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Flashcards in Forefoot Pain Deck (93):
1

Metatarsalgia

􏰀 Physical Exam


􏰀 Generalized pain with palpation just proximal to metatarsal heads plantarly
􏰀 Little to no external signs of inflammation (swelling, redness, increase temperature)
􏰀 Occasionally will palpate a prominent metatarsal and detect fat pad atrophy
􏰀 Can see associated submetatarsal bursitis


􏰀 Pathogenesis
-Excessive pronation
-Collapse of transverse arch

2

Metatarsalgia
􏰀 Diagnosis



􏰀Predominantly history and physical exam

􏰀Radiographs to help exclude other pathology

3

Metatarsalgia

Treatment

ORIO- NIA

Treatment
􏰀Rest (decrease, but don’t stop activity)
􏰀Ice
􏰀OTC analgesics (acetaminophen, ibuprofen, naproxen)
􏰀Stable, supportive shoes (Athletic style)
􏰀Metatarsal pads
􏰀Orthotics
􏰀Surgery to correct metatarsal deformities

4

Classification of Nerve Injury

􏰀 Compression

-Neuropraxia
-Axonotmesis

􏰀 Transection
-Neurotmesis

􏰀 Ischemia
􏰀 Radiation
􏰀 Inflammation
􏰀 Degeneration

5

Nerve Injury

􏰀 Neuropraxia
􏰀Most common problem->lower extremity



Distally
􏰀Tibial nerve (tourniquet, casts)
􏰀Peroneal nerve (improper padding during surgery, casts, leg crossing)
􏰀Sural nerve (shoes, casts)
􏰀Intermediate dorsal cutaneous nerve (shoes)

􏰀If proximally (herniated disc)
􏰀Transient or intermittent loss of sensation and/or function (days to weeks )
􏰀Reversible ischemia
􏰀NCV slower until remyelination occurs

6

Metatarsalgia


􏰀 Painful condition of forefoot
􏰀Predominantly plantar
􏰀Mainly “ball of the foot”...can spread to toes
􏰀 Catch all term or wastebasket term
􏰀 Can be self limiting and may respond well to conservative care
􏰀 Aggravated by activity
􏰀 Must make appropriate diagnosis to treat adequately
􏰀Rule out other processes

7

Metatarsalgia 􏰀 Physical Exam


􏰀 Generalized pain with palpation just proximal to metatarsal heads plantarly
􏰀 Little to no external signs of inflammation (swelling, redness, increase temperature)
􏰀 Occasionally will palpate a prominent metatarsal and detect fat pad atrophy
􏰀 Can see associated submetatarsal bursitis 􏰀
􏰀 Pathogenesis
􏰀Excessive pronation 􏰀Collapse of transverse arch

8

Metatarsalgia 􏰀 Diagnosis


􏰀Predominantly history and physical exam 􏰀Radiographs to help exclude other pathology
􏰀 Treatment
􏰀Rest (decrease, but don’t stop activity)
􏰀Ice
􏰀OTC analgesics (acetaminophen, ibuprofen, naproxen) 􏰀Stable, supportive shoes (Athletic style)
􏰀Metatarsal pads
􏰀Orthotics
􏰀Surgery to correct metatarsal deformities

9

Classification of Nerve Injury 􏰀 Compression


􏰀Neuropraxia
􏰀Axonotmesis 􏰀 Transection
􏰀 Neurotmesis 􏰀 Ischemia
􏰀 Radiation
􏰀 Inflammation 􏰀 Degeneration

10

Nerve Injury 􏰀 Neuropraxia


􏰀Most common problem that affects neuronal structures of the lower extremity 􏰀Distally
􏰀Tibial nerve (tourniquet, casts)
􏰀Peroneal nerve (improper padding during surgery, casts, leg crossing) 􏰀Sural nerve (shoes, casts)
􏰀Intermediate dorsal cutaneous nerve (shoes)
􏰀More common proximally (herniated disc)
􏰀Transient or intermittent loss of sensation and/or function for several days to weeks 􏰀Reversible ischemia
􏰀NCV slower until remyelination occurs

