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Hallux Valgus (Bunion)

Hallux Valgus also called a Bunion, is a deformity of the first metatarsophalangeal joint (the joint at the base of the big toe). “Hallux” is the big toe and “valgus” means the deformity of the big toe. It is more common in women. Family history of hallux valgus is the main cause of this deformity, more so than ill-fitting shoes. In feet with bunions, there is an imbalance between the following muscles of the feet: flexor halluces brevis, and adductor and abductor halluces muscles. The severity of the bunion is determined by the degree of the following angles: the hallux valgus angle (HVA) and intermetatarsal angle (IMA). As the metatarsophalangeal joint is compressed and widened during repeated impact when walking, additional bone is added to the first metatarsal head at the site of the bunion. This joint also becomes dorsiflexed and inverted, hence it’s shape.

     Many people with bunions will only experience pain at the site of the bunion when wearing tight narrow shoes with a small toe box. Some will complain of redness, tenderness, swelling, and pain with plantar flexion. If the bunion is severe, the second toe may become “hammered”: the two joints of the second toe become permanently flexed. The second toe may overlap the big toe.

     Proper fitting foot orthotics with a rocker sole, no seams over the bunion, and a deep vamp are the best treatment option. A pedorthist, podiatrist, or chiropodist may place a metatarsal pad under the top cover of the orthotic just underneath metatarsal heads (the joints at the base of the toes) will help unload the pressure off the forefoot. Surgery may be considered if pain in the bunion is extreme or for aesthetic reasons. It is not covered by OHIP and tends to be expensive. Complications of a surgical procedure include long-term pain in metatarsal heads, recurrence of bunions, and necrosis of the first metatarsal.

Who Is a Foot Care Nurse and What Does a Foot Care Nurse Do?

A foot care nurse can be a Registered Nurse or a Registered Practical Nurse. She will assess the skin condition, hair distribution, and structure of your feet as well as your pulses and feeling with a monofilament to test the dermatomes. This confirms presence of adequate or inadequate circulation. The monofilament is used to check for neuropathy, a lack of feeling in the feet that could be an advanced sign of Diabetes. The nurse will also check what medications you are on and for what health conditions. History of surgery or injury to the feet, ankles, hips, and back is especially important because foot care must be tailored to support the feet as they are with all their health history. Of course, nails are cut, callouses are reduced, and corns are removed. However, a foot care nurse is not just there for the one-time visit, but someone who oversees the state of your feet and provides ongoing care, health teaching, and recommendations about self-care. If nail fungus or Athlete’s foot is present, the foot care nurse will let you know and explain which over-the-counter or home remedies can be used as long as it does not interact with what is prescribed by your healthcare practitioner. In summary, a foot care nurse knows what your feet have been through and how to optimize their health.

Haglund’s Deformity (also called Bauer bump or pump bump)

This type of deformity looks like an enlargement of the bone (the bone is called calcaneus) just above and behind the heel. There is no swelling at the site, only pain and/or soreness. If a person wears shoes with a tight heel counter (the part of the shoe around the heel), then they aggravate it so wearing sandals is more comfortable.

Haglund’s deformity is caused by an inflexible heel counter that is often present in ice skates and high-heeled shoes. This is when the bony prominence (exostosis) begins to develop; soreness develops only later.

This type of deformity can lead to retrocalcaneal bursitis (inflammation of the bursa behind the calcaneus). Furthermore, the prominence itself leads to more bursitis by irritating it. In fact, Haglund’s deformity is often misdiagnosed as retrocalcaneal bursitis. While both