Musculoskeletal Disorders Part 6 Disorders of The Feet

Disorders of Feet
Maria Carmela L. Domocmat, RN, MSN Instructor Northern Luzon Adventist College
2
Maria Carmela L. Domocmat, RN, MSN 3/5/2012
Overview
Part 1: Degenerative & Metabolic bone disorders: Part 2: Bone infections Part 3: Muscular disorders Part 4: Disorders of the hand Part 5: Spinal column deformities Part 6 : Disorders of feet Part 7: Sports Injuries
3
Disorders of Feet
Hallux valgus (bunions) Mortons neuroma (plantar neuroma) Hammer toe Tarsal tunnel syndrome Plantar Fasciitis Corn Callus Ingrown Nail Hypertrophic Ungual Labium
4
Disorders of Feet
Hallux valgus (bunions), Mortons neuroma (plantar neuroma), Hammer toe , Tarsal tunnel syndrome , Plantar Fasciitis, Corn, Callus, Ingrown Nail, Hypertrophic Ungual Labium
5
Maria Carmela L. Domocmat, RN, MSN
3/5/2012
http://familyfootcarenj.com/web/images/layout/conditions_map.jpg
6
3/5/2012
7
8
Hallux valgus
is a condition that affects the joint at the base of the big toe. The condition is commonly called a bunion.
bunion - refers to the bump that grows on the side of the first metatarsophalangeal (MTP) joint.
9
Hallux valgus (bunion)

The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal. Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral).
http://www.footankleinstitute.com/hallux-valgus-bunion-surgery/
10

As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground. this constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot.
11

The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due to the mal-positioned joint. A bunion deformity is always progressive. It will always get worse over time.
12
13
3/5/2012
14

term hallux valgus actually describes what happens to the big toe.
Hallux - medical term for big toe Valgus - anatomic term that means the deformity goes in a direction away from the midline of the body.
hallux valgus - big toe begins to point towards the outside of the foot.
As this condition worsens, other changes occur in the foot that increase the problem.
15
Etiology
Contrary to common belief,
high-heeled shoes with a small toe box or tightfitting shoes do not cause hallux valgus. such footwear does keep the hallux in an abducted position if hallux valgus is present, causing mechanical stretch and deviation of the medial soft tissue. In addition, tight shoes can cause medial bump pain and nerve entrapment.
16
Etiology
Biomechanical instability Arthritic/metabolic conditions Structural deformity Neuromuscular disease Traumatic compromise
17
Etiology
Biomechanical instability
most common yet most difficult to understand etiology Contributing factors, if present, include
gastrocnemius or gastrocsoleus equinus, flexible or rigid pes plano valgus, rigid or flexible forefoot varus, dorsiflexed first ray, hypermobility, or short first metatarsal. Most often, excessive pronation at the midtarsal and subtalar joints compensates for these factors throughout the gait cycle.
18
Etiology
Some pronation must occur in gait to absorb ground-reactive forces. However, excessive pronation produces too much midfoot mobility, which decreases stability and prevents resupination and creation of a rigid lever arm; these effects make propulsion difficult.
19
Etiology
During normal propulsion
approximately 65 of dorsiflexion is necessary at the first metatarsophalangeal joint, only 20-30 is available from hallux dorsiflexion. Therefore, the first metatarsal must plantarflex at the sesamoid complex to gain the additional 40 of motion needed. Failure to attain the full 65 because of jamming of the joint during pronation subjects the first metatarsophalangeal to intense forces from which hallux valgus develops.
If the foot is sufficiently hypermobile as a result of excessive pronation, the metatarsal tends to drift medially and the hallux drifts laterally, producing hallux valgus. If no hypermobility is present, hallux rigidus develops instead.
Maria Carmela L. Domocmat, RN, MSN 20
3/5/2012
Etiology
Arthritic/metabolic conditions Structural deformity
Gouty arthritis Rheumatoid arthritis Psoriatic arthritis Connective tissue disorders such as Ehlers-Danlos syndrome, Marfan syndrome, Down syndrome, and ligamentous laxity
Malalignment of articular surface or metatarsal shaft Abnormal metatarsal length Metatarsus primus elevatus External tibial torsion Genu varum or valgum Femoral retrotorsion
21
3/5/2012
Etiology
Neuromuscular disease Traumatic compromise
Multiple sclerosis Charcot-Marie-Tooth disease Cerebral palsy
Malunions Intra-articular damage Soft-tissue sprains Dislocations
22
Symptoms
Symptoms of Hallux valgus depending on the degree of severity:
Aesthetic problem. Formation of calluses, chronic irritation of the skin and bursa. Increasing pain under load and when moving. Progressive arthrosis and stiffening in the base joint of the toe. Corollary deformities such as hammer and claw http://www.hallufix.org/english/hallux_valgus.html toe.
23
3/5/2012
Types of Hallux valgus

Degree 1 Degree 2
Toe malpositioning below 20 degrees. No symptoms.
Malpositioning between 20 and 30 degrees. Occasional pain.
3/5/2012
Types of Hallux valgus

