Soft tissue foot problems

Ingrown toenails

• If infection or significant granulation absent
  • Daily elevation of nail with wisp of cotton or dental floss between nail plate and skin
  • Daily foot soaks and avoidance of pressure on nail may help
  • Can remove a small spicule of nail edge if not infected under digital block (1-2/3 of the way back)

Ingrown toenails

• If granulation or infection present
  • Larger partial removal of nail plate indicated
  • Longitudinally, cut entire affected edge of nail from tip to base (1/4 of nail plate)
  • Grasp and remove from nail groove
  • Debride the nail groove
  • Place chlorsig ointment in wound and bulky dressing over the top
  • Check toe in 24-48 hours
  • Can use phenol for chemical metricectomy (cotton bud dipped in phenol 88% massaged with rotation towards lateral nail fold for 1 minute)
    • Irrigate nail matrix with isopropyl alcohol afterwards to neutralise phenol
  • Postprocedure antibiotics only if cellulitis proximal to toe
  • If recurrent, refer to podiatrist for permanent nail ablation

Bursitis in feet

• Aspirate if able
• Otherwise, conservative therapies unless infection suspected

Plantar fasciitis

• Most common cause of heel pain
• Peak age 40-60
• Younger peak in runners
• Anchors plantar skin to bone and provides support to foot during gait
• Cause is overuse
• Pain on plantar surface of foot, worse when initiating walking
• Usually point of deep tenderness at anteromedial aspect of calcaneus (point of attachment)
• Pain and tenderness worse with toe dorsiflexion

Plantar fasciitis

• Diagnosis is clinical
• Generally self-limited – 80% resolve within 12 months
• Rest, ice, NSAID’s, heel and arch supporting shoe inserts and dorsiflexion night splints
• Plantar-specific stretch exercises are the most effective therapy in acute phase
  • Ankle dorsiflexed, use one hand to dorsiflex toes and other hand palpate plantar aponeurosis to ensure tension
• Stretch Achilles, avoid barefoot walking and avoid flat shoes

Tarsal tunnel syndrome

• Uncommon source of foot pain in runners with compression of posterior tibial nerve as it courses behind the medial malleolus
• Usually prior injury or overpronation during running (inward rotation)
• Restrictive footwear, oedema in pregnancy, ganglion cysts and tumors also causative
• Numbness or burning pain to sole of foot, sometimes limited to heel mimicking plantar fasciitis
• Pain often worse with running, at night and after standing

Tarsal tunnel syndrome

• Tinel sign – Percussion pain radiating to sole of foot over inferior to medial malleolus
• To differentiate from plantar fasciitis
  • Worse throughout day (vs. plantar fasciitis worse when initiating walking in morning)
  • Pain focussed medially and arch (vs. anteromedial heel)
  • Distal calf pain from radiation (plantar fasciitis does not radiate to calf)
• Conservative management and orthopaedic evaluation

Deep peroneal nerve entrapment

• Mostly where courses under inferior extensor retinaculum
• Oedema, recurrent ankle sprains, acute trauma or tight footwear most common causes
• Dorsal and medial foot pain with hypoaesthesia over first web space
• May be loss of toe hyperextension
• Plantarlfexion with inversion can reproduce sympoms
• Nighttime pain is common
• Conservative therapy + podiatry/ortho referral

Tenosynovitis

• Typically pain over affected tendon
• Flexor hallucis longus most commonly affected
• Presents similar to plantar fasciitis and tarsal tunnel syndrome
• Conservative management usually effective

Morton’s neuroma

• Plantar interdigital neuroma
• Mostly 3^rd interspace
• Tight-fitting shoes leading to local irritation of nerve
• Women 25-50 mostly
• Pain located in area of metatarsal head, burning, cramping, aching, worse with walking and better with rest
• Pain reproduced with palpation and may feel mass
• Diagnosis clinical or US
• Conservative Rx – Wide shoes, metatarsal head offloading inserts
• Surgical removal for refractory cases

Compartment syndrome of foot

• Crush injury or multiple fractures typically
• Calcaneal and Lisfranc injuries especially, burns, contusions, bleeding disorders, post-ischaemic reperfusion injury, venous obstruction, exercise and pressure areas from casts/splints
• Need high index of suspicion
• Pain out of proportion
• Compartment pressures with ortho and elevate to level of heart while awaiting ortho

Malignant melanoma

• 15% of cutaneous melanomas
• Atypical, pigmented or non-healing lesions of the foot (incl. nail)
• Often imitate fungal infections, foot ulcers and plantar warts
• Maintain high index of suspicion
• Acral lentiginous melanoma is an aggressive form affecting non-whites mostly on plantar surface of foot often
• All atypical or non-healing lesions should be referred for biopsy

Last Updated on October 6, 2020 by Andrew Crofton