Alliance Foot & Ankle: An overview of Bunions

Alliance Foot & Ankle: An overview of Bunions

An overview of Bunions

http://alaskapodiatry.com/resources_bunion.html

Visit our website!!

Here at Alliance Foot and Ankle, we take pride in educating our patients on their foot pathology, diagnosis and treatment options.  We encourage our patients and their families to visit our website, www.alaskapodiatry.com, for current information on a multitude of foot and ankle conditions.  We also enjoy answering any questions you may have through our blog, so do not hesitate to leave a comment or question.

Neuroma or "Pinched Nerve"

A neuroma is a benign growth of nerve tissue that can occur to any of the nerves in the foot. Forefoot nerves are more susceptible to this process because of their specific location. The ball of the forefoot undergoes a great deal of motion as the toes flex and extend. There is also a limited amount of space between the metatarsal heads through which the forefoot nerves travel before dividing into digital nerves to provide sensation to the toes. The increased motion and limited space of the forefoot can cause the nerves to be stretched, tethered, or compressed; all of which can start the process of neuroma formation. Certain activities that require an increase in forefoot motion and stress (i.e., dance, baseball catcher) or occupations that require squatting (i.e., tile or carpet layer) can also aggravate the forefoot nerves leading to possible neuroma development. Acute or repetitive trauma to any nerve in the foot can lead to perineural fibrosis (scar tissue surrounding nerve) or neuroma formation.

By far, the most common site in the foot for a neuroma to occur is between the third and fourth toes in an area called the third intermetatarsal space. A neuroma in this region affects the third common plantar digital nerve and is commonly referred to as a “Morton’s Neuroma”.

The region of nerve undergoing neuroma formation appears thickened and swollen. Patients complain of a lump under the forefoot, the sensation of a sock rolled up in the area, numb toes, shooting electrical pain, or pain and discomfort so great that, at times, they must take off their shoes and massage their forefoot. The condition is usually progressive.

Conservative treatment consists of orthoses with metatarsal accommodations, injections of local anesthetic mixed with a steroid, proper selection of shoes, and/or a short course of physical therapy or anti-inflammatories to reduce perineural fibrosis and swelling.

Surgical excision, either from the dorsal or plantar approach, is recommended only after failed conservative care. Procedures are usually performed as an outpatient.

Fungus Infection

Fungal infection of the foot, or Tinea pedis (athletes foot), is a superficial infection caused by a dermatophyte. Dermatophytes are fungi that thrive in a nonviable tissue of the skin, nails, or hair. Trichophyton and Epidermophyton are the principle genera causing infection. Dermatophytosis can involve the entire plantar foot with extensive scaling, hyperkeratosis or even bulla formation. Infection between the toes (Tinea pedis interdigitalis) is quite common. When involvement of the nails occurs (onychomycosis) they take on a very thick, discolored (yellow/brown) appearance. Diagnosis is usually clinical, but a fungal culture or potassium hydroxide mount (KOH) of skin or nail scrapings can help diagnose unclear presentations by showing the presence of a fungal organism within the sample.

Tinea pedis can usually be resolved after several weeks of treatment with topical medications. Oral antifungals (i.e., Lamisil, Griseofulvin,) can be used for extensive infection or poor topical response. Onychomycosis is more difficult to eradicate. Topical therapy results are poor, and recurrence is common after completion of successful oral treatment. Temporary nail avulsion or permanent nail removal (matrixectomy) may be indicated for several deformed, painful onychomycotic nails.

High Arched Foot

High Arched Foot (Cavus)

The cavus, or high arched foot, is described as having a high medial longitudinal arch. The shape is caused by the osseous structure of the hindfoot and forefoot. A patient may have a reducible (supple) nature. There are many etiologies for a cavus foot type. Many stem from an inherited neuromuscular disorder. Not all high arched feet are symptomatic. In some, symptoms may occur in the foot, ankle, or leg. Claw toes (flexion at the proximal and distal interphalangeal joints) are very common with cavus foot types. Painful callosities may develop on the dorsal aspects of the digits and the plantar aspects of the metatarsal heads. With hindfoot or combined cavus, a prominent posterior aspect of the calcaneus may occur, which can be irritated by the heel counter or the shoes. Severe cramps in the legs may result from a true or pseudo Achilles tendon equinus (inability to lift the foot up at the ankle). In conditions caused by peripheral nerve pathology (i.e., Charcot Marie Tooth disease) tendon imbalances may occur, including the loss of entire muscle groups which can lead to a drop foot condition.

Proper diagnosis is needed to assess whether neurologic pathology is present and, if so, to determine its classification and stage. This is important to determine if the condition may progress overtime.

The cavus (high arch) is a clinical challenge, especially in progressive conditions. Many times conservative treatments provide pain-free ambulation. Treatment is initially aimed at alleviating painful callosities by proper shoeing, accommodative orthoses, or an AFO (ankle foot orthoses) if a drop foot is present. If conservative and palliative measures fail to alleviate symptoms, surgical reconstruction is considered. Using a combination of soft tissue(i.e., tendon transfers, releases) and osseous procedures, the painful cavus foot is reconstructed. For some cavus conditions, digital deformities (single or multiple) are all that need correction, but for others, multiple hindfoot fusions with tendon transfers from the posterior leg are necessary (i.e., to treat a painful hindfoot with a drop foot).

Bunion

Bunion (Hallux Valgus)

Hallux valgus (bunion deformity) is a misalignment of the first metatarsophalangeal joint (MTPJ) that causes the big toe (hallux) to deviate towards the second toe. The deviation can be so great that the big toe under-rides the second toe. A large bump appears clinically on the medial aspect of the first MTPJ. Pain can be experienced at the bump or in the joint (MTPJ) causing a poor quality and limitations of motion. The simple act of wearing shoes can be excruciation but does not actually cause the deformity, it only exacerbates it. Hallux valgus can be a progressive deformity causing limitation of big toe motion, degeneration of the big toe joint, and pain during ambulation.

Bunions are generally not inherited, but certain foot types are that may lead to hallux valgus at some point. Ligamentous laxity, a hypermobile foot, a foot that pronates (flattens) excessively, or arthritides (such as rheumatoid or gout) are all conditions that may predispose a person to develop hallux valgus.

Conservative approaches to treatment are aimed at decreasing symptoms and slowing progression. A brief course of anti-inflammatories, padding, changing shoe styles, and orthotics are all modalities that may decrease pain and slow the progression, but will not make the “bump” go away. Once the hallux has deviated in position and changes in joint congruity have occurred, surgical reconstruction is the only definitive treatment that can change the clinical appearance. The extent of the surgical reconstruction depends on the complexity of the deformity, patient age, health status, degree of symptoms, and concomitant pathology.