Evaluation and Treatment ofCommon Podiatric Problems
Author: Ronald L. Valmassy, DPM, Professor and Past Chairman, Department of Podiatric Biomechanics, California College of Podiatric Medicine, San Francisco, CA; Staff Podiatrist, Center for Sports Medicine, Saint Francis Memorial Hospital, San Francisco, CA.
Peer Reviewers: Len Scarpinato, DO, Program Director, Racine Family Practice Residency, Racine, WI; Stephen A. Weeber, DPM, FACFAS, Ankle & Foot Center, Kettering, OH.
Editor’s NotePodiatric disorders are among the most widespread and neglected health concerns affecting the population of the United States. Although it has been estimated by the American Podiatric Medical Association that more than 75% of all Americans will experience foot problems of some type during the course of their lives, most will not seek medical attention.1 (See Table 1.) This is due to the fact that most individuals neglect their feet and consider foot pain and discomfort to be a naturally occurring situation. Over the past several years, the importance of recognizing and treating disorders of the lower extremities has become more essential as more and more individuals attempt to improve their quality of life by participating in regular health and fitness programs. Unfortunately, this quest for fitness has led to a high number of podiatric problems. Additionally, as the number of older Americans is increasing (approximately 3 times as fast as the population as a whole), the overall type and number of potential foot disorders has begun to increase. Conversely, one must recognize the presence of a host of lower extremity conditions present in the pediatric and adolescent population, which not only are evaluated and treated in a different fashion than many of the conditions affecting the adult population but, if recognized early, may preclude the development of more debilitating problems in adulthood.
Although there are countless ways of presenting the various conditions affecting the lower extremities, for the purpose of this paper, they will be presented via the following categories: musculoskeletal, sports injuries, pediatric, and dermatological. In this fashion, the majority of the common problems affecting the feet may be presented. Although it will not be possible to cover each area in great depth, the hallmarks of the evaluation, diagnosis, and treatment of the most common anomalies in each category will be presented.
Although most foot problems are exacerbated and aggravated via improperly fitted shoes and increased levels of activity, there is typically a biomechanical or functional component that significantly influences the overall onset and severity of each of the following conditions. The increased incidence of certain lower extremity conditions that are noted in some families is attributable to the fact that family members typically inherit their foot problems because they inherit the family’s particular biomechanical makeup and locomotor function. It is for this reason that at least a cursory evaluation of a patient’s gait pattern should be performed whenever dealing with the common musculoskeletal problems occurring in this section. When a child initiates ambulation at approximately 12 months of age (normal range, 9-16 months), his foot is "fat, flat, and floppy" with a moderate heel valgus and a normally everted calcaneal stance position of approximately 7-8°.2 Additionally, the standing and walking pattern is of marked abduction with a wide base of gait and full foot contact with each successive step. By the age of 3 or 4, there should be an initiation of a heel-to-toe type of gait pattern. By 14 years of age, all transverse plane deformities (e.g., femoral and tibial torsion) should be outgrown.3 Normal adult ambulation is characterized by lateral heel strike due to the normally occurring tibial varum or inherent bowleggedness that the majority of individuals possess (this is what causes the outer one-third of the heel of a shoe to wear). Upon heel contact, the foot initially moves through a motion of pronation or flattening. This is accomplished via movement of the subtalar joint, which is composed of the talus and calcaneus. This normal amount of pronation occurs through the initial 25-30% of the stance phase of gait and is considered to function as the body’s inherent shock absorbing mechanism. This initial pronation is responsible for allowing internal rotation of the tibia, which subsequently allows the knee to flex, thereby cushioning each foot fall.4 This initial movement dampens approximately 125% of our body weight with each heel strike while walking and up to 3.6 times body weight with running. Once this movement occurs, the midtarsal joint (comprised of the talonavicular and calcaneo-cuboid articulations) unlocks to allow the foot to assume its "mobile adaptor" role to allow the foot to conform to the irregularities of the underlying surface. At this point, the degree in velocity of the initial pronation ceases, and the function of the foot changes to that of a "rigid lever" in order to propel one onto his next walking or running step. It is in instances when this normal heel contact pronation is increased either in degree or duration that a host of foot and leg problems increases dramatically.
