Bunions are one of the most common conditions we treat. A bunion is any swelling around the great toe MTP(metatarsophalangeal) joint but is often caused when the big toe joint moves out of alignment. Arthritis of the toe joint may also be present.
Hallux valgus is a term used to describe lateral deviation of the great toe. The word bunion is derived from the Latin "bunio" meaning turnip. Hallux valgus is associated with a medial swelling or bunion. Approximately 30% of people who wear shoes will develop hallux valgus compared with 2% of people who don't. The incidence is much higher in women than in men. A positive family history is found in 60-90% of patients with hallux valgus. Hallux valgus can be classified into 3 groups: Congruent, Incongruent, Degenerative
A congruent hallux valgus deformity is often found in younger patients and may reflect a congenital abnormality. The commonest form of hallux valgus deformity is incongruent. The first metatarsal escapes medially. The proximal phalanx through its attachment to the lateral sesamoid subluxes laterally. In time degenerative changes can develop due to the persistent subluxation.
Illustration demonstrating corrective osteotomy and a realignment procedure to treat hallux valgusview
The treatment of hallux valgus depends on the severity of the deformity, the age of the patient, the general health of the patient, but most importantly the symptoms suffered. Initially modifications to shoe wear and orthotics can be helpful. Surgery is indicated when patients suffer persistent intrusive pain despite appropriate conservative treatment. One of the most successful treatments for hallux valgus is to realign the great toe. This is usually achieved by undertaking a first metatarsal osteotomy and sometimes a further osteotomy to the proximal phalanx. This must be combined with a release of the tight lateral structures and a tightening of the medial soft tissues. In cases where there is significant arthrosis the options are more limited. One is to realign and arthodese the joint.
Heel pain can be broadly divided into sub-calcaneal and superior. The commonest cause of sub-calcaneal pain is plantar fasciitis. Plantar fasciitis is inflammation of the origin of the plantar fascia. The plantar fascia is a fibrous band originating from the plantar medial tubercle of the calcaneus extending to the plantar plates of the metatarso-phalangeal joints. Micro tears of the origin plantar fascia lead to chronic inflammation. There are many causes of plantar fasciitis. It is most common in patients in the age range 40 to 70 years and is more common in women than men. It is also more common in athletes and sports people. Patients complain of a gradual onset of pain around the plantar medial aspect of the heel. Symptoms are usually worst first thing in the morning. X-rays may reveal a plantar spur. Although the incidence of heel pain is higher in patients with a plantar spur many patients with plantar fasciitis have no radiological evidence of a spur.
X-ray showing a Haglund deformity - a bony prominence of the posterior superior heel above the parallel pitch lineview
Other causes of plantar heel pain include atrophy of the fat pad and an entrapment neuropathy of the first branch of the lateral plantar nerve. Structural causes such as a stress fracture of the os calcis should also be considered. The commonest cause of superior heel pain is an insertional Achilles tendonitis. This is often associated with a retro calcaneal bursitis and a prominent Haglund deformity. In many instances symptoms result from a change in shoe wear or level of sporting activity. Non-operative treatment including activity modification, antiinflammatories, physiotherapy and orthotics will resolve most cases. In persisting cases however, surgery may be indicated. This consists of resection of any inflamed paratenon, debridement of any degenerate tendon and resection of a prominent Haglund deformity. As well as the obvious mechanical causes of heel pain it is important to consider metabolic, inflammatory and bone disorders such as gout, hyper lipidaemias, diabetes, hypothyroidism, myeloma and Paget's disease, all of which can present with heel pain.
The treatment of plantar fasciitis initially is conservative consisting of physiotherapy, orthotics, anti-inflammatories and modification of activity. Should the symptoms continue then a steroid injection can be of some benefit. Atrophy of the heel pad can occur following a steroid injection and patients must be warned of this. Overall approximately 80-90% of patients will see an improvement in their symptoms over a 12 month period with conservative treatment alone. Should conservative measures fail then a surgical release of the plantar fascia can be considered.
Hallux rigidus is a term used to describe a painful stiff great toe as a result of osteoarthritis. Osteoarthritis of the great toe can be graded depending on the severity of the symptoms suffered by the patient, the restriction in movement, and the radiological findings.
The treatment for hallux rigidus depends on the stage of the disease.
