MANAGING FOOT LESIONS IN THE
OFFICE/TRAINING ROOM
Soft-tissue lesions of the foot are frustrating for active people-especially for competitive athletes. Prompt non-surgical treatment on the field, in the training room, or in the office is essential to enable patients to return to full participation.
Soft-tissue lesions that can cause disability include nail injuries, blisters, and plantar warts. Painful hyperkeratotic lesions of the foot-calluses, intractable plantar keratoses, and corns-can also hamper performance or the pleasure of activity.
Nail Injuries
Identifying toenail injuries is important; if left untreated, pain, deformity, and disability may result.
Paronychia. An inflammation of the folds of the skin around the nail bed, paronychia is common in athletes and is characterized by swelling, erythema, pain, and a purulent discharge. It is often caused by pressure from the shoe or by secondary infection from another process(eg, ingrown toenail). The great toe is usually affected, although the lesser toes may be involved.
Early treatment consists of warm soaks, elevation, and relief of shoe pressure. If suppuration develops, incision and drainage are needed to evacuate the pus and relieve the pressure. To perform this procedure:
-Anesthetize the toe with a digital toe block or, if needed, an ankle block.
-Lift the edge of the involved nail out of the nail fold.
-Excise a 2-to 3-mm wide linear portion of the nail to the matrix.
-Paint the granulation tissue in the remaining edematous nail groove with a silver nitrate stick.
-Apply a sterile dressing.
Onycholysis. A separation of all or part of the nail from its nail bed, onycholysis is often seen in ballet dancers who dance on pointe and in any athlete with improper shoes who experience chronic pressure on the end of the nail by the shoe. The distal portion of the nail bends upward when the patient's weight is on the tuft of the distal phalanx. Delamination of the nail may result, along with transverse cracks. Nail removal should be avoided especially for dancers. Several layers of clear nail polish can help contain cracking, and a single layer of adhesive tape can secure a piece of loose nail.
Complete separation of the nail, if associated with a phalanx fracture, requires replacement of the avulsed nail to provide a splint. If the nail is lost, treatment is symptomatic for 3 to 4 months while a new nail grows.
Subungual hematoma. A shearing or crushing injury to the toenail can cause a subungual hematoma. Hemorrhage under the nail causes pressure and pain and can lift the nail off its bed. Treatment involves draining the subungual blood to relieve the pressure. This can be done by either drilling drainage holes in the nail with a heated paper clip or needle or by slipping a #11 scalpel between the nail and the nail bed. We prefer the use of a disposable needle-cautery. Care must be taken if using a scalpel, to avoid injury to the nail matrix by maintaining scalpel pressure on the underside of the nail. Following either method, sterile dressings are needed to avoid infection.
Sometimes a large subungual hematoma can lead to complete loss of the nail. If possible, preserve any remaining attachments prior to complete nail loss, and allow the nail to remain in place as a biological dressing. If the nail is completely detached from the bed, a sterile antibiotic gauze is inserted in the nail folds to maintain an opening for the nail to grow. The dressing is changed each day until the nail bed is dry and heals. It is important to advise the athlete that injury to the matrix of the new nail may cause permanent deformity of the new nail.
Protecting the toe. For any nail injury, the nail and toe should be protected as the athlete returns to activity. Toe caps-foam shells that fit over the toe and inside the shoe-can be used. However, if the toe is swollen and will not fit in the shoe, the pedorthist, trainer, or physician can cut a hole in the shoe over the affected toe and cover the exposed area with a protective shell. To provide protection for nail injuries, stable phalangeal fractures, and toe contusions, we recommended that you construct a protective shell to be worn with shoes during competition.
Blisters
Fluid-filled blisters (bullae), familiar to most athletes, are caused by excessive friction between the foot and shoe. The best treatment is prevention, and well-fitted shoes are a must. Athletes should be encouraged to break in new shoes gradually; they can stretch or pad their shoes during the break-in period to avoid blisters. The athlete should wear one pair of cotton or cotton-blend sweat socks (usually cotton and acrylic). Recently, sport-specific socks have become available that provide extra padding in the area most affected by a particular sport. While some authors have claimed an objective clinical benefit of these socks, other authors have stated that no real proof exists.
Toe glides made of coated paper can also prevent blisters of the forefoot by reducing friction between the sock and the foot. The toe glide is placed directly over the forefoot under the sock. Body heat "melts" the glide to fit the foot.
Lubricating the skin with petroleum jelly and applying foam padding can help prevent blisters by reducing friction at the heel beneath the counter of the shoe or at the anterior ankle beneath the laces. This method is especially needed when the ankle is taped.
