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Home / Foot and Ankle / Toe deformities and forefoot pain syndromes
Foot and Ankle

Toe deformities and forefoot pain syndromes

Toe deformity management plus forefoot pain syndromes such as hammer toes and Morton's neuroma

19 questions 3 source pages

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19 questions
Q1What is the deformity in hammer toes and what causes it?▸
  • PIPJ flexed, DIP extended, MTP neutral or extended
  • Due to simultaneous contraction of extrinsic flexors and extensors without the modifying action of intrinsics
  • Weak intrinsics or plantar plate rupture causes MTPJ extension and PIPJ flexion
Q2How are hammer toes treated?▸
  • Flexible: tendon transfer (FDL to EDL, EDL lengthening)
  • Fixed: tendon + bone procedure (PIPJ excisional arthroplasty, PIPJ arthrodesis)
Q3What is the deformity in claw toes and what causes it?▸
  • Intrinsic minus deformity: MTPJ hyperextended, PIPJ and DIPJ flexed
  • Causes: neurological, synovitis, trauma, compartment syndrome
Q4How do you treat claw toes?▸
  • Conservative: plantar padding at MTPJ, orthosis to offload MT heads
  • PIPJ flexible: Girdlestone-Taylor flexor to extensor hood transfer +/- EBD tenotomy
  • PIPJ fixed, MTPJ flexible: distal PP resection + PIPJ fusion (DuVries) + EDL tenotomy
  • PIPJ fixed, MTPJ fixed (not subluxed): DuVries + EDL lengthening, EBD tenotomy, dorsal capsulotomy + collateral release
  • PIPJ fixed, MTPJ fixed and subluxed: Weil osteotomy
Q5What is the function of the lesser toes?▸
  • Dissipate forefoot pressure
  • Maintain the arch through the windlass mechanism
Q6Describe the X-ray finding in this patient.▸
  • Spur at the calcaneal tuberosity protruding from the parallel pitch line
  • Consistent with a Haglund deformity
Q7What is a Haglund deformity and how is it treated?▸
  • Bony spur at the posterosuperior tubercle of the calcaneum, measured by the parallel pitch line
  • Tenderness 2-3 cm proximal to the Achilles insertion
  • Compresses the bursa on ankle dorsiflexion causing retrocalcaneal bursitis
  • Conservative: NSAID, padding; NOT steroid injection (may cause rupture)
  • Operative: excision of bursa and Haglund lesion
Q8How is insertional Achilles tendinitis treated?▸
  • Treat the underlying cause, e.g. removal of a Haglund lesion
  • Conservative: physiotherapy with TA stretching, small heel raise
  • Operative depends on the size of the diseased tendon
  • <50%: debridement +/- reattach tendon to bone
  • >50%: reattach tendon to bone +/- FDL transfer if gap >5 cm
Q9What is the pathophysiology of paratenonitis and Achilles tendinosis?▸
  • Overuse with repetitive stress on the Achilles
  • Cook and Purdam continuum model (reactive, reparative, degenerative)
  • Myofibroblasts proliferate and synthesize more collagen III at the paratenon causing scarring and shrinkage
  • Causes ischemic damage to the tendon at the watershed region
Q10How is Achilles tendinosis treated?▸
  • Physiotherapy: eccentric training + stretching (Alfredson protocol)
  • Padding + small heel raise
  • Operative: 50% debride; >50% FHL transfer
Q11How is the parallel pitch line constructed?▸
  • 1st line: on the calcaneal tuberosity to the anterior calcaneal tubercle
  • 2nd line: parallel to this and touching the posterior lip of the posterior facet
  • A spur protruding from the line indicates a Haglund deformity
Q12What conditions make up the Achilles tendinopathy group?▸
  • Haglund deformity + retrocalcaneal bursitis = Haglund syndrome
  • Insertional Achilles tendinitis
  • Achilles tendinosis
Q13What is the etiology and presentation of insertional Achilles tendinitis?▸
  • Etiology: retrocalcaneal bursitis, RA/AS with enthesopathy
  • Repeated trauma leads to inflammation then metaplasia of tendon to cartilage/ bone
  • Tenderness at the insertion, may have bony swelling
Q14What is a Morton's neuroma?▸
  • A neuroma caused by compressive neuropathy
  • Most common over the 2nd inter-digital nerve between the 3rd and 4th metatarsal heads
  • Confluence of branches of the lateral and medial plantar nerves
  • Compression by the intermetatarsal ligament
  • More common in women
Q15How does Morton's neuroma present and how is it examined?▸
  • 60% pain, 40% numbness; worse with tight shoes and high heels
  • Palpation: plantar tenderness
  • Squeeze test: compressing the forefoot while palpating the web space reproduces symptoms
  • Mulder click: squeeze elicits an occasional bursal click
  • MTPJ drawer test for instability; nerve block test is diagnostic
Q16What is the differential diagnosis and how do you rule it out?▸
  • XR and MRI to rule out stress fracture, MTPJ arthritis, metatarsalgia, MTP synovitis and Freiberg disease
  • Ddx for a mass in the sole: bursitis, fibroma over tendon sheath, vascular lesion
Q17What are the treatment options for Morton's neuroma?▸
  • Conservative: shoewear, MT pads proximal to the focus of pain (decompress), short-term steroid
  • Surgical: neurectomy + bury end
  • Dorsal approach: less plantar scar
  • Plantar approach: less recurrent neuroma, no need to incise the ligament
Q18Describe the dorsal neurectomy and its commonest complication.▸
  • Incise the transverse intermetatarsal ligament
  • Identify the common digital nerve and resect it 2-3 cm proximal to the intermetatarsal ligament, proximal to the small plantar branches
  • Commonest complication: stump neuroma due to inadequate retraction or inadequate resection
Q19What causes Morton's neuroma?▸
  • Compressive neuropathy; compression by the intermetatarsal ligament
  • Physiology poorly understood: tension/compression/microtrauma
  • More common in women; associated with tight shoe wear and high heels
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