Degree 3 Degree 4
Malpositioning between 30 and 50 degrees. Regular pain. Increasing restraints on activities. Pronounced malpositioning!
Severest form with malpositionings over 50 degrees and painful restraints on the activities of everyday life. Surgical treatment
25
Treatment
Medical Therapy
Adapting footwear Pharmacologic or physical therapy Functional orthotic therapy
Surgical Therapy
Capsulotendon balancing or exostectomy Osteotomy Resectional arthroplasty Resectional arthroplasty with implant First metatarsophalangeal joint arthrodesis First metatarsocuneiform joint arthrodesis
26
27
3/5/2012
28
Bunionectomy
remove the bump that makes up the bunion. performed through a small incision on the side of the foot immediately over the area of the bunion. Once the skin is opened the bump is removed using a special surgical saw or chisel. The bone is smoothed of all rough edges and the skin incision is closed with small stitches. It is more likely that realignment of the big toe will also be necessary. The major decision that must be made is whether or not the metatarsal bone will need to be cut and realigned as well. The angle made between the first metatarsal and the second metatarsal is used to make this decision. The normal angle is around nine or ten degrees. If the angle is 13 degrees or more, the metatarsal will probably need to be cut and realigned. When a surgeon cuts and repositions a bone, it is referred to as an osteotomy. There are two basic techniques used to perform an osteotomy to realign the first metatarsal.
http://www.concordortho.com/patient-education/topic-detailpopup.aspx?topicID=a5cea3a8a6d8093483657c959125dbaf
29
Distal Osteotomy
the far end of the bone is cut and moved laterally This effectively reduces the angle between the first and second metatarsal bones. usually requires one or two small incisions in the foot. Once the surgeon is satisfied with the position of the bones, the osteotomy is held in the desired position with one, or several,metal pins. Once the bone heals, the pin is removed. The metal pins are usually removed between three and six weeks following surgery.
30
Proximal Osteotomy
the first metatarsal is cut at the near end of the bone usually requires two or three small incisions in the foot. Once the skin is opened the surgeon performs the osteotomy. The bone is then realigned and held in place with metal pins until it heals. Again, this reduces the angle between the first and second metatarsal bones. Realignment of the big toe is then done by releasing the tight structures on the lateral, or outer, side of the first MTP joint. This includes the tight joint capsule and the tendon of the adductor hallucis muscle. This muscle tends to pull the big toe inward. By releasing the tendon, the toe is no longer pulled out of alignment. The toe is realigned and the joint capsule on the side of the big toe closest to the other toe is tightened to keep the toe straight, or balanced. Once the surgeon is satisfied that the toe is straight and well balanced, the skin incisions are closed with small stitches. A bulky bandage is applied to the foot before you are returned to the recovery room.
31
Good footwear is often all that is needed

Wearing good footwear does not cure the deformity but may ease symptoms of pain and discomfort. Ideally, get advice about footwear from a podiatrist or chiropodist. Advice may include: Wear shoes, trainers or slippers that fit well and are roomy. Don't wear high-heeled, pointed or tight shoes. You might find that shoes with laces or straps are best, as they can be adjusted to the width of your foot. Padding over the bunion may help, as may ice packs. Devices which help to straighten the toe (orthoses) are still occasionally recommended, although trials investigating their use have not found them much better than no treatment at all.
http://www.patient.co.uk/health/Bunions-(Hallux-Valgus).htm
32
How to Choose Shoes

1. Know your foot. Take a look at your old shoes. Look at what areas the most worn out shoes. A well-chosen shoes will help to endure the physical stress well. One way to determine your foot's shape is to do a "wet test"--wet your foot, step on a piece of brown paper and trace your footprint. Or just look at where your last pair of shoes shows the most wear. 2. Don't buy uncomfortable shoes even if they are hot! 3. Ideally, you should avoid wearing heels 4. Don't make shoes multitask.
http://hallux-valgusrigidus.com/index.php?option=com_content&view=article&id=74&Itemid=88
33
34
How to Choose Shoes

5. Knowing your foot's particular quirks is key to selecting the right pair of shoes. 6. You must find shoes with well cushioned soles and ideally, some type of soft arch-support. 7. 7. Measure your foot frequently. Foot size changes as we get older. 8. 8. You should not buy shoes in the morning. The size of our feet at night more than in the morning. Feet swell over the course of the day; they also expand while you run or walk, so shoes should fit your feet when they're at their largest.
35
3/5/2012
36
How to Choose Shoes

9. Always buy shoes to fit the larger or wider foot. Buy well-fitting shoes with a wide toe box. 10. Use bunion shields, bunion pads or bunion cushions to protect the bunion when wearing shoes. A bunion sleeve can be especially effective at relieving shoe pressure when walking with a hallux valgus. 11. Utilize an orthotic device or insert, such as a bunion splint or bunion brace, to redistribute the pressure along the arch and ball of the foot and control the separation of the bones. These devices help support your foot and reduce the tendency toward hallux valgus formation. 12. Use a bunion regulator to stretch tight tendons and toe muscles overnight especially if you want to avoid surgery.
37
3/5/2012
38
Resectional arthroplasty
is a joint-destructive procedure most commonly reserved for elderly patients with advanced degenerative joint disease and significant limitation of motion. The typical resectional arthroplasty that is performed is known as a Keller procedure.
http://emedicine.medscape.com/article/1232902-treatment#showall
39
Resectional arthroplasty
performed when morbidity might be increased with the more aggressive osteotomy that would otherwise be selected. The procedure includes resection of the base of the proximal phalanx with reapproximation of the abductor and adductor tendon groups. The technique is inherently unstable and should be used judiciously. The postoperative course includes limited-to-full weight bearing in a surgical shoe immediately after the procedure.
40
Resectional arthroplasty with implant

is the same procedure as the resectional arthroplasty, with similar indications, but stability is markedly improved with the addition of the total implant.
41
3/5/2012
Resectional arthroplasty with implant

