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FOREFOOT

Jump to metatarsalgia / hallux rigidus / hallux valgus / bunionette / lesser toe deformities / in growing toenail / stress fracture / morton's neuroma

Metatarsalgia

Pain under the forefoot is often caused by abnormal loading of the metatarsal heads. It is usually a symptom of another foot pathology which is affecting weight distribution, such as hallux valgus, hammer toes, cavus foot or tight heel cord.

 

Symptoms

  • Pain beneath the metatarsal heads which is worse on walking distances. Feels ‘like walking on pebbles’. 

 

Signs

  • Callosities beneath metatarsal heads.
  • Hammer toe deformity.
  • May co-exist with hallux valgus.
  • Tight heel cord (achilles or gastrocnemius contracture) – check ankle dorsiflexion first with knee flexed and then with knee extended.
  • Often confused with a Morton’s neuroma – check for neurological symptoms.

 

Treatment

  • Well padded footwear.
  • Insole incorporating metatarsal bar to pad the metatarsal heads.
  • Eccentric calf stretching exercises (heel dips on a step).

 

Investigations

  • Weightbearing AP and lateral foot x-ray.

 

Referral?

Co-existing hallux valgus, high arch (cavus) or hammer toe may need to be corrected. Persistent cases can be treated with calf muscle lengthening surgery or metatarsal osteotomies to elevate metatarsal heads. Muscle lengthening is performed under GA via a short incision on the medial aspect of the calf. If an osteotomy is required, the patient will be fully weightbearing in a stiff-soled shoe for six weeks. They will be unable to work or drive during this period.

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Hallux rigidus

This is arthritis of the big toe metatarsophalangeal joint. It may co-exist with severe hallux valgus, gout or rheumatoid arthritis. Often associated with historic repetitive injury.

 

Symptoms

  • Stiffness of big toe.
  • Pain on movement of big toe.
  • Bone spurs (osteophytes) rubbing on shoes.

 

Signs

  • Inflamed tender hallux MTPJ.
  • Restricted dorsiflexion (normal >80˚).
  • Osteophytes.
  • Hallux valgus may be present.

 

Treatment

  • Stiff-sole wide fitting shoes.
  • Rocker-bottomed shoes reduce MTPJ movement (see page 27 re MBT shoes).
  • Full length orthotic (ask for steel shank to prevent MTPJ movement).
  • Analgesia (try topical NSAIDs).

Activity modification.

  • Injection. This can be difficult in very arthritic joints:
  • Try applying traction as you inject dorsomedially, angling slightly distally to account for the curve of the metatarsal head. Use blue needle, 40mg kenalog in 1ml 0.5% marcaine.

 

Investigations

  • Weightbearing AP and lateral foot x-ray.

 

Referral?

There are two surgical options. Cheilectomy is debridement of the joint and removal of bone spurs. More severe cases require fusion. Both are day case procedures under GA. The patient will be fully weightbearing afterwards in a special shoe. Recovery is 2-4 weeks for cheilectomy (although stiffness may take longer to resolve), 6-8 weeks for fusion.

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Hallux valgus (bunion)

This is a very common problem caused by genetic influences and exacerbated by narrow footwear. In adolescents it is often associated with hypermobility.

 

Symptoms

  • Medial deviation of the metatarsal, lateral deviation of the toe.
  • Resultant ‘uncovering’ of metatarsal head with painful inflamed bunion medially.
  • May progress to overcrowd lesser toes resulting in hammer toe and metatarsalgia.

 

Signs

  • Deformity, worse on weightbearing.
  • Assess movement of first MTPJ and presence of arthritis.
  • Check sole of foot for callosities beneath metatarsal heads.
  • Examine for lesser toe deformity or hammer toes.
  • Look for presence of bunionette (see below).
  • In adolescents check for generalised hypermobility.

 

Treatment

  • Wide fitting footwear.
  • Various straps, spacers and pads exist which may reduce symptoms but will not alter rate of progression.

 

Investigations

  • Weightbearing AP and lateral foot x-ray.

 

Referral?

