Diseases information. Disorders. Treatment. » Heel Pain

Another reason why people get hammertoes

Jammy B. — Tue, 05 Feb 2008 14:35:08 +0000

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Another reason why people get hammertoes is they have neuromuscular problems which usually manifest as pes cavus or a very high arched foot. But as this mechanical overload occurs and it’s tendon imbalance occurs, what are some of the secondary things that happen? Well, the fat pad migrates. You can imagine if your toes go from being straight to being curled up, you start to thin out the padding under those metatarsal heads. You are pulling it distal, you are pulling it beyond the metatarsal heads, so now you don’t have the normal cushion to take the weight bearing surfaces. Also, as your toes curl up, as the proximal phalanx in each toe extends, the first metatarsal head is effectively driven down through the bottom of the floor, again, now you’re pushing that metatarsal head out the bottom of the foot so to speak, and that hurts, and then you get the callous formation, that is the obvious manifestation of too much weight and too small an area. So what do we need to do to treat this? Well, we need to offload the metatarsal head and this slide over here showing you some very simple things that can be done for this, they are called metatarsal pads. These have a sticky back adhesive, you can put them directly into patient’s shoes, you can send them to a shoe shop, they can do that for you as well. But the idea here and I described this as you want to make the metatarsal heads float. You don’t want the metatarsal heads to hit the ground so hard. Again, too much pressure, inflammation of the joint, the toes are curling up and it’s hurting them. So you need to get the weight bearing forces back into the arch of the foot, so this padding is placed just proximal to the heads, you can see you have different gradations of thickness here, you can sort of control the effect of how much offloading you do with those metatarsal heads. You can also have this built in to an orthotic as well as being an isolated pad that you put in the shoe, and again, appropriate shoe wear, they are going to need high, wide toe box shoes with an orthotic or metatarsal pad in order to distribute the weight bearing forces better, and they need physical therapy. Sometimes with these people with hammertoes, there can also be contracture of the Achilles tendon, so we need to stretch that Achilles tendon out a bit so they don’t overload their forefoot, they start to put weight back in their hindfoot and their heel. Viagra Soft Tabs

We need to do physical therapy

Jammy B. — Fri, 25 Jan 2008 16:32:40 +0000

We need to do physical therapy. They need to strengthen the posterior tibial tendon, as I said before, that is the tendon that is going to help support the arch. They also need to work on the peroneus longus tendon. As we get later in the talk, the peroneus longus tendon runs along the lateral border of the foot, it then runs under the arch of the foot to attach to the base of the first metatarsal, so you can imagine if that tendon pulls hard, if there is active contraction, it’s going to pull the first metatarsal down, so it’s going to bring that first metatarsal head down which is going to bring the arch up. So those are the things that I write on my physical therapy prescription for someone that first comes to see me with hallux valgus problems and arch problems.
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The other thing is, appropriate shoe wear. They have to be in shoes that fit the shape of their foot. When someone has a hallux valgus deformity, they are very wide through here. They tend to get shoes that narrow and taper here so that there is rubbing over the bony prominence here, the rubbing out here on the distal aspect of their toe and they are also starting to have pain over here because the baby toe and fifth metatarsal head are rubbing in the shoe. This is somebody that needs a shoe with a square toe box. They also need a shoe with a high toe box if the second metatarsal is popping up, you need to have room so it doesn’t rub on the top of the shoe, and this can be a hard thing to convince the patient of. When I see a lady that comes in with shoes like that, there is absolutely no way I am going to convince her to wear shoes like this. So, hammertoes, metatarsalgia, forefoot pain under the metatarsal heads, what is going on here, well they are going to come and tell you, my toes are all curled up and they don’t touch the ground.
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This is as though we are looking up on the foot here, but as you can see, there is the toe, it’s like no rest of the toe, you are just seeing the toe pulp on the end here because his toes are all curled up, and again, it rubs against the top of their shoe. They have that painful callous over the PIP joint of each lesser toe, and they sometimes tell you, well when I’m walking in the bathroom or on my kitchen floor on a really hard surface, it feels like I’ve got rocks under the balls of my feet. It may not project well but there is a large diffuse callous there over the lesser metatarsal heads here and here. So what’s happening, there is mechanical overload of the MTP joint. Often I see hammertoes and metatarsalgia in association with people with hallux valgus. Remember, that hypermobile first ray. So if the first ray doesn’t carry it’s share of the weight bearing load, it’s going to go to the adjacent metatarsals. There is also a tendon imbalance. The flexor tendons on the plantar aspect of the foot become contracted. They pull the toe down, the extensor tendons which work across the MTP joint, they are pulling the toe up, so they are going from having straight toes to having toes that curled up like this, because the tendons are over pulling through their respective joints and curling the toe up.
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Hallux valgus

