Understanding & treating common foot pathology
- 1. 6/21/2021 1 Understanding & treating common foot pathology Poly Ghosh M.Sc (P & O), Workshop Manager (P & O), NILD, Kolkata
- 2. Objectives • Introduction • Foot anatomy • Examination & evaluation of foot deformity • Different foot pathology & their Orthotic treatment 6/21/2021 2
- 3. 6/21/2021 Ref: 3 Select right footwear
- 4. Foot anatomy • The feet are flexible structures of bones, joints, muscles, and soft tissues that let us stand upright and perform activities like walking, running, and jumping. • The foot contain : 1. 26 bones 2. 2 Sesamoid Bones 3. 33 joints 4. 19 muscles 5. 107 ligaments 6. 3 Arches 6/21/2021 Ref: Huson A. Functional anatomy of the foot. Disorders of the foot and ankle. 1991;1:409-31. 4
- 5. • Foot are divided into three parts: 1. Forefoot 2. Midfoot 3. Hindfoot 6/21/2021 Ref: Huson A. Functional anatomy of the foot. Disorders of the foot and ankle. 1991;1:409-31. 5
- 7. Plantar Fascia • An important stabilizer in the foot where a great deal of foot pathology begins. • It originates from the plantar surface of the calcaneus and attaches to the plantar surfaces of the five metatarsal heads and proximal phalanges of the toes. • It acts as a major stabilizer of the foot • It helps maintain the arch of the foot and is an antipronator. • In its function of maintaining the congruity of the relationship between the calcaneus and the metatarsal heads, it resists the torsion movement of the forefoot in relation to the hindfoot during pronation. Most of the eversion of pronation occurs in the mid and forefoot while the calcaneus remains stable in the hindfoot. 7
- 8. Evaluation of foot disorders Quality, Location, Radiation, Severity, Duration, exacerbating and/or relieving factors related to the pain A family history of congenital or acquired disorders history of previous injuries, occupational and recreational activities, any recent changes in the type or amount of activity. 6/21/2021 Ref: Ayub, A., Yale, S. H., & Bibbo, C. (2005). Common foot disorders. Clinical medicine & research, 3(2), 116–119. https://doi.org/10.3121/cmr.3.2.116 8
- 9. Contd.. • Current or previous treatment(s). • Observation : • Patient’s gait • foot position • Inspection of his/her footwear 6/21/2021 9
- 10. Foot disorder Adult foot problem- Bunion, Plantar fascitis, Calcaneum Spur, Retrocalcaneal Bursitis, Corn, Mortons neuroma Neuropathic/Diabetic foot Charcot foot • Pediatric foot problem: • CTEV • Metatarsus adductus • Flat foot • Pesplanovalgus • Intoeing of foot 6/21/2021 Ref: 10
- 11. Bunions • Bursa sac that develops over the first metatarsophalangeal (MTP) joint as a result of a hallux valgus deformity of this joint • Women are prone to develop • Etiology: • Primary in the absence of any known underlying diseases or secondary to a variety of metabolic, structural or inflammatory disorders. • Ill fitted shoe 6/21/2021 Ref: 11
- 12. Pathophysiology • Genetic predisposition from ligamentous laxity and hyperpronation of the foot. • The MTP joint gets larger and protrudes from the inside of the forefoot. • complex relationship of the first ray biomechanics and hindfoot mechanics influence bunion development. • any disorder resulting in first MTP joint inflammation may weaken MTP soft tissue restraints, predisposing to bunion formation. 6/21/2021 Ref: 12
- 13. Symptoms • Pain and tenderness • Redness and inflammation • Hardened skin on the bottom of the foot • A callus or corn on the bump • Stiffness and restricted motion in the big toe, which may lead to difficulty in walking 6/21/2021 Ref: 13
- 14. 6/21/2021 Ref: 14 •A bunionette, or "tailor's bunion," occurs on the outside of the foot near the base of the little toe. •A bunionette is very much like a bunion. •Painful bursitis and a hard corn or callus over the bump.