11

Nerve Injury

􏰀 Axonotmesis

Compressing too long, from casting


􏰀Crush or severe compression injury
􏰀Demyelination occurs with increased compression time and pressure
􏰀basement membrane intact
􏰀Loss of sensation and/or function for several weeks to months
􏰀Axonal regeneration and remyelination takes place
􏰀NCV slow until healing takes place
􏰀Possible Wallerian degeneration in severe cases resulting in loss of function (permanent)
􏰀Distal segment degeneration similar to transection in severe cases

12

Nerve Injury

􏰀 Neurotmesis (Transection)

From Trauma, surgery


􏰀Least common type of peripheral nerve injury
􏰀Axon and connective tissue are lacerated
􏰀Surgery
􏰀Trauma (knife wounds)
􏰀Lacerated nerve ends are not aligned
􏰀Basement membrane of each nerve cell no longer intact
􏰀Wallerian degeneration takes place
􏰀NCV - no action potential
􏰀Permanent and irreversible w/o intervention (repair)
􏰀Even with repair outcomes are not predictable

13

Nerve injury

Nerve ischemia/infarct


􏰀Vasculitis
􏰀Atherosclerotic disease
􏰀Conduction velocity slowing does not occur
􏰀Nerve degeneration occurs within several days of acute infarct
􏰀Basement membrane intact
􏰀Nerve regeneration is possible
􏰀Must control underlying disease process
􏰀Most common symptomatic area in lower extremity
􏰀Sciatic nerve at mid-thigh level
􏰀Other areas of occurrence in the lower extremity
- peroneal and tibial nerves

14

Nerve Injury

􏰀 Radiation-induced injury


􏰀Mainly seen with radiation treatments for neoplastic diseases
􏰀Pelvic radiation (cervical cancer)
􏰀Delayed presentation; manifests years later 􏰀Progressive weakness
􏰀Sensory loss
􏰀Proprioceptive dysfunction

15

Nerve Injury

􏰀 Inflammatory


􏰀Sensory loss and motor dysfunction 􏰀Infectious
􏰀Herpes Simplex virus
􏰀Epstein-Barr virus
􏰀Herpes Zoster virus (most common)
􏰀Idiopathic
􏰀Lumbosacral plexitis
􏰀Diabetes
􏰀Diabetic radiculopathy
􏰀Diabetic amytrophy
􏰀Dorsal root ganglion
􏰀Sjogren’s syndrome

16

Nerve Injury

􏰀 Degeneration


􏰀Distal (most common)
􏰀Gradual distal to proximal degeneration
􏰀Longest nerves affected first
- Distal-most segments of nerve are most vulnerable to metabolic pathology and toxic issues
􏰀Axonal polyneuropathies
􏰀Proximal (rare)

17


14 Nerve Injury

􏰀 Common Symptoms

Pain (burning, shooting)

Paresthesia (numbness, tingling and burning)

Pruritis

Motor function loss

Anesthesia (numbness)

18

Most common cause of lower extremity peripheral n syndromes

L5- back pain radiating down to lateral leg to foot

19

Nerve Injury

􏰀 Autonomic involvement


􏰀Involvement of autonomic nerves may cause trophic skin changes

􏰀Thin, red, dry and shiny skin

􏰀May lead to ulceration or slow wound healing
-Abnormal nerve supply to arterial smooth muscle

20

Physical Exam - Nerve Injury


􏰀 Valleix Sign
􏰀Pain radiating proximal and distal upon palpation or percussion of the entrapped nerve

􏰀 Tinel’s Sign
􏰀Distal tingling or radiation of pain upon percussion of the entrapped nerve

21

Common Nerve Entrapments or Compressions

􏰀 Morton’s – common digital nerve
􏰀 Joplin’s – medial proper digital nerve to hallux


