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Foot and Ankle

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Foot and Ankle Powered By Docstoc
					Steven J. Lawrence, MD
Head of Orthopedic Foot and
Ankle Section
UK Health and Wellness
Symposium
May 18, 2007
Objectives:

 Present seven common foot and ankle
 ailments.
 Explain the anatomic problem.
 Provide DIY treatment and rationale.
 Suggest when to see a doctor.
The Foot

Leonardo DaVinci:
The foot is a masterpiece
  of engineering and
  work of art.”
The Foot



Socrates:
“When our feet hurt, we
  hurt all over.”
Foot Facts

 The average American
 walks 10,000 steps per
 day (4 miles/day) or
 115,000 miles in a
 lifetime. That is
 equivalent to walking
 around the earth 4
 times.
Foot Facts


 The foot consists of at least 26 bones, 33 joints, 20
 muscles, 31 tendons, and over 107 ligaments.
 Over 250,000 sweat glands in each foot.
Foot Facts



 Largest shoe size?
 Matthew McGrory: 7’4”
 with a size 28 ½ shoe
Foot Facts

 25 percent of bones are
 located in our feet.
 Most feet are not
 symmetric in size.
 Women with 4x the risk
 of having foot pain.
 Absorb hundred of tons
 of force per day.
Mechanical

 The foot is a marvelous
 biomechanical device
 Shock absorption, rigid
 lever.
 Ignored, until they hurt.
 Tremendous
 stress/strain of foot and
 ankle
Agony of da Feet

 Shoe wear has a considerable
 influence on the incidence of bunion
 surgery.
Shoe Selection

 Mismatch of shoes and
 foot contours in many
 females.
 Dr. Carol Frey: FAI
 1993 study of 356
 women. 82% with ill
 fitting shoes. Few had
 their shoes
 professionally sized
 within past 5 years.
Selection of shoes

 Shop in the afternoon.
 Wide toe box
 Low heel
 Good shock-absorbing
 properties
 Medial arch support
 Width of shoe as
 important as the length.
Common problems associated with
foot pain

 Achilles tendonitis
 Heel spurs (plantar
 fasciitis)
 Stress fractures
 Bunions
 Corns and calluses
 Morton’s neuroma
 Diabetic neuropathy
Achilles Tendonitis

 Achilles was mythical
 Greek warrior whose
 only vulnerable body
 part was his Achilles
 tendon.
Achilles tendonitis

  Strongest tendon in the
  foot
  Ankle plantar flexor-
  ”push off tendon”

Subtypes:
  Watershed--may
  rupture
  Insertional
Achilles Tendonitis

Treatment:
  Stretching
  Avoid stairs/hills
  Anti-inflammatories
  Ice
  Short-term
  immobilization
Plantar Fasciitis-Heel Spurs

 “Bow-string” of the
 arch.
 Degenerative condition
 where the arch
 supports become
 painful.
 Morning stiffness is
 very common.
 Contracture of the
 plantar fascia and
 Achilles tendon.
Plantar fasciitis

 Conservative
 management:
 stretching, stretching,
 and more stretching
 Anti-inflammatory
 medications, ie: Aleve
 or Motrin
 Ice after activity
 Shoe inserts
 Weight loss
Plantar Fasciitis

 If primary treatment
 fails: steroid injections
 and/or use of physical
 therapy modalities may
 be helpful.
 Rarely is surgery
 necessary—as it may
 result in a flattened
 foot.
Stress Fractures

    Fracture due to
    repetitive load.
    Often seen in
    osteoporosis.
    May be due to
    sudden increase in
    activity.
    Most common in the
    second metatarsal.
Stress Fractures

 If you suspect a stress
 fracture, you should
 see a physician to
 confirm the diagnosis.
 Treatment is similar to
 other foot fractures.
 May need to rule out
 correctible causes for
 bone weakness ie
 thyroid, kidney etc.
Gout

 Usually involve the
 great toe joint
 Acute onset of severe
 pain usually in the great
 toe.
 Build up of uric acid in
 the blood.
 Precipitation of crystals
 within the joint which
 causes synovial
 irritation.
Gout

 More common in males
 Usually only affects 1-2
 joints
 Episodic attacks
 Family history
 Alcohol and dietary
 influences
 Certain diuretics
Gout


