A REVIEW OF THE FOOT & ANKLE Geoff Kraemer, DPM AACFAS

GOALS

About Me

Who is today’s Podiatrist?

Topics Anatomy Concepts in conservative and surgical management Common pathology Common injuries Diabetic Foot Care and & Ulcer Prevention

ABOUT ME

Podiatrist at Hutchinson Clinic

From Dubuque, Iowa

Undergraduate – U of Iowa

Podiatric Medical School – Des Moines University

Residency – Houston, Texas

Married to Christina

2 dogs

Animals and Land

WHAT IS A PODIATRIST?

DPM – Doctor of Podiatric Medicine Kansas Includes the ankle*

4 year Podiatric Medical School

3 year residency – PMSR/RRA Certificate

Foot & Ankle Specialist Conservative treatment & surgical treatment

ANATOMY

26 bones

33 Joints

100 muscles, ligaments and tendons

CONCEPTS IN TREATMENT

Conservative

Life goes on regardless of how your foot/ankle feels Can I put pressure on it or do I have to stay off

of it?

Will this make it better?

Is it going to come back?

Surgical

Does it hurt?

Determining what type Degree of deformity Age Health Status Compliance

Movement vs. No Movement

COMMON PATHOLOGY

Corns and Calluses

Warts

Nails Ingrown nails Fungal nails

CORNS & CALLUSES

What are they?

What is the difference?

Why are they there? For a reason

Biomechanics

deformity

Protective response to pressure and friction At risk patients must be properly evaluated

Callus Diffuse, Plantar Soft callus – Heloma Molle

Between toes

Corns Focal Porokeratosis If you are diabetic – do not use medicated pads without approval

POROKERATOSIS

HELOMA MOLLE (SOFT CALLUS)

TREATMENT FOR CORNS & CALLUSES Understanding why this developed Shoes Socks Pressure Deformity

Padding and/or spacers

Debridement

Surgery

WARTS

Virus 100 types Infection of top layer of skin

Common Plantar vs. mosaic

Not painful

Treatment Most go away on their own Home remedy…if you have time Salicylic Acid Liquid Nitrogen Other Chemicals that trick your body into attacking the wart

NAILS

Ingrown Nails Nail Fungus

Other things look like fungus

Topical Treatments at best ~ 30% effective • Fancy new ones… • Rx • OTC • Home remedies

• Vinegar • Vicks

Oral • ~75% effective • May not be possible due to drug interactions • Takes up to 9-12 months to see result

COMMON FOOT & ANKLE PAIN

Heel Pain

Forefoot Pain

Bunions

Hammertoes

Ankle Instability

Stress Fractures

Flatfoot deformity

Joint Pain

HEEL PAIN

Plantar Fasciitis # 1 reason • Yes support • No Cushion • Treatment

• STRETCHING !!! • Shoes • Orthotics • Steroid injection? • Ice

Other causes • Stress fracture • Nerve entrapment • Low back pain

TREATMENT FOR PLANTAR FASCIITIS

#1 = Stretching

Proper support Shoe gear Orthotics Not going barefoot

Decrease inflammation Pill vs. shot

Modify Activity

Patience

BUNIONS & HAMMERTOES

What causes bunions and hammertoes? Muscle and Tendon imbalance

Why do I have them? Multiple reasons Genetic

Shoes

Ligamentous laxity

Foot Structure

Other

What to do about it? No pain = Nothing Pain = Fix it

CONSERVATIVE TREATMENT

Try and hold it in place Will not prevent further development

Padding

Wider/taller shoes

DEGREES OF BUNIONS

SURGICAL TREATMENT OF BUNIONS

Depends on severity & etiology Big implications Walk on it today

Must wait up to 6 weeks to walk on

SURGICAL TREATMENT OF HAMMERTOES

FOREFOOT PAIN

Neuroma

Metatarsalgia

Fat Pad Atrophy

COMMON SPORTING INJURIES

Sprained Ankles

Plantar Fasciitis

Achilles Tendonitis

Stress Fractures

ANKLE SPRAINS

3 Types of Sprains

RICE Rest Ice Compression Elevate

3 Stages of Rehabilitation RICE Restore ROM and Strength Return to Activity

Chronic Ankle Sprains

CHRONIC ANKLE INSTABILITY

Patients say: I roll my ankle easily I feel unsteady walking on uneven ground I only feel comfortable wearing boots

Repetitive Ankle Sprains Stretch out ligaments Weakens & prevents proper functioning