Preoperative radiograph shows degenerative joint disease. Postoperative radiograph obtained after resectional arthroplasty and total joint implant placement.
42
First metatarsophalangeal joint arthrodesis

is a joint-destructive procedure that offers a higher degree of stability and functionality. considered the definitive procedure for degenerative joint disease. results in complete loss of motion at the first metatarsophalangeal joint and is reserved for patients with high activity levels and functional demands.
43
3/5/2012
First metatarsophalangeal joint arthrodesis

Preoperative radiograph shows arthrodesis. Postoperative radiograph show arthrodesis.
44
First metatarsocuneiform joint arthrodesis

Significant and/or hypermobile hallux abductovalgus may be reduced with arthrodesis of the first metatarsocuneiform joint (see images below). Indications include metatarsus primus varus, hypermobility of the first ray, metatarsalgia of the lesser metatarsals, and degenerative joint disease of the metatarsocuneiform joint.
45
3/5/2012
First metatarsocuneiform joint arthrodesis

Preoperative radiograph shows a hypermobile first ray. Postoperative radiograph shows arthrodesis of the first metatarsocuneiform.
46
47
Marfan syndrome (MFS)

is a spectrum disorder caused by a heritable genetic defect of connective tissue that has an autosomal dominant mode of transmission The defect itself has been isolated to the FBN1 gene on chromosome 15, which codes for the connective tissue protein fibrillin. Abnormalities in this protein cause a myriad of distinct clinical problems, of which the musculoskeletal, cardiac, and ocular system problems predominate.
48

The skeleton of patients with MFS typically displays multiple deformities including arachnodactyly (ie, abnormally long and thin digits), dolichostenomelia (ie, long limbs relative to trunk length), pectus deformities (ie, pectus excavatum and pectus carinatum), and thoracolumbar scoliosis
49

In the cardiovascular system, aortic dilatation, aortic regurgitation, and aneurysms are the most worrisome clinical findings. Mitral valve prolapse that requires valve replacement can occur as well. Ocular findings include myopia,cataracts, retinal detachment and superior dislocation of the lens

50
3/5/2012
pectus carinatum
pectus excavatum
51
Genetics of Ehlers-Danlos Syndrome

Ehlers-Danlos family of disorders is a group of related conditions that share a common decrease in the tensile strength and integrity of the skin, joints, and other connective tissues.
52
Genetics of Ehlers-Danlos Syndrome

The first detailed clinical description of the syndrome is attributed to Tschernogobow in 1892. The syndrome derives its name from reports by Edward Ehlers, a Danish dermatologist, in 1901 and by Henri-Alexandre Danlos, a French physician with expertise in chemistry of skin disorders, in 1908. These 2 physicians combined the pertinent features of the condition and accurately delineated the phenotype of this group of disorders.
53
Ehlers-Danlos syndrome
The amazing, almost unnatural, contortions that some patients with Ehlers-Danlos syndrome can perform often arouse curiosity. Historically, some patients with Ehlers-Danlos syndrome displayed the maneuvers publically in circuses, shows, and performance tours.
54
Some achieved modest degrees of fame and bore titles such as "The India Rubber Man," "The Elastic Lady," and "The Human Pretzel." Such clinical features also raise suspicion of the diagnosis when identified upon physical examination. Unfortunately, patients often go many years before being diagnosed
55
3/5/2012
Patient with Ehlers-Danlos syndrome mitis. Joint hypermobility is less intense than with other conditions. Patient with Ehlers-Danlos syndrome. Note the abnormal ability to elevate the right toe.
56
3/5/2012
Girl with Ehlers-Danlos syndrome. Dorsiflexion of all the fingers is easy and absolutely painless.
57
All forms of Ehlers-Danlos syndrome share the following primary features to varying degrees:
Skin hyperextensibility Joint hypermobility and excessive dislocations Tissue fragility Poor wound healing, leading to wide thin scars: The classic description of abnormal scar formation in Ehlers-Danlos syndrome is "cigarette paper scars." Easy bruising
58
Type
Inheritan PreviousMaria Carmela L. Domocmat, RN, MSN 3/5/2012 Major Minor Diagnostic ce Nomencla Diagnostic Criteria ture Criteria Tissue fragility, easy bruising, arterial rupture, marfanoid, microcornea, osteopenia, positive family history (affected sibling)
Kypho- AutoType VI Joint laxity, scoliosis somal lysyl severe recessive hydroxyla hypotonia at se birth, scoliosis, deficiency progressive scleral fragility or rupture of globe
59
Type
Inheritance Previous Major Diagnostic Minor Diagnostic Nomenclatur Criteria Criteria e Skin hyperextensibility, tissue fragility with atrophic scars, muscle hypotonia, easy bruising, kyphoscoliosis, mild osteopenia Soft, doughy skin; easy bruising; premature rupture of membranes; hernias (umbilical and inguinal)
Arthro Autosomal Type VII A, B Congenital bilateral chalasi dominant a dislocated hips, severe joint hypermobility, recurrent subluxations
Derma Autosomal Type VII C tospara recessive xis
Severe skin fragility; saggy, redundant skin
60 Type Inheritan Previous Major Diagnostic Criteria Minor Diagnostic Criteria ce Nomenclatu re
Classic
Autoso Types I and Skin mal II hyperextensibility, domina nt wide atrophic scars, joint hypermobility
Smooth, velvety skin; easy bruising; molluscoid pseudotumors; subcutaneous spheroids; joint hypermobility; muscle hypotonia; postoperative complication (eg, hernia); positive family history; manifestations of tissue fragility (eg, hernia, prolapse)
61
Type
Inherita Previous nce Nomenclat ure Hyperm Autoso Type III obility mal domina nt
Major Diagnostic Criteria
Minor Diagnostic Criteria
Vascular Autoso Type IV mal domina nt
Skin involvement (soft, Recurrent joint smooth and velvety), dislocation; chronic joint hypermobility joint pain, limb pain, or both; positive family history Thin, translucent skin; Acrogeria, arterial/intestinal hypermobile small fragility or rupture; joints; tendon/muscle extensive bruising; rupture; clubfoot; early characteristic facial onset varicose veins; appearance arteriovenous, carotidcavernous sinus fistula; pneumothorax; gingival recession; positive family history; sudden death in close relative
62
Down syndrome
Down syndrome is by far the most common and best known chromosomal disorder in humans and the most common cause of intellectual disability. Mental retardation, dysmorphic facial features, and other distinctive phenotypic traits characterize the syndrome
63
64
Corn
induration and thickening of skin caused by friction and pressure, painful conical mass appear as a horny thickening of the skin on the toes. this thickening appears as a cone shaped mass pointing down into the skin.
65
66
Types of Corn
o Hard corns
most common are concentrated areas of dry, hardened skin about the size of a pea usually located on the outer surface of the little toe or on the upper surface of the other toes, but can occur between the toes may develop within a broader area of callused skin sometimes called digital corns
67
Types of Corn
o Soft corns
are white and rubbery can be extremely painful and tend to develop between toes are like hard corns that have been softened by continual exposure to moisture, usually because you dont dry between toes properly or from sweat. may form opposite one another and are known as kissing lesions. Sometimes, soft corns can become infected by bacteria or fungi.
68
Other, rarer types of corn include:

