Common Foot & Ankle Problems
Neuroma (Morton’s Neuroma)
- Burning/Numbing sensation
- Cramping
- Pebble under foot sensation
- Massage foot
- Radiates to toes
- Aggravated by walking/ foot gear (heels/ tight shoes)
- Pain relief by rest
- Entrapment of nerve in foot as it passes between the metatarsal heads (ball of foot)
- Entraped nerve undergoes vascular and neurological degernative changes
- Trauma
- Metatarsophalangeal joint deviation
- Soft tissue lesion (ganglion/ lipoma)
- Interdigital Bursa
- Capsulitis
- Stress Fracture (Metatarsal)
- Degenerative disk disease
- Soft tissue tumor
- Peripheral Neuropathy
- Tarsal Tunnel Syndrome
- Lesion of medial/ lateral plantar nerve
- Freidberg’s Infarction
- Arthrosis of metatarsophalangeal joint
- Synovial Cyst
- Plantar pad degeneration
- Goal- Decrease inflammation and remove pathologic forces
- Injections
- Wider Shoes
- Tapping & Padding
- Surgical Excision
- Orthotics
- Physical Therapy
Callosities (Corns and Calluses)
- Foot deformities (bunions, hammertoes, etc)
- Poor fitting shoes
- Bony prominences
- Hammertoes
- High activity levels
PROTECTION?
Mechanical stress–>hyperkaratosis–> increase pressure–>hyperkaratosis
- Symptomatic relief
- Debridement
- Padding
- Footgear
- Creams
SURGERY
- Correction of Hammertoes
- Metatarsal osteotomies
Paronychia
CAUSES
- Disruption between the nail plate and fold
- Aggressive manicuring
- Ingrown nail
- shoegear
- Penetrating trauma
PRESENTATION
- Inflammation
- Unilateral or Bilateral
- Purulent drainage
COMPLICATIONS
- Abscess formation
- Osteomyelitis
- Sepsis
TREATMENT
- Soaks
- Incision and Drainage
- Nail Avulsion
Athletes Foot (Tinea Pedis)
Affects~ 15% of US population
Dermatophyte (Most common organism)
- 3 genera (Trichophyton, Micosporum and Epidermophyton)
-Infected skin fragments
-Infects and destroys keratin
SYMPTOMS
- Erythema
- pruritic
- Scaling
- Fissuring
- Pain
- Hyperkaratosis
- Maceration
DIFFERENTIAL DIAGNOSIS
- Psoriasis
- Dyhidrotic eczema
- Atopic dermatitis
- Xerosis
- Conatact dermatitis
- Syphillis
DIAGNOSIS
- KOH
- Culture
TREATMENT
- Change Environmental factors
- Foot Hygeine
- 30-40% cure rates with washing feet b.i.d
- OTC agents (1-2x qd x 4 wks)
-Lotrimin (clotriamazole)
-Meconazole (Monistat-Derm)
-Terbinafine (Lamisil AT)
-Tolnaftate (tinactin)
-Undecyclenic Acid (Desenex)
Recurrence very common*
Onychomycosis- fungal nail infection
2-13% prevalence
~ 50% diagnosed from appearance
SYMPTOMS
- Thick- hyperkaratotic stratum corneum
Hard- tissue hydration, previous tx, vascular status, organism
- Maloder- trapped debris and bacteria
- Discolored
- Separation of nail from nail bed
COMPLICATIONS
- Physical and Occupational
- Inablitity to cut ones nail
- Inability to wear work boots
- Psychological State
- Feeling less attractive
- Embarrassment
- Feeling of poor health
SOCIAL COMPLICATIONS
- Avoidance or problems with social interactions
- Somatic
- Pain and discomfort from nails
SERIOUS COMPLICATIONS
- Bacterial infection
Nail bed ulceration due to the accumulation of subungal debris
DEFINITE DIAGNOSIS
- KOH prep
- PAS staining
- Culture
-T. rubrum in nail
AGE ASSOCIATION
- Considered age related
- Changes in immune system
- Changes in skin
- Vascular changes
-<0.5% under 18
-15-20% between 40-60
-30% by age 60
TREATMENT
- Presentation and severity
- Medical condition and current medications
- Physician and patient preference
- Cost of therapy
- Debridement
- Topical
-Lack of penetration of agent into the nail
