Forefoot Problems Flashcards
6 forefoot problems
- Hallux Valgus (bunion)
- Hallux Rigidus
- Lesser toe deformities
- Morton’s neuroma
- Metatarsalgia (symptom not a diagnosis)
- Rheumatoid forefoot
Aetiology of hallux valgus
- Footwear
- Women more likely
- Genetic
Symptoms of hallux valgus
- Pressure symptoms of from shoe wear
- Pain from crossing over of toes
- Metatarsalgia
Pathogenesis of hallux valgus
- Lateral angulation of big toe
- Tendons pull realigned to
- Vicious cycle of increased pull creating increased deformity
- Sesamoid bones sublux, less weight goes through big toe
- As deformity progresses abnormalities of lesser toes occur
How to diagnose hallux valgus
-Clinical
-X-ray
Determines the severity of underlying bony deformation
Excludes associated degenerative change
Non-surgical Rx of hallux valgus
- Shoe modification (wide +/- high toe box)
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesia
Surgical Rx of hallux valgus
Only if non-surgical Rx fails
-Release lateral soft tissues
-Osteotomy 1st metatarsal +/- proximal phalanx
Generally good outcome but recurrence inevitable
What is hallux rigidus
- Latin = Stiff big toe
- Osteoarthritis of 1st MTP joint
Aetiology of hallux rigidus
- Unknown
- Maybe genetic or multiple micro-traumas
Symptoms of hallux rigidus
- Many asymptomatic
- Pain (often at extreme of dorsiflexion)
- Limitation of ROM
How to diagnose hallux rigidus
- Clinical
- Radiographs
Non-surgical Rx of hallux rigidus
- Activity modification
- Shoe wear with a rigid sole
- Analgesia
Surgical Rx of hallux rigidus
- Cheilectomy (removal of bone spurs from base of big toe)
- Arthrodesis
- Arthroplasty
3 lesser toe deformities
- Claw toes
- Hammer toes
- Mallet toes
Aetiology of lesser toe deformities
- Shoe wear
- Rheumatoid arthritis
- Neurological
- Imbalance between flexors/extensors
- Idiopathic
Symptoms of lesser toe deformities
- Deformity
- Pain from dorsum
- Pain from plantar side (metatarsalgia)
Non-surgical Rx of lesser toe deformities
- Activity modification
- Flat shoes with a high toe box to accommodate deformity
- Orthotic insoles (metatarsal bar/dome support)
Surgical Rx of lesser toe deformities
- Fusion of IPJ
- Release of metatarsophalangeal joint
- Shortening osteotomy of metatarsal
Aetiology of Morton’s neuroma
- Mechanically induced degenerative neuropathy
- Associated with wearing high heels
- Common digital nerve relatively tethered to one metatarsal + movement in adjacent metatarsal causing mechanical shear
what group is Morton’s neuroma most commonly seen
Women aged 40-60
Symptoms of Morton’s neuroma
- Neuralgic burning pain into toes
- Intermittent
- Altered sensation in webspaces
- Typically affect 3rd followed by 2nd webspaces/toes
How to diagnose Morton’s neuroma
- Clinical
- Mulder’s click
- US (gold standard)
- MRI (good but not best)
Rx of Morton’s neuroma
- Injection for small lesions (?steroids?)
- Surgical excision of lesion + a section of normal nerve
Problems with surgical Rx of Morton’s neuroma
- Numbness
- Recurrence
- 30% have pain 1 year post-op
What is metatarsalgia
- Common overuse injury
- Describes + and inflammation in the ball of the foot
Causes of metatarsalgia
- Synovitis
- Bursitis
- Arthritis
- Neuralgia
- Neuromata
- Freiberg’s disease
etc…
If there’s no obvious cause of metatarsalgia what should you consider
Tight gastrocnemius
Non-surgical Rx for rheumatoid foot
- Shoewear
- Orthotics
- Activity modification
Surgical Rx for rheumatoid foot
- 1st MTPJ arthrodesis
- 2-5th toe excision arthroplasty
Both are current gold standard
