Podiatry Resource Network - Dr. Glass DPM

Sugical Survey - 03 - Morton’s Neuroma

Thu, 4 Dec 2008 08:16:03 -0500

Project Lead: Nicholas Giovinco
Resources Consultant: Kelly Powers
Producer: Nicholas Giovinco

A Morton's neuroma is a pathological condition which is caused by a benign neoplasm of the plantar interdigital nerve in the foot. This results from a tumorous growth of the perineurial tissue called a fibroma, thus a Morton's neuroma is not a true neuroma.

Although a Morton's neuroma most commonly arises in the 3rd interspace, between the 3rd and 4th metatarsal heads, it may also be found in the 2nd or 4th interspace as well.

Symptoms of a Morton's neuroma may include numbness, paraesthesia, and a sharp, shooting pain, which radiates towards the affected toes. This sensation is elicited or exaggerated by compressing the metatarsal heads together which, in turn, compresses the enlarged nervous structure.

Conservative care of a Morton's neuroma may include sclerosing and anti-inflamatory injections, as well accommodative orthosis. Although these methods may relieve painful and immobilizing neuroma conditions, surgical intervention may be required.

This involves soft tissue exposure or dissection of the enlarged nerve body. Once this is done, the neuroma must be isolated and removed by cutting away the stem, proximally, and the branches, distally.

Because the nerve is removed, there will be a loss of sensation in the affected area for several months or even years. Over time, this area will re-innervate by means of communicating branches from surrounding nerves.

VidDoc - 02 - International Institute for Foot and Ankle Surgery

Wed, 3 Dec 2008 18:26:54 -0500

Cinamatography: Greg Roten
Resources Consultant: Kelly Powers
Producer: Nicholas Giovinco

In August of 2008, the International Institute for Foot and Ankle Surgery embarked on its 4th annual medical mission to El Salvador. Founded by Dr. Joseph D. Giovinco, an Atlanta podiatrist, the IIFAS continues to freely offer citizens of the world the same standard of podiatric medical care as their United States counterparts.

This years eight day podiatric medical campaign was successfully headed by podiatrists Dr. Joseph D. Giovinco and Dr. Chris Menke. The non-profit organization arrived to this native country, equipped with over $25,000 worth of corporate and privately donated medical hardware and supplies.

With the assistance of local supporters, the campaign was able to transport across the country towards the town of San Miguel. It is here that campaign members lived with the local family of Dr. Salvador Perez, who is the chief of surgery at the hospital of Nueva Guadeloupe. Collaboration between Dr. Giovinco and Dr. Salvador Perez, resulted in an organized team of 17 volunteers which included both American podiatrists and El Salvadorian surgeons.

To start the campaign, this mission made an initial excursion to several rural villages embedded along the country-side of El Salvador. This leg of the campaign provided members of the mission team an opportunity to offer in-home care to some of the more remote and financially burdened citizens.

The next stage of the campaign took place at the hospital of Nueva Guadalupe. Here, the campaign utilized the hospital's clinical quarters and services to evaluate and treat over 100 individual patients, who were able to make the long pilgrimage.

Although these patients presented with a variety of conditions, the overall population of El Salvador is without proper podiatric medical care. This results in an unfortunate number of people and children with neglected deformities and post traumatic ailments.

Children with congenital deformities were evaluated for treatment by means of gait analysis and physical examination. If left untreated, one can see how these imperfections not only effect the biomechanical function of the body, but can compromise the patient's overall quality of life.

Based on age and severity of the underlying condition, some of these patients were able to begin a serial casting regiment. This is a method used to correct a young child's clubfoot deformity, whereby a gradual sequence of reduction is utilized before the foot becomes ossified and rigid.

For patients who posses neglected or severe deformities, surgical treatment was offered. This took place in the hospital's operating rooms, where team members worked side by side with resident doctors to provide an uncompromising standard of medical care.