seed corns
may appear as one corn or as clusters of small corns on the bottom foot; they are usually painless
vascular corns
occur in blood vessels and bleed if cut
fibrous corns
are corns that have been around for a long time and have become attached to the deeper layers of your skin, sometimes causing pain
69
Causes of corns
o Corns are caused by constant pressure on a bony area of foot. This can happen for a number of different reasons. These include:
poorly fitting footwear for example, shoes that are too small, cramp toes or have uneven soles; this is the most common cause of corns being very active doing lots of exercise can put pressure on feet prominent bones these can press against shoes
70
Causes of corns
o Corns are caused by constant pressure on a bony area of foot. This can happen for a number of different reasons. These include:
a misshapen foot because foot or toes have developed unusually may have a toe that is overly curved or a particular bone that is too short poorly healed fractures if have broken a toe or another bone in foot, it may have set out of place causing foot to press against shoe
71
Corn
Treatment:
surgical removal by podiatrist
72
Prevention of corns
o wearing sensible, low-heeled footwear (maximum 4cm heel) with a rounded toe o not wearing slip-on shoes because these cause feet to move forward and squash toes o not wearing court shoes because they dont support feet and can cramp toes
73
Corn pad
74
Prevention of corns
o drying properly between toes o losing excess weight this will help to reduce pressure on feet o If already have a corn, apply an antifungal or antibacterial powder after washing foot to help prevent it becoming infected.
75
76
77
Callus
flat, poorly defined mass on the sole over a bony prominence caused by pressure When skin is exposed to lots of pressure or friction, the keratin layer thickens to protect it, and develops into a callus. Although calluses can cover a wide area, they aren't usually painful.
78
Callus
Treatment: o padding and lanolin creams o overall good skin hygiene
79
Self treatment or management of corns and callus includes:

