HALLUX VALGUS (BUNIONS)
This well known deformity is more that just a bump or bunion on the medial side of the foot. The bunion itself is just an overgrowth of new bone and soft tissue. The actual prominence of this bump arises from the metatarsal head drifting inwards.
On squeezing into a shoe, there is an increased outward directed pressure on the big toe. Initially, the toe corrects itself when the shoe is removed but with time the deformity becomes stuck down and fixed. The proximal phalanx of the big toe pushes the metatarsal head more medially, worsening the deformity. Only half the cases are related to poor footwear, with many patients also having a positive family history for Hallux Valgus.
What simple non-surgical methods can we try?
Appropriate shoe wear is the key. I advise patients to wear soft lace-up leather
shoes or trainers for commuting to work or when walking long distances. A shoe with a strap or laces means you are less dependent on curling your toes (the site of the pain!) to keep the shoe on. Keep a pair of formal shoes under your desk for meetings. Heels greater than
an inch are best avoided as the foot tends to slide down the shoe squashing the
toes into the toe box of the shoe. Silicone spacers or bunion cushions may help
but can widen the foot further, making shoe wear more difficult.
When would we consider surgery?
If the patient has tried the above measures but the foot still hurts on a fairly regular
basis or if the patient is starting to develop problems with the 2nd toe.
What does surgery entail?
By the time a patient presents to their GP, the deformity is usually advanced
and the metatarsal needs to be broken and reset so that the foot is narrower
and of a more natural shape.
For a moderate or severe deformity, the bone is broken (osteotomy) close to the metatarsal head. The osteotomy I use for this is the scarf osteotomy. This is a powerful, popular and proven osteotomy. Results are the most consistent and the fixation is very strong.
Here the metatarsal has to be split along its length with a specialist z-shaped bone cut. The metatarsal is held in its new postion with a small screw that means a plaster is not needed. Your own bone will heal around the screw. Sometimes for additional cosmetic correction, another bone in the big toe is broken (an Akin osteotomy). This is held with a small staple. The scar fades with time and as it is on the side of the foot is often not visible when standing or in ballet pumps. Once the bones mend the screw and/or staple are not needed but as they usually can’t be felt theycan be left in the foot.
If the joint is very arthritic then a fusion procedure may be necessary.
In severe deformities or in cases where surgery has previously been done, the other toes may also start to develop problems. Common patterns include pain under the lesser metatarsal heads (metatarsalgia), dislocation of the toes and formation of hammer toes. This is technically more difficult to treat and is often because the bunion has been left too long. Nevertheless good results can still be obtained if we break and fix the other toes as required so as to leave a forefoot, which is more level and comfortable.
The lesser metatarsals may be broken and fixed with a small screw (Weil osteotomy) and the hammer toes corrected
Is the operation painful and slow to recover from?
No. This is one area where we have made drastic progress. The main reason
bunion surgery was painful in the past was that bones were held with plaster or pins only allowing grating from the cut bone ends and a chance that the fixation
could be lost. We now use small screws and specialist bone cuts to ensure a
solid fixation of the bone. This allows earlier weight bearing and movement
in the toes, ensuring faster rehabilitation and a better long-term outcome.
In surgery, the use of selective ankle nerve blocks with a long acting local anaesthetic numbs the toes, minimising initial post-operative pain.
What will my mobility be like after the procedure?
You will be given a special sandal before discharge from hospital. You may need crutches for comfort or reassurance. It is important whenever resting to keep the foot up. The initial dressing stays on for 2 weeks and they are reduced in the clinic where I check the wound. At this stage we start toe exercises. If it is just the big toe that has been operated on then by 3 weeks you will usually be walking in soft sandals or trainers that allow the toe to bend. After correction of more severe deformities you may need the special shoe for 5 weeks. The foot will swell for 3- 6 months after the procedure especially towards the end of the day. Pain tends not to be a problem. If the lesser toes have been shortened then they may not feel normal again for upto 6 months while the muscles and tendons adjust themselves.
You can swim from week3, low impact gym work from week 5 and running or high impact from week 10.
Driving varies and one should check with their insurer. Even if they allow it, keep to the absolute minimum as you are certainly not able to keep the leg elevated!