Grade 1 represents the mildest form. Patients suffer intermittent pain in the great toe with no significant reduction in movement. The x-rays should show a well preserved joint space although a true lateral view may reveal a small dorsal osteophyte.
The treatment for this stage of the disease usually consists of activity modification, orthotics and anti-inflammatories.
Grade 2 of the disease represents a progression of the arthritis. Patients complain of more constant pain in the great toe. There is a reduction in movement and the x-rays show some loss of the joint space.
The treatment for this stage stage of the disease if conservative measures fail is to undertake a cheilectomy (a surgical debridement of the joint) and removal of the osteophyte.
Illustration showing Grade 3 arthritis in great toeview
In Grade 3 of the disease there is marked stiffness in the great toe and x-rays reveal a complete loss of the joint space.
There are a number of surgical options to treat this grade of disease. These include a fusion of the great toe MTP joint, an excisional arthroplasty, and a great toe replacement. A fusion still remains one of the most reliable ways of improving pain and function in Grade 3 disease. There remain questions about the long time survivor ship of great toe replacements.
Metatarsalgia is a term used to describe pain in the forefoot around the metatarsal heads. This can be mechanical or neuritic in nature. Mechanical metatarsalgia can be localised as seen in conditions such as second metatarsal over length or instability of the second metatarso-phalangeal joint. Symptoms can also be more diffuse as seen in patients with rheumatoid arthritis with subluxation of all the metatarso-phalangeal joints.
The treatment of mechanical metatarsalgia initially consists of orthotics and modified shoe wear to try and offload the painful area. Should this fail there are a number of surgical options including shortening osteotomies of the metatarsals such as a Weil osteotomy, or in the case of severe rheumatoid arthritis excision of the metatarsal heads.
Illustration showing Morton's neuroma excised from footview
Neuritic symptoms usually result from Morton's neuroma. This is an entrapment neuropathy of the common digital nerve as it passes beneath the deep inter metarsalligament. The condition affects women more than men and is most often localised to the third web space. Patients complain of pain in the plantar aspect of the forefoot between the metatarsal heads which often radiates into the toes. Examination often reveals tenderness in the affected web space and also a Mulder's click. A Mulder's click occurs when the enlarged common digital nerve subluxes between the metatarsal heads when they are compressed.
The treatment of Morton's neuroma consists initially of shoe wear and activity modification together with orthotics. If symptoms persist despite this approach then consideration can be given to a steroid injection. Failure of conservative treatment is an indication for surgery. This consists of either division of the deep inter metatarsal ligament or more usually excision of the neuroma itself.
Mallet, Hammer, Claw and Overlapping 5th Toe
Illustration showing toe deformitiesview
A mallet toe is a flexion deformity of the distal inter phalangeal joint of a toe. The deformity can be fixed or mobile. In the first instance consideration should be given to conservative treatment with padding, taping and orthotics. In the mobile deformity if conservative measures have failed then a tenotomy of the FDL tendon can be performed. In a fixed or recurrent deformity then the treatment of choice is a fusion of the distal inter phalangeal joint using a K-wire.
A hammer toe is a flexion deformity of the proximal inter phalangeal joint of the toe. Again the deformity can be fixed or mobile. Conservative treatment again consists of padding, taping and orthotics. Should these fail then surgery may be indicated. In the mobile deformity a flexor to extensor transfer has been described. In situations where there is a recurrent or fixed deformity then a fusion of the proximal inter phalangeal joint is usually performed.
Claw toe is a flexion deformity of the proximal inter phalangeal joint and the distal inter phalangeal joint of a toe together with hyper extension of the metatarso-phalangeal joint. If bilateral and severe in nature it is important to consider an underlying predisposing cause such as a neurological abnormality. Treatment again is conservative first with accommodative shoe wear, padding, taping and orthotics. If symptoms persist then a number of surgical options have been described. If the deformity is mobile again a flexor to extensor transfer has been described combined with a release of the metatarso-phalangeal joint and a lengthening of the extensor tendon. In a fixed deformity patients will often require a fusion of the proximal inter phalangeal joint. In severe deformities this may need to be combined with a shortening osteotomy of the metatarsal.
The overlapping 5th toe deformity is a common congenital abnormality. Although the condition can often be managed with accommodative shoe wear the toe may still become painful due to pressure effects. In these instances a soft tissue release of the metatarso-phalangeal joint together with a transfer of the extensor digitoroum longus tendon in severe cases can provide good correction of the deformity.
