Structural Disorders
A bunion is a prominence of the medial portion of the 1st metatarsal head. Symptoms may include pain, redness, bursitis medial to the joint, and synovitis. Diagnosis is by physical examination. Treatment is usually a shoe with a wide toe box, protective pads, and orthoses. For complications such as bursitis or synovitis, corticosteroid injection is helpful.
Bunions are often caused by variations in position of the 1st metatarsal bone or great toe, such as hallux valgus (lateral angulation of the great toe). Contributing factors may include excessive pronation (turning in) of the ankles and occasionally trauma. Joint misalignment leads to osteoarthritis with cartilage erosion and exostosis formation, which can cause hallux limitus (limited joint motion) or hallux rigidus (absent joint motion). In late stages, osteoarthritic synovitis occurs. In response to pressure from tight shoes, an adventitious bursa can develop medial to the joint prominence; the bursa can become painful, swollen, and inflamed (called adventitial bursitis).
Symptoms and Signs
The initial symptom may be pain at the joint prominence when certain shoes are worn. The joint capsule may be tender at any stage. In late stages, a painful, warm, red, cystic, movable, fluctuant swelling may develop medially (due to adventitial bursitis); swelling and mild inflammation may affect the entire joint more circumferentially (due to osteoarthritic synovitis). Passive joint motion is restricted in patients with hallux limitus and impossible in patients with hallux rigidus; usually, the lateral aspect of the joint is tender, and dorsiflexion of the distal phalanx is increased.
Diagnosis
Diagnosis is by physical examination. Acute, circumferential, and intense pain with warmth, swelling, and redness suggest gouty or infectious arthritis. Involvement of multiple joints often indicates a systemic rheumatic disorder. If clinical diagnosis of osteoarthritic synovitis is equivocal, x-rays are taken. Findings suggesting this disorder include joint space narrowing and bony spurs extending from the metatarsal head or sometimes from the base of the proximal phalanx. Periarticular erosions seen on x-ray suggest gout.
Treatment
Mild discomfort may be alleviated by wearing shoes with a wide toe box. If not, bunion pads, available in most pharmacies, can shield the painful area. Orthoses can also be prescribed to redistribute and relieve pressure from the affected joint. If conservative therapy is ineffective or if the patient is unwilling to wear large, wide shoes and orthoses because they are unattractive, surgery to correct abnormal bony alignments and restore joint mobility should be considered.
For bursitis, bursal aspiration with injection of a corticosteroid is indicated. For osteoarthritic synovitis, oral NSAIDs or intra-articular injection of a corticosteroid/anesthetic mixture reduces symptoms. Treatment of hallux limitus or hallux rigidus aims to preserve joint mobility by using passive stretching exercises, which occasionally require injection of a local anesthetic to relieve muscle spasm. Sometimes contractures require surgical release.
Hammer toe is a C-shaped deformity caused by dorsal subluxation at the metatarsophalangeal joint.
Hammer toe is usually caused by misalignment of the joint surfaces due to a genetic predisposition toward aberrant foot biomechanics and tendon contractures, compounded by years of wearing ill-fitting shoes. Toes 2 and 5 are most often affected. Second-toe hammer toes commonly result from pressure due to hallux valgus (an excessively abducted, laterally angulated great toe), causing a bunion. Hammer toe often results in painful corns, particularly on the 5th toe. Reactive adventitial bursae often develop under corns, which may become inflamed.
Symptoms include pain while wearing shoes (especially shoes with low, narrow toe boxes) and sometimes metatarsalgia. Diagnosis is by history and physical examination.
Shoes should have a wide toe box. Aperture pads, available in pharmacies, help shield the toes from the overlying shoe. If these measures are ineffective, surgical correction of the deformity often relieves symptoms. For patients with metatarsalgia, orthoses are prescribed.
Foot Fractures
Elderly people are prone to falls and foot fractures. Symptoms and signs may include pain, swelling, deformity, ecchymosis, crepitus, localized bony tenderness, and, with some toe fractures, subungual hematoma. X-rays using the dorsoplantar, lateral, and oblique views are helpful for diagnosis.
Immediately applying ice to the fracture helps minimize swelling; analgesics are given. Treatment is dictated by the type of fracture, the patient's ambulatory status, and sometimes the patient's surgical risk. Virtually all foot fractures require restriction of weight bearing. Toe fractures may be treated by taping the injured toe to an adjacent one (buddy taping or dynamic splinting). Displaced toe fractures are realigned after a local anesthetic is given. Subungual hematomas can be drained with an 18-gauge needle.
This topic was last updated May 2006.
|
