Care of Musculoskeletal Problems in the Outpatient Setting - part 10 pptx

15. Foot Problems 317 FIGURE 15.5. Hindfoot examination. F IGURE 15.6. Midfoot examination for inversion and eversion. 318 M. Petrizzi and E.J. Shahady F IGURE 15.7. (A) Forefoot examination for dorsiflexion. (B) Forefoot examination for plantar flexion. 15. Foot Problems 319 The longevity of a running shoe is determined by how long the sole main- tains its cushioning. This usually is between 350 and 500 miles, depending on the weight of the runner and the quality of the shoe. Some extension of the life of a shoe can be gained by using a liquid rubber solution (usually obtain- able at sporting goods stores) to build up the areas of early sole wear. Suggest to runners that they change shoes regularly at 500 miles or sooner for heav- ier athletes. It is often best in aggressive distance runners to use several pairs of shoes simultaneously so that break-in can occur gradually. 5.2. Orthotics Orthotics are inserts for the shoe designed to correct for an alignment or bio- mechanical abnormality of the foot. Figure 15.9 demonstrates arch supports for an orthotic that helps decrease pronation. In addition to helping with pronation, they help relieve pressure from other areas of the foot by coming in other shapes. Orthotics come in three basic groups: soft, semirigid, and rigid. Soft orthotics are made of felt or soft foam and are available over-the counter at pharmacies and sporting goods stores. Semirigid orthotics are custom- made from a moldable plastic, such as plastazote. Rigid orthotics are made FIGURE 15.8. Shoe wear from heel strike. 320 M. Petrizzi and E.J. Shahady from hard plastic and usually require a casting of the foot. Semirigid orthotics are cheaper and somewhat easier to fabricate. They are more for- giving, so that the mold does not have to be perfect. They are used most com- monly to relieve pressure in mild to moderate pronators. Rigid orthotics are more expensive and harder to fit. They often cause problems if used on a high-arched cavus foot. Rigid orthotics are best suited for moderate to severe pronators, when semirigid orthotics fail to alleviate the symptoms. 6. Hindfoot Injuries This area includes the talus, calcaneus, plantar fascia, heel pad, and the tarsal tunnel. The peroneal as well as anterior and posterior tibial tendons traverse this area going to their more distal insertions. The hindfoot is the most com- mon site of pain and injury for all these structures. Achilles tendonitis and rupture, a cause of pain in the hindfoot, is discussed in Chapter 13. 7. Case 7.1. History and Exam A 36-year-old man presents to your office with left foot pain that is limiting his ability to run. He says the foot has been sore for several months, but he has been able to keep running by icing it and by stopping his running pro- gram for a few days when the pain increases. On the morning of the visit to his physician, he experienced severe foot pain 4 miles into his usual 7-mile run. He was unable to complete his run and walked with a limp back to his FIGURE 15.9. Orthotic arch support. 15. Foot Problems 321 home. He was in the middle of a significant hill climb when the pain intensi- fied. The patient has been a runner for about 10 years, and indicates that he had a stress fracture in the calcaneus of the left foot 8 years ago. He is won- dering if the current pain is a return of his prior fracture. Prior to the recent event he noted the pain to be worse upon arising in the morning, especially when he first put his foot on the floor. The pain diminishes with continued ambulation and recurs with exercise. Pain occurs with running when the heel strikes the ground, and is increased when he pushes off. There is no history of numbness and tingling. Examination of his gait is normal with no prona- tion. He does have high-arched or pes cavus (Figure 15.4) feet. Palpation of the left heel over the medical tubercle of the calcaneus reveals significant ten- derness (Figure 15.10). The pain is aggravated by dorsiflexion of the great toe and standing on the tips of his toes. There is no tenderness over the plantar surface of the foot or any of the joints. Dorsiflexion of the left foot is decreased compared with the right foot. Tapping over the area posterior to the medial malleolus does not produce any numbness or tingling (negative Tinel’s sign). Strength is adequate and equal in both feet. An X-ray of the cal- caneus was negative. He was diagnosed with plantar fasciitis and treated with NSAIDs, stretching, cross training on a stair master, and a splint to prevent plantar flexing during sleep. He responded to this treatment and within 3 months was able to return to his running program. FIGURE 15.10. Medial tuberosity tenderness. 