Reflex Sympathetic Dystrophy (Complex Regional Pain Syndrome)

In 1598, Pare first recorded awareness of the condition. Then, later during the American Civil War, Reflex Sympathetic Dystrophy (RSD) was recognized and described. The hallmark of Complex Regional Pain Syndrome (CRPS) is severe, spontaneous pain associated with local features of autonomic dysfunction that occurs after trauma or operation to a limb. It is defined as a disordered response by an extremity to a noxious (hurtful) stimulus.

The exact cause is unknown.

The five major signs and symptoms are:

• Pain out of proportion to the injury
• Edema
• Autonomic dysfunction
• Movement disorder, and
• Trophic changes

Causes of CRPS include accidental trauma. Injury may be the result of fractures, dislocations or sprains, amputations, crush injuries or even minor cuts of the toes or feet. Other etiologic (causative) factors include surgical procedures, diabetes mellitus, hemiparesis, venipuncture, and infections. It usually results from incomplete nerve trauma or soft tissue injury, and most commonly affects the hands and feet.

Genant proposed criteria for diagnosis of RSD which included pain and tenderness in the extremity, soft-tissue swelling, decreased motor function, trophic skin changes, vasomotor instability and patchy oteoporosis.

Histological findings on synovial biopsies characteristic for RSD that Kozin noted include proliferation and disarray of synovial lining cells, increased numbers of small blood vessels, mild perivascular inflammatory infiltrate and synovial edema.

Stages of RSD (CRPS)

1. STAGE I occurs between 1-3 months. The foot displays soft, puffy edema, antalgic guarding of the part, pronounced pain, allodynia(hyperesthesia to light touch-pressure), hyperhidrosis(excessive perspiration); spotty osteoporosis on radiographic inspection; pain aggravated by movement and emotional stress.
2. STAGE II occurs between 3-6 months. Edema is still present, range of motion decreases, dystonia (impairment of muscle tone), mottled or cyanotic coloration, and progressive spotty bone demineralization noted radiographically. Hair growth is decreased, nails are brittle, and there is muscle wasting causing limited joint mobility.
3. STAGE III occurs between 6-9 months. There is a cool, dry foot with pallor;with the skin slightly taut, waxy and thin; stiffness and disability are pronounced, marked disuse atrophy of bone (Sudek's atrophy).

Techniques to confirm clinical diagnosis

Plethysmography(the determination of changes in volume by using an instrument for recording variations in volume of an organ, part, or limb) and venous blood gas measurement for determination of vasoconstriction.

Thermography or videothermogram to evaluate near-surface blood flow. A positive thermogram will show significant coolness in the affected extremity.

Xenon clearance or laser Doppler to measure peripheral blood flow.

Serologic tests, such as antinuclear antibody and rheumatoid factor (are usually negative).

Plain film radiographic examination reveals patchy osteoporosis, which may progress to a diffuse ground-glass appearance.

Three-phase Technetium bone scan, showing diffuse uptake in the blood flow, pool and delayed phase. In the delayed phase, periarticular uptake is noted in the affected part.

Other studies include electromyography(the recording and study of the electrical properties of skeletal muscle) and nerve conduction velocity studies, arteriography(radiography of an artery or arterial system after injection of a contrast medium into the blood stream), and erythrocyte sedimentation rate. The results of these studies are negative. Quantitative bone density testing is also used.

Pharmaceutical treatment for CRPS is Prednisone, Elavil, Procardia, NSAIDS(Non-Steroidal Anti-Inflammatory Drugs), Neurontin, Dilantin

PHYSICAL THERAPY treatment may be administered including, massage, ultrasound, ROM(range of motion) exercises, splint, hydrotherapy and contrast baths, transcutaneous electrical nerve stimulation (TENS), trigger point electrical stimulation, acupuncture.

