Podiatry

-mechanical factors: -excessive pronation -extreme foot types (pos planus, caves) -anything that causes extra strain on the longitudinal arch, causing pull on the plantar fascia

after ruling out systemic causes of plantar fasciitis, what might you consider?

it causes a periosteal reaction where it attaches to the heel because pulling and tugging to get gross inflammation and rare. irritating periosteal reaction makes the bone spur

because the plantar fascia is stronger than the bone it attaches to, what occurs?

how callus forms. toe cramped up drives metatarsal head down mechanically. fat pad is anteriorly displaced -could have been from flip flops or leather sandals

explain what's happening here what could the cause have been?

-isolated lesions or mosaic (cluster) -contagious -wet surfaces, yoga mat, gymnastic mat -inherited -question of immunodeficiency -avoid them by spraying bottom of shower with lysol.

how can you get warts? are they contagious? how can they appear?

not common! so if someone comes in with a painful foot, esp big toe joint, many conclude gout but really it's not that common so you have to question it. -90% of gout cases are male -INHERiteD extremely so ask about father, grandfather - if answer is not, it's likely not gout -gout can be strong alcoholism -gout can be from large doses of diuretics b/c drying out and leaving uric acid inside. gout is high concentration of uric acid in system because kidneys not pulling it out

how common is gout? what gender more common in? what factors do you look at?

feel for dentation above ankle bone.

how do you assess for plantar fasciitis?

verruca: pinpoint bleeding when shave down surface. tiny black dots. plantar warts hurt when SQUEEZE and calluses hurt when PUSH on it. lateral pressure w/ verruca. hurt when squeeze b/c it's deep into the skin and if you squeeze the wart, you feel hard knot. -IPK: no bleeding, direct pressure -plantar warts need treatment but calluses don't

how do you differentiate verruca from IPK? why is it important?

-toes should be able to spread apart. if hitting end of shoe you take away the natural shock. shoes shouldn't be too narrow. -grab end of shoe - thickness of fingers between end of toe and end of shoe. if shoe is stretching, it's too small

how do you know your shoe is the right fit?

-wear appropriate size shoes -cut nails straight across

how do you prevent getting ingrown nails?

-tape the toes together if well-aligned. put something between the toes to avoid emaceration. can leave on for a week but keep dry. -DON'T DO NOTHING b/c it hurts and can't grow together. if you have 2 fragments moving, callus can't form and osteoclasts/blasts can't work and get malunion. -don't need x-ray especially if aligned

how do you treat a broken toe?

DON'T FREEZE THEM B/C MEAT OF WART IS INSIDE THE FOOT. -need liquid acid absorbed by wart in layers - twice a day. can use emory board to shave off dead stuff and throw away so don't reimpregnate the wart -usually gone 4-6 weeks -direct approach: numb w/ novocaine and cut out wart - gone in 5-6 days -before bed, put shoes in garbage bag and freezer over night to clear inside of shoes to kill fungus and stuff in them -duct tape has no medical evidence but may occlude and keeps kids from picking it.

how do you treat warts? how long do they last typically? duct tape?

affects how we walk. if you lose weight, feet often come back in again and adjust orthotics

how does weight affect plantar fasciitis?

6-8 weeks for any bone, big or small

how long does it take for a broken bone to heal?

it's probably from how they're walking, leaning into medial side of foot and might give insert sooner rather than later

if a patient is pregnant and complaining of fasciitis what might you do?

watch it. it may be red one day but can get necrosis 2 weeks later if it doesn't change

if someone's vascular compromised and has a callus what should you do?

remove it

if you wear orthotics, what do you do with insert in your shoe?

not a tear but irritates the junction so starts to grow and get spurring. Spur is Not cause of pain. it's the result of mechanism that causes the pain.

if you were to jump off a couch what might happen b/c of periosteal reaction?

unilateral. if it's bilateral, it's because they've been ignoring it so much.

is plantar fasciitis usually unilateral or bilateral?

long crystal looking that are large and heavy so this is about gravity - they settle in feet and biggest open space is big toe joint so predominantly metartsal phalangeal joint?

microscopically, what does gout look like? why the big toe?

end of fibula, tibia, square talus (top of foot inside socket supposed to lock in when stand so line up 90 degrees)

the ankle is made up of what 3 bones?

