PODIATRY FOR PRIMARY CARE AMOPS 2015 CONFERENCE

PODIATRY FOR PRIMARY
CARE
AMOPS 2015 CONFERENCE
Jennifer A D’Amico, DPM
Asst. Prof. WUHS, College
of Podiatric Medicine
PODIATRY FOR PRIMARY CARE
You see what you know
PODIATRY FOR PRIMARY CARE
Weeding out
Simple from
Complex
Using a Team Based
approach
Physician Extenders
Physical Therapy
Prosthetics/Orthotics
Topics Include
Heel Pain
Ankle Sprains
Dermatology
Trauma
Overuse Syndrome
Diabetic Foot
Pediatrics
HEEL PROBLEMS
Plantar Fasciitis
Plantar Fibroma
Posterior Heel
Sever’s disease
Achilles Tendinopathies
PLANTAR FASCIA
 Strong Ligament
 Stabilizing to Medial Arch
 Originates-Plantar Tubercle
Calcaneus
 Inserts into Plantar Plate of
Digits
ETIOLOGY OF PLANTAR
FASCIITIS
Biomechanical
 Weight Gain/Loss
 Excessive STJ pronation
 Flat foot
 Cavus foot
 Normal foot
Proximal
Etiologies:
 Limb length discrepancy
 Ankle equinus
SIGNS AND SYMPTOMS
Post-static dyskinesia
 After-rest, painful motion
 Sleep or TV or Travel
Tenderness
 plantar fascia, esp. at plantar medial calcaneal
tubercle
Pain that Inc. with ankle digital
dorsiflexion
TREATMENT OF PLANTAR
FASCIITIS
Jbjs Vol 88-A No 8 2006 1775-81
PLANTAR
FIBROMA
CALCANEAL
APOPHYSITIS
(SEVER’S)
Achilles Force on
Open Apophysis
Children- Sports - Boys 10-12,
Girls 8-10
 High Impact Sports
 New Season
 Poor Shoe Gear
Pain
 Lateral COMPRESSION
 Relieved by Toe Walking
Treatment
Physical Therapy
Lower leg stretching on slant
board
 Hamstring to Achilles
Heel cups/ lifts
NWB Cast 1-2 Mm-Severe
ACHILLES TENDINOPATHY
Insertional or Mid-substance degeneration
Prevalence in Adults 2.35 per 1000
Athletic Population-18% of all injuries
Treatment
 Eccentric Exercise- 12 Week Program Alfredson et al 90%
Good Results
 ECSWT, Injection Therapy-PRP, Prolotherapy(hypertonic
glucose w/Lido), Laser Therapy
 Surgery
POSTERIOR ANKLE
Dancer’s impingement
 Ballet
 Techniques most at risk
 Relevé, Plié, Demi-plié
Sports/Activities
Nutcracker…
 Volleyball
 Basketball
 High Jump
PHYSICAL EXAM
Pain on Palpation of
Ankle Joint
 Palpate AM, AL, PM and
PL
 Diagnostic Injection in area
of Posterior Calcaneus
relieves pain
FHL Tendinitis A.K.A. Dance
Tendinitis
Pain is elicited when
Dorsiflexing the Great toe
ANKLE SPRAINS
Common Injury
 Sports, Hiking, Climbing, etc.
Protocol
 Offload-Ace Wrap VS Cam Boot
 Physical therapy
 Dec Pain, Inc Proprioception
When to refer to Podiatrist
 Multiple Ankle Sprains-Instability
 Likely Surgical, Failed PT etc.
Kenoshaorthopedics.com
ANKLE SPRAINS
Common Injury
 Sports, Hiking, Climbing,etc
Protocol
 Offload-Ace Wrap VS Cam Boot
 Physical therapy
 Dec Pain, Inc Proprioception
When to refer to Podiatrist
 Multiple Ankle Sprains-Instability
 Likely Surgical, Failed PT etc.
Kenoshaorthopedics.com
ANKLE SPRAINS
Common Injury
 Sports, Hiking, Climbing
Protocol
 Offload-Ace Wrap VS Cam Boot
 Physical therapy
 Dec Pain, Inc Proprioception
When to refer to Podiatrist
 Multiple Ankle Sprains-Instability
 Likely Surgical, Failed PT etc.
Kenoshaorthopedics.com
ANKLE SPRAINS
Common Injury
 Sports, Hiking, Climbing
Protocol
 Offload-Ace Wrap VS Cam Boot
 Physical therapy
 Dec Pain, Inc Proprioception
When to refer to Podiatrist
 Multiple Ankle Sprains-Instability
 Likely Surgical, Failed PT etc.