Through hours of tireless effort, the 2008 IIFAS campaign was able to surgically address more than two dozen complex and immobilizing conditions. This involved a variety of high caliber surgical procedures and techniques to restore and improve function to the feet and legs of El Salvador's citizens.
 The IIFAS has many goals, aside from providing the impoverished with high quality podiatric medical care. The central mission of the institute is to empower indigenous health care providers to offer the same level of care for themselves through education and training.
 This continuing effort is made possible by both the local ancillary services offered by the hospital of Nueva Guadalupe, as well as the overwhelming support of local residents and hospital staff. In addition to volunteer translation service and medical assistance, these local citizens also provide travel and housing arrangements to the campaigns members.

This integration and cooperation with the native cultural community remains an important touchstone of the IIFAS. It is a vital component in the effort to achieve a lasting relationship with the people of the world around us.

For more information about the International Institute for Foot and Ankle Surgery's current and future campaigns, please visit the official website at www.iifas.net. It is important to remember that this organization's effort could not be made possible without your contributions; please visit the donations section to place your benefaction to the future of podiatric medical mission work, today!

Sugical Survey - 02 - Hallux Abducto Valgus Bunion

Tue, 23 Sep 2008 06:53:06 -0400

Project Lead: Nicholas Giovinco
Resources Consultant: Kelly Powers
Producer: Nicholas Giovinco

A "Hallux Valgus" or "Hallux Abducto-Valgus" deformity, is commonly referred to as a "Bunion." This describes a pathological condition involving the position of the "hallux" in relation to the first metatarsal.

A bunion deformity can clinically present with a variety of characteristics. The foot itself may present with a wide splaying of the forefoot and a painful bump on the medial aspect of the first metatarsal phalangeal joint. In addition, the hallux may be abducted from the midline of the body, with a valgus rotation in the frontal plane.

A radiographic analysis of a bunion deformity in the Anterior/Posterior or Dorsal/Plantar view will reveal a variety of pathological components. Most notably so, is the exaggerated inter-metatarsal angle between the first and second metatarsal. This may be accompanied by a displacement of the first metatarsal from its position over the sesamoids, such that the metatarsal demonstrates a medial alignment away from the sesamoids which lie to the lateral side.

In some cases, the proximal articular set angle at the head of the first metatarsal may be off-set. This "PASA" is one of the factors which determines the position of the proximal phalanx on the metatarsal during movement as well as at rest.

Although conservative care may involve shoe modifications, padding, strapping, and custom orthosis; surgical reconstruction may be required to alleviate painful and immobilizing bunion conditions.

Soft tissue components of the bunion deformity are primarily addressed by means of a capsular modification, as well as a tenotomy of the adductor tendon at its insertion on the base of the proximal phalanx. The fibular sesamoid may be repositioned by a release of the surrounding ligaments.

Surgical management of the bone or osseous components of a bunion deformity will commonly include an osteotomy and correction to re-establish a more functional position of the first metatarsal within the forefoot. This capital fragment of bone is held in place with hardware fixation in order to secure a proper alignment during the healing phase, thus allowing the hallux to return to a more functionally useful position in the sagittal plane.

VidDoc - 01 - Inter-Podiatric College Student Research Symposium (IPCSRS).

Tue, 29 Apr 2008 16:38:54 -0400

Project Lead: Nicholas Giovinco
Resources Consultant: Kelly Powers
Producer: Nicholas Giovinco

