CONDITIONS

What are bunions?

A bunion, known medically as ‘Hallux Valgus’ is an abnormal alignment of the big toe. The first metatarsal begins to drift towards the other foot whilst the big toe deviates across towards the smaller toes.

 

The big toe joint becomes more prominent, widening the ball of the foot, which can cause footwear fitting difficulties, joint inflammation and pain. Poor joint alignment may also cause abnormal wear and tear resulting in arthritic changes.

 

As the bunion progresses the smaller toes become crowded and may adopt abnormal positions with painful corns or calluses. 

 

Pain may also be experienced under the second toe ‘knuckle’ joint because the big toe is not functioning properly. 

    

What causes bunions?

Although shoes are often thought to be the cause, bunions are most likely to be an inherited condition. Therefore, they can often be seen in different generations within the family.

 

The way in which the foot works during walking can affect the big toe joint and abnormal movement has been thought to affect bunion formation.

 

Bunions are also associated with joint diseases such as rheumatoid and osteo-arthritis.

 

Shoes, which are tight fitting in the toe area, will make the problem worse. 

 

Who do bunions affect?

Anyone can get bunions, even children, known as ‘juvenile hallux valgus’, although they more commonly affect women. 

 

Most evidence indicates that bunions are a progressive condition and worsen over time. It is therefore more common to see bunions in middle and later age. 

 

TREATMENT OPTIONS:

 

Depending upon the degree of pain, deviation of your big toe, and extent of smaller toe involvement, there are several options:

 

Non- surgical treatments

• Good fitting footwear / avoid high heels

•  Joint padding and protective shields

• Gel / silicone wedges between the toes

• Bunion night splints

• Surgical footwear 

• Cortisone (steroid) injections

• Insoles (orthoses)

• In one study that followed patients for 1 year, only 24% who had no treatment reported an improvement compared with 46% of those provided with orthoses and 83% who had surgery.

 

Surgical intervention

• Over 120 operations have been reported for treatment of bunions, some more effective than others.

• The type of surgery recommended is based around you, your bunion (type, size and degree of pain), and lifestyle requirements after surgery. As a result not everybody is offered exactly the same surgery… the surgery is tailored to you as an individual.

• Minimally invasive surgery techniques (M.I.S) are also offered for bunions that meet the exact criteria for those patients who have mild bunion deformities.

 

Intended benefits of an operation

 The aims of a bunion operation are to improve the big toe position and appearance, and prevent footwear irritation, thereby improving comfort.

 

If you are considering surgery, please be aware we do not advise patients to undertake air travel until at least 6 weeks post surgery. 

You should be aware that these complications are relatively uncommon. They mostly resolve without permanent disability or pain using medications, therapy and on occasions further surgery, but even allowing for these, sometimes you may not achieve the result that you want.

 

Hammer toe deformities

What are Hammer, Mallet, and Claw toes? 

Hammer, Mallet, and Claw toes are descriptions of different abnormal toe positions.

Normally the bones in the smaller toes are straight.

When these become mal-aligned the top of the joints become prominent and rub on footwear. The tip of the toe can also bear too much pressure becoming irritated.

Commonly, painful hard skin or corns develop over the prominent joints and tips of the toes. In some cases a bursa (like a deep blister) can develop and become inflamed (bursitis) and painful.

As the toes become misshapen, and do not bear weight properly, the knuckle joints on the ball of the foot become prominent and can become another source of pain, often feeling like walking on a marble.

    

What cause Hammer, Mallet, and Claw toes? 

There are many different causes of abnormal toe position.

The way in which the foot works during walking, and tight fitting shoes are the commonest causes.

If the foot is too mobile and / or the tendons that control toe movement are too active, there is increased pull on the toes, which may result in deformity.

Injury to the joint can also result in deformity.

 

Who do Hammer, Mallet, and Claw toes affect? 

Anyone can get toe deformities, even children although these tend to be more flexible.

Women are affected more than men as they tend to wear tighter, narrower shoes with higher heels. These place more pressure onto the joint and predispose to the altered position. 

Patients with conditions such as diabetes, rheumatoid arthritis, and neuromuscular disorders are more likely to develop hammer toes.

 

 

TREATMENT OPTIONS:

 

Generally, the toe positions will worsen over time and slowly stiffen to become rigid, often developing osteo-arthritic changes. 

Depending upon the degree of pain, deviation, and flexibility of your toe(s) there are several options:

 

Non- surgical treatments

Avoid high heels, and tight footwear.

Joint padding and protective shields.

