Anatomy 1% 29% 64% 6%

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Ashlee Thornton
6 years ago
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1 Mortons Neuroma Perineural fibrosis of the plantar digital nerve Females rd plantar webspace most commonly effected Burning pain Sensory changes 3&4 digits / interdigital space

2 Etiology Excessive metatarsal shearing compression during toe off phase of gait Plantar digital nerve aggravated by the transverse metatarsal ligament Narrow footwear ± wide foot Intermetarsal space narrowest between 2/3 and 3/4 The 3rd digital nerve is the largest digital nerve formed by branches of both the medial and lateral plantar nerves

3 Anatomy

4 Anatomy 1% 29% 64% 6%

5 Clinical tests Sensory test Web space pressure Metatarsal approximation Mulders click Digital nerve stretch test Gauthier s test

6 Sensory test

7 Web space palpation

8 Mulders click

9 Digital nerve stretch

10 Treatment Mortons Neuroma Metatarsal pad Footwear modification Orthotic devices Ultrasound scan Hydrocortisone Neurectomy

11 Metatarsal pad

12 Orthotic therapy / Footwear

13 Excessive foot pronation

14 Imaging

15 Imaging

16 Neuroma

17 Bursae

18 Corticosteroid injections Anatomical landmark v image-guided Site of injection Patients body habitus (superficial or deep) Size and accessibility of the structure to be injected Image guided adds significant cost (non- ACC $236 + $400 or ACC $91 + $140)

19 Injecting interdigital neuroma 25g 1 needle 2ml 1% lignocaine + 1ml Kenacort A40 Patient advice sheet Advised relative rest period

20 Corticosteroid

21 Neurectomy

22 Summary Common cause of forefoot pain Females 8-10 times more common Perform a thorough examination using relevant clinical tests Refer to podiatrist Imaging if conservative treatment fails Corticosteroid 66% - 80% effective

23 Plantar fasciitis 7% of all foot pain in adults >65 years 25% of foot pain in athletes Generally two types Acute (arch) Chronic / insidious (heel) Fasciosis degenerative as opposed to inflammatory Pain worse in morning or upon weight-bearing from rest Pain lessens with activity however worsens with prolonged weight-bearing

24 Etiology Unknown Risk factors Age years Calf tightness High BMI Work related weight bearing Athletic activity running, ballet, gymnastics, aerobics Foot type

27 Clinical Examination Medial palpation Plantar palpation

28 Windlass

29 Active weightbearing 50% 100% 200%

30 Calf flexibility

31 Treatment Plantar fasciitis NSAID s Rest Taping Stretching Footwear Soft orthoses Corticosteroid ESWT

32 Low dye strapping

33 Orthotic therapy

34 Footwear

35 Stretching

36 Extracorporeal shockwave therapy

37 Corticosteroid

38 Injecting plantar fascia 25g 1 needle 2ml 1% lignocaine + 1ml Kenacort A40 tape afterwards

39 Imaging

40 Imaging

41 Summary Pain in morning and upon arising from rest Insidious onset Aggressive conservative management Refer to podiatrist Calcaneal spur not the cause of pain Seronegative spondyloarthropathies

42 Stress fractures Repetitive submaximal loading where bone resorption and formation imbalances occur Continuum from stress reaction to fracture Runners, military recruits, landing sports Females High risk or low risk types

43 Common sites Metatarsals 2 nd / 3 rd Proximal - HIGH RISK Distal LOW RISK 5 th HIGH RISK Navicular HIGH RISK Calcaneus LOW RISK

44 Second metatarsal Distal and proximal fracture types Mortice restraint Mortons foot more susceptibile Excessive foot pronation causes loading due to the 1 st ray becoming dorsiflexed Greater plantar pressure in the forefoot after prolonged running

45 Anatomy

47 Distal 2 nd Metatarsal

48 Distal 2 nd Metatarsal

49 Distal 2 nd Metatarsal 29/01/ /03/2008

50 Distal 2 nd Metatarsal

51 Distal 3 rd Metatarsal

52 Calcaneus

53 Proximal 2 nd Metatarsal

54 Proximal 2 nd Metatarsal

55 5 th Metatarsal

57 5 th Metatarsal

58 5 th Metatarsal

59 5 th Metatarsal

60 Navicular

61 N-Spot

62 Resisted inversion / dorsiflexion

63 Active weight-bearing 50% 100% 200%

64 Treatment Stress Fracture Rest Orthoses Footwear Modify Activity Partial weightbearing Non weightbearing

65 Orthotic therapy

66 Orthotic therapy

67 Footwear

68 Rest Activity modification Full weight-bearing Orthotic device Partial weight-bearing Non weight-bearing

69 Summary History taking is important Know your anatomy particularly of the high risk # sites Check for abnormal foot biomechanics Watch the patient walk or run Consider systemic causes of # when loading does not seem excessive Refer if in doubt

BUCKS MSK: FOOT AND ANKLE PATHWAY GP MANAGEMENT. Hallux Valgus. Assessment: Early Management. (must be attempted prior to any referral to imsk):

BUCKS MSK: FOOT AND ANKLE PATHWAY GP MANAGEMENT. Hallux Valgus. Assessment: Early Management. (must be attempted prior to any referral to imsk): Hallux Valgus Common condition: affecting around 28% of the adult population. Prevalence increases with age and in females. Observation: Lateral deviation of the great toe. May cause secondary irritation