following the advice of a Podiatrist proper fitting of footwear proper foot hygiene and the use of emollients to keep the skin in good condition
80
81
Neuromas
are non-cancerous growths of the nerve tissue that develop in different parts of the body.
82
Mortons Neuroma
affects a nerve in the foot, often times the nerve between the third and fourth toe. thickens the tissue around the nerves that lead to the toes, causing sharp, burning sensations in the ball of the foot, as well as a numbing or stinging feeling. AKA: plantar neuroma or intermetatarsal neuroma.
83
http://www.footdoc.ca/www.FootDoc.ca/ Website_Neuroma.gif
84
Sex
The female-to-male ratio for Morton's neuroma is 5:1.
Age
The highest prevalence of Morton's neuroma is found in patients aged 15-50 years, but the condition may occur in any ambulatory patient.
http://emedicine.medscape.com/article/308284-clinical#showall
85
Causes
Various factors have been implicated in the precipitation of Morton's neuroma. Morton's neuroma is known to develop as a result of chronic nerve stress and irritation, particularly with excessive toe dorsiflexion. Poorly fitting and constricting shoes (ie, small toe box) or shoes with heel lifts often contribute to Morton's neuroma. Women who wear high-heeled shoes for a number of years or men who are required to wear constrictive shoe gear are at risk.
86
Causes
A biomechanical theory of causation involves the mechanics of the foot and ankle. For instance, individuals with tight gastrocnemius-soleus muscles or who excessively pronate the foot may compensate by dorsiflexion of the metatarsals subsequently irritating of the interdigital nerve. Certain activities carry increased risk of excessive toe dorsiflexion, such as prolonged walking, running, squatting, and demi-pointe position in ballet.
87
Manifestations
Obtaining an accurate history is important to making the diagnosis of Morton's neuroma. Possible reported findings provided by the patient with Morton's neuroma include the following: The most common presenting complaints include pain and dysesthesias in the forefoot and corresponding toes adjacent to the neuroma. Pain is described as sharp and burning, and it may be associated with cramping.
88
89
Manifestations
Numbness often is observed in the toes adjacent to the neuroma and seems to occur along with episodes of pain. Pain typically is intermittent, as episodes often occur for minutes to hours at a time and have long intervals (ie, weeks to months) between a single or small group of multiple attacks. Some patients describe the sensation as "walking on a marble." Massage of the affected area offers significant relief. Narrow tight high-heeled shoes aggravate the symptoms. Night pain is reported but is rare.
90
Dx tests
palpable mass or a "click" between the bones. Doctor put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot.
91
Treatment
Rehabilitation Program: Physical Therapy Treatment strategies range from conservative to surgical management. The conservative approach may benefit from the involvement of a PT.
Recommend soft-soled shoes with a wide toe box and low heel (eg, an athletic shoe). High-heeled, narrow, nonpadded shoes should not be worn, because they aggravate the condition.
92
Treatment
Rehabilitation Program: PT conservative management
to alter alignment of the metatarsal heads. One recommended action is to elevate the metatarsal head medial and adjacent to the neuroma, thereby preventing compression and irritation of the digital nerve. A plantar pad is used most often for elevation. Have the patient insert a felt or gel pad into the shoe to achieve the desired elevation of the above metatarsal head.
93
Treatment
Rehabilitation Program: PT Cryotherapy Ultrasonography deep tissue massage stretching exercises.
94
Treatment
Rehabilitation Program: PT Ice is beneficial to decrease the associated inflammation. Phonophoresis also can be used, rather than just ultrasonography, to further decrease pain and inflammation.
95
Phonophoresis
96
Phonophoresis
97
Treatment
Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal. Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.
http://orthoinfo.aaos.org/topic.cfm?topic=a00158
98
Treatment
Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief. Combination
Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton's Neuroma. http://orthoinfo.aaos.org/topic.cfm?topic=a00158
99
Surgical Intervention
When conservative measures for Morton's neuroma are unsuccessful, surgical excision of the area of fibrosis in the common digital nerve may be curative. Common adverse outcomes include
dysesthesias radiating from a painful nerve stump. Dysesthesias may be treated as any other dysesthetic pain.
Surgical options include the following:

Neurectomy with nerve burial Transverse intermetatarsal ligament release, with or without neurolysis Endoscopic decompression of the transverse metatarsal ligament
100
Other Treatment
Perform injection into the dorsal aspect of the foot, 1-2 cm proximal to the webspace, in line with the MTP joints. Advance the needle through the midwebspace into the plantar aspect of the foot until the needle gently tents the skin. Then withdraw it about 1 cm to where the tip of the neuroma is located.
101
Other Treatment
Inject a corticosteroid/anesthetic mix. A reasonable volume is 1 mL of corticosteroid and 2 mL of anesthetic. T the anesthetic used should not contain epinephrine, as necrosis may result. Care also should be taken not to inject into the plantar pad.
102
Other Treatment
Adverse outcomes include plantar fat pad necrosis. Transient numbness of the toes also may occur. Although many practitioners use multiple injections, the likelihood of benefit from subsequent injections, after failure to achieve relief from the initial injection, is negligible.
103
Other Treatment
An Australian investigation using a single, ultrasonographically guided corticosteroid injection for Morton's neuroma found that 9 months after treatment, complete pain relief had occurred in 11 of the 39 neuromas studied.
104
3/5/2012
Neurectomy: typical incision location. Neurectomy: superficial exposure.
Neurectomy: deeper dissection.
Neuroma and adherent fibrofatty tissue.
105
Medication Summary
Dysesthesias may be treated as any other dysesthetic pain. Tricyclic antidepressants, such as amitriptyline at 10-25 mg PO qhs, may be tried. If this approach is unsuccessful, anticonvulsants (eg, gabapentin, carbamazepine) often are effective.
106
Tricyclic Antidepressants
A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission, and they block the active reuptake of norepinephrine and serotonin. Amitriptyline (Elavil)
Analgesic for certain chronic and neuropathic pain. Low doses, 10-25 mg qhs, may provide pain relief from burning and tingling occurring at rest but function only as an adjunct to definitive treatment.
107
Anticonvulsants
Use of certain antiepileptic drugs (AEDs), such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Thus, although unstudied, a trial of such an agent might conceivably provide analgesia for symptomatic neuropathy. Used for dysesthesias not controlled with definitive treatment plus tricyclic antidepressants (or in patients unable to take tricyclic antidepressants). Gabapentin (Neurontin)
Neuromembrane stabilizer useful in pain reduction with dysesthetic pain. Has antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA, but does not interact with GABA receptors.
108
Anticonvulsants
Pregabalin (Lyrica)
Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.
109
Serotonin-Norepinephrine Reuptake Inhibitors

