The Most Common Foot and Ankle Conditions Every Primary ...
Transcript of The Most Common Foot and Ankle Conditions Every Primary ...
The Most Common Foot and Ankle Conditions Every Primary Care Physician May Encounter
Alan Y. Yan, MD FAAOS
Assistant Professor in Orthopedic Surgery
University of Pittsburgh Medical Center
How Popular are they? • Population study: 18-63% report pain,
aching or stiffness in feet.
• More with bunions, corns, calluses, nail issues
Garrow AP , Silman AJ , MacfarlaneGJ . The Cheshire Foot Pain and Disability Survey: a population survey assessing prevalence and associations, Pain , 2004
Who Usually get Foot Ankle Problems?• Everyone but more of high-risk factors in
1. Elderly: degenerative, inflammatory arthritis
2. Female: high heels & shoe wear
3. Obesity: degenerative, mechanical
4. Diabetic Patients: PND, PVD, Charcot, Ulceration, limb threatening & life threatening
5. Athletes & High-Risk Occupations
6. Congenital Deformities Issues
Who involved in the Care?
• Primary Care Physicians
• Orthopedic Surgeons
• Sports Meds
• Rheumatologist
• Podiatrists
• Wound Nurse
• Physical Therapist
• Orthotists
• Social Workers
How are we designed to withstand…
• Wedge shaped: keystone.
• Staples: Inferior edges of the stones are tied together.
• Tie beam: connecting the ends to prevent separation of
• Pillars and sagging of the arch.
• Suspension bridge: Multiple supports suspending the arch from the cable above the level of bridge.
Ankle Sprain: More Complicated than It Sounds
• Most Common Foot Ankle Injures You will Guarantee to See in your Clinic & commonly misdiagnosed: 23,000 each day in the U.S.
• Roll in vs Roll out
• Mechanism: from walking down the street to high level sports injury
• Symptoms: from some pain and swelling, to grapefruit sized swelling and not able to walk
Ottawa Rule: rule out fracture
• Inability to walk 4 steps
• Localized tenderness at the posterior edge or tip of either malleolus
• Localized tenderness of the navicular bone or base of the 5th
MT
R.I.C.E.
• Acute Ankle Sprain: mostly NO need for surgery
• Rest, Ice, Compression, Elevation
• Brace or Boot with Crutches
• MRI needed if not better in 6 to 8 weeks
• Recurrent with chronic instability
More on High Ankle Sprain: • Different set of ligament
involved.
• Above joint level.
• Syndesmosis injury.
Pitfalls: may NOT look as bad
• May have less swelling and bruising
• Does not LOOK THAT BAD: however took twice as long to heal
• Syndesmosis squeeze test
• May need surgery
Heel Pain: Plantar Fasciitis
• Most common cause of heel pain without injury history
• 1 million visits to medical doctors per year
• 60% goes to primary care
• More of degenerative changes in fascia than an inflammatory process
• More accurate term should be: plantar fasciosis
Clinical Dx:
• Multifactorial: age, obesity, limited ankle dorsiflexion, prolonged WB, inappropriate shoe wear, rapid increase activity level.
• Overload at insertion at calc, micro tear, perifasicial edema, increased heel pad thickness.
• Medial heel pain with the first few steps in the morning or after a period of inactivity.
Good News & Bad News:
• Usually self limited and resolve in 80% in one year regardless of therapy
• Injection???
• Surgery???
Bunion: not just an ugly foot
• Hallux Valgus Deformity: pronation, valgus deviation
• Bursitis medially: pain in tight fitting shoes
• Imbalance of all supporting structures
Metatarsalgia & Morton's Neuroma: walking on Pebbles• Entrapment of one of the common digital N.
• Women to men: 8 to 1
• High heel narrow toe box
• Rule out stress fx
Diabetic Foot Problems: limbs in danger• Alarming numbers: DM causes more than
70% leg amputation
• DM cause more amputation then land mines in war zones
• Foot ulceration, sepsis and amputation
Scope of Problem:
• Long stretching hospitalization
• Mounting high expenses
• End result of amputation
Pathogenesis: Mutifactorial
• Neuropathy
• Vasculopathy
• Immune dysfunction
• Prolonged hyperglycemia glycosylation
Sensory Neuropathy• Loss of pain
• Unnoticed trauma
• Lesion unchecked
• Callus formation
• Tissue necrosis
• Ulcerformation
Automomic neuropathy:
• Decrease sweating
• Dry brittle skin
• Fissures cracks
• Infection
• Ulceration
Vasculopathy:
• Macroangiopathy: artherosclerosis of large arteries
• Microangiopathy: capillary damage
Charcot Foot:
• Differentiate from infected foot: challenge for the PCP and ER.
• Always remain a high suspicion in any diabetic patient with PND with red, hot, swollen foot.
Team approach management:
• Mechanical control
• Metabolic control
• Microbiological control
• Vascular management
• Education
REFER TO THE SPECIALIST!!!
• SOME GENERAL PRACTITIONERS AND GENERAL SURGEONS ARE NOTORIOUSLY NOT GOOD AT REFERRING OUT.
• WHEN IN DOUBT, REFER IT OUT.