􏰀 Anterior Tarsal Tunnel – deep peroneal nerve
􏰀 Lemont’s Nerve – superficial peroneal nerve (intermediate dorsal cutaneous nerve)

􏰀 Sural Nerve
􏰀 Tarsal Tunnel Syndrome – posterior tibial nerve
􏰀 Common Peroneal Nerve

22

Morton’s Neuroma

􏰀 Aka – Interdigital Perineural Fibrosis


􏰀 Nerve compression syndrome involving the common digital nerves

􏰀 Tumor-like mass of neurilemmal cells and scar tissue along the course of an intact nerve

􏰀 Not a neoplasm, but a reaction to trauma

􏰀 A form of mechanical nerve entrapment

23

Morton’s Neuroma

􏰀 3rd common digital nerve in 3rd interspace most common


􏰀Largest digital nerve as part of the medial and lateral plantar nerves combine

􏰀80-85%

􏰀2nd interspace 15-20%

􏰀Other interspaces consider other etiologies

􏰀 Most common in women and middle age

24

Morton’s Neuroma- Anatomy. ******

􏰂 Nerve passes deep to DTIL

􏰂 Nerves then bifurcate into the toes

Etiology?: Nerve compressed by DTIL or adjacent metatarsal heads

25

Morton’s Neuroma


􏰂 Intermetatarso-phalangeal bursa is believed to be bigger in this interspace

26

Morton’s Neuroma-Symptoms

􏰂 Pain in the forefoot can radiate to toes or proximally into foot causing burning or tingling

􏰂 Can also be a sharp pain, stabbing pain or numbness

􏰂 “Pebble” or “sock bunched up”


􏰂 Pain usually worse with walking and toe-off

􏰂 Can be worse with high heeled shoes or shoes with narrow toe-box and with activity

􏰂 Predilection for women

􏰂 Patients report they can only get relief by removing shoes and rubbing the foot

27

Morton’s Neuroma-Diagnosis

􏰂 Based primarily on H n P – clinical diagnosis
- Do not see redness, increase temperature, or swelling

􏰂 Neurological exam
- Decreased sensation on adjacent sides of the toe

􏰂 Mulder’s Sign- compress med to lat, hearing clicking sound

􏰂 Pencil test

􏰂 Palpation plantar aspect of metatarsal interspace yields pain

􏰂 Dorsiflexion of the toes may cause pain

􏰂 Lidocaine injection as diagnostic block

28

Mulder’s Sign


􏰂 Palpable click in interspace with compression of adjacent metatarsal heads

􏰂 Foot is squeezed (medial to lateral) at metatarsal heads and interspace is palpated

􏰂 (+) sign: palpable click of swollen nerve on metatarsals with reproduction of symptoms

29

Pencil Test


􏰂 Pencil, pen or other simple device is placed in web space – downward pressure applied
􏰂 Pain elicited with neuroma
􏰂 May use finger in web space

30

Sullivan’s Sign


􏰂 Clinical the toes adjacent to the neuroma splay apart

􏰂 Visible radiographically

􏰂 Explanation: Neuroma mass displaces digits apart

􏰂 Not reliable as a sole means of diagnosis
- Soft tissue (capsular) weakness can also result in digital position changes

31

Morton’s Neuroma-Diagnosis

When ordering MRI, order w contrast*****

Check for negative findings as well as to rule out other pathology
􏰂Pain under metatarsal heads
􏰂Pain to palpation of MTPJ’s
􏰂Pain on ROM MTPJ’s
􏰂Pain with attempt to sublux MTPJ


Bursa-Neuroma Relationship
􏰂Trauma ->Inflammation
􏰂Inflamed bursa ->Pressure on nerve ->Inflamed nerve
􏰂2nd, 3rd webspace more likely than 4th

32

Morton’s Neuroma-Imaging




􏰂 Radiographs – r/o other pathology

􏰂 MRI – r/o other pathology
􏰂 Bone scan – r/o other pathology
􏰂 Ultrasound – operator dependent (more useful)

