Top 10 Foot &
Ankle
Conditions
What you need to
know
By Patrick A.
DeHeer, DPM
Hoosier Foot & Ankle
317-346-7722
Top 10 Foot & Ankle
Conditions
•
•
•
•
•
Equinus
Heel Pain
Onychocryptosis
Onychomycosis
Verrucae Plantaris
• Hallux Abducto
Valgus
• Hammer Digit
Syndrome
• Hallux Rigidus
• Morton’s Neuroma
• Insertional Achilles
Tendonitis
Equinus
• Definition – no
standard
– < 5° AJ DF with KE
– STJ NP & MTJ
Locked
• Types –
– Uncompensated
– Partially
Compensated
– Compensated
Equinus
• Biomechanics
– Balanced standing
– Equinus effect on
CoP
– STJ axis
relationship
– Pressure changes
Equinus & Abnormal STJ
Axis
Equinus Related Conditions
80-85% Foot & Ankle Pathologies
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Heel Spur Syndrome/Plantar Fasciitis
Achilles Tendinopathy
Posterior Tibial Tendon Dysfunction
Diabetic Foot Ulcers
Charcot Neuropathy
Metatarsalgia
Morton’s Neuroma
Lesser MPJ pathologies – PDS, Capsulitis
Hallux Valgus
Hammer Digit Syndrome
Ankle Fracture/Sprains
Sever’s Disease
Pediatric Flatfoot Deformity
Osteoarthritis Forefoot/Midfoot
1st Ray Hypermobility
Pes Plano Valgus
Hallux Limitus
Sesamoiditis
Lateral Column Syndrome
Freiberg’s Infarction
Forefoot Callus
Equinus Conservative
Management
• Ineffective
Conservative Care
– Manual stretching
– Casting
– Night splints
• Effective
Conservative Care
– EQ/IQ Brace
Equinus Surgical
Management
Heel Pain
• 2,000,000 cases
per year in US
• Diagnosis
–
–
–
–
–
History
Physical
Radiology
MRI
Ultrasound
Heel Pain Treatment
• Short term acute
treatment
– Treat symptoms
and etiology
– Symptoms –
•
•
•
•
MDP
Steroid injection
RICE
PT
– Etiology –
• Equinus
– Pronates foot
– Twice pressure
on PF as body
weight
– Bracing superior
• Strapping – 3 to 4
times
• Plantar Fascia
Brace
• Immobilzation
Heel Pain Treatment
• Long term
treatment – 80 to
90% improved
– Stretching
• 2 to 3 months
• Maintenance
therapy
– Long-term arch
support
• Custom Orthoses
• Resistant Cases –
10 to 15%
– Baxter’s Neuritis –
entrapment of 1st
branch of LPN
• Clinical SSX
• MRI – ABH muscle
belly
• Dx injection
• Release of nerve
entrapment and
plantar fasciectomy
Heel Pain Treatment
• EWST – high
amplitude, fast rising,
asymmetrical, low
frequency sound
energy
– 80 to 90% effective in
literature
– 3 treatments spaced
weekly
– 2 to 3 bars, 11 to 13
Hz, 2000 to 3000
pulses
– No NSAIDs for 8
weeks
Heel Pain Surgical
Treatment
• Plantar fascia
release
– 80 to 85% effective
– Heel spur is not
addressed
– Biomechanical
considerations
– Gastroc Recession
+/- PF relase
Onychocryptosis
• Dx – +/- paronychia
–
–
–
–
–
–
Incurvated nail plate
HNF
Granulation
POP
Erythema
Drainage
• Phenol & alcohol
procedure
– 95% effective
Onychocryptosis
Onychomycosis
• Dx – 6.5 to 8.7%
– History – other skin
conditions?
• Immune system
compromise?
• Age?
• Injury?
– Physical Exam –
• Thick, yellow,
dystrophic,
discolored,
onycholysis, odor,
subungal debris
– PAS stain –
• False negatives
– Poor specimens
• Fungal elements
– T. Rubrum
– T.
Epidermophyton
– T. Microsporum
• Histological
examination
• Mixed results?