  • Most cases can be treated with appropriate shoes, but it can be difficult to persuade the patient! Cases in which pain is severe or there is lesser toe involvement may be suitable for surgery.
  • The treatment is to realign the first metatarsal with the second. Scarf osteotomy is the most frequently used technique: the bone is cut longitudinally and held with screws. An additional ‘Akin’ osteotomy of the proximal phalynx may also be required. Lesser toe deformity can be corrected at the same time.
  • Surgery is usually performed as a day case under GA. There is no need for plaster, but a special sandal is provided to allow heel-weightbearing afterwards. Return to work and driving are possible at 6-8 weeks, but the foot is often sore and swollen for up to 12 weeks.

 

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Bunionette

This is equivalent to a bunion of the little toe. There is lateral deviation of the fifth metatarsal leading to tenderness over fifth metatarsal head and medial deviation of little toe.

 

Symptoms

  • Painful swelling over fifth toe MTPJ, worse in footwear.
  • Patients often prefer to wear sandals or flip-flops.

 

Signs

  • Painful swelling over fifth toe MTPJ.
  • Prominent fifth metatarsal head.
  • Callosity beneath fifth metatarsal head.
  • The forefoot may appear wide.
  • Often associated with hallux valgus.

 

Treatment

  • Wide-fitting footwear.
  • Padding over tender metatarsal head may allow symptoms to settle.

 

Investigations

  • Weightbearing AP and lateral foot x-ray.

 

Referral?

  • Patients with persistent pain despite appropriate footwear or co-existing hallux valgus may be considered for surgery.
  • Treatment is corrective osteotomy of the fifth metatarsal combined with resection of prominent bone.
  • If hallux valgus is present this may be corrected too. Surgery is usually a day case, under GA.
  • Patients require a stiff soled shoe afterwards, and should be heel weightbearing for six weeks. They may return to work and driving after 6-8 weeks.

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Lesser toe deformities

Hammer toes, mallet toes and claw toes are complex deformities. The aetiology is  multifactorial but includes abnormal muscle tone, overcrowding due to hallux valgus or direct injury to the toe.

 

Symptoms

  • Pain caused by pressure and rubbing on footwear.
  • Mallet and claw toes cause pain at tips of toes due to pressure on the ground.
  • Hammer toes cause sores on top of proximal interphalangeal joints.
  • Loss of the normal plantar fat pad position may result in metatarsalgia.

 

Signs

  • Painful deformity at joints of lesser toes.
  • Check for correctability and flexibility.
  • Assess MTPJ for presence of dislocation.
  • Callosity beneath metatarsal head.
  • May be associated with hallux valgus, cavovarus foot deformity or neurological dysfunction (cerebral palsy, post-compartment syndrome), so examine for these.

 

Treatment

  • Passively correctable deformity in one or two toes may respond to taping:
  • Use a loop of tape over the toe and secured to the sole of the foot to pull the toe down and straight.
  • Extra-deep shoes can reduce pressure symptoms;
  • Metatarsal bar for metatarsalgia.

 

Investigations

  • Weightbearing AP and lateral foot x-ray.

 

Referral?

  • Cases which fail to respond to conservative treatment, and patients with multiple toe involvement, presence of neurological abnormality, cavus foot or severe hallux valgus should be referred.
  • Treatment depends on the deformity, but surgery involves tendon re-balancing, soft tissue lengthening and fusion of stiff joints.
  • Fusions are generally held with a wire which protrudes from the end of the toe.
  • Patients can weightbear in a stiff-soled sandal. Wires are removed at six weeks in clinic. No driving or prolonged standing for 6-8 weeks.

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In growing toenail

A common problem, often in young men. Usually affects medial edge of the big toe nail. Causes include tight footwear, repetitive microtrauma and poor foot hygiene. Infection may be severe in diabetics or immunosuppressed patients.

 

Symptoms

  • Recurrent infection.
  • Pain.
  • Hypertrophy of nail folds.

 

Signs

  • Painful swelling.
  • Foul discharge.
  • Tenderness.