1. pain around involved metatarsal heads, radiating distally 2. mild relief upon removal of shoes 3. palpable nodule 4. splaying of adjacent digits 5. positive mulder's sign: push b/w metatarsal heads and if have neuroma, there's popping between toes. (massage feet makes it feel better. some toes together - splaying - mostly b/w 3 and 4, never 1 and 2 b/c that's a different nerve.)

what are signs and symptoms of Morton's neuroma?

-heel pads -"doughnut" pads -pads anterior to spur -low-dye strapping -plastic heel cups -orthotics: body becomes dependent on inserts. -BK casts -NSAI's -injection of locals w/ steroids -combo of above can't do physical therapy b/c all tendons, not muscles

what are some conservative treatment for plantar fasciitis?

-arthritic group: OA, RA, gout -Venereal Disease, Reiter's -fibromyalgia (heel is a hot spot_

what are some systemic etiologies of plantar fasciitis?

lots of pain just walking into a room or wind -bright red, warm to touch tests: uric acid levels and ESR; do it soon b/c often spikes in tests and then goes down so if wait 6 days, system settled down.

what are sxs of gout? what test can you get?

cause: chronic trauma, inclined treadmill put strain on metatarsala pt might dance in high shoes, feel fine and a few days later have pain top of foot. X-ray may look fine and 1 mo later might show a stress fracture. -x-ray is NOT DIAGNOSTIC for stress fracture in bone b/c looking for remodeling of bone and with stress fracture, you see healing process, not initial injury. -DON'T NEED MRI.

what can the cause of a stress fracture be? what might show up on x-ray? do you need MRI?

having diabetes and a callus and continuing to walk and not feel it. callus is hard dead material and break down

what could be the cause of this?

-cut nails -inspection -surgery -check reflexes, capillary refill (should be 3 sec or less) -check pulses; dorsalis pedis, posterior tibial -palliative care: creams, powders -check sensory -under big toe, baby toe, web space, perineal, heals (4 types of nerves)-sharp/dull, hot/cold, pressure/vibration. check when vibration stops (neuropathy can't tell)

what do podiatrists do?

bone scan - painless, inexpensive, diagnostic

what do stress fractures (cracks in integrity of bone) need?

plantar fascia goes out into separate bands

what does this show?

-they get bigger -each pregnancy they go up 1/2-1 full size because when we get bigger there's release of hormones that allow ligaments to stretch (not just hip ligaments but fingers and feet). when stop being pregnant, feet are permanent b/c stand on feet all the time so doesn't go back. with menopause same thing happens

what happens to feet as we get older? pregnancy?

-pain in ball of feet -predominantly female caused by lateral pressure and women's shoes -sensory and motor nerves and this is ALL SENSORY NERVES. the main sensory comes to top of foot and metatarsal head area goes to common and proper digital nerves. where the nerve is the thickest is where the space is narrowest where metatarsal heads are. -nerves are surrounded by Schwann cells - lots of lateral pressure - bones bang nerves and cause swelling = vicious cycle that creates scar called Morton's neuroma b/c scar around the nerve. it's scarring of the Schwann cell AROUND the nerve not the nerve. hurts on bottom and radiates into toes, not foot.

what is morton's neuroma?

when talus rotates in medially - extra bump close to navicular - head of talus inside of feet -cause: inherited. 30% walk in pronated stance (foot goes in medially-->knee goes in medially= knee pain, hip pain, lower back pain that could be result b/c collapsing lateral side of knee. -susceptible to shin splints -some have problems and some don't at all (based on lifestyle or how body compensates for it)

what is pronation? what's the cause? what problems may these people have?

spasm of small vessels. arterioles are unique b/c bands of muscle wrapped around that open and close vessel depending on temp. if hot out=open up vessel, constrict w/ cold weather. -with raynaud's, they sea shut and can slam shut at 40 degrees and don't get perfusion. ears, nose, fingers, toes most common b/c extremity and small vessels.

what is raynaud's?

-foreign body from stepping on something -tell them to draw circle around entry point b/c often moves -pseudomonas most common

what is this and what should you tell your patient to do? what's the most common organism?

