Table of contents
- 1. Foot Intro
- 2. Calcaneus
- 3. Talus
- 4. Midfoot (Navicular Cuboid and Cuneiforms)
- 4.1. Navicular
- 4.2. Cuboid/Cuneiform
- 5. Lisfranc Joint Fracture-Dislocation
- 6. Metatarsal Fractures
- 7. Toe Fractures
- 8. Plantar Fasciitis
- 8.1. Heel Pad Atrophy
- 9. Soft Tissue Injury and Dislocations
- 9.1. Subtalar Dislocations
- 9.2. Toe Diclocations
- 9.3. Compartment Syndrome of Foot
- 9.4. Infection
- 9.5. Puncture Wounds
- 9.6. Achilles Tendon Rupture
- 9.7. Achilles Tendinopathy
- 9.8. Foot Strain
- 9.9. Metatarsalgia
- 9.10. Morton's Neuroma
- 9.11. Ingrown Toenail.
- 9.12. Hallux Valgus
Foot Intro
- Three regions:
- 1. Hindfoot (talus and calcaneous)
- 2. Midfoot (navicular, cuneiform, and cuboid)
- 3. Forefoot (metatarsals and phalanges)
- Foot Fractures result from:
- 1. Direct Trauma
- 2. Indirect Trauma
- 3. Overuse
- Foot Anatomy:
- Imaging
- AP, (medial two TMT joints)
- Oblique (lateral three TMT joints)
- Lateral views (calcaneal)
- Sessamoid bones - Bones within tendons over joints (such as the patella). Help protect tendon from joint, and lifts the tendon from the joint space.
- Secondary ossification centers - many in foot.
Calcaneus
- Most common tarsal injury (60% of tarsal injuries)
- Anatomy:
- Forms bottom of subtalar joint, which has three articular surfaces:
- Anterior, middle, and posterior.
- Sustentaculum talus is medial extension of calcaneus that supports anterior and middle articular facets.
- Peroneal tubercle: on lateral surface provides a groove for peroneal tendons and groove where peroneal retinaculum attaches.
- 75% of calcaneal fractures are intra-articular, 75% depressed.
- Forms bottom of subtalar joint, which has three articular surfaces:
- Mechanism: Usually fall from height, often >8 feet.
- Complciations:
- Compartment Syndrome
- Fracture blisters (clear or blood-filled), may delay surgery to avoid high rates of infection.
- Sural nerve entrapment.
- Based on mechanism:
- Thoracolumbar Compression Fractures. (10%)
- Compartment syndrome (10%)
- Imaging:
- Easy to see on AP/oblique/lateral views.
- Bohler's Angle (20-40° normal)
-
Bohler's Angle (Normal: 20-40°)
- Calculated by measuring angle between two lines
- 1. From superior margin of posterior calcaneal tuberosity (back-top tip) to superior tip of posterior facet (back-top tip of ST joint).
- 2. From superior tip of anterior facet (front-top of ST joint) to superior tip of posterior facet (back-top of ST joint).
- Calculated by measuring angle between two lines
- If angle is <20°:
- 1. Depressed fracture present even if not seen on Xray
- 2. Worse outcome regardless of intervention.
- Bohler angle can be normal even with bad fractures, so it does not rule-out anything.
-
- Can do Harris view to see extent of intra-articular involvement and degree of depression.
- Shoot obliquely across plantar heel of dorsiflexed foot.
- CT: Gold standard, can see extent of damage (xrays can't see extent in half cases)
- Do CT if surgery needed.
- Treatment:
- ALL:
- Ice, elevate (decreases soft-tissue injury, decrease blisters)
- Immobilize: Bulky compression dressing + posterior splint.
- Non-weight bearing: Give crutches to prevent further bone+soft tissue injury.
- If intra-articular or displaced: non-wt bearing x6-8w.
- If extra-articular: non-wt bearing x4-6w.
- then gradual increase in activity.
- Hydrothreapy
- Surgery: Controversial.
- Should consult ortho in all cases unless non-displaced, extra-articular
- Surgery if compartment syndrome
- Displaced intra-articular: controversial. (can wait 7-10 days, especially if swelling)
- If comminuted, displaced, depressed: need to re-establish joint congruity, so prob need surgery. (ORIF: often pins).
