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    Asclepius1's Avatar
    Asclepius1 is offline Ultimate Member 537 points
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    FOOT PROBLEMS AND INJURIES

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    FOOT PROBLEMS AND INJURIES


    From the 39th Annual Primary Care and Family Practice Symposium, presented April 19-24, 2004
    by the Medical College of Georgia


    The goal of this program is to educate the listener about running injuries and common foot problems. After hearing and assimilating this program, the participant will be better able to:
    1. Describe the pain syndrome of the 5 most common running injuries.
    2. Explain therapy approaches such as stretching and cryotherapy.
    3. Recommend the appropriate type of running shoe based on patient’s foot structure and clinical findings.
    4. Describe the function and mechanics of the foot.
    5. Assess foot structure, range of motion, and toenail pain.

    RUNNING INJURIES AND RUNNING SHOES—Joel S. Brenner, MD, Assistant Professor of Pediatrics and Orthopaedics, Director of Pediatric and Adolescent Sports Medicine, Medical College of Georgia, Augusta
    Introduction: 30 to 40 million runners in United States; approximately 40% run greater than or equal to 3 times per week; 35% to 45% injured per year
    Factors in running injuries: extrinsic—training errors (eg, “too much too soon”); running on concrete; inappropriate footwear; intrinsic—faulty biomechanics; inadequate flexibility or strength
    Patellofemoral pain syndrome: patients describe dull achy or sharp stabbing pain around patella, or gritty sensation under kneecap; knee hurts when standing after sitting for long time and when ascending or descending stairs; sensation of buckling due to dysfunction of quadriceps muscle; treatment—stretching and strengthening of quadriceps, hamstrings, and calf muscles; cryotherapy; physical therapy for proper patellar tracking; evaluate training habits; proper footwear
    Medial tibial stress syndrome: shin splints; pain at medial aspect of tibia (at junction of muscle and bone); tibialis posterior likely source of pain; press and determine whether pain directly on tibia or on medial aspect of tibia; can be due to combination of periostitis, myositis, and tendonitis; syndrome ranges from mild (eg, shin splints) to more severe (eg, inflammation of bone; fractures); differentiating from stress fractures—pain improves as muscle warms up (pain due to stress fractures worsens with continued exercise); pain adjacent to bone (pain localized on bone with stress fractures); treatment—stretching of gastrocnemius and soleus muscles; strengthening of lower extremities and ankles; cryotherapy (eg, ice massage along medial border of tibia for 5 min twice daily); iontophoresis with dexamethasone; evaluate training habits and footwear
    Achilles tendonitis and tendinosis: tendonitis—inflammation of tendon; tendinosis—degeneration of tendon; caused by excessive stress; pain at Achilles tendon (3- to 5-cm area where tendon attaches to calcaneus); treatment—stretching calf muscles and ankles; ice massage for 5 min 2 to 3 times daily; ultrasound therapy; physical therapy; heel lifts in shoes
    Plantar fasciitis: inflammation of plantar fascia (tissue extending from calcaneus to forefoot); pain at attachment point of medial aspect of plantar fascia along calcaneus; treatment—stretching foot muscles before getting out of bed; strengthening foot muscles; cryotherapy; ultrasound; night splints (second- or third-line therapy; difficult to wear during sleep) to maintain proper positioning; shockwave therapy; proper training modification; injection—find point of maximum tenderness at medial aspect; avoid hitting nerve and back off if patient feels tingling; give 2 mL of lidocaine and steroid (eg, triamcinolone [Kenalog]); do not give >2 injections per year; most patients have good relief after first injection; risk for rupture of plantar fascia and fat atrophy; heel spurs—do not cause pain; radiographic finding; may be due to traction on calcaneus; eliminating heel spurs does not eliminate pain at plantar fascia; heel cushioning and supportive footwear may be helpful; injection therapy not first-line therapy; advise patients to avoid going barefoot
    Iliotibial band syndrome: iliotibial band begins as tensor fascia lata at hip, extends down to knee, and attaches to tibia; friction develops over lateral femoral condyle and results in inflammation of iliotibial band and pain on lateral aspect of knee; differentiate from torn meniscus or injured cartilage; treatment—strengthening of buttocks muscles; cryotherapy effective; ultrasound; training modification
    Function of foot: provides supportive base and rigid structure for walking and running; adapts to uneven surfaces; absorbs rotation of lower extremities; absorbs shock (depending on individual foot mechanics)
    Foot test: examine imprint of foot (eg, imprint of wet foot on towel or cardboard); normal foot—visible arch connection from forefoot to rearfoot; when running, foot lands on outside of heel, pronates inward, resupinates toward lateral aspect; pronation helps absorb shock; flat foot—arch connection “one big blob”; during running, foot strikes on outside of heel and rolls inward (overpronates); high-arched foot—no visible arch connection due to height of arch; during running, foot supinates or underpronates, resulting in lack of shock absorption; patients require extrinsic shock absorbers