- 15. OrthoticTreatment • Foot padding, • Night splints, • Hallux valgus splint • Modified foot wear (e.G. Roomy toe-box, toe- Bar,etc) - Toe spreader • Adequate space in the shoe to prevent further injury. 6/21/2021 15
- 17. Plantar fascitis • Plantar fasciitis, once viewed as an inflammatory condition caused by repetitive micro tearing of the plantar fascia, is now thought to be a degenerative condition • Plantar fasciitis is a clinical diagnosis that is most commonly seen in younger runners and patients between the ages of 40 and 60 years of age who are often slightly overweight and may be deconditioned • Heel spurs or calcaneal osteophytes have no relationship to plantar fasciitis. In fact, heel spurs occur in 15% to 20% of the asymptomatic population and are absent in many people with plantar fasciitis. additionally, the plantar calcaneal spur originates at a different anatomic layer of the foot than the plantar fascia. 6/21/2021 17
- 18. Epidemiology • Plantar fasciitis makes up approximately 25% of all foot injuries in runners 10 and up to 8% of all injuries to people participating in sporting activities.11 Plantar fasciitis is usually unilateral, but it is bilateral in up to 15% of patient • It is a common cause of heel pain in active working adults between the ages of 25 and 65 years old. 6/21/2021 18
- 19. Symptoms • Pain and tenderness under the heel on weight bearing, resulting in limitations of physical activity. • Pain is worst with the first few steps in the morning, patients often notice pain at the beginning of activity that lessens or resolves as they warm up. • The pain may also occur with prolonged standing and is sometimes accompanied by stiffness. • In more severe cases, the pain will also worsen toward the end of the day.3 • Patients sometimes describe contra lateral pain when weight is shifted to the other leg 6/21/2021 19
- 20. Risk factors for developing plantar fascitis • Biomechanical risk factors: excessive pronation, structural deformities such as forefoot varus, higher-arched foot, low arched foot, flattening of the medial arch with excessive pronation, rearfoot varus, • anatomical risk factor such as discrepancy in leg length, excessive lateral tibial torsion and excessive femoral anteversion, • include tightness and weakness in the gastronomies, soleus, achilles tendon and intrinsic foot muscles13 • training error, excessive weight, age related degenerative changes, occupations requiring prolonged standing or ambulation those falling into this category include teachers, construction workers, cooks, nurses, military personnel, and athletes training for long distance running events, and shoes with poor cushioning 6/21/2021 20
- 22. Orthotics management • Arch support, • heel pad, • prefabricated night splint • foot orthosis(functional foot orthosis, UCBL) 6/21/2021 22
- 23. Calcaneum spur • When a bony outgrowth forms the calcaneum tuberosity just anterior to the medial process of the calcaneal tuberosity, • Most common cause of heel pain 6/21/2021 23
- 24. Etiology • According to Bergmann, it originates from the repetitive traction of the insertion of the plantar fascia into the calcaneus, which leads to inflammation, and reactive ossification of the enthesis. However, according to, Kumai and Benjamin plantar spurs develop from vertical compression instead and cannot be traction spurs, as they do not develop within the plantar fascia itself. They are thus fundamentally different from spurs in the Achilles tendon since they develop as a consequence of degenerative changes that occur in the plantar fascia enthesis 6/21/2021 24
- 25. Orthotic treatment • Modified foot orthosis • Excavated heel with sponge insert 6/21/2021 25
- 26. Retrocalcaneal bursitis • Retrocalcaneal bursitis is the most common heel bursitis. Bursitis is the inflammation of a bursa. Retrocalcaneal bursitis is in inflammation of the bursa located between the calcaneus and the anterior surface of the Achilles tendon[ • Management: • Heel raise 6/21/2021 26
- 27. Mortons neuroma • is a reactive fibrosis of a communicating branch of the third nerve and, histopathologically, is not a true neuroma.1 The neuroma is believed to be mechanically induced and most commonly affects the third common digital nerve located in the region of the third webspace of the foot • The diagnosis of Morton’s neuroma is suspected clinically when patients complain of pain located in the webspace of their toes. Early in the course, patients may describe burning or tingling in this region. These symptoms may progress to the more typical paroxysmal, severe, sharp, lancinating pain that occurs with weightbearing and walking and is relieved by sitting, removing the shoes, and massaging and manipulating the affected region of the forefoot 6/21/2021 27