Kenoshaorthopedics.com
DERMATOLOGY
Onychocryptosis
(Ingrown Nail)
Etiology
 Improper Trimming
 Abnormal Nail-Plate
Trauma
Shoe gear
 Digital deformities
INGROWN TOENAIL
ANTIBIOTIC THERAPY
3 Groups (n=154)
with infected ingrown
A. Abx with chemical matrixectomy
B. Abx 1 wk then matrixectomy
C. Immediate matrixectomy
No decrease in healing time or
post- procedure morbidity
Healing times 1.9, 2.3 and 2.0
weeks respectively
Reyzelman et al. Are Antibiotics Necessary in the Treatment of Locally Infected Ingrown Toenails? Archives of Family Medicine.
9:930-932, Sept/Oct 2000.
INGROWN NAIL
Treatment
Partial avulsion
Partial matrixectomy
 Chemical
Surgical
OTHER NAIL CONCERNS
Mycotic
Pincer
Dystrophic
Ingrown
TINEA PEDIS ( ATHLETES FEET)
Etiology
 Hyperhidrosis
 Immunopathy
 Poor Hygiene
Types
Acute Inflammatory
Chronic Hyperkeratotic
TINEA PEDIS ( ATHLETES FEET)
Clinical/ Differential Diagnosis
Dyshydrosis
Erythrasma
Contact dermatitis
Hyperhidrosis
Candidiasis
Neurodermatitis
TINEA PEDIS ( ATHLETES FEET)
Treatment
Acute inflammatory
Wet to dry dressing
Chronic
Topical agent
Lotrimin
Lamisil
Loprox
Micatin
Tinactin
CONFOUNDING DERMATOLOGY
Dyshidrotic
eczema
Clear vesicles on a none
erythematous base
Nervous, hyperhidrotic
patients
More common in
summer months
Treatment
 Topical
Steroid Cream
FIRST MPJ PATHOLOGY
Types
Hallux Valgus ( Bunion)
Hallux Limitus/ Rigidus
Sesamoids
Sesamoiditis
Fracture
Osteochondritis
Flexor tendonitis
HALLUX VALGUS
 Etiology
 Hereditary
 Biomechanical
 Pronation
 Metabolic
 Traumatic
FIRST MPJ PATHOLOGY
Treatment
Shoe Modification
Orthotics
Rollbar
Surgery
MORTON’S NEUROMA
Commonly Female
Paresthesia plantar
forefoot
Pain reproduce by
palpation of IS
Mulder’s Click
MORTON’S NEUROMA
Commonly Female
Paresthesia plantar
forefoot
Pain reproduce by
palpation of IS
Mulder’s Click
MORTON’S NEUROMA
 Treatment
 Padding
 Injection
 Excision
LESSER METATARSAL DISORDERS
Metarsalgia/Capsuli
tis/Bursitis
Treatment
 Tapping/Strapping
 Immobilization
 NSAIDs
 Injection
 Orthotics
STRESS SYNDROME
Etiology
Mechanical
Pronation
Constant low grade stress
Anatomical
Limb Length Discrepancy
Poor Foot Alignment
www.healthychildren.o
TRAUMA
TRAUMA
DIABETIC FOOT EXAM
Yearly, Now by PCP
Derm:
 Dry Skin-Leads to Infection
 Hypertrophic-Skin Breakdown
Vasc: Poor Perfusion-Poor Healing
Neuro: No Sensation- Unseen
Damage
MSK: Deformities- Pressure
To Prevent
DIABETIC FOOT EXAM
Yearly, Now by PCP
Derm:
 Check Turgor, Texture
Vasc:
 DP/PT Pulses, CFT, Atrophy signs
Neuro:
 Light touch, vibratory, Semmes-Weinstein
MSK:
 Joint ROM, irritation points.
To Prevent
PEDIATRICS
Flat foot
Club foot
Brachymetatarsia
Juvenile bunion
PESPLANOVALGUS
Rigid
Tarsal Coalition
 Vertical Talus
 Arthrogryposis

Flexible
 Lig. Lax
 Hereditary
 Anatomic
 Syndromal
PES PLANOVALGUS
Rigid
Tarsal Coalition
CN>MFSTJ>TN
Vertical Talus
Genetic Abnormalities
Trauma
Evaluation
Stress XR, CT
Resupination, ROM

PESPLANOVALGUS
Surgery-
Pain/Behavior Chngs despite all
conservative Methods
Being Carried
Pes Plano Valgus
can be physiologic spontaneously
resolve?