If a serous or blood blister does develop, the following treatment program can relieve symptoms and promote rapid healing;
-Open the intact blister with a #11 scalpel or a 20 g. needle at the junction between the blister and surrounding skin, but leave the overlying skin as a biological dressing.
-Drain the fluid with sterile gauze.
-Fill the blister pocket with an antiseptic and analgesic cream (eg, dibucaine).
-Spray the area around the blister carefully with pretape spray.
-Place cotton-backed adhesive tape directly over the blister.
-Remove the tape after 3 days. Also remove the dead skin over the blister, beveling blister edges until smooth.
-Reapply the tape and leave in place for 3 more days. If the blister remains tender, apply tape a third time.
Avoid treating blisters with small ovals or donuts. These devices can create excess friction at blister margins and cause other problems. If decreased weight bearing is needed, use a large foam pad with a cutout over the blister area.
CALLUSES
Calluses (tyloma) are thickenings of the skin that when symptomatic are painful on weight-bearing and tender to touch. Thin, diffuse callus formation on the plantar surface of the foot is normal, especially in athletes. But when calluses become thicker and localized, they may be come symptomatic. When they occur on the plantar surface of the foot and are well localized, callosities are called intractable plantar keratoses.
Intractable plantar keratoses result from intermittent external pressure on the skin from the shoe and internal resistance from the bone. Several factors can promote callus formation in athletes. These include:
-Improper footwear (eg. missing pads or inserts, improper size),
-Structural abnormalities (eg, varus or valgus foot alignment leading to uneven weight distribution, a plantar flexed ray, a long metatarsal, malunited fracture), and
-Wounds on the plantar surface of the foot (eg, lacerations, surgical scars, puncture wounds).
Calluses are usually painful to direct pressure, have a hard and smooth center, and are avascular. Histologically, basal-layer cells proliferate, increasing local keratinization. Calluses are usually conical, with the point facing the dorsum of the foot.
Intractable plantar keratoses are most often seen beneath the fibular condyles of the second and third metatarsal heads. They are also seen beneath the tibial sesamoid of the first metatarsophalangeal joint, over the plantar and lateral surfaces of the fifth metatarsal head, on the medial side of the great toe, and over the posterior aspect of the heel.
Nonsurgical treatment of intractable plantar keratoses has two goals: to relieve pressure on underlying soft tissues and nerves by trimming the callus and to decrease weight-bearing on affected areas by redistributing the patient's weight. The patient is instructed to trim the callus daily by soaking the foot and using a pumice stone in the shower or bath to debride the superficial layers of keratinized skin. the Physician can also trim the callus by shaving the superficial layers with a sharp razor or a #15 scalpel. If the area bleeds, another diagnosis such as plantar warts should be considered.
Alterations in footwear are usually needed to prevent further callus development. The athlete's shoe should have adequate room for the forefoot; if the shoe is too short, calluses can form when
the toes are forced into flexion and the metatarsal heads are forced plantarward. When the toe box is too narrow, calluses can develop over the medial side of the first metatarsophalangeal joint and over the lateral side of the fifth metatarsophalangeal joint.
Shoe inserts may help prevent calluses. Full sole orthoses are helpful in the varus or valgus foot. Pads can reduce weight-bearing when localized osseous abnormalities such as plantar-flexed rays, hammertoes or mallet toes occur in an active patient.
Surgery to correct underlying osseous abnormalities should only be considered if nonoperative treatment fails.
Corns
A corn is a conical wedge of keratinized tissue with the apex pointing toward the subcutaneous tissue. Compared to calluses, corns are more localized and have a deeper central core. Corns can be very painful,; often, the apex touches nerve fibers in the subcutaneous tissue. Histologically, a corn is virtually identical to a callus. Both consist of increased keratinized tissue from the basal layer. There are two types of corns: hard and soft.
Hard corns (heloma durum or clavus durus) have hard central cores that overlie bony prominences. The most common site is at the fifth toe over the dorsolateral aspect of the head of the proximal phalanx. Other common sites include the dorsa of the proximal interphalangeal and distal interphalangeal joints.
Extrinsic or intrinsic pressure causes hard corns. Tight or ill-fitting shoes frequently cause extrinsic pressure. Intrinsic pressure is usually caused by an enlarged condyle, a bony prominence, a hammertoe deformity, or an unreduced joint dislocation.
Hard corns should be pared using a #15 scalpel. The goal is to enucleate the central core, which should be avascular. Patients should wear shoes that provided more room at the forefoot for the metatarsal heads. Shoe inserts such as toe splints and hammertoe crests are useful for flexible hammertoe deformities. Over-the-counter corn pads, decrease the pressure on hard corns and relieve irritation of underlying nerve fibers.