- Admit if suspect compartment syndrome.
- ALL:
- SPECIFIC FRACTURES:
- Anterior Process Fracture: (15% of talar fractures)
- Sustentaculum Tali Fracture:
- Uncommon.
- Mechanism: axial compression of heel with inverted ankle.
- Pain worse with inversion of foot or hyperextension of great toe. (Flexor hallucis longus passes beneath sustentaculum tali).
- Tx:
- Non-displaced:
- Cast, and non-wt bearing for 8wks.
- Ortho referral.
- Chronic pain common
- Displaced: Emergency ortho referral + ORIF. (Sx in 10 days after swelling better).
- Non-displaced:
- Lateral Calcaneal process and Peroneal Tubercle Fractures.
- Medial Calcaneal process fracturs: Uncommon, look up
- Calcaneal Tuberosity Fractures:
- Avlusion by Achilles tendon.
- Mechanism: Fall or jump landing on doris-flexed foot with knee extended.
- ON Exam: weak plantarflexion, inability to walk, pain in this area.
- Tx:
- Non-displaced:
- non-wt bearing cast in slight plantarflexion x6-8wks.
- Ortho consult.
- Displaced: Ortho ---> ORIF (especially if putting tension on soft-tissue).
- Non-displaced:
Talus
- Uncommon <1% of all fractures.
- Difficult to visualize
- Anatomically three segments:
- Head, neck body.
- Held in place by ligaments, no muscle insertions.
- Blood supply enters via deltoid ligament, talocalcaneal ligament, anterior capsul, and sinus tarsi.
- Fractures: Major vs. Minor
- Major Fractures:
- Involve head, neck or central portion of body.
- Neck fractures divided into Hawkins Types:
- Type I - nondisplaced
- Type II - displacement w subluxation or displacement of subtalar joint.
- Type III - Process displacement + dislocation from subtalar and ankle joint.
- Type IV - Displaced from subtalar joint and talar head dislocated.
- Minor Fractures:
- Fractures of body of talus (include lateral process, posterior process, and osteochondral talar dome).
- "Snowboarder's ankle": lateral process fractures (axial loading, dorsiflexion, eversion, ext rotation.
- Posterior process: uncommon, hyperextension.
- Major Fractures:
- Mechanism:
- Neck Fractures: Acute dorsiflexion.
- Called "Aviator's astragalus" b/c occured in WWII pilots after rudder forcibly dorsiflexed ankle when crashlanding planes after bombing missions.
- Body Fractures: Acute hyperextension
- Neck Fractures: Acute dorsiflexion.
- Treatment:
- "Major" fractures:
- Ice, elevate
- Immobilize: crutches
- Early consult.
- Non-weight bearing cast for 6-8wks.
- ORIF if talonavicular joint instability, displaced in articular step-off or later than 50% of articular surface.
- Non-displaced: short-leg walking cast for 6wks followed by 3 weeks of partial wt bearing.
- "Minor" fractures:
- ice, elevation, immobilization in short-leg spint. (keep ankle in neural position).
- Crutches + ortho referral.
- OR if >2mm displaced.
- "Major" fractures:
- Complications:
- Talar Head: Talonavicular OA or chondromalacia.
- Talar neck: AVN, peroneal tendon dislocations, delayed union.
Midfoot (Navicular Cuboid and Cuneiforms)
- Rare, non-mobile segments.
- Sensitivy of xrays is 25-33% of detecting midfoot fractures
Navicular
- Four types:
- 1. Dorsal avulsion # (most common)
- 2. Tuberosity #
- 3. Body fracture
- 4. Compression fracture.
- Anatomy notes:
- Tibialis posterior tendon attaches to navicular tuberosity.
- Mechanism
- Dorsal avulsion: Acute flexion with inversion of foot. The talonavicular joint capsule is stressed and avulses the proximal dorsal aspect of navicular.
- Tubercle avulsion: Eversion of foot increases tibialis post. tendon --> avulses tubercle.
- Imaging:
- Difficult to diagnose subtle fractures.
- Often need CT or MRI. (especially stress fractures).
