Fore Foot Conditions
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Bunion (Hallux Valgus) Deformity
A bunion is a deformity of the big toe in which instead of lying straight the big toe bends towards the smaller toes. A bony prominence appears on the inside of the foot at the base of the big toe. This prominence often rubs on shoes causing inflammation and pain.
Once a deformity has appeared it often progresses but the rate of progression is highly variable. As the deformity worsens, pressure is exerted on the smaller toes, especially the second, which then themselves become deformed and painful as they rub on the top of the shoe.
Because the big toe is deformed it can predispose to arthritis.
Symptoms
The main problem is usually the pressure of the shoe over the bony prominence, which causes discomfort or pain. Sometimes the skin over the lump becomes red, blistered or infected. The foot may become so broad that it is difficult to get wide enough shoes. The big toe sometimes tilts over so much that it rubs on the second toe, or pushes it up out of place so it presses on the shoe. Also, the big toe does not work as well with a bunion, and the other toes have to take more of the weight of the body as you walk. This can cause pain under the ball of the foot.
Cause
There is no single cause of bunions. They tend to run in families and you may be aware that your mother or grandmother had them. They are also commoner in women than in men. Bunions do occur in cultures in which shoes are not worn, but much less commonly. Shoes which squeeze the big toe, do not fit properly, or have an excessively high heel can probably help to cause the deformity especially in people who are at higher risk anyway. Inflammation of the joint due to conditions such as Rheumatoid Arthritis and Gout can also cause the deformity.
Establishing a Diagnosis
The diagnosis is obvious on examination of the feet. You will also be examined for small toe deformities and areas of pressure under the ball of the foot. It is also important to assess the whole shape of the foot as mal-alignment of other parts of the foot and ankle can be a cause of the deformity.
X-rays will be performed to demonstrate the degree of deformity and the presence of any arthritis.
Treatment Options
As symptoms are usually due to pressure on the bunion the first step is to find comfortable shoes that give the front of the foot enough room. Patients often find that the bunions do not cause significant symptoms in the summer as sandals can be worn. However when the weather becomes colder and enclosed shoes are worn, symptoms may develop. Some patients find benefit in wearing pressure relieving plasters or inserts between their toes. All of these things can help to relieve symptoms but they will not stop the progress of the bunion.
If simple measures fail to provide acceptable relief of symptoms then surgery can be considered. There are a lot of different operations for bunions, depending on the severity of the deformity, the shape of your foot and whether arthritis has developed in the big toe joint. The operation will remove the prominence on the inner side of the big toe and also straighten it. If there are symptomatic deformities of the smaller toes then these can all be addressed at the same time.
There is a myth that bunion surgery is very painful. This is probably because techniques commonly used until 5 years ago involved cutting the bone but not using any screws to stabilize it. This was indeed often painful but using modern surgical techniques, the bones are solidly fixed with small screws. This means that the operation is much less painful than it was just a few years ago and post-operative mobilisation is quicker. It is only in occasional cases that a plaster cast is required after a bunion operation. When this is combined with local anaesthetic techniques, most patients are up and walking within hours of the surgery without significant discomfort.
Forefoot problems in Rheumatoid Arthritis
Rheumatoid arthritis is an inflammatory condition that very commonly causes problems with the feet. Whilst any of the joints in the foot and ankle may be affected it is often the toes that are most severely involved and cause the most problems.
The classical changes that affect patients with rheumatoid arthritis are that they will develop a bunion so the big toe will deviate towards the lesser toes. As well as this the lesser toes become deformed with hammering or clawing. The lesser toes will slowly become more deformed and because the ligaments holding the toes in place becomes weakened by the arthritis they will eventually dislocate upwards out of position. Because the toes themselves are out of joint it exposes the bones in the sole of the foot (metatarsal heads) to more pressure and they can often be felt just underneath the skin.
Symptoms
There are varying degrees of severity. Initially you may only notice pain, swelling and warmth of a single joint, usually one at the base of the toes. As the disease progresses the deformities will increase. Symptoms will be felt from the bunion and the dislocated toes as they will rub on shoes. Due to the prominent bones in the sole of the foot it often feels as if you are walking with a pebble in your shoe. This is often very painful. It will be difficult to buy shoes that are comfortable and it may be necessary to have specially made shoes.