Ankle Medial to Foot
PES PLANOVALGUS
Non Surgical
Orthoses
Custom Shoes
Monitoring
99% >>25%
Surgical
Fusions/Realignment/Soft Tissue
ARTHROERESIS
12y M
Preop
3m post
op
CLUBFOOT
1st
5th
Ponseti.info
NEGLECTED CLUBFOOT
CLUBFOOT
BRACHYMETATARSIA
Etiology:
Premature closure of epiphyseal
plate
Trauma
Tumors
Prevalence:
F > M
BRACHYMETATARSIA
Treatments
Benign Neglect
Acute Correction
Gradual Correction
Surgery usually held until
physis is closed.
BRACHYMETATARSIA
JUVENILE HAV
EtiologyAnoxic-CP
Hereditary
Chromosomal-T21
Female > Male
Frequently Associated with
Pes planovalgus
Ted Nissen
JUVENILE HAV
Surgical Tx
Wait until skeletal maturity
If Patient having pain refer
to Surgeon
LATERAL HEMIEPIPHYSIODESIS
(LHE)
Guided
Growth-
1st Described in
knee, initially for
Blount’s Dz
Growth charts
(Nelson’s), skeletal
age, length
JHAV
Together we can climb Mountains
Thank You
Any
Questions?
REFERENCES
1.
Plantar Fascia Specific Stretching... J Bone Joint Surg Am, 2006 Aug; 88 (8): 1775 -
1781 .
2.
Heavy-load eccentric calf muscle training for the treatment of chronic Achilles
tendinosis. Am J Sports Med. 1998 May-Jun;26(3):360-6.
3.
Calcaneal apophysitis (Sever disease) CLHendrix Podiatr Med Surg22 (2005) 55– 62
4.
Effectiveness of Orthotic Devices in the Treatment of AchillesTendinopathy: A
Systematic Review Sports Med (2015) 45:95–110
5.
Isolated Gastrocnemius Recession for AchillesTendinopathy: Strength and Functional
Outcomes Nawoczenski DA et al JBJS-Am 2015;97:99-105
6.
Management of the Ingrown Toenail Heidelbaugh JJ, Lee H AFP 79;4 303-308
7.
Reyzelman AM, Trombello KA, Vayser DJ, ArmstrongDG, Harkless LB. Are antibiotics
necessary in the treatmentof locally infected ingrown toenails? Arch FamMed.
2000;9(9):930-932.
8.
CAN CUSTOM-MADE BIOMECHANIC SHOE ORTHOSESPREVENT PROBLEMS IN THE BACK
AND LOWEREXTREMITIES? A RANDOMIZED, CONTROLLEDINTERVENTION TRIAL OF 146
MILITARY CONSCRIPTS Larsen K et al 2002 Journal of Manip and Physio Therap Vol
25;5 327-331
REFERENCES-PEDIATRICS
1.
Morrissy, RT. Weinstein SL Lovell and Winter’s Pediatric Orthopedics LWW, 2006 6th Ed Chap 28
2.
Labovitz, JM Pediatric Foot and Ankle Disorders, Clin Pod Med Surg 23(1) 2006
3.
Herzenberg, JH Lamm B Pediatric Foot Deformities Balti Limb Def Course 2008
4.
McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery LWW, 2001 3rd Ed Chap 19, 26,27
5.
Thomson P, Volpe R Introduction to Podopediatrics Churchill Livingstone , 2001 2nd Ed
6.
Kirienko A, Villa A, Calhoun JH Ilizarov Technique for Complex Foot and Ankle Deformities Taylor & Francis Boca Raton, Fl
2004
7.
Rubin Institue Survival Guide, RIAO 2009
8.
www.emedicine.com
9.
Jay, RM Pediatric Foot and Ankle Surgery Philadelphia, PA 1999
10.
www.bioretec.com
11.
"sucking reflex." Encyclopædia Britannica. 2010. Encyclopædia Britannica Online. 29 Sep. 2010
<http://www.britannica.com/EBchecked/topic/571333/sucking-reflex>.
12.
Rotational profile exam Zadeh.co.uk
13.
Winfssi.com
14.
Wheeles’ Textbook of Orthopedics, 2010
15.
Pediatric Exam, best practice.bmj.com
16.
Reflexes, movementandlearning.com.au