Hallux

Question 1

What does POLICE stand for?

Answer 1

• protect
• optimal loading
• ice
• compression
• elevate

Question 2

Most common cause of big toe pain

Answer 2

Hallux valgus (Mc In elderly women)

Question 3

2nd most common cause of big toe pain?

Answer 3

Hallux limitus/rigidus (most common in 55+)

Question 4

What is hallux rigidus/limitus

Answer 4

Degenerative osteoarthritis of 1st MTP (osteophyte on dorsal aspect of MTP) limiting dorsi flexion

Question 5

Predisposing factors of hallux rigidus?

Answer 5

Forefoot supination, overweight, anything that alters normal joint movement

Question 6

Hallux rigidus is arthritis and would present with what pattern

Answer 6

Morning stiffness that decreases with movement
Crepitus
Progressive/ intermittent

Question 7

What cause turf toe?

Answer 7

Traumatic hyperextension injury to big toe

Question 8

What is the difference in pain patterns for turf toe vs. hallux rigidus?

Answer 8

Turf toe- plantar surface

Hallux rigidus - dorsal surface

Question 9

How does compression affect pain with turf toe and hallux rigidus?

Answer 9

Makes pain worse with rigidus but not turf toe

Question 10

Early treatment for turf toe and hallux rigidus?

Answer 10

• police
• protect with taping, bracing, padding, rocker bottom shoes
• US, TENS, IFC
• mobilization
• modify activity

Question 11

What is the prognosis for Turf toe and hallux rigidus?

Answer 11

• 6-8 weeks for turf toe

- can not cure, only control progression of hallux

Question 12

The sesamoids are within what tendon?

Answer 12

Flexor hallicus brevis

Question 13

What is the clinical presentation of sesamoiditis?

Answer 13

• Slow onset with recent increased activity.
• Pain provoked with weight bearing
• focal tenderness and sharp pain on plantar metatarsal head with end range dorsiflexion

Question 14

What is the primary risk factor for sesamoiditis?

Answer 14

Pes cavus foot

Question 15

What is the DDX for sesamoiditis?

Answer 15

Fracture, osteochondritis, avascular necrosis

Question 16

Degenerative arthritis where dorsomedial capsule attenuates and the abductor hallucis tendon slides under the metatarsal head, pulling the hallux into pronation and causing a lateral deformity in which the phalanx is abducted

Answer 16

Hallux valgus

Question 17

Hallux valgus is defined as adduction of the proximal hallux phalange. What other deformities result?

Answer 17

• metatarsal adducts causing a bunion (while phalanx abducts)
• medial rotation of the toenail toward midline

Question 18

What is a bunion?

Answer 18

Prominent and inflammed metatarsophalangeal joint with overlying bursa due to adduction of the metatarsal in the 1st digit

Question 19

Who commonly gets hallux valgus?

Answer 19

Older females with a family history of valgus derformity, pes planus , toe clawing or metatarsus primus varus

Question 20

What is the underlying cause of hallux valgus in 80% of cases?

Answer 20

Metatarsus primus varus

Question 21

What is metatarsus primus varus?

Answer 21

Varus positioning of metatarsal- cuneiform joint. It causes playing of the MTs, increasing load on 1st ray

Question 22

What is the manipulation/mobilization for hallux valgus?

Answer 22

M to L glide of distal metatarsal by contacting the metatarsal head and distracting the proximal phalange

Question 23

What kind of shoes are recommended for people with hallux valgus?

Answer 23

Wider toe box

Question 24

What is the prognosis for hallux valgus?

Answer 24

Weeks to months for improvement

Chronic cases may need referral for injections or surgical intervention

Question 25

Other than manipulation and shoes with a wide toe box, what other treatments can be done for hallux valgus>

Answer 25

- taping/bracing | - bunion pads

Question 26

Specific or generalized forefoot pain?

Answer 26

Metatarsalgia?

Question 27

Metatarsalgia may be a symptom in what conditions?

Answer 27

- over pronation syndrome - Morton’s neuroma - stress fracture - Osteoarthritis - RA - Gout - osteochondrosis - sesamoiditis

Question 28

Aseptic ischemic necrosis of the ossification canters at the epiphysis in children?

Answer 28

Osteochondrosis

Question 29

Osteochondrosis (aseptic ischemic necrosis of epiphysis) at the 2nd or 3rd metatarsal head?

Answer 29

Freiberg’s disease

Question 30

Patient reports the feeling of a pebble in their shoe or arch pain/cramp. What is this likely?

Answer 30

Metatarsalgia or Morton’s neuroma

Question 31

What are some risk factors for metatarsalgia?

Answer 31

- too tight footwear - lack of support in footwear - running or extended standing, especially on hard surfaces like concrete - obesity - old age - diabetes

Question 32

What are associated symptom for metatarsalgia?

Answer 32

- Callous formation on the plantar metatarsal head area | - splay foot, loss of transverse arch due to laxity

Question 33

Intermetatarsal plantar nerve entrapment by the transverse ligament, usually between 2-3rd or 3-4th digits?

Answer 33

Morton’s neuroma/metatarsalgia AKA plantar digital neuritis

Question 34

Who commonly gets Morton’s neuroma?

Answer 34

Women over 50

Question 35

What is the early treatment for Morton’s neuroma and metatarsalgia?

Answer 35

- ID cause and eliminate (footwear, hard floors, etc) - POLICE - intrinsic for mm exercises (short foot) - CMT - support with tape/padding at metatarsal

Question 36

What is the late management for metatarsalgia and Morton’s neuroma?

Answer 36

- return to ADL - continue strengthening intrinsic foot mm - continue CMT - massage - orthotics/support

Question 37

Morton’s neuroma May require additional interventions if conservative care fails. What are they?

Answer 37

- extracorporeal shockwave therapy - injections - surgical intervention

Question 38

What is the prognosis for metatarsalgia?

Answer 38

Improvement in 1-3 weeks

Question 39

What is the prognosis for Morton’s neuroma?

Answer 39

12-16 weeks (3-4 months) If not resolved in this time, may need injections or surgery

Question 40

What is Morton’s foot and how does it relate to Morton’s neuroma?

Answer 40

2nd digit is longer than 1st digit Has nothing to do with Morton’s neuroma