PODIATRIC TICKLERS FOR THE EM DOC - KATHLEEN COWLING MCEP WINTER SYMPOSIUM JANUARY 29TH 2021
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KATHLEEN
COWLING
PODIATRIC
MCEP WINTER
SYMPOSIUM
TICKLERS FOR
JANUARY 29TH 2021
THE EM DOC
FUN FOOT FACTS
Toenails grow at an average of 1.62 mm per month,
much slower than fingernails.
May take over a year to completely grow back.
Biotin 2.5 mg daily can help them be stronger and
less prone to breakage.
Keep nails trimmed and cuticles pushed back for
optimum health.
PLANTAR PUNCTURE WOUND Uncomplicated superficial puncture wounds should have wound care Tetanus prophylaxis Plain films if any suspicion of foreign body, recognizing that rubber from athletic shoes will likely not show up Antibiotics for patients that are high risk e.g. Diabetics Particularly covering Pseudomonas
PLANTAR PUNCTURE WOUND Cellulitis usually will show up within 4 days Should prompt imaging for retained foreign body Begin 10 day course of anti strep and staph tx Osteomyelitis occurs in 2% of all plantar wounds Usually, forefoot wounds occurring in athletic shoes Remember plain films are normal in early osteo Follow closely elderly, DM, PVD, immunocompromised
TINEA PEDIS = ATHLETE’S FOOT
Most common dermatophytosis
chronic intertriginous, caused by Trichophyton
erythema and erosion of interdigital skin
usually lateral 3 toes
Diagnose clinically, or with Potassium Hydroxide
Differentiate from dyshidrotic eczema, allergic dermatitis and
psoriasis
Treatment is moisture reduction and topical antifungal
PO therapy if recurrent with itraconazole 200mg QD month
Or Terbinafine 250 mg PO 2-6 weeks
https://www.merckmanuals.com/professional/dermatologic-disorders/fungal-skin-infections/tinea-pedis-athletes-foot
TINEA PEDIS = ATHLETE’S FOOT = HYPERKERATOTIC
NAIL FUNGUS = ONYCHOMYCOSIS = TINEA UNGUIUM
Affects about 8-10 % of the general population
Causes discolored nails, toenails 10x more common than
fingers
Risk factors: tinea pedis, older, males, PVD, DM, exposure
to it (public bathing)
60-80% dermatophytes (Trichophyton) the rest are
(Aspergillus, Scopulariopsis, Fusarium)
Difficult to treat, high relapse rates, oral is better than
topical
Diagnose: clinical, PCR, Potassium Hydroxide wet mount,
must get sample from proximal portion of the nail
Terbinafine has higher efficacy 250mg QD x 12 weeks
STINKY FEET = BROMHIDROSIS Foul smelling odor from bacteria on the skin that eat your sweat Feet have more sweat (eccrine) glands than any other part of the body when the sweat is trapped by footwear, the bacteria produce isovaleric acid
STINKY FEET = BROMHIDROSIS Cleanse feet daily, dry thoroughly Don’t wear the same shoes day after day Using foot powder may help Avoid wearing shoes that are made from materials that don’t let the feet breathe Coating the soles with aluminum chloride hexahydrate 20% can help keep the sweat minimized
BIOMECHANICS OF GAIT
RUNNING https://youtu.be/QyiX0Fb-Lfw
Flat feet (also called pes planus or fallen arches) is a postural deformity in which the arches of the foot collapse, with the entire sole of the foot coming into complete or near-complete contact with the ground. There is a functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg. The arch provides an elastic, springy connection between the forefoot and the hind foot so that a majority of the forces incurred during weight bearing on the foot can be dissipated before the force reaches the long bones of the leg and thigh.
https://en.wikipedia.org/wiki/Flat_feet
PES PLANUS True or False? Children that go barefoot more have a greater likelihood of developing flat feet.
POSTERIOR TIBIAL TENDON DYSFUNCTION = PTTD The posterior tibial tendon is one of the major supports of the arch When it becomes dysfunctional it leads to flattening of the arch Often caused by overuse Symptoms include pain, swelling and over pronation of the ankle
BIOMECHANICS OF FEET
Overpronators have too flexible feet
The feet of overpronators collapse too much and don’t get a good, rigid push-off when
they step because their foot is rolled in onto their arch
Supinators have too stiff feet
Supinators have arches that are raised too much, so they don’t absorb shock very well
when their feet first hit the ground
https://wexnermedical.osu.edu/blog/what-are-the-bottom-of-your-shoes-telling-youBIOMECHANICS OF FEET
BIOMECHANICS OF FEET
According to the American Academy of Podiatric Sports Medicine, check
your athletic shoes after a total of 300 to 500 miles of running or walking,
or 45 to 60 hours of sports, such as basketball, dance, or tennis.