Other forms of treatment include chemical sympathectomy, epidural block, lidocaine, morphine pump, and amputation

References

• Banks, Alan S., et al McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia:Lippincott Williams and Wilkins, 2001.
• Kozin F. Reflex sympathetic dystrophy syndrome:a review. Clin Exp Rheumatol 1992;10:401-409.
• Schwartzman RJ, McLellan TL. Reflex sympathetic dystrophy.Arch Neurol 1987;44:555-561.
• Schwartzman RJ. Reflex sympathetic dystrophy. Curr Opin Neurol Neurosurg 1993;6:531-536.
• Stanton-Hicks MD. Upper and lower extremity pain. In: Raj P, ed. Practical Management of pain. St. louis:Mosby-Year-Book, 1992:312-328.
• Bej MD, Schwartzman RJ. Abnormalities of cutaneous blood flow regulation in patients with reflex sympathetic dystrophy as measured by laser Dopler fluxmetry. Arch Neurol 1991;48:912-915.
• Amadio PC, Mackinnon SE, Merritt WH, et al. Reflex sympathetic dystrophy syndrome:consensus report on an ad hoc committee of the American Association for Hand Surgery on the definition of reflex sympathetic dystrophy syndrome. Plast Reconstr Surg 1991;87:371-375.
• Schwartzman RJ. The diagnosis and staging of RSD: an overview of the problem. Reflex sympathetic dystrophy: current strategies in diagnosis and treatment. Paper presented at Jefferson Medical College, Philadelphia, April 10, 1992.

Hallux limitus describes a condition in which there is limitation of motion of the 1st metatarsal phalangeal joint in the sagittal plane.

Hallux limitus is the inability of the hallux to dorsiflex at the 1st MPJ. This limited range of motion results in jamming of the 1st metatarsal phalangeal joint (1st MPJ).

Over time, repetitive jamming will contribute to arthritis of the 1st MPJ. The most characteristic sign of hallux limitus is a bump (exostosis) on top of the head of the 1st metatarsal. In fact, many doctors also refer to hallux limitus as a dorsal bunion.

Incidence

Ages 30 to 50 years old, men and women equally. Tends to occur in the pronated foot.

Pathogenesis

Hallux limitus is caused by four contributing factors. These factors include the following:

1. A long 1st metatarsal.
2. An elevated 1st metatarsal. (Metatarsus primus elevatus)
3. An impaction injury (trauma) of the 1st MPJ resulting in an osteochondral defect (OCD) of the joint.
4. Systemic diseases that cause injury to the joint such as rheumatoid arthritis, lupus, or gout.

Clinical Presentation

Patient usually presents with pain in the bottom of the 1st MPJ where a callous can develop due to the toe not bending upward enough. Another consequence of the jamming of the 1st MPJ is the development of spurs on the top of the joint, which can become painful as a result of shoe pressure. Evaluation of the range of motion of the 1st MPJ can be performed in two positions; relaxed and functional. In a relaxed position, with no resistance exerted by the calf, the 1st MPJ shows normal range of motion without pain. In a functional position, when resistance is applied by the calf, the range of motion of the 1st MPJ changes and hallux limitus can be more appropriately assessed. The term functional hallux limitus is applied to cases that have normal range of motion in a relaxed position, but decreased range of motion in a functional position.

Joint Fluid Analysis Findings

Non-inflammatorty, but can be used to rule out differentials

Useful Lab Tests/Studies

Diagnosis is made by performing a physical exam of the foot and the use of x-rays. Physical exam will reveal pain and limitation in motion of the 1st MPJ. The motion at the 1st MPJ is less than 65 degrees dorsiflexion. There is commonly mild swelling and bony prominences associated with the 1st MPJ. X-rays of the foot will reveal the true severity of the patient's condition. It will allow the physician to evaluate the joint for bone spurs, decrease in joint space, flattening of joint surfaces, and loose bodies in the joint. X-rays can also reveal the cause of hallux limitus such as an elongated or elevated 1st metatarsal.

Radiographic Findings

Uneven joint space narrowing, at the site of abnormal applied force. Subcondral sclerosis (Eburnation) adjacent to the site of the joint space narrowing, can be more diffuse in severe cases. Osteophytosis, typically at the margins of the affected joint, can be an isolated finding absent of joint space narrowing or subchondral sclerosis. Subchondral cyst in affected joint. Loose osseous body in affected joint. The loose body appears as a bone fragment or ossicle within the joint. It can be the initiating factor and caused by trauma, or it could be a fractured osteophyte in an already existing osteoarthritic joint. These 5 finds are also found in osteoarthritis which is essentially what hallux limitus is.