- 28. Orthotic management • avoiding pointed and/or high-heeled shoes, • metatarsal pads, 6/21/2021 28
- 29. Corn • A corn (heloma) is a result of pressure from improperly fitting shoes • Hard corns are often associated with hammer toes • Soft corns result from wearing narrow shoes and excessive foot perspiration Management:- For soft corns – good fitting shoes are necessary in conjunction with good foot hygiene Use of padding or cotton to separate toes is helpful Soaking in warm soapy water will also aid in softening of corns 29
- 30. Diabetic Foot • It is a metabolic disorder characterized by a relative or absolute deficiency of insulin affecting metabolism of protein, fat, carbohydrate, water and electrolyte • It is diagnosed on the basis of elevated blood glucose concentration 30
- 31. Orthotic management • Weight distribution - Footbed - Total contact cast - Weight transfer - Weight distributions-mobility aids • Pressure distribution - copolymer gel - Gel heel cushion • Protection - gel socks - custom made shoe with MCR rubber lining 31
- 32. Charcot Foot • It is a rare but fascinating complication of diabetes and describe changes of neuropathy – a chronic painless degenerative process affecting the wt. bearing jts. of the foot. • Occur in 1% of diabetic 32
- 33. Management of Charcot Foot • Removable cast walker with custom molded foot orthosis. • Custom shoes may be required. • If deformity is significant, clamshell style 2 piece custom ankle foot orthosis. • Soft materials are recommended, and reassessment of these orthoses is required to ensure adequate padding remains as wear and tear are applied. • Total contact cast 33
- 34. CTEV • 1:1000 live births • male:female 2:1 • 50% bilateral • Characterized by : → hindfoot equinus → subtalar varus/ inversion → cavus foot → forefoot adduction 34
- 35. Management of CTEV Weekly serial manipulation Correction achieved Orthotic management Correction not achieved Surgery External fixators 35
- 36. 36 Principles of treatment- • Correction of the deformity by non-operative or operative methods. • Followed by maintenance of the foot in the corrected position (orthotic management) • Sequence of deformity correction- adduction- invertion- equinus, in severe cases, cavus and tibial tortion should also be corrected. • Orthotic management (O.M.)- in case of flexible CTEV:- • To prevent forefoot adduction- straight inner border of shoe and Dennis Browne splint. • To prevent invertion- lateral wedge and reverse thomas heel. To prevent equinus- lower shoe heel and sole elevation.
- 37. 37 DB & SB splint
- 38. CTEV - AFO • newborn -> 6/12 dynamic correction • In case of fixed ctev- The weight bearing pattern is modified by accommodating the deformity . Medial sole wedge and heel elevation. 38
- 39. Metatarsus adductus • Metatarsus Adductus is a common congenital condition in infants that is thought to be caused by intra-uterine positioning that lead to abnormal adduction of the forefoot at the tarsometatarsal joint. • Diagnosis is made clinically with medial deviation of the forefoot with normal alignment of the hindfoot. 6/21/2021 39
- 40. Orthotic management • Straight last & reverse last shoes in sequence • Bebax boot – adjustable forefoot bracing • Plastic AFO in slight hindfoot varus & forefoot abduction (Wheaton brace) 40
- 41. Flat feet • Longitudinal medial arch support • UCBL 6/21/2021 41
- 42. Pes plano-valgus • It refers to the loss of the medial longitudinal arch. • Characterized by :- - obliterated med. Arch - navicular bone is prominent - finger cannot be inserted under the arch - wt. bearing area increses and may show increase callosity • May be - Flexible - Rigid - Static 42
- 43. 43 flat foot high arched foot normal
- 44. Management of Pes plano-valgus Between 3-9 yr 1) Asymptomatic cases need parent education. 2) Symptomatic cases requires need Orthopedics shoes (with modifications e.g arch support, C&E heel,etc) & attachments if required (e.g med.single lat. bar with med. T-strap & arch support, wedge if needed). Between 10-14 yr 1) Asymptomatic cases need no treatment. 2) Symptomatic cases need molded orthoses worn in a sturdy shoes Surgical intervention – after exhausting conservative management & when persistent pain is present. - arthrodesis - osteotomies, etc. 44
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