- Treatment:
- Dorsal avulsion & compression #'s: ice, elevate, compressive dressing.
- Weight bear w crutches x2 weeks until pain better.
- Operate if >25% of articular surface (large fracturses) - use wires.
- Tuberosity fracture:
- Compression dressing, short leg splint.
- When swelling better: short-leg cast with foot in inversion x6weeks.
- Body fractures:
- Ice, elevation, post. splint.
- Definitive management: well-molded walking cast x6-8weeks.
- Dorsal avulsion & compression #'s: ice, elevate, compressive dressing.
Cuboid/Cuneiform
- Cuboid Fractures
- Cuneiform Fractures
- Usually fractures occur together from direct crush injury.
- On Exam: midfoot motion will be painful. Tender over the cuboid/cuneiform.
- Cuboid/Cuneiform fractures are associated with tarsometatarsal dislocation (which may have spontaneously reduced).
- Therefore: Assume dislocation until proven otherwise.
- Tx
- Ice, Elevation, Splint with crutches.
- Non-weight bearing short-leg cast x6-8weeks.
- After cast removal longitudinal arch support for 5-6mo
- Surgery: if displaced or comminuted.
Lisfranc Joint Fracture-Dislocation
- Spectrum from stable sprain to unstable fracture dislocations.
- Lisfranc fracture-dislocations are rare (0.2% of all fractures), but high incidence of chronic pain and functional disability.
- 20% rate of misdiagnosis (one of the most common malpractice lawsuits against ER physicians).
- If not properly managed --> HIGH POTENTIAL OF DISABILITY
- Anatomy:
- Lisfranc Joint: articulation of midfoot with metatarsals
- Cuneiforms articulate with first three metatarsals
- Cuboid articulates with last two metatarsals.
- Ligaments:
- TMT ligament (tarsometatarsal) binds each of the metatarsal bones to a bone of midfoot.
- Transverse intermetatarsal ligament: binds proximal aspects of second through fifth metatarsals. (strong ligament!)
- Lisfranc ligament: Very strong ligament binding across from the 2nd metatarsal to medial cuneiform.
- No ligament btwn 1st and 2nd metatarsals.
- NOTE: 2nd metatarsal is bound by three ligaments, so usually fractures rather than dislocates.
-
- NOTE: Fracture of base of 2nd metatarsal suggests a Lisfranc fracture-dislocation until proven otherwise!!!
- Lisfranc Joint: articulation of midfoot with metatarsals
- Classification (not prognostic!!!)
- Classification based on whether or not all of the lisfranc joints disrupted (total/partial incongruity)
- Direction of displacement is noted: Medial, lateral, dorsal, or plantar.
- "Homolateral" dislocations are common (4 or 5 metatarsals moved to same direction)
- "Divergent" dislocations occur usually between 1st and 2nd metatarsals (opposite directions) b/c weakest joint.
- Direct force splits the groove btwn 1st and 2nd mt's.
- Mechanism:
- Usually MVA..
- Direct force - or indirect via axial loading on plantarflexed foot.
- High risk of compartment syndrome!
- Exam:
- Tenderness over the joint.
- Patient may be able to amulate!! cannot exclude diagnosis.
- Ecchymosis may be present on plantar aspect of foot.
- Pain on passive dorsiflexion of toes suggest compartment syndrome.
- Imaging:
- AP, oblique, and lateral radiographs.
- AP better 1st and 2nd metatarsal.
- 1. 1st metatarsal aligns with medial cuneiform.
- 2. Medial borders of 2nd metatarsal and middle cuneiform aligned.
- 3. Distance btwn bases of 1st and 2nd mtls should be <3mm.
- Oblique better for others.
- 4. Lateral borders of 3rd mtsl and lateral cuneiform aligned.
- 5. Medial borders of 4th mtsl and cuboid aligned.
- Lateral
- Evalute dorsal and plantar dislocation
- 6. Dorsal surface of metatarsals is in line with respective tarsal. Never disrupted.
-
Medial aspect of middle cuneiform and 2nd metatarsal align. Any disruption of this is indicative of dislocation, which may have spontaneously reduced.