Morphological Changes

Narrowing of joint spaces and break down of cartilage, formations of cysts and exostosis of the bone around areas of cartilage that have been broken down due to increased pressure. Sclerosis of subchondral bone in response to increased pressure on an area. Progressively get worse as the disease progresses to hallux rigidus.

Differential Diagnosis

Osteoarthritis, Gout, Pseudogout, Rheumatoid arthritis, Lupus, septic arthritis, sesamoiditis, and sesamoid fractures.

Impact of Disease

Patient will have decreased ambulation due to the pain and limitation of motion at the 1st MPJ and therefore have a decreased quality of life.

Treatment

Conservative- anti-inflammatories, physical therapy, ice, MPJ ROM exercises once painful symptoms resolve, strapping to reduce motion of joint, padding, shoe gear with stiff soles, orthotic control. Long term conservative treatment is usually not very effective. Patients who do not respond to conservative treatment (especially patients with Hallux Rigidus) require surgery. One example of surgery preformed is a bunionectomy with an implant. The arthritic part of the bone and joint is removed and replaced with an implant.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Plantar Fasciitis [plantar (on the sole of the foot) heel pain] and heel spur syndrome results from prolonged, excessive tension in the plantar fascia and leads to inflammation and fibrosis at the attachment of the plantar fascia to the calcaneus. Then, an elongated plantar spur may develop at the attachment of the fascia.

A patient with plantar fasciitis usually presents with pain in the heel on arising in the morning or after periods of rest (poststatic dyskinesia). The pain may subside after several steps, and then slowly worsen as the day progresses. In worse cases, the pain is persistent and may awaken the patient while sleeping. Some people describe a "stone bruise," sharp, sticking sensation, numbness or tingling in the sole of the foot.

Examination reveals two groups of patients with plantar fasciitis.

The first subgroup has plantar central palpatory tenderness at the insertion of the central band of the plantar fascia into the calcaneal (heel) tuberosity. Patients have little to no tenderness medial to this area. The calcaneal tuber is often prominent, and bursa are occasionally present.

The larger group of patients has increased palpatory tenderness along the plantar medial and inferior medial wall of the calcaneus. Pain may be elicited by active or passive extension of the foot and digits. Palpatory tenderness extends along the fascial band into the medial arch.

The heel spur or calcaneal spur is an osteophytic growth anterior to the medial calcaneal tuberosity that usually extends its entire width or about 2-2.5cm. DuVries described three types of calcaneal spurs:

1. Spurs that are large and asymptomatic because the angle of growth of the spur does not become a weight-bearing point or the inflammatory changes remain subacute.
2. Spurs that are large and painful with weight bearing because the pitch of the calcaneus has been altered by depression of the longitudinal arch. As a result, the spur becomes a weight-bearing point causing intractable pain through myositis of the intrinsic musculature and adventitious bursa formation.
3. Spurs that have a small amount of bony proliferation and whose outline is irregular and jagged, accompanied by an area of decreased density around the origin of the plantar fascia indicating a subacute inflammatory response.

Conservative treatment combines pharmacological, biomechanical, physical, and surgical therapies. Corticosteroids are the most potent group of medications. Any of the injectable preparations may appear to be appropriate, given through a medial or plantar approach.

NSAIDS (non-steroidal anti-inflammatory drugs) provide relief.

Physical therapy has a useful and sometimes limited role. Icing after periods of activity and stretching of the Achilles Tendon and plantar fascia appear helpful, especially when used after rest.

Night splints play a role by applying a constant passive stretch to tendons, fascia, and muscles by keeping the foot and ankle extended.

Short leg casting has proven effective. Successful orthotic therapy has been reported in podiatric literature.

O'Brien and Martin noted that orthotics were most helpful in patients with a history of heel pain lasting longer than 2.5 years. The use of heel cushions has been reported as a successful modality. Low dye strappings appear helpful.

Surgical procedures include neurolysis (excision of the lateral plantar nerve), heel spur resection, plantar fasciotomy (releasing the plantar fascia), and endoscopic plantar fasciotomy.

