|
*The following information was provided by the American
College of Foot and Ankle Surgeons*
Corns, calluses and pain may indicate joint problems
Many
disorders can affect the joints of the toes, causing pain and preventing the
foot from functioning as it should. People of all ages can have toe problems,
from infants born with deformities, to older adults with acquired deformities.
The major culprit of toe deformities in adults is tendon imbalance. When the
natural function of the foot is disrupted (through a variety of causes), the
tendons may stretch or tighten to compensate. Thus, people with abnormally long
toes arches have a greater tendency to develop toe deformities.
Arthritis that slowly destroys the joint surface is another major cause of
discomfort and deformity. Toe deformities can also be aggravated by restrictive
or ill-fitting footwear worn for a prolonged amount of time. Or, problems with
toe position may occur if a fractured toe heals in a poor position.
Common deformities
The most common
digital deformities are hammertoes, claw toes, mallet toes, bones spurs,
overlapping and underlapping toes, and curled toes.
These deformities may or may not be painful. Corns and calluses - a buildup
of skin on the affected joint, often associated with bursitis (inflammation of
small pouches, called bursas, which lie above the joint between the tendon and
skin) - are perhaps noticeable and bothersome symptoms. If deformities are left
untreated, the toe's mobility may become limited, and more serious problems,
such as skin ulceration and infection, may develop.
Hammertoes
A hammertoe may be flexible or rigid, and may occur on any of the lesser
toes. Ligaments and tendons that have tightened cause the toe's joints to
buckle, cocking the toe upward. Shoes then rub on the prominent portion of the
toe, leading to inflammation or bursitis. Corns and calluses soon form.
During the early stages, a hammertoe remains flexible, meaning it will
straighten when pressure is applied to the buckled area. As time passes, the toe
can become permanently buckled or rigid, requiring surgery for correction.
Painful calluses on the bottom of the foot may accompany rigid hammertoes
because of pressure generated on the joint.
Mallet toes and claw toes
Mallet toes and claw toes are similar in appearance to hammertoes, but
joints at different locations on the toe are affected. The joint at the end of
the toe buckles in a mallet toe, while a claw toe involves abnormal positions of
all three joints of the toe.
Bone spur
A bone spur is an overgrowth of bone that may occur alone or along with a
hammertoe. Pain, corns and calluses are the major symptoms. Left untreated, a
bone spur may eventually be accompanied by bursitis or small skin ulceration.
Overlapping and underlapping toes
Any one of the toes can overlap or underlap, pushing on adjacent toes and
causing irritation.
Overlapping or underlapping of the fifth toe is a common congenital problem
that is easily corrected in children. Bunions can cause the second toe to
overlap in adults.
Pain, inflammation and small corns or areas of built up tissue may result.
This deformity also can interfere with the normal function of the foot, and if
left untreated, may lead to enlargement of bone or bone spur formation.
Treatments for toe deformities
Any toe
problems that causes pain or discomfort while walking should be given prompt
attention by a podiatric surgeon. Ignoring the symptoms can aggravate the
condition, and over time may lead to an infection, a breakdown of tissue or
ulceration. For people with poor circulation or an underlying medical problem,
loss of the toe is possible.
Recommended treatments will vary depending upon the severity of the
condition.
Conservative treatments
For people who
have minor discomfort, less advanced conditions or are unable to undergo
surgery, the symptoms may be treated conservatively (without surgery). This
usually involves:
- Trimming or padding corns and calluses.
- Wearing supportive orthotics (individually fitted plastic or leather
inserts) in shoes. This helps relieve pressure on toe deformities and allows
the toes and major joints of the foot to function more appropriately.
- Splints or small straps to realign the toe.
- Wearing shoes with a wider toe box.
In certain cases, anti-inflammatory medications may be injected to relieve
pain and inflammation. Medications have proven to be successful in relieving the
discomfort associated with bursitis.
Unfortunately, conservative treatments provide only temporary relief of
symptoms - they do not correct the deformity.
Surgical treatments
When the deformity
is painful or permanent, surgical correction is recommended to relieve pain,
correct the problem and provide a stable, functional toe. Some of the most
common surgical procedures are described below.
Depending on health status, surgery may be conducted on an outpatient basis
at the surgeon's office. The procedures are usually comfortably performed under
local anesthesia or with intravenous sedatives administered by trained
anesthesia personnel.
Tenoplasty and capsulotomy
Tenoplasty and/or capsulotomy refer, respectively, to the release or
lengthening of tightened tendons and ligaments that have caused the joints to
contract. In some flexible hammertoe cases, the toe straightens out after these
soft tissue structures are lengthened or cut and relaxed. Surgery relieves pain
and improves the toe's mobility.