Bunions (hallux abducto valgus). Although these deformities are often related to stylish or improperly fitted shoes, one need only review the incidence of bunion deformities occurring in non-shoe wearing populations to appreciate the biomechanical influence on this condition. Characterized by pain, redness, and edema overlying the medial eminence of the first metatarsal head, the deformity is progressive in nature and develops through four stages, which may be clinically and radiographically evaluated (see Table 2).4 Other bunions are located on the dorsum of the first metatarsal phalangeal joint and are typically associated with a marked limitation of joint flexibility and motion. Although these are typically associated with abnormal foot mechanics as well, this problem may be attributable to a previous traumatic episode ultimately leading to an underlying degenerative joint disease process.5 Finally, some juvenile bunions have an underlying congenital structural defect that will allow the condition to be clinically noted from the age of 3 or 4. When combined with abnormal foot mechanics, this deformity will likely be quite significant by the time the youngster reaches adolescence. Further, young girls participating in ballet with juvenile bunions should not be encouraged to perform early pointe work, as this would markedly increase the progression of the deformity. Initial treatment for bunion deformities may be provided via recommendations for shoes with a wider toebox and lower heel as well as the use of foam toe spacers to maintain the hallux in a more appropriately aligned position. The use of over-the-counter or prescription foot orthoses is often beneficial in improving the mechanics of the joint and decreasing symptomatology. A foam or one-eighth inch adhesive felt aperture pad may also prove beneficial in relieving some of the associated soft-tissue inflammation.6 If marked inflammation is noted, a corticosteroid injection may be beneficial in reducing the symptomatology precipitated by an associated bursitis. When deformity or symptomatology progresses, surgical intervention is advisable in order to re-establish a more normal joint configuration and function. In these cases, consideration must be given to greater than 100 different bunion procedures and modifications that may be used to achieve the optimal result.7
Tailor’s Bunion. A tailor’s bunion is a painful enlargement or prominence of the fifth metatarsal head. The pain is generally precipitated by the sheering forces of the shoe just as in a hallux abducto valgus deformity. In this instance, an adventitious bursa may be precipitated, increasing the overall discomfort. In that this deformity is similar to a hallux abducto valgus deformity, treatment is generally the same and includes changing to wider shoes, padding the involved area with an aperture pad, injecting a corticosteroid to decrease symptomatology of an inflamed bursa, or prescribing orthotic devices to decrease abnormal foot function, which typically exacerbates the condition.8 In cases where the deformity persists, resection of the lateral aspect of the fifth metatarsal head or performing a metatarsal osteotomy becomes an appropriate consideration.
Hammertoes. This represents the dorsal contraction of a digit. Although this may occasionally affect the hallux, it most typically affects one or more of the lesser digits. This deformity is generally associated with abnormal foot function, leading to excessive flexing and clawing of the toes, which ultimately become fixed in this flexed and rotated varus position.4 Additionally, long-term wearing of improperly fitted shoes will also cause the deformity to occur. The typical pain associated with this condition occurs when a hard (heloma dura) or soft (heloma molle) corn is formed. The dorsal hard corns are a source of discomfort with most shoes and may often lead to marked disability. Initial treatment includes palliation via debridement and padding of the area as well as an alteration of shoes or stretching of existing shoes. The use of lambswool or cotton aperture pads is also beneficial. A soft corn typically occurs between the fourth and fifth toes or, in some instances, the hallux and second toe. The lesion in the fourth innerspace is typically precipitated by improperly fitting shoes or the presence of an underlying spur on one of the digits. This lesion may be confused with a tinea pedis infection due to its macerated appearance and will not improve with the use of topical antifungal agents. Oftentimes, this condition will ultimately develop into a significant infection with an associated cellulitis. In these instances, aggressive treatment via oral or IV antibiotics will be necessary along with the aforementioned debridement and padding. The likelihood of this occurring seems to increase in those instances where individuals use over-the-counter acid preparations to remove the accumulated hyperkeratotic tissue, especially if used interdigitally.