Morton Neuroma is the inflammation of a nerve due to the compression of surrounding bones. It most commonly occurs between the third and fourth toes at the ball of the feet. Possible causes include flat feet and wearing shoes that do not fit properly. More women will suffer from this type of neuroma from wearing pointed, high-heeled shoes that constrict the toes.

Patients will usually notice symptoms of Morton's neuroma during or after pressure has been placed on the balls of the feet by doing such activities as standing, walking, and running. Some of the most frequently described symptoms are:

• Localized pain between the toes (dull or sharp)
• Burning
• Loss of sensation
• Tingling
• Cramping
• Inflammation
• Sore to the touch

Your podiatrist must first rule out other conditions like rheumatoid arthritis and diabetic neuropathy, which have very similar symptoms. During your exam, your doctor may pull up on your first, second, and third toes while pushing down on your fourth and fifth toes. In most cases of Morton's neuroma, you will hear a click noise that is known as Morton's sign.

If he or she then determines that you are suffering from Morton's neuroma, a more conservative treatment is chosen first. The use of metatarsal pads, custom orthotics, and the use of proper fitting footwear can be expected for treatment.

The sooner you are diagnosed, the greater chance you have of successful conservative treatment.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Osteoarthritis (Degenerative Joint Disease)

Osteoarthritis (OA) is a disease characterized by progressive loss of articular cartilage, appositional new bone formation in the subchondral trabeculae, and formation of new cartilage and new bone at the joint margins. The exact mechanisms by which primary osteoarthritis develops are unknown.

Secondary osteoarthritis is applied to the disease when it appears in response to some local or systemic pathology (disease process).

As far as pathology is concerned, the cartilage appears thicker than normal. An increase in water content leads to swelling of cartilage and an increase in the net rate of proteoglycan (any of a group of glycoproteins (class of protein) present in connective tissue and formed of subunits of disaccharides linked together and joined to a protein core. It serves as a binding or cementing material.) synthesis. The integrity of joint surface is lost and this leads to exposed bone.

Some symptoms include pain early after joint uses, particularly after prolonged activity of the joint and is relieved by rest. As the disease progresses, pain occurs at rest. One may have stiffness or muscle spasms.

One may experience tenderness on one side of the body and pain on joint range of motion. There may be joint enlargement due to bone proliferation, spurs, chronic synovitis (inflammation of synovial membrane) or effusion (escape of fluid into a part). One can have pain on passive range of motion and crepitus (crackling sound).

Xrays or radiographs appear normal in early stages, but may also show uneven joint space narrowing, marginal osteophytes (spurs), bone cysts and joint mice (loose osseous bodies).

Nonspecific synovial fluid reveals minimal abnormalities if any.

Primary OA's cause is unknown. In the hands one may see Heberden's nodes at the distal interphalangeal joints and Bouchard's nodes at the poriximal interphalangeal joints. In the feet one can have OA at the 1st metatarsophalangeal joint. OA is also seen in the knees, hips, and spine.

Secondary OA is caused by a local or systemic pathology. There may be trauma (post-traumatic joint malalignment). It may be due to metabolic or endocrine processes such as acromegaly(abnormal enlargement of the extremities of the skeleton). Another cause is Charcot joints.

Treatment includes patient education, rest, physical therapy (heat/ice, exercise, gait training), occupational therapy-splints, joint protection, assistive devices). Analgesics like asprin and acetaminophen may be used. Anti-inflammatory agents (NSAIDS, intra-articular corticosteroids) are helpful.

Surgical intervention may include correction of joint malalignment, debridement of loose bodies, spurs, osteotomy, arthrodesis (bone fusion) or partial or total joint replacement.

Foot corns - the irritating bumps that can appear on the sides of your toes, at the foot sole and in between toes, are the result of friction. Foot corns are your body's response to the pressure and irritation your shoes cause as they rub against your feet.

Corns develop from a buildup of dead skin cells that become thick and hard on the foot. They usually appear on the tops, tips, and sides of the toes. The cone-shaped core of a corn places pressure on the nerve below it, which can be very painful. Corns often become more irritated by the steady rubbing and pressure from your shoes.

