Regional Foot Pain 3: Forefoot

Front 1

List 3 common, 3 less common and 1 not to be missed forms of forefoot pain

Back 1

Common:

• Hallus-abducto-valgus (HAV)
• Hallux Limitus/Rigidus
• Morton's Neuroma
• Stress # of MT

Less Common:

• Tailors Bunion
• Stress # sesamoid
• Freibergs infraction
• Claw Toes

Not to be missed:

• CRPS

Front 2

Describe HAV

Back 2

• characterized by lateral deviation of the great toe
• Abd and ER of 1st tie and IR of 1st MT
• Displacement occurs at MPJ
• MT displaced at MT and M.Cuniform joint

Front 3

At what degrees is a HAV deformity said to exist?

Back 3

• When and of hallux on MT is greater than 10-12 degrees

Front 4

10 factors in which severity of deformity of HAV is dependant on and 9 = ...........

Back 4

1. Extent of abnormal STJ Pronation
2. Extent of STJ and MTJ subluxation
3. Overall degree of calcalaneal eversion
4. Amont of forefoot adducts present
5. Extent of inflammation affecting 1st MPJ
6. Angle and base of gait
7. Stride length
8. Presence or absence of a propulsive gait phase
9. Weight
10. Footwear

Thus a FLEXIBLE FOOT TYPE

Front 5

Difference between a bursae and bursitis

Back 5

• Bursae: present but not inflammed
• Bursitis: when inflammed

• Used for protection when bony prominence

Front 6

Effect of footwear on HAV

Back 6

• Hereditry, silly shoes just speed up process can't be prevented.

Front 7

Stage 1 of HAV development?

Back 7

• Apparent abd or lateral shifting of the base of proximal phalanx relative to 1st MT head
• minor degree of lateral seasmoid displacement
• slightly sore and swollen

Front 8

Stage 2 of HAV development?

Back 8

• Actual and of hallux against the 2nd toe
• Clinically see medial bump pain, lateral hallux nail symptoms, H.Molle in 1st and 4th ID and HD overlying 5th digit- due to pushing- shoe pressure

Front 9

Stage 3 of HAV development?

Back 9

• Increased widening of the foot, w marked increase between 1st and 2nd MT on radiograph.

Front 10

Stage 4 of HAV development?

Back 10

• Subluxation or complete dislocation of MPJ, generally only seen in conduction with RA

Front 11

Describe Hallux Limitus

Back 11

• Limited ROM of hallux
• Doesn't facilitate sagittal plane movement- forward movement- to allow body to get over foot in gait.
• Compensate with swing of hips over feet or duck feet.

Front 12

Difference between structural and functional HL

Back 12

• SHL: involves the lack of hallux DF w NWB and WB, usually originates with trauma that disrupts the joint.

• FHL: normal range of hallux dorsiflexion during non-weightbearing but there is a dramatic decrease in hallux DF during WB.

Front 13

Best shoe and orthoses for Rigid foot and flexible foot

Back 13

• Rigid: Flexible shoe/orthoses
• Flexible: Rigid shoe/orthoses

Front 14

Describe Hallux Rigidus

Back 14

• Endpoint of HL, now no ROM, requires shoe wear modification and may require surgical intervention.

Front 15

Describe Sesamoiditis

Back 15

• Inflammation of sesamoid bones
• pain w gradual onset
• painful active ROM

Front 16

Role and anatomy of sesamoids

Back 16

• Tibial and fibular sesamoids are located within tendons of FHB
• Increased mechanical advantage of FHB
• Assists with WB under great MT
• Elevates MT head off the ground
• Helps DF of hallux

Front 17

Differential diagnosis of sesamoiditis

Back 17

• Bipartite sesamoid: split sesamoid
• #

Front 18

Describe Bipartite sesamoid/ sesamoid #

Back 18

• 25% of pop have B.sesamoid but 85% bilateral (BF)
• Tibial more often be bipartite than lateral
• Bipartite have smooth margins where as # have irregular # lines (fluffing)

Front 19

Describe mortons neuroma

Back 19

• Painful nerve compression of inter metatarsal plantar nerve
• Burning, tingling down interspace of involved toes, radiating pain to toes, paint radiate up leg
• worse when walking particualry in high heels or tight shoes, relieved by rest

Front 20

Pathomechanics of morons neuroma

Back 20

• At toe-off the interdigital nerve compressed by interMT lig w compression of common digital nerve by edge of transverse MT ligament as nerve passes dorsally under ligament to bifurcate into toes

Front 21

Rx mortons neuroma

Back 21

• Reduce or remove pressure (MT dome, made of foam forces bone heads apart, relieving ID pressure).
• padding
• surgery

Front 22

Where do ID neuromas not occur in the foot?

Back 22

• between 1st and 4th web space- other cause

Front 23

Describe Turf Toe and Rx

Back 23

• Acute (traumatic) tear of joint capsule from MT head and sublux/dis of 1st MPJ
• Caused by hyperextension, hyper flexion or valgus injury

• Rx: reduce activity and wear orthosis to block DF

Front 24

Healing time of ligaments vs #

Back 24

• Ligament: 6-12 months
• # = 6-8 weeks

Front 25

Describe Freibergs Infraction and Dx

Back 25

• Caused by avascular necrosis of the MT head
• Micro# at junction of metaphysics and growth plate
• # deprive epiphysis of sufficient circulation

• Usually localised to head of 2nd MT
• Repetative stress, pivoting motion on bend knee i.e netball >young girls

Dx on x-ray, shows bone slightly eaten away, rough joint space and whiter

Front 26

Foot type with 2nd MT > 1st MT

Back 26

• Mortons toe, ass with Freibergs Infraction as increases weight on 2nd MT head

Front 27

Describe Tailors Bunion

Back 27

• caused as a result of inflammation of the fifth metatarsal bone at the base of the little toe.
• may be created by wide 4-5 interMT angle
• Often accompanied by H.Mol caused by pressure of bone of prox phalanx of 5th toe
• swelling and redness

Front 28

Describe Claw Toes

Back 28

• Hyperextension at MPJ and flexion at proximal and distal IPJ's
• Imbalance between extensor tendons and flexor tendons of MPJ
• Results from spontaneous contraction of extensors and flexors
• Flexed IPJ constantly irritated by shoe, callosities develop

Front 29

Differential diagnosis of claw toes

Back 29

• Hammer toes: extended MPJ, flexed at PIPJ and hyperextended at DIPJ.

Front 30

Claw toe v Hammer toe

Back 30

• Claw toe: nail hits the ground> HE at MPJ, Flexed at PIPJ and DIPJ.

• Hammer toe: nail doesn't hit ground> E at MPJ, flexed at PIPJ and HE at DIPJ

Front 31

Predisposing conditions ass with Claw Toes:

Back 31

• RA
• Age
• Diabetes
• Polio
• Charcot Marie Tooth
• Stroke
• Pes Cavus- high arch, cave under