These agents inhibit neuronal serotonin and norepinephrine reuptake. Duloxetine (Cymbalta)
Description Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake
110
111
Hammer toe
is a deformity of the toe, in which the end of the toe is bent downward. usually affects the second toe. However, it may also affect the other toes. The toe moves into a claw-like position.
112
3/5/2012
Hammer toe
113
Causes, incidence, and risk factors

most common cause of hammer toe is wearing short, narrow shoes that are too tight. The toe is forced into a bent position. Muscles and tendons in the toe tighten and become shorter.
114

Hammer toe is more likely to occur in:
Women who wear shoes that do not fit well or have high heels Children who keep wearing shoes they have outgrown
The condition may be present at birth (congenital) or develop over time. In rare cases, all of the toes are affected. This may be caused by a problem with the nerves or spinal cord.
115

may be present at birth (congenital) or develop over time. In rare cases, all of the toes are affected. This may be caused by a problem with the nerves or spinal cord.
116
Symptoms
The middle joint of the toe is bent. The end part of the toe bends down into a claw-like deformity. At first, you may be able to move and straighten the toe. Over time, you will no longer be able to move the toe. A corn often forms on the top of the toe. A callus is found on the sole of the foot. Walking or wearing shoes can be painful.
117
3/5/2012
Hammer toe
118
Dx tests
physical examination of the foot decreased and painful movement in the toes.
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9360.jp g
119
http://www.myfootshop.com/images/medical/ortho/hammer_toe_differences_mod.j pg
120
Treatment
Mild hammer toe in children can be treated by manipulating and splinting the affected toe.
http://www.family-foot.com/images/hammer_toe_whatis.jpg
121
Treatment
The following changes in footwear may help relieve symptoms:
Wear the right size shoes or shoes with wide toe boxes for comfort, and to avoid making hammer toe worse. Avoid high heels as much as possible. Wear soft insoles to relieve pressure on the toe. Protect the joint that is sticking out with corn pads or felt pads
122
Treatment
A foot doctor can make foot devices called hammer toe regulators or straighteners for you, or you can buy them at the store. Exercises may be helpful.
You can try gentle stretching exercises if the toe is not already in a fixed position. Picking up a towel with your toes can help stretch and straighten the small muscles in the foot.
123
Treatment
For severe hammer toe, you will need an operation to straighten the joint. The surgery often involves cutting or moving tendons and ligaments. Sometimes the bones on each side of the joint need to be connected (fussed) together. Most of the time, you will go home on the same day as the surgery. The toe may still be stiff afterward, and it may be shorter.
124
Prevention and Cure of Hammer Toes with Products

Hammer Toe Regulator Hammer Toe Cushion Foam Toe Tubes Gel Toe Cap Toe Spreader Silicone Toe Crest Toe Spacer Cushion Digital Toe Pad Yoga Toes Toe Stretcher Toe Rings Toe Brace Toe Alignment Splint Toe Trainers Hammer Toe Straightener
125
126
Hammer Toe Correction Bandage

Price $14.95
127
3/5/2012
Hammer Toe Regulator

Toe regulator efficiently integrates the middle joint of toe with other joints. It reduces the pressure and irritation at toe tips and region over the toes. The toe regulator straightens the joint of hammer toes (or) claw toes with a slight and smooth pressure. Toe regulator is effective for pain relief and proper alignment of hammer toes.
128
3/5/2012
Hammer Toe Regulator
129
3/5/2012
Hammer Toe Cushion

provides ease feel over the contracted part and comforts Hammer toe with enough support. assists for a stress free movement and aid in lifting the toe to normal position. minimizes pressure at the top and tip of toes with a spongy effect. is provided with an adjustable toe loop for comfortable and secure fit.
130
3/5/2012
Foam Toe Tubes

The soft foam present in the tube safeguard toes from rash rubbing against footwear. Foam toe tube is easy to wear for getting effective pain relief from hammer toes. It reduce the pressure and swelling over Hammer toes for trouble free walks.
131
3/5/2012
Gel Toe Cap

Gel Toe Cap softens the Hammer toes giving excellent cushioning to the painful deformed toes. It also relieves extreme pain at the top and tip of toes effectively. Gel maintains the spongy comfort and reduces pressure all over the hammer toe.
132
3/5/2012
Silicone Toe Crest

The reinforced loop with elastic fabric of the toe crest holds the toe perfectly straight. The toe crest provides soft feel under three toes excluding the big and little toe. It relieves the pain caused by hammer toe. It adds strength to the toe and gives extra smoothness to the affected spot. Silicone soothes the toe for ease feel. Toe crest is durable and can be worn comfortably with a snug fit.
133
Toe Alignment Splint

Toe alignment splint reduces the pressure and pain caused by Hammer toes and Bunions. specifically aligns the toe placing it in correct position. The smooth cotton band with elastic property gives secure fit around the foot. Its thin straps can be placed over affected toes and the rigidity is adjustable using hook-and loop strap. Unique T-strap of the splint reduces the pain of bunion and prevents the big toe to slant over hammer toes (or) crooked toes. Toe alignment splint is comfortable to wear with casual shoes.
134
Toe Toe trainer comforts Trainers
flexible hammer toes. It gives better relief against the pain and irritation. Toe trainer separates the toes and aligns them to look straight. It is an effective item to cure slightly movable Hammer toes. The cotton-covered foam provides secure feel to the crooked toes. Toe trainer is easy to wear and fits snugly for efficient correction of hammer toes.
135
HammerStraightener perfectly aligns The toe Toe Straightener

