PLANTAR FASCIITIS

Symptoms:

Stabbing sensation in the heel

Pain worse in the morning when getting out of bed or after prolonged seating and decreases after the first several steps.

Limping, tenderness, swelling, stiff sensation

Can be caused by prolonged standing

PLANTAR FASCIITIS

PLANTAR FASCIITIS

One of the most common causes of heel pain.

Caused by inflammation, micro tearing of the fascia

PLANTAR FASCIITIS RISKS

Obesity

Working long hours on hard surfaces

Age

Exercise with repetitive stress to the heels

Foot mechanics ie. Pes planus, pes cavus

Can be caused by pronation, tight achilles.

PLANTAR FASCIITIS

Can get xray but will commonly see a heel spur. These are common and often blamed for plantar fascial symptoms but can also be seen on xrays in people who do not have plantar fasciitis.

Stress fracture

Pinched nerve

Calcaneal bursitis

PLANTAR FASCIITIS

Differential diagnosis

1. pinched nerve

2. Calcaneal stress fracture

3. Calcaneal bursitis

PLANTAR FASCIITIS TREATMENT

Anti-inflammatories

Physical therapy

Night splints

Orthotics

Steroid shots.

ECSWT, Tenex, etc

Surgery

Prolotherapy

PLANTAR FASCIITIS TREATMENT CONTINUED

Weight loss

Supportive shoe gear, changing shoes frequently if a runner

Changing exercises

Icing

Stretching

Wedges in shoes

Shortening stride and increasing cadence during running

FREIDBERG’S

Avascular necrosis of the metatarsal head. Most commonly affects the 2nd metatarsal head.

Can be difficult to diagnose on plain radiographs

Diagnosis primarily made on H& P

FREIDBERG’S

FREIGBERG’S SYMPTOMS

Swelling

Pain upon ROM of the 2nd MPJ

Pain with compaction of the MPJ

Pain with ambulation

FREIBERG’S DIAGNOSIS

Xray- may not show anything initially but can eventually see osteopenia in the metatarsal head, flattening of metatarsal head, loose bodies, arthritic changes

MRI- can be used to diagnose in the early stages will show increase signal intensity on T-2 images

FREIBERG’S TREATMENT

Conservative: immobilization in boot or cast with or without crutches for 4-6 weeks, or until symptoms resolve then gradual return to normal activity. Orthotics, shoes modifications.

Surgical: cleaning up the joint, cartilage replacement, implants, resection of the metatarsal head.

HALLUX LIMITUS DEFINITION

Hallux limitus:-A degenerative process of the joint characterized by decreased Range of Motion of the Hallux. Over a period of time this jamming forms a dorsal bump on the head of the 1st Metatarsal and is often referred to as a dorsal bunion. Eventually can lead to joint ankyloses and loss of motion.

HALLUX LIMITUS

Several etiologies including Biomechanical, Neuromuscular, Iatrogenic, traumatic, metabolic, anatomic/structural. Four common factors is: 1) Systemic dz (Gout, RA), 2)Injury to the joint (turf toe, jamming etc.) 3)Metatarsus primus elevatus 4) Long 1st metatarsal

HALLUX LIMITUS

Stage I – No symptoms to vague joint pain, decreased dorsiflexion of the 1st MPJ. X-rays show no changes, can show mild dorsal enlargement. One or more etiologic factors.

HALLUX LIMITUS

Stage II – Decreased dorsiflexion, pain with end ROM, increased frequency of pain. x-ray finding such as subchondral sclerosis, mild joint space narrowing with asymmetry, mild dorsal exostosis.

HALLUX LIMITUS

HALLUX LIMITUS

Stage III- Inflammatory arthritis, pain with activity, Limited ROM which is very noticeable. Impingement with nerve type symptoms with shoe gear. Increased dorsal exostosis, subchondral cyst, irregular narrowing with practical obliteration.

HALLUX LIMITUS

HALLUX LIMITUS

Stage IV- Significant pain with attempted ROM of the joint to no pain within the joint just with bony protrusions of joint. Joint is enlarged. X-ray findings can show flattening of the joint with surrounding spurring of the joint to ankyloses with no joint space visible.

