1. Looking at common lower-
extremity problems and what
to do about them

2. Common Pedal Complaints
Skin Problems: nails, blisters, calluses, wounds
and misc. dermatology
Bone Problems: tumors, deformities, fractures
Arthritities: bunions, hammertoes, general arthritis,
sero-negative arthropathies
Pain Syndromes: enthesiopathies, acute trauma,
causalgia and RSD
Diabetic Concerns: vasculopathy, neuropathy,
immunopathy and attendant problems

3. Skin Problems
Ingrown nails:
Use antibiotics if cellulitis is seen
Surgical removal of offending border:
anaesthesia of lidocaine (with or without epi)
and Marcaine buffered with NaCO3
if one border involved, consider if the nail is
worth saving
Phenol matrixectomy, saline flush
dress with topical abx and gauze sponge, not
Band-Aid™
Epsom salt soaks to draw out drainage

4. Skin Problems
Calluses:
Tell patients not to use medicated pads
palliative care for comfort: trimming, cushions and
wide toe-box shoes
radiograph of foot may show underlying bone spur,
indicating a progressive problem
Tinea:
Typical presentation is flaky (T. rubrum)
rule out psoriasis, eczema
bullous type is T. mentagraphytes
rule out contact dermatitis

5. Bone Problems
Tumors
Gout
None are common in
Fractures
the foot
Control diet (tyromines)
if seen, think
use anti-inflammatories If seen in digits,
osteochondroma,
‘buddy splint’
enchondroma, use colchicine
unicameral bone cyst, other bones need
get blood work
multiple myeloma casting, ORIF
possible joint tap

6. Arthritities
Emphasize
accommodation (shoes with
wide toe-boxes, padding, trimming
of corns, lesions)
Sometimes surgery is
And hammertoes the only choice, but it
requires time off the
surgical extremity
Bunions
The patient who is--or is
suspected of being--a
poor candidate for surgery
Usually indicative of
needs accommodation
overall foot-type

7. Arthritities
Heel pain General osteoarthritis
typically in the hypermobile
Rheumatoid (sero +)
flatfoot patient
Sero-negative:
rule out recent trauma
rule out fracture
Reiter’s
rule out radiculopathy
Psoriatic
rule out sero-negative
Irritable bowel
arthropathies
Anklyosing spondlilitis
Gonococcal arthritis
SLE (systemic lupus
erythematosis)
Behçet’s syndrome

8. Pain Syndromes
Insertion of
Achilles
with
calcification
Inferior
calcaneus
Heel Pain
Actually a nerve entrapment
syndrome, the spur means nothing
Rule out radiculopathy, sero-
Entheseopathies
negative causes

9. Diabetic Concerns
—
™
˜
š
–
‚ Transfer lesions
ƒ Mallet-toe lesions
„ intertrigenous lesions
… hammertoe lesions
† xerotic skin problems

10. Diabetic Concerns
Importance:
if you can’t feel your feet, you can’t
feel if they’re injured
if you injure your feet, it will take less
force to cause ulcers
if you ulcerate the skin, it will be
harder to heal
if the ulceration reaches bone, it may
3 changes seen: 3 types of neuropathy:
mean amputation
neuropathy autonomic
angiopathy motor
the amputation level may be proximal
sensory
immunopathy
to injury to heal site
it is unusual to have one amputation
not lead to others

11. When to refer out to your local foot guy
Nail infections with bone involvement,
which have been treated, but have recurred,
or you feel unsure about treating
Wounds which need debridement, off-
loading or more than simple care
Bone problems (tumors, fractures, arthritic
deformities)
Unremitting pain recalcitrant to
conservative treatment
Biomechanical instability (hyperpronation),
or gross deforming changes to the structure
of the foot/ankle (tendon or ligament strains,
sprains or tears)
Yearly diabetic evaluation and assessment
When you’re fed-up and don’t want to deal
with it anymore!

12. T ankYou
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