 

Treatment

  • Acute episodes of infection should be treated with oral antibiotics. Gram positive organisms are common, although consider broad spectrum antibiotics to cover gram negatives and anaerobes in diabetics and the immunosuppressed.
  • Saline soaks and packing beneath the corner of the nail help to discourage further ingrowth.
  • Patients should be encourage to cut the nail square and improve hygiene if this is an issue.

 

Investigations

  • No specific investigations are required, although microbiology swabs can be helpful.

 

Referral?

  • Recurrent cases can be treated with excision of all or part of the nail. This can be performed under local anaesthetic.
  • The nail bed is removed and treated with phenol to prevent regrowth.
  • Patients will have an exposed nail bed which takes several weeks to heal and will require simple dressings during this period.

 

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Stress fracture

Repetitive micro-trauma to bone results in a stress fracture. They can occur anywhere in the skeleton, but the metatarsals are the most common site. Also known as a ‘march fracture’, it occurs when running or walking activity is suddenly and markedly increased, for example in training for a marathon or in new military recruits. Stress fracture can also occur if the metatarsal is abnormally loaded, such as in severe hallux valgus.

 

Symptoms

  • Activity-related pain in the mid or forefoot.
  • Tends to resolve with rest but recurs when activity is resumed.

 

Signs

  • May be associated with swelling or palpable lump on the metatarsal shaft.

 

Treatment

  • Rest and avoid running or walking long distances. This can be very trying for dedicated runners. Alternative forms of exercise such as swimming or cycling may be suggested.
  • Supportive shoes with stiff soles help in the recovery period.
  • Average time to return to running is around 12 weeks.
  • Vitamin D and calcium supplementation is helpful in speeding recovery.

 

Investigations

  • Weightbearing AP, lateral and oblique foot x-rays should be performed.
  • Vitamin D insufficiency is under-recognised and very common, especially in females.
  • If a stress fracture fails to heal, check calcium and hydroxylated vitamin D levels. The expected value for 25(OH)D is 50nmol/L. Vitamin D supplementation can be given in the form of Ergocalciferol 800 units daily.

 

Referral?

  • Idiopathic stress fracture as a result of excessive exercise rarely needs surgical intervention.
  • However, fractures as a result of hallux valgus or other form of mechanical derangement may require surgery and these cases should be referred. 
  • Stress fractures of the midfoot, talus and calcaneum may require surgical stabilisation.

 

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Morton’s neuroma

A swelling of the nerve between the metatarsal heads. Often associated with tight shoes or high heels. It is most common between 3rd and 4th metatarsal heads, but may occur between 2nd and 3rd. Rarely is it found elsewhere. It may be difficult to differentiate from metatarsalgia, stress fracture or MTPJ synovitis.

 

Symptoms

  • Pain between third and fourth toes.
  • Worse on prolonged standing or in tight shoes.
  • May radiate into toes.
  • ‘Electric shock’ or numbness in webspace.

 

Signs

  • Focal tenderness between metatarsal heads.
  • Palpable swelling in webspace.
  • Positive ‘Mulder’s click’:
  • Pinch the webspace from above and below, while you squeeze the metatarsal heads togeher with the other hand. A positive finding is a painful click as the neuroma is squeezed out from between the metatarsals.
  • It is very important (and often difficult) to differentiate Morton’s neuroma from other causes of metatarsalgia – look for plantar callosity, irritable or unstable MTP joint which may indicate another diagnosis.

 

Treatment

  • Wide-fitting shoes can help alleviate symptoms.
  • An injection may be diagnostic as well as therapeutic.
  • Use 1ml lignocaine and 40mg kenalog with a blue needle. Inject from the dorsum of the foot right between the metatarsal heads, aiming to get the needle just tenting the plantar skin. Withdraw 2-3mm, aspirate and inject.

 

Investigations

  • Weightbearing AP and lateral x-ray will exclude other diagnoses such as stress fracture.
  • Ultrasound is better than MRI as targeted injection can be performed simultaneously if a neuroma is identified.

 

Referral?

  • Suspected neuromata or cases where the diagnosis remains unclear should be referred.
  • Treatment is excision under GA through a dorsal incision.
  • Patients can fully weightbear immediately but need to keep the wound dry until healed.
  • Return to work and driving is possible in 7-10 days.

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