In instances where symptomatology is not arrested via conservative measures, surgical intervention may be suggested. With flexible contractures, successful resolution of symptomatology may be achieved via a tenotomy, while a more rigid fixed deformity would be more appropriately addressed via arthroplasty or arthrodesis. In cases in which the individual’s excessive toe length may be an associated finding, the latter two procedures typically prove more effective.
Neuroma. This deformity is characterized by pain and discomfort located primarily in the third interspace. The next most common locations in order are the second, fourth, and first interspaces. The patient will note a burning paresthesia that typically radiates to the adjacent digits. Additionally, numbness may be an associated finding. The pain is typically relieved by massaging the affected interspace or by removing shoes. The symptoms increase with athletic activity, weightbearing, or tight shoes and are typically associated with mechanical abnormalities. From a functional perspective, the first three metatarsals, articulating with their respective cuneiforms, should be considered as one functional unit, while the fourth and fifth metatarsals, which articulate with the cuboid, act as another. Excessive movement between these two segments is typically precipitated by abnormal rearfoot and midfoot pronation.8 This typically contributes, at least in part, to the formation and exacerbation of the condition. Although radiographic evaluation may be helpful in delineating abnormal metatarsal head shapes and positioning, the neuroma itself is not visible. Magnetic resonance imaging may prove beneficial in cases where multiple neuromas are suspected. Treatment recommendations include wider shoes and shoe padding to spread the involved adjacent metatarsal heads. A series of 2-3 cortico-steroid injections (e.g., 1.5 cc 2% lidocaine plain with 0.5 cc dexamethazone) over a 4-6-week period often proves successful. These should be administered from the dorsal aspect of the involved interspace. Prescription orthoses to decrease abnormal foot motion are also quite effective. In cases of unremitting or increased discomfort, surgical excision of the involved portion of nerve is recommended.
Heel Pain (Calcaneal Spur/Plantar Fasciitis). This condition is characterized by pain that is present at the plantar medial aspect of the calcaneus at the level of the medial tubercle. The symptoms are often described as an ache or soreness and are typically present upon arising in the morning or following periods of rest. Symptoms may be present with marked activity or exercise. The pain may be associated with inflammation of the plantar fascia at its attachment to the calcaneus or with the proliferative periosteal reaction that often occurs as the spur is formed. Excessive tension directed to the area is demonstrated in cases of excessive calcaneal eversion with foot flattening wherein the plantar fascia becomes chronically stretched. Conversely, a highly arched, supinated cavus foot type in which the plantar fascia is markedly taut and contracted may also lead to this deformity. Lateral radiographs may or may not demonstrate spurring regardless of the level of the symptoms. Minimal periosteal involvement may be noted initially, with more obvious spur formation noted on subsequent films. Although the most common causes of heel spur syndrome are mechanical, the differential diagnosis includes several different pathological conditions (see Table 3).9 Aggravating factors include obesity or recent weight gain along with increased athletic activity or a change in foot gear. In that the most common types of heel pain are associated with mechanical problems, treatment is generally directed toward this area of management. Initial treatment may include changing shoes to a more supportive athletic type of shoe. Additionally, taping the foot into a supinated position or using over-the-counter or prescription foot orthoses proves quite effective in decreasing symptomatology. The administration of corticosteroid injections (2-3 injections over a 4- to 6-week period) may also be indicated. The use of physical therapy including electrogalvanic stimulation, ultrasound with iontophoresis, and deep-friction massage are also beneficial. Finally, the use of a posterior night splint with the foot maintained in a dorsiflexed attitude of approximately 5-10° proves quite beneficial in eliminating morning discomfort and eventually proves beneficial in decreasing the overall level of symptomatology.10 A below-the-knee walking cast for four weeks is sometimes helpful, while in some instances surgical intervention to release the plantar fascia or resect the involved heel spur may become appropriate. When the problem is precipitated by a tarsal tunnel syndrome or the presence of a neuroma of the medial calcaneal branch, surgical intervention directed at releasing these structures becomes appropriate.