Illustration demonstrating syndactyly between 2nd and 3rd toesview
Syndactyly can be divided into two types zygosyndactyly and polysyndactyly. Zygosyndactyly consists of complete or incomplete webbing between the toes usually the second or third. It is rarely symptomatic and rarely requires treatment. In polysyndactyly there is often duplication of the fifth toe with webbing between it and the original toe. Surgery may be indicated to amputate the duplicated toe to narrow the foot.
Illustration showing degenerative posterior tibial tendon on the left. The illustration on the right shows an FDL tendon transfer to reconstruct the foot deformityview
Pes planus is a term used to describe flattening of the medial longitudinal arch. In the child pes planus can be broadly divided into 2 groups - physiological and non-physiological. All infants have flat feet and in the majority an arch will develop by the age of 6 years. If a child is asked to stand on tiptoes the arch should reform and the heel should move into varus. Passive dorsiflexion of the great toe also reforms the arch in a physiological flat foot.
Non-physiological flat foot can be caused by CVT, paralytic conditions(cerebal palsy, spina bifida), generalised ligamentous laxity, tight Achilles tendon, tarsal coalition and sub-talar irritability (juvenile chronic arthritis, sub-talar arthritis, osteoid osteoma).
A peroneal spastic flat foot is a term used to describe a rigid painful flat foot. The classic description refers to patients with a tarsal coalition although irritability of the sub-talar joint caused by septic arthritis, juvenile chronic arthritis, and an osteoid osteoma have also been described. Tarsal coalition usually presents in children between the ages of 10 to 14 years. The commonest forms of tarsal coalition are calcaneo-navicular and talocalcaneal.
Tarsal coalition results from a failure of segmentation. The cartilaginous bar is thought to ossify around the time of presentation. The ossification process is thought to lead to a loss of mobility and subsequent pain. Not all patients with a tarsal coalition however will develop pain and stiffness. A calcaneo-navicular bar can often be diagnosed on an oblique xray.
Talo-calcaneal and other forms of coalition require further imaging such as an MRI scan. Treatment depends on the severity of symptoms. In mild cases orthotics may suffice. In acutely symptomatic cases a short period of immobilisation can be helpful. Persistently painful cases often require surgery. Resection of a calcaneo-navicular bar often produces good results. The operation is performed through an Oilier type incision. The EDB is transferred into the defect following resection of the bar. Results following resection of talo-calcaneal coalitions are less predictable. The bar is usually medially placed. There may be associated deformity of the sub-talar joint or degenerative changes leading to poorer results. In the mature foot a triple arthrodesis can be used to realign the foot and improve pain.
In the adult the acquired flat foot deformity usually results from a rupture of the tibialis posterior tendon, degenerative changes within the sub-talar joint, or in association with inflammatory arthropathies classically rheumatoid arthritis.Following a rupture of the posterior tibial tendon a number of surgical options exist if non-operative treatment with orthotics fails. These include an FDL transfer and medial heel shift if the deformity is flexible. Where a fixed deformity or significant arthrosis exists a fusion is usually indicated either of the sub-talar joint or a triple fusion.
Image showing a cavovarys foot associated with Charcot Marie Tooth diseaseview
Excessively high arches can be neuromuscular in origin which causes an imbalance between two pairs of muscles or structural in origin following trauma or underlying deformity.
Pes Cavus is used to describe an excessively high medial longitudinal arch. The cavus deformity of the mid foot is often associated with a varus deformity of the hind foot producing a cavo-varus deformity. Table 3 lists some of the causes of pes cavus.
- Cerebral palsy
- Friedreich's ataxia
- Spinal dysraphism, polio
- Hereditary motor and sensory neuropathies
- Duchenne muscular dystrophy
- Residual deformity related to CTEV
In neuromuscular cases there is often an imbalance between two pairs of muscles. There is often a relative weakness of the peroneus brevis muscle compared with the tibialis posterior. There is also often a relative weakness of the tibialis anterior relative to the peroneus longus. This leads to plantar flexion of the first metatarsal. In order to engage the lateral metatarsal heads with the floor the patient supinates the forefoot and indirectly inverts the heel causing a further exacerbation of the cavovarus deformity. This represents the basis for the "Coleman Block Test". The patient is asked to place the affected foot on a raised wooden block with the medial aspect of the heel and the great toe unsupported. In a mobile cavo-varus deformity this manoeuvre should cause the heel to move back into valgus.