Gel / silicone wedge beneath the toe to try and straighten it (only if the joint is flexible)

If the toe position is flexible treatment may help to prevent progression although this is not a guarantee.

If it is not flexible (rigid) non-surgical treatments will not correct the position, but may make the toe more comfortable. 

 

Surgical intervention

There are various surgical options available to straighten the toe(s):

- Joint arthroplasty, joint arthrodesis, and or tendon lengthening.

- Minimally invasive surgery (M.I.S) is also available for those patients who would be     suitable.

The type of surgery recommended is based around you, your toe(s) (type, size and degree of pain), and lifestyle requirements after surgery. As a result not everybody is offered exactly the same surgery… the surgery is tailored to you as an individual.

 

Intended benefits of an operation

The aims of an operation are to straighten the toe(s) and prevent footwear irritation, thereby improving comfort.

If you are considering surgery, please be aware we do not advise patients to undertake air travel until at least 6 weeks post-op.  

 

You should be aware that in a small number of patients  complications can occur but in general these are relatively uncommon. They mostly resolve without permanent disability or pain using medications, therapy and on occasions further surgery, but even allowing for these, sometimes you may not achieve the result that you want.

 

Pain in the forefoot (metatarsalgia)

What is metatarsalgia?

Metatarsalgia is a term used to describe pain in the ball of the foot.

The term refers to the bones present in the ball of the foot, called metatarsals.

Pain in the ball of the foot can be caused by many different factors. These include the bones themselves, the joints, or soft tissues such as nerves around them.

 

Who does metatarsalgia affect?

·  Anyone can get metatarsalgia, although it more commonly affects those who stand or walk for prolonged periods during the day.

·  Symptoms are worsened if walking on hard uneven surfaces, especially if in tight, high heeled shoes with thin hard soles. 

    

What causes metatarsalgia? 

1. Wear and tear of the knuckle joints can give rise to joint pain and metatarsalgia.

·      In this instance, the cartilage which normally protects the joint surface becomes worn away, resulting in bone grinding against bone resulting in pain and stiffness.

 

 

 

 

 

 

 

                                                 

 

 

2. Abnormal weight distribution across the ball of the foot.

All the knuckle joints across the ball of the foot should take an even proportion of the body’s weight when walking and standing.

If one of these joints takes more weight than it should, it becomes irritated, inflamed and painful. 

 

 

 

 

 

                                      

 

 

 

Abnormal weight distribution across the ball of the foot can occur in many ways:

 The cause can be directly related to the bone (such as in cases where it is too long, short or prominent on the underside of the foot). This leads to the bone / joint becoming overused and inflamed. 

Another cause of overload pain is related to the way in which the foot works during walking. Abnormal ‘rolling-in’ and flattening of the foot arch, known as over pronation; or high arched feet are associated with abnormal pressure distribution through the ball of the foot.

Pre existing foot conditions such as ‘bunions’, a stiff big toe, and / or abnormal positions of the smaller toes can also cause an abnormal painful overload of the knuckle joints.

Shoes which are tight fitting in the toe area and high heeled shoes will force more weight on to the ball of the foot and give rise to metatarsalgia.

 

 

 

 

 

 

                                      

 

 

3. Nerve irritation 

Sometimes the nerves that run between the metatarsal bones can become irritated and swollen causing sharp, painful shooting pain.

The nerves can be irritated by poor foot function with can result in the metatarsal bones ‘pinching’ the nerve.

The nerve may become permanently swollen and painful, known as a ‘Morton’s neuroma’

 

 

 

 

 

                                                        

 

4.Metatarsal stress fracture

Repeated trauma and overload of a metatarsal can sometimes lead to a hairline crack in the bone known as a stress fracture.

 

TREATMENT OPTIONS:

 

Depending upon the degree of pain and length of time it has been present, there are several options:

 

 Non- surgical treatments: Prevention

·  Avoid long periods of standing, especially in thin soled shoes.

·  Wear as supportive, cushioning, roomy footwear is possible.

·  Use cushioning insoles within shoes.

·  Obtain custom made ‘orthotic’ insoles which can be custom made to fit your foot. These aim to improve foot function and distribute pressure more evenly across the ball of the foot. 

 

Non- surgical treatments: Treatment when acutely painful

·  As above plus:

·  Local anti-inflammatory measures such as ice packs, ibuprofen gels, foot elevation and massage of the painful area.

·  Cortisone (steroid) injections into the painful joint or area. Cortisone is a potent anti-inflammatory agent and a course of up to 3 injections may quickly reduce the pain of metatarsalgia. 