    Function of shoes: protect foot; increase friction to improve traction; provide stability, shock attenuation, energy return, and foundation for orthotics
    Anatomy of shoes: last—comprised of hard plastic, wood, or metal; provides size and shape of shoe; usually straight, semicurved, or curved; board-lasted shoes have board sewn from back to front of shoe to provide extra rigidity and stability; slip-lasted shoes (light and flexible; can be twisted) sewn together like moccasin; some shoes combination lasted; outsole—provides durability and traction; midsole—helps with shock absorption; located between outer sole and footbed; wears down (shoes should be replaced every 6 mo or 300-500 miles); some shoes have multidensity midsoles; contain gel, air, or posting to provide cushioning and stability; insole—contacts foot; helps absorb shock; provides stability; can be modified by trimming, adding pads, or replacing with orthotics; upper—comprised of heel counter, rearfoot stabilizer, tongue, Achilles notch; features vary
    Types of shoes: motion control—most rigid; helps control motion; heavy shoe; durable outer sole; often board lasted or straight lasted; medial posting helps control pronation; wider base of support prevents pronation; firm heel counter reduces heel motion; helpful for runners with flat feet (overpronators), runners who require orthotics, and heavier runners; stability—provides good combination of cushioning and motion control; usually board lasted or combination lasted; recommended for runners who do not have severe motion-control problems; medial support with good durability; runners with normal arches; cushion—soft with cushioned midsole; usually slip lasted and curve lasted or semicurve lasted; no rigidity on medial aspect; recommended for underpronators and more efficient runners who do not require extra medial support
    Selecting shoes: spend approximately 1 hr in shoe store and try on different brands for best fit; shop at end of day when feet larger; take athletic socks; choose shoe with half-inch to thumb-width space between longest toe and end of shoe when standing; width should allow unrestricted movement and little heel movement; break in shoes gradually; models of shoes change every year; running specialty stores helpful
    EVALUATION AND TREATMENT OF COMMON FOOT PROBLEMS—Anthony B. Cresci, DPM, Assistant Professor, Department of Orthopaedics, Medical College of Georgia, Augusta
    Introduction: approximately 75% of Americans have foot problems during lifetime; foot problems can cause falls and fractures in elderly patients; $200 million spent annually on foot remedies; counsel patients about products (eg, corn removers containing salicylic acid)
    Foot evaluation: foot acts as mobile adapter and rigid lever; determine whether patient’s foot adapts to ground and becomes rigid for forward progression; patients with severe arthritis and limited motion unable to adapt to ground and develop stress problems in foot and lower extremities; patients with limited mobility need cushioned shoes; flat hypermobile feet fail to act as rigid levers; consider repetitive stress on feet
    Mechanics: foot functions as sagittal plane; body comes over foot and foot stabilized by muscles; leg swings through and develops momentum to bring body over foot; normal gait requires approximately 75º of sagittal plane motion; sagittal plane motion rocker system—1) landing on heel and rolling forward; 2) when foot flat on ground, leg comes over with greater than or equal to 10º of ankle joint dorsiflexion; 3) dorsiflexion at metatarsophalangeal (MTP) joints (affected in patients with arthritis)
    Compensation: abnormal foot compensates and leads to problems in other areas; tarsal coalition—lack of subtalar joint motion; ankle problems develop due to ball-and-socket ankle joint motion; patients may not have pain in subtalar joint; limb length discrepancy—longer limb pronates and is hypermobile; shorter leg supinates and becomes rigid; patients develop different problems in each foot; stroke—patients have anterior tibial weakness and develop hallux malleus (similar to clawed toes); pronation—patients who cannot achieve 10º of dorsiflexion at ankle joint often compensate by using subtalar and midtarsal joints (results in pronation of everted rearfoot with flattened arch); pronated hypermobile foot can splay and cause problems (eg, clawtoe, bunions); supination—allows adaptation to ground; foot flattens and leg rotates internally; placing more pressure on outside of foot forms arch and leads to external rotation; patients who hyperpronate can develop knee problems; supination and pronation are normal motions
