The practice of podiatric medicine and surgery involves an assortment of services needed by many patients for simple and complex foot problems. Most of the care podiatric physicians provide utilizes specific instrumentation and supplies. With extensive training in foot pathology, podiatrists are the primary care physicians of the foot.
Most of the pathology seen in the podiatry office is common. Frequent problems include heel pain, hammertoes and associated callus formations, ingrown toenails, bunions, sprains, fractures and the complications of diabetes. Podiatrists are often the first to diagnose systemic diseases through signs and symptoms related to the foot.. The following reviews the most common patient complaints and some new advances in the field of podiatric medicine and surgery.
The function of the foot in everyday stance and gait predisposes the heel to stresses that often produce pathologic conditions. With the current emphasis on aerobic exercise, heel pain complaints are becoming more common. Research shows approximately 15% of all adult foot complaints are caused by heel pain1.
Subcalcaneal pain can present in almost any patient2. Frequently, the patients are female, overweight and/or are employed in occupations that require extended weight bearing or heavy lifting3,4,5. The pain is typically of a radiating, deep aching that is located over the medial aspect of the heel. The onset may be gradual or acute and typically progresses over weeks or months before the patient seeks professional help. Initial weight bearing and ambulation in the morning are especially painful, followed by a period of decreased symptoms with subsequent activity only to become more symptomatic as the day progresses. While symptoms are usually unilateral, bilateral involvement is common. The usual presentation is of a patient that excessively pronates at the subtalar joint to compensate for a forefoot varus, flexible valgus, limb length discrepancy, or ankle equinus deformity. Many patients also have secondary biomechanical changes such as hallux abducto valgus (bunions) and contracted digits (hammertoes with or without associated clavi). The pain is most often elicited on deep palpation of the anterior aspect of the medial calcaneal tubercle. Frequently there is increased thickness of the plantar fat pad and subfacsial tissues6.
The pain of plantar fasciitis must be differentiated from pain caused by other pathology. Subcalcaneal bursitis is a frequent cause of heel pain and may be elicited on deep palpation of the centerpoint of the plantar heel fat pad. Other causes of heel pain include contusion, tendinitis of the first layer of plantar musculature or quadratus plantae, nerve entrapment,7-10 heel neuroma,11,12,13 herniation through the plantar fascia14, neoplasms, systemic diseases such as gout, rheumatoid arthritis, and other seronegative arthritides15.
Nonoperative treatment of heel pain is frequently effective. Plantar rest strappings (low-dye) and arch supports, NSAIDS, and physical therapy aimed at stretching the Achilles tendon and toning the plantar intrinsic musculature are attempted first. Local infiltration of soluble corticosteroids mixed with a local anesthetic provides a potent anti-inflammatory response and may be periodically repeated depending on the duration of pain relief. Long-term biomechanical control of excessive flexible pronatory forces, or accommodation of rigid cavus deformities, is an essential element in the permanent resolution of symptoms. In cases involving an atrophic or damaged plantar fat pad, a cushioned insole that cups the heel can be very effective. Posterior tibial nerve block and below-knee casting for several weeks may be useful for late-stage, non-surgical patients with persistent symptoms6.
Posterior calcaneal traction spurs are initially managed with accomodative padding. Injection therapy has proved effective, but the physician must be aware of the deleterious sequelae of corticosteroid infiltraion near the Achilles tendon insertion.
While nonoperative therapy is often successful in relieving a patient's symptoms, surgical intervention may be indicated in certain cases. Plantar and posterior calcaneal traction spurs, degeneration and calcification of the Achilles tendon at or near its insertion point, inflammatory changes related to arthritis or systemic desease, and structural calcaneal deformities that fail to respond satisfactorily to medical treatment can often be treated successfully with surgical intervention6.
Preoperative considerations include the advantages and disadvantages of isolated plantar fasciotomy (with its associated shorter convalescence) versus the combination of soft tissue release and exostectomy of the plantar traction spur. Eighty percent of patients experience postoperative improvement with 50% showing marked improvement with heel surgery. An open, medial approach is often used to release the plantar fascia directly or to excise the traction spur6. Another approach includes minimal incision resection of the spur using a plantar approach under direct flouroscopic examination. It has been well documented that plantar fasciotomy alone, without resection of the plantar traction spur, is effective in relieving plantar fasciitis16. Recently, endoscopic plantar fasciotomy has become the treatment of choice for the patient and surgeon. This procedure releases the medial band of the plantar fascia where the majority of the inflammatory response to hyperpronation is localized. The endoscopic approach minimizes disability by returning patients to full weight bearing immediately after the procedure allowing use of regular shoes in 7 - 10 days.
During the heel strike phases of gait, the minimally supinated rearfoot immediately pronates about the subtalar and midtarsal joints. This allows the foot to accomodate irregular ground surfaces by effectively "loosening up" the internal structures of the foot. As the body moves over the supporting limb, the foot re-supinates and locks the subtalar and midtarsal joint to affect a stable lever arm about the first ray to maximize propulsive forces. Just before toe-off, the foot pronates again to prepare for the swing phase where dorsiflexion is necessary for clearance of the toes. It is during the initial supination that the foot elongates and stretches the plantar fascia, most severly along the medial band and at its insertional point on the medial calcaneal tubercle. Such excessive stress results in a hypertrophic connective tissue response that progresses from fibrocartilage to osseous spur formation17.