HALLUX LIMITUS

HALLUX LIMITUS

HALLUX LIMITUS

STAGE I- Orthotics with reverse morton’s extension or padding, rigid rocker bottom type shoes

HALLUX LIMITUS/HALLUX RIGIDUS

PLANTAR WARTS

Caused by Human papillomavirus (HPV) which enters the body via tiny abrasions in the skin. These can cause discomfort and pain.

PLANTAR WARTS

Black pinpoints which are small clotted vessels

Disrupts normal lines and ridges of the skin in the foot.

PLANTAR WARTS

Treatment:

Most clear up on their own but laser therapy, cryotherapy, acid treatments ( Salicyclicacid, cantharone) surgical excision. No single treatment is 100% effective

Imiquimod

5-Flurouracil

Bleomycin sulphate

Candida antigen

Interferon-alpha

PLANTAR WARTS

Oral medication (Retinoids, Cimetidine, Diindolymethane)

Laser

Surgical excision

ONYCHOMYCOSIS

A fairly common disease of the toenail . The two most common causes of Onychomycosis are Trichophyton mentagrophytes and Trichophyton rubrum. Less commonly it can be caused by molds or yeast as well. Some families have a genetic predisposition for T. rubrum.

ONYCHOMYCOSIS

ONYCHOMYCOSIS

Test that can be ordered to confirm onychomycosis are Periodic acid-Schiff (PAS), KOH, PCR. Fungal cultures are more difficult to obtain, hard to culture and takes weeks to grow cultures.

ONYCHOMYCOSIS

Tinea pedis is linked to onychomycosis. Onychomycosis often starts as Tinea pedis. Important that you treat both of these. If you only treat tinea pedis and patient has onychomycosis, onychomycosis can re-infect the skin.

Onychomycosis is more common in diabetic than those who are non-diabetic.

ONYCHOMYCOSIS

Lasers: has become quite popular very little data to determine if this is effective . The FDA approved it because it can cause “temporary improvement of the appearance of the toenail” and not actually labelled for treatment of Onychomycosis.

ONYCHOMYCOSIS CONTROLLING RECURRENCE

Use maintenance regimens of antifungal agents (Limits growth of fungi on nails)

Discard old shoes (removes fungal reservoir)

Alternate wearing different pairs of shoes (allows shoes to dry, reduces fungal load in footwear.

Wash feet regularly ( minimizes fungal presence on the feet.

Alert provider at first sign of infection (minimizes progression of infection)

ONYCHOMYCOSIS (TREATMENT)

Topical (Efinaconazole- 53-55% effective)

Oral (Itraconazole 54% , Terbinafine 70%)

% of Mycologic cure

STRESS FRACTURES

Overuse injury of bone. The more the load the more calcium will be placed at the site . Increased overloads can overwhelm repair and small cracks can occur within the bone structure.

STRESS FRACTURE

STRESS FRACTURE -SYMPTOMS

Pain

Swelling

Inability to bear weight

STRESS FRACTURE DIAGNOSIS

Plain film may not initially show fracture should plan to treat as a fracture and see patient back in 2 weeks to repeat xrays.

MRI

CT Scan

STRESS FRACTURE (TREATMENT)

Rest, Ice , compression, elevation

Immobilize (cast or boot) sometimes for at least 6-8 weeks depending on bone fractured.

PT once healing has occurred and in athletes to try and prevent future injury.

PLANTAR PLATE INJURY

Common in over pronators and in middle aged women.

Plantar plate is a thick ligament which inserts into the base of the phalanges plantarly. It protects the head of the metatarsal from pressure and prevents over extension of our toes also spreading or splaying.

PLANTAR PLATE INJURY

PLANTAR PLATE SYMPTOMS

Swelling under the ball of the foot extending into the toes seen commonly in the 2nd

MPJ and sometimes on the dorsum of the foot.

Sensation of walking on bones

Positive Lachman’s test

Splaying of toes and clawing

PLANTAR PLATE INJURY DIAGNOSIS

Careful history

Xrays

Diagnostic ultrasound

MRI

PLANTAR PLATE INJURY TREATMENT

Conservative (anti-inflammatories, strapping of toe, offloading padding, altering activity, changing shoe gear, determining biomechanical cause, orthotics)

Surgical ( plantar plate repair, osteotomy)

Can take 3-4 months to improve symptoms in some cases.

