Forefoot pathology

Question 1

What is hallux valgus?

Answer 1

“Bunions”

Question 2

What is the aetiology of hallux valgus?

Answer 2

• Genetic
• Foot wear
• Significant female preponderance

Question 3

SSx of hallux valgus?

Answer 3

• Pressure symptoms from shoe wear
• Pain from crossing toes over
• Metatarsalgia (pain and injury in ball of foot)

Question 4

Pathogenesis of hallux valgus?

Answer 4

• Lateral angulation of big toe
• Tendons will pull realigned to lateral of centre of rotation of toe, worsening deformity
• Vicious cycle of increased pull creating increased deformity

Question 5

How do we diagnose hallux valgus?

Answer 5

• Clinical
• Xray: determine severity of underlying bone deformity/exclude degenerative change

Question 6

How do we manage hallux valgus?

Answer 6

Non-operative

• shoe modification
• Orthotics to offload pressure/correct deformity
• Activity modification
• Analgesics

Operative

• Release lateral soft tissues
• Osteotomy 1st metatarsal

Question 7

What is hallux rigidus?

Answer 7

‘A stiff big toe’

Osteoarthritis of 1st MTP joint

Question 8

Aetiology of hallux rigidus?

Answer 8

• Not really known
• Possibly genetic/possibly multiple microtrauma

Question 9

SSx of hallux rigidus?

Answer 9

• Many are assymptomatic
• Pain [often at extreme of dorsiflexion]
• Limited range of movement

Question 10

How does one diagnose hallux rigidus?

Answer 10

Via clinical judgement and radiography

Question 11

Management of hallux rigidus?

Answer 11

Non-operative

• Activity mods
• Shoe wear with rigid sole
• Analgesia

Surgery

• Cheilectomy [remove bony lump]
• Arthrodesis [immobilisation of joint]
• Arthroplasty [reconstruction of joint]

Question 12

What are the two main operations for hallux rigidus?

Answer 12

• 1st MTPJ fusion
  
  • gold standard treatment
  • permanent
• 1st MTPJ hemiartroplasty
  
  • good option to maintain ROM
  • high failure rate
  • better for low demand patients

Question 13

What are three lesser toe deformities?

Answer 13

• Claw toes
• Hammer toes
• Mallet toes

Question 14

What is the aetiology of the lesser toe deformities?

Answer 14

• Imbalance between flexors/extensors
• Shoe wear
• Rheumatoid arthritis
• Idiopathic

Question 15

SSx for lesser toe deformities?

Answer 15

• Deformity
• Pain on dorsum
• Pain from plantar side

Question 16

Management for lesser toe deformities?

Answer 16

Non-operative

• Activity mods
• Shoe wear - flat shoes with high toe box to accomodate deformity
• Orthotic insoles

Operative

• FLexor to extensor transfer
• Fusion to interphalangeal joint
• Release metatarsophalangeal joint
• Shortening osteotomy of metatarsal

Question 17

What is interdigital neuralgia (Morton’s neuroma)?

Answer 17

A common interdigital nerve block

Question 18

Aetiology of Morton’s neuroma?

Answer 18

• Mechanically induced degenerative neuropathy
• Affects females 40-60 generally
• Often associated with high heel use
• Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear

Question 19

SSx of Morton’s neuroma?

Answer 19

• Typically effects 3rd followed by 2nd webspace/toes
• Neuralgia burning pain into toes
• Intermittant
• Altered sensation in webspace

Question 20

Diagnostic signs for Morton’s neuroma?

Answer 20

• Clinical diagnosis (duhh)
• Mulder’s click
• USS is best investigation

Question 21

Management for Morton’s neuroma?

Answer 21

• Injection for small lesions
• Surgery: excision of lesion including a section of normal nerve
  
  • numbness
  • recurrance
  • up to 30% have pain 1yr after surgery

Question 22

What is metatarsalgia?

Answer 22

‘Pain under the metatarsal bones’

A symptom not a diagnosis

Careful examination should localise site.

Question 23

Differential for metatarsalgia?

Answer 23

• Synovitis
• Bursitis
• Arthritis
• Neuralgia

Question 24

What is the treatment for rheumatoid forefoot?

Answer 24

Non-operative

• shoewear, orthotics, activity

Operative

• Many described techniques
• Current gold standard
  
  • 1st MTPJ arthrodesis
  • 2-5th toe excision arthroplasty