    Assessment: match history with physical examination, eg, consider claudication and vascular problems and check pulses in patients who must stop and rest after walking certain distance; burning type pain may indicate tarsal tunnel or neuroma; posterior tibial tendon dysfunction—posterior tibial tendon injury leads to flattening of foot (usually unilateral); check range of motion (patient needs greater than or equal to 75º of sagittal plane motion); patients with decreased motion likely to have arthritic problem; assess deformities (eg, bunions, clawtoe) and skin problems; important to determine whether patient’s foot structure allows too much motion or limits motion and shock absorption
    Heel pain: plantar fasciitis—pain at medial tubercle of insertion of plantar fascia (weakest point of plantar fascia); strain can occur in distal part of plantar fascia or middle of arch; pain directly under plantar aspect of heel may indicate bursitis or fat pad atrophy; medial burning pain likely to be nerve entrapment; fat pad atrophy—common in older patients; calcaneus palpable; heel cup or gel heel pad helpful for cushioning; pain increases with time spent on feet; tarsal tunnel—entrapment at tarsal tunnel area posterior to medial malleolus; dorsiflexing ankle and MTP joints helpful; plantar fascia provides static longitudinal arch support and involved in dynamic shock absorption; patients with foot problems usually have flat hyperpronated foot or high arch with tight plantar fascia; calcaneal spur—not usually factor in heel pain; pain due to microtears in plantar fascia from increased stress; study found 125 of 425 foot x-rays had calcaneal spur and only 10% symptomatic; fractured large spurs symptomatic; spur usually in horizontal position and does not press into soft tissue when foot pressed to ground; symptoms usually occur in morning and resolve during day
    Treatment: shoes—motion-control shoe for patients with hypermobile foot; cushioned shoe for patients with high arches and problems with shock absorption; recommend wearing clog-type shoe at home because walking barefoot can exacerbate symptoms; orthosis—maintains foot in neutral position where foot most efficient; rigid; useful in patients with hyperpronated foot; night splints—helpful for stretching and for patients with plantar fasciitis who have ankle equinus (lack of flexibility at ankle joint); taping—eg, plantar rest strap placed on lateral side along arch to support medial arch; helpful, but relief short-term; aerobic exercise, strengthening exercise, and stretching prevents lower extremity injury; patients who take nonsteroidal anti-inflammatory drugs (NSAIDs) should be advised to take them regularly; 90% of patients with plantar fasciitis improve with conservative treatment; in patients who have problems longer than 6 mo, consider surgery; plantar fascial release—releases 50% to 70% of fascia to remove tension; if patient also has nerve entrapment, release fascia from abductor hallucis muscle to take entrapment off first branch of lateral plantar nerve
    Paronychia: infection; hypergranulation (inflammatory response to irritation of nail growing into nail border); offending nail border must be removed; external factors include tight shoes and tight socks; nail must grow past nail groove; if nail cut too short, nail can grow past border and become entrapped; some patients prone to paronychia due to anatomy (eg, wide nail folds or incurvated nails); thickened nails due to onychomycosis can increase pressure; treatment— proper nail care; proper shoes and socks; cotton splint rolled up like cigar and placed into nail groove to push skin away from nail; cut nail (tissue must be pushed back so nail can grow past tissue); total nail resection removes structure that braces soft tissue down and can lead to clubbed-type nail and irritation of protruding skin; some patients may have ischemic problems, peripheral vascular disease, and pain; permanent nail procedures that use acid (eg, phenol matrixectomy) in patients with poor circulation can lead to serious burns that do not heal
    Bunions (hallux abducto valgus): occurs in patients with hypermobile foot; splaying of foot and medial deviation of first metatarsal results in buckling of first MTP joint; can lead to nerve irritation, overlapping of toes, and clawing of toes; weightbearing x-rays—recommended for viewing position of joints when foot in stance; not recommended in patients with trauma or soft tissue problems; less splaying seen on weightbearing x-ray; sesamoids act as sling underneath MTP joint and help flex toe down; when metatarsal drifts medially, tendons abduct toe and pull in lateral position and can worsen condition; treatment—sufficiently wide shoes; conservative treatment in patients with long history and doing fine; surgery reduces intermetatarsal angle by osteotomy and shifting bone over with soft tissue release to properly align toe; aggressive treatment for juvenile patients due to risk of developing compensatory problems
    Conclusion: many problems can be avoided with proper foot care and healthy lifestyle; replace shoes every 9 mo to 1 yr

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    BrotherMan's Avatar
    BrotherMan is offline Senior Member 511 points
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    interesting.....
    But when I start to feel that pull, turns out I just pulled myself-Weezer

    Ah, you don't want to deal with patients- Words of a wise pathologist

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