Operational Podiatry
Ingrown toenail
This condition usually presents with erythema, edema, a crusted
drainage, and pain along the affected nail border. Usually the etiology involves trauma, a
diseased nail, ill-fitting footgear, or injudicious cutting of the nail.
Treatment
A digital block is obtained with 3 to 5cc of 1% lidocaine and a 25 or 27 gauge 1 1/4
inch needle at the proximal portion of the toe making sure to address all four nerves
(dorsomedial, plantar medial, dorso-lateral, and plantar-lateral). Once anesthesia is
achieved, prep the toe with betadine and remove approximately 1/8th of the offending nail
border. Using a thin instrument, slide under the offending nail border from distal to
proximal. With the same instrument detach the dorsal part of the nail from the proximal
toe tissue fold. With iris scissors, cut the detached 1/8th of the nail boarder from
distal to proximal making sure to cut the nail under the proximal toe tissue fold, then
roll the detached nail out with a hemostat.
Have the patient soak in warm water twice a day for 1 or 2
days. Post nail removal pain relief can be achieved with NSAIDs. The patient may need a
day or two of no marching. If an ingrown toenail is a chronic problem (three or more
removals from the same side) the patient may be referred to podiatry for permanent
removal. The majority of patients will not need antibiotics. This condition may be
perceived as a foreign body reaction. When the foreign body (the nail) is removed the
problem is solved.
Corns and Calluses
Corns and calluses are specific accumulations of stratum corneum over bony prominences.
Corns most often occur on the dorsal aspect of hammer toes. Calluses usually appear
plantar near the metatarsal heads. Corns and callus are the reaction of normal skin to an
abnormal amount of intermittent friction and pressure. They can be quite tender and can
interfere with work as well as off duty activity. Calluses are often misdiagnosed as
planter warts. Plantar warts have pinpoint spots of punctate bleeding on debridement while
calluses are free of bleeding during debridement.
Treatment
The treatment for corns and calluses are focused at decreasing the skin build up and
reducing the friction and pressure from the affected area(s). Debride the excess skin with
a 10 or 15 blade. Corns are best treated after debridement with a larger, wider shoe and a
moleskin appeture pad with a cut out area over the lesion. A callus is treated with
debridement along with the placement of a Spenco® insole into the work shoe. Spenco®
insoles are carried by most military exchanges.
Discourage the use of medicated pads or liquid corn removers since these treatments can
cause ulceration. A routine consult to podiatry is appropriate when the patient is on
shore duty and wishes more aggressive treatment.
Plantar Foot Laceration
Treatment
Flush the wound with 1% lidocaine
containing 1:100,000 epinephrine. Inspect the wound
for any foreign bodies. Copiously flush the wound with sterile water from a 10 cc syringe
until all debris is washed or picked out. If the wound is clean and 6 hours old or less,
anesthetize the area and close with 3-0 or 4-0 nylon sutures. If the wound is old or dirty
lightly pack it open with moist Nu-gauze. Dress the wound with nonadherent gauze, gauze
fluff, and roller gauze (kling). Keep patient's foot elevated for 2 days and keep patient
non-weight bearing on crutches for 2 weeks. If the wound is healed, sutures can be removed
after 2 weeks. Unremovable foreign bodies in the foot should be referred to podiatry.
Heel Spur Syndrome and
Plantar Fasciitis
Heel spur syndrome and planter fasciitis are similar conditions on the plantar aspect
of the foot. Both conditions involve the structure known as the planter fascia. Heel spur
syndrome presents with pain on the plantar medial side of the heel and is usually presents
as pain during the "first step in the morning." Plantar Fasciitis can present as
tenderness throughout the arch with pain also experienced as the "first step in the
morning". However, pain is experienced usually later in the day during exercising or
other daily activities. Both heel spur syndrome and plantar fasciitis are overuse-related
conditions. These can be secondary to foot type, life style (Marine) or overweight body
habitus.
Treatment
Have the patient buy an over the counter arch support such as the Spenco -Walker
Runner® or Sorbathain® arch support. Medications should include NSAIDs. Educate the
patient in stretching the plantar facie twice a day by dorsiflexing the foot, dorsiflexing
their toes, and massaging the planter fascia with their other hand. The patient may also
massage the planter fascia with ice. Place the patient on about 30 days light duty. If
pain persists for more than one month inject the point of max tenderness with a 1:1:1 mix
of 1% lidocaine without epinephrine + 0.5% marcaine without epinephrine + kenalog 10, 3cc
total. If pain continues for more than 2 months referral to podiatry or physical therapy
is recommended.
Reviewed by CDR Richard Baker, MSC, USN, Department of Podiatry, National Naval
Medical Center, Bethesda, MD (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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