The Foot

Fig. 11.1

Foot – plantar aspect

Red Flags

Inflammatory Arthritis. About 90 % of people with rheumatoid arthritis eventually develop symptoms related to the foot or ankle. Symptoms may occur in any segment of the foot. Other inflammatory types of arthritis that affect the foot and ankle include gout, ankylosing spondylitis, psoriatic arthritis, and Reiter’s syndrome. Symptoms can be vague with these problems and include warmth, swelling, and pain in the joints. Rheumatoid arthritis has a hallmark symptom of stiffness in the morning that usually improves after a few hours.

Neuropathy. Most common cause is diabetic related but many etiologies have been described. An insensate foot can be prone to neurotrophic ulcers, foreign bodies, infections, etc. Charcot neuroarthropathy is a potentially severe destruction of the bony anatomy. In the acute phase, it presents similar to infection with erythema, swelling, warmth, and pain. As opposed to infection, the erythema associated with Charcot arthropathy will typically resolve with elevation. Suspicion of Charcot arthropathy should trigger specialist referral.

Trauma. Pain in the midfoot after trauma can indicate a Lisfranc injury. This is a serious problem that occurs at the midfoot tarsometatarsal joint (Fig. 11.2). A sprain of this joint occurs as a result of a low energy type of injury like rolling over of the foot or dropping objects on the foot. A fracture dislocation of this joint occurs as a result of a high energy type of injury like a car accident or fall from a high position. Symptoms can include pain over the Lisfranc joint complex (Fig 11.1), bruising over the bottom of the foot (plantar ecchymosis sign), inability to bear weight, and pain with stress exam. Weight-bearing AP X-ray of bilateral feet might show instability of the midfoot and will allow detection of subtle asymmetry. This is a commonly missed injury, but when identified, it needs orthopedic referral.

Fig. 11.2

Foot – dorsal aspect

Talus and calcaneal fractures are serious injuries that require orthopedic referral. Talus fractures are higher-energy injuries, whereas calcaneal fractures usually occur after fall from height.

Exam

Evaluation of the foot should always involve examination of the ankle joint as described in the previous chapter. Foot examination can be divided into forefoot, midfoot, and hindfoot exams. Observe the foot in weight-bearing position, walking, and on heel rise. Inspect and palpate for hindfoot and forefoot alignment, arch height, deformities of the toes or foot, callus formation, tenderness, and changes in neurological examination both sensory and motor. If any deformity is observed, it is useful to see if it is passively correctable with the patient in a seated position. Inspection of the shoe inside and out along with the sole for abnormal wear can also be helpful.

Forefoot

Metatarsalgia (Forefoot Pain)

Claw toes and hammer toes are the common causes of metatarsalgia due to subluxation of the MCP joints of the toes, and the metatarsal heads become prominent on the sole causing the callosities and tender spots. Treating the causes will help treat metatarsalgia. Patients with a cavus (high-arched) foot commonly have metatarsalgia because of increased pressure over the metatarsal-phalangeal joint (MPJ). Equinus contracture also contributes to forefoot overload. Metatarsalgia is common in elderly patients due to loss of the plantar fat pad with aging. Offloading with orthotics or metatarsal pads should be the first-line treatment.

Hammer Toe and Claw Toe

Typically these develop due to flexor/extensor imbalance. This imbalance leads to flexion at the proximal interphalangeal joint and extension at the metatarsal phalangeal joint, creating the clawing effect. It usually affects the lesser 4 toes. These deformities may be flexible or fixed. Conservative treatment while the deformity is still correctable passively can be effective. Treatment options include wearing shoes with wide toe box, padding the dorsal aspect of the toes involved, taping, and over-the-counter orthotics. Resistant and rigid deformities of claw or hammer toes which are symptomatic may need surgical correction.

Hallux Valgus (Bunion) Deformity

Valgus deformities of the first metatarsal phalangeal joint with prominent bump (medial eminence) on the medial forefoot. Hallux valgus may have a genetic predisposition, so they “usually run in the family.” Women are affected more than men; this can often be related to shoewear choices. The degree of the deformity does not always correlate well with the severity of the symptoms. It is important to obtain full weight-bearing X-rays in order to adequately assess the alignment in the hallux valgus deformity. This will help in determining the treatment options. Most bunions are treatable without surgery. Properly fitting comfortable shoes with a wide nonconstrictive toe box is important in all cases. Medial bunion pads may also be helpful in decreasing the symptoms associated with the bunion, and a toe spacer placed between the great toe and the second toe can help reduce the bunion deformity. Surgery is indicated when pain and discomfort are not getting better with conservative management and not for cosmetic reasons. Always treat according to the severity of patient’s symptoms.

A deformity similar to a bunion on the lateral forefoot is called a bunionette (tailor’s bunion). This can lead to a hard corn and occasionally painful bursitis. This is largely caused by poorly fitting tight shoes. Bunionette deformities can be treated conservatively with a change in shoes to those with a large toe box. This allows plenty of toe space decreasing constriction and relieving symptoms. In the rare case of persistent pain, surgical correction may be necessary.

Morton’s Neuroma

Morton’s neuroma is a thickening of the tissue that surrounds the digital nerve leading to the toes. Morton’s neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma, or excessive pressure between the metatarsal heads. The incidence of Morton’s neuroma is eight to 10 times greater in women than in men. The common symptoms include the feeling of “walking on a marble” or burning pain in the ball of the foot that may radiate into the toes. The patient can also experience tingling or numbness in the toes. High-heeled and tight narrow shoes aggravate this condition. Treatment can include offloading, NSAIDs, and occasional steroid injections. Neuroma resistant to conservative treatment may be surgically excised.

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