HALLUX RIGIDUS (ARTHRITIC BIG TOE)
Stiffness or ‘rigidity’ of the first metatarsophalangeal joint can occur in any age from adolescence onwards. In young people it may follow trauma leading to local cartilage damage. In older patients, it may be due to osteoarthritis or longstanding gout.
Patients complain of pain with activity which they localise to this joint. Inspection of the shoes may show stretching of the leather on the top of the foot and increased wear on the outside of the foot as the patient walks to avoid taking weight through the big toe.
There may be a reduction in joint dorsiflexion and plantarflexion. Gout or hallux valgus is the main differential diagnosis, though advanced case of bunions may also have an arthritic component.
Weight bearing X-rays will show the hallmarks of arthritis including the loss of joint space between the bones as the natural spacer, the cartilage, has worn thin. Bone spurs that may be seen on the top and around the joint.
Footwear advice. Initial treatment includes shoe wear modification. Although soft shoes can ease the discomfort from the dorsal osteophytes, the arthritic pain caused by movement can be relieved by a stiff soled shoe as this limits bending at the first metatarso-phalangeal joint. An even better alternative is a shoe with a rocker bottom sole. One such shoe is an MBT shoe which allows you to roll and therefore not bend the big toe as much when you walk.
Surgery. If the main problem is caused by the dorsal osteophytes and the underlying joint is in reasonable condition then an operation called a cheilectomy in which the impinging osteophytes are removed to prevent the pinching of soft tissues is indicated. Sometimes by realigning one of the bones (Moberg osteotomy) we can redirect less useful downward motion to upward motion .
A fusion operation (arthrodesis) may be indicated for more advanced cases,. In the fusion operation, the joint surfaces are excised so that the two bones will heal together. If there is no movement there will be no pain.
Joint replacement is possible but wanting in long-term data.
HAMMERTOE/ CLAW TOE/ MALLET TOE
A hammer toe is a flexion deformity of the proximal interphalangeal joint, a mallet toe is a similar deformity of the distal interphalangeal joint.
Claw toe is associated with hyperextension at the MTP joint and flexion at both interphalangeal joints
Hammer and mallet toes become painful as the deformity causes the affected joint to rub on the shoe.
This can lead to excess callus formation over the inter-phalangeal joint and under the metatarsal head.
Claw toes may be associated with neurological problems or rheumatoid arthritis.
Conservative treatments include using silicone sleeves that roll over the toe.
If appropriate then a deep toe box shoe will limit rubbing on the toes.
Surgery may be considered if conservative treatment fails to relieve the pain.
If the deformity is passively correctable then a soft tissue release and temporary pinning of the toe will suffice.
If the deformity is fixed then the joint needs to be excised or fused straight. The toe needs to be held with a fine wire to allow healing or by using a small-buried staple.
This is a common condition especially in males. The nail rather than growing outwards starts to grow vertically downward in the nail grove. Once embedded it sets off an inflammatory response with ulceration of the skin and a deep infection.
In initial stages a short course of antibiotics may be helpful but when persistent the portion of germinal matrix from which the ingrowing nail arises needs to be ablated chemically, with caustic phenol, or by curettage.
Preventative measures include cutting the nail square after lifting the corners up with a cotton bud.
Attempts at hooking out remnants of ingrown nail without anaesthetic can make the pain and infection worse.
The commonest procedure to treat this involves using local anaesthetic to numb the toe. A 3-4mm wedge of nail is excised in addition to the part that has grown in. I don’t want this bit to grow back, so we specifically destroy the cells with a chemical from which that corner of nail would grow. If the rest of the nail is healthy it should continue to grow as normal.
FLAT FEET (PES PLANUS)
It is important to differentiate whether this is congenital or acquired
Congenital flat can be a flexible or stiff.
The arch of a flexible flat foot can be reconstituted by extending the big toe. It is rarely symptomatic and reassurance is usually all that is required.
A stiff flatfoot that cannot be corrected by manipulation suggests a pathological disorder such as a coalition in which the bones of the hind foot are joined abnormally together. This needs specialist investigation
An acquired flat foot is a separate problem more commonly seen in adults. It can be caused by inflammation in the tibialis posterior tendon – the major support of the medial arch.
A coalition may be visible as a bony bar on an X-ray where the pathognomic sign is the ‘anteaters sign’ on the lateral x-ray of the ankle.
An MRI scan can identify both bony and fibrous bars
The treatment varies according to the cause.
Mild cases may be treated by an insole with a medial arch.
