FOOT PROBLEMS AND LOW BACK PAIN
From the 32nd Annual Family Practice Refresher Course, presented May 31 to June 4, 2005, by the David Geffen
School of Medicine at the University of California, Los Angeles
| OFFICE PODIATRY— Alan M. Singer, DPM, Assistant Clinical Professor, Department of Surgery, David Geffen
School of Medicine at the University of California, Los Angeles
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| Onychomycosis: most topical antifungal agents ineffective because of inability to penetrate nail “at any kind of concentration
to really do very much”; rarely painful; aesthetic problem; false-negative rate of KOH test 30%; treatment—
discuss with patient; topical agents; oral antifungal agents—fairly effective (75%-80% of patients satisfied with results);
difficulty obtaining reimbursement from insurance companies increasing; terbinafine (Lamisil) 250 mg once
daily for 90 days; itraconazole (Sporanox; pulse or daily dosing); check liver function and repeat after 90 days; side effects
(particularly of Lamisil) include taste disturbances (resolve after drug discontinued); long (7-9 mo) half-life in
keratin cells; discontinue if 90-day course ineffective
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| Ingrown toenail: oral antibiotics (eg, cephalexin [Keflex], dicloxacillin, erythromycin) acceptable in diabetic or immunocompromised
patients unless cellulitis present; ciprofloxacin (Cipro) for Pseudomonas; amoxicillin and potassium clavulanate
(Augmentin) good drug to start with in diabetic patients; levofloxacin (Levaquin) for patients with allergy; nail
avulsion—perform if proper instruments (eg, blunt-tipped nail cutter) and reasonable time (4-5 min) available; local
anesthesia (≤3 mL of lidocaine or bupivacaine [Marcaine]) for hallux or lesser toe; do not block into toe (proximal phalanx
thins along middle of shaft); avulse entire nail if nail loose, painful, or suffered trauma; avulse corner of nail if ingrown
on one side of toe; apply compressive bandage and topical antibiotic; recommend warm water soaks;
matricectomy—review patient’s history; use phenol (3 30-sec applications); warm water soaks for 10 days; patients
may resume physical activity immediately
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| Plantar warts: pinpoint petechiae; often seen with bruising; more painful with squeezing from side to side than with
direct palpation; difficult to treat because wart sits deep in basement membrane between epidermis and dermis;
bleomycin—antibacterial that works as antiviral agent; 1 mL of combination of local anesthesia and bleomycin injected
with Dermo-Jet once or twice into lesion; painful; blood blister develops in 10 days, and lesion sloughs off in
3 to 4 wk; 95% effective on single isolated lesions in speaker’s office; expensive; topical fluorouracil (5-FU)—5%
cream; good results seen in children; debride lesion and apply once or twice daily with cotton-tipped applicator;
cover with bandage; results seen in 2 to 3 mo
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| Intractable plantar keratoma: callus; differentiate from warts; isolated to areas under bony structures; caused by pressure
from ground and bone; size 15 or 10 scalpel blade used for trimming; use pads and orthotics; change shoe gear in
older patients; use creams; if callus too deep to trim (rare), surgery may be required (“not the best of procedures”)
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| Foreign bodies: perform x-ray; even nonneuropathic patients often do not recall stepping on sharp objects; use ultrasonography
to detect nonradiopaque objects
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| Neuromas: theorized that nerve located farther plantar than dorsal; nerves may get caught up and rubbed on between
metatarsal heads (results in swelling); treatment—cortisone injections; after long duration of pain, surgical removal
or series of injections of 4% ethyl alcohol (50%-80% efficacy) into interspace every 7 to 10 days;
diagnosis—vague pain in middle part of foot; patients complain of hot and cold sensations and periods of anesthesia;
problem precipitated by certain activities; palpable click; use ultrasonography; typically not visible on magnetic
resonance imaging (MRI)
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| Ganglion cyst: depends on which anatomic part being irritated; determine whether painful, hard, soft, and freely movable;
perform needle biopsy; most cysts have high regrowth rate; treatment—cortisone injections; shoes with cutouts
for patients not candidates for surgery
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| Hallux abducto valgus: genetic; not caused by ill-fitting shoes; once deformity starts, wearing tight shoes exacerbates
pain; bunion—normal bone in abnormal position; differentiate from low-level gout and bursitis (may resolve with
anti-inflammatory agent or cortisone injection); conservative treatment includes wearing sandals, wider shoes, and
orthotics (ineffective on larger bunions)