7.2. Thinking Process Tarsal tunnel syndrome (compression of the posterior tibial nerve) would pro- duce similar pain but the Tinel’s sign is negative and he has no history of numb- ness or tingling. A recurrence of his calcaneal stress fracture is possible but ruled out by the negative X-ray and lack of persistence of the pain in between bouts of exercise. Gout or another type of inflammatory arthritis is not likely. Gout of the foot is most common in the first metotarsalphlangeal MTP joint of the big toe and both rheumatoid and osteoarthritis affect the subtalar joint. Heel pain that begins with the first few steps in the morning and reproduction of the pain by compression of the medial tubercle of the calcaneus is character- istic of plantar fasciitis. High-arched cavus feet predispose to plantar fasciitis. Decreased dorsiflexion indicates tightness of the gastrocnemius, and soleus (the calf muscles). This tightness can occur with a variety of lower leg problems but when combined with the above signs the diagnosis of plantar fasciitis is clinched. 8. Plantar Fasciitis The plantar fascia is a thick band of connective tissue that originates at the bot- tom of the heel and progresses forward toward the ball of the foot. It helps maintain the arch of the foot. The tissue is not very well-vascularized and is constantly being stressed, even in sedentary activities. Plantar fasciitis is one of the most common foot problems seen in primary care. It is a challenge to treat and may take up to 12 months for complete recovery. It can occur in active or inactive individuals in all age groups. It seems to affect women more than men. The patient usually complains of burning electricity-like pain as soon as the foot touches the floor after arising from bed. Repetitive microtears and colla- gen degeneration of the plantar fascia at the medial tubercle of the calcaneus cause plantar fasciitis. The pain is worse in the morning because the foot assumes a plantar-flexed position during sleep and the microtears that occurred during the day start the healing process with the foot in plantar-flexed position. As soon as weight-bearing activity begins, the plantar fascia length- ens, microtears recur, pain appears, and what little was gained overnight is lost. The stiff “high-arch foot” may lead to painful swelling because the force is concentrated at the origin of the plantar fascia, as is noted in the above case. Excessive pronation also causes the same problem because of increased tor- sional forces. 8.1. Imaging An X-ray is not needed to diagnose plantar fasciitis. Some physicians like to obtain a plain film with plantar fasciitis to look for a heel spur. This leads to confusion. Plantar fasciitis is often incorrectly called heel spur syndrome. This terminology is incorrect because 15% to 25% of the general population 322 M. Petrizzi and E.J. Shahady 15. Foot Problems 323 without symptoms have heel spurs and many individuals with plantar fasciitis do not have a heel spur. Heel spurs play no part in the diagnosis or treatment of plantar fasciitis. 8.2. Treatment Start by addressing mechanical problems and training errors. Good shoes that provide appropriate support are important. Shoes should be worn as often as possible (e.g., including a walk to the bathroom in the middle of the night) to decrease the strain on the fascia. The use of orthotics is appropriate for excessive pronation. A heel cup, particularly one that is soft and well- padded, can help plantar fasciitis in the high-arched foot. Heel cups are often of benefit in pain from the heel pad. Ice is helpful along with use of NSAIDs. With plantar fasciitis, the judicious injection of corticosteroid and local anes- thesia may be of benefit. Corticosteroids may cause fat atrophy, and repeti- tive injections should be avoided. Redeveloping the strength of the intrinsic muscles of the foot is important for rehabilitation in plantar fasciitis. Exercises such as towel stretches (see Figure 14.10) and walking on soft surfaces such as the sand or grass (once pain is diminished) can strengthen intrinsic muscles. The tight calf muscles must be addressed. Stretches like those demonstrated in the calf stretch (see Figure 14.12) are helpful. Stretching the plantar fascia with a cold water bot- tle as demonstrated in Figure 15.11 relieves pain and reduces edema. Telling an active person especially a runner to rest will not usually work. Relative rest is more likely to be an acceptable alternative. Cross training with a bike, FIGURE 15.11. Frozen bottle roll. 324 M. Petrizzi and E.J. Shahady swimming, or a stair master will work. Inform patients of the value of changing the exercise type and ask them to think about an alternative. The patient will choose no matter what you recommend. Night splints or an ace wrap decreases the pain noted with arising and facilitates the healing process. The splints work by decreasing nighttime plan- tar flexion and facilitates the healing process in a neutral position. Night splints can be made or purchased from a supply house. For those patients who find the night splints uncomfortable an ace wrap is an acceptable alter- native. The ace wrap is applied to limit night time plantar flexion. 