More severe cases may require corrective surgery. If the deformities are mild then tendon transfers are an option, more fixed deformities may require multiple hind foot joints to be fused, the so called triple fusion.
In the child, the bones of the foot occasionally develop abnormally and an extra bone called an accessory navicular is present towards the inside of the foot, in front of the ankle. This bone is present in approximately 10% of the general population but not large enough to cause symptoms in the majority of these individuals
The extra bone lump may present first in childhood. It can be quite uncomfortable because it rubs on shoes. Feet associated with the accessory navicular are invariably flat. In adults it may be first noted after a twisting injury or overuse when the cartilage band that attaches the small extra bone to the main host bone gets sprained or torn. Injury may aggravate the inflammation of the tendon that attaches to the accessory navicular. This tendon is called the posterior tibial tendon and is responsible for maintaining the strength of the arch of the foot. Treatment of the accessory navicular begins with rest. Rest may include activity modification or temporary immobilization in a boot or a brace.
Once the inflammation subsides the foot needs to be supported. The support consists of a specially designed orthotic arch support. Occasionally, the orthotic will often dig into the edge of the accessory navicular bone under the arch of the foot. This is very uncomfortable. For this reason the orthotic support needs to be carefully made. The orthotic support will help control (but not cure) the flat foot and will often decrease the inflammation on the navicular.
Once the navicular inflammation has lessened it is not necessary to perform surgery unless the foot becomes progressively flatter or continues to be painful. Surgery can correct the problem by removing the accessory navicular bone and tightening up the posterior tibial tendon that attaches to the navicular bone. Sometimes the heel bone needs to be realigned. The strength of this tendon is integral to the success of this surgery as well as the arch of the foot.
Pes cavus is a foot with an higher arch than normal. It may be associated with clawing of the toes. The appearances are similar to those of a neurological foot suggesting that this condition is related to a muscle imbalance. It is seen in conditions such as hereditary sensory motor neuropathy, spinal cord abnormalities and polio.
The toes are clawed, the metatarsal heads are forced down into the sole causing metatarsalgia, the heel is inverted and the Achilles tendon and calf are often tight.
Neurological abnormalities must be considered.
Treatment is rarely required. If the forefoot is painful then an insole that distributes the weight all over the sole of the foot may be useful.
Surgery is indicated if the foot is still painful.
If the deformities are flexible then tendon release and lengthening and osteotomies to realign the bones are indicated.
As the deformity becomes more fixed with irreversible damage to the joints, fusion surgery may be the only option.
This is a term used to describe general pain in the ball of the foot. It is usually caused by an uneven weight distribution with patients reporting a feeling of walking on marbles or stones. Certain shapes of foot predispose to this, in particular those with relatively long 2nd and 3rd metatarsals. Patients with a high arch foot (pes cavus) load their metatarsals more. Treatment may be thicker padded insoles or offloading the painful area with a felt or silicone metatarsal pad.
Repetitive trauma to the interdigital nerves from tight or ill fitting shoes may lead to the nerve being thickened and inflamed and give rise to a painful neuroma. The ball of the foot is one of the most unpleasant places to have a neuroma as one takes weight at this point.
Patients may complain of numbness or burning, typically in the 3rd webspace, though 10% are found in the second webspace. Pinching pressure at this point recreates the pain, A large neuroma may be associated with a clicking sensation (a ‘mulders’ click) when the metatarsal heads are squashed together.
An ultrasound is the most accurate method of diagnosis, an MRI scan may also be used.
A metatarsal pad can take pressure off this area.
A steroid injection can reduce, temporarily, some of the inflammation and discomfort . This may be administered at the same time as the ultrasound scan.
Excision. If the pain persists, a more permanent solution is excision of the neuroma and affected interdigital nerve. The web space will be permanently numb but not painful. The numbness is often only noted when I examine the toe in the clinic!
This is the commonest cause of a painful heel. It is caused by inflammation and microtearing of the plantar fascia, one of the ligaments that attaches to the underside of the back of the heel. It is also associated with certain foot types as well as repetitive, strenuous activity that may cause bruising and inflammation of the back of the heel.
Patients may report it starting after overuse or a change in shoe wear.
