Digital (Toe) Deformities
Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. They are among the most common toe deformities and cause joint pain and skin lesions due to excessive pressure and friction on socks and the shoe. Besides heredity, improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases are responsible for the appearance of toe deformities.
Whilst in severe cases surgery is often deemed the most appropriate treatment. In the early stages interventions such as exercise and mobilisation techniques, orthotic therapy, footwear modifications and on occasion, injection therapy can improve discomfort levels.
Hallux Valgus / Bunions
The common term for hallux valgus is bunion. It is characterised by a mostly painful medial deviation of the first metatarsal head and the simultaneous deviation of the first phalanx laterally towards the other toes. As a result, deformities and displacements of the other toes may occur.
The causes have not yet been definitively determined. However, there may be a unbalance of the extrinsic and intrinsic foot muscles, a biomechanical disorder such as hyperpronation, or heredity issues. The development of hallux valgus is promoted by the following factors: - Wearing shoes that are pointed at the front.
- Wearing shoes with a raised heel area (heels) due to overloading and pushing apart the metatarso-phalangeal joints
- insufficient training of the foot muscles
More rarely, hallux valgus develops as a result of trauma or rheumatoid arthritis.
The conservative treatment consists in reducing the symptoms. - Shoe modification: Low-heeled, wide shoes.
- Orthoses: Improves alignment and support.
- Analgesics and NSAIDs.
- Ice: Icing the inflamed deformity to reduce inflammation.
- Medial bunion pads: Prevents irritation of HV deformity.
- Stretching: Helps maintain joint mobility in the affected joint.
Surgical methods can be used when conservative treatments are not sufficient:
Differential Diagnosis to Hallux valgus deformity
• Freiberg’s disease
• Hallux rigidus
• Morton's neuroma
• Turf toe
• Septic joint
Pes planovalgus (i.e., flatfoot) is a common condition among young children and also is encountered in adults. In children, congenital pes planus typically resolves with age as the foot musculature strengthens. Flexible pes planus is defined as a normal arch during non-weight- bearing activity or tiptoeing, with a flattening arch on standing. In rigid pes planus, the arch remains stiff and collapsed with or without weight bearing. Patients with flexible pes planus, in the absence of signs of rheumatologic, neuromuscular, genetic, or collagen conditions, should be treated conservatively.
Asymptomatic children should be monitored and maintenance of a healthy weight should be encouraged. Surgical intervention for refractory symptomatic pediatric pes planus may be considered but there is little evidence to support it. Several etiologies of acquired pes planus in adults have been identified as posterior tibial tendon dysfunction. Clinical and x-ray evaluation can assist in staging the condition and guiding treatment decisions.
A Podiatrist can reduce the symptoms through conservative treatments; advise appropriate shoes and exercises, they can prescribe custom made orthotics and rest or advise surgery when recommended. The correct foot position will help avoiding the risk of further problems, especially in severe cases and for further deformity especially in children.
The flat foot may impact on quality of life: pain and stiffness may cause disability and limitation at any age. There are many conservative and simple ways to reduce pain and limitation. The Podiatrist will evalute your condition and advice or treat if needed.
Overriding Digit / Digitus Superductus Deformity
Digitus superductus deformity is characterised by hyperextension of the corresponding metatarsophalangeal joint and lateral or medial deviation of the toe that comes to lay over the other.
Digitus superductus deformity usually occurs in combination with complex forefoot deformity like splayfoot and hallux valgus or digitus quintus varus deformity.
The raised toe shows pressure sores and corns and the plantar plate is under permanent tension which can lead to a destabilisation of the metatarsophalangeal joint with subsequent joint dislocation.
The aim of the treatment is to reduce the pressure points and restore a nearly normal rolling motion.
Treatment from your podiatrist may consist of:
• Wear soft shoes with a high toe box
• Use cushioning tubes and toe spreaders to reduce friction on the shoe and socks
• Use bandages, supports like orthosis and tape in case of flexible deformity even in newborn
• remove excessive callus and receive advice for pressure relief
• Wear a soft-bedded shoe insole to distribute weight and reduce pain under the forefoot.
• Correction of the toe position can be achieved by surgery
• If the joint is not dislocated, the toe position can be corrected by a minimally invasive procedure
• Correction of the cause (the big toe malposition) is necessary and from various surgical options the best tailored method can be chosen. For better stability the plantar aponeurosis is sutured
Plantar fasciitis is a common and a disabling musculoskeletal disorder primarily affecting the fascial enthesis; it is thought to have a mechanical origin. It is predominantly a clinical diagnosis. Symptoms are stabbing, inferior heel non radiating pain in the morning; the pain becomes worse at the end of the day and can be triggered and aggravated by prolonged standing, walking, running and obesity
In particular, pes planus foot types and lower-limb biomechanics that result in a lowered medial longitudinal arch are thought to create excessive tensile strain within the fascia, producing microscopic tears: inflammation is rarely observed in chronic plantar fasciitis. Evidence indicates a link between arch function and heel pain. With proper treatment, 80% of patients with plantar fasciitis improve within 12 months.
A Podiatric complete differential diagnosis of plantar heel pain is important; a comprehensive history and physical examination guide accurate diagnosis. Many nonsurgical treatment modalities are used in managing the disorder, including rest, drugs, custom and off-the-shelf orthoses, injections, physical and shock wave therapy as nonsurgical management of plantar fasciitis is successful in approximately 90% of patients.
Treatments and investigations include: gait analysis, shockwave therapy, strapping techniques, appropriate shoes, custom made orthotics, injection therapy. An accurate diagnosis can reduce pain and ai to prevent future flare ups.
Plantar Digital Neuroma
Morton's neuroma is a painful nerve disease of the foot due to chronic compression, which is caused by swelling and nodular thickening of the interdigital nerves (neuroma) mainly in the area of the metatarsal heads III and IV, more rarely between II and III.
Additional compression can also be generated by an inflammatory altered and enlarged bursa, which is also located between the heads of the metatarsals and can form a conglomerate with the nerve node. Other foot deformities such as splayfoot and hallux valgus, which can also be caused by wearing unsuitable shoes that are too tight, are particularly conducive to the development of Morton's neuroma. Symptoms are severe pain in the area of the metatarsus heads up to the toes especially after longer walking distances due to the rolling of the foot and can be detected by the compression of the Metatarsal heads, the “squeeze test”, which is very painful in Morton ́s neuralgia.
At the same time, there is usually numbness of the toes in the shoe, requiring patients to remove their shoes and massage their feet. These
intermittent paraesthesia and pain in the forefoot are caused by sclerosing thickening of the nerves digitales plantares communes. Conservative treatment may consist of padding and spreading the anterior transverse arch, also with orthosis, to widen the spaces between and straighten the toes and thereby relieve the neuroma. Also, temporary pain management with local anaesthesia or infiltration of a local anaesthetic may be performed.
Surgical removal of the neuroma may be necessary.