INTERMETATARSAL NEUROMA

Commonly occurring between the 3rd and 4th metatarsals called “Morton’s neuroma”

Thickening/enlargement of the nerve as a result of irritation of the nerve

INTERMETATARSAL NEUROMA

INTERMETATARSAL NEUROMA

Causes:

1. Compression from shoe gear

2. Activities such as running, court sports, any activity that involve repetitive irritation to the ball of the foot.

INTERMETATARSAL NEUROMA

Symptoms:

1. Pain

2. Feeling of “bunched up sock”

3. Feeling of a “pea”

4. Burning numbness, tingling sensation

INTERMETATARAL NEUROMA

Treatment:

1. Activity modifications

2. Padding

3. Anti-inflammatories, icing

4. Orthotics

5. Wide toe box shoes

6. Injection therapy –cortisone, injections, alcohol sclerosing injection therapy

REFERENCES:

Dananberg HJ. Sagittal plane biomechanics. In: Subotnick SI, ed. Sports Medicine of the lower extremity. New York: Churchill Livingstone; 1999: 137-156

Hetherington VJ, Carnett J, Patterson BA. Motion of the first metatarsophalangeal joint. J Foot Surgery 1989;28(1):13-19.

Clough JG. Functional hallux limitus and lesser metatarsal overload. J Am Podiatric Med Assoc 2005;95(6):593-601

Photos: Myfootshop.com, fdafac.com

Video: www.drglass.org http://www.youtube.com/watch?v=1gPcoRVuF9I

REFERENCES:

Levy LA. Epidemiology of onychomycosis in special risk populations. J AM Podiatr Med Assoc. 1997: 87 (12):546-50

Bodman, M. Keys to managing severe Onychomycosis. Podiatry today. Volume 25-Issue 5-May 2013

Gupta AK. Simpson FC. New therapeutic options for onychomycosis. Expert OpinPharmacothera. 2012 Jun;13 (8):1131-42

Weber C, Hoffman K. How to treat recalcitrant plantar warts. Podiatry today. Volume 26- issuey- July 2013

Leung L. Recalcitrant nongenital warts. Aust Family Physician. 2011;40(1-2):40-2.

REFERENCES

Jacobs, A. An Evidence-Based Medicine approach to plantar fasciitis. Podiatry Today. Volume 26-Issue11-Nov 2013

Mahowald S, LeggeBS, Grady JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J AM PodiatrMed Assoc. 2011;101(5):385-9

Cerrato RA. Freiberg’s disease. Foot Ankle Clin N AM. 2011; 16(4):647-58.

Joseph. W. Onychomycosis and the Role of Topical Antifungals. (table1:Preventative strategies to control recurrence of Onychomycosis). Podiatry today: Nov 2013

REFERENCES:Leung L. Recalcitrant nongenital warts. Aust Family Physician. 2011: 40 (1-2):40-2James WD, Berger TG, et al. Andrews’ Diseases of the Skin:Clinical Dermatology.

Saunders Elsevier, Philadelphia, 2006.Fullem, B. Managing Stress Fractures in Athletes. Podiatry Today. Volume 25-Issue 1-

January 2012.Cruveilhier J. The Anatomy of the Human Body Harper& Bros, New York, 1844, pp.176Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle.

1993;14:309-319.DeHeer, P. A Practical approach to Morton’s Neuroma. Podiatry today. Sept 2010. Br.

J. Sports Med., Sonographically guided intratendinous injections for the treatment of chronic plantar fasciitis of hyperosmolar dextrose/lidocaine: a pilot study.

M B Ryan, A D Wong, J H Gillies, J Wong and J E Taunton. Br. J. Sports Med., Sonographicallyguided intratendinous injections for the treatment of chronic plantar fasciitis of hyperosmolar dextrose/lidocaine: a pilot study. 2009;43;303-306; originally published online 19 Nov 2008; doi:10.1136/bjsm.2008.050021