After that time, your shoes will have endured approximately one million
steps and may have lost their cushioning and support.
http://www.aapsm.org/replace_shoes.htmlOBESITY IS RELATED TO FOOT AND ANKLE INJURIES
Obesity (classified as BMI of 30 kg/m2 or greater) is becoming more prevalent in
America and so are musculoskeletal issues associated with it.
The healthy ankle joint allows for normal walking, and injuries to the joint, including
fractures, can have devastating effects if not properly addressed. The recent study
identified a correlation between more severe ankle fractures and obesity, especially for
obese men younger than 25, and obese women older than 50.
https://www.foothealthfacts.org/article/obesity-doubles-ankle-fracture-riskSPLAY FOOT = PES TRANSVERSOPLANUS Fan-like spreading of the metatarsal bones Mainly occurs from chronic obesity Places increased pressure on the medial metatarsophalangeal joint of the great toe This leads to re-distribution of loading on the heads of the other metatarsals, leading to callus formation, and hammertoes
INGROWN TOENAILS = ONYCHOCRYPTOSIS
Usually blamed on poor trimming but not always the case
#1 risk is the shape of the nail, usually inherited trait
Trimming too far down, leaving a sharp corner can precipitate it
Pressure from tight shoes or trauma can increase risk
http://www.epodiatry.com/ingrown_nails.htmINCOMPLETE MATRIXECTOMY Partial nail removal
MATRIXECTOMY Digital block Nail splitter Remove entire lateral edge Phenol applied for 30 seconds to wound base
PINCER NAIL = TRANSVERSE OVER-CURVATURE Causes of pincer nails include Psoriasis Fungal infection Beta-blockers Arthritis and biomechanical changes Too narrow toe box
PINCER NAIL = TRANSVERSE OVER-CURVATURE Treatment may require surgical resection of the widened matrix Must include the entire length of the lateral edge of the matrix May need to both sides Treatment with 90% phenol is then applied to the base
LISFRANC JOINT INJURY
Traumatic injury of high force: MVA, falls
Disruption of the articulation of the medial cuneiform
And the base of the second metatarsal
Injury usually operative repair
Important not to miss because of the risk for
Compartment syndrome
https://www.orthobullets.com/foot-and-ankle/7030/lisfranc-injuryCALCANEAL FRACTURE
Most often caused from a fall
Look out for other related injuries, e.g. spine
Open fractures have a high risk for infectionCALCANEAL FRACTURE If there is any question on plain films, get the CT Watch out for compartment syndrome Place in a bulky Jones dressing with supportive posterior splint Non-weight bearing May require surgical fixation
5TH METATARSAL FRACTURE
90% are zone 1
Resulting from plantarflexion and hindfoot inversion
Zone 2 has vascular watershed supply which makes these prone to non-union
Zone 3 fracture is distal to the 4-5th metatarsal articulation, common site for stress fracture in athletes
https://www.foothealthfacts.org/conditions/fractures-of-the-fifth-metatarsalCRACKED HEELS = XEROSIS Skin around the heel is prone to being dry and developing thickening around the edges Prolonged standing on hard surfaces Obesity Medical conditions involving the skin e.g. eczema can lead to dryness, hypothyroidism This can all lead to developing fissures that can bleed
CRACKED HEELS = XEROSIS Treatment includes good hygiene applying oil-based moisturizers daily Reducing the thickness gently using a pumice stone, regular maintenance Appropriate footwear
CORNS & CALLUS = HYPERKERATOSIS Skin thickens due to a response to increase pressure Usually “corns” on the toes and “callus” under the metatarsals Biomechanical abnormalities caused by improper footwear, anatomy When they become severe enough the body begins to reject it as a foreign body Can be prone to infection if torn or cracked
CORNS & CALLUS = HYPERKERATOSIS Proper foot hygiene, and appropriate footwear is critical Avoid OTC topical acids and ”self” surgery Surgical correction of bony prominence may ultimately be necessary Adhesive cushions don’t fix the problem
