Australian Doctor Australian Doctor 3rd November 2017 | Page 18

How to Treat – Foot pain
Forefoot pain
THE common causes of forefoot
pain are hallux valgus (bunions),
hallux rigidus (arthritis of the
great toe), lesser toe deformi-
ties and Morton’s neuroma. This
section will deal with these over-
lapping conditions and how to
manage them.
Hallux valgus
Aetiology
The development of hallux valgus
appears to be due to both genetic
and environmental factors. A
positive family history is seen in
around 90% of patients. 3 Studies
on non-shoe-wearing populations
have shown hallux valgus does
occur in these populations but to a
very low degree, suggesting wear-
ing shoes is a significant predispos-
ing factor. 4
Figure 1. Moderate bunion. Figure 3. Bunions.
History
When taking a history in hallux
valgus, it is important to assess the
exact nature of the patient’s main
complaint. Common presenting
symptoms are pain over the bun-
ion itself, pain under the metatar-
sal heads, rubbing over deformed
lesser toes, difficulty with shoe
wear or unease with the deform-
ity. 5 Management can be tailored
to each of these presentations.
Carefully elicit a history of ‘just
in case’ as many patients will
request management as they are
currently not symptomatic but
do not want to end up “like their
mother”. Although this is a rea-
sonable concern, progression of
hallux valgus is often slow and the
management of each foot should
be taken on its own merit. It is not
recommended to operate on an
asymptomatic hallux valgus.
Always ask about diabetes, and
a history of rheumatoid disease
and vascular disease. Decreased
sensation, common in diabetes,
may lead to ulceration and may
justify early correction. Inflam-
matory arthropathy may be best
managed medically and may slow
progression of the disease. Vascu-
lar compromise adds a significant
risk of wound healing and good
control of vascular disease is para-
mount before considering surgical
management. Figure 2. Severe bunions with lesser toe deformities. Figure 4. Dorsal bunion.
Investigations
The mainstay of investigation for
hallux valgus is a weight-bear-
ing anteroposterior and lateral
radiograph. Non-weight-bearing
radiographs do not provide useful
information about alignment and
defo