Dysfunctional Posterior Tibial Tendon. This condition is seen in association with a flattening and elongating foot that has been precipitated by an abnormally functioning posterior tendon. A dysfunctioning posterior tibial tendon may be the result of acute or chronic injuries to the tendon or associated with a rheumatic inflammatory disease process. This condition will typically lead to generalized foot weakness and discomfort, with an associated degree of postural symptomatology additionally affecting the knee, hip, and back.11 Early treatment includes shoe modifications with a full-length varus sole wedge, custom orthotic devices, and, in some instances, an ankle foot orthosis (AFO). Although corticosteroid injections are sometimes recommended to treat the associated soft-tissue inflammation, these will occasionally increase the extent of tendinous disruption. When conservative treatment proves ineffective, surgical intervention involving a triple arthrodesis becomes appropriate.
Stress Fractures. Stress fractures are most often caused by excessive repetitive trauma to a specific area of the foot or lower leg such as occurs with running. Consider that when a 150-pound athlete runs three miles, the accumulative impact on each foot is greater than 150 tons.12 Faulty foot mechanics often contribute to the development and exacerbation of this condition. Stress fractures are typically characterized by pinpoint pain with associated edema and erythema. In most instances, pain is present that is aggravated by weight bearing. This condition is generally associated with the neck or shaft of the lesser metatarsals, with the second and third metatarsals being most commonly affected. Interestingly, stress fractures affecting the base of the second metatarsal occur most commonly in ballet. Additionally, stress fractures may often affect the sesamoids, the distal one-third of the tibia and fibula, and the proximal aspect of the tibia. As initial radiographs are often inconclusive in diagnosing the presence of a stress fracture, bone scans are often recommended to rule out the presence of this condition. Rest, taping, and immobilization of the affected area are all effective in treating this injury.
Sesamoiditis. This condition is characterized by pain and inflammation plantar to the first metatarsal head and is associated with excessive pressure to the area. Symptoms are present with active and passive joint motion as well as upon muscle testing. The symptomatic foot generally demonstrates an increased amount of edema associated with the first metatarsal phalangeal joint primarily along the medial and plantar margins. Pre-disposing etiologic factors include a plantarflexed first metatarsal and enlarged or multiple sesamoids, acute or repetitive trauma, and inappropriate shoes. In the differential diagnosis, one must include the possibility of a fractured sesamoid. In most instances, this will result from one specific traumatic episode, while a stress fracture should be suspected in cases of overuse (increased walking or running). When initial radiographs prove inconsistent, a bone scan would assist in determining the presence of a stress fracture or acute fracture. Treatment for this condition includes padding, contrast baths or ice, oral anti-inflammatories, and a recommendation for more supportive shoes. Over-the-counter inserts often prove effective if one is involved in a regular exercise program.
Tendinitis
Achilles Tendinitis. Insertional Achilles tendinitis may be associated with a retrocalcaneal exostosis or bursitis. In most cases, however, the actual area of involvement is proximal to the insertion into the calcaneus. Inflammation in this area may be caused by a congenitally tight or functionally contracted gastrocnemius or gastrocnemius-soleus complex or by strenuous athletic activity. This condition is often exacerbated by a pronated foot type, which causes frontal plane torquing of the tendon. Initial treatment for an Achilles tendinitis includes rest, with a specific reduction in climbing stairs, the use of one-quarter inch bilateral heel lifts at all times, Achilles tendon stretches (held 30 seconds, 10 repetitions, 2-3 times daily), oral anti-inflammatories, and ice massage. If symptoms persist, a course of physical therapy is often helpful, as are the use of shoe inserts if excessive heel eversion is noted.13 Persistent symptoms may require a below-the-knee cast. Corticosteroid injections into the tendon (especially in the active individual) should be avoided due to the likelihood of precipitating a spontaneous rupture.