33

Differential diagnosis

􏰂Tarsal tunnel syndrome
􏰂 Peripheral neuritis/neuropathy
􏰂 RA, Capsulitis
􏰂 ST Tissue tumor of the forefoot
􏰂 Metatarsal tumor / stress fracture
􏰂 Calluses associated with HT and claw toes
􏰂 Freiberg's
􏰂 Bursitis

34

Joplin’s Neuroma


􏰂 Compression and/or entrapment neuropathy of the plantar proper digital nerve to the hallux
􏰂 Uncommon in literature
􏰂 Perineural fibrosis of the nerve 1st described in 1971 by Joplin

35

Joplin’s Neuroma


􏰂 Condition originally described in conjunction with HAV deformity

􏰂 Repeated trauma to nerve from shoegear and pressure on medial eminence of bunion
deformity cause symptoms

􏰂 Pain and numbness or tingling in medial aspect of hallux

36

Neuroma Treatment

􏰂 Conservative care:


􏰂Success of therapy: Length of time symptoms

􏰂Some believe that conservative therapy will never make patient completely
asymptomatic

37

Neuroma Treatment

􏰂 Conservative care:



􏰂Padding/Offloading
􏰂Shoe modification
􏰂Orthotics
􏰂 Strapping/Taping
􏰂Injection
􏰂Corticosteroid
􏰂Sclerosing Alcohol Solution

(newer-small 1ml+ local anesthetic-> injecting this causes extensive sclerosing); 7-10 injections in 7-10 wks ; when failed, surgery recommentded

38

Neuroma Treatment

􏰂 Surgical excision of neuroma




ICES



􏰂 Incision of DTIM ligament (decompression)
􏰂 Cryosurgery (cryogenic neuroablation)
􏰂 EDIN procedure
(endoscopic decompression interdigital neuroma)

39

Complications




Re-visited DC

􏰂Recurrent neuroma (stump neuroma)

􏰂 CRPS

􏰂 Digital deformity secondary to transection of a lumbricale or interossei tendon

40

Anterior Tarsal Tunnel

􏰂 Deep peroneal nerve



RATS passed DEEP TIGHT Door


􏰂 Rare

􏰂 Anterior aspect of the ankle midway between the malleoli

􏰂 Trauma/Contusion to ankle or dorsum

􏰂 Soft tissue mass (ganglion)

􏰂 Dorsal beaking/osteophyte formation at T-N or Naviculo-cuneiform joints

􏰂 Tight fitting rim/strap/laces from shoe

41

Anterior Tarsal Tunnel

􏰂 Pain on anterior ankle (where foot meets leg)


􏰂 Minimal weakness
􏰂 Sensory disturbance – 1st interspace area
􏰂 Physical Exam: Limited abnormal findings
􏰂 Foot type: Pes cavus
􏰂 NCV: prolonged distal motor latency
􏰂 EMG: abnormal EDB

42

Lemont’s Nerve


􏰂 Superficial peroneal nerve
- Intermediate dorsal cutaneous and medial dorsal cutaneous nerves

SUPER INTEResting SIT



􏰂 Subject to trauma due to superficial nature
􏰂 Intermediate dorsal cutaneous nerve may be injured in severe inversion ankle sprain
􏰂 Tight fitting shoes

43

Sural Nerve


􏰂 Superficial as it courses posterior to lateral malleolus

􏰂 Subject to external and internal compression at that point

􏰂Internal – Peroneal tendon pathology, lipomas, cysts

􏰂 External – shoe pressure

􏰂 May be entrapped at base of 5th metatarsal and at CC joint

44

Common Peroneal Nerve


Courses around neck of fibula an through peroneus longus muscle belly


􏰂 May be compressed at either site

􏰂 Compression usually before it splits into deep and superficial branches

􏰂 Causes: external pressure on nerve from prolonged lying (surgery), crossing legs,
prolonged squatting, casts