Patients with cavo-varus deformities usually present with pain under the forefoot especially the first metatarsal head. They also often complain of hind foot pain and ankle instability. The cavo-varus deformity is also associated with clawing of the toes and these can result in painful callosities over the dorsal aspects of the inter phalangeal joints. A careful neurological assessment should be performed on all patients with cavo-varus deformities preferably by a neurologist. The orthopaedic assessment should evaluate the severity of the deformity and whether or not the deformity is fixed.
Initial treatment is usually non-operative consisting of accommodative shoe wear and orthotics. There are a wide range of operative procedures described in the management of a patient with pes cavus. In the mobile foot a dorsiflexion osteotomy of the first metatarsal combined with a lateral heel shift can help improve foot position and pain. This can be combined with soft tissue procedures such as a transfer of the tibialis posterior tendon to the lateral aspect of the foot and a release of the plantar fascia. In the more severe cases procedures such as a wedge tarsectomy can be performed. In the stiff cavo-varus foot a triple fusion can be used to improve the foot position and stability. An alternative option is a gradual correction using an Ilizarov frame.
X-ray showing rheumatoid forefoot before and after a forefoot arthroplastyview
The rheumatoid foot is a whole subject in itself. Ninety per cent of patients with rheumatoid arthritis will have involvement of their feet. This usually affects the metatarso-phalangeal joints of both feet symmetrically. Patients develop hallux valgus deformities with gradual subluxation and dislocation of the lesser toe MTP joints. The usual complaint is the feeling of "walking on pebbles" due to the prominent metatarsal heads.
Treatment is initially by accommodative shoe wear and orthotics. Surgical treatment consists of excision of the metatarsal heads and a realignment and fusion of the great toe MTP joints. This so called forefoot arthroplasty provides excellent symptomatic relief both in the short and long term.
Rheumatoid arthritis can also affect the hind foot classically producing a marked piano valgus deformity. This is managed initially with accommodative shoe wear and orthotics. If this approach fails a triple fusion is often the procedure of choice. In patients with rheumatoid arthritis great care must be taken with the soft tissues and, as in all foot surgery, a careful assessment of the peripheral vascular supply must be taken.
The Achilles tendon is the largest and strongest tendon in the body. The tendon may be required to withstand forces of up to 10 times the patient's body weight with activity. The Achilles tendon is prone to tendonitis, tendinosis and ruptures. Tendonitis can be divided into insertional and non-insertional. There are two bursae associated with the insertion of the Achilles tendon, one deep to the tendon the retro-calcaneal bursa and one superficial. Achilles tendonitis is associated with over use syndromes, postural problems, problems with shoe wear and also inflammatory arthropathies. The Achilles tendon does not have a true synovial sheath but a peritenon. Achilles tendonitis can be classified into three stages:
- Stage 1 - Peritendonitis
- Stage 2 - Peritendonitis and Tendinosis
- State 3 - Tendinosis
The treatment of Achilles tendonitis can be divided into operative and nonoperative. Non-operative treatment consists of rest, anti-inflammatories, orthotics and activity modification. Should symptoms persist despite this approach then surgery has been described. Surgery usually consists of resection of the inflamed peritenon together with a debridement of the degenerate tendon.
In cases of insertional Achilles tendonitis this may need to be combined with a resection of a prominent Haglund deformity (a prominence of the posterior superior aspect of the calcaneus).
Rupture of the Achilles tendon is well recognised ana usually occurs in the middle aged patient. Patients usually experience a snap or blow to the back of the leg. Most ruptures occur in the intra tendinous region. There is still a range of opinion regarding the best way of managing ruptures of the Achilles tendon. Non-operative treatment in an equinus plaster is associated with a higher rerupture rate and the tendon healing in an over lengthened position. Operative treatment allows accurate tensioning of the gastroc-soleus complex. Surgery also carries with it a lower re-rupture rate and a higher chance of returning to the level of sport at which the injury was sustained. Surgery however carries with it risks, in particular poor wound healing, infection and nerve injury.