Red, swollen, and
  inflamed great toe is
  characteristic.
Gout

Prevention:
  Avoid alcohol and meat-laden
  diet.
  May require lab work to confirm
  the diagnosis.
  May cause uric acid crystals in
  the kidney.
  May require medication to help
  the kidneys excrete the uric
  acid from of the body.
Bunions


 Babies are not born
 with bunions.
 The path of straight
 toes to crooked
 toes.
 Shoes are
 contributory.
Bunions

 There are various forms
 of bunion surgery with
 varying recuperation
 times.
 Surgical correction
 generally requires an
 osteotomy of the
 metatarsal to correct
 the alignment.
 Occasionally, a joint
 must be welded to
 make it straight again.
Bunions

 Deformity cause by
 outward rotation of the
 first metatarsal.
 There is inward rotation
 of the toe.
 Crowding of the second
 toe may result in a
 hammertoe.
Bunions


          Metatarsal swings
          outward.
          Toe swings inward.
          Which occurs as the
          primary event?
          Sesamoid Pain

Two small bones on the
bottom of the 1st
metatarsal.
Bones are inside the
toe flexor tendons.
Tremendous
compression loads.
Tendonitis, fracture,
arthritis, AVN
Treatment of Sesamoid pain


 Stiff-soled shoe
 prevents rollover of
 foot.
 Inserts to off-load the
 bones.
Corns and Calluses

 A thickening of the skin
 due to repetitive
 irritation.
 May be due to poor
 fitting shoes
 Can be pared.
 Salicylic acid can be
 used to remove the
 thickened skin.
Hammertoes
Hammertoes

 Crooked toes
 May be secondary to
 small shoes that crowd
 the toes, esp. if the
 second MT is longer
 that the first.
Hammertoes

 Splints can be applied
 to stretch the deformed
 joints and to relieve
 pressure.
Hammertoes

 If stretching and using
 pads do not work,
 consider seeing your
 physician.
 If the joint is stiff, you
 may require surgical
 intervention.
Morton’s Neuroma
 Irritation or entrapment of a
 digital nerve.
 This nerve is on the bottom
 of the foot and between the
 toes.
 Usually 2-3 or 3-4
 interspace.
 Worse with use of tight
 shoes-due to crowding.
 “feels like a marble on the
 bottom of my foot.”
 Stinging pain shooting to the
 2nd and 3rd toes
Morton’s Neuroma
Morton’s Neuroma

 Conservative care with
 wider shoes or
 transverse arch
 supports to widen the
 space between the
 metatarsals.
 Injections provide
 diagnostic and
 therapeutic benefit.
Morton's Neuroma

 Surgical
 decompression versus
 excision.
 Excision of the digital
 nerve cause permanent
 numbness in two toes
 and may result in a
 surgical neuroma.
Tarsal Tunnel Syndrome

 Tibial nerve is
 entrapped in the
 hindfoot.
 Somewhat similar to
 carpal tunnel syndrome
 Relieve nerve stretch
 with the use of inserts,
 if there is significant
 hindfoot deformity.
Tarsal Tunnel Syndrome


 Nerve-soothing
 medications
 Surgical
 decompression
 Rule out a L-5 lumbar
 radiculopathy
Diabetic Foot Care

 Wash and dry feet daily-
 especially between the toes.
 Daily inspection with mirror.
 Emollient cream to prevent
 cracking and fissures
 Cut nails to shape of toe
 Don’t dig into corners
 Be vigilant about cuts and
 abrasions.
Diabetic Neuropathy

 Problem is lack of
 sensibility
 If painful, the problem
 may be due to nerve
 irritation.
 High glucose levels are
 harmful to the nerves.
Diabetic Neuropathy

 Burning and stinging
 pain.
 Commonly treated with
 better control of
 glucose levels and
 medications that soothe
 the irritated nerves.
Diabetic Neuropathy
 Lack of sensation leads to
 ulcers and ultimately to
 amputation.
 Extra-depth shoes and
 plastizote inserts are
 recommended.
 The insert is very spongy
 and help to offload pressure
 from any bony prominences.
  Unfortunately, they loose
 their spring after about 6
 months and need to be
 replaced.
Diabetic Foot Care

 Need to have primary
 care physician optimize
 glucose control.
 May see podiatrist for
 foot care—nail
 trimmings and callus
 shavings.
 If an ulcer develops,
 you need to see your
 doctor promptly.
Thanks for your attention

				
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