-winnegrab procedure: took a piece of nail and skin and distal phalanx and sow it up. very painful for pt but worked great. -CHECK PEOPLE'S SHOE SIZE

what is this showing?

walking and this goes up and down so if short and remove this bounce, you take away the power it has to shock absorb

what is this showing?

fungal infection that was ignored (onychomycosis) -not a sign of poor health or hygiene - it's an inherited trait. pedicure passes this around -typically not treated once past 70 yrs old or so. -oral: lamisal is a med but 10% incidence liver damage (not good trade off) - takes 3 months, needing monthly LFT, so not given much. -topical: 6-9 mo course and have to be good about applying it. -encourage pt that fungal infections are ok to live with. 40 yo may be more self conscious. -podiatrist can cut nails

what is this the result of? do you have to treat?

-mycotic (fungal) toenail; most common and mostly geriatric

what is this?

callus

what is this?

chill blades (pre frostbite)-red dark brown blistering tips of toes. Raynaud's. there is frost bite but it's not that common. we get lots of raynaud's.

what is this?

corns: on top of toes

what is this?

fish mouth incision. not done anymore. -notch in bottom of calcaneus, cut through whole calcaneus and swung achilles tendon into calcaneus with cast for 2 years.

what is this?

gout

what is this?

pes cavous this fasciitis is harder to treat

what is this?

pes planus "flat foot"

what is this?

plantar wart

what is this?

plantar wart - b/w metartsal head so it's wart not a callus

what is this?

trying to shave down corn. this is preamputation. don't put chemical on corn! this pt here had compromised vascular dz

what is this?

verucca vulgaris or verucca plantaris they're plantar warts that are only on bottom of feet or toes. look for little black dots

what is this?

heel spur: heel pain is common. this is calcaneus at both w/ shelf of bone. the spur is not causing pain

what is this? is this causing pain?

fungal infection -thick nails. this pt in 40s. -cause: trauma, older, immunocompromised

what is this? what's often the cause?

treating ingrown toenails 0.5% marcaine and lidocaine. DON'T PUT EPINEPHRINE INTO TOES. 5-6cc is all you need to numb toe. -don't do injection into the nail; inject at base of nail. toe has 4 digital nerves so make sure you knock out 4 points

what is this? where do you do the injection?

corns painful and you get more as you get older

what is this? are they painful or painless?

STRAPPING MOST IMPORTANT THING b/c need to control how the foot functions and can't do it with something under arch. physical therapist or podiatrist can do this. -once it calms down: naproxen or Motrin, aleve; you're giving anti-inflammatory NOT for pain but for inflammation so pt needs to continue it usually 7-10 days. frozen waterball recommended

what is this? how important is it? what should you do once it calms down?

calluses -calluses on bottom of feet. corns are on toes. from excessive pressure though too

what is this? where is the common location?

-ingrown toe nail is a foreign body reaction. -onychocryptosis.

what kind of reaction do you get with ingrown toe nail? -what's the formal name?

don't use a razor and carve it!! don't put chemical on it!! corn pads are fine but not for corn removal --1st degree burns b/c they abscess. chemicals are bad

what should you NOT do with a corn?

-use emory board -moisturizer -check shoes -pad corns (Dr. Scholl works). pad where the corn is NOT present

what should you do if you have a corn?

chronic gout perforation - get buildup of white masses under skin - gouty arthritis; can have joint destruction from buildup. -people on chronic doses of allopurinol and very restricted diet. usually get operated food to open skin and remove white stuff. it often hits other joints and get gouty toephite.

what's a complication of chronic gout? if you have chronic gout, what do you discuss?

-put something b/w toes and get realignment. not curative. -take it off and foot goes back to where it is. it's for comfort -if bunion doesn't hurt, lead it alone

what's a palliative measure for bunions? not curative

-partial plantar release; detach medial third of fascia from calcaneus and rather than stretching it, you make fascia long. -very vascular and painful and 20% of time you get dehiscence and bad wound

what's a surgery that's rarely done now for plantar fasciitis?