CALCANEAL APOPHYSITIS = “SEVER’S” DISEASE Typically seen in early adolescents Calcaneal ossification center gets disturbed Pain relieved with rest May cause an antalgic gait High impact sports and sudden activities can bring it on Obesity and tight calve muscles make it worse
CALCANEAL APOPHYSITIS = “SEVER’S” DISEASE Short period of rest Ice, especially after activity Stretch calve muscles NSAIDS Avoid going barefoot Appropriate footwear, including a soft cushion heel raise
BUNIONS = HALLUX ABDUCTO VALGUS 1st metatarsophalangeal joint enlargement Main contributing factor is footwear with tight toebox Higher prevalence in women Activities like ballet dancing can increase the proclivity of developing Must have surgery if the problem becomes too severe Proper footwear is key Padding may help, especially if used between the toes
CRYSTAL ARTHROPATHY = GOUT First metatarsal is the most common site Affects men mostly until menopause and then women get it about the same Swollen, and VERY painful to touch Uric acid crystals precipitate out from hyperuricemia Obesity, alcohol, high purine intake, renal disease all increase risk
CRYSTAL ARTHROPATHY = GOUT
Monosodium urate crystals in synovial fluid
Remember that you do not need an elevated serum uric acid level to have
Acute gout
Negatively birefringent urate crystals are seen on polarizing examination
https://journals.lww.com/em-news/Fulltext/2010/03000/Diagnosing_Gout__The_Basics.5.aspxN Engl J Med 2011; 364:443-452
COMPARTMENT SYNDROME
Traumatic crush injury
Swelling increases pressure inside the fascial
compartment
Can cause vascular occlusion and ischemiaCOMPARTMENT SYNDROME
Pain out of proportion
Pain with passive dorsiflexion
Decreased sensation
Loss of pulses
Tense swollen foot
https://www.orthobullets.com/trauma/1065/foot-compartment-syndromeCUTANEOUS LARVA MIGRANS Hookworm infection, usually self limited, migrating larvae die by 5 wks Severe pruritus usually leads patients to want immediate treatment Single dose of albendazole or ivermectin will work
PLANTAR FASCIITIS Really a degenerative condition from wear and tear on the fascia, more a fasciopathy Prolonged standing Obesity Unsupportive footwear Age >40 High impact exercise Tight calf muscles Abnormal biomechanics, pes planus or cavus
PLANTAR FASCIITIS- WORK UP AND DIAGNOSIS Pain most severe upon first stance Plain radiographs, more to rule out other causes Ultrasound MRI
PLANTAR FASCIITIS- TREATMENT Rest from high impact activities Footwear, orthotics Night splints Stretching – this is the biggest preventative factor NSAIDS Physical therapy ESWT- extracorporeal shockwave therapy-create microtears Injections- AVOID steroids, cause fat pad atrophy, which is permanent Proximal medial Gastrocnemius release
MORTONS NEUROMA Not really a neuroma, but fibrosis around the interdigital nerve 9x more common in women, middle age, wearing tight shoes Most common site is between the 3rd and 4th metatarsal heads Sharp shooting pain most common symptom
MORTONS NEUROMA
Avoid tight shoes, wider toe box
Steroid injection may help
NSAIDS
Surgery if conservative management unsuccessful
Likely will have permanent numbnessN Engl J Med 2017; 377:1559-1567
https://stanfordmedicine25.stanford.edu/the25/ankle-brachial-index.html
PLANTAR WARTS = VERRUCA PLANTARIS
https://www.cfaortho.com/plantar-warts-plantarwartsPLANTAR WARTS = VERRUCA PLANTARIS Warts involve the epithelium of the skin and are caused by infection with the human papillomavirus (HPV). Warts are the most common viral infection of the skin, affecting 7 to 10 percent of the general population. HPV thrives in warm, moist environments, such as public swimming pools and locker rooms, and transmits by direct contact, possibly through small cuts or abrasions in the stratum corneum layer of the skin Conventional treatment of warts frequently involves several ablative modalities including debridement, topical keratolytics (salicylic acid) and cantharone, with occlusive dressing. take care not to enter the dermis on dissection due to the potential to create painful scar tissue with healing.