2 types of Instability Functional Responds to physical therapy

Mechanical Does not respond to physical therapy Surgery – Tigthen/Recreate ligaments

CHRONIC ANKLE INSTABILITY REPAIR

Multiple ways to repair – Same concept Native tissue/tendon Cadaver tendon Synthetic tape

Associated injuries Osteochondral defects Peroneal tendon tears Other

Chronic instability can lead to chronic ankle pain…

CHRONIC ANKLE PAIN

Osteoarthritis

Rheumatoid Arthritis

Post-traumatic

Chronic Ankle Instability

Deformity

Treatment Bracing Steroid Injection Ankle Arthroscopy Fusion vs. Replacement

ANKLE ARTHROSCOPY

Goals Clean up joint Remove chronic inflamed tissue

Examine joint surface

Rehabilitation Outpatient – 20/30 minute procedure Isolated – can walk in 2-3 days w/ crutch

ACHILLES TENDON

Equinus

Tendinitis & Tendinosis Insertional “Heel spur” on back of foot

Non-insertional

ACHILLES TENDON DISORDERS

STRESS FRACTURES

Focal pain, swelling, redness

Related to new/increased activity

Can be difficult to see on x-ray

Most commonly seen in forefoot

Treatment • CAMboot…but you are usually allowed to walk on it • Possibly check Vitamin D and Calcium

• Vitamin D3 – 1000 units/day

• Calcium – 1000 mg/day

• Takes 4-6 weeks to heal

FLATFOOT DEFORMITY

Collapse of arch

Also known as: Adult Acquired Flatfoot (AAFD) Posterior Tibial Tendon Dysfunction (PTTD)

Symptoms Pain at arch Pain inside anke Pain/inability to stand on toes Pain outside of ankle

Progressive, with stages Rest Immobilization Long term bracing Surgery

JOINT PAIN & ARTHRODESIS

Arthrodesis vs. Replacement

Arthrodesis – 2 bones become 1 bone Pain Instability Deformity

Other joints take up motion Increased risk of development of arthritis

Common sites of Joint Fusion 1st MPJ Talo-navicular Sub-talar Ankle

PEDIATRIC FOOT & ANKLE

General rules about Kids and Feet • They don’t complain • Watch for

• Avoidance of physical activity • Trip and fall on level ground

Answering a few common questions I receive… • It is normal/ok for kids to walk on their toes up to the age of 7 • A child’s arch does not develop until the age of 7, they don’t necessarily have “flat feet” • It is common for 12-14 years have heel pain related to activity – it is “growing pains” i.e. Sever’s Disease

With that said: • Good supportive shoes • Watch them and ask questions

DIABETES

Increasing – 5.5% in 1990 to 9.3% in 2010 29 million adults with diabetes

15% will develop foot ulcer in their lifetime 15-25% of ulcers require an amputation 10-20% amputation same foot w/in 1 year 25-50% amputation same/other foot w/in 5 years

5 year mortality rate after diabetic amputation – 43%-55% Higher than prostrate, breast, and colon cancer

Impact of DFU -Physical, social, physchological and economical Annual cost of LEA $70,000 Higher rates of depression, lower quality of life

RISK FACTORS FOR DIABETIC FOOT ULCERS

History of Ulcer

Peripheral Neuropathy

Foot Deformity

Peripheral Vascular Disease

Visual Impairment

Diabetic Nephropathy (specifically those on dialysis)

Cigarette Smoking

Up to 50% of patients at risk will have no symptoms – thus physical exam is critical

MULTI-DISCIPLINARY TEAM

Podiatrist

Vascular Surgery

Internal Medicine

Endocrinologist

Infectious Disease

Cardiology

Nephrology

Ophthalmology

DO’S AND DON’TS OF DIABETIC FOOT CARE

Do

Control your blood sugar • Numbness/Tingling related to poor control • Slower wound healing related to poor control

Inspect your feet daily • Mirror if necessary

Wear supportive shoes • At risk – diabetic shoes/socks

Moisturize your feet

See your doctor yearly

Don’t

Go barefoot • Rocks/sharp objects can cause wounds

Ignore cuts/scrapes

Use medicated corn pads/chemicals

Perform bathroom surgery

THANK YOU

Website for basic information on foot & ankle conditions www.foothealthfacts.org

My contact info:

Geoff Kraemer, DPM

Hutchinson Clinic

Phone: (620) 669-2554

www.hutchclinic.com/kraemer