9. Fat Pad Syndrome (Stone Bruise) The fat pad of the heel is a specialized cushioning area, where there are thick fibrous septae dividing the pad into numerous compartments. This specialized area cushions heel strike. With aging, atrophy of the fat within these com- partments may decrease the cushioning effect and lead to heel pain in the fat pad itself. Direct trauma may lead to bleeding into the fat pad. The problem is more common in older patients and in those who performed some type of activity that places a new and significant stress on the fat pad. One example is shoveling dirt that requires pushing hard with the heel. The syndrome is some- times referred to as a “stone bruise.” Once other entities are ruled out treat with extra padding or a heel cup. This usually provides symptom relief. 10. Tarsal Tunnel Syndrome Tarsal tunnel syndrome is caused by pressure on the posterior tibial nerve, or one of it terminal branches (medial or lateral plantar nerves and calcaneal branch), at the level of the flexor retinaculum near the medial malleolus or more distally. Symptoms are often vague and intermittent. Symptoms include nighttime calf pain and activity-related pain in the heel or sole of the foot. The pain is accompanied by tingling and burning on the bottom of the foot at the heel and cramping at the arch when the calcaneal branch is involved. Involvement of the medial and lateral branches produces pain and tingling on the plantar surface of the foot down to the toes. Examination reveals ten- derness over the tarsal tunnel below the medial malleolus (Figure 15.12). Compression with a finger for 30 s or percussion over the area (Tinel’s sign) usually reproduces the numbness and tingling. An electromyogram and nerve conduction studies may be required to confirm this diagnosis. Treatment is usually a challenge. Try conservative measures like orthotics, NSAIDs, steroid injections, and proper shoe wear first. Surgery may help with some patients. Consider early referral for patients resistant to therapy. Posterior tibial tendonitis has similar symptoms and is included in the differential diag- nosis. This entity is covered in Section 11. 15. Foot Problems 325 11. Tibialis Posterior Tenosynovitis/ Tibialis Posterior Dysfunction This entity is not that common but when seen is a diagnostic and therapeutic challenge. It is in the differential diagnosis of tarsal tunnel syndrome and plan- tar fasciitis. It can be quiet disabling and the patient usually seeks medical attention. The patient is usually a runner who has had chronic discomfort and experiences an acute traumatic event. The symptoms are confined to the medial side of the ankle and foot. There is swelling and tenderness along the posterior portion of the medial malleolus down to the medial portion of the foot. This follows the anatomy of the posterior tibial muscle and tendon around the pos- terior malleolus to the insertion of the tendon onto the navicular bone. Chronic tenosynovitis may render the tibialis posterior tendon insufficient to perform its tasks of plantar flexion, inversion and stabilization of the medial longitudinal arch. This description applies best to the weight-bearing posture of the foot, and the inability to perform each task varies in severity depending on the stage of tibialis posterior dysfunction. There are three stages of tibialis posterior tendon insufficiency. Stage I is characterized by swelling, pain, inflammation, and often effusion within the tibialis posterior tendon sheath. Passive eversion of the foot produces dis- comfort along the course of the tibialis posterior tendon. There may be some mild weakness to resisted inversion but no unilateral flat foot deformity. The Posterior Tibial Nerve FIGURE 15.12. Tarsal tunnel area. patient is able to invert the foot actively on a double-leg toe raise test and is able to perform a single-leg toe raise. Stage II disease is characterized by swelling, pain and inflammation, and the loss of function as indicated by an inability to perform a single-leg toe raise. In stage III disease, loss of function of the tibialis posterior tendon occurs. The asymmetrical pes planus (flat foot) now appears. Patients may report foot and ankle fatigue after limited activity and not feeling ankle support during ambulation. Shoes may wear out medially because of the foot rolling out. Pain occurs medially at first, but with long-standing pronation, the pain localizes laterally. 11.1. Examination Examination reveals swelling around the medial malleolus and tenderness along the course of the tendon. Figure 15.13A is of a patient with posterior tibial ten- donitis. Swelling can be observed over the left medial malleolus. Inverting and everting the foot may produce pain and a squeak or click as the inflamed 326 M. Petrizzi and E.J. Shahady FIGURE 15.13A. Patient with posterior tibial tendonitis [...]