INTRACTABLE PLANTAR KERATOSIS = IPK
Accumulation of dead skin cells that harden and thicken
Normally under the metatarsal head, heel or medial
aspect of great toe
https://www.semanticscholar.org/paper/Er%3AYAG-Laser-Treatment-of-
Intractable-Plantar-(IPK)-Koltaj/797859d52f093e287a5fe88c93ad4c8c8bf4f897INTRACTABLE PLANTAR KERATOSIS - IPK
Painful lesion
Plantar surface
Typically, under metatarsal head
Clinical diagnosis, discern from verruca and epidermal inclusion cyst
Can cause antalgic gait, feels like walking on a marble/stone
Usually treated non-operatively, redistributing pressure, orthotics
Surgical treatment with YAG laserSUPERFICIAL CALCANEAL BURSITIS
https://www.lfaclinic.co.uk/conditions/superficial-calcaneal-bursitis/WORK UP Plain radiographs Ultrasound, looking for retrocalcaneal bursitis MRI
TREATMENT Start with short rest period, avoiding sports/activity that trigger pain Modify footwear, wearing sandals ICE NSAIDS/analgesics Physical therapy focused on flexibility, biomechanical correction Referral to DPM/ORTHO if not improving
RETROCALCANEAL BURSITIS
Ultrasound-guided Diagnostic and Therapeutic Approach to Retrocalcaneal Bursitis
The Journal of Rheumatology February 2011, 38 (2) 391-392; DOI:HAGLUND’S DEFORMITY
Anatomical variant
Wearing tight shoes, high heels, overuse activities
https://www.lfaclinic.co.uk/conditions/haglunds-deformity/WORK UP Good examination, tenderness is above the calcaneus and anterior to the Achilles tendon Plain films Ultrasound MRI
TREATMENT
Rest period
ICE
NSAIDS/analgesics
Physical therapy
Stretching, correcting biomechanics
Operative
Calcaneus-Exostectomy-and-Achilles-Tendon-Reattachment-for-the-Treatment-of-Haglund-DeformityCRPS = COMPLEX REGIONAL PAIN SYNDROME
Complex Regional Pain Syndrome
Sustained sympathetic activity
Pain out of proportion
Trauma with an exaggerated response, e.g. crush injury
Prolonged immobilization
ACE inhibitors on board at time of trauma
Smoking
Fibromyalgia
Females:males 4:1
40% occur in lower extremitiesCRPS = COMPLEX REGIONAL PAIN SYNDROME TREATMENT
Physical therapy
Nerve stimulation
Surgical sympathectomy
NSAIDS
Alpha and beta blockers
Antidepressants, GABA agonists
ketamineSAPHENOUS NERVE BLOCK
http://www.tamingthesru.com/ankle-and-foot-nerve-blocksSURAL NERVE BLOCK
http://www.tamingthesru.com/ankle-and-foot-nerve-blocksSUPERFICIAL PERONEAL NERVE BLOCK
http://www.tamingthesru.com/ankle-and-foot-nerve-blocksPOSTERIOR TIBIAL NERVE BLOCK
http://www.tamingthesru.com/ankle-and-foot-nerve-blocksREGIONAL FOOT BLOCKS
BLOCKSREFERENCES Evaluation and Management of Lower-Extremity Ulcers, October 19, 2017 Gout, February 3, 2011 N Engl J Med 2011; 364:443-452 https://www.podiatrytoday.com/how-treat-recalcitrant-plantar-warts https://www.lfaclinic.co.uk/conditions/superficial-calcaneal-bursitis/ https://www.lfaclinic.co.uk/conditions/haglunds-deformity/ https://www.jrheum.org/content/38/2/391 https://www.researchgate.net/profile/Phinit_Phisitkul/publication/317758943_Calcaneus_Exostectomy_and_Achilles_Tendon_Reattachment_ for_the_Treatment_of_Haglund_Deformity/links/5b2d3a28a6fdcc8506c2abfc/Calcaneus-Exostectomy-and-Achilles-Tendon-Reattachment https://www.ipfh.org/images/research_materials/2012_National_Foot_Health_Assessment_June_2012.pdf https://www.semanticscholar.org/paper/Er%3AYAG-Laser-Treatment-of-Intractable-Plantar-(IPK)- Koltaj/797859d52f093e287a5fe88c93ad4c8c8bf4f897 https://www.jospt.org/doi/pdf/10.2519/jospt.1985.7.3.91
REFERENCES https://pubmed.ncbi.nlm.nih.gov/23107625/ http://www.epodiatry.com/ingrown_nails.htm https://wexnermedical.osu.edu/blog/what-are-the-bottom-of-your-shoes-telling-you http://www.aapsm.org/replace_shoes.html https://www.jospt.org/doi/pdf/10.2519/jospt.1985.7.3.96 https://podiatrym.com/cme/August2000Levitz.pdf https://www.foothealthfacts.org/conditions/obesity-and-your-feet https://journals.lww.com/em-news/Fulltext/2010/03000/Diagnosing_Gout__The_Basics.5.aspx https://www.orthobullets.com/trauma/1065/foot-compartment-syndrome https://pubmed.ncbi.nlm.nih.gov/17403258/ https://www.merckmanuals.com/professional/dermatologic-disorders/fungal-skin-infections/tinea-pedis-athletes-foot http://www.tamingthesru.com/ankle-and-foot-nerve-blocks https://en.wikipedia.org/wiki/Flat_feet https://stanfordmedicine25.stanford.edu/the25/ankle-brachial-index.html
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