Onychomycosis
Onychomycosis Treatment
• Topical – 10 to 30
% effective
– Best combined with
other treatments
– Formula 3
• Jojba oil
• Tolnafatate
– Chronic Tinea
Pedis treatment?
– Hyperhidrosis
treatment?
• Oral – 70 to 75%
effective
– Lamisil 250 mg qd
– LFTs pre and
midway
– 3 month therapy
– 9 to 12 months to
evaluate success
• Chronic Tinea
resolution at 1
month
Onychomycosis Treatment
• Laser Therapy
– Cool Touch CT3
CoolBreeze
– 1320 nm
– Nd:Yag laser
– 5 mm spot size
– 6 joules
– 40° to 45° C
– 80% Effective
Onychomcosis Treatment
Verrucae Plantaris
• Human Papilloma
Virus – 46 strains
• 10% incidence in
children and young
adults
• Can resolve
spontaneously
• Transmitted by
contact
• Sites of trauma or
irritation
• Contracted from other
individuals in public
traffic areas
• Located in epidermal
layer – no scarring
• Clinically –
–
–
–
–
–
No skin lines
Encapsulated
PSTSP
Rete-pegs
HPK overlying
Verrucae Plantaris
Verrucae Plantaris
• VP treatment – not
penetrate dermis
– Oral vitamin A
10,000 IU with 15
mg zinc BID x 2
months
– Oral Tagamet 1600
mg per day in
divided doses
• Teens and younger
• 90% effective
• Keratolytic therapy – 20%,
40%, 60% Salicylic acid
–
–
–
–
Must debride HPK
Occlusion helpful
Changed dialy
Pumice stone to remove
mascerated tissue and
HPK
• Chemotherapy – similar to
Keratolytic
–
–
–
Monochloroacetic acid
Bichloroacetic acid
Cantharidin 0.7% to 1.0% green blister beetle
Verrucae Plantaris
• Cyrosurgery –
carbon dioxide,
liquefied nitrous
oxide or liquid
nitrogen
– Freeze-thaw cycles
– Ice formation,
cellular dehydration,
vascular stasis
– Multiple treatments
• Candida injections
• Laser therapy
Verrucae Plantaris
Hallux Abducto Valgus
• Laterally deviated
hallux with valgus
rotation
• History –
–
–
–
–
–
Injury
Arthritis – OA, RA
Shoe gear
Activity level
Pain
• Physical exam –
– Mild, moderate, severe
– Hypermobile 1st ray
– Erythema 1st MTH
medially
– POP
– PROM
– Tracking
– Crepitus
– Reducible
– Equinus factor
– Foot structure pronated
Hallux Abducto Valgus
Hallux Abucto Valgus
• Radiologic Exam –
– AP, Lateral, LO WB
•
•
•
•
•
•
IM <
HA <
TSP
PASA
MPE
Joint alignment
• Treatment –
–
–
–
–
Watchful neglect
Shoe gear change
Custom orthoses
Equinus
management
– Surgical
• Distal Procedures Austin/Akin
• Proximal Procedures
– Lapidus/Akin
Hallux Abucto Valgus
Hammer Digit Syndrome
• Etiology –
– Flexor stabalization
– Extensor substituion
– Flexor substitution
• Types –
– Hammer toe
– Mallet toe
– Claw toe
• Associated conditions
– PDS
– Cross-over toe
Hammer Digit Syndrome
• Symptoms –
–
–
–
–
–
–
Erythema
Helloma Durum
Helloma Molle
Pain
Edema
Arthrosis
• Physical Exam –
–
–
–
–
Rigid vs. Flexible
Level of deformity
MPJ involvement
Associated deformity –
hypermobile 1st ray
• Treatment –
–
–
–
–
–
Watchful neglect
Splinting
Toe spreader
Orthoses
Equinus
management
– Surgery
• Flexible – FDL
Transfer
• Rigid – arthrodesis
vs. arthroplasty
Hammer Digit Syndrome
Hammer Digit Syndrome
Hammer Digit Syndrome
Hallux Rigidus
• Normal 1st MPJ DF 60° to 70°
• Normal gait requires
35° DF 1st MPJ
• Etiologies –
– MPE due
hypermobile 1st ray
– FF supinatus
– Long 1st MT
– DJD
– HAV
– Systemtic arthritis
• SSx –
–
–
–
–
–
Pain