Tendon transfer
Tendon transfer is another treatment for a flexible hammertoe deformity,
involves the repositioning of a tendon to straighten the toe.
Bone arthroplasty
During bone arthroplasty procedures, some bone and cartilage is removed to
correct the deformity. A small portion of bone is removed at the joint,
eliminating pressure on the toe, relieving pain and straightening the digit. The
tendons and ligaments surrounding the joint also may be reconstructed. Multiple
digits can be operated on simultaneously in certain cases.
Derotation arthroplasty
Derotation arthroplasty is a variation of arthroplasty used to realign the
toe. A small wedge of skin is removed and the toe is properly positioned. The
surgeon also may remove a small amount of bone, and will repair the toe's
tendons and ligaments.
Implant arthroplasty
Implant arthroplasty is similar to arthroplasty in that a small portion of
bone is removed. A silicone rubber or metal implant specially designed for the
toe is inserted to replace the gliding surfaces of the joint and to act as a
joint spacer. Implant arthroplasty helps maintain toe length while relieving
pain, and realigning and stabilizing the joint. Implants may be recommended when
previous surgery has left the toe improperly positioned or without skeletal
support.
Fusion
Fusion of the toe is most often used to correct toe fractures or, like
implant arthroplasty, to increase the stability of the toe after arthroplasty.
After the bone ends are removed, they are positioned together and compressed so
that the bones unite.
What to do about a bunion
In the front
of the foot, the joint at the base of the great toe is the most complex. Here,
the bones, tendons and ligaments work together to transmit he body's weight,
especially during movement. Should this joint become abnormally stressed over an
extended period of time, a bunion deformity may result.
A bunion (from the latin "bunio," meaning enlargement) is a
protuberance of bone or tissue around the joint. The enlargement occurs either
at the base of the great toe or on the outside of the foot, at the base of the
little toe. This is called a "bunionette" or "tailor's
bunion."
Bunions at the base of the toe usually begin when the big toe starts moving
toward the smaller toes (as when tight, pointed shoes are worn). This crowding
puts pressure on the joint, pushing it outward. The movement of the joint in
this outward direction starts the formation of a bunion.
A common deformity of the big toe joint, a bunion occurs mostly among people
who wear shoes. Women are more frequently affected with bunions because of
tight, pointed, confining or high heeled shoes. Wearing high heels is especially
stressful on the joints of the foot because all of the body's weight rests
there; the foot is then forced into a narrowed toe box, compounding the problem.
Older people are also vulnerable to bunions because of the higher incidence of
arthritis affecting the big toe joint.
What causes a bunion?
A bunion is most
often a symptom of faulty mechanics of the foot. The deformity does run in
families; however, it is the foot type that is hereditary, not the bunion.
People with flat feet or low arches seem more prone to develop the problem than
those with higher arches.
A fracture or break into the joint may lead to arthritic changes and the
development of bunion deformities with limited range of motion.
Bunions may also be associated with various forms of arthritis. The arthritis
can cause the joint's protective covering of cartilage to deteriorate, leaving
the joint damaged with a decreased range of motion.
Symptoms
Pain from a bunion can be
mild, moderate or severe, making it difficult to walk in normal shoes,
especially those with high heels the skin and deeper tissues around the bunion
may also be swollen or inflamed.
The other toes can be affected by a bunion, as a result of pressure from the
great toe pushing inward toward the lesser toes. Toenails may begin to grow into
the sides of the nail bed; the smaller toes can develop corns and become bent
(hammertoes); or calluses can form on the bottom of the foot.
Types of bunions
- Simple bunion
Only slight malalignment of the joint is noticeable.
- Moderate bunion
The joint is clearly angled inward.
- Severe bunion
A severe bunion is marked by a strong angulation or displacement of the
joint. X-rays show that the joint is partially dislocated.
Treatments
Treatments for bunions vary
depending on the severity of pain and deformity. In any case, evaluation by a
podiatric surgeon should be sought at the first sign of pain or discomfort, so
that severe deformity can be avoided.
A parent who has a bunion, for example, should be aware that there is a
strong hereditary predisposition to bunion development, and should have his or
her child evaluated if early signs of deformity and /or discomfort are evident.
If the child has the same foot type, there is a possibility that a bunion will
eventually develop.
Early treatment
The main purpose of
early treatment is to relieve pressure on the bunion and smaller toes, and to
diminish the progression of joint deformities.
Padding
Important first step, as is
wearing shoes that are large enough to comfortably accommodate the bunion ( such
as sandals, athletic shoes or shoes made from soft leather). Stiff leather shoes
may be stretched slightly for greater comfort. Tight, confining or high-heeled
shoes should be avoided.