Jammy B. — Fri, 25 Jan 2008 16:29:31 +0000

Hallux valgus. So as we go through this section of the talk, we are going to try and think of these problems as their primary pathology and their secondary manifestations and that is going to drive how we treat these problems. This is going to be a situation where someone is going to present to you with a painful bunion. The medial eminence of their foot rubs in a shoe, it gets sore, it gets red, it hurts them. In very severe cases, they are also going to complain bitterly of the fact that the second toe just doesn’t behave, cocks up and rubs in the top of the shoe, and they may have even more painful callous or even an open sore right there at the PIP joint because that is where the apex of the deformity, is and it’s just rubbing at the top of the shoe every time they walk. They also can have calloses on the under surface of their foot, but this is a lady who basically came in wearing beach sandals to see me. She couldn’t wear closed toe shoes, and even in the winter time, she put on wool socks over these beach sandals because this hurt too much in her shoes. What is the primary pathology here; well the way that I see the problem with hallux valgus and have been taught to look at it, it is hypermobility at the tarsal metatarsal joint. That is the joint right about here, that’s the joint that separates the first metatarsal from the cuneiform, so the junction of the midfoot and the forefoot, and over time, as weight bearing occurs, you develop laxity here, so instead of this being a rigid stabilizer when the first metatarsal head strikes the ground, it actually drifts off. Well, as the first metatarsal head drifts off, that is going to decrease the medial longitudinal arch here, and as you can see, this lady doesn’t have much of an arch. She came to see me because her bunion was bothering her, and was rubbing in her shoe and her second toe was bothering her, but she said, oh yes, I sort have been losing my arch over time. Also, as the arch collapses here, there is also a problem with the Achilles tendon. It becomes contracted.
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As the arch drifts down, you can sort of think of the heel as drifting up, shortening the distance for the Achilles tendon mechanism to work. It becomes contracted. It begins to overload the forefoot even more, more hypermobility develops, more bunion problems. Here is an example of that hypermobility that I’m talking about. Here, we’re looking from the side of the lady’s foot. What I’ve done here is demonstrate that I have the first metatarsal aligned with the other metatarsals. As you can see, here is the first metatarsal, there are the toes and they all seem to be in alignment. When I try to displace the first metatarsal dorsally with my thumb, you can see how that rises up and now you can’t see across the foot, you can just barely see the second toe here, where before you could see it clearly. Another thing you can notice is that bunion, which looks prominent there, looks even more prominent here, because as that metatarsal drifts up, it is also drifting out, so if you were looking at this slide, it’s drifting out into your direction, so it’s going to rub even harder in the shoe. Again, as the hypermobility develops back here at the tarsal metatarsal joint and this first metatarsal drifts medially and up, hallux valgus develops at this joint. Because this first metatarsal head doesn’t touch the ground well, weight goes to the second metatarsal, a lot of overload occurs at the second metatarsal head and the second MTP joint. That weakens the structures on the plantar aspect of that joint and the toe begins to cockup or hammer-up, and there this lady circled her point of pain. This is constantly rubbing in her shoe. Also, the arch side begins to worsen, again, as the first metatarsal comes up, the arch starts to hit the ground.
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So what’s the treatment for this? Well it needs to be directed at the primary problem, then we can also deal with the secondary manifestations. We need an orthotic to support the arch, we need to deal with that arch sag and that hypermobility that is going along at the tarsal metatarsal joint.

