Podiatric Procedures

Footpad Use

Footpads redistribute pressure over an inflamed, tender area of the foot. The particular type of footpad and its placement depend on the condition being treated ( Fig. 51.1 ). Commercially available aperture footpads are recommended for the temporary relief of warts, corns, hyperkeratoses, and bunions. Verruca virus introduced into the plantar surface of the foot may produce a painful hyperkeratotic lesion, commonly referred to as a plantar wart , on the sole of the foot. A simple callus may be painful and result in the formation of a “hard corn” when formed over the bony prominence of a digit. Once recognized, and after other conditions are ruled out, definitive care of these lesions is rarely indicated in the ED.

When tenderness is elicited over more than one metatarsal head, the diagnosis is metatarsalgia. Pain that is progressively worse while walking but relieved by rest, often beneath the second or third metatarsal head, is typical in this case. A pad placed under the first metatarsal head to raise the second and third metatarsals may provide some relief.

A bunion develops when unbalanced forces applied to the first metatarsal cause lateral displacement of the distal end of the hallux. Bunions typically form in women wearing heeled shoes with narrow toe boxes. The patient may complain of numbness over the distal, medial aspect of the first toe as a result of compression of the terminal branch of the medial dorsal cutaneous nerve. The mechanical forces that precipitate bunion formation may also cause other painful conditions, including intermetatarsal neuromas, hammertoes, ingrown toenails, corns, and calluses. Bursitis may develop over the medial bony prominence of the first metatarsophalangeal (MTP) joint. Self-adherent bunion pads placed over the first MTP joint may provide temporary relief ( Fig. 51.2 ). In the ED, treat patients suffering from these common disorders with analgesics and footpads, followed by referral for definitive care. Recommend that the patient avoid wearing the offending shoes. In men and postmenopausal women consider gout when evaluating pain over the first MTP joint, particularly in the presence of other signs of inflammation (e.g., redness, swelling, warmth).

Heel Pain Syndromes

Bony spurs on the plantar surface of the calcaneus, retrocalcaneal bursitis, calcaneal apophysitis, and other conditions may cause heel pain. Treat most of these conditions with rest, nonsteroidal antiinflammatory drugs (NSAIDs), modification of physical activities or shoe wear, footpads, and orthoses. Some clinicians also include injection of anesthetics or steroids for these conditions.

Heel spur pain can be quite bothersome and chronic or recurrent. This condition is not easily remedied in the ED, and after other conditions are ruled out, such as an unexpected foreign body (FB), minimal intervention with podiatric referral is often the best course of action. Patients typically have pain over the medial border of the plantar aspect of the calcaneus. The pain gradually worsens over a period of months. A bony prominence that begins as periostitis extends from the medial aspect of the calcaneal tuberosity into the central plantar fascia and may be seen on radiographs. Radiographs of the calcaneus that do not demonstrate a bony spur suggest plantar fasciitis (see the later section on Painful Conditions of the Plantar Surface of the Foot ), even though many patients with plantar fasciitis have plantar calcaneal and Achilles spurs. Plantar calcaneal heel spurs are found in nearly 15% of the population, only 30% of whom have heel pain. Although many persons with heel spurs are asymptomatic, 75% of patients with heel pain have heel spurs. However, radiographs have little value in evaluating nontraumatic heel pain because they rarely demonstrate radiographic abnormalities that prompt additional treatment.

Shoe supports with a heel pad or cup, or a doughnut-shaped orthotic often help reduce the discomfort by redistributing weight. Few randomized controlled trials have evaluated steroid therapy; those that have do not provide substantial evidence supporting its long-term efficacy. Treatment for the painful site is 10 to 20 mg of methylprednisolone injected into the medial aspect of the foot while avoiding the sensitive plantar surface. Some evidence suggests that injecting 25 mg of prednisolone acetate into the medial aspect of the heel provides partial pain relief at 1 month in comparison to lidocaine only, but no advantage can be detected at 3 months. A short-leg walking cast may be effective in some patients with recalcitrant heel pain. There is little evidence to suggest that specific interventions aimed at reducing heel pain are superior to conservative, supportive treatment alone.

Painful Conditions of the Plantar Surface of the Foot

Plantar Fasciitis

Repeated microtrauma to the plantar aponeurosis causes pain on the plantar surface of the foot ( Fig. 51.3 A ) . Plantar fasciitis is typically unilateral and found in women who wear high-heeled shoes. The pain is maximally severe in the morning or after prolonged sitting and improves after walking, often referred to as first-step pain. Some patients with plantar fasciitis may also have a calcaneal heel spur, but the presence or absence of this radiographic finding is clinically irrelevant. Pain is elicited with palpation (see Fig. 51.3 B ), toe walking, or passive stretching of the plantar aponeurosis. Frequently, this annoying condition resolves spontaneously, but resolution is slow, with as long as 6 to 18 months needed. Conservative therapy, including rest, elevation, ice, and NSAIDs, results in a satisfactory outcome after 6 to 8 weeks in 90% of patients. The pain improves over time in most patients, with or without NSAIDs, although the addition of NSAIDs appears to increase pain relief when compared with conservative treatments alone. The emergency clinician can do little to treat this chronic, distressing condition. Stretching exercises each morning and evening can be suggested (see Fig. 51.3 D ). Night splinting to keep the foot dorsiflexed and custom orthoses made from the patient's foot impression can be very helpful but usually require referral to podiatry for proper fitting (see Fig. 51.3 C ). Corticosteroid injection is used by some clinicians; however, its benefit remains unproved. A single injection may be warranted as supplemental therapy in resistant cases. Repeated injections of corticosteroids should be avoided and have been associated with rupture of the plantar fascia and fat pad atrophy. Some authors suggest the injection of autologous PRP when plantar fasciitis is chronic. The benefits of PRP remain unproved. In a 2010 study, 50 units of botulinum toxin type A injected into the plantar fascia decreased pain in comparison to placebo but did not cure the disease.