CHAPTER 56
Foot and Ankle: Miscellaneous Conditions
Köhler Disease
INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY
• Köhler disease refers to osteochondrosis of the tarsal navicular.
• It most commonly presents in boys between 4 and 7 years of age.
• Ossification of the navicular begins between 18 and 36 months of age, and the navicular is the last tarsal bone to ossify.
— Compression of the nonossified navicular between the other tarsal bones may lead to compromise of its tenuous blood supply and subsequent osteonecrosis. Multiple etiologic factors have been implicated, including macrotrauma or microtrauma (minor trauma) and vascular insult, but most cases are considered idiopathic.
• Irregularities in navicular ossification may be found in up to 20% to 30% of children.
• Many children with radiographic findings consistent with Köhler disease are asymptomatic.
SIGNS AND SYMPTOMS
• Insidious onset of medial midfoot pain, particularly after running or activity
• Tenderness over the navicular; there may also be swelling.
• Gait may be antalgic.
DIFFERENTIAL DIAGNOSIS
• Symptomatic accessory navicular bone (see Chapter 50, Foot and Ankle: General Considerations, Figure 50-2)
• Navicular stress fracture: tenderness of the navicular in adolescent athletes (particularly females) raises suspicion.
• Posterior tibial tendon dysfunction, especially in children with pes planus
• Osteomyelitis: Köhler disease will not produce changes in C-reactive protein level or erythrocyte sedimentation rate
Figure 56-1. Köhler disease: Lateral radiograph of the foot showing a shattered, fragmented navicular (arrowhead).
Reproduced with permission from Kasser JR, ed. Orthopaedic Knowledge Update 5. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1996:503–514.
DIAGNOSTIC CONSIDERATIONS
• Diagnosis is established based on physical examination and radiographs.
• Anteroposterior (AP), lateral, and oblique radiographs reveal sclerosis and collapse of the navicular (Figure 56-1).
• Because many asymptomatic children have radiographic irregularities of the navicular, diagnosis of Köhler disease depends on symptoms, not radiographic appearance alone.
TREATMENT
• Goal is to achieve pain-free ambulation
• Initial strategies include activity modification, changing shoe type, and over-the-counter shoe orthoses with medial arch support.
— If significant symptoms or gait alterations persist, a pediatric walking boot, casting, or custom orthoses may be considered.
• While symptoms may resolve sooner with casting for 6 to 8 weeks, casting does not seem to affect long-term outcome.
• Return to full activities and sports
— Allowed as symptoms abate, usually within 8 to 10 weeks
— Radiographic normalization may take several years and should not be used to determine return to activity.
EXPECTED OUTCOMES/PROGNOSIS
• Natural history is for complete resolution with time.
• Long-term outcome is universally favorable without long-term sequelae, regardless of treatment choice.
WHEN TO REFER
• If activity modification does not relieve symptoms within 2 to 3 weeks, refer for custom shoe orthoses or to a pediatric orthopaedic specialist for possible casting.
Freiberg Infraction/Disease
INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY
• Freiberg infraction is osteochondrosis of any of the lesser metatarsal heads.
• This condition most commonly affects the second metatarsal.
• It typically presents between 11 and 17 years of age.
• Female-to-male ratio is about 5:1
• Multiple etiologic factors have been implicated, including repetitive microtrauma and vascular embarrassment.
• Feet with a second toe longer than the first (also known as a Morton toe) (Figure 56-2) are at greater risk, probably because of increased mechanical stress across the longer toe.
SIGNS AND SYMPTOMS
• Insidious onset of forefoot pain and swelling that worsens with activity
• Tenderness over the involved metatarsophalangeal (MTP) joint
• Pain and limitation with passive MTP joint motion
• Gait may be antalgic.
DIFFERENTIAL DIAGNOSIS
• Stress fractures in the foot are most common in the second metatarsal and in feet with a long second ray but tend to produce pain and tenderness more proximally along the metatarsal, rather than directly over the MTP joint.
• Morton neuroma will be most tender in the intermetatarsal space, which may have a palpable nodule.
• Metatarsalgia is nonspecific pain of one or more metatarsals.
DIAGNOSTIC CONSIDERATIONS
• Radiographs (AP, lateral, and oblique views) may reveal the deformity (Figure 56-3), although they are often normal during the first several weeks of symptoms.
Figure 56-2. Morton toe, bilateral hallux valgus, and bunions in an adolescent dancer.
Photo courtesy of Eliza Lussier, PT.
Figure 56-3. Radiograph showing Freiberg infraction. Note flattening and fragmentation at the head of the second metatarsal (arrow).
From Armstrong AD, Hubbard MC, eds. Essentials of Musculoskeletal Care. 5th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016:1039. Reproduced with permission.
• Bilateral AP views are helpful for comparison because findings may be subtle.
• Magnetic resonance imaging or bone scan may identify early subchondral changes.
TREATMENT
• Goal is pain-free ambulation
• Activity modifications, followed by gradual increase in activity as symptoms allow
• Shoes with a wider toe box and rigid support under the forefoot, or shoe orthoses, such as a metatarsal bar or pad just proximal to the MTP joint, may help reduce pain with ambulation.
• Immobilization in a cast or boot, or a period of non-weight bearing, is sometimes required during the acute phase (6–12 weeks).
• Some experts consider surgical intervention after a 6-month trial of conservative treatment.
EXPECTED OUTCOMES/PROGNOSIS
• Long-term outcomes are variable and may include joint stiffness or persistent discomfort.
• Best results occur with early recognition and initiation of conservative or surgical treatments that may enhance remodeling of the MTP joint
• Cases identified late may require resection rather than reconstruction of the joint, with outcomes that may be less favorable.