Medications
Medications such as nonsteroidal anti-inflammatory drugs or cortisone
injections, may be prescribed to ease pain and inflammation caused by joint
deformities.
Physical therapy (PT)
PT techniques such as ultrasound, and whirlpool baths can also provide some
temporary relief from symptoms.
Splint
A splint may be recommended to slow the progression of the deformity.
Orthoses
For those with a painful bunion that has not yet caused a significant bony
abnormality at the joint, orthoses (special inserts for shoes) may be useful in
controlling abnormal foot mechanics, and may reduce the symptoms.
If a systemic disease like rheumatoid arthritis or gouty arthritis is related
to the bunion, then appropriate medical treatment may be recommended by the
podiatric surgeon.
Surgical treatment
When conservative treatments do not provide satisfactory relief from
symptoms, or when the condition is significant, surgery may be necessary.
Pain and deformity are significantly reduced in the great majority of
patients who undergo bunion surgery. In addition to easing pain, the purpose of
bunion surgery is to remove the enlargement and realign the joint so that it
functions as it should. This means that after surgery, the foot can carry the
body's weight properly, and that special shoes should no longer be needed.
Postoperative orthoses or supportive devices may be recommended to improve foot
function.
Surgery may be performed at a hospital, surgical center or properly equipped
office operating room. Depending on the procedure, the facility at which it is
performed and the patient's medical status, the surgeon may choose a local,
spinal or general anesthetic. In many cases, the procedure can be performed
under local anesthesia with sedation given by anesthesia personnel.
- Simple bunion surgery
For a simple
bunion, the podiatric surgeon may remove the enlarged portion of bone and
realign the muscles, tendons and ligaments surrounding the joint.
- Moderate bunion surgery
For a moderate bunion, the podiatric surgeon may cut the bone and shift
it to its proper position. Whether or not the bone is cut depends on the
severity and location of the deformity. In addition, the surrounding tendons
and ligaments may need to be repositioned.
- Severe bunion surgery
For a severe bunion, a combination of the following procedures may be
necessary: removal of the enlarged portion of the bone; cutting and
realignment of the bone; and correction f the tendons and ligaments.
Surgery for joints beyond repair
If
the joint is destroyed beyond repair (common in cases of arthritis), it may need
to be reconstructed or replaced utilizing an artificial joint. Implants
contribute to pain relief as well as the flexibility and stability of the joint.
After the damaged joint is removed, one of several types of implants may be
inserted.
When both sides of the joint require reconstruction, a flexible hinge implant
with stems that fit within the bones may be used. The wide, flexible midsection
of the implant rests between the bones, permitting the toe to bend.
When bone on only one side of the joint is damaged, an implant with one stem
may be used.
What is an intermetatarsal neuroma?
An
intermetatarsal neuroma (IMN) is any irrative process of the common digital
nerve branch that supplies the plantar (bottom) of adjacent toes. It most
frequently involves the nerve that supplies sensation to adjacent sides of the
third and fourth toes, but can also affect other toes of the foot. A neuroma is
not cancerous and is not a true tumor but a reactive, degenerative process such
as a scar. Therefore, a neuroma is a benign enlargement of the nerve.
What are the symptoms?
Besides pain,
you may also experience numbness and burning of your foot. Symptoms are
aggravated by walking shoes and relieved by removing shoes, resting and
massaging the foot. Pain that occurs at rest may suggest that neuroma is
worsening.
What are the causes of intermetatarsal neuroma?
Intermetatarsal
neuroma occurs in all adult age groups and is most prevalent among females.
Although the exact etiology of IMN is unclear, several factors contribute to its
occurrence. High-heeled shoes, trauma, inflammatory conditions such as arthritis
and occupational and recreational activities are several of these factors. Any
condition that causes constriction or irritation of the ne development of an
intermetatarsal neuroma.
How is an intermetatarsal neuroma treated?
Although
some patients may not receive complete relief, it is expected that the vast
majority will gain significant improvement from therapy. treatment may be
surgical or nonsurgical. Nonsurgical treatment is often attempted before
surgical intervention. Your podiatric surgeon will decide the appropriate method
of therapy for you.
Conservative treatment for intermetatarsal neuroma usually includes modifying
shoes, orthoses or arch supports. These conservative therapies may provide
complete, partial or no relief of symptoms. The decision to surgically intervene
is based on your symptoms, the judgement of your podiatric surgeon and your
preference. A neurectomy or surgical removal of a neuroma is performed when
conservative treatment proves ineffective.
|