-Inconsistent penetration of drugs into target tissue
- Oral
-Good tissue levels
-Side Effects: Skin rash (12%); GI (11%)-Nausea, diarrhea, dyspepsia, abdominal pain; Abnormal liver-function test (2.4%); Headache (3.3%)
Plantar Warts
Papillomas- tumors of the skin and mucosal surfaces formed by keratinocytes that have been transformed by HPV
~ 130 different kinds
most diverse virus infecting humans
Infect cornified (keratinization) stratified squamous epithelium of skin or cornified mucous membranes
- Verruca plantaris
TRANSMISSION OF WARTS
- Contact
-directly- person to person; worse if skin is macerated,
-indirectly- exposure after minor trauma (skin abrasion); common in swimming pools and communal washing area
TREATMENTS
Therapies are based on destruction, immunostimulation, and antimitotic effect
Wart clearance requires complex and variable process of:
-Skin barrier protection
-Innate and acquired immunity
- Physical
-surgical destruction
-electrodesiccation
- Chemical
-cantharidin
-formaldehyde
-salicyclic Acid (different concentrations; destroys infected cells; placebo controlled study suggest a cure rate of 65%)
- Cryotherapy
-destroys the epithelium through single or multiple freeze-thaw cycle necrosis occurs with ice formation, cellular dehydration, and ultimately, vascular stasis
-Induces local inflammation
Cure rates of 52% (aggressive) and 32% (gentle)
- CO2 Laser- vaporizes warts
-Burn skins–>blister–> Immune response
Pulse Dye Laser (~585 nm)-emmits pulses of light absorbed by the red blood cells within the lesion; starves the lesion of blood
Excision- removes warts and cuaterizes blood vessels
CONTACT SENSITIZERS
Dinitrochlorobenze-involves an autoimmune response to a concentrated chemical
- Dinitrochlorobenzene (DNCB)
squaric acid dibutyl ester-allergic reactions common side effect
Intralesional Bleomycin- Causes necrosis of epidermis; body forms blisters beneath wart
Bleomyin- wart is deroofed; blister comes off with wart
-Wide range of cure rates-16-94%
FACTORS AFFECTING TREATMENT WART SUCCESS
- Age
- Site
- Comorbid disease
- Patient preference
- Source of infection
- Patient lifestyle
Bunion (Hallux Valgus)
CAUSES
- Tight, ill fitting shoes
- Biomechanical abnormalities
- Crista erosion
- Excessive Pronation
- Arthritic conditions
- Neuromuscular disease
- Tibial sesamoidectomy
CLINICAL SYMPTOMS
- Painful bump on side of foot
- Widening of forefoot
- Pain with shoegear/ ambulation
- Swelling
- Redness
TREATMENT
- Wider, lower-heeled shoes
- Bunion pads
- Ice
- OTC analgesics
- Patient education
- Footwear evaluation
Big toe Joint Arthritis (Hallux Limitus/Rigidus)
CAUSES
- Trauma (including repetitive microtrauma)
- Family history
- Flatfeet (Excessive Pronation)
- Female Gender
- Long First Metatarsal
- Short First Metatarsal
- Family History
CLINICAL SYMPTOMS
- Decreased range of motion in the big toe joint accompanied with pain and swelling
- Stiffness and pain with ambulation and standing; usually relieved by rest
- Pain with shoegear/ ambulation
- Bony bump on top of big toe joint
TREATMENT
- Rigid shoe gear
- Custom orthotics
- Ice
- OTC analgesics
- Steriod Injection
- Surgery
Hammertoes
CAUSES
- Bunions (Hallux Abductovalgus)
- Arthritis
- Shoe gear
- Congenital
- Neuromuscular
- Biomechanics
SYMPTOMS
- Dorsally contracted digit
- Corn
- Metatarsalgia
TREATMENT
- Palliation of corns and calluses
- Padding
- Shoegear modification
- Arthroplasty
- Arthrodesis
- Joint implant
Heel Pain