45

Common Peroneal Nerve

Acute foot drop
􏰂Limp foot; difficulty walking
􏰂Trip over foot unless they compensate by flexing hip = Steppage gait



􏰂 Parasthesias/sensory loss over dorsal foot/lateral shin
􏰂 Rarely painful
􏰂 Normal reflexes
􏰂 EMG and NCV can be useful in diagnosis

46

Common Peroneal Nerve

􏰂 Treatment difficult


􏰂Remove compression ( if it's not too late)
􏰂AFOs ( if it's late)(n is permanently damaged)
Drop foot, unable to DF,
-etc: electrical signal band
-more rigid drop ft->surgery

􏰂Physical therapy

􏰂Prognosis: depends on degree of pathology
􏰂Complete lesions: No recovery
􏰂Incomplete lesions (mildly preserved strength): Full recovery

47

Diagnostic Testing

􏰂 EMG (Electromyography)

􏰂 Nerve conduction studies (NCS)=Nerve Conduction Velocity (NCV)

􏰂 Imaging
-MRI first line in lumbosacral spine disease, sensory loss over dorsal foot, weakness of L5 muscles
-CT and Plain film radiography

􏰂 Serologic testing
-Limited value
-HbA1c, fasting blood glucose, Lyme titers

􏰂 Lumbar Puncture
-Unusual presentations

48

Stress Fracture

...result from cumulative repetitive forces insufficient to cause an acute fracture, but which eventually lead to stress failure of the involved bone.” (Sarrafin, 1991)

􏰂 Stress fractures are divided into fatigue fractures and insufficiency fractures

􏰂 Breithaupt 1855 first described

49

Stress Fracture

􏰂 Break in bone caused by repetitive stress injury/trauma

Wolf’s Law

􏰂Dynamic Tissue
􏰂Osteoclastic activity > osteoblastic activity
􏰂Microfracture

50

Stress Fracture – Risk Factors

Anatomic

􏰂Abnormal sagittal plane position of metatarsals
􏰂Long 2nd metatarsal
􏰂Equinus
􏰂Pes planus foot structure
􏰂Limb length discrepancy


Physiologic

􏰂Obesity
􏰂Osteopenia (amenorrhea, malabsorption syndromes, bariatric surgery, poor nutrition,
medication (steroids), EtOH (chronic alcohol)
􏰂Age

51

Stress Fracture – Risk Factors

External factors




Ppac


􏰂Poorly fitting shoes

􏰂Abrupt increase in training volume/intensity

􏰂Change in training surface

􏰂Post-surgery

52

Stress Fractures

Insufficiency Fractures

***Normal bone-> stress fracture
***Osteoporosis-> insufficient fracture


􏰂Osteoporosis
􏰂Rheumatoid arthritis
􏰂Osteomalacia
􏰂Fibrous Dysplasia
􏰂Paget’s disease
􏰂Osteogenesis imperfecta 􏰂Hyperparathyroidism
􏰂Scurvy
􏰂Irradiation

53

Metatarsal Stress Fractures (2,5,1)

􏰂 March Fracture
􏰂Military recruits


􏰂Break in cortex of bone
􏰂Repetitive stress
􏰂Possible overt fracture without treatment
-Sagittal plane deformity most problematic

􏰂 2nd Metatarsal most common followed by 3rd
􏰂Metatarsal neck

54

Metatarsal Stress Fractures

􏰂1st metatarsal
􏰂Rare
􏰂Metaphyseal-Diaphyseal junction


􏰂5th metatarsal (more common than 1st, less common than 2nd)
􏰂Proximal metatarsal
􏰂Worse prognosis
􏰂Nonunion
􏰂More aggressive treatment