Most hyperkeratotic lesions are a secondary response to altered biomechanics and associated osseous adaptations. Lesions on the dorsum of digits and beneath the metatarsal heads are the most common. Interdigital lesions are also common. The altered dynamic pull of tendons and muscles in the foot secondary to biomechanical abnormalities or systemic diseases like diabetes and its intrinsic muscle denervation, predisposes the patient to digital contractures. Frictional forces between the inner shoegear and contracted digit causes hyperkeratotic formations that become quite painful. These lesions are most frequently located on the dorsal surfaces of the joints and may ulcerate if neglected. Periodic paring of the clavi symptomatically relieves the pain and accomodative padding is used to reduce direct pressure. Frequently surgical intervention is requested to alleviate symptoms. A sequential soft-tissue release is performed, often with resection of the appropriate phalangeal head. This effectively decompresses the digit and reduces the deformity and may be performed in the podiatric office surgical suite under digital block.
Dorsally contracted digits are a major predisposing factor on the formation of sub-metatarsal head calluses. Contracted digits impart retrograde force onto the metatarsal head, effectively driving the metatarsal head into the ground. The sub-metatarsal head fat pad displaces anteriorly. Reactive hyperkeratoses commences, further increasing the focal pressure on the metatarsal head. This contributes to metatarsophalangeal joint capsulitis syndrome which further debilitates the patient because of pain. Other causes of sub-metatarsal head clavi include a hypertrophic plantar condyle, a plantarflexed and/or elongated metatarsal, or a combination of the above. Non-operative measures of periodic paring of the lesions and accomodative padding is frequently effective. Surgical intervention is often needed and is aimed at reducing the pathologic forces causing the lesions. This may include elevation of the metatarsal head, reduction of metatarsal length, reduction of retrograde forces from a contracted digit, or a combination of the above.
Interdigital lesions are usually secondary to frictional forces from hypertrophic condyles on the medial and lateral surfaces of the joints of neighboring digits. Medical care is frequently adequate in relieving a patients symptoms. Surgical intervention is aimed at resecting the appropriate hypertrophic condyles and may be perfomed in the podiatric surgical suite.
T.G. Morton is credited with the misnomer used to describe this painful pedal neuropathy18. The lesion is a benign enlargement of the third common digital branch of the medial plantar nerve located between, and often distal to, the third and fouth metatarsal heads. The region is usually supplied by a communicating branch from the lateral plantar nerve as well19. The second interspace is the next most common site for intermetatarsal neuromas, though they may present in any interspace. Histologic evidence supports the concept that Morton's neuroma syndrome is an entrapment neuropathy resulting from compressive forces, especially the deep transverse metatarsal ligament. Also seen is local demyelination and telescoping of myelin in opposite directions on either side of the lesion20 - 27.
Morton's neuroma is predominately a disease of women, 30-50. The patient is likely to be overweight28, and describes the sensation of walking on a wrinkle in the stocking or a lump in the shoe. If the neuroma is large enough, the adjacent toes may be forced to spread apart on weight bearing. Because Morton's neuroma causes a distinct set of clinical symptoms, diagnosis most often can be made from the patient history. The pain from this syndrome is often described as sharp, dull, throbbing, or of electricity shooting into the toes. The patient may describe numbness in the adjacent toes, though there is rarely a sensory deficit29. The pain is aggravated by walking and is relieved by rest. Most patients state that removing the shoes and rubbing the feet provide the best relief.
Tenderness and reproduction of the described pain can often be elicited by squeezing each interspace in a dorso-plantar direction at or distal to the metatarsophalangeal space. A palpable mass may be present. Lateral compression while squeezing the interspace may elicit a palpable click known as a positive Mulder's sign30. Local tenderness needs to be differentiated from arthritic pain by palpating the adjacent metatarsophalangeal joints. The differential diagnosis may include a stress fracture, rheumatoid arthritis, osteochondritis dissecans (Freiberg's infraction), vasculitis, ischemia, tarsal tunnel syndrome, and peripheral neuropathy6.
Non-operative treatment is frequently beneficial to the patient and should be geared toward avoiding irritation to the neuroma. Wider shoes with adequate toe space and good arch support are a good starting point. Metatarsal pads applied to the proximal edge of the metatarsal head parabola may help displace weight proximally off the neuroma and splay the metatarsals. These may be combined with toe-crest pads or low-dye strappings. If pads and strappings provide good relief, then neutral position orthoses will most likely be successful. The goal of this thereapy is to limit pronatory hypermobility of the forefoot which is irritating the neuroma31-34.
Injection therapy with a corticosteroid mixed with a local anesthetic may provide extended relief, but is rarely definitive35-37. It does, however, serve as an excellent diagnostic indicator. The patient should be cautioned of the lag time before effects of the steroid are noted38.
Results show 20% to 30% of patients respond favorably to non-operative care, and as such, patients should be made aware of this poor prognosis early in their management. Surgical excision is usually definitive, though 7% to 24% of patients may experience unsatisfactory results39-42. The surgery is usually performed at an outpatient facility under intravenous sedation and local nerve block. The dorsal approach is most commonly used, but the plantar approach may be justified in recurring cases. Complications include hematoma formation, vascular compromise, and contracted digits secondary to severing of the deep transverse metatarsal ligament and loss of the fulcrum for the lumbrical tendon that helps stabilize the toe43. There is, however, a 75% success rate with excision39-42. Recurrent neuromas do occur, and the plantar approach toward resection is best6. Some surgeons advocate prophylactic measures to minimize further adhesions or stump formations. These include intraneural steroid injections believed to impede adhesions and sensitive axon sprouts at the nerve ending, sclerosing the nerve with 4% or stronger alcohol, metal ligation clamps and silicone caps19. The best measure of prophylaxis is clear identification of the neuroma and its proper digital branches intraoperatively and complete resection.
References
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