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Foot Problems

When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations that they are coming to me to complain about foot pain, plantar fasciitis? The foot is a complex weight.

 There re 28 bones and nearly 60 articulating surfaces, so there are a lot of inter-relationships going on between the different segments of the foot, the hind foot, mid foot and forefoot, and problems in one region can have manifestations elsewhere. So it is very important to recognize what the root cause of the problem is.

So when I think of the problems, I start to look at the structural malalignments that might be present in the patient’s foot, is the arch too high, is it too low? Is there some imbalance of the muscle forces that is causing that problem; or imbalance of those muscle balance forces driving the secondary manifestations. Also, as I talked about before, compensatory deformities. There could be a problem in the hindfoot, but the patient comes in to see you because there is a forefoot problem. That is where it hurts them, that is where it’s difficult for them to wear their shoes. So by way of the anatomy, the osteology of the foot.

There are the seven tarsal bones in the hindfoot region, we have that defined as the calcaneus, and the talus, that separates the hindfoot from the midfoot through the transverse tarsal joint. The remaining five tarsal bones are the middle, medial and lateral cuneiform, the cuboid bone, and the navicular. Then you enter into the forefoot which has the five metatarsal bones and the 14 phalanges. As you know, in the hallux, there are only two phalanges, whereas in the lesser toes, there are three, and then the two sesamoids that are under the first metatarsal head. Ligaments are important for static stabilization of the arch of the foot, both it’s longitudinal arch.

The spring ligament, if you look on the slide here, again we are looking up under the foot, here is the calcaneus, here are the metatarsals down here, the spring ligament is sort of a sling that runs from the calcaneus to the navicular, a sling for the arch and the medial aspect of the foot. The long plantar ligament is an important ligament for stabilizing the lateral border of the foot and then Lisfranc ligament, you may have heard about those in terms of people having foot dislocations, when the common location is through the Lisfranc joint, that is the joint that separates the midfoot bones, those five bones, the cuneiforms and the cuboid from the metatarsals, and there are strong ligaments on the plantar surface at that junction that helps stabilize.

Hallux valgus. So as we go through this section of the talk, we are going to try and think of these problems as their primary pathology and their secondary manifestations and that is going to drive how we treat these problems. This is going to be a situation where someone is going to present to you with a painful bunion. The medial eminence of their foot.

What is the primary pathology here; well the way that I see the problem with hallux valgus and have been taught to look at it, it is hypermobility at the tarsal metatarsal joint. That is the joint right about here, that’s the joint that separates the first metatarsal from the cuneiform, so the junction of the midfoot and the forefoot, and over time, as weight bearing occurs, you develop laxity here, so instead of this being a rigid stabilizer when the first metatarsal head strikes the ground.

Posterior tibial tendonitis - this can be an older person, male or female, probably more commonly female, she may tell you I have had this ankle sprain on the inside.

It hurts, it swells, they told me it’s arthritis, they told me it’s a bad sprain, it’s old age, but it’s hurting my, and oh by the way, I think I have been falling out of my shoes over the past few months, well this ankle pain hasn’t gotten better. Sometimes in severe cases, they complain of lateral foot pain; why? Because as this foot turns out.

Pes cavus, or the high arched foot. This is a problem that can come in many different presentations. In the most severe case, he walks into the examining room to see you, he is walking on the outer edge of his foot. In a severe case, he or she is almost like bow-legged, sort of like a cowboy, they have a lot of genu varum at the knee and they are walking on the lateral border of their foot. When you look underneath their foot, the have these thick, thick callouses.

Posterior heel pain - this might be a man or woman that presents to you with a painful pump bump, a bump on the lateral border of their heel just adjacent to the attachment of the Achilles tendon to the calcaneus. It can be just a bony prominence, it can be a red, hot swollen hot spot if they have been wearing shoes that have been rubbing on that, and exacerbated a bursa.

Plantar fasciitis. This is a person who has sharp, sharp pain, stabbing pain in the posterior medial aspect of their heel. They may give the classic story of, as soon as I get up to get out of bed to go take my shower and start my day, it’s like someone sticking a knife back here in my heel. Why does that happen? Well at night when you’re sleeping, your foot can droop down.

Peroneal tendonitis. This could be the person again that has a chronic ankle sprain that didn’t get better. What could be the problem there? Well, they may also say there is pain, there is swelling and on occasion when they put their foot in different positions, they get popping in the posterior lateral corner of their ankle. They may also have some limitation in plantar flexion.

Hallux rigidus. This person is going to come in with a very painful, stiff great toe. They may complain of a bump on the dorsal aspect, dorsal bunion over the MTP joint and they have a hard time with shoe wear. So what happens here, is there is accumulative trauma to that joint, increased joint stresses and here is an intraoperative picture showing you, here is the articular surface, there is that dorsal osteophyte that they complain about, there is that dorsal bunion that rubs in their show.

The diabetic foot. This is something that is a very significant problem, it leads to amputation, and in many cases over time, it leads to the patient’s mortality from their manifestation and their diabetic foot. This is the person that comes into your office with that stinking, smelling, nasty ulcer on the plantar aspect of the foot that has been there for a while, and they haven’t noticed it, but now the foot is starting to get red hot and swollen, and they are wondering what needs to be done about that. If you look at the x-rays and look at the foot, that ulcer is happening because there is an underlying deformity, neither the bone or the joint is putting increased pressure, increased forces on the skin and it’s broken down, so they man come to the office.