55

Metatarsal Stress Fractures


􏰂 No radiographic evidence until 10-21 days post symptoms

􏰂 Bone scan and MRI show almost immediately

*** order bone scan- show hot spots, some level of ionization

56

Metatarsal Stress Fractures

Symptoms


􏰂Gradual worsening of pain in forefoot

􏰂Onset with new activity

􏰂Sharp pain in forefoot aggravated by ambulation

􏰂Pain to palpation localized dorsally

􏰂Diffuse edema dorsally with possible focal increase in temperature

􏰂Axial load elicits pain(weight body pushing you down)
􏰂Helps rule out isolated soft tissue injury

57

Metatarsal Stress Fractures

Diagnosis


􏰂Clinical examination
􏰂Serial radiographs
􏰂Bone scan
􏰂MRI

58

Metatarsal Stress Fractures

Differential Diagnosis


􏰂Muscle/tendon strain
􏰂Toe or metatarsal shaft fracture
􏰂Turf toe
􏰂Metatarsalgia
􏰂Sesamoiditis/Sesamoid fracture
􏰂Morton’s neuroma
􏰂Plantar fasciitis
􏰂Ligament sprain
􏰂Osteomyelitis
􏰂Bone cyst/tumor

59

Metatarsal Stress Fractures

Treatment
􏰂Basic analgesia
-Caution with NSAIDs and fracture healing


BARSS

BARSS

􏰂Activity restriction
􏰂R.I.C.E. therapy
􏰂Surgical shoe or stiff soled shoe
􏰂Supportive cushioned running shoe

60

Freiberg’s Infraction/Disease

􏰂 infraction, incomplete fracture without displacement of fragments

􏰂 Osteochondritis of the 2nd, 3rd or 4th metatarsal head


􏰂 Trauma vs. primary avascular necrosis of the metatarsal head, or combination

􏰂 F > M, (>11-13yrs)

􏰂 Flattening and widening of metatarsal head

􏰂 Unilateral, 2nd metatarsal most common

􏰂 External stress resulting in avascular bone

61

Freiberg’s Disease

Clinical presentation

􏰂Forefoot pain worse at end ROM


􏰂Gradual onset, dull aching pain

􏰂Pain worse with ambulation

􏰂Most pain palpable plantarly at metatarsal head

􏰂Radiographic findings
-Early phase subchondral fractures may be seen
-As it progresses resorption of necrotic bone occurs
-Flattening of metatarsal head occurs with deformity

62

Freiberg’s Disease

Treatment

􏰂Can be self limiting or asymptomatic



*** dont fuse metatarsal????.


􏰂Early catch->short term immobilization

􏰂Later stages, metatarsal bar or pad

􏰂NSAIDs

􏰂Surgical if conservative fails

63

Sesamoiditis


􏰂 Inflammation of the region surrounding the sesamoid apparatus

􏰂 Repetitive, excessive pressure of the forefoot

􏰂 Ballet dancers, baseball catchers, construction workers

64

Sesamoiditis

Symptoms


􏰂Gradual onset

􏰂Mild ache that increase to intense throbbing over time

􏰂Rarely bruising

􏰂Pain increased with activity/walking and running

􏰂Localized edema occasionally

􏰂Sesamoid may have some damage

65

Sesamoiditis

􏰂 Clinically


􏰂Localized signfiicant pain to the sesamoid on plantar palpation

􏰂Exacerbated by hallux dorsiflexion

􏰂Diagnosis is by H n P

􏰂Radiographs used to R/O fracture or other pathology ( not helpful)

66

Sesamoiditis

Treatment
􏰂Insole with modification cutout for sesamoid relief (Dancer’s pad)
􏰂Ice masssage
􏰂NSAIDs

JOIN ABC InS


􏰂Orthotics, soft pads, stiff soled shoes, avoid high heels
􏰂Joint immobilization with strappings
􏰂Activity modification
􏰂BK cast
􏰂Corticosteroid injection
􏰂Surgery

