Hallux valgus
- Commonest deformity of the foot
- Results in excessive valgus angulation of the big toe
- Only seen in populations that wear shoes
- Splaying of the forefoot with varus angulation of the first
metatarsal predisposes
- The anatomical deformity consists of:
- Increased forefoot width
- Lateral deviation of the hallux
- Prominence of the first metatarsal head
- As deformity increases long tendons of the hallux are shifted
laterally
Clinical features
- More common in women
- Often bilateral
- Symptoms result from
- A bursa over metatarsal head = bunion
- Hammer toes
- Metatarsalgia
- Osteoarthritis of the first MTPJ
- Diagnosis can be confirmed on x-ray
- Intermetatarsal angle should be less than 20 degrees
- Hallux angle should be less than 15 degrees
Picture provided by Ronan Caspi, Tel Aviv, Israel
Management
- Surgical management should be considered if patient is symptomatic
- Options include:
- First metatarsal osteotomy
- Exostectomy and capsulorraphy
- Excision of proximal one-third of proximal phalanx (Keller
operation)
- Arthrodesis
Hallux rigidus
- Due to osteoarthritis of first MTPJ
- Affects men more often than women
- Results in pain on walking, especially on rough ground
- There is no valgus deviation of the hallux
- MTPJ is swollen and enlarged
- Dorsiflexion of the MTPJ is reduced
- A rocker-soled shoe may improve symptoms
- If significant symptoms occur then surgery may be required
- Options include:
- Extension osteotomy
- Cheilectomy
- Arthroplasty
- Arthrodesis
Claw toes
- Results from:
- Flexion of the interphalangeal joints
- Hyperextension of the metatarsophalangeal joints
- Often idiopathic
- Can be associated with:
- Rheumatoid arthritis
- Poliomyelitis
- Peroneal muscular atrophy
Clinical features
- Pain in the forefoot = metatarsalgia
- Symptoms are usually bilateral
- Walking may be restricted
- Painful callosities on the dorsum of the toes or under the
metatarsal heads
Picture provided by Ronan Caspi, Tel Aviv, Israel
Management
- If the toes can be passively straightened than a 'metatarsal bar'
may help
- Special footwear may reduce symptoms
- If non-operative management fails then surgical options include
- Interphalangeal arthrodesis
- Joint excision
- Metatarsal osteotomy
- Digital amputation
Plantar fasciitis
- Self-limiting condition that occurs in middle age
- Presents with intermittent inferior heal pain
- Usually unilateral but 15% cases are bilateral
- Pain often worse early in the morning
- Examination show tenderness over the medial plantar aspect of the
calcaneal tuberosity
- 50% have heel spur on plain x-ray
- Differential diagnosis includes:
- Reiter's syndrome
- Entrapment neuropathy
- Calcaneal stress fracture
- Management should involve the use of
- Supportive heel pads and other orthotic devices
- Non-steroidal anti-inflammatory drugs
- Surgery is rarely indicated
Morton's neuroma
- Painful forefoot disorder
- Caused by thickening and fibrosis of interdigital nerves
- Aetiology is unknown
- Usually affects second or third web space
- Causes plantar pain at level of metatarsal heads
- May be associated with distal sensory loss
- Differential diagnosis includes
- Metatarsalgia
- Metatarsophalangeal synovitis
- Stress fracture
- Frieberg's infarction
- Initial management is non-operative
- Surgical excision of the neuroma should be considered if symptoms
fail to settle
Bibliography
Coughlin M J. Hallux valgus. J Bone Joint Surg Am
1996; 78; 932-936
Ferrari J, Higgins J P, Williams R L. Interventions
for treating hallux valgus (abductovalgus) and bunions. Cochrane
Database Syst Rev 2000; CD000964.
Singh S K, Loli J P, Chiodo C P. The surgical
treatment of Morton's neuroma. Current Orthopaedics 2005:
19: 379-384 |