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Common Conditions of the Foot
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Bunion deformities are the most common deformities in the foot. The medical term for bunions is “hallux valgus” which refers to an excessive inward (valgus) turn of the big toe at the joint between the foot and toe. Usually both feet are affected by this disorder. It is ten times more common in females than males and tends to run in families.
Bunions usually produce an obvious deformity, with the big toe rotating inward and a prominence on the inside aspect of the toe joint, occasionally with callus formation. Pain, redness, and swelling are the usual complaints, and these are aggravated by shoe wear. Motion in the big toe is usually unaffected. There may be associated deformities of other toes as well. Sometimes the second toe will cross over the big toe, called a “crossover deformity”. Other associated deformities of the other toes may be a “hammertoe”, where one of the toe joints is bent abnormally upward, or a “bunionette”, where a bunion-like prominence develops on the outside of the fifth toe joint. Corns and calluses are frequent problems. Numbness or tingling in the inside of the big toe from irritation of an associated nerve may or may not be present.
Diagnosis of a bunion deformity is made by a careful history and physical, but the severity of the condition is determined by the patient’s level of pain as well as x-rays to assess various angles in the foot and toes.
Treatment of a bunion deformity depends on how much it bothers you, the patient. If no symptoms are present in spite of deformity, treatment is not necessary. Intervention usually initially involves modifications in shoe wear and education on alterations of activities. Shoes should be wide and padded, and have as little stitching over the bunion deformity as possible. Your physician may refer you to a orthotist, someone who can help with shoe modifications. High heels are not recommended at any time for patients with bunion deformities. Despite conservative measures, some patients will only benefit from surgical correction of the deformity, and there are several techniques to do this effectively. Weight bearing is painful at first and usually initially requires crutches as well as the use of a stiff soled shoe, but is usually allowed during the recovery period which takes approximately six to eight weeks.
Other toes besides the big toe can have deformities. A deformity in the second, third, fourth, or fifth toe is called a lesser toe deformity. There are several types of common deformities, including hammer toe, clawtoe, mallet toe, or bunnionette deformity. Shown below is a diagram of each type of deformity.
- Claw toe: similar to hammer toe, but usually in all the lesser toes at once (not just one or two) and related to a neuro-muscular disorder. In addition, there is almost always an additional deformity in the toes present at the other surrounding joints.
- Hammertoe: abnormal flexion at PIP joint, usually present in one or two toes only. Can be a fixed deformity (immovable) or flexible deformity (able to be corrected by manipulating)
- Mallet toe: abnormal flexion of the DIP joint, usually in the longest toe (usually the second toe) as it presses up against shoes and over time turns downward.
- Bunnionette: (not shown) similar to a bunion deformity of the big toe, this is an abnormal prominence of the fifth metatarsal bone.
Many times there is no known cause for lesser toe deformities, but there are often obvious long-term patterns that can explain the persistence of the deformity. They may occur at birth or they may be related to long time use of poor fitting, constricting shoes that cause an imbalance in the way different muscles pull at the toes. These deformities are commonly seen in diabetic persons, especially those with declining nerve function in their lower extremities. Often, these deformities are in conjunction with a bunion deformity in the big toe.
Besides an obvious deformity that is present, pain is usually felt because of pressure points that get irritated with weight bearing and wearing of shoes. In addition, it is not uncommon for corns and/ or calluses to develop in a number of locations as a result of these pressure points. Diagnosis of these deformities is often obvious with a careful history and physical examination, but x-rays are usually taken to evaluate the severity of the angulation or deformity.
Treatment of lesser toe deformities depends on the severity of the symptoms. Non-surgical options, such as the use of wide, well-padded shoes might be recommended as well as possible alternative cushioning or supportive inserts, or daily taping and manipulation. These measures are often not curative however, and surgical correction is the mainstay for patients who have unbearable pain or inability to do activities because of pain. As with bunion deformities, surgery is not recommended for cosmetic reasons only. Surgical correction might involve any combination of releasing, lengthening, or tightening the surrounding soft tissues and tendons or possibly altering the bone at the affected joint(s) to correct the alignment. Wires might be used to hold the bones in the proper position. After surgery, a bulky dressing is worn under a stiff-soled shoe and crutches are used for weight-bearing until your physician feels deformity has healed.
Many nerves and nerve branches exist in the foot to provide sensation and function. Digital nerves are those nerves that branch out from a common nerve and course alongside both sides of each of the toes. Morton’s neuroma, also called plantar interdigital neuroma, is a condition where two digital nerves fibrose or scar-in together when they should be separately coursing between two toes. Irritation and rubbing from compression over time, as with tight shoe wear is the most common cause for this condition, and is likely the reason it is five times more common in females than in males. Morton’s neuroma usually occurs between the third and fourth toes, but is also seen between the second and third toes. It is rare for this condition to occur multiply in the same foot at the same time.
Morton’s neuroma produces a gradual onset of burning forefoot pain in between the affected web space on the ball of the foot. The neuroma might feel like a marble or a wrinkle in your socks. Pain is increased with shoe wear (especially confining shoes) and with walking and standing. Pressing in between the web space on the bottom of the foot with one hand while squeezing the foot together with the other hand will often exacerbate the pain. Sensation changes in the two affected toes, such as numbness or tingling, varies among patients. Patients often modify their walking by walking on the outside of the foot, sometimes producing secondary ankle pain. Removing shoes and rubbing the foot often relieves the pain.
Morton’s neuroma is diagnosed primarily with a careful history and physical examination. X-rays may be taken to look for any abnormal bony prominences, fractures, or arthritis that may cause similar symptoms in the same area. If a stress fracture is suspected, this is often undetectable on x-rays and a bone scan may be recommended.
There are several conservative treatment methods that can alleviate the symptoms caused by an interdigital neuroma. Sticky felt or gel pads, when placed correctly, can effectively keep the bony toes in the forefoot, and thus the interdigital nerves, from rubbing and irritating one another. These are inexpensive and if found to be effective, can be modeled into a more permanent shoe insert (called an orthotic) for more durable and lasting relief. A cortisone injection into the affected area is theoretically beneficial, but not routinely practiced as damage to nearby ligaments or nerves can result in other deformities in the toes. If conservative management fails, surgery to excise the fibrosed area of nerves or to divide the ligament that is constricting them together can be done as a same day or outpatient procedure.
The plantar fascia is a thick fibrous band of tissue on the bottom of the foot, attaching from the inside aspect of the calcaneous (heel bone) and spreading to the toes. The function of the plantar fascia is to help maintain the arch of the foot and provides support to the foot this way.
The fibrous fascia also tries to repair, but often lays down weaker, thicker scar tissue which can increase the irritation. Predisposing factors to plantar fasciitis include female gender, sports participation, and overweight persons. Contrary to common belief, the American Academy of Orthopedic Surgeons states it is not associated with a particular foot type (flat or high-arched feet).
Heel tenderness is often maximal on the inside of the heel bone and may be increased when the foot is forced into a flexed position. Patients commonly feel a “tearing” pain usually in the first few steps in the morning when the fascia is stretched. The condition is often aggravated by prolonged standing and walking but is often alleviated by sitting.
Diagnosis of plantar fasciitis is usually made by a careful history and physical alone, although other tests may be ordered by your physician to exclude other problems that might present in a similar way.
Treatment of plantar fasciitis is almost always non-operative. This may include a one or a combination of heel pads, taping, stretching exercises, night splints, ice, or anti-inflammatory medications. A cortisone injection may be merited if symptoms persist. Casting and/ or surgical treatment to release the plantar fascia is reserved for severe cases and even then may not be recommended by your physician. |
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