It needs to be rigid when you’re standing on it

Jammy B. — Fri, 25 Jan 2008 16:27:17 +0000

It needs to be rigid when you’re standing on it, and it needs to be flexible as it strikes to the ground, so it can absorb the shock forces and the weight bearing forces as it strikes the ground. These static restraints such as the ligaments, as they start to weaken and the foot starts to collapse, you start to overwork or atrophy some of the dynamic restraints, the tendons that are trying to stabilize the foot along that axis of balance, and the axis of balance becomes disrupted. I put this slide up here to show you a relatively well aligned foot in this patient. Her left foot is widened out here, but essentially there is the center of her calcaneus and that weight bearing axis runs between the second and third metatarsal. On this side where she has a very severe flat foot, here is her hindfoot, we sort of estimate that here is about the center of the calcaneus, and you see if you draw that straight line, the axis of balance is shifted. Pretty much now all her metatarsals now shifted out laterally, as she is adducting through this talar navicular joint. You can imagine structures over here become lax, both the tendons and the ligaments, structures over here become contracted. So now, you have the axis of balance disrupted and now you have further forces that are acting to contribute to worsening of the deformity. Foot posture – it is very important to get weight bearing x-rays, nonweight bearing x-rays of the foot, and even later when we get to the ankle, x-rays can look very normal of the foot when you are not standing on it, and a lot of pathology and malalignments come out when you get those weight bearing views. Again, I tend to think of foot posture into three different situations, pes planus valgus of the flat foot as demonstrated in the slide here, essentially, this person had no arch, or their mid foot bones are essentially touching the ground instead of being a good 2 cm up and off the ground, versus a high arch foot, a cavus foot, and then the standard neutral or balance foot, which we call plantar grade.

Posterior Heel Pain

Jammy B. — Tue, 22 Jan 2008 14:59:57 +0000

When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations that they are coming to me to complain about? The foot is a complex weight bearing surface. There re 28 bones and nearly 60 articulating surfaces, so there are a lot of inter-relationships going on between the different segments of the foot, the hind foot, mid foot and forefoot, and problems in one region can have manifestations elsewhere. So it is very important to recognize what the root cause of the problem is, as well as identifying all the secondary manifestations. So when I think of the problems, I start to look at the structural malalignments that might be present in the patient’s foot, is the arch too high, is it too low? Is there some imbalance of the muscle forces that is causing that problem; or imbalance of those muscle balance forces driving the secondary manifestations. Also, as I talked about before, compensatory deformities. There could be a problem in the hindfoot, but the patient comes in to see you because there is a forefoot problem. That is where it hurts them, that is where it’s difficult for them to wear their shoes. So by way of the anatomy, the osteology of the foot, as I said, overall there are 28 bones.
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There are the seven tarsal bones in the hindfoot region, we have that defined as the calcaneus, and the talus, that separates the hindfoot from the midfoot through the transverse tarsal joint. The remaining five tarsal bones are the middle, medial and lateral cuneiform, the cuboid bone, and the navicular. Then you enter into the forefoot which has the five metatarsal bones and the 14 phalanges. As you know, in the hallux, there are only two phalanges, whereas in the lesser toes, there are three, and then the two sesamoids that are under the first metatarsal head. Ligaments are important for static stabilization of the arch of the foot, both it’s longitudinal arch and the transverse arch. The spring ligament, if you look on the slide here, again we are looking up under the foot, here is the calcaneus, here are the metatarsals down here, the spring ligament is sort of a sling that runs from the calcaneus to the navicular, a sling for the arch and the medial aspect of the foot. The long plantar ligament is an important ligament for stabilizing the lateral border of the foot and then Lisfranc ligament, you may have heard about those in terms of people having foot dislocations, when the common location is through the Lisfranc joint, that is the joint that separates the midfoot bones, those five bones, the cuneiforms and the cuboid from the metatarsals, and there are strong ligaments on the plantar surface at that junction that helps stabilize the forefoot.
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Another concept that I use frequently when I am looking at foot problems, is that the foot should have an axis of balance. That axis of balance runs along the sagittal plane. It goes from the center of the calcaneus, to the center of the midfoot, and runs between the second and third metatarsals in the forefoot. Weight bearing forces are balanced across that access medially and laterally, in fact, minimal muscle activity is required for quiet standing. The muscle forces, or the dynamic forces during the phases of gait are also balanced across this access for dorsiflexion, plantar flexion, but mostly for inversion and eversion of the foot to stabilize and square the foot up to the ground surface. Now that axis of balance is dynamic, you can lock and unlock the arch of your foot during gait when the primary movers of that is the posterior tibial tendon which attaches to the navicular and into the midfoot, and it maintains the arch. Then there are the everters of the foot, the peroneal tendons that help turn it out to the side, so those are the two main players in trying to stabilize that axis of balance. So your foot needs to effectively lock and unlock during gait.
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Achilles Tendonitis and Posterior Heel Pain