- Standing Stress Views:
- May be required. Up to 10% of Lisfranc injuries cannot be seen without stress views.
- Poorly tolerated due to pain.
- CT is best! 25% seen on CT and not on xray.
- Complications:
- 1. Fracture of base of 2nd metatarsal
- 2. Avulsion fractures of tarsals and metatarsals.
- 3. Cuboid, cuneiform, navicular injuries.
- 4. Compartment syndrome.
- Degenerative arthritis, chronic pain, etc..
- Tx:
- Analgesics, ice, elevation, immobilization.
- HIGH POTENTIAL OF DISABILITY
- Even a mild sprain of the joint with normal radiographs should be kept non-wt bearing until further evaluation.
- Fracture-dislocations ALMOST ALWAYS require ortho consult + operative repair.
- If indicated, do surgery in 12-24hrs after injury, sometimes need to wait 7-10d for swelling to decr.
- Closed reduction with cast will reduce, but not be stable enough. (need pins+screws).
- Need Custom arch support for 12 months after.
- 90% success with good management.
Metatarsal Fractures
First Metatarsal
- Usually direct crush.
- Pain with axial loading.
- Tx:
- Ice, elevation, analgesics, immobilization.
- Crutches, NON-weight bearing.
- If Stable, non-displaced - cast x4-6 weeks.
- If displaced or comminuted - require ORIF.
- STABILITY is not definite until stress (weight-bearing) xrays show no displacement.
Central Metatarsal
- 2nd 3rd and 4rth metatarsals.
- if fracture of base - check Lisfranc joint.
- Usually direct crush injury.
- Stress fractures common 2nd and 4rd mtls after repetitive trauma to forefoot.
- Often stable fractures because lots of ligaments hold them in place (unlike 1st mtsl).
- Often non-displaced.
- Tx:
- Elevate, Ice, analgesics.
- Non-displaced generally heal well with hard-sole shoe. (distributes force and reduce stress on MTP joints).
- May not be stable if multiple metatarsals fractured, less stabilizing effect of adjacent ones.
- Closed reduction if:
- Displaced >3mm or angulated >10°
- Need to reduce - toes in finger traps, with weight, and counterraction on tibia.
- Splint and non-wt bearing.
Proximal 5th Metatarsal Fractures
- Three types:
- 1. Tuberosity avulsion fractures.
- 2. Jones' Fractures
- 3. Diaphyseal stress fractures.
- Do not confuse os vesalianum (secondary ossification center) with fracture.
-
- Secondary ossification centers are often smooth, rounded, bilateral and often sclerotic margins.
-
- Tuberosity avulsion fractures often treated conservatively, unless complicated.
- Jones and Diaphyseal stress fractures often require surgery due to high rates of non-union.
- Tuberosity avulsion fractures (90% of base 5th mtl fractures)
- Pseudo-Jones Fractures.
- Defined as proximal to articulation btwn 4rth and 5th metatarsals.
- Transverse or oblique, often extra-articular but may extend into space btwn cuboid and 5th mtsl.
- Mechanism:
- Forced inversion of foot with ankle in plantarflexion
- Avulses b/c both peroneus brevis tendon and lateral cord of plantar aponeurosis attaches there.
- Tx:
- Compression Dressing, hard-soled or cast shoe.
- Wt-bearing as tolerated.
- Heals for 4-6weeks.
- If severe pain: can put in in post-splint with crutches or short-leg walking cast x2-3wks.
- Refer to ortho and surgery if:
- Comminuted or intra-articular involvement btwn metatarsal and cuboid >30% of joint space with significant step-off.
-
A transverse fracture of the base of 5th metatarsal should be confused with fracture that invovles the tuberosity. Treatment and prognosis are entirely different.
- Jones' Fracture
- Fracture at junction of diaphysis and metaphysis.
- Involve artcular facet btwn 4th and 5th mtsls.
- Problematic b/c may disrupt blood supply to distal portion of proximal fragment.
- Mechanism:
- Laterally-directed force on forefoot that disrupts plantar-flexed foot.
- Tx:
- Ice, elevate, immobilize, non-wt bearing.
- Short-leg non-wt bearing cast for 6-8wks.
- Refer to Ortho b/c high incidence of non-union.
