Common Disorders of the Foot & Ankle
Transcript of Common Disorders of the Foot & Ankle
Common Disorders of the
Foot & Ankle
Lee Wittenberg, DPM
Apache Foot & Ankle Specialists
(702) 362-2622
Foot and Ankle Anatomy
• The foot and ankle are very complex structures,
without which we would not be able to walk, run,
or perform common activities of daily life.
• A combination of 28 bones, 33 joints, 112
ligaments, and a network of tendons, nerves,
and blood vessels all work together for proper
foot function.
• Pathology can occur at any of these levels.
Skin and Nail Disorders
• Corns and Calluses
– Caused by shear forces and pressure due to
the skin getting trapped between a boney
prominence (such as a hammer toe or a
bunion) and the shoe or the surface you are
walking on.
– Also called ‘Hyperkeratosis’ (a build up of the outer Keratin layer of the skin)5
Skin and Nail Disorders
Treated by debridement (trimming by your
Podiatrist), Creams, callus files and
pumice stones, and sometimes by surgery
Skin and Nail Disorders
• Onychomycosis (Fungal Toenails)
– Dermatophytosis of the toenails.
– Fungus is a micro organism that may invade the skin or toenails.
– Fungus thrives in warm, moist, dark places. Our shoes are a perfect environment for fungus to grow.
– Causes thickening, dystrophy (changes in shape) and yellow, brown, or black discoloration of the nail plate.
Skin and Nail Disorders
• Onychomycosis is treatable with oral
antifungal medications, topical
medications, or permanent removal of the
nail plate.
• Oral medication may be contraindicated
with certain medications and medical
problems.
Skin and Nail Disorders
• Tinea Pedis (Athletes Foot)
– Caused by similar dermatophytes that cause
Onychomycosis.
– Much more easily treated with topical
antifungals.
– Severe cases may require oral therapy.
Skin and Nail Disorders
• Paronychia (Infected, Ingrown Toenail)
– When a nail grows into the nail fold, the body sees it as a ‘foreign body.
– An immune response develops, and the skin around the nail becomes red, swollen, and very painful in shoes or to the touch.
– A small abscess may form, and pus may develop.
– May be caused by tight shoe gear, pedicures, improper cutting of nails, or genetics
Skin and Nail Disorders
• Paronychia
– Treated by excision of the offending nails
spicule, antibiotics and ointments, and
soaking.
– A permanent procedure may be done for
repeated problems.
Skin and Nail Disorders
• Verruca Plantaris (Plantar Warts)
– Caused by an infection by the Human
Papilloma Virus (HPV)
– Lives in the deepest layers of the skin before
the layer of subcutaneous fat.
– The virus recruits your body’s own blood vessels to nourish itself.
– Rarely may undergo malignant
transformation.
Skin and Nail Disorders
• Sometimes very stubborn and difficult to
treat.
– Debridements with application of acids and
other chemicals (may require multiple
treatments)
– Debridement with freezing or burning. May
be done with lasers.
Skin and Nail Disorders
• Cracking and Fissuring of the Skin
– Caused by Hyperhidrosis (excessive
sweating) and excessive soaking of feet.
– The skin gets dried out from too much water
causing it to split, crack, and fissure.
– May cause bleeding and may be an entry
point for bacteria, which may lead to a serious
infection.
Skin and Nail Disorders
• Treated with agents to decrease sweating,
special creams with enzymes or acids to
soften the skin, and debridements and
filing.
Tendon and Ligament Disorders
• Tendons and ligaments are made of more
dense and less vascular tissue. When
they are injured, it may take longer for
them to heal due to their lower blood
supply and to constant stress put on them
by walking and normal function.
Tendons and Ligaments
• Plantar Fasciitis (‘Heel Spur Syndrome’) – Inflammation at the insertion of, or along the
course of the plantar fascia.
– The Plantar Fascia is a long ligament that
runs across the bottom of the foot from the
heel to the ball and is one of the main
supports for the medial arch.
– Intimately associated with the achilles tendon
Tendons and Ligaments
• When the arch collapses, the plantar
fascia tightens like a rubber band. This
causes inflammation and irritation, usually
at the heel, but may occur anywhere along
the course of the ligament.
Tendons and Ligaments
• Symptoms of plantar fasciitis usually
include pain with the first step in the
morning, after periods of rest, and
eventually radiating up the back of the
ankle and leg.
Tendons and Ligaments
• A heel spur may occur secondary to the
inflammation around the periosteum
(covering of the bone), but is not the cause
of the pain.
Tendons and Ligaments
• Treatment of Plantar Fasciitis includes injections with local steroids (cortisone type medications), oral anti-inflammatory drugs, strappings of the foot by your Podiatrist, stretching, ultrasound, physical therapy, orthotics (arch supports), and in very rare instances, surgical intervention.
• Surgery is only indicated after 7-9 months of failed conservative care.
