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

Disclosure:

No Conflicts with the Current Topics.

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

Stats: CommonIssues & Complaints

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

Parts of Foot & Ankle: Nomenclatures

•

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.

Painless Plantigrade Foot & Ankle:

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

Low Ankle Sprain vs High Ankle SprainBelow ankle or above ankle

Pictorial Understanding:

What Else Can Go Wrong?

And More?

And ?Cartilage Injuries: OLT or OCD lesions

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

Maisonneuve Injury: DO NOT MISS IT.

Acute Ankle Injury or Achilles rupture?

MUST consider and exam if an acute ankle injury

Weekend Warrior’s Typical Story: Patient believe they just sprain the ankle.

Midfoot Sprain or Lisfranc injury:

Different Mechanism:

Recognize this!!!

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???

DO NOT MISS Fx:vs. infection, tumor etc.

Bunion: not just an ugly foot

• Hallux Valgus Deformity: pronation, valgus deviation

• Bursitis medially: pain in tight fitting shoes

• Imbalance of all supporting structures

Anatomical understanding:

It is a surgical issue: fancy braces DOES NOT WORK

Bunionette: Taylor’s bunion

Other pain in the joints: Hallux Rigidus, inflammation or infection

Arthrocentesis:

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

Motor Neuropathy

• Weak intrinsic foot muscles

• Foot deformity

• Abnormal gait

• Ulceration

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

To Catch a Tumor: lumps and bumps

REFER TO THE SPECIALIST!!!

• SOME GENERAL PRACTITIONERS AND GENERAL SURGEONS ARE NOTORIOUSLY NOT GOOD AT REFERRING OUT.

• WHEN IN DOUBT, REFER IT OUT.

Thanks for your attention: