Common Disorders of the Foot & Ankle

Common Disorders of the

Foot & Ankle

Lee Wittenberg, DPM

Apache Foot & Ankle Specialists

(702) 362-2622

Foot and Ankle Anatomy

• The foot and ankle are very complex structures,

without which we would not be able to walk, run,

or perform common activities of daily life.

• A combination of 28 bones, 33 joints, 112

ligaments, and a network of tendons, nerves,

and blood vessels all work together for proper

foot function.

• Pathology can occur at any of these levels.

Bones of the Foot & Ankle

Muscles and Tendons of the Foot

and Ankle

Skin and Nail Disorders

• Corns and Calluses

– Caused by shear forces and pressure due to

the skin getting trapped between a boney

prominence (such as a hammer toe or a

bunion) and the shoe or the surface you are

walking on.

– Also called ‘Hyperkeratosis’ (a build up of the outer Keratin layer of the skin)5


Treated by debridement (trimming by your

Podiatrist), Creams, callus files and

pumice stones, and sometimes by surgery


• Onychomycosis (Fungal Toenails)

– Dermatophytosis of the toenails.

– Fungus is a micro organism that may invade the skin or toenails.

– Fungus thrives in warm, moist, dark places. Our shoes are a perfect environment for fungus to grow.

– Causes thickening, dystrophy (changes in shape) and yellow, brown, or black discoloration of the nail plate.


• Onychomycosis is treatable with oral

antifungal medications, topical

medications, or permanent removal of the

nail plate.

• Oral medication may be contraindicated

with certain medications and medical

problems.


• Tinea Pedis (Athletes Foot)

– Caused by similar dermatophytes that cause

Onychomycosis.

– Much more easily treated with topical

antifungals.

– Severe cases may require oral therapy.


• Paronychia (Infected, Ingrown Toenail)

– When a nail grows into the nail fold, the body sees it as a ‘foreign body.

– An immune response develops, and the skin around the nail becomes red, swollen, and very painful in shoes or to the touch.

– A small abscess may form, and pus may develop.

– May be caused by tight shoe gear, pedicures, improper cutting of nails, or genetics


• Paronychia

– Treated by excision of the offending nails

spicule, antibiotics and ointments, and

soaking.

– A permanent procedure may be done for

repeated problems.


• Verruca Plantaris (Plantar Warts)

– Caused by an infection by the Human

Papilloma Virus (HPV)

– Lives in the deepest layers of the skin before

the layer of subcutaneous fat.

– The virus recruits your body’s own blood vessels to nourish itself.

– Rarely may undergo malignant

transformation.


• Sometimes very stubborn and difficult to

treat.

– Debridements with application of acids and

other chemicals (may require multiple

treatments)

– Debridement with freezing or burning. May

be done with lasers.


• Cracking and Fissuring of the Skin

– Caused by Hyperhidrosis (excessive

sweating) and excessive soaking of feet.

– The skin gets dried out from too much water

causing it to split, crack, and fissure.

– May cause bleeding and may be an entry

point for bacteria, which may lead to a serious

infection.


• Treated with agents to decrease sweating,

special creams with enzymes or acids to

soften the skin, and debridements and

filing.

Tendon and Ligament Disorders

• Tendons and ligaments are made of more

dense and less vascular tissue. When

they are injured, it may take longer for

them to heal due to their lower blood

supply and to constant stress put on them

by walking and normal function.

Tendons and Ligaments

• Plantar Fasciitis (‘Heel Spur Syndrome’) – Inflammation at the insertion of, or along the

course of the plantar fascia.

– The Plantar Fascia is a long ligament that

runs across the bottom of the foot from the

heel to the ball and is one of the main

supports for the medial arch.

– Intimately associated with the achilles tendon


• When the arch collapses, the plantar

fascia tightens like a rubber band. This

causes inflammation and irritation, usually

at the heel, but may occur anywhere along

the course of the ligament.


• Symptoms of plantar fasciitis usually

include pain with the first step in the

morning, after periods of rest, and

eventually radiating up the back of the

ankle and leg.


• A heel spur may occur secondary to the

inflammation around the periosteum

(covering of the bone), but is not the cause

of the pain.


• Treatment of Plantar Fasciitis includes injections with local steroids (cortisone type medications), oral anti-inflammatory drugs, strappings of the foot by your Podiatrist, stretching, ultrasound, physical therapy, orthotics (arch supports), and in very rare instances, surgical intervention.

• Surgery is only indicated after 7-9 months of failed conservative care.


• Ankle Sprains

– There is a set of ligaments on the inside and outside of your ankle. The ligaments on the outside of the ankle are much weaker, and more susceptible to stretching or tearing when you have an ankle sprain.

– >15-20% of ankle sprains result in Ankle Fractures. If you can not immediately walk on your ankle after a sprain, seek medical attention ASAP.