-edema -discoloration -positioning -is it vascular, HF, breakdown of small vessel dz?

what's abnormal?

large plate of nail that curves into he flesh of lateral folds. -skin inside the groove is thicker which protects the toe as nail grows out

what's an ingrown toenail?

the way a person walks

what's plantar fasciitis caused by?

inflammation of fascia (bottom of foot) pain often at plantar aspect of calcaneus through to the metatarsal head (the bow string of bow and arrow- it goes up and down)--if you take away the bounce, you're asking plantar fascia to work harder - why shoes are important.

what's plantar fasciitis?

-allopurinol preventative med and colchicine would not be used in pseudo gout but in gout prophylaxis. colchicine is not pleasant b/c of diarrhea.

what's prophylaxis tx for gout?

don't have crystals, body is reacting to another product. it's treated similarly b/c want to break down the inflammatory process.

what's pseudo gout?

-inherited factor -way you walk (pronate) b/c walk more on medial side of toe -shoes b/c toes can't spread out how they should

what's the cause of bunion?

pressure and friction; hyperkeratotic tissue that forms from a pressure point. skin thickens to protect itself

what's the cause of corns?

supination - 5%

what's the opposite of pronation? how common is it?

calcaneous and metatarsals

what's the plantar fascia attach to?

surgery - 3 month recovery and it won't cure; high chance for recurrence. can't wear heels after. male more successful than female for that reason. -orthotics don't cure but can keep from getting worse. -cortisone injection can be given if acute capsulitis but really need to look at shoes and next step

what's the treatment for bunion?

pad where the callus is not to help take the pressure off. full cushion can help.

what's the treatment for callus?

-cortison injection directly into joint: 0.25cc Marcain 0.25cc lidocaine 2%, 0.5cc dexamethasone = Celestone soluspan -can use oral indocin if want but rough on stomach (2 as loading dose and 1 BID x 5 days). if not better after 5 days, it's not gout or need something else. -diet: decrease food high in purines (red meat, shellfish, tomatoes, dark green veggies, beer and wine, organ meats). -talk about high dose diuretics being the cause

what's the treatment for gout?

inject cocktail: Celestone b/w the bones and return in 1 week. either pain is gone. if 50% better, do second injection and same test. if nothing helps, then there's more scar tissue than swelling and need removal. -tell them wider shoes to support metatarsal arch

what's the tx for Morton's neuroma?

-NSAID -strapping -don't give insert w/ acute fasciitis. so, use taping and scraping and injection for acute - 0.5cc marcaine, lidocaine = Celestone injection -injection: go from medial side - 25 needle, 1.5 inches. broadly along attachment of fascia and inject all the way and on the way out. it's painful. can use steroids- medrol dose pak to decrease inflammation.

what's the tx for fasciitis acutely and chronically?

most give abs but NEED TO REMOVE THE OFFENDING AGENT then maybe give topical antibiotic

what's the tx for ingrown nail?

none -could do vasodilator but makes you lethargic -keep extremities warm, avoid tight shoes. let surgeons know b/c affects healing process and circulation do capillary filling test or cross hands and see pattern where fingers were squeezing.

what's the tx for raynaud's?

immobilization, support may f/u w/ x-ray if conservative tx not working

what's the tx for stress fracture? what happens if conservative tx doesn't work?

bunion: NOT A GROWTH. it's a head of metatarsal. it's malalignment of first metatarsal phalangeal joint. as big toe goes laterally, forces metatarsal to swing in medially

what's this? IS IT A GROWTH?

7-10 days then about 80-90% better. not everyone wears sneakers all the time so you have to find a happy medium

when can you start inserts for plantar fasciitis?

soooo many DDX for heel pain. think outside the box

when someone comes in with heel pain what's important to think?

grow where pressure is NOT usually. they're alive and trying to survive so often not under bony prominence

where do warts typically grow? alive or dead skin?

females and it's genetic. you're born with it.

who is raynaud's more common in?

space shoe! -charcot feet - break down of bones from diabetic neuropathy. make a mold for the sole to accommodate whole foot

who might wear these?

-ignore it and it gets worse -most people wear wrong size shoes - lateral pressure (squeezing of foot, pushes skin and nail together)

why do people get ingrown nails?

more rigid foot = more flexible orthotic more flexible foot = more rigid orthotic -rigid deformation - can't get out of pronation or supination, use softer orthotic -fasciitis and pronation/supination need orthotics

with orthotics, the more rigid the foot the____orthotic.