67

Sesamoid Fracture

􏰂 Many overlapping symptoms with sesamoiditis, often times more intense


􏰂 Substantial swelling

􏰂 More likely to have ecchymosis

􏰂 Limited and painful ROM of 1st MPJ

􏰂 Usually correlates with a traumatic incident

68

Sesamoid Fracture

-Radiographs: AP, MO, FF Axial

-Determine between fracture and bipartite sesamoid
􏰂25% of population, of that 85% -bilateral
􏰂Tibial sesamoid more often bipartite
􏰂Bipartite usually has smooth, distinct lines and the two pieces together usually larger
then the other sesamoid

-Bone Scan or MRI may be needed

69

Sesamoid Fracture

Treatment


8 BOCS N Tax


􏰂NSAIDs
􏰂BK casting
􏰂> 8 weeks

􏰂Treatment parallels sesamoiditis treatment options
-Off-loading orthotic
-Corticosteroid injection
-Surgical

70

Hallux Limitus/Rigidus

Normal ROM 1st MPJ dorsiflexion 65o

Types:


􏰂Functional – decreased ROM with loading of 1st metatarsal but normal ROM in open chain kinetics

􏰂Structural – decreased ROM with loading of 1st metatarsal and in open chain kinetics

71

Hallux Limitus/Rigidus

Symptoms:


􏰂begin in early adult life with discomfort (during daily and athletic activities )

􏰂As time goes on, more destruction leads to increase in pain, immobility, joint
destruction, thus converting Hallux Limitus to Hallux Rigidus

72

Hallux Limitus/Rigidus

Etiologies

-Structural
􏰂Metatarsus primus elevatus
􏰂Long 1st ray
􏰂Short 1st ray
􏰂Hypermobility of the 1st ray

-DJD (degenerative joint ds)

-Iatrogenic – complication from a previous surgery

-Trauma

-Gout

-Infection

-Osteochondritis dissecans (lesions)

73

Hallux Limitus/Rigidus

􏰂 Radiologic Findings




SLOT SUJO


􏰂Joint space narrowing
􏰂Subchondral sclerosis (eburnation) 􏰂Osteophytosis
􏰂Subchondral cyst formation
􏰂Loose body (“joint mouse”)
􏰂 These findings are consistent with osteoarthritis

74

Hallux Limitus/Rigidus


􏰂 Treatment



LOSS PR


􏰂Reduce acute inflammatory phase
􏰂Padding and strapping
􏰂Stiff sole shoe
􏰂Orthotic control – Morton’s extension
􏰂Long term conservative care usually is inadequate
􏰂Surgery

75

Digital Deformities

􏰂 Hammertoes
􏰂 Clawtoes
􏰂 Mallet toe
􏰂 Adductovarus 4th and 5th digits

76

Etiology


􏰂 The main causes of a hammertoe fall into 3 dynamic categories:


􏰂Flexor stabilization

􏰂Flexor substitution

􏰂Extensor substitution

77

******Flexor Stabilization

􏰂 most common cause of hammertoes


􏰂 occur with pronated foot type-cause flexors to fire longer and harder

􏰂 seen in late stance phase of gait

􏰂 associated with adductovarus of 4th and 5th digit due to loss of mechanical advantage of
quadratus plantae

􏰂 weak interossei

78

Flexor Stabilization Treatment

􏰂 arthroplasty is usually the mainstay of treatment


(Arthroplasty- removing a piece of joint, but not fusing together)
(Arthrodesis- fusing joint)


􏰂 corrective orthotics are needed to neutralize the etiology of pronation

79

Flexor Substitution

􏰂 least common cause of hammertoes


􏰂 occurs in a supinated foot type
􏰂 seen in late stance phase of gait
􏰂 flexors gain mechanical advantage
􏰂 occurs with weak triceps surae complex **

80

Flexor Substitution Treatment

􏰂 tendon transfer to strengthen the weakened triceps surae


􏰂 arthrodesis of the digits
􏰂 simple arthroplasty would not be enough to neutralize the deforming force