Types of Foot Corns

1. Hard Corns, and
2. Soft Corns

A hard corn is most commonly located on the second through fifth toes and is hard to the touch. Occasionally, a hard corn may appear on other toes.

A soft corn typically shows up between the fourth and fifth toes.

What causes Corns?

Foot corns can be painful and aren't exactly aesthetically pleasing, but a foot corn does provide protection against contact with an offending surface - usually an ill-fitting shoe. Women, who often wear poorly fitting shoes in the name of fashion, develop corns more often than men.

Some of the most common reasons people develop corns are:

• Having toes that are deformed
• Wearing shoes that are too tight
• Wearing socks or stockings that are too tight
• Shoes with narrow toe boxes, especially women's dress shoes
• Increased moisture trapped between toes
• Toe friction inside shoes or socks
• Pressure of high-heeled shoes
• Contracted Toes (Hammertoes)

Symptoms

Foot corns, thickened patches of dead skin that commonly emerge on toe knuckles, especially the pinky toe - are concentrated and feel much harder than the surrounding skin.

You can recognize a corn by asking the following questions:

1. Do you have a small patch of excess skin on a toe?
2. Is there an area on your toe that feels hard?
3. Do any patches of skin on your feet seem higher than the smooth skin surface?

Relief and Prevention Tips for avoiding foot corns

The following may help to both prevent and treat corns:

• Start wearing properly fitted shoes.
• Stop wearing shoes that inflict pressure or irritation.
• Limit the length of time you wear high heels, or stop wearing them altogether.
• Use insoles and inserts in your shoes to combat pressure points and rubbing.
• Surgical correction of contracted toes (Hammertoe correction)
• Wear socks and stockings that fit comfortably
• Orthotics

If you already have a corn, try trimming down excess skin with pedicure files, or applying softening cream to help eliminate discomfort. Also try wearing shoes with a wider toe box to decrease the pressure inflicted on current foot corns.

Although foot corns do not present a long-term or serious health risk, they can be very painful. If changing your shoes and other treatments do not alleviate symptoms, you should see a podiatrist for additional treatment.

Those who have diabetes and poor circulation should not use any chemicals to get rid of corns.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Congenital dislocated hip is an abnormality that is seen at birth. The role that podiatrists play in pediatrics is remarkable. With the first sign of stance or walking abnormality, a parent's concern will be great enough to rush their child off to the doctor. We will learn about the many tools and techniques, which cater to the pediatric patient, that allow a congenital dislocated hip to be diagnosed and treated.

Children are born with a congenital dislocated hip. The word congenital means to be born with. It is a condition in which the head of the thigh bone, the femur, is detached from the pocket that it sits in, which is called the acetabulum. Studies have shown that females are affected more than males and occur 1 in every 1000 births. Oddly enough it has even been shown that the left hip is dislocated more often than the right.

A child's birth position can cause a dislocated hip. The most common birth position for congenital dislocated hip is a breech position. This is where the child presents buttocks first. The defect can also be seen with the transverse position, where the child presents other than head first. If the child presents feet first, there is opportunity for defect due to the doctor pulling the legs. Other factors that can cause a dislocated hip are:

• Deformed Acetabulum
• Acetabulum Slope
• Ligament Laxity

So how would you know if the child has a dislocated hip? Well, on the effected hip you will see shortening of that limb. The child will present with a limp while walking. The child will also have limitation of abduction (moving the thigh out from the body) with the thigh flexed. The telescoping sign will be present. This is where the podiatrist would be able to push the leg beyond the hip joints normal articulation. The side of the deformity will present with increased skin folds on the child's buttocks.

There are tests which diagnose and confirm congenital hip dislocation. The first test is Ortolani's Sign. In this test the knees are bent and a "clunk" sound is heard as the femoral head is repositioned over the acetabulum. Now you don't necessarily have to hear a clunk sound, but you will be able to feel the relocation. The other test is Barlow's Sign. This is with the infant's knee flexed. The podiatrist will apply thumb pressure over the anterior thigh. The femoral head should displace posteriorly.