The First Annual Inter-Podiatric College Student Research Symposium (IPCSRS) was held at the New York College of Podiatric Medicine (NYCPM) on February 16th & 17th, 2008. The IPCSRS was hosted and organized by members of the NYCPM student body, Samir Lalani, Kurt Rode, Rafael Ramirez, and Nicholas Giovinco along with faculty advisor Dr. Anthony Iorio. This conference was the first student-run event to offer members of all the 8 American podiatric medical colleges and the Canadian Podiatric Medical College in Quebec an opportunity to present research posters in an academic arena. In an attempt to promote the discipline of evidence based medicine, this research symposium was developed to deliver a constructive experience to its participants while offering a survey of the latest clinical applications.
Presented by their authors, these poster submissions were judged on a variety of criteria including layout, construction, methods, and the presenters responses questions. Although this was a first time experience for many, it was a well received component to the educational value of the competition. The traveling symposium trophy was awarded to first place contestant Benjamin Carelock, with his poster titled "Osseous Changes in the Forefoot of Indoor Rock Climbers," from the Arizona Podiatric Medical Program. Second place honors were awarded to Christy King and James Johnston from the California School of Podiatric Medicine, and the 3rd place prize was awarded to Krupa Patel from the New York College of Podiatric Medicine.
In addition to the presenting forum, the conference itself kicked off with a keynote address by the American Podiatric Medical Association's (APMA) President-Elect Dr. Ross Taubman. Dr. Taubman's discussed the APMA's goal of "Vision 2015" Dr. Taubman's remarks were followed by numerous lectures and presentations ranging from topics such as Diabetic Wound Care, Biopsy Techniques, Vascular Intervention, and Surgical Innovations.
These lectures were accompanied by several hands on workshops from a variety of specialty tracks. By breaking guests into smaller rotation groups, these sessions offered attendees the opportunity to experience a wide sampling of the most current advancements in podiatric medical care. These tracks included orthopedics, internal and external fixation, wound care, vascular intervention, and podiatric dermatopathology.
The symposium's educational training by day, was matched with social gatherings and get-togethers by night. The main event was the "Veins and Vines" wine and cheese party on Saturday evening. Held at the Jazz on the Park hostel in Manhattan's upper west side.
With over a dozen corporate sponsors and participants, the First Annual IPCSRS proved to be a "one of a kind" event in podiatric medical education. "We are grateful to have received such participation from our sponsors," said Samir Lalani in his closing remarks. The NYCPM Student Association President then went on to say, "However, this event could not have been possible without the amazing support we received from Dr. Anthony Iorio. Without his help and guidance, this symposium would never have happened."

Sugical Survey - 01 - Hallux Limitus / Rigidus.

Tue, 19 Feb 2008 07:35:01 -0500

Project Lead: Nicholas Giovinco
Resources Consultant: Kelly Powers
Producer: Nicholas Giovinco

"Hallux Limitus" and "Hallux Rigidus" describe a pathological condition involving the first metatarsalphalangeal joint. Hallux limitus refers to a limited range of motion during functional use, such as walking and running especially on inclines. When the structural degeneration advances to the state where there is no motion of the first MTPJ at all, it is then called Hallux Rigidus.

Morphologic characteristics of Hallux Limitus are visible with the use of Radiography. A radiograph in the AP view would be needed to assess a relatively long first metatarsal in comparison to the lesser metatarsals. When viewed on a lateral radiograph, Hallux Limitus may be noted in correlation with an elevated 1st metatarsal, where either the entire metatarsal itself is abnormally elevated above the lesser metatarsals or simply the head itself is in a relatively dorsiflexed position over the shaft. Over time, Hallux Limitus can lead to the formation of an exostosis on the dorsal surface of the first metatarsal head and a painful swelling on the dorsal surface overlying the first metatarsal head.

When conservative care fails, surgical intervention may then be utilized. This procedure involves dissection through the capsule to the joint, followed by an adhesiotomy of fibrotic material on the articulating surface and cheilectomy of superfluous bone and cartilaginous formation. The elevated first metatarsal is brought to a plantar position by use of a variety osteotomy procedures which will result in the alignment of the first metatarsal head with the lesser metatarsals.

Functional Orthopedics - 02 - Ankle Joint Complex.

Tue, 22 Jan 2008 04:39:46 -0500

Project Lead: Shane Baker
Resources Consultant: Kelly Powers
Producer: Nicholas Giovinco

The Rearfoot or ankle joint complex is unique in that it is the interface between the upper segment and the lower segment of the lower extremity. The ankle joint complex has the primary responsibility of managing the body’s weight with and against the ground reaction forces below. Successful negotiation of these forces are critical to accomplish multi-plane motion and bipedal ambulation. This biomechanical complex consists of the bones of the hind foot (talus and calcaneus) and two anatomically distinct joints; the Ankle or tibio-talar joint, and the subtalar joint.

For this illustration, we will begin by describing the Ankle Joint. This joint exists between the smoothed spindle shape trochlear surface of the Talus and the ankle mortise formed by the two malleoli and the plafond of the tibia.