• Treatment of Ankle Sprains involves

R.I.C.E. (Rest, Ice, Compression, and

Elevation) therapy. Immobilization is

recommended for severe ankle sprains,

and Physical Therapy is often utilized.

• Ankle Fractures are unstable

and often require surgical

intervention.


• TENDONITIS is a common pathology.

• There may be inflammation surrounding a tendon (peritenonitis), of the tendon itself (tendonitis)

• Tendonitis may come from strain on the muscle and tendon, improper function of the foot and from systemic diseases.

• May cause attenuation (stretching) of the tendon, weakening, damage to the substance or an entire segement of the tendon, scarring and thickening, or even tears or complete rupture of the tendon.


• Most Common types of tendonitis

– Achilles Tendonitis

– Posterior Tibial Tendonitis

– Peroneal Tendonitis


• Tendonitis is treated with Immobilization and R.I.C.E. therapy.

– Immobilization may be prolonged, as tendons have very poor vascularity and tend to heal more slowly.

– An MRI or Diagnostic Ultrasound may be utilized to evaluate tears or ruptures of a tendon if symptoms do not subside.

– Surgery may be required to repair ruptures or tears.


• Treatment of tendonitis starts with

immobilization in a cast or walking boot

and compressive bandages. It is essential

to relieve the tension and strain of the

tendon, and staying off of the foot as much

as possible is essential.


• If immobilization does not alleviate the problem, an MRI will be performed to examine the extend of the damage and to evaluate tears or ruptures.

• In extreme cases, surgery is required to repair or augment the tendon with grafts or transfers of other tendons to regain the function the tendon/muscle is responsible for.

Nerve Disorders

• Neuritis-inflammation of any nerve in the body.

• Neuroma-inflammation of the intermetatarsal and interdigital nerves.

• Tarsal Tunnel Syndrome-Similar to carpal tunnel.

• All are secondary to impingement or constriction of a nerve which causes inflammation and irritation.

Nerve Disorders

• All are treated conservatively with local

steroid injections and compressive

bandaging to alleviate the impingement

and inflammation.

• Surgical Decompression or Chemical

Neurolysis (destruction of a nerve using

certain medical agents) may be necessary

• May leave areas of numbness.

Nerve Disorders

Symptoms of Nerve Pain include

Numbness, Tingling, and Burning Pain

Bone and Structural Problems

• Most Common structural problems are

Bunions, Hammer Toes, and Flat Foot

deformities.


• Many structural deformities are caused by muscle imbalances.

• Once a deformity is set in motion, it may be possible to slow the progression with a good pair of orthotics, but it is almost impossible to stop.

• Surgical intervention is usually required to correct these deformities when they are symptomatic.


• Fractures

– Usually from traumatic injuries.

– People with Osteoporosis or certain diseases may be

prone to get fractures with very little trauma or force

– Stress fractures may occur from repetitive, normal

every-day activity.

– Some fractures will heal with immobilization, but more

unstable fractures require surgical correction with

screws, plates, and fixation devices


• Stress Fractures may not show up on x-

ray for several weeks and may be difficult

to diagnose.


• Arthritis

– Osteoarthritis- “Wear and Tear Arthritis” Occurs from normal function, with repetative

impact and trauma to the cartilage. As the cartilage degenerates, the bones begin to rub against each other and cause inflammation, pain, joint narrowing, and build up of extra bone around the joint.

Creates pain, stiffness, and difficulty with ambulation, activities, and shoe gear.


• Osteoarthritis-Treatment includes

injections, anti-inflammatory drugs, joint

clean-up, replacement, and joint fusion.


• Treatment


• Rheumatoid Arthritis (RA)

– An auto-immune disease (a disease in which

your own body produces antibodies against

itself) in which the lining of the joint grows out

of control. This releases enzymes that

degrade the cartilage and loosen the joint

capsules and ligaments around the joints.

– This causes pain, inflammation, and severe

deformities of the hands and feet.


• Rheumatoid Arthritis


• Treatment of RA

– DMARDS (Disease Modifying Antirheumatic

Drugs)

– Anti-Inflammatory Drugs

– Bracing and custom made shoes

– Joint destructive and joint replacement

surgical procedures

Conclusion

• The Foot and Ankle are complex structures and

many things can occur which will cause you pain

or give you difficulty with ambulation and

activities of daily living.

• If you have persistent pain, see your Podiatrist

before you end up with a more serious and

difficult problem. The longer you are in pain, the

harder it may be to get rid of!

Lee Wittenberg, DPM

• Apache Foot & Ankle Specialists

4840 St. Fort Apache Rd., Ste.

101

2980 St. Rose Parkway, Ste. 140

(702) 362-2622

www.apachefootandanklespecialists.com

Common Disorders of the Foot & Ankle

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