The diagnostic feature of the history is whether the pain is at its worst on getting out of bed in the morning or after having been at a desk or behind a steering wheel for a while, so-called ‘start-up pain.’ As the foot is put down on the ground there is a sudden, searing sensation on the back of the undersurface of the heel. The pain continues and as the foot stretches out a little bit with walking, some of the pain subsides.
Typically this improves slightly, only to worsen again as standing and walking increase over the course of the day. The diagnosis of plantar fasciitis is confirmed by very specific examination of the back of the heel related to the location of the pain under the heel. There is often a nerve that is simultaneously inflamed or pinched underneath the fascia. This can aggravate the pain even further.
The main treatment involves cushioning the heel with a silicone heel pad. Stretching exercises for the back of the heel are done on a regular basis, two to three times daily. The natural position of the foot during sleep rests the fascia, which then is subjected to vigorous stress again when getting up and walking in the morning. Keeping the fascia stretched at all times (but particularly at night) seems to help.
Stretching out the foot at night using an off the shelf night splint maintains the foot in a straight up position. This prevents it from dropping down during the night. If these methods of treatment fail, a cortisone injection into the back of the heel will often reduce the inflammation. More than one cortisone injection is not a good idea because it weakens the heel pad and can even aggravate the condition. If none of these treatments are sufficient, the next alternatives are shockwave therapy or surgery. In shockwave therapy a high frequency, ultrasound impulse is transmitted to the back of the heel to break up the scarring.
You may have heard of similar treatments to treat kidney stones. This is not the same as ultrasound used by physiotherapists. Alternatively, surgery may be performed through a small incision on the back of the heel to release the plantar fascia and, in some cases, release the nerve that is pinched at the same time. The treatments may be effective in relieving the chronic pain if cushioning, stretching and immobilization fail.
This is a crushing type of osteochondritis of the second, and occasionally the third, metatarsal head. It typically affects young adults, mostly women. The metatarsal head becomes enlarged and the joint palpable and painful on stressing. X-rays may shoe the head to be flattened Initial treatment comprises resting the foot in a boot, hard soled shoe or a cast. A custom insole can take pressure off the joint. If these measures fail to relieve the pain, an open debridement of the joint and a simple realignment osteotomy of the metatarsal head which shortens and decompresses the joint and rotates the good cartilage upwards can treat the pain successfully.
Callosities/corns appear as areas of hardened, sometimes yellow skin on pressure points or around bony areas of the foot. Corns form on or between toes; callosities form on the bottom of the feet. They develop to protect the foot from damage but can be a source of pain. Excessive pressure and friction on one area of the foot causes the skin cells to multiply and then die. This leads to a thickened area of skin known as a corn or callus.
Calluses protect bones that don’t have natural fat pads to protect them and develop usually after prolonged wear and tear or rubbing on the shoe. They tend to be a broad area of thickened skin. They are often painless but those that form because of structural problems can become painful on walking. Corns often form as a result of irritation from tight shoes. Hard corns may form on the top of structural problems and at the sides of toes, soft corns form between the toes.
Treatment starts by removing the cause -initially by advising shoe wear adjustments. Wider shoes with a shallow heel allow more space for the toes whereas pointed heels make the foot slide downhill into the shoe, cramming the toes into an already narrow toe box.
Redistributing foot pressure away from the area of callus by a custom insole may also help.
Corns caused by hammer or claw toes often settle once the bony deformity is corrected.
Plantar callus which is often seen under the 2nd and 3rd metatarsals may be treated surgically by a shortening osteotomy of the metatarsals to redistribute load around the foot more evenly.
An important exception is the presence of diabetes or peripheral neuropathy. These patients need to be cared for by a specialist podiatrist because any skin break is associated with a higher rate of skin infection and serious complications.
PLANTAR FIBROMATOSIS/ DUPUYTRENS OF THE FOOT
These are benign growths that occur on the bottom of the foot. A similar condition occurs on the palms of the hands, Dupuytren’s contracture and on the Penis (Peyronies Disease).Its cause is unknown. It may be the result of tiny tears in the plantar fascia which then undergo rapid repair, and actually over repair the area. Thickened nodules develop along the course of the plantar fascia which may invade the overlying dermis and sometimes the flexor tendons on the bottom of the foot.
The nodules may lay dormant for years only to rapidly increase in size in a very short period of time. It is commoner in men and 25 % of cases are bilateral. Typically, patients present more out of concern about the lump than pain, but the lumps can become painful. If the nodules are not painful the treatment of choice is to leave them alone.If there is pain, simple care involves padding in the shoe to keep pressure off the lumps. If conservative measures fail to remove the pain the only other option is surgical excision.