Tendons and Ligaments
• Ankle Sprains
– There is a set of ligaments on the inside and outside of your ankle. The ligaments on the outside of the ankle are much weaker, and more susceptible to stretching or tearing when you have an ankle sprain.
– >15-20% of ankle sprains result in Ankle Fractures. If you can not immediately walk on your ankle after a sprain, seek medical attention ASAP.
Tendons and Ligaments
• Treatment of Ankle Sprains involves
R.I.C.E. (Rest, Ice, Compression, and
Elevation) therapy. Immobilization is
recommended for severe ankle sprains,
and Physical Therapy is often utilized.
• Ankle Fractures are unstable
and often require surgical
intervention.
Tendons and Ligaments
• TENDONITIS is a common pathology.
• There may be inflammation surrounding a tendon (peritenonitis), of the tendon itself (tendonitis)
• Tendonitis may come from strain on the muscle and tendon, improper function of the foot and from systemic diseases.
• May cause attenuation (stretching) of the tendon, weakening, damage to the substance or an entire segement of the tendon, scarring and thickening, or even tears or complete rupture of the tendon.
Tendons and Ligaments
• Most Common types of tendonitis
– Achilles Tendonitis
– Posterior Tibial Tendonitis
– Peroneal Tendonitis
Tendons and Ligaments
• Tendonitis is treated with Immobilization and R.I.C.E. therapy.
– Immobilization may be prolonged, as tendons have very poor vascularity and tend to heal more slowly.
– An MRI or Diagnostic Ultrasound may be utilized to evaluate tears or ruptures of a tendon if symptoms do not subside.
– Surgery may be required to repair ruptures or tears.
Tendons and Ligaments
• Treatment of tendonitis starts with
immobilization in a cast or walking boot
and compressive bandages. It is essential
to relieve the tension and strain of the
tendon, and staying off of the foot as much
as possible is essential.
Tendons and Ligaments
• If immobilization does not alleviate the problem, an MRI will be performed to examine the extend of the damage and to evaluate tears or ruptures.
• In extreme cases, surgery is required to repair or augment the tendon with grafts or transfers of other tendons to regain the function the tendon/muscle is responsible for.
Nerve Disorders
• Neuritis-inflammation of any nerve in the body.
• Neuroma-inflammation of the intermetatarsal and interdigital nerves.
• Tarsal Tunnel Syndrome-Similar to carpal tunnel.
• All are secondary to impingement or constriction of a nerve which causes inflammation and irritation.
Nerve Disorders
• All are treated conservatively with local
steroid injections and compressive
bandaging to alleviate the impingement
and inflammation.
• Surgical Decompression or Chemical
Neurolysis (destruction of a nerve using
certain medical agents) may be necessary
• May leave areas of numbness.
Bone and Structural Problems
• Most Common structural problems are
Bunions, Hammer Toes, and Flat Foot
deformities.
Bone and Structural Problems
• Many structural deformities are caused by muscle imbalances.
• Once a deformity is set in motion, it may be possible to slow the progression with a good pair of orthotics, but it is almost impossible to stop.
• Surgical intervention is usually required to correct these deformities when they are symptomatic.
Bone and Structural Problems
• Fractures
– Usually from traumatic injuries.
– People with Osteoporosis or certain diseases may be
prone to get fractures with very little trauma or force
– Stress fractures may occur from repetitive, normal
every-day activity.
– Some fractures will heal with immobilization, but more
unstable fractures require surgical correction with
screws, plates, and fixation devices
Bone and Structural Problems
• Stress Fractures may not show up on x-
ray for several weeks and may be difficult
to diagnose.
Bone and Structural Problems
• Arthritis
– Osteoarthritis- “Wear and Tear Arthritis” Occurs from normal function, with repetative
impact and trauma to the cartilage. As the cartilage degenerates, the bones begin to rub against each other and cause inflammation, pain, joint narrowing, and build up of extra bone around the joint.
Creates pain, stiffness, and difficulty with ambulation, activities, and shoe gear.
Bone and Structural Problems
• Osteoarthritis-Treatment includes
injections, anti-inflammatory drugs, joint
clean-up, replacement, and joint fusion.
Bone and Structural Problems
• Rheumatoid Arthritis (RA)
– An auto-immune disease (a disease in which
your own body produces antibodies against
itself) in which the lining of the joint grows out
of control. This releases enzymes that
degrade the cartilage and loosen the joint
capsules and ligaments around the joints.
– This causes pain, inflammation, and severe
deformities of the hands and feet.
Bone and Structural Problems
• Treatment of RA
– DMARDS (Disease Modifying Antirheumatic
Drugs)
– Anti-Inflammatory Drugs
– Bracing and custom made shoes
– Joint destructive and joint replacement
surgical procedures
Conclusion
• The Foot and Ankle are complex structures and
many things can occur which will cause you pain
or give you difficulty with ambulation and
activities of daily living.
• If you have persistent pain, see your Podiatrist
before you end up with a more serious and
difficult problem. The longer you are in pain, the
harder it may be to get rid of!