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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

The Foot

Briant W. Smith, MD

Orthopedic Surgery

TPMG Santa Rosa

general considerations
General Considerations
  • VERY common problems.
  • Systemic disease is a major player (diabetes, vascular and neurologic diseases, inflammatory arthritis)
divide the foot into thirds
Divide the Foot into Thirds

Hindfoot Midfoot Forefoot

order standing radiographs
Order Standing Radiographs
  • AP and Lateral are Standing
  • Oblique is supine
forefoot problems
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
  • 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
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
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
The Forefoot
  • Bunions
  • Funny toes
  • Metatarsalgia
  • Interdigital Neuroma
  • Sesamoiditis
  • Stress Fracture
bunions hallux valgus
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
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
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.
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.

  • 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
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
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
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
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
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
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
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
Foot Examination
  • Become comfortable with apparent deformities, joint mobility, tendon insertions, vascular and neurologic examinations.
vascular examination
Vascular Examination
  • Foot color—dependent and on elevation
  • Edema
  • Pulses
  • Capillary Refill
  • Hair distribution
neurologic examination
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
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
  • Achilles insertion and body of tendon
  • Posterior tibial tendon
  • Peroneal tendons
  • Pump bump
  • Talar head
  • NWB and WB for pes planus/cavus
  • 1st MTP joint
  • Lesser toes
treatment arsenal
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
Treatment Options
  • Physical therapy
    • Ultrasound
    • Interferential stimulation
  • Contrast soaks (10 mins warm, 30 secs ice cold, repeat x2, end with cold)
  • Injections