Hammer toes with little pressure. Its cotton-covered loop with elasticity holds the toe firmly in proper place and it can be easily adjusted for stress free movements. The smooth foam pad molds accordingly with the foot shape and renders superior cushioning at the bottom of the feet. It also stops the pain caused by hammer toes. The hook closure present in the toe straightener pulls down and aligns the deformed toes to keep you always smiling. Hammer toe Straightener assists for healthy feet by strengthening the toes and forefoot muscles.
136
Prevention
Avoid wearing shoes that are too short or narrow. Check children's shoe sizes often, especially during periods of fast growth.
137
Expectations (prognosis)
If the condition is treated early, you can often avoid surgery. Treatment will reduce pain and walking difficulty.
138
Complications
Foot deformity Posture changes caused by difficulty in walking
139
140
141
Tarsal tunnel syndrome

the ankle version of carpal tunnel syndrome (CTS) posterior tibial nerve in the ankle becomes compressed, resulting in loss of sensation and pain in a portion of the foot
142
143
Tarsal tunnel syndrome

median and lateral plantar branches, which supply the sole of the and distal phalanges, are affected by nerve compression dx and treatment: same with CTS
144
145
Plantar fasciitis
an inflammation of the plantar fascia, which is located in the area of the arch of the foot common: middle-aged and older adults, athletes esp runners
146
Plantar fasciitis
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19568.jpg
147
Plantar fascia
A very thick band of tissue that covers the bones on the bottom of the foot. extends from the heel to the bones of the ball of the foot and acts like a rubber band to create tension which maintains the arch of the foot. If the band is long it allows the arch of the foot to be low, which is most commonly known as having a flat foot. A short band of tissue causes a high arch. This fascia can become inflamed and painful in some people, making walking more difficult.
148
Plantar fascia
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004438/bin/19567.jpg
149
Risk factors
o Foot arch problems (both flat feet and high arches) o Obesity or sudden weight gain o Long-distance running, especially running downhill or on uneven surfaces o Sudden weight gain o Tight Achilles tendon (the tendon connecting the calf muscles to the heel) o Shoes with poor arch support or soft soles
150
s/s:
The most common complaint is pain and stiffness in the bottom of the heel. The heel pain may be dull or sharp. The bottom of the foot may also ache or burn.
151
s/s
o The pain is usually worse:
In the morning when you take r first steps After standing or sitting for a while When climbing stairs After intense activity
o The pain may develop slowly over time, or suddenly after intense activity.
152
Treatment
o conservative treatment:
rest ice - at least twice a day for 10 - 15 minutes, more often in the first couple of days. stretching exercises strapping of foot to maintain arch orthotics
153
Treatment
o conservative treatment:
heel stretching exercises resting as much as possible for at least a week shoes with good support and cushions wear heel cup, felt pads in the heel area, or shoe inserts use night splints to stretch the injured fascia and allow it to heal.
154
Treatment
o If these treatments do not work, doctor may recommend:
Wearing a boot cast, which looks like a ski boot, for 3-6 weeks. It can be removed for bathing. Custom-made shoe inserts (orthotics) Steroid shots or injections into the heel NSAIDs or steroids endoscopic surgery to remove inflamed tissue may be required
155
3/5/2012
Boot cast
156
Orthotics
157
Orthotic devices
158
Expectations (prognosis)
o Nonsurgical treatments almost always improve the pain.
Treatment can last from several months to 2 years before symptoms get better. Most patients feel better in 9 months. Some people need surgery to relieve the pain.
159
Complications
o Pain may continue despite treatment. o Some may need surgery.
160
161
Ingrown Nail
nail silver penetration of the skin, causing inflammation occurs when the edge of the nail grows down and into the skin of the toe. There may be pain, redness, and swelling around the nail.
162
Anatomy of a toenail
163
Ingrown Nail
AKA:
Onychocryptosis Unguis incarnatus Nail avlusion Matrix excision
164

An ingrown toenail can result from a number of things, but poorly fitting shoes and toenails that are not trimmed properly are the most common causes. The skin along the edge of a toenail may become red and infected. The great toe is usually affected, but any toenail can become ingrown.
165
166

Ingrown toenails may occur when extra pressure is placed on toe. Most commonly, this pressure is caused by shoes that are too tight or too loose. If walk often or participate in athletics, a shoe that is even a little tight can cause this problem. Some deformities of the foot or toes can also place extra pressure on the toe.
167
Infected ingrown toenail
168

o Nails that are not trimmed properly can also cause ingrown toenails.
When toenails are trimmed too short or the edges are rounded rather than cut straight across, the nail may curl downward and grow into the skin. Poor eyesight and physical inability to reach the toe easily, as well as having thick nails, can make improper trimming of the nails more likely. Picking or tearing at the corners of the nails can also cause an ingrown toenail.
169