Soft corns (heloma molle or clavus mollis) develop from interdigital pressure on one toe by the condyle of the adjacent toe. Moisture between the toes makes the corn soft. they are painful and appear as flat, white, soggy areas, most commonly between the fourth and fifth toes.
To treat soft corns, pare with a #15 scalpel as for hard corns. Toe separators, such as toe combs that are available over-the-counter, can alleviate the pain and prevent further soft corn development. Lambskin or moleskin placed between the toes is equally effective. If these nonoperative measures fail, surgical excision of the prominent condyle may be curative.
Plantar Warts
The causative agent of warts ia a DNA virus that belongs to the papovavirus group and has an average life span of 4 to 5 months.
Warts can occur anywhere on the foot. They are usually hard, white, small growths that are flat on the plantar surface and cauliflowerlike on the dorsum of the foot. Plantar warts have three clinical presentations: solitary, multiple, or mosaic. Solitary warts are often surrounded by callus tissue. Multiple or cluster warts are composed of a large wart surrounded by smaller warts. Mosaic warts are larger (up to several centimeters); patches of nodules come together to form a mosaic pattern.
Plantar warts usually have an irregular shape. They have a soft center that may be found underneath a callus. Since and multiple warts are painful to lateral pinch. Mosaic warts are usually painless. Plantar warts are vascular and will bleed with debridement. After removal of overlying callus, close inspection of the central area reveals vertical blood vessels that rise to the surface of the wart.
Pain-free plantar warts require only observation. Because the viral life span is 4 to 5 months most warts will undergo spontaneous regression. Painful warts require nonsurgical treatment; scar formation after surgery is more painful and troublesome than the wart itself. Many different methods are used to treat painful warts, including chemical debridement, cryosurgery, blunt dissection, and electrosurgery. Laser vaporization with a carbon dioxide laser can be a highly effective treatment for solitary untreated lesions. However, disadvantages of laser therapy include its high cost and limited availability. In addition, the smoke given off by the laser has been shown to contain viable viral particles, making mask, goggles and vacuum filtration use necessary. Forty-percent salicylic acid plaster is an effective nonoperative treatment. The patient cuts the plaster to the size and shape of the wart, places it on the wart, and tapes it to the foot. The patient changes the plaster daily. This method, a good treatment for all types of warts is usually painless and leaves no scars. But as with all nonoperative methods, weeks of months of treatment may be required, and plantar warts have a strong tendency to recur.
Make Foot Care a Priority
Soft-tissue injuries of the foot are common in athletes at all levels, from Pop Warner to professional. However, these injuries often go untreated. It is important for physicians to be familiar with these injuries and treat them in an office setting so that active patients can safely return to their sports.
Most of these conditions are preventable. Incorporating a foot exam into an active patient's annual physical exam or an athlete's preseason physical exam provides opportunities to institute preventive measures that will go a long way toward avoiding many of these problems.
Proper footwear, orthoses (inserts) when indicated, and flexibility all are very important to athletes and will help minimize, if not prevent many of these problems.
References
1. Mann, RA: Keratotic disorders of the plantar skin, in Mann, RA (ed): Surgery of the Foot, ed 5, St. Louis, CV; Mosby Co., 1986, pp 180-198.
2. Mann RA: Intractable plantar keratosis. Instructional Course Lectures 1984; 33:287-301.
3. Kalivas J: Treatment of skin disorders of the feet and nails, in Kiene RH, Johnson KE (eds): American Academy of Orthopaedic surgeons Symposium on the Foot and Ankle. St. Louis, CV Mosby Co., 1983, p. 124.
4. Mancuso JE, Abramow P, Dimichino BO, et al: Carbon dioxide laser management of plantar verruca: a 6-6ear follow-up survey. J. Foot Surg 1991; 30(3) 238-243.
5. Benda C: Stepping into the right sock, Phys Sportsmed 1991; 19(12); 125-128.
6. Reese RC, Burruss TP: Athletic training techniques and protective equipment, in Nicholas JA, Hershman EB (eds): The Lower Extremity and Spine in Sports Medicine. St. Louis, CV Mosby Co., 1986, p. 245.
7. Sammarco GJ: The foot and ankle in classical ballet and modern dance, in Jahss MH (ed): Disorders of the Foot, ed. 1 Philadelphia, WB Saunders Co, 1982, p. 1626.
8. Ramsey ML: Plantar warts: choosing treatment for active patients. Physicians in Sportsmed 1982; 20(11):69-88.
9. Katchis, SD, Hershman,EB: Broken Nails to Blistered Heels. Phys. Sportsmed 1993; 21(5):95-104.
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