Now that we know what a congenital dislocated hip is and how to identify it, let's talk about how podiatrist treat and fix the problem. The main goal of hip relocation is to abduct the thighs and force the head of the femur back into the acetabulum. A cast called a bachelors cast, which extends from the groin to the ankles, can be applied. The knees on this casting procedure are joined by a cross bar to hold the correct abducted procedure. The best recognized treatment for congenital dislocated hip is the Pavlik Harness. With this harness the legs are held in and abducted position as well as allowed to move in flexion. This allows the child to be able to crawl.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Plantar warts are just one of several soft tissue conditions caused by a virus invading the skin. They are often contracted by walking bare foot on unclean surfaces.

Although warts may appear anywhere on the foot, plantar warts commonly grow on the soles.

They may spread from one part of the body to another, or from one person to another. Children, teenagers, and people with allergies or weakened immune systems are more prone to warts; however, some people seem to be immune and will never develop them.

Warts are usually harmless, but can be very painful.

Plantar warts are generally hard, flat, and rough-surfaced with well-defined boundaries. They tend to be brown or gray with a center consisting of black pinpoints.

What can I do to prevent plantar warts?

Proper foot hygiene and regular inspection of the feet and toes are the best ways to prevent this condition. You should also:

• Keep your bath or shower area clean
• Wear shower shoes whenever possible, in public showering facilities
• Wash your feet with soap and water every day
• Dry your feet well, particularly between the toes
• Always wear clean socks
• Change shoes after two days to give them time to dry out
• Check your child's feet regularly
• Avoid contact with warts - either from other parts of your body or from other people
• Visit our podiatrist annually

What treatments are available?

Self treatment is not recommended for anyone with warts, especially people with diabetes and those with cardiovascular or circulatory disorders.

Your treatment may include freezing or burning the affected area, over the counter medication, or a simple surgical procedure performed under local anesthetic. A procedure known as CO2 laser surgery is also becoming a more popular treatment option for people with plantar warts.

If you do not seek treatment, warts can grow to an inch or more in perimeter and multiply.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Brachymetatarsia(short metatarsal) is a hereditary anomaly that occurs as a result of premature closure of the growth center of a metatarsal or metatarsals. When multiple metatarsals are involved the name is brachymetapody. Most commonly the fourth metatarsal is affected. The other metatarsals continue to grow and the length becomes exaggerated.

Brachymetatarsia can result from trauma to the metatarsal or from an infectious process. It has also been associated with Down's Syndrome, Sickle-cell anemia, and polio. The defect is not always noted at birth but, becomes more evident between 4-15 years of age. Brachymetatarsia may occur unilateral or bilaterally, though mostly seen on one side.

Clinically, the younger patient notices a shortened or floating toe. Calluses may develop under the adjacent metatarsal heads with pain. The adjacent toes underlap the involved toe.

Radiographs reveal a short, underdeveloped metatarsal with deficient bone content and osteoporosis of the metatarsal head. The affected toe is usually straight, in an extended position, and floats above the weight-bearing plane. Conservatively one may use orthotics.

For surgical correction bone lengthening procedures are performed, bone grafts may be inserted, extensor tenotomy performed, and skin plasty may be performed. Below knee non-weight bearing cast may be applied. Callus distraction (with pins and external fixation) is another procedure performed to attempt to lenghthen the metatarsal. Soft tissues can gradually elongate with the bone. Postoperative non-weight bearing is used for 2-3 months pending xrays evidence of bone healing.

Complications include risk of neurovascular compromise, non-union, collapse of the graft if implemented, painful pseudoarthrosis and painful limitation of motion at the joint.

Bibliography

• Banks, Alan S., et al McGlamry's Comprehensive Textbook of Foot and Ankle Surgery.Philadelphia:Lippincott Williams and Wilkins, 2001.
• McGlamry ED, Fenton CF. Brachymetatarsia:a case report. J AM Podiatry Assoc 1983;73:75-78.
• Robinson J, Ouzounian T. Brachymetatarsia:congenitally short third and fourth metatarsal treatment by distraction lengthening- a case report and literature summary. Foot Ankle Int 1998;19:713-718.