Shin Splints. This typical overuse problem commonly involves the anterior portion of the lower leg and is precipitated by overuse such as running up and down hills. Medial or posterior shin splints generally involve the posterior tibial tendon and are typically precipitated by overuse in an individual who overpronates or who is using non-supportive shoes. In both instances, increased symptomatology with associated neurological deficit may be indicative of a compartment syndrome, while pinpoint pain associated with a case of "shin splints" may actually represent a tibial stress fracture and should be ruled out via bone scan. Treatment recommendations include rest, ice, a change of shoes, and shoe inserts when a biomechanical problem is diagnosed.14
Patellofemoral Dysfunction. Lateral distraction of the patella over the lateral femoral condyle may be due to a host of problems including a weak vastus medialis obliquus, increased Q-angle, overactivity, etc. One should note that increased foot pronation leading to internal rotation of the tibia will typically precipitate lateral displacement of the patella with resultant peripatellar discomfort. This is typically associated with sitting, stair climbing, or exercising. In these instances, overall management of the condition (e.g., quadricep strengthening, hamstring stretching, McConnell taping) should include either an over-the-counter or a prescription shoe insert to enhance patellar function and tracking.13,15-17
Ankle Sprains. This most common of podiatric injuries is typically precipitated by an inversion and plantarflexion type mechanism, with the injury typically involving the lateral collateral ligaments. Generally, the less common eversion type injury will involve the deltoid ligament. In all instances, specific pain upon palpation or percussion of either malleolus, the styloid process of the fifth metatarsal, or the navicular would require radiographs to rule out a fracture. Additionally, evaluation of the posterior margin of the ankle in the area of the posterior process of the talus (os trigonum) should also be performed. Individual muscle testing of the flexor hallucis longus will reproduce posterior ankle pain if a fracture has occurred involving the os trigonum. Associated injuries precipitated by an inversion sprain include a subluxed cuboid, extensor digitorum brevis tendinitis, or peroneal tendinitis. Initial treatment for soft-tissue injury includes RICE (Rest, Ice, Compression, Elevation). Initially, crutches may be used to decrease weight bearing, with additional treatment consisting of contrast baths, range-of-motion exercises, and strengthening exercises thereafter, as tolerated. Returning the individual to his pre-injury level of foot and ankle strength is essential in order to minimize recurrent injuries and to decrease the likelihood of lateral instability and dysfunction. Single-foot balancing held for 30 seconds/10 repetitions, followed by forefoot-balancing, again for 30 seconds/10 repetitions, is an easy and effective method of restoring normal strength once an individual is capable of performing this activity. When a fracture has occurred, careful evaluation for possible internal fixation is essential. When no displacement has occurred, a period of 4-8 weeks of casting (either weightbearing or non-weightbearing, depending on the specific injury) is recommended. Again, aggressive use of physical therapy following this period of immobilization is essential in order to restore the individual to his pre-injury level of function.
Turf Toe. This injury is generally associated with painful jamming or hyperextension of the hallux, leading to a flexor hallucis longus tendinitis or first metatarsal phalangeal joint capsulitis. Although this typically occurs on artificial turf, it may occur on grass as well. Immediate treatment includes the RICE regimen and wearing a stiffer shoe. Splinting the toe to limit extension also proves beneficial.
Subungual Hematoma. This common injury typically occurs with running or tennis, where there is excessive movement of the foot distally into the toebox of the shoe. This may also occur traumatically when an object is dropped onto a toe or someone lands on the forefoot during athletic activity. Although minor involvement may be treated via ice and compression, most injuries warrant drainage via either drilling or laser to allow the accumulated serosanguinous fluid to be released.
