Hallux
valgus
Deviation
of the great toe (hallux) to the outer side of the foot is referred
to as hallux valgus. The midfoot (metatarsus) is usually widened
(splay foot) with a prominent bunion at the inner margin of the
foot. Hallux valgus may result from various causes, most commonly
from shoes with a narrow toe-box and a high heel. Frequent symptoms
are pain at a prominent bunion, pain underneath the forefoot (metatarsalgia)
and pain from pressure against the lesser toes. Conservative treatment
with splints and insoles can not significantly improve the orientation
of the great toe. If significant pain is present in normal shoes,
surgery is indicated. In younger patients (under 60-70 years),
anatomic reconstruction is achieved by dividing the bones and
correcting the alignment (osteotomy), and/or by a soft tissue
procedure to correct the soft tissue alignment around the hallux
joint. In older patients (over 60-70 years), a slice of bone is
removed from the hallux at the joint (resection arthroplasty),
which results in slight shortening of the great toe. Both procedures
are able to relieve symptoms in the vast majority of patients.
Hallux
rigidus
A stiff great
toe (hallux rigidus) is most often caused by degeneration of the
hallux joint (arthrosis). This may be caused by repetitive minor
injuries, e.g. in soccer players. Pain is usually present when
the foot pushes off the ground during walking. Wearing shoes with
a hard and convex sole may alleviate symptoms. Conservative treatment
is by local anti-inflammatory ointments and injections. If symptoms
are sufficiently severe, surgery is indicated. In the early stage
of hallux rigidus, this may be removal of painful bone spurs and
articular surface (cheilectomy), which preserves the joint. In
more advanced disease, the joint is fused (arthrodesis), which
results in permanent pain relief and excellent function. Joint
replacement at the hallux with a prosthesis has only had limited
success on the long term.
Hammer
toes and claw toes
The lesser
toes commonly deviate upward from their normal position. This
is often due to hallux valgus, which pushes against the small
toes and forces them up. A hammer toe is the milder variant, when
the tip of the toe still touches the ground. In a claw toe, the
toe is completely off the ground when standing. Patients may have
marked pain around the basal joint of the affected tow before
this starts to move upwards. Once the deformity has set in, pain
is most commonly at the surface of the toe, caused by pressure
against the shoe, or between the toes. Conservative treatment
with splints and insoles usually has little success. Surgery most
commonly consists of removing a small bone fragment (condylectomy),
rarely a tendon transfer is indicated.
Metatarsalgia
Pain underneath
the metatarsal heads, just proximal toe the base of the toes and
usually under the centre of the forefoot is the most common foot
complaint. It is caused by tissue atrophy because this part of
the foot receives the gretaes load when walking. Often, a change
to a soft shoe with no high heel is helful. A metatarsal pad inserted
into the shoe, just proximal to the painful area, relieves pressure
at the affected bones. Custom made insoles are a more expensive
alternative. Surgery is rarely indicated, not always successful
and only performed if all other treatments have failed.
Flat foot
The medial
border of the foot does not have its normal longitudinal arch
but rests on the ground when standing. Children up to the age
of six to ten commonly have flat feet and the longitudinal arch
usually rises with further growth. Flat feet in children and adults
rarely cause pain and in this case require no treatment. If pain
is present, an insole should be used which elevates and cushions
the medial foot border. Only of pain persists, surgery may be
considered. If painful flat foot develops in patients age 50 or
older, this may be due to a tendon defect and require a tendon
transfer.
Heel pain
Pain underneath
the heel is a common complaint. It may be caused by excessive
exertion but often has no evident reason. The heel looks normal
but is quite tender just under the heel bone (calcaneus). Radiographs
may show a heel spur, but this is present in approximately 5 percent
of normal individuals and is not the cause of the pain. Treatment
is with stretching exercises and heel pads. Injections may also
be helpful. Surgery is almost never indicated and often not successful.
Shock wave treatment is under investigation and may be beneficial.
Ankle arthrosis
Degeneration
of the ankle joint (arthrosis) is often caused by a fracture many
years before but may also have no apparent cause (idiopathic arthrosis).
Pain occurs during and after weight bearing and is most commonly
located at the front side of the ankle. Eventually, the range
of motion decreases and the foot can not be elevated beyond the
horizontal position. Shoes with a rounded (convex) under surface
as well as anti-inflammatory medicine locally or as tablets are
often helpful. In the early stage, removal at the anterior border
of the ankle joint (cheilectomy) is often helpful. In advanced
arthrosis, ankle fusion or joint replacement with a prosthesis
may be performed. The former allows excellent function and is
a permanent solution. The latter provides 20-30° more motion
but may loosen with time.