Establishing a Diagnosis
If you have significant deformities you will almost undoubtedly have been under the care of a rheumatologist, probably for many years. The diagnosis of the foot problems will be obvious on examination but x-rays will be taken to confirm the severity of the forefoot involvement.
If you present with swelling and pain in a single joint or possibly several of the toes and rheumatoid arthritis has not been diagnosed you will need to be fully assessed. It is necessary to perform blood tests to obtain a definitive diagnosis and it may also be necessary to have further x-rays and ultrasound scans to give further information. If rheumatoid has not been formally diagnosed you will be referred to a rheumatologist who is best placed to undertake the tests and start treatment which will be in the form of medication to calm the inflammation.
Treatment Options
For patients with long-standing forefoot changes and significant deformities the first stage of treatment involves the use of insoles to alleviate pressure on the prominent areas and obtaining appropriate shoes that allow enough room for the toes without them rubbing. It may be necessary for these shoes to be specially made for your feet. If you have ongoing pain and difficulty then surgery may be required. The exact operation that is performed will depend on the severity of the deformities that you have. There are many techniques and they include cutting the bones to re-align them, fusing them in a better position or simply removing the prominent sections of bone. Surgery for foot problems in rheumatoid arthritis is usually very successful and most patients are delighted with the results.
In-growing Toenail
This is when the edge of the toenail (usually the big toe) digs into the skin fold beside the nail. This is often very painful, and sometimes bacteria from the skin get into the inflamed skin and an infection begins. The side of the toe becomes red, hot, tender and swollen and pus may discharge from the edge of the nail.
Cause
The nail edge may dig in because of its shape, because it becomes ragged and sharp (due to picking or inappropriate cutting) or because of an injury.
Whilst it is not always possible to prevent in growing toenails, if you look after your toenails well and prevent them from getting ragged or developing painful spikes, you will reduce the chance of getting one. If you cut your nails straight across they will not have spikes on the end and the end will be clear of the edge of the nail fold where it usually digs in.
Treatment Options
If the nail is only mildly inflamed, trimming it straight across and easing the spike or nail edge out of the irritated area in the nail fold can help. Salt baths can help reduce the inflammation. Salt water can be made by boiling a pint of water and then adding a teaspoon of salt. The water should be allowed to cool before use.
If you have an in growing toenail that is not getting better with simple treatment and is interfering with your life it is worth contacting your GP or a chiropodist.
They will want to check that you have tried all the simple measures outlined above. If the nail is still not getting better, it is usually best to partially or completely remove the nail to allow the nail to heal. This is usually done under a local anaesthetic to numb the toe.
Many in growing toenails will heal after this treatment, but many others will not. If the in growing toenail recurs it is often best to remove the corner of the nail bed to stop the edge of the nail growing again. This may be done either with a chemical (phenol) or by cutting it out surgically.
Morton's Neuroma
A Morton's neuroma is a benign swelling of a nerve in the ball of the foot. It affects the nerves which supply sensation to the toes, most commonly the nerve between the third and fourth toes. Thomas Morton was an American doctor who described the condition in 1876.
Symptoms
Pain is felt in the ball of the foot, when walking and standing, that may radiate down into the toes. It is worse when wearing shoes, particularly with a high heel. Relief is felt on removing shoes at the end of the day. It may feel as if you are walking on a pebble and you may also feel a clicking sensation in the ball of the foot. The swollen nerve may make two adjacent toes spread apart.
Cause
The cause of nerve swelling is repeated compression. The nerve sits in a tight space between 2 bones (metatarsal heads) and underneath a ligament that connects the 2 bones. The nerve becomes trapped when standing and walking. The nerve becomes inflamed and scar tissue is laid down around the nerve. It therefore has even less room and is more liable to further compression.
It affects women 10 times more commonly than men and usually between the ages of 30-60. It most commonly occurs between the third and fourth toes, and less frequently between the second and third toes.