An active youngster who sustains an injury to his lower extremity is likely to injure the growth plate of the involved area. Because the epiphyses do not close until 15-17 years of age in boys and 13-15 years of age in girls, the potential for epiphyseal injuries is significant. In acute injuries, epiphyseal involvement should be expected in any child sustaining an ankle injury, in that ligamentous and tendinous structures are stronger than their associated bony points of attachment.18 For that reason, soft-tissue injuries in the young child and adolescent do not occur as often as epiphyseal injuries. The Salter-Harris Classification outlines the potential of epiphyseal involvement in levels of injury (Stages I-V). In those cases in which it is difficult to ascertain if an epiphysis has been compromised, it is more appropriate to err on the side of immobilization until symptomatology diminishes. A common area of chronic involvement occurs in the athletic youngster between 10 and 13 years of age who may develop chronic heel pain with activity. A calcaneal apophysitis (Sever’s disease) is accompanied by pain upon activity and specific heel pain upon palpation of the calcaneal apophysis. Although radiographs typically demonstrate the normal multi-fragmented appearance of the calcaneal apophysis and do not confirm the diagnosis, they still should be taken to rule out other anomalies such as a unicameral bone cyst. Initial treatment includes rest, ice, and oral anti-inflammatories. An effective method of decreasing discomfort is to use a heel cup lined with foam in combination with a one-quarter inch heel lift. A below-the-knee cast may be employed if symptoms persists or if the patient is non-compliant.19 Because this injury often occurs in youngsters with tight posterior musculature20 or a pronated foot, stretching exercises and over-the-counter or prescription inserts may prove effective. A similar process occurs in the navicular and typically presents in younger children; for this reason, chronic midfoot pain in the young soccer player should be evaluated for this condition.
Growing Pains. Although it is normal for a developing youngster to experience growing pains, these typically last for only several months and may be precipitated by increased bone growth with secondary soft-tissue discomfort as the posterior muscle groups attempt to "catch up" with their new functional position. One should note that chronic pain, night cramps, or fatigue with normal activity may be indicative of congenital muscle tightening or excessive foot flattening. If evaluation of a youngster’s gait demonstrates increased heel valgus, then initial conservative treatment via shoe inserts and muscle stretching is appropriate.21,22
In-Toe/Out-Toe. Although a majority of these problems are outgrown by adolescence, one must be aware of the potential for compensation to occur in gait as a child undergoes normal development. In most instances, tibial torsion is outgrown by the age of 7-8, while femoral rotation is completed by the age of 13-14. Any variations in angle of gait patterns attributable to tibial or femoral rotation noted beyond these ages will typically not resolve and may lead to secondary musculoskeletal or postural complaints. Additionally, the pre-walker should be evaluated for cases of metatarsus adductus or talipes calcaneovalgus. Although these deformities commonly improve over time, the more rigid forms should be treated prior to the initiation of ambulation. In these instances, a series of 4-8 casts followed by night-splint therapy and prescription shoes prove effective in reversing the condition. If left untreated, these musculoskeletal problems will most likely result in a lifetime of shoe-fit problems and musculoskeletal symptomatology.22
Verruca. Most verrucae affecting the lower extremities occur on the plantar aspect of the foot. The virus that causes a verruca to form typically enters through the plantar surface of the skin through a defect such as is caused by a cut or blister. Once the virus has been established, it increases in size and may appear as a single lesion or as a multi-faceted mosaic verruca. Although often confused with a callus, the verruca is more painful upon medial to lateral compression, as opposed to direct compression, and exhibits multiple areas of pinpoint bleeding noted upon palliation (due to capillary infiltration into the verruca). Although these lesions may be found in almost any individual who walks barefooted and comes in contact with the virus, individuals with a depressed immune system appear to develop the problem more readily. Overall successful treatment may be achieved via debridement and the continuous use of a variety of over-the-counter acid preparations. When the size of the wart or the degree of the symptomatology increases, surgical excision with or without laser ablatement is recommended.
Onychocryptosis. Ingrown nail borders leading to an onychia often affect the hallux. These are caused by tight-fitting shoes, improper cutting techniques, or the presence of a congenitally malformed nail. In some instances, a subungual exostosis (visualized on a lateral radiograph of the hallux) will precipitate chronic symptomotology. This condition often appears as an acute infection for which oral antibiotics are prescribed. However, as long as the involved portion of nail continues to press against the adjacent ungualabia, the condition will persist. Although avulsion of the corner of the offending nail may be accomplished without anesthesia, the degree of edema and symptomatology may preclude this. In these instances, the hallux is anesthetized, and the entire involved nail border is avulsed. Soaking and topical antibiotics are then recommended, with the possible use of oral antibiotics recommended if the clinical situation warrants this. In cases of recurring symptomatology, the aforementioned nail procedure followed by either a chemical,23 laser, or surgical matrixectomy is recommended in order to permanently resolve the condition. In some instances, this is accompanied by a subungual exostectomy if it is felt that this is contributing to the overall situation.