Swelling
Stiffness
Crepitus
Dorsal bony
prominence
– Sub hallux IPJ HPK
– Sub 2nd MTH HPK
– Lateral metatarsalgia
Hallux Rigidus
• Radiologic Exam –
– Subchondral
sclerosis
– Joint space
narrowing
– Flattening of MTH
– Osteophytes
Hallux Rigidus
• Non Surgical Tx –
–
–
–
–
–
Rocker sole shoes
Custom orthoses
Equinus management
PT
Anti-inflammatory
medication
– Activity modification
– Steroid injection
• Surgical Tx –
– Joint preservation –
• Chielectomy
• Austin osteotomy
• Lapidus procedure
– Joint destructive –
• 1st MPJ arthrodesis
• Implant arthroplasty
Hallux Rigidus
Morton’s Neuroma
• Definition –
perineural fibrosis
• Not a true
neoplasm
• 3rd IMS – Morton
– MPN and LPN
– Associated with IM
Bursae
• Mulder’s Test
• SSx –
–
–
–
–
–
–
–
Pain b/w 3rd & 4th MTH
Burning
Shooting pain
Aggravated by WB
Aggravated by shoegear
Alleviated by rest
Alleviated by massage
• Diagnostic Examination
–
–
–
–
X-ray
MRI
Ultrasound
L/S injection
Morton’s Neuroma
Morton’s Neuroma
• Treatment –
–
–
–
–
–
Steroid injection
Oral steroids
Strapping
Orthoses
Change of shoe
gear
– EtOH injections
– ESWT?
– Surgery
Insertional Achilles Tendonitis
• Patient Type – Older, less athletic,
overweight and sedentary
pts.
– Young adult males seronegative
spondyloarthropathies
• SSX –
– Posterior heel pain – dull
aching pain
• Increased with standing,
walking or running
• Aggravated by either
active or passive ROM
• Clinical Exam –
– Localized tenderness
near achilles insertion
– May have localized
edema
– Achilles tendonitis and
retrocalcaneal bursitis
often seen with insertional
posterior heel pain
– Tendon thicken at
insertion
– Ankle equinus often
associated finding
Insertional Achilles
Tendonitis
• Radiographic Exam –
– Ossification in the most
proximal extent of the
achilles insertion
– Spurs may be
incidental findings on xrays and not be
associated with any
SSX - usually chronic
inflammation is
required for pain
Treatment
• Conservative TX – may be
helpful initially
– Training modification in
athlete
– NSAIDs
– Heel lifts
– Stretching and
strengthening
– Widening and deepening
heel counter on shoes
– Padding of the posterior
heel
– Night splint for more
aggressive stretching
– Immobilization x 6 weeks
•
Surgical TX – when
conservative TX fails and
SSX persist
–
Approach –
• Medial
• Lateral
• Posterior – linear or
curvilinear
• Medial and lateral
combined
–
Tendon reflection –
• Longitudinal midline incision
of the achilles tendon
• Lateral to medial reflection
of the achilles tendon
• Minimal reflection if spur is
primarily posterior to tendon
Treatment
• Resection of inflamed
calcaneal bursa as needed
• Spur reduction and
posterior calcaneal
remodeling
• Achilles reattachment – AJ
in NP
– Soft Tissue anchors – 1 to
3 (inverted triangle)
– Bone wax to prevent
osseous activity due to
exposed bleeding
cancellous bone
– Repair any soft tissue
attachments to the tendon
at this point with 2-0
absorbable suture
Treatment
Questions????????????
• Patrick A. DeHeer, DPM
Shirley M. Catoire, DPM
• IU North – Johnson
Memorial Hospital –
Greenwood –Columbus –
Shelbyville – Johnson
Memorial Wound
Healing Center
• Tel: 800-615-1363
• Hoosierfootandankle.co
m
• padeheer@sbcglobal.ne
t