 

Surgical intervention

·  If non-surgical treatments fail to relieve pain, an operation may be needed to correct the problem.

·  There are many different types of operations for metatarsalgia; the type of surgery recommended is based around you, the degree of pain suffering, type and cause of metatarsalgia, and lifestyle requirements after surgery. 

·  As a result not everybody is offered exactly the same surgery… the surgery is tailored to you as an individual.

 

What might surgery involve?

The aim of surgery is to improve the pain of metatarsalgia.

Depending upon the cause, it may involve

Shortening an overlong metatarsal bone.

Elevating a dropped knuckle joint.

Straightening an associated abnormal toe position (such as a bunion or hammer toe).

Removing excessive arthritic overgrowth of bone.

Removing a swollen nerve (neurectomy).

Specific information sheets are available which describe relevant operations in more detail.

 

Although surgery can be an effective form of intervention, unfortunately all operations carry a small risk of complications. 

 

 

If you are considering surgery, please be aware we do not advise patients to undertake air travel until at least 6 weeks post surgery.  

 

You should be aware that these complications are relatively uncommon. They mostly resolve without permanent disability or pain using medications, therapy and on occasions further surgery, but even allowing for these, sometimes you may not achieve the result that you want.

 

 

Morton’s Neuroma

What is Morton’s Neuroma? 

Thomas Morton first described the condition in 1876.

Nerves run between the long bones (metatarsals) in the ball of the foot supplying sensation to the toes.  

 If these nerves become irritated, the nerve can become thickened and scarred, termed ‘Morton’s neuroma’. 

There are many other descriptions of the same condition including; ‘intermetatarsal neuroma’, ‘plantar digital neuritis/ neuroma’, and ‘Durlacher’s’ neuroma.

A ‘neuroma’ means nerve tumour, however in this case the nerve is enlarged, and NOT a cancer or likely to spread.

Classically the Morton’s neuroma is located between the third and fourth toes, and to a lesser degree the second and third.

 

  

What causes Morton’s Neuroma?

The nerve becomes irritated as a result of repeated injury from compression or irritation.

The nerve becomes trapped between the metatarsals when standing and walking.

Over time, the nerve becomes increasingly thickened and scarred, and as it becomes larger, it is more easily injured. 

Shoes that are tight fitting particularly around the ball of the foot will squeeze the metatarsals together and pinch the nerve. This will cause or make the problem worse. 

As a consequence, women are more likely to suffer this condition.

The way in which the foot works during walking has also been thought to affect neuroma formation.

 

What are the symptoms?

Stinging, burning, shooting, electric shock type pain in the ball of the foot.

Pain and numbness in the 3rd and 4th toes.

The pain may come and go, and is worse in tighter footwear

Some can experience a ‘clicking’ or ‘popping’ sensation which is the nerve moving back and forth between the bones.

Symptoms may be relieved by shoe removal and rubbing the area.

 

TREATMENT OPTIONS:

 

Depending upon the degree, frequency, and duration of pain, there are several options:

 

Non- surgical treatments

Avoid high heels; wear a soft-soled shoe that loosely fits around the ball of the foot.

Anti-inflammatory tablets may be helpful   

Insoles (orthoses): at present NO evidence exists to show that these cure neuromas, although they may reduce ‘pinching’ of the nerve and reduce pain.

Cortisone (steroid) injections

Overall success rate less than 50% of cases.

 

Surgical intervention

 In longstanding cases, or in cases that have failed to respond to treatment, surgical removal of the neuroma is an option. 

This is termed a ‘neurectomy’.

Since the nerve is removed, there is a permanent numbness in the 3rd and 4th toes. This is not usually a problem.

 

Intended benefits of an operation

 The aim of a neurectomy is to alleviate or improve the pain associated with the neuroma.  It is successful in 80% of cases.

 

About day case surgery under local anaesthetic

 Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation, and will not have to stay in hospital overnight.

Injections, usually around the ankle are undertaken to numb your foot. Most patients find these to be more comfortable than a dental injection and 98% are happy to undergo this procedure again if they require further surgery.

A screen will prevent you from seeing the operation.

You can eat normally on the day of surgery; there is no need for fasting.

The operation may take up to 1 hour but you should be prepared to be at the clinic longer than this to allow for preparation and recovery.

You will have a large bandage, special shoe and usually crutches will be provided for use after surgery.

If you decide to have surgery, you will be invited back to attend a pre-surgical clinic. We run through your medical history, and any medication that you are taking, and carry out any necessary clinical examinations and investigations.  This is a good opportunity to ask us any questions or concerns you may have about the procedure.