Foot Problems - Forefoot

Question 1

Contains:

Answer 1

Hallux Valgus
Hallux Rigidus
Lesser Toe deformities 
Morton's Neuroma
Metatarsalgia
Rheumatoid forefoot

Question 2

What is hallux valgus? [3]

Answer 2

A bunion
Lateral angulation of the big toe [1] the tendons then pull lateral to the toes center of rotation [1] leading to worsening angulation [1]

Question 3

What cause Hallux Valgus? [3]

Answer 3

Genetics and Foot Wear

It has a significant female proponderance

Question 4

Symptoms of Hallux Valgus? [3]

Answer 4

Pressure symptoms from the shoe
Pain of the toes crossing over ie
Metatarsalgia - pain at ball of foot

Question 5

How do we diagnose Hallux Valgus? [2]

Answer 5

Clinical diagnosis

Can use X-rays to determine severity of deformity

Question 6

How do we manage Hallux Valgus?

• Non operative
• Operative [2]

Answer 6

Non-operative:
- Wide fitting shoes

Operative:

• Release lateral soft tissue
• Osteotomy of 1st metatarsal

Question 7

What is Hallux Rigidus? [2]

Answer 7

Translates to “Stiff Big Toe”

Its osteoarthritis [1] of the 1st MTP joint [1]

Question 8

What’s the postulated etiology of Hallux Rigidus? [2]

Answer 8

Possibly genetic [1] or due to multiple microtrauma [1]

Question 9

How does hallux rigidus present? [2]

Answer 9

Many are asymptomatic.

Others have a limited range of motion [1] and pain (often at extreme of dorsiflexion) [1]

Question 10

How do we diagnose hallux rigidus? [2]

Answer 10

Clinically [1]

And with radiographs to spot the OA [1]

Question 11

How do we manage Hallux Rigidus?
Non-operative [1]
Operative [3]

Answer 11

Rigid sole

Operative

• Cheilectomy (removing the dorsal impingement)
• Arthrodesis (1st MTPJ fusion is gold standard but permanent)
• Arthroplasty (1st MTPJ hemiarthroplasty is good for maintaining ROM but fails alot)

Question 12

What are the types of lesser toe deformities? [3]

Answer 12

Claw Toe - both IP joints flexed
Hammer Toe - Proximal IP joint flexed
Mallet Toe - Distal IP joint flexed

Question 13

What causes a lesser toe deformity? [6]

Answer 13

Flexor/extensor imbalance
Shoe Wear
Greek toe
Neurological conditions
Rheumatoid arthritis
Idiopathic

Question 14

How does a lesser toe deformity present? [3]

Answer 14

Visible deformity +/- dorsal pain +/- plantar pain (metatarsalgia)

Question 15

How do we treat a deformed lesser toe?

• Non-operative [2]
• Operative [4]

Answer 15

Shoe mod - flat shoes with high toe box to accommodate deformity
Orthotic insoles - metatarsal bar/dome support under proximal metatarsal head may help to straighten toe

Operative:

• Flexor to extensor transfer
• IP joint fusion
• MTP joint release
• Shortening osteotomy of metatarsal

Question 16

What is Morton’s Neuroma aka Interdigital Neuroma?

Epidemiology [2]

Answer 16

a mechanically induced degenerative neuropathy [1] of a common digital nerve [1], typically in the 3rd then 2nd web spaces [1]

Associated with women in their 40s/50s [1] who frequently wear high heels [1]

Question 17

How does Morton’s Neuroma present? [4]

Answer 17

Intermittent [1] Neuralgic burning pain [1] into toes along with altered sensation in the webspaces [1]
Typically affects the 3rd then 2nd webspaces [1]

Question 18

How do we diagnose Morton’s Neuroma? [3]

Answer 18

Clinical presentation
Mulder’s Click
US or MRI

Question 19

How do we manage Morton’s Neuroma? [2]

Answer 19

Steroid Injection

Surgical excision of lesion (associated with numbess & recurrence)

Question 20

How do we treat Rheumatoid Forefoot?

• Non operative
• Operative [2]

Answer 20

Non-operative: as per standard
Operative:
- 1st MTPJ arthrodesis
- 2-5th toe excision arthroplasty