A Guide To Common Forefoot Problems
Forefoot problems are a common occurrence in any primary care physician's office. By far, treatment of these conditions is non-surgical, with early intervention by a knowledgeable clinician saving time, money, and pain to the affected patient population. We will try to provide a systematic approach to the diagnosis and treatment of these conditions, beginning with definitions of the conditions.
Bunions, by definition, are a bursal sack over the first metatarsal head. They are not only growths from the bone, but a deformity that has several components, including medial deviation of the first metatarsal, and lateral deviation, and supination of the great toe. The second toe may or may not be pushed up by the deviated greater toe.
A bunionette is a bursa over the fifth metatarsal head. It can also produce pain and symptoms that are most likely related to footwear. Usually, pressure exerted from the shoe cause typical symptoms.
Corns are a thickening of the skin that is secondary to pressure on bony prominences. Depending on the location, corns are divided into categories of hard and soft. Hard corns are typically lesions that are located on the dorsum of toes having an underlying claw toe and hammertoe deformity.
By definition, metatarsalgia is pain under the ball of the foot. Typically, the symptoms are localized in the metatarsal head area. The symptoms are caused by either increased pressure applied by deformities or by atrophy of the plantar fat pad. Metatarsalgia presents with a painful callous localized underneath a metatarsal head.
Treatment for bunions usually consists of using a wider shoe with a soft upper that will not put pressure on the area. Unfortunately, there are still a number of patients that will not be comfortable with this type of footwear or even bare feet. It is this type of patient that will need further evaluation to determine the type of bunion and its treatment; selection of the type of bunion surgery depends on several factors including the patient's age, degree of hallux valgus angle, degree of intermetatarsal angle, flexibility, and presence of arthritis in the joint.
Management of a bunionette is typically non-surgical. Treatment consists of using a wider and softer shoe that will accommodate the prominence in the fifth metatarsal phalangeal joint area. Several over-the-counter splints, orthosis and pads can be found to relieve the pressure and most of the time, they do. Still, there are a number of patients that will not respond to this simple but effective way of management. These patients usually benefit from surgical intervention to correct underlying malalignments and to remove bony and soft tissue prominences. Different procedures have been described for treatment of bunionettes. They include partial resection of the metatarsal head prominence, osteotomies to correct angular deviation of the metatarsal, and resection arthroplasties.
The management of corns is mainly non-surgical. Shoe modifications that have wider and higher toe boxes, corn pads, and other orthosis will relieve the pressure of these bony prominences and allow the patient to function in a comfortable manner. When the corns are secondary to underlying bony deformities that are not amenable to shoe modifications, surgical correction of the associated deformity is indicated. Most of the time, this does not require a prolonged period of disability. The patient can return to usual activity after several days.
The treatment of metatarsalgia usually consists of padding the shoe to relieve the pressure from the metatarsal heads. This is effectively done by adding a metatarsal pad just proximal to the metatarsal heads of the involved bone. Also, serial paring of the callus can be done in the office by using a disposable number 10 or 15 blade. This will not only treat the problem by relieving some of the pressure from the bottom but it will also help in the diagnosis by differentiating between calluses and plantar warts. Surgical management for persistent symptoms of metatarsalgia includes realignment procedures that allow balancing of the weight distribution under each metatarsal head.
The gastrocnemius and the soleus muscles combine distally to form the Achilles tendon which inserts in the posterior process of the calcaneus. The tendon itself is covered by a paratenon that allows easy gliding of the tendon. The blood supply to the tendon comes from the musculotendinous junction, the osseus insertion into the calcaneus, and the vessels from the mesotendon that penetrate through the paratenon to reach the tendon substance. The least vascularized portion of the Achilles tendon is localized from two to six centimeters proximal to its osseus insertion. This is the area where most pathologic processes of the Achilles tendon occur.
Until recently, the terminology used to describe tendon problems has not been uniform. Lately, a histopathologic classification has been developed to standardize the diagnosis and treatment of Achilles tendon disorders. Paratenonitis refers to an inflammation which is limited to the paratenon or the envelope of the Achilles tendon itself. Tendinosis refers to intratendinous degeneration from a previous longitudinal tear without an inflammatory response. Partial and complete tendon ruptures are usually easy to differentiate from each other clinically.