- Surgery vs. Conservative:
- Now often treat with ORIF.
- Surgery especially if displaced
- High incidence of delayed and non-union due to poor blood supply.
- Often screw fixation to increase rate of primary union and decrease union time and earlier return to activity.
- Up to 50% of #'s originally treated with immobilization later required surgery b/c of non-union or refracture.
- Diaphyseal Stress Fracture.
- Distal to ligamentous attachments of bone. >1.5cm into diaphysis.
- Often asymptomatic for several days before presentation (unlike Jones and avulsion #'s that acutely injured).
- Often ppl enganaged in strenuous activities.
- Tx:
- Acute: immobilization and non-weight bearing x6-10wks similar to acute Jones' fractures.
- Requires greater immobilization (up to 20wks sometimes with delayed union).
- Often managed with screw fixation or bone grafting b/c high incidence of non-union.
- Distal to ligamentous attachments of bone. >1.5cm into diaphysis.
Toe Fractures
- Phalanx Fractures are most common in forefoot.
- Mechanism
- Majority from direct blow. (heavy object dropped)
- Some stubbing toe.
- Abrupt abduction ("night walker's fracture").
- Tx:
- Most non-displaced or minimally displaced
- Dynamic splinting (use cotton padding btween affected toe and neighbour
- Change splint every few days for 2-3weeks.
- Subungual hematomas can be drained with electrocautery or 18G needle.
- 1st Metatarsal:
- Important in weight bearing and balance... consider referring.
- Especially refer if fracture intra-articular and >25% joint space involved.
- Can buddy tape, hard-sole shoe. If painful, can do posterior splint.
- Comminuted: Need walking cast (dynamic splinting not enough immobilization)
- Important in weight bearing and balance... consider referring.
- If Displaced:
- Reduce in ER.
- Digital block.
- Traction + Manipulate (use nail for rotational guidance).
- Postreduction film.
- Reduce in ER.
- Sessamoids:
- Two sessamoids (flexor hallucis brevis).
- Often acute-on-chronic trauma.
- Local pain on palpation.
- Pain with phalanx extension.
- Treat conservatively (orthotics, hard sole shoe... can do walking cast if extremely painful).
- If all else fails surgically resect sessamoid.
Plantar Fasciitis
- 15% of foot problems.
- Typically 40-60yo, but earlier in runners (10% of runners).
- Presentation:
- Pain on undersurface of heel on standing or walking, and relieved with rest.
- Frequently patients note pain after a period of bed rest, lessens after some activity, then severe again after duration of weight bearing..
- (can say worse in morning when gets up, then better w activity, then worse with more activity)
- Mechanism:
- Infalmmatory and Degenerative condition at site of origin of plantar fascia (medial tuberosity of calcaneus).
- Irritation of periosteum can cause bone spur.
- Risk Factors:
- Excessive walking/standing/running.
- Obseity
- Poorly cushioned footwear.
- Exam:
- local tenderness at anteromedial surface of calcaneus where plantar fascia attaches.
- Dorsiflexion of toes worsens pain.
- Pain always anterior to heel, and may radiate to sole.
- 1/3 bilateral:
- If bilateral R/O rheumatoid arthritis, SLE, gout.
- Imaging:
- Clinical diagnosis, often no need imaging.
- Radiographs or bone scans done sometimes to R/O spurs and stress fractures.
- (15-25% of pop-n have spurs, most are asymptomatic)
- Treatment:
- Rest, ice for symptoms.
- Physical therapy, stretching
- Stretch Achilles tendon
-
Achilles Stretch
- Lean against wall, one foot 1foot away, the other foot next to wall with forefoot extended up the wall). Hold position x10secs and repeat 3x. Perform stretch up to 5x/day initially and then couple of times per day for recurrence.
-
- Stretch Achilles tendon
- Foot-wear: new shoes, arch support, orthotics, night splits,
- Use heel pad (1/2 inch) + arch support to reduce plantar fascia stretch.
- Can also tape.
- (Apply 2-inch tape with tension on plantar aspect of foot. Tape extends from base of 5th metatarsal to head of 5th metatarsal. Tape should be bow-strung in arch area.)