Some people are born with nails that are curved and tend to grow downward. Others have toenails that are too large for their toes. Stubbing your toe or other injuries can also lead to an ingrown toenail.
170
Treatment
If have diabetes, nerve damage in the leg or foot, poor blood circulation to foot, or an infection around the nail, go to the doctor right away. Do NOT try to treat this problem at home (Bathroom treatment)
171
Treatment
o To treat an ingrown nail at home:
Soak the foot in warm water 3 to 4 times a day if possible. Keep the toe dry, otherwise. Gently massage over the inflamed skin. Place a small piece of cotton or dental floss under the nail. Wet the cotton with water or antiseptic.
172
Treatment
may trim the toenail one time, if needed. When trimming toenails:
Consider briefly soaking your foot in warm water to soften the nail. Use a clean, sharp trimmer. Trim toenails straight across the top. Do not taper or round the corners or trim too short. Do not try to cut out the ingrown portion of the nail. This will only make the problem worse. Consider wearing sandals until the problem has gone away. Over-the-counter medications that are placed over the ingrown toenail may help some with the pain but do not treat the problem.
173
Proper and improper toenail trimming.
174
Treatment
If this does not work and the ingrown nail gets worse, see family doctor, a foot specialist (podiatrist) or a skin specialist (dermatologist). removal of silver by podiatrist
175
partial nail avulsion o If ingrown nail does not heal or keeps coming back, doctor may remove part of the nail. o Numbing medicine is first injected into the toe. o Using scissors, your doctor then cuts along the edge of the nail where the skin is growing over. This portion of the nail is then removed. This is called a partial nail avulsion. o It will take 2 to 4 months for the nail to regrow
176
Sometimes doctor will use a chemical, electrical current, or another small surgical cut to destroy or remove the area from which a new nail may grow. antibiotic ointment - If the toe is infected
177
Prevention
Wear shoes that fit properly. Shoes worn every day should have plenty of room around toes. Shoes that wear for walking briskly or for running should have plenty of room also, but not be too loose.
178
Prevention
o When trimming toenails:
Considering briefly soaking foot in warm water to soften the nail. Use a clean, sharp nail trimmer. Trim toenails straight across the top. Do not taper or round the corners or trim too short. Do not pick or tear at the nails. Keep the feet clean and dry. People with diabetes should have routine foot exams and nail care.
179
180
181
Hypertrophic Ungual Labium

chronic hypertrophy of nail lip caused by improper nail trimming results from untreated ingrown toenail treatment: o surgical removal of necrotic nail and skin o treatment of secondary infection
182
183
References
Krug RJ, Lee EH, Dugan S, Mashey K. Hammer toe. In: Frontera WR, Silver JK, Rizzo TD Jr., eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 82. http://www.ncbi.nlm.nih.gov/pubmedhealth/P MH0002215/
184
References
Ignatavicius and Workman (2006). Medical surgical nursing [5th ed]. Singapore: Elsevier. http://www.epodiatry.com/corns-callus.htm http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 0004438/ http://www.bupa.co.uk/individuals/healthinformation/directory/c/corns http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 0002217/ http://orthoinfo.aaos.org/topic.cfm?topic=a00154

Musculoskeletal Disorders Part 6 Disorders of The Feet

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Musculoskeletal Disorders Part 6 Disorders of The Feet

Загружено:

Авторское право:

Доступные форматы

Disorders of Feet

Hallux valgus (bunion)

Hallux valgus (bunion)

Hallux valgus (bunion)

Hallux valgus (bunion)

Maria Carmela L. Domocmat, RN, MSN 20

Multiple sclerosis Charcot-Marie-Tooth disease Cerebral palsy

Malunions Intra-articular damage Soft-tissue sprains Dislocations

Types of Hallux valgus

Toe malpositioning below 20 degrees. No symptoms.

Malpositioning between 20 and 30 degrees. Occasional pain.

Maria Carmela L. Domocmat, RN, MSN

Types of Hallux valgus

Good footwear is often all that is needed

How to Choose Shoes

How to Choose Shoes

How to Choose Shoes

Resectional arthroplasty with implant

Resectional arthroplasty with implant

First metatarsophalangeal joint arthrodesis

First metatarsophalangeal joint arthrodesis

First metatarsocuneiform joint arthrodesis

First metatarsocuneiform joint arthrodesis

Marfan syndrome (MFS)

Marfan syndrome (MFS)

Marfan syndrome (MFS)

Maria Carmela L. Domocmat, RN, MSN

Genetics of Ehlers-Danlos Syndrome

Genetics of Ehlers-Danlos Syndrome

Derma Autosomal Type VII C tospara recessive xis

Severe skin fragility; saggy, redundant skin

Major Diagnostic Criteria

Minor Diagnostic Criteria

Vascular Autoso Type IV mal domina nt

Other, rarer types of corn include:

Self treatment or management of corns and callus includes:

Surgical options include the following:

Neurectomy: typical incision location. Neurectomy: superficial exposure.

Neurectomy: deeper dissection.

Neuroma and adherent fibrofatty tissue.

Serotonin-Norepinephrine Reuptake Inhibitors

Causes, incidence, and risk factors

Causes, incidence, and risk factors

Causes, incidence, and risk factors

Prevention and Cure of Hammer Toes with Products

Hammer Toe Correction Bandage

Hammer Toe Regulator

Hammer Toe Regulator

Hammer Toe Cushion

Foam Toe Tubes

Gel Toe Cap

Silicone Toe Crest

Toe Alignment Splint

Toe Toe trainer comforts Trainers

HammerStraightener perfectly aligns The toe Toe Straightener

Tarsal tunnel syndrome

Tarsal tunnel syndrome

Causes, incidence, and risk factors

Causes, incidence, and risk factors

Infected ingrown toenail

Causes, incidence, and risk factors

Causes, incidence, and risk factors

Proper and improper toenail trimming.