Picture showing dislocation of the peroneal tendons including a peroneus quartius.view
The peroneal tendons are positioned on the lateral (outer) side of the ankle. There are usually three tendons the longus, the brevis and the tertius. Some people have a 4th peroneal tendon, the quartius. This can be risk factor for subluxation or dislocation. Injuries to the peroneal tendons are common and can result in tendinitis, splits, subluxation or dislocation. Inversion injuries and lateral ankle sprains in sports such as rugby and football can lead to splits of the peroneus brevis. Eversion and dorsiflexion injuries in skiers in particular can result in subluxation or dislocation of the peroneal tendons. The peroneal tendons can be imaged accurately by ultrasound. Tendinitis and splits are often managed conservatively. Subluxation and dislocation often require surgery to stabilize the tendons.
Tenosynovitis usually occurs because of over use. Tenosynovitis may also occur as a result of a plantar flexion inversion injury to the ankle. This can be associated with a tendon tear or rupture. The peroneus longus usually compresses the brevis against the fibula causing a longitudinal split.
Subluxation or dislocation usually occur as a result of a specific traumatic event. The most common mechanism of injury being forced dorsiflexion. The peroneal tendons sublux anteriorly around the lateral edge of the fibula. Although conservative treatment with a period of immobilisation has yielded good results in at least 50% of patients, operative treatment is advocated in the young athlete. This usually consists of an anatomic repair of the superior peroneal retinaculum combined with a fibular groove deepening procedure.
We regularly treat patients with peroneal tendon disorders here at the A2F clinic.
The posterior tibial tendon adducts and supinates the forefoot and inverts the sub-talar joint. Dysfunction of the tendon can be classified into three stages.
Stage 1 represents tendonitis. Treatment initially consists of a short period of immobilisation followed by physiotherapy and orthotics. If symptoms persist despite this approach then the tendon can be decompressed and a synovectomy performed.
In Stage 2 disease the tendon dysfunction is associated with a mobile flat foot deformity and in stage three disease the patient develops a fixed flat foot deformity. From a surgical point of view Stage 2 disease can be managed with an FDL transfer and medial heel shift.
Stage 3 disease often requires some form of fusion either of the sub-talar joint or a triple fusion.
Osteochondritis is a painful disease of the joint where the cartilage or bone in a joint is inflamed. It is a condition that can affect many of the bones and joints of the foot.
Osteochondritis of the talus affects the supero-Iateral and supero-medial corners of the talus. It usually presents in children in the age range of 10 to 14 years with pain and swelling around the ankle. The condition is more common in boys. There may be a history of trauma although the aetiology is thought to be an avascular event. The lesion can often be defined on plain xrays although an MRI scan is more sensitive and descriptive.
Initial treatment consists of modification of activities. In some instances symptoms persist either because of a loose body or a failure of the fragmented articular surface to heal. In these situations surgery may be indicated either to remove the loose bodies or debride or graft the areas of chondral damage.
Figure showing screw fixation of 5th metatarsal.view
5th metatarsal stress fractures are most commonly seen in good amateur and professional athletes. They usually present with vague lateral foot pain during or after exercise. Sometimes they can present with sudden severe pain when running and suddenly changing direction for example without any direct trauma to the foot. Early diagnosis is important usually with x-ray and MRI. Early diagnosis allows early treatment and immobilisation often avoiding the need for surgery. Chronic 5th metatarsal stress fractures on the other hand often require screw fixation to achieve bony healing.
Figure showing established navicular stress in a professional athlete.view
Navicular stress fractures are most common in middle distance runners. They usually present with vague midfoot pain during or after exercise. Early diagnosis with MRI and CT allows early treatment and immobilisation. Patients often however present late with well established fractures. These usually require screw fixation.
Figure showing widening of the space between the 1st and 2nd metatarsals characteristic of a Lisfranc injury.view
Jacques Lisfranc de St Martin was a surgeon in Napoleon's Army and first described the lisfranc injury in 1813. A common mechanism then was falling from a horse whilst trapping their foot in the stirrup. This resulted in a fracture at the base of the second metatarsal and separation of the metatarsals. The injury is nowadays most commonly seen in sports people especially rugby players. Pain and swelling in the midfoot following an external rotation injury usually during a tackle are signs highly suggestive of a Lisfranc injury. The diagnosis is made with x-rays and CT scans. Undisplaced fractures can be treated non-operatively but displaced fractures require fixation. A delay in treatment adversely affects the outcome so early diagnosis is very important.