divide the foot into thirds l.jpg
Divide the Foot into Thirds

Hindfoot Midfoot Forefoot

Order standing radiographs l.jpg
Order Standing Radiographs

  • AP and Lateral are Standing

  • Oblique is supine

Forefoot problems l.jpg
Forefoot Problems

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

    • Bunions

    • Neuromas

    • Metatarsalgia

    • Sesamoiditis

Over pronation l.jpg

  • 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

Midfoot problems l.jpg
Midfoot Problems

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

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

Hindfoot problems l.jpg
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.

The forefoot l.jpg
The Forefoot

  • Bunions

  • Funny toes

  • Metatarsalgia

  • Interdigital Neuroma

  • Sesamoiditis

  • Stress Fracture

Bunions hallux valgus l.jpg
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)

1 st mtp arthritis l.jpg
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

Funny toes hammer and claw toes l.jpg
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.

Metatarsalgia l.jpg

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.


Sesamoiditis l.jpg

  • 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.

Interdigital neuroma l.jpg
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.

Stress fracture l.jpg
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.

Midfoot arthritis31 l.jpg
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 l.jpg
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 heel pain l.jpg
Plantar Heel Pain

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

  • Add a pad, like Spenco gel heel cushions.

Posterior tibial tendinitis ptt l.jpg
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.

Tarsal tunnel syndrome l.jpg
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.

Foot examination l.jpg
Foot Examination

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

Vascular examination l.jpg
Vascular Examination

  • Foot color—dependent and on elevation

  • Edema

  • Pulses

  • Capillary Refill

  • Hair distribution

Neurologic examination l.jpg
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 l.jpg
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

Tendons l.jpg

  • Achilles insertion and body of tendon

  • Posterior tibial tendon

  • Peroneal tendons

Deformities l.jpg

  • Pump bump

  • Talar head

  • NWB and WB for pes planus/cavus

  • 1st MTP joint

  • Lesser toes

Treatment arsenal l.jpg
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 l.jpg
Treatment Options

  • Physical therapy

    • Ultrasound

    • Interferential stimulation

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


  • Injections