WHEN TO REFER
• If activity modification does not relieve symptoms within 2 to 3 weeks, refer for shoe orthoses or to a pediatric orthopaedic specialist for possible casting.
• Refer to a pediatric orthopaedic specialist for persistent symptoms after 6 months of nonoperative management.
PREVENTION
• Minimizing use of high heels and maintaining adequate calf muscle flexibility reduces mechanical stress across the forefoot and may help prevent symptoms in susceptible individuals.
Juvenile Bunions (Hallux Valgus)
INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY
• Juvenile bunions are a valgus deformity of the first MTP joint.
• They tend to be bilateral and familial.
• They are common in pediatric and adult populations.
• Juvenile bunions usually present in early to mid-adolescence and may be a different entity than those presenting in adults, with a more favorable natural history and less arthrosis.
• Female-to-male ratio is about 3:1
• Commonly associated with flexible pes planus and generalized ligamentous laxity
• Activities that place increased stress across the MTP joint, such as dance and gymnastics, and shoes with narrow toe boxes, may contribute to bunion formation in susceptible individuals.
SIGNS AND SYMPTOMS
• Inspection in weight-bearing position reveals the characteristic medial prominence of the first MTP joint (see Figure 56-2 and Figure 56-4).
• There may be an overlying bursa with erythema or inflammation, but this is much less common in children than in adults.
• Metatarsal-phalangeal joint range of motion should be assessed but is usually preserved in adolescent bunions.
DIFFERENTIAL DIAGNOSIS
• Sesamoiditis or sesamoid stress fracture produces pain over plantar aspect of MTP joint
• Turf toe (see “Turf Toe” section later in this chapter)
DIAGNOSTIC CONSIDERATIONS
• Physical examination identifies valgus at first MTP joint (see Figure 56-2 and Figure 56-4)
Figure 56-4. Adolescent with hallux valgus, bunion, bunionette, and fourth and fifth curly toes.
• Imaging is generally not necessary in minor cases.
• If the deformity is severe or if there is concern about rapid progression, radiographs may be helpful (Figure 56-5).
— Weight-bearing AP radiographs are inspected for bony congruence of the MTP joint.
— Valgus angulation of the MTP joint and the intermetatarsal angle between the first and second metatarsal are measured.
— Angle measures serve as a marker for progression if serial radiographs are obtained.
TREATMENT
• Asymptomatic bunions do not require treatment.
• Patients with painful bunions should be advised to select shoes that do not compress the involved region and to avoid high heels.
• Medial arch supports (commonly sold over the counter as anti-pronation orthoses) may also help relieve MTP pressure in patients with bunion and a flexible pes planus.
• For overlying hot spots, donut padding may help relieve any pressure over the region.
• Once appropriate shoes and protection are obtained, normal activities and athletic participation can often continue.
• Surgery is associated with high recurrence and complication rates, and it is appropriate for adolescent patients with significant pain despite prolonged attempts at conservative management.
Figure 56-5. Hallux valgus severity is assessed by measuring the hallux valgus angle and the intermetatarsal (IM) angle on a weight-bearing anteroposterior (AP) radiograph of the foot. A, Diagram showing the hallux valgus angle and the IM angle. B, AP radiograph of the feet of a patient with hallux valgus demonstrates IM angle of 14 degrees in the left foot and 17 degrees in the right foot. Note lateral displacement of sesamoids.
Part A is adapted with permission from Pedowitz W. Bunion deformity, in Pfeffer G, Frey C, eds. Current Practice in Foot and Ankle Surgery. New York, NY: McGraw Hill; 1993:219–242. Reproduced with permission from McGraw Hill LLC. Part B is reproduced with permission from Sarwark JF, ed. Essentials of Musculoskeletal Care. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:859.
EXPECTED OUTCOMES/PROGNOSIS
• Most respond to nonoperative treatment.
• Outcomes after surgery are highly variable. Most studies report complications in 14.3% to 16.7% of patients. Athletes, and dancers in particular, may be unable to return to their previous level of performance after surgical intervention if MTP range of motion is compromised.
WHEN TO REFER
• Refer to a pediatric orthopaedic surgeon for significant pain despite compliance with conservative measures.
PREVENTION
• Symptoms can often be prevented by choosing footwear with toe boxes wide enough to accommodate the MTP joint without causing undue pressure over the region.
Bunionette (Tailors Bunion)
INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY
• A bunionette (see Figure 56-4) is a deformity of the fifth MTP joint.
• Widened intermetatarsal angle could be caused by genetic or anatomic abnormality
• Activities that place increased stress across the fourth to fifth MTP joint and/ or a supinated gait may contribute to bunionette formation in susceptible individuals.
SIGNS AND SYMPTOMS
• Inspection in weight-bearing position reveals lateral prominence of the fifth MTP joint; callus may be present.
• Redness or tenderness directly over the fifth MTP is seen with an overlying bursitis.
DIFFERENTIAL DIAGNOSIS
• Metatarsal fracture or stress fracture
DIAGNOSTIC CONSIDERATIONS
• Physical examination identifies varus deformity at the fifth MTP joint (see Figure 56-4).
• Imaging is generally not necessary.
• If the deformity is severe or if there is concern about rapid progression, weight-bearing AP radiographs may be helpful and are inspected for bony congruence of the MTP joint.
— Varus angulation of the MTP joint and the intermetatarsal angle between the fourth and fifth metatarsal are measured.
— Angle measures serve as a marker for progression if serial radiographs are obtained.
TREATMENT
• Asymptomatic bunionette does not require treatment.
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