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from page 22 mer toe but would likely relieve the neuroma pain without excision of the neuroma thus avoiding toe numbness. Barbara is concerned about the prolonged recovery from bunion surgery due to the
A |
time needed off work.
After discussions with me, her family and her employers, she opts for bunion correction surgery. The procedure goes smoothly and she has an uneventful post- operative recovery.
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C |
At three months post-surgery, she is back at work, happy with her feet and her neuroma pain had disappeared without any surgery to the neuroma itself( see figures B and C). |
Summary CHRONIC foot pain is common and has a variety of overlapping causes.
A thorough history and a focussed examination are the basis for treatment of foot conditions.
Carefully explore the patient’ s expectations and concerns as many asymptomatic foot deformities require reassurance alone. Even in cases of complex deformity, simple solutions such as toe sleeves to stop rubbing of a painful toe may be all the patient requires.
Weight-bearing anteroposterior
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and lateral radiographs should be the first-line investigation for all chronic foot pathologies and can confirm the diagnosis in most cases.
Most common foot and ankle conditions can be successfully diagnosed and managed in the community. In cases where the diagnosis is in doubt, after a thorough initial assessment and appropriate investigations, a specialist referral can help elucidate the cause of symptoms and guide appropriate management.
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Key points |
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1. Which THREE are common causes of forefoot pain? a) Morton’ s neuroma. b) Hallux varus. c) Lesser toe deformities. d) Hallux rigidus.
2. Which TWO statements regarding hallux valgus are correct? a) The development of hallux valgus appears to be due to both genetic and environmental factors, with a positive family history seen in around 50 % of patients. b) Progression of hallux valgus is often slow and the management of each foot should be taken on its own merit. c) The mainstay of investigation for hallux valgus is a weight-bearing anteroposterior and lateral radiograph. d) Examination is best carried out with the patient supine, so the feet can be gently manipulated by the examiner.
3. Which THREE are appropriate in the management of hallux valgus? a) Reassurance in patients with asymptomatic hallux valgus with mild deformity.
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b) Bunion splints as an alternative to surgery. c) Orthotic referral for a metatarsal dome. d) Surgical correction.
4. Which THREE conditions may result in a hallux rigidus? a) History of trauma. b) Adult acquired flatfoot deformity. c) Hypermobile first ray. d) Gout.
5. Which statement best describes a claw toe? a) Hyperflexion of the middle joint of the toe. b) Hyperflexion of the end joint of the toe. c) Hyperflexion of both toe joints. d) Hyperflexion of the middle joint of the toe with hyperextension of the end joint.
6. Which TWO statements regarding the management of lesser foot deformities are correct? a) Conservative management, on the whole, consists of footwear modification. b) Lesser toe correction involves a careful balancing of soft tissues and bone. c) Painful rubbing of at least three toes on each
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foot is an indication for surgical intervention. d) A metatarsal dome is useful for relieving pain in the toes.
7. Which THREE statements regarding Morton’ s neuroma are correct? a) The pain is exacerbated by footwear, particularly those with a tight toe box and high heel. b) A tight Achilles and plantar fascia can exacerbate a Morton’ s neuroma. c) Operative intervention will leave the patient with numbness in the distribution of the nerve. d) Conservative measures involve splinting the toes on either side of the neuroma to limit movement of the affected rays.
8. Which TWO statements regarding adult acquired flatfoot deformity are correct? a) The most important differential diagnoses to exclude is a tarsal coalition. b) In the midfoot the most common condition causing pain is adult acquired flatfoot deformity. c) Presentation and the location of pain will vary depending on the stage of the disease.
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d) Heels going into varus when the patient stands on tiptoes suggest significant chronicity of disease and arthritis in the hindfoot.
9. Which THREE statements regarding adult acquired flatfoot deformity are correct? a) The‘ too many toes sign’ suggests forefoot abduction. b) With a classical history, clinical finding and X-ray changes, further investigations are not required to make the diagnosis. c) First line of treatment for all patients, irrespective of the stage of disease, is surgical. d) Recovery after any adult acquired flatfoot deformity procedure is prolonged with six weeks’ immobilisation after osteotomy and 12 weeks after hindfoot fusion.
10. Which TWO factors may predispose to the development of plantar fasciitis? a) Obesity. b) Male gender. c) Standing on hard surfaces. d) Overpronation.
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CPD POINTS |