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The Most Common Podiatric Complaints in the Primary Care Setting
The Most Common Podiatric Complaints in the Primary Care Setting. When to treat, and when to refer. Elizabeth Plovanich DPM, AACFAS November 13, 2013 GIM conference Purpose of the lecture We will discuss• common podiatric complaints • first line treatments for the most common complaints • imaging- what kind and when to get it • when to refer to podiatry Heel Pain • The most common complaint that brings people into the Podiatrist’s office • About 30% of my total patients in one day Heel Pain • Typical complains – – – – “Doc, my feet hurt. I’ve done everything” “I’ve spent so much money on shoes and inserts…” “The first step out of bed in the morning is a killer” “My heels are on fire!” – Heel and/or arch pain – May be bilateral but more likely unilateral • it started unilateral and is now bilateral – 1-12 month duration – Sporadic use of NSAIDs, changes in shoes, OTC inserts and cessation of athletic activities Heel Pain • Inflammation occurs at • • the insertion of the plantar fascia and the plantar calcaneal tuberosity. Repeated activity and chronic inflammation causes micro-tears in the fascia. Micro-tears cause inflammation and......the vicious cycle repeats. Heel Pain • First line treatment – Focus on mechanical causes of plantar fasciitis – Allow the plantar fascia to repair itself – Treat inflammation – Use at home physical therapy techniques Heel Pain • 6 steps to treat PF – Good supportive athletic shoes • Asics, New Balance, Brooks, Saucony • 24/7 unless in the shower or in bed • NO BAREFOOT! (Barefoot means barefoot, socks, slippers, flip flops, crocs etc) – Inserts • Gel heel cups • Superfeet, Power-steps • If you can bend the insert in half, it is not a good insert (ie a Dr Scholl’s gel insert) Heel Pain – Ice • 2-3 times a day with a frozen water bottle – Stretching • Equinus deformity is a • large contributing factor to plantar fasciitis 2-3 times a day stretching calf muscles, hamstrings and plantar foot Heel Pain – Rest • Avoid all high impact activities until pain begins to resolve • Then increase activities 15-20% per week – NSAIDS • 4 week course • Use for anti-inflammatory benefit not the pain reduction. – Naproxen, Feldene Heel Pain • Imaging – It is NOT the heel spurs fault – The heel spur is the result of chronic plantar fasciitis • We do not remove the heel spur- it destabilizes the foot Always order weightbearing films An MRI may be considered after 6 weeks of conservative treatments have failed Heel Pain • Refer when the previous treatments do not provide relief in 6 weeks • What we can offer – – – – – – – – – – – – – – Cortisone injections Taping applications Night splints AirCast Immobilization Fiberglass Immobilization Therapeutic Ultrasound Iontophoresis Referral for formal physical therapy Temporary orthotics Custom orthotics OTC Bracing Custom Bracing PRP study Surgery Ingrown Toenails and Paronychia Ingrown Toenails and Paronychia • Usually caused by– Narrow shoes – Trauma-sometimes insignificant – Athletics – Incorrect trimming of toenails – “Bathroom Surgery” – Genetics – Compression Hose Ingrown Toenails and Paronychia • Treatment – Antibiotics may or may not be necessary – Keep the toe clean and covered – Epsom salt soaks twice daily Refer for I&D or Matrixectomy • Please don’t do this Ingrown Toenails and Paronychia • • • • 50 year old male Treated for 8 months 3 attempted I&D 3 courses of antibiotics • High risk for osteomyelitis Ingrown Toenails and Paronychia • Incision and Drainage – – Most rapid relief of pain and resolution of infection Nail will grow back unchanged • Matrixectomy – – – – – Permanent removal of incurvated nail border 3-4 week healing time Can be done for nail borders or total nails Uses 89% phenol to deaden nail matrix Has approximately 5% chance of failure when done in the presence of infection • Surgical Procedures – Done in the OR when traditional office procedures have failed. • Winograd Ingrown Toenails and Paronychia • Imaging – X rays, 3 views with a raised hallux on the lateral view, should be done if the paronychia has been present for more than 3 months – MRI used infrequently- only if osteomyelitis is suspected Onychomycosis • Complaints – Hard, thick toenails • “My toenail clipper doesn’t work anymore” – Painful in shoe gear – Unable to trim toenails due to hip replacement, body habitus, loss of eyesight, arthritis, etc. – Infection from elongated nail growing into the distal toe, or ulceration of the nail bed from shoe pressure Onychomycosis • Treatments – Routine debridement • Manual and Mechanical • • debridement Only Diabetics with vascular compromise & peripheral neuropathy and non-Diabetics with Severe Arterial Insufficiency are covered by Medicare for debridement every 62 days Onychomycosis alone is not enough to get the debridement covered Onychomycosis • Treatments – Topical treatments- 2040% success rate • Less success with more • • • • nails involved and the extent to which each nail is involved Vick’s Vapo Rub White vinegar Tee Tree Oil Antifungal creams, lotions, paints, sprays etc. Onychomycosis • Treatments – Oral treatments- 50-80% success rate • Less success with more nails • • • • involved and the extent to which each nail is involved Taken for 3 months and then pulsed if more treatment is needed 50% recurrence rate at 2 years Antifungal creams, lotions, paints, sprays etc. should be used in combination ALT, AST, CBC with diff should be drawn at the beginning and mid way through the treatment to monitor liver enzymes. Onychomycosis • Treatments – Laser treatments • Closest centers in Sauk • • and Milwaukee Expensive and not covered by insurance Success rates are variable – Total Matrixectomy • Permanent toenail • removal 4-8 weeks healing time – Longer in elderly and diabetics Plantar Warts • Casues – Verruca virus – May be a result of a small puncture type trauma to the plantar foot – May or may not be painful depending on the weightbearing location – Warts can enlarge rapidly – May or may not spread on the affected foot or the contralateral foot Plantar Warts • Treatments – OTC preparations/At home treatments • Duct tape • Mediplast- tape • Compound W etc.- sal acid – “Low and Slow” method- usually takes 3 months can take a year – Liquid or patch form – Cryotherapy • Less effective on glabrous skin – Chemocautery • Cantherone liquid-Blistering agent • “Fast and Furious” Method • Usually done in combination with 5FU, mediplast etc • Treatments are done every 2 weeks – Treatments cause painful blistering and skin slough – Laser ablation • Refer to Dermatology if 4 chemocautery treatments are not showing progress – Excision • Done for the most recalcitrant cases Plantar Warts • Imaging – Not necessary – Refer when the OTC/topical treatments or Cryotherapy have failed or when more rapid treatments are desired. Thank You • Questions?? • Feel free to contact me with any questions – University Podiatry Associates – 608-831-8086 – [email protected]