- DO NOT walk bearfoot, and replace worn-out shoes.
- Anti-infammatories, i.e. NSAIDs
- Injections (if all fails, effective, but cause fat pad atrophy --> pain!)
- Surgery (Fasciotomy or release if all else fails)
- 80% improve 12months, but early tx (within 6w) hastens recovery.
Heel Pad Atrophy
- Usually older patients, obese, poor shoe cushion, hard floors.
- Use NSAID
- Use Dispersion pad.
- Refer to chiropodist (heel dispersion padding, orthotics).
Soft Tissue Injury and Dislocations
Subtalar Dislocations
- Rare
- Fall from height, inversion, eversion
- Treat: reduce to prevent skin necrosis.
- Refer to ortho for reduction, if ortho not available, can reduce in ER w/ analgesics, flexed knee to relax gastrocs.
- Countertraction at leg (knee), and traction on forefoot + abduction/adduction depending on injury.
Toe Diclocations
- Rare
- Simple vs complex (interposed soft tissue, sesamoid bones).
- Can be dorsal or volar (usually dorsal).
- Usually big toe.
- Reduction:
- Dorsal MTP dislocation: hyperextension with distal traction. (same as injuring force)
- Stable reductions: hard-soled shoe and dynamic splinting.
- Surgery if cannot reduce or if crepitus after reduction (soft tissue in joint)
Compartment Syndrome of Foot
- Three compartments:
- Medial (Medial to first metatarsal)
- Abductor hallucis brevis and flexor hallucis brevis
- Lateral (Inferior and lateral to 5th metatarsal)
- Abductor digiti minimi and flexor digiti minimi brevis.
- Central
- Flexor digitorum longus and brevis.
- Medial (Medial to first metatarsal)
Infection
- Soft-tissue infections: staph and strep.
- Osteiomyelitis 90% pseudomonas, others include:
- E.coli
- Staph Aureus
- mixed flora.
Puncture Wounds
- High risk of infection.
- If only through soft-tissue, can irrigate, ask pt to clean twice daily, etc..
- If deeper: must explore (either with sterile forceps, or by removing tissue around it).
- High risk of becoming infected.
- Prophylactic antibiotics do not help in studies.
- Puncture wounds that are infected and have a foreign body require abx and surgery.
- If infected: aggressive treatment: surgery, FB removal, debridgement. etc..
Achilles Tendon Rupture
- Commonly missed.
- Achilles tendon: gastroc + soleus insertion.
- forceful dorsiflexion when tendon is in relaxed state or direct trauma to back of ankle.
- Exam:
- Pt can still dorsiflex due to posterior tibial muscle, but weak.
- May palpate empty space, but hard if swollen.
- Calf-squeeze test: (Most common)
- calves squeezed bilaterally and foot is observed in plantarflexion. If no dorsiflexion then tendon ruptured.
- Knee flexion test
- Supine patient asked to flex knee to 90°. Foot is observed: if tendon tear present, foot falls into neutral or dorsiflexion.
- Sphygmomanometer test:
- Wrap BP cuff around mid-calf, inflat to 100mmHg. The foot is dorsiflexed, the manometer pressure will rise to ~140° if tendon is intact.
- Tx:
- Ice, analgesics, immobilization in "gravity equinus position" with ankle plantarflexed in comfortable position.
- Give crutches, and NO weight bearing.
- Treatment controversial:
- Non-surgical:
- 1. Splint immobilization in 20° plantarflexion x2 weeks to allow hematoma consolidation.
- 2. Next, the lower extremity is immobilized in short-leg cast or removable boot with elevated heel x6-8weeks.
- 3. Next, gradual range of motion and 2cm heel lift is weaned over 2 months.
- Disadvantage: decreased muscle strength (lengthened healed tendon and high rate of recurrent rupture 8-39%).
- NOTE: If diagnosis delayed >1week, prefer surgical management.
- Surgical:
- Preferred in younger + athletic pts.
- ROM in 3-7d after surgery, but walking boot worn x6weeks.
- Advantages: better strength, risk of recurrence less (5%)
- Diadvantages: higher cost, post-surgical complications (infection, skin sloughing, nerve injury).