... weight bearing and often described as “walking with a pebble in the shoe.” The examination will reveal the primary or secondary associated conditions that may be causing the metatarsalgia Thorough evaluation of the foot facilitates making the diagnosis Both non-weight-bearing positions and weight-bearing positions are included in the examination In a non-weightbearing position, inspect for swelling, masses,... landing on the firmly planted heel), and a crush injury to the dorsal foot are mechanisms of spraining this ligament The clinician should maintain a high index of suspicion for Lisfranc injury when evaluating active individuals with midfoot pain Patients with Lisfranc injuries will present with complaints of midfoot pain They may not recall the specific event in which they were injured More subtle injuries... Process The lack of acute trauma, pain of 2-week duration now becoming worse, and a recent substantial increase in the amount of running is a common story for stress fractures The location of the pain in the foot and not the tibia makes tibial stress fracture less likely The absence of pain, numbness, and tingling along the medial side of the heel and a negative Tinel’s test FIGURE 15.16 Fifth metatarsal... foot and the inability to invert the foot when going up on the toes 11.2 Imaging Plain films are only helpful to rule out other cases of the pain like a fracture or arthritis Magnetic resonance imaging (MRI) has become a useful tool in evaluation of tibialis posterior tendon insufficiency If the patient has a swollen, painful tendon, MRI aids in the recognition of degenerative changes within the tendon,... metatarsal joint compared with the other foot A small avulsion fracture at the base of the second metatarsal may be the only subtle finding of a more severe injury Treatment of midfoot sprains that have no diastasis or instability includes non-weight-bearing for 4 to 6 weeks with progressive weight bearing as FIGURE 15.14 Lisfranc area 15 Foot Problems 331 tolerated in a short leg walking cast Return... surgically to hasten their return to competition All type III injuries are treated surgically Cessation of all weight-bearing exercise and choosing some type of alternative non-weight-bearing exercise like swimming or biking will help maintain conditioning Physical therapy consultation may be beneficial Altering training programs is important for treatment and prevention in the future 16.2 Imaging An MRI is... when he first places his foot on the ground in the morning, there is no numbness or tingling on his heel, or any decrease in his ability to dorsiflex or plantar-flex the foot The pain increases in intensity as the day wears on He has recently increased his running routine from 20 min three times a week to 1 h five times a week to attempt to lose weight The physical examination reveals a negative Thompson... known to increase the risk of this injury including hard and unyielding artificial playing surfaces, increased shoe– surface traction, limited MTP motion, type of sport and player position, as well as age, weight, and prior injury The mechanism of injury is hyperextension of the first MTP joint The hyperextension stresses and potentially tears the joint capsule and surrounding ligaments at their attachment... syndrome unlikely Lack of significant pain over the medial calcaneal tubercle and lack of pain when first placing weight on the foot in the morning makes plantar fasciitis less likely A negative Thompson test rules out Achilles tendon rupture and Achilles tendonitis is not likely with absence of pain in the back of the heel Pain over the fifth metatarsal on the lateral portion of the foot makes a fifth... show the typical, often subtle, radiographic appearance The fracture best seen on the lateral standing radiograph usually occurs in the dorsal two-thirds of the calcaneus An MRI or technetium bone scan may be required to make the diagnosis In acute fractures, the diagnosis is usually clear on plain film 12.1 Treatment Treatment of stress fractures includes decreasing the quantity and intensity of running, . are often vague and intermittent. Symptoms include nighttime calf pain and activity-related pain in the heel or sole of the foot. The pain is accompanied by tingling and burning on the bottom of. band of connective tissue that originates at the bot- tom of the heel and progresses forward toward the ball of the foot. It helps maintain the arch of the foot. The tissue is not very well-vascularized. area going to their more distal insertions. The hindfoot is the most com- mon site of pain and injury for all these structures. Achilles tendonitis and rupture, a cause of pain in the hindfoot,