Establishing a Diagnosis
This is based on the symptoms and examination findings. Examination may reveal tenderness between two toes and specific tests may reproduce the pain. The diagnosis is usually confirmed by further imaging (ultrasound or MRI)
Treatment Options
Initial treatment is by shoe modification. High heels and tight fitting shoes should be avoided. An insole may be of benefit to relieve pressure on the affected area. A steroid injection can be used in the early stages of treatment. If symptoms fail to settle then the neuroma can be removed surgically.
Osteoarthritis of Base of Great Toe
Hallux rigidus is arthritis of the main joint at the base of the great toe. It may affect one or both feet but it is not normally associated with generalized arthritis throughout the body.
Symptoms
Pain is felt at the base of the great toe. This is made worse on walking and is more noticeable when going up-hill or when wearing a higher heeled shoe. The base of the great toe becomes stiff, particularly limiting the upward bend of the toe. The downward bend is less affected but is often painful. A swelling may develop on the top of the joint, and this represents the extra bone that has been laid down in response to the arthritis. There may be altered sensation on the top of the great toe.
Cause
In most people there is no particular cause but in others it may follow an injury or another joint disease such as gout or infection. If the great toe is deformed (bunion), then this predisposes the joint to arthritis. The response of the joint to arthritis is to lay down extra bone.
Establishing a Diagnosis
This is based on the symptoms and examination findings. The bony swelling may be palpable. There will be a reduction in the amount of upward movement of the great toe and this is usually painful. An x-ray will be taken to confirm the diagnosis and assess the severity of the condition
Treatment Options
Simple measures should be tried in the first instance. These include avoiding activities that exacerbate the pain, taking analgesics and wearing comfortable shoes that do not rub. Usually stiffer soled shoes are better as they limit the amount of movement of the great toe. High-heeled shoes may also make the pain worse.
If symptoms continue then treatment depends on the severity of the condition. Initially a steroid and local anaesthetic injection can be performed to reduce the pain in the joint.
If the arthritis is more advanced but only affects part of the joint, then an operation can be performed which will remove the extra bone which has been laid down and the joint can also be cleaned out. This is known as a cheilectomy. It should reduce the pain and increase the range of movement of the toe.
If the whole joint is affected then the most common operation performed is a fusion. This involves removing the joint surfaces and then holding them together with screws until they knit together. Following this the toe is stiff but pain free.
Replacement of the joint is a newer technique. To date, long-term studies are not available and outcome is less predictable. Because of this, very careful consideration needs to be given before undergoing a replacement.
Small Toe Deformities
The small toes are important in walking, especially when pushing off with the foot towards the next step. They share the pressure with the big toe and the ball of the foot.
There are many different types of toe deformity with different names such as hammer, mallet and claw toe.
Symptoms
The main problem with deformed toes is that they tend to rub on shoes, either on top or at the tip, or both. This rubbing may simply be uncomfortable, or the skin may be rubbed raw.
If the toe is bent upwards, particularly if it is stiff, it may cause pressure underneath the ball of the foot.
Cause
Toes become deformed when the pressures on the toe are stronger than their joints can resist. This may be because the joints are weak or the pressures strong, or both. The joints may be weak because they have been damaged by injury or arthritis. The muscles that control them may become unbalanced, so that one set pulls harder than another and causes the toe to bend.
Pressure on the toe from the shoe gradually causes the toe to buckle. The toe may curve over the next toe and rub on it. This is especially common in the 2nd toe, particularly if the big toe bends towards the second toe (bunion).
Treatment Options
As the symptoms are due to pressure on the top or tip of the toe or under the ball of the foot, the most important thing is to buy shoes that have enough room in the toe area for your toes to fit comfortably. Avoid high heels, which tend to force the toes down into the tip of the shoe. Small pads on the top or end or the toe may improve the discomfort.
If your toes are interfering with your daily activities and the problem is not helped by he simple measures outlined above, then an operation to straighten the toes may be necessary.
There are a number of different operations which can be used, depending on the shape of your toes and how stiff they are.