- Non-surgical:
Achilles Tendinopathy
- Achilles tendon constitutes distal insertion of soleus and gastrocnemius.
- AKA: achilles tendonitis, tenosynovitis, peritendinitis, tendonitis, achillodynia...etc.
- Mechanism:
- Acute truma
- Chronic overuse.
- Overexertion
- Often in long-distance runners and ballet dancers.
- Predisposing factors: improper muscle flexibility, increased foot pronation, leg-length discrepancy..etc..
- Exam:
- Swelling, tenderness around the tendon.
- Fine crepitus on motion of foot due to presence of fibrin exucate with the paratendon.
- Pain with activity, relieved by rest.
- Stiff in mornings.
- Passive dorsiflexion aggravates pain.
- Imaging: need MRI or U/S, but not necessary.
- Tx:
- Conservative:
- decrease activity, Ice after activity.
- Elevate heel inside the shoe with small felt pad.
- Runners: sustained stretching of Achilles complex.
- Oral NSAIDs can be used.
- NOTE: Steroid injections can cause tendon rupture, should be avoided!!!
- If pain really bad: use short-leg walking cast or boot.
- If pain still bad >6months: can surgically release tendon.
- Conservative:
Foot Strain
- Many tendons can be strained.
- Foot has longitudinal and transverse arch. Function to spring-board forward motion.
- When they are stretched by excessive weight, pressure, poor muscle tone, foot is strained.
- Localize pain under navicular or under any point in arch: worse with activity, relieved by rest.
- Tx:
- Rest, hot soakes.
- Support arch: sponge rubber pad under arch.
- Simple rest, gradual return to activity.
- Refer to podiatrist to rpevent complications (ligament elongation, joint inflammation, arthrosis, etc..)
Metatarsalgia
- Normally two sesamoids and first metatarsal head bear 1/3 of body weight.
- In flattened foot, 2nd 3rd, 4rth metatarsal head bear greater weight.
- Transverse arch becomes relaxed and subject to strain.
- Often in high-heeled shoes.
- Pain + tenderness over metatarsal heads during wt bearing, relieved with rest.
- May be some edema on bottom of foot.
- Often seen in pts with cavus deformity of foot and who wear high-heeled shoes.
- Tx:
- NSAIDs.
- Use Low-heeled shoes.
- Refer to podiatrist.
Morton's Neuroma
- Middle-aged women.
- Sudden attacks of sharp pain that radiates to toes.
- cutaneous branches of the digital nerves divide on plantar aspect of transverse metatarsal ligament and supply sides of toes.
- Neuroma occurs proximal to bifurcation.
- After sudden attacks tenderness stays for days.
- Can get tenderness in 3rd web space.
- Severe pain by squeezing metatarsal heads together.
Ingrown Toenail.
- Distinguish from Subungual Exostosis.
- Lateral margins of nail dig into surroudning nail fold. --> may lead to paronychial infection.
- Causes:
- Excessive external pressure (poorly fitted shoes).
- Improperly trimmed nails.
- Hyperhidrosis.
- Commonly 20-30yolds.
- Tx:
- Depends on stage.
- Early stage: Only erythema, swelling.
- Warm soaks, elevation of leading corner of nail with cotton pledget soaked in antiseptic solution.
- Advised on proper nail trimming, do not wear narrow shoes. or with high heels.
- Later Stages: acutely inflamed, or paronychial infection
- Excission of lateral nail plate + lateral matricectomy.
- Prep great toe with iodine/povidone soln, block with local anesthetic.
- Fine scissors or hemostat is used to carefully lift the lateral nail plate.
- Scissors is used to cut nail plate, and nail is removed.
- The nail matrix is now exposed, and tissue can be ablated with cotton-tipped applicator soaked in phenol or electrocautery. (must ablate, otherwise nail will come back).
- Excission of lateral nail plate + lateral matricectomy.
Hallux Valgus
- Large toe deviates laterally and bony prominence develops over the medeal aspect of first mtsl head.
- MTP joint may become inflamed+thickened.
- Can present to ER with bursitis.
- Tx:
- Warm moise soaks.
- Pad placed over medial toe
- Refer to podiatrist.
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