John Tassone, Jr., DPM Thunderbird Internal Medicine Arizona School of Podiatric Medicine, Midwestern University

Transcription

1 MANAGING DAY-TO-DAY FUNCTIONAL CHANGES IN THE AGING PATIENT PODIATRY ISSUES: BOTTOMS UP John Tassone, Jr., DPM Thunderbird Internal Medicine Arizona School of Podiatric Medicine, Midwestern University Learning Objectives: Identify the common causes of forefoot pain in the elderly. Discuss heel pain and list its many possible etiologies. Manage foot pain in the geriatric population and appraise if referral is recommended. DISCLOSURE OF COMMERCIAL SUPPORT John Tassone, Jr., DPM does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. 1

2 Podiatry Issues: Bottoms up John Tassone DPM Arizona School Of Podiatric Medicine Topics Heel pain Bunion Hammertoes Tailors bunion Neuroma Hallux rigidus Stress fracture Nail pathology Neuropathy Charcot Neuroarthropathy Diabetic Complications Posterior tibial tendon dysfunction Heel Pain is the most common foot condition More than 60% of the US population suffers from heel pain at some point in their life!!! 2

3 Causes of Heel Pain: Plantar Fasciosis(Fasciitis) Infracalcaneal Fat Pad Atrophy Medical Calcaneal Nerve entrapment Tarsal Tunnel Syndrome Rheumatoid Arthritis Reiter s syndrome Ankylosingspondylitis Psoriatic Arthritis Gout Posterior Enethesopathies SLE Fibromyalgia Sciatica Lateral Plantar N. branch to ADQ Calcaneal Stress fracture Calcaneal tumors/cysts Intraosseous edema of calcaneus History Insidious onset No trauma Post static dyskinesia Feels better after walking for awhile Shoes help Throbbing pain at times Feels like stepping on a nail Plantar Fasciitis Clinical Presentation Pain with Dorsiflexion of foot Pain on direct palpation Little or no swelling 3

4 Watch for! Sciatica ( lumbar x rays, MRI, referral) Stress fracture (x rays, MRI, Boot) Tarsal tunnel ( Gabapentin, Lyrica, referral)) Peripheral neuropathy (Gabapentin, Lyrica, referral)) Fat pad atrophy ( cushion) 3 x-rays Lateral foot Medial Oblique foot Calcaneal axial Standard of care Why X rays? 4

5 Standard of care NSAIDS/voltaren Steroids Prednisone Biomechanical control ( OTC Inserts) Stretching (a must!) ( physical therapy?) Rest from activity (Boot) Referral ( injections, custom orthotics, surgery) Hallux Abductovalgus (Bunion) Often an inherited tendency More common in women Causes crowding of lesser digits with subsequent hammertoe Will gradually worsen if left untreated treatment Shoes Wider with more toe box Tie shoes vs. valcro Avoid stiff leather Diabetic shoes Custom molded NSAIDS, voltaren gel, injection Orthotics surgery 5

6 Digital Deformities Symptoms Dorsal corns Distal callus/ulcers Pain at the joint Pain from shoes UNSTABLE TOES Treatment Debridement of any lesion Butress padding and silopos padding Shoes*** Met pads Surgical options Soft tissue (flexor tenonotomy) Bone (arthroplasty) Tailor s Bunion (Bunionette) Enlarged 5 th met head Splayed 5 th metatarsal Bursitis or callus Shoe irritation is common Therapeutic choices include Shoe changes Padding Surgery 6

7 Padding Inflammation and fibrosis of nerves, most commonly the 3 rd intermetatarsal nerve Aggravated by narrow shoes and higher heels May be affected by occupations requiring prolonged dorsiflexion of MPJ s Neuroma Nerve entrapment 7

8 Diagnosis of Nerve Compression Nerve pain Mulder s click Pain on compression of webspace Splayed digits on radiographs from swelling Neuroma treatment Shoe change ( wide, open) NSAIDS? Voltaren gel? Referral Injection Dorsal approach 30 gauge cocktail (.5 cc Dex,.5 cc.5 % marcaine) Go deep Up to 3 ( per year) Surgical ( endoscopic decompression) Avoid cutting nerve Hallux Rigidus 8

9 Symptoms Pain at 1 st MPJ Deep ache aggravated by walking Dorsal pain at the joint Dorsal spurring Parasthesias (medial dorsal cutaneous nerve) Compensatory symptoms IPJ 2 nd MPJ Lateral weight transfer treatment Stiff soled shoe Rockerbottom shoe NSAIDS / Voltaren gel OTC inserts Referral Injections Custom orthotics surgery History Foot swelling Pain with activity Better with rest No trauma Insidious onset Possibly a change in activity Stress fracture Clinical findings Dorsal foot swollen Possibly mild warmth and erythema Pain on dorsal metatarsal Possible negative x-rays May need MRI to confirm 9