Affects 1/10 people in a lifetime
COMMON CAUSES
- Nerve entrapment
- Fat pad atrophy
- Calcaneal stress fracture
- Arthritis
- Tumors ( calcaneal or soft tissue)
- Achilles insertional problems
- Subchondral bursitis
- Calcaneal periostitis
- Plantar Fasciitis
SYMPTOMS
- Pian in Heel especially after taking the first few steps in the morning (Poststatic dyskinesia)
- Dull aching pain
RISK FACTORS
- Athletes
- Runners
- Overweight
- Prolonged standing
- Hard surfaces
- Going Barefoot
TREATMENT
- ~ 90% respond to conservative treatment
- Tapping and padding
- Orthotics
- Ice/Heat
- Injections
- Shockwave
- Ionotophoresis
- Stretching/ Physical Therapy
- Show modification
- Night Splint/ Casting
- Surgery
- Partial or total resection of the plantar fascia
Flatfeet
CAUSES
- Neuromuscular
- Flexible Flatfoot
- Tarsal Coalition (fusion between bones in foot)
- Posterior Tibial Tendon Tendonitis
- Flexible Flatfoot (not relating to Posterior Tibial Tendon Dysfunction)
- Arthritis
- Trauma
TREATMENT
- Custom molded Foot Orthotics (Inserts that goes inside shoes)
- Braces (Richie etc.)
- Tendon Procedures (Transpositions etc)
- Jont Fusions
- Osteotomies
- Injections
- Coalition resection
Guidelines for Proper Shoe Fit
Properly fitted shoes do not need to be broken in, but instead should be comfortable to wear right out of the box.
Shoes should be fitted on both feet during weight bearing, preferably at the end of the day when the feet are most swollen.
Allow a space of one-half inch between the end of the shoe and the longest toe. In athletic shoes, allow up to one inch. Check the width. Adequate room should be allowed across the ball of the foot. The first metatarsophalangeal (Big Toe) joint should be in the widest part of the shoe. The heel should fit snugly.
The fit over the instep should be checked. A shoe that laces allows for adjustment of this area.
Prevention Tips
Wash your feet every day. Clean between your toes then dry your feet well, and wear clean socks, or hosiery. Dry, clean feet help stop a fungus from taking root, growing, or spreading. An extra tip: Socks made of nylon and other synthetic materials shed moisture, wicking it away faster.
Use a talcum foot powder to keep your feet clean and dry. Moisture and sweat help the infection take root and grow. Talcum powders help more than cornstarch powders.
Wear shower shoes (flip-flops) when walking in public swimming and shower areas. This helps keep you from picking up a toenail fungus infection from someone else. (Or from spreading an infection if you have one.)
Clip your toenails straight across so that the toenail does not extend beyond the tip of the toe. This will reduce the risk of breaking, cracking, or splitting the toenail.
Get manicures and pedicures only at salons and spas that sterilize their tools. This will reduce the risk of picking up a fungus from a tool that was recently used on an infected nail. You may even want to keep a set of your own tools to bring with you for the manicurist to use.
Wear comfortable shoes that fit properly and are made of materials that breathe, such as canvas, leather, or mesh materials. The less moisture that’s trapped in your shoes, the less chance a fungus has to take root, grow, and spread.
Location
Milwaukee Advanced Foot & Ankle Clinic
414.763.2305
Office Hours
Monday: 8:30 am – 5:00 pm Tuesday: 8:30 am – 5:00 pm Wednesday: 8:30 am – 5:00 pm Thursday: 8:30 am – 5:00 pm Friday: 8:30 am – 5:00 pm Saturday: Closed Sunday: Closed