Achilles tendon problems are particularly common in runners, and running accounts for more than ten percent of Achilles tendon injuries. Aging, poor training technique and anatomic abnormalities can contribute to Achilles tendon morbidity.
In paratenonitis, the patient typically shows a gradual onset of pain, swelling and warmth localized in the Achilles tendon area. Usually, symptoms are exacerbated by "overuse" or strenuous exercise and the patient may feel some crepitation along with the motion of the Achilles tendon. More advanced cases can present symptoms when performing normal activities or while at rest.
Achilles tendinosis is also common and presents as a palpable tendon nodule that may or may not be associated with swelling and signs of inflammation. This typically occurs in the area of the least blood supply to the Achilles tendon (two to six centimeters proximal to the insertion). Tendinosis is one cause of Achilles tendon ruptures.
Usually, the history and physical examination are enough to determine whether the patient has a complete rupture versus a partial rupture. However, in cases of paratenonitis and associated tendinosis, an MRI of the Achilles tendon can be useful to differentiate between simple inflammation and intratendinous degeneration or partial tear. Ultrasound has also been useful to evaluate the Achilles tendon because it allows dynamic evaluation of the tendon function.
Most cases of paratenonitis with or without tendinosis or partial rupture can be managed successfully in a non-surgical way. Useful modalities include rest, physical therapy in the form of iontophoresis and stretching exercises, as well as the use of anti-inflammatory medications and orthosis. The patient can begin a gradual return to activity and training with some modifications as the symptoms subside. The use of steroid injections for cases of paratenonitis with or without tendinosis have to be very judicious, because steroid injections have been implicated with tears of the Achilles tendon.
Complete ruptures of the Achilles tendon usually occur in sedentary, middle-aged men who engage in episodic over-activity. Some factors that predispose to ruptures include tendinosis, with or without associated paratenonitis, age related changes of the tendon or muscle, and deconditioning. Other associated causes include direct trauma, a dramatic increase in training programs and mechanical overload from sudden elongation of the tendon. Rupture of a normal tendon can occur as a result of an extreme mechanical overload to the tendon. The patient will typically complain of a sharp tearing sensation of the posterior aspect of the leg and, sometimes, will refer a feeling that something hit the back of the calf.
Complete tears can be treated surgically or non-surgically, and the optimal treatment is still debatable. Complications of non-operative treatment include a higher re-rupture rate and power deficit up to forty percent. On the other hand, the reported operative complication rate is approximately twenty percent and may include fistulas, skin necrosis, and infection of the tendon. In choosing between surgical and non-surgical treatment for an Achilles tendon rupture, the risks and benefits must be weighed in each case. For professional athletes, the need to return to full function combined with reduced chances for re-rupture often point in the direction of surgical management. Surgical intervention of end-to-end repair also requires protection in a plantar flexed cast. By the fourth week after surgery, non-weight bearing range of motion exercises and progressive dorsiflexion of the ankle may begin as progressive physical therapy is planned.
Non-surgical management consists of a cast, in plantigrade position, for the first six to eight weeks. It is progressively brought to a plantigrade or neutral position as the symptoms and clinical situation permit. Then, range of motion, strengthening, and proprioceptive exercises are prescribed after eight to twelve weeks. Patients with chronic rupture present late and may have had little or no pain at the time of the rupture; they complain of weakness and increased difficulty in tasks such as going up stairs. Delayed treatment often results in a gap that requires the use of a tendon transfer or some other surgical technique to correct the defect. Late reconstruction also carries a higher rate of complications, such as delayed healing and wound dehiscence.
REFERENCES
1. Sammarco GJ. Foot and Ankle Manual. Lea & Febiger, Philadelphia: 1991.
2. Baxter DE: The Foot in Running. In Mann RA, Coughlin MO, ed. Surgery of the Foot and Ankle. Mosby, St. Louis: 1993: 1224-1240.
3. Jahss MH: Tendon Disorders of the Foot and Ankle. In Jahss MH. Disorders of the Foot and Ankle. WB Sanders Co., Philadelphia. 1991: 1461-1513.
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