Jammy B. — Tue, 22 Jan 2008 14:55:12 +0000

Achilles tendonitis presents as a painful bump on the lateral border of their heel just adjacent to the attachment of the Achilles tendon to the calcaneus. It can be just a bony prominence, it can be a red, hot swollen hot spot if they have been wearing shoes that have been rubbing on that, and exacerbated a bursa that has formed over time. There is also pain and stiffness and swelling in this region, the Achilles tendon might be a bit contracted or have tendonitis, there can also be pain at the bursa between the Achilles tendon and the calcaneus, and they may have a lot of morning start up pain and stiffness, and they sort of work it out as the day goes along, and certainly, if this is a big, red hot swollen bump here, they are having a hard time wearing shoes. They may be the person that comes in wearing sandals or some backless shoe, so it doesn’t rub as they are walking.

So what’s going on here? There may be some component of insertional Achilles tendonitis, retrocalcaneal bursitis and that’s the sac between the anterior aspect of the Achilles tendon and the posterior aspect of the calcaneus sort of a bump cushion there to prevent rubbing. So what do we do for these problems? Well, we need to reduce the local inflammation, that can be oral anti-inflammatories, that can be local treatment such as iontophoresis or a steroid gel or cream that we try to rub into this area here to quiet down the inflammation. I don’t inject this, I don’t like to do steroid injections, I think if you inject in this region, you run the risk, in the worse severe case, cause iatrogenic rupture of the Achilles tendon. Some people say I’m not injecting the tendon, IM’s injecting the bursa, but there have been anatomic studies that show there are communications between the two, so if people say their injecting in front of the Achilles tendon to quiet down this hot bursa, you still run the possibility that you are directly infusing steroid right into the tendon. They need to have physical therapy, as this has become inflamed , it becomes less compliant, has less elasticity, it’s right and it hurts, so we need to work on first getting rid of the inflammation, and then working on getting rid of some of the contracture, increasing the compliance or elasticity of the tendon.

Another thing that is going to help them in the short term, they need a padded shoe counter, so where that shoe rubs back here, they need a nice padding on that so it doesn’t rub so hard on the pump bump, but another thing that is going to help is giving them a heel lift. You can imagine, if you put a quarter inch, half inch heel lift here, the ankle is going to plantar flex, the calcaneus is going to rotate up, and you are actually going to increase the space between the front of the Achilles and the back of the calcaneus, so there is going to be less impingement back here when they ambulate.