This is not a straightforward procedure. Recurrence is high as, unlike in the hand, all the diseased tissue cannot be removed as the plantar fascia is critical to normal gait. Also as the incision usually has to be on the bottom of the foot the patient may exchange the fibroma for a painful scar that hurts just as much to walk on as the original lump.
For severe cases we can use radiotherapy. If Mr Singh feels this is appropriate then he will refer you to a leading specialist for this.
A prominence on the outside of the foot, at the base of the little toe, is called a bunionette, or tailors bunion.
A bunionette is a visible deformity, an enlargement of the outer part of the joint. It results from the movement of the little toe inward, toward the other toes, as may happen, for example, when tight shoes are worn. The pressure on the little toe caused by this crowding not only forces the toe inward, it puts pressure on the toe joint to move outward, where it presses and rubs against the shoe, eventually resulting in a bunionette.
What are the causes of Bunionette?
Bunionettes are caused over time (even several years) by abnormal pressure and rubbing on the toe joint. A major cause is wearing shoes that are too tight and that tend to squeeze the toes together. “Tailor’s bunions” are much more common in women than in men (from wearing high heels), but any shoes that are pointed can cause the condition. It can also run in families and may be associated with a bunion of the big toe.
A bunionette is a lump that is a visible deformity. Over time, this lump is subject to increased pressure and rubbing against the shoe, forming a callous. Eventually this can become irritated and painful, causing pain that makes walking and standing difficult. Corns may develop, and abnormalities may develop in the other toes as well. Finding shoes that one can stand to walk in can also be a challenge.
Bunion treatment without surgery may include one or more of the following:
• Roomier shoes
• Bunionette pad to reduce pressure and rubbing
If these methods fail then bunionnette cerrective surgery may be suggested. Sometimes just shaving a piece of bone off will make a difference but in my experience, better results are obtained by breaking and realigning the 5th metatarsal bone . This leaves a narrower foot that rubs less on the shoe. This minimises the chance of it coming back. We use a small screw to hold the bones together. The bone then mends around the screw in 4-5 weeks. For that period a protective sandal is needed.
What is midfoot arthritis?
Midfoot arthritis can results from a history of trauma to the middle section of the foot such as a direct or indirect trauma sustained secondary to falls, twisting and crush injuries. Fractures and dislocations of the midfoot (eg Lisfranc fractures) are especially common in the sporting population. However, it may also develop due to abnormal foot posture (eg. flat foot deformity, severe bunions), or secondary to inflammatory diseases such as rheumatoid arthritis or gout.
Midfoot arthritis occurs when there has been damage to the joint cartilage that normally covers and protects the bones of the ankle joint.
What are the signs or symptoms of midfoot arthritis?
Pain across the middle of the foot, swelling and stiffness are the most common symptoms of midfoot arthritis. Stiffness in the midfoot is often noticed on the first few steps out of bed in the mornings. The pain is often aggravated by increasing activity, wearing unsupportive footwear and when walking on uneven terrain. You may also have difficulty with stair ascent and descent and in activities that require heel raise. You may notice a collapsed arch and the development of a flat foot.
How is midfoot arthritis diagnosed?
Midfoot arthritis is usually diagnosed after taking a history and performing a physical examination. Midfoot arthritis can be seen on plain foot xrays with loss of normal joint space, development of bony spurs around the joint and other signs of joint degeneration.
How is midfoot arthritis treated?
The goals of reatment are to minimise pain and discomfort, and improve function by enhancing midfoot stability and modifying loads sustained at the inflamed joints. Treatment options depend on the patient’s symptoms and severity of the arthritis.
It may incorporate a combination of the following:
- supportive stable footwear, sometimes medical grade footwear is required;
- insoles to improve foot posture, stabilise the midfoot joints and help dissipate some of the force that would normally go through the foot with each step;
- weight loss;
- advice on pain medicines –paracetomol may be helpful
- home exercise programs – exercises designed to keep the joints moving and the muscles that control the foot and ankle strong;
- activity modification
- Steroid Injections in the affected joints
- Sometimes surgery, which may be to correct the underlying cause such as severe bunion deformities, severe flat foot or fusion of the diseased joints.