10 Stress Fracture Treatment/Recovery RICE Shoe/walking Boot/ cast for weeks Non wt. bearing exercise ok 10% increase in intensity or duration from week to week Non union is possible complication Orthotics have not shown to help??? distal Onychomycosis proximal 10

11 superficial onychomycosis total Onychomycosis Testing nail clippings KOH ( false negatives) PAS ( more sensitive) Causative organisms dermatophytes T. Rubres T. mentagryphytes E. Floccossum Candida Treatment Oral Lamisil ( dermatophytes, yeast (?)) 90 days Sporanox (dermatophytes, yeast) Pulse dosing x 3 months Topical Jublia (efinaconazole) inhibit ergosterol Brush Keradyn (Tavaborale) Inhibit protein synthesis Dropper Penlac ( ciclopirox ) inhibit catalase Lacquer 11

12 Subungual Hematoma AKA runner s s toe or tennis toe Repetitive trauma is cause Purple/ red / brown discoloration beneath the nail bed Look to shoegear****** Look to toe deformity Recent exercise change Acute Subungual hematoma Subacute/chronic Watch for No history of trauma Hutchinson sign No subungual debris.7 to 3.5 % of all diagnosed melanoma Common sites Hallux Ring finger Index finger 10-30% five year survival due to late dx melanoma 12

13 melanoma Quiz Hematoma Treatment Subungual Hematoma Acute/ pain Trephination ( punch, blade, hot needle) Avulse the nail Chronic non painful Find source of pressure No treatment needed Melanoma Punch biopsy needed Psoriatic Arthritis 13

14 Psoriatic Arthritis Gouty Arthritis Incidence ( Geriatric) Females approach males Onset Not as quick in females Symptoms at joint Erythema Swelling Warmth Sites ( hallux, ankle, midfoot) Gouty Arthritis 14

15 Gouty Arthritis Neuropathic Osteoarthropathy Charcot Repetitive trauma in an insensate foot Locations Mainly midfoot***** Ankle Forefoot Early red, warm, swollen, painful ( if sensate) Late deformed foot Early charcot 15

16 Neuropathic Osteoarthropathy Suspect if: Neuropathy Red, warm, swollen No trauma Protect off the foot****** X-rays Address any concerning differential cellulitis Late Charcot Neuropathic Osteoarthropathy 16

17 Diabetic Foot Clinical Findings Diabetic foot assessment Check for wounds/ hot spots/lesions Don t forget between the toes Check shoes Size in width and length ( at end of day) Inside the shoes Make sure they wear shoes Nail issues Muscle strength ( especially dorsiflexion) Neuropathy If not diabetic? Other causes Spinal stenosis/ lumbar problems Chemotherapy alcohol Anemia Thyroid Meds ( Amiodarone, Hydralazine, Flagyl, Phenotoin, Dapsone) Hereditary ( Charcot Marie Tooth) 17

18 Symptoms Extremities Weakness Cramps Tingling, burning, numbness Dry cracked skin Cold feeling Hot feeling Hypohydrosis/hyperhydrosis Unilateral symptoms Testing Clinical signs and symptoms NCV/EMG 50 % unreliable vibrometer Neurometer Pressure specific sensory device Monofilament testing. ** Recommended Vibratory and postional Ipswitch touch test (IpTT) Index finger 8 sites ( 4 sites per foot) Hallux ( dorsal and plantar) 3 rd toe and 5 th toe ( tip) Positive when diminished at 2 or more Sensitivity 78.3%; specificity 93.9% Positive predictor 81.2% Negative predictor -92.8% 18

19 Current Treatments Opioid analgesics Anti convulsants ( neurontin and lyrica)*** M.I.R.E. Capsaicin cream Others (B Vitamin, primrose oil, alpha lipoic acid ) Citalopram Compounding cream*** Neurogenix (new)*** IV infusion alpha lipoic acid Decompression surgery Increased pressure Inability know to adjust to decrease pressure. Skin is more fragile Inability to feel pain to address the ulcer. Inability to heal normally. Immune system altered so prone to infection. Ulcer 19

20 Osteomylitis Presence of infection Constitutional symptoms Fever, chills, nausea, nightsweats Inflammatory Source ( hematogenous,contiguous,direct) Labwork (sed rate of 70) Imaging ( X-rays, MRI***, Bone scan) Posterior Tibial Dysfunction Symptoms Pain, swelling along PT tendon and spring ligament Weakness & decreased endurance Walking on inside of ankle Knee pain Pain in arch of foot Etiology of dysfunction: mechanical causes Degenerative: more common Population commonly 4 th -6 th decade, women>men; other factors such as obesity, DM, HTN can accelerate degenerative changes Progressive tendon pathology in previously normal foot -OR - Progressive tendon pathology in congenital pes planus 20

21 Treatment options - limited amount of good quality evidence Strengthening (stages I & II) Bracing & support (stages I & II) Shoe modification (stages II & III) Immobilization (possible w/all stages) Surgery (stages II & III) Thank you 21