The neutral orientation of the Ankle Joint axis is that of a pronatory / supinatory joint which runs lateral, posterior, and plantar to medial, anterior and dorsal. This arrangement corresponds to the deviation of the malleoli in the ankle mortise. The spacial orientation of this joint’s axis in relation to the three cardinal body planes is: 8 degrees from transverse plane, 82 degrees from the sagittal plane, and 20-30 degrees from the frontal plane.

With this configuration we can consider the planal dominance of the ankle joint. Since the ankle joint has the largest deviation from the sagittal plane; we can conclude that the dominate motions in the ankle joint thus are planterflexion and dorsiflexion.

An exception to this concept is frontal plane motion. Because of the ankle mortise and soft tissue that surrounds the joint, we clinically see less frontal plane movement than would be inferred from the deviation of the axis from the frontal plane. Thus, the resulting motion of the frontal plane is clinically insignificant because of this soft tissue and osseous block.

The joint axis changes dynamically between plantarflexion and dorsiflexion. At neutral and dorsiflexed positions the joint axis runs from lateral, posterior, and plantar to medial, anterior and dorsal. However, with plantarflexion the axis shifts or tilt ever so slightly in the frontal plane, therefore running lateral, posterior, and dorsal to medial, anterior and plantar. This is because of the spindle shape trochlear surface of the talus is maintaining contact with the plafond of the tibia, and therefore resulting in a slight seesawing motion of the joint axis in the frontal plane.

In Gait, the Ankle Joint functions in two mode, open chain and closed chain. Open chain is when the foot is off the ground with the distal segment free and closed chain the foot is in contact with the ground where the distal segment in not free.

Open chain motion in the Ankle Joint occurs at the distal portion of the joint where the calcaneus and foot will be in motion relative to the fixed position of talus and leg.

Open chain pronation in the Ankle joint result with the foot in dorsiflexion, abduction and with some clinical insignificant eversion. Open chain supernation results in of the foot in planterflexion, adduction and some clinical insignificant inversion. Remember these motions are produced by the movement of the calcaneus and foot on a fixed talus and leg.

Closed chain motion is more complicated because rotation of the foot is blocked by the ground and thus all movement is produced by the moving leg relative to a fixed foot.

In closed chain dorsiflexion the leg is brought toward the fixed foot, and the abduction that occurred in open chain is now seen as internal rotation of the leg. During closed chain planterflexion the leg is moving to a position away from the fixed foot and adduction that occurred in open chain now exists as external rotation of the leg. It always important to remember that closed chain motion is a function of the lower extremity where a motion occurs in and around a relatively fixed foot position.

This illustration of the ankle joint complex will focus on the Subtalar joint, which lies inferiorly to the Tibio-Talar Joint. It exists between the anterior, middle, and posterior facets on the plantar surface of the talus and the anterior, middle, and posterior facets of the dorsal surface of the calcaneous.

The orientation of the Subtalar axis is that of a pronatory / supinatory joint which run lateral, posterior, and plantar to medial, anterior and dorsal which can demonstrated to bisect the posterior facet of the calcaneus. The degrees of orientation of the joint axis relative to the three cardinal body planes are: 48 degrees from the transverse plane, 42 degrees from the frontal plane, and 16 degrees from the sagittal plane.

The planal dominance in the subtalar joint is different from the Ankle joint. Since we see a relatively equal deviation of the joint axis from the frontal and transverse planes, we clinically see a co-dominance in mobility in both of these planes. This relationship exists as a nearly 1:1 ratio; thus it can be clinically inferred that for every degree of motion produced in the frontal plane will result in the production of an equal degree of motion in the horizontal plane.

This relationship has been compared to a mitered hinge; which is a hinge at 45 degrees that acts as a torque converter and takes rotation forces of the frontal(or vertical segment) and produces equal rotation of the horizontal segment. Clinically; because of this 1:1 ratio we can consider the frontal and horizontal axis and motion one in the same.