Onychomycosis. Individuals with a fungal infection of their nails typically wish to eradicate the condition due to its appearance, discomfort, associated skin involvement, and the limitations it places on shoewear secondary to the associated hypertrophic and dystrophic changes. Those who suffer chronic diseases such as diabetes, circulatory problems, or immune deficiency conditions are especially prone to this.24 Recent studies have demonstrated that the majority of distal subungual onychomycoses are caused by Trichophyton rubrum, while superficial onychomycosis (which accounts for approximately 10% of all infections) is caused by Trichophyton mentagrophytes. Proximal subungual onychomycosis accounts for less than 1% of all cases and is caused by T. rubrum.25 Although it is rare in healthy individuals, it is seen most typically in patients with AIDS. Often, other clinical conditions such as psoriasis may mimic an onychomycotic infection. Although a psoriatic nail will appear dystrophic, it will be characterized by multiple areas of pitting, which are clinically evident. Prior to initiating treatment for a suspected onychomycosis, the diagnosis must be established via the identification of fungal hyphaeonkoh and growth of fungus on culture. Treatment recommendations include periodic nail debridement and grinding accompanied by the use of any of the available topical antifungal agents. Although these work effectively for the superficial type of infection, they are generally ineffective against the distal subungual forms. In some instances, the entire nail may be avulsed, with the underlying nail bed treated with a topical agent. More effective treatment seems to be available with the new oral antifungal agents. Once the absence of any pre-existing liver diseases is established, treatment may be initiated via any of the recommended courses (see Table 4).26,27 Additional evaluation of liver function following two months of therapy and then at the conclusion of therapy is appropriate. The medications vary, and the results are reported as a "mycologic cure" or "clinical cure." Because of this, the most important figure to evaluate in clinical trials is the actual clinical success rate. Recent studies by Tosti et al indicated that, of the three most commonly used methods of treatment (see above), the most effective at this time is continuous use of terbinafine for four months.28,29
Ulcerations. Ulcers affecting the lower extremity must be managed aggressively and effectively in order to allow the lesions to heal as quickly as possible. Lower extremity ulcers occurring in the diabetic patient population typically develop from a combination of factors including neuropathy, mechanical stress, and vascular disease. Typically, those patients with a history of ulceration exhibit higher peak plantar pressures than patients without ulceration.30,31 Overall, this condition is a common and potentially serious complication of diabetes mellitus. Diabetic patients are at high risk for amputation when foot ulcers become infected, and survival falls drastically after amputation. The incidence of lower extremity amputations is 30-fold higher in patients with diabetes than in patients without diabetes.32,33 At-risk patients may be easily screened via the Semmes-Weinstein monofilament, which is a quick and inexpensive clinical test to predict the diabetic patient who is more prone to foot ulceration. The most effective method for treating diabetic ulcerations is to decrease pressure to the involved area. Recent studies demonstrate that a molded Plastazote shoe insert proves to be an effective method of decreasing pressure to the involved site.34-36 Local wound care consisting of debridement of necrotic and hypertrophic tissue, controlling infection, and protecting the skin wound with any of a variety of dressings is essential for the overall resolution of this condition. Venous ulcers affect approximately 500,000-700,000 patients in the United States each year and demonstrate a high (up to 90%) recurrence rate. Typically a result of chronic venous insufficiency or trauma, the involved area responds well to local wound care, external leg compression, and elevation.
The early recognition and treatment of a host of podiatric conditions in pediatric and adult patients will allow those individuals to stand, walk, and exercise in a comfortable and efficient fashion. A heightened awareness of when and how to treat the most common lower extremity conditions presented in this paper will allow appropriate treatment to be provided in a timely fashion.
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