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| Hammertoe: corn, rubbed skin, or mild bursitis develops on top of toes; genetic; as toe starts to contract, flexor tendon
on plantar surface gains mechanical advantage and contracts; hammertoe reducible (ie, can be straightened
manually), but in older patients, toe becomes fixed and rigid; problems include painful lesion on dorsal surface of
head of proximal phalanx or on distal tip of toe (problem for diabetic patients because toe can ulcerate and cause
osteomyelitis); do not use salicylic acid on diabetic patients; treatment—use size 15 or 10 blade to remove dead
skin; cover toe and reduce friction with proper shoe gear; surgical straightening for more rigid or ulcerated cases
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| Hallux limitus: looks similar to bunion, but bump on dorsal (rather than medial) aspect of toe; more painful than hallux
valgus; caused by accident or biomechanics of foot; first metatarsal functions slightly elevated during walking; proximal
phalanx moves up dorsally, resulting in jamming and loose pieces of bone; treatment—stiff shoes; thin graphite insoles
to stiffen shoes; orthotics; cortisone injections; surgery
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| Stress fracture: history of increased trauma (from, eg, running); swelling and pinpoint tenderness visible; may not be
visible on plain films until after 10 to 14 days; when suspicious, place foot in soft cast and stiff-splinted shoe; can
be diagnosed by bone scan or MRI
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| Biomechanics: problems caused by overpronation; observe whether patient’s heel comes off ground while walking
(indicates tight Achilles’ tendon)
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| Heel spur: not related to plantar heel pain; pain caused by plantar fascia and usually presents during weight bearing
after period of rest; treatment—cortisone injections (give from medial aspect); surgery when conservative treatment
fails (never remove heel spur; cut plantar fascia); anti-inflammatory agents; low-dye straps (tape bottom of
foot to supinate into high arch and to prevent flattening; tape 2 strips of 1-inch cloth tape around fifth metatarsal
around to first metatarsal; tape 3 pieces of 2-in cloth tape laterally to medially); improves within 7 to 10 days; heel
cup; high heels helpful in women; stretching of Achilles’ tendon; frozen water bottle for massage, stretching, and
anti-inflammatory effect; orthotics
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| Questions and answers: do runners with bunions have increased risk for hallux limitus?—first metatarsal moves medially
and slightly dorsal and can result in hallux limitus and tracking; wart treatment—bleomycin results in painful
hematoma; topical 5-FU not limited by number of lesions; using acids on callus—acids penetrate skin; risk for
infection in older patients; hyfrecator—used by speaker after cutting lesion out; useful for cutting base of verruca
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| LOW BACK PAIN —David E. Fish, MD, MPH, Assistant Professor, Department of Orthopaedics, David Geffen
School of Medicine at the University of California, Los Angeles
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| Introduction: patient history important; pay attention to problems that appear minor; management requires team approach;
aim to restore patient’s quality of life and function rather than eliminate pain
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| Evaluation: if patient has distribution of pain, possible to guess where disc herniation or stenosis may be, based on location
of symptoms; consider involvement of ligaments, muscles, and skin; determine whether pain in leg, ankle,
hip, or back; spine disease can cause headache, neck pain, back pain (axial pain) vs radicular pain (pain in hands
and feet); greater trochanteric bursitis—palpate side of hip; mimics L5 radiculopathy; treat by injecting bursa with
lidocaine and steroid
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| Waddell’s signs: used to determine whether patient has true anatomic problem or malingering or secondary gain; applies
to patients with pain for >6 mo; ≥3 of 5 signs implies greater chance for secondary gain or malingering; sham
rotation—ask patients to stand and rotate using knees while keeping spine stable; patients should not feel pain in
back; axial loading—push on top of standing patient’s head; patients usually bend knees (“doesn’t quite make
sense”); overreaction—patient overreacts from light pinch on area of pain; regionalization—patient has disc problem
at L4-5 but pain in legs and arms “doesn’t quite fit” picture of problem; distraction—patient does not feel pain
when raising leg while sitting with legs straight but feels pain when raising leg while lying flat
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| Mental health: many patients with long-standing back pain present with depression; patients need support (from, eg,
psychologist or psychiatrist); check Waddell’s signs, strength testing, rectal tone, and opioid use