Open chain movement at the subtalar joint is produced by motion of the calcaneus which lies distal to the talus. This results in the calcaneus and remainder of the foot, to move about the fixed talus and leg.

Open chain pronation at the subtalar joint is a result of the foot being dorsiflexied, abducted and everted. Whereas, open chain supination is a result of the foot being plantarflexed, adducted, and inverted. Remember these motions are produced by the movement of the calcaneus and remaining foot while the talus and leg fixed.

Closed chain motion is more complicated because a majority calcaneal motion is inhibited by the ground and all movement which is blocked by the ground is produced by equal and opposite motion at the proximal talus and leg in relation to the foot. It is important to know that not all motion is blocked by the ground at the calcaneus. While sagittal and transverse motions become limited in a closed chain environment, calcaneal motion in the frontal plane remains the same.

Thus in closed chain pronation, the calcaneus will still evert, but abduction and dorsiflexion are performed by talar planterflexion and adduction with internal rotation of the leg. This process of closed chain pronation produces a morphologically lower and wider foot because the talus is lowered from the calcaneus while protruding out medially.

Likewise, in closed chain supernation, the calcaneus will still invert, but adduction and planterflexion are performed by talar dorsiflexion and abduction with external rotation of the leg. This process of closed chain supination produces a morphologically taller and thinner foot because talus becomes stacked over the calcaneus and rotated into a narrower configuration.

This completes the illustrations of the ankle joint complex. The two components of the ankle joint complex are the tibio-talar joint which has planal dominance in the sagittal plane and the subtalar joint which has planal dominance in the transverse and frontal planes. The Ankle joint complex is highly specialized thereby resulting in efficient translation and dissipation of external forces being produced by the ground and the weight of the body during the gait cycle.

Functional Orthopedics - 01 - Cardinal Planes.

Wed, 28 Nov 2007 19:04:34 -0500

Project Lead: Shane Baker
Resources Consultant: Kelly Powers
Producer: Nicholas Giovinco

This is an illustration that depicts the cardinal plane movements of the lower extremity. This is a biomechanical demonstration of the functional orthopedic nature of podiatry

“In the anatomical lower extremity, there exist three cardinal planes: Sagittal, Frontal, & Transverse. Anatomical motion that occur parallel to these planes are considered to be the dominate motions of that plane.

The Horizontal, or Transverse, plane divides the foot in a superior and inferior half. Adduction and Abduction are the motion that occur. Parallel to this plane, adduction is when the foot and leg are medially rotated towards the midline of the body, and Abduction is when the foot and leg are laterally rotated away from the midline.

The Frontal, or Coronal, plane divides the foot in to Anterior and Posterior portions. Inversion and Eversion are the motions that occur parallel in this plane. Inversion is when the plantar surface of the foot rotates toward the midline of the body and Eversion is then the plantar surface of the foot rotates away from the midline of the body.

The Sagittal plane, which in the foot is approximated to the osteological axis of the 2nd metatarsal, separates the foot in to medial and lateral halves. Parallel to this plane, Dorsiflexion and Plantarflexion refer to the relationship between the surface of the foot and the anterior surface of the leg.

Thus dorsiflexion is when the dorsum of the foot moves toward the leg whereas plantarflexion is defined when the dorsal surface of the foot moves away from the leg. It should be noted that process of the walking happens in the sagittal plane.

Triplaner motions does not occur in parallel to any of the three cardinal body planes mentioned. It is merely ONE motion consisting of components from all three body planes. This can be demonstrated in the lower extremity by the actions of Pronation and Supination which are triplaner motions.

Pronation is a motion of the foot which is comprised of eversion, dorsiflexion, and abduction. With this, the foot is seen to move toward the anterior leg while the toes and plantar surface moving away from the midline.

Whereas supination consists of inversion, plantarflexion, and adduction, resulting in the foot to move away from the anterior leg and with the toes and plantar surface moving toward the midline.

At a particular joint, in order for a given triplaner motion to be in supination or pronations it must consist of the motions disgust above. The amount of each movement depends of the anatomy of the joint. With that said it is critical to understand that pronation and supination are triplanar motions, but not all triplanar motions are considered pronation or supination.”