Flex your foot and ankle exam skills
By Mollie Frost
Much of office-based primary care is orthopedics, but newer internists are often more prepared to handle more life-threatening conditions, according to orthopedic surgeon Edward (Ted) Parks, MD, who’s taught orthopedics to medical residents for 25 years.
“Residents tell me all the time that … they’re very, very comfortable taking care of a person in the ICU on three drips and a ventilator, but they’re scared to death of an ankle sprain, because they don’t have any training in that,” he said. “And they go out and they start a private practice outpatient clinic, and they see a ton of ankle sprains.”
During Wednesday’s Practical Office Orthopedics and Sports Medicine for the Internist precourse at Internal Medicine Meeting 2022, Dr. Parks reviewed physical exam techniques and treatments for common orthopedic problems in primary care, starting from the ground up with the foot and ankle.
This painful condition, which most commonly occurs in the third webspace of the toes, is a product of somewhat unfortunate anatomy, explained Dr. Parks, an associate clinical professor at the University of Colorado School of Medicine in Denver.
“Right where things are very narrow and cramped, that's where the nerve bifurcates into the proper digital nerves,” he said. “So, it's a place where that nerve can be irritated, and when it gets irritated, it gets swollen … because it’s getting rubbed by the two adjacent metatarsal heads.”
Patients with Morton’s neuroma will typically report pain (which may radiate into the toes) and numbness, and many will also feel a mass, as if there were a pebble in their shoe, Dr. Parks said. “That’s the actual mass of the neuroma, and it’s worse if you wear shoes with high heels, and that includes cowboy boots,” he said, noting that high heels can cause the metatarsals to tilt vertically and crowd the nerve.
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