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| Diagnostic tools: radiography—x-rays “don’t tell you much”; provides information about bone structure, alignment,
and presence of fracture; neck films show alignment and instability; MRI—shows detail of discs (eg, herniation)
and bone structure; computed tomography (CT) and myelography—used by surgeons to identify nerve infringement;
bone scanning—shows tumor or bone metastases; electromyography (EMG) and nerve conduction testing—
best for carpal tunnel; useful for identifying radiculopathy or peripheral neuropathy; needle examination of muscle
used to identify whether nerves communicating with muscle (abnormal finding diagnoses radiculopathy); check
speed of nerve to check whether nerve damaged; useful for neuropathies, brachial plexus injuries, radiculopathies,
and tarsal tunnel syndrome; if weakness or atrophy present, determine whether nerves or muscles regenerating; diagnostic
injections—diagnosis often made if pain (from, eg, greater trochanteric bursa) improves after injection;
history and physical examination
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| Nonfluoroscopic treatment: physical therapy; continue alternative medicine (eg, acupuncture) if effective; lidocaine
injection for trigger points; piriformis syndrome—abnormal pull in muscle; piriformis stretch results in pain in
buttock that can radiate to leg; blocking piriformis muscle improves pain; botulinum toxin type A (Botox)—used
for greater muscle relaxation after trigger point injection; some success in paraspinal muscle; worth trying, especially
if patient not to undergo surgery; reversible (lasts 3-4 mo)
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| Fluoroscopic treatment: C-arm fluoroscopy—obtain anteroposterior (AP) and lateral views and identify injection
site; epidural—effect may be placebo effect; medicate near nerve root to help radicular-component pain; some
success with stenosis; foraminal approach (entering from side in foramen) places medication more anteriorly along
back of disc than laminar approach (entering through back in laminar space); facet joints—effects of medicating
facet joints may not be permanent; blocking nerve roots (rhizotomy) may result in longer (6-12 mo) relief; sympathetic
blocks—used especially in patients with complex regional pain syndrome; hardware injections—hardware
(eg, screws) in patients who underwent surgery can cause irritation and bursitis; block screw heads; removal of
hardware shown to improve back pain; sacroiliac (SI) joint injections—SI joints tortuous; consider after other therapies
fail; discography—insert needle into disc to mimic pain; intradiscal electrothermal therapy (IDET)—may
be helpful in younger patients with one-disc problem; insert needle into herniated disc, wrap coil around herniation,
and scar area with heat; “it just doesn’t work”; nucleoplasty—insert needle and liquify herniation; ineffective;
compression fracture—vertebroplasty (placing cement in anterior space to solidify fracture) successful in older
women with osteoporotic compression fractures; spinal cord stimulation—in patients who underwent surgery and
have radicular pain in leg due to scarring, place stimulation leads over dorsal columns to augment pain sensation
(pain becomes more numbing or tingling sensation); requires implantation of battery; do not proceed if trial unsuccessful
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| Summary: take multidisciplinary approach; know diagnosis; good communication with patients; discontinue ineffective
therapy; do not be afraid to try alternative therapy; “do what makes sense”
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| Referrals: surgical—refer patients with neurologic progression and bowel and bladder loss; to obtain second surgical
opinion; refer if conservative management fails, surgical complications develop, and work-up complete;
nonsurgical—refer if new problem presents, surgery fails, work-up incomplete, or diagnosis unclear
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| Questions and answers: methylprednisolone (Medrol) dose packs—may be used to decrease inflammation in patients
with acute (onset within 1-2 wk) pain; indications for surgery—conservative treatment before surgery, unless patient
suffers drastic neurologic loss; corsets—not shown effective; may be used if helpful; may inhibit muscle strengthening;
not shown to stabilize spine; exercises—aerobic exercise only exercise shown to help back pain; exercises with
pelvic stabilization with superficial modalities recommended; back rests—useful in car while driving; provide good
support; avoid driving for long periods; use of occipital blocks before Botox—try before using Botox (since Botox
not covered by insurance)
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Educational Objectives
| The goal of this program is to educate the listener about common foot problems and low back pain. After hearing and
assimilating this program, the participant will be better able to:
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 | 1. Choose effective therapy for onychomycosis, ingrown toenails, and plantar warts.
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| 2. Explain causes of hallux abducto valgus, hammertoes, and hallux limitus.
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| 3. Use conservative treatment for heel spurs.
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| 4. Select the proper diagnostic tool for low back pain.
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| 5. Select appropriate treatment of low back pain, depending on its cause.
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Discussed on This Program
Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin, Augmentin ES-600, Augmentin XR]]
Bleomycin sulfate (BLM) [Blenoxane]
Botulinum toxin type A [Botox, Botox Cosmetic, Dysport]
Bupivacaine HCl [Marcaine HCl, Marcaine Spinal, Sensorcaine, Sensorcaine MPF, Sensorcaine MPF Spinal]
Cephalexin [Biocef, Keflex]
Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR]
Dicloxacillin sodium [Dycill, Dynapen, Pathocil]
Erythromycin [Akne-Mycin, A/T/S, Emgel, Eryderm 2%, Erygel, Ery Pads, Ilotycin, Staticin, T-Stat]
Fluorouracil (5-fluorouracil, 5-FU) [Adrucil, Carac, Efudex, Fluoroplex]
Itraconazole [Sporanox]
Levofloxacin [Levaquin, Quixin]
Lidocaine HCl (several trade names)
Methylprednisolone [Medrol]
Phenol [Cheracol Sore Throat, Children’s Vicks Chloraseptic, Mycinette, Phenaseptic, Phylorinol, Sore Throat Spray,
Throto-Ceptic, Vicks Chloraseptic]
Terbinafine HCl [DesenesMax, Lamisil, Lamisil AT, Lamisil DermGel 1%]
Suggested Reading
Centeno CJ et al: Waddell's signs revisited? Spine 29:1392, 2004; Derby R et al: Effect of intradiscal electrothermal
treatment with a short heating catheter and fibrin on discogenic low back pain. Am J Phys Med Rehabil 84:560, 2005;
Difazio M et al: A focused review of the use of botulinum toxins for low back pain. Clin J Pain 18:S155, 2002; Finn
KP et al: Disk entry: a complication of transforaminal epidural injection--a case report. Arch Phys Med Rehabil
86:1489, 2005; Giurini JM et al: Diabetic foot complications: diagnosis and management. Int J Low Extrem Wounds
4:171, 2005; Harmonson JK et al: Operative procedures for the correction of hammertoe, claw toe, and mallet toe: a
literature review. Clin Podiatr Med Surg 13:211, 1996; Hodge J: Facet, nerve root, and epidural block. Semin Ultrasound
CT MR 26:98, 2005; Iscimen A et al: Intralesional 5-fluorouracil, lidocaine and epinephrine mixture for the
treatment of verrucae: a prospective placebo-controlled, single-blind randomized study. J Eur Acad Dermatol Venereol
18:455, 2004; Koizuka S et al: Percutaneous radiofrequency lumbar facet rhizotomy guided by computed tomography
fluoroscopy. J Anesth 19:167, 2005; McAllister DR et al: Plantar ganglion cyst associated with stress
fracture of the third metatarsal. Am J Orthop 32:35, 2003; McAloon C: Bleomycin sulfate in the treatment of mosaic
plantar verrucae. J Foot Ankle Surg 36:70, 1997; Menz HB et al: Footwear characteristics and foot problems in older
people. Gerontology 51:346, 2005; Robinson AH et al: Modern concepts in the treatment of hallux valgus. J Bone
Joint Surg Br 87:1038, 2005; Rounding C et al: Surgical treatments for ingrowing toenails. Cochrane Database Syst
Rev 2005; Rowles JS: Lumbar discography: a tool for understanding spinal pain. AANA J 73:173, 2005; Tosti A et al:
Patients at risk of onychomycosis - risk factor identification and active prevention. J Eur Acad Dermatol Venereol 19
Suppl 1:13, 2005; van Wijk RM et al: Radiofrequency denervation of lumbar facet joints in the treatment of chronic
low back pain: a randomized, double-blind, sham lesion-controlled trial. Clin J Pain 21:335, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Singer and Fish spoke in Los Angeles at the 32nd Annual Family Practice Refresher Course, presented May 31 to
June 4, 2005, by the David Geffen School of Medicine at the University of California, Los Angeles. The Audio-Digest
Foundation thanks the speakers and the David Geffen School of Medicine for their cooperation in the production
of this program.
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