Chapter 223: Management of Select Podiatric Conditions

INTRODUCTION

Socrates once said “To him whose feet hurt, everything hurts.” Patients with foot pain and deformities are commonly seen in the Emergency Department complaining of compromised mobility. The decreased mobility causes a decreased quality of life. The frequency of these disorders increases with age. This chapter addresses common presentations and procedures for the management of the painful foot. Numerous other podiatric procedures (e.g., local anesthesia, ingrown toenails, plantar warts, puncture wounds, toe fractures, ganglionic cysts, neuromas) are discussed in other chapters of this book.

The foot is divided into the forefoot, midfoot, and hindfoot (Figure 223-1).^1-3 The forefoot is composed of the five metatarsals and the phalanges. The great toe has two phalanges and each of the remaining toes has three phalanges. The forefoot is important in normal gait. The gait consists of a heel strike, forefoot contact, heel lift, peak forefoot loading with metatarsophalangeal joint extension, and toe lift. The first metatarsal bears a large force during walking and running. The first metatarsal supports the longitudinal arch of the foot. The great toe provides stability during forefoot loading. The great toe is involved in the biomechanics of walking. The bones of the midfoot and hindfoot are referred collectively as the tarsus. The midfoot comprises the cuboid, cuneiform (i.e., medial, intermediate, and lateral), and navicular bones. The hindfoot is composed of the talus and calcaneus. These bones are stressed during walking and running.

Foot injuries are very common. The chief complaint of foot pain often is followed by the clinical examination and radiologic imaging. A detailed knowledge of imaging anatomy is essential for an accurate diagnosis of an injury and to avoid missing an injury. The radiographic superimposition of the midfoot and hindfoot can make the identification of injuries difficult. These injuries are commonly missed during the clinical examination and subsequent imaging.

MANAGEMENT OF PLANTAR LESIONS

INTRODUCTION

The skin on the sole (i.e., plantar surface) of the foot is the thickest skin on the entire body. It is adapted to protect the internal structures from environmental demands. A 150-lb person has dissipated 60 tons of force with each foot after walking a mile.⁴ Hyperkeratosis (i.e., callosity) occurs when the process of keratinization becomes overactive due to shearing forces and pressure points over bony prominences (Figure 223-2). This is a normal protective response as the body attempts to protect the irritated skin. It may be seen on the hands of a laborer or on the plantar surfaces of feet in those who walk barefoot. A vicious cycle begins over time. The hyperkeratotic area becomes prominent, increases the pressure in a tight shoe, produces ...