81

Extensor Substitution

􏰂 seen in swing phase of gait


􏰂 extensors>lumbricales
􏰂 MPJ dorsal contraction >90
􏰂 begins as flexible and progresses to rigid
􏰂 reduced early on with weight bearing
􏰂 due to pes cavus, ankle equinus, lumbrical weakness, EDL spasticity and pain & TA
weakness

82


97 Extensor Substitution Treatment

􏰂 arthrodesis would be the procedure of choice
􏰂 with a flexible deformity, a Hibbs tenosuspension would be helpful

83

****Hammertoes

(exten MTP->flex PIP-> ext DIP) ***
claw(ext-flex-flx)


􏰂 Extension contracture of Metatarsalphalangeal Joint (MPJ)


􏰂 Flexion contracture of the Proximal Interphalangeal Joint (PIPJ)
􏰂 Extension contracture of the Distal Interphalangeal Joint (DIPJ)
For the Hallux the contracture is only at the MPJ and Interphalangeal Joint (IPJ)

84

Hammertoes

Etiology

􏰂Idiopathic


Under SLIIM shoE


􏰂Excessively plantarflexed metatarsal 􏰂Shoe pressure
􏰂Intrinsic muscle imbalance
􏰂Long and short extensors dysfunction
􏰂MPJ instability
􏰂Underriding hallux secondary to HAV

85

Hallux Hammertoe

􏰂 Etiology


􏰂Imbalance between hallux extensors and flexors
􏰂Loss of function of flexor hallucis brevis secondary to removal of both sesamoids

86

Clawtoes

Same as hammertoe etiologies


􏰂 Extension contracture of the MPJ
􏰂 Flexion contracture of the PIPJ
􏰂 Flexion contracture of the DIPJ

87

Mallet Toe

(Straight ->DIPJ is flexed)

Mallet Toe
􏰂 Flexion contracture of the DIPJ
􏰂 Relatively normal position of the PIPJ and MPJ 􏰂 Not very common

Etiology
􏰂Imbalance between the extensors, flexors and intrinsic muscles to the digit

88

Adductovarus Digital Rotation

􏰂 Adduction, varus rotation and some flexion of the 3rd, 4th and 5th toes

􏰂 Deformities are greater distally

􏰂 Severity: 5th > 4th > 3rd toe

89

Adductovarus Digital Rotation

􏰂 Etiology


􏰂Pronated foot late in midstance and propulsive period of gait leads to forefoot abduction relative to the rearfoot.

This creates an abnormal medial posterior pull on the long flexors at the distal phalanges.

Final result over period of time is adductovarus rotation.

90

Pathologies of Digital Deformities

􏰂 Pathology



i HAUS


􏰂Heloma dura -dorsal, lateral aspect, callus looking

􏰂Adventitial bursa - blister under the skin

􏰂Ulcerations

􏰂Infections

􏰂Sub-metatarsal pain

91

Lesions with Digital Deformities

􏰂 Hammertoes
PIPJ, distal tip of digit, sub-metatarsal head


􏰂 Clawtoes
-PIPJ, DIPJ, distal tip of digit, sub-metatarsal head

􏰂 Mallet Toe
-DIPJ, distal tip of digit

􏰂 Adductovarus
􏰂5th – dorsolateral PIPJ, 4th – distolateral digit or in the webspace

92

Digital Deformity Treatments

Palliative:
Surgical:

Palliative:
􏰂Reduce lesions
􏰂Pad lesions
􏰂Shoe modifications

Surgical

93

Forefoot Pain

CMINT


􏰂Congenital – TEV, metatarsus adductus, Morton’s foot, Long 1st ray, Plantarflexed 1st ray, 1st metatarsal elevatus, limb length discrepency
􏰂Metabolic – Gout, RA, psoriatic arthritis
􏰂Infectious – Septic joint, cellulitis
􏰂Neoplasms – Soft tissue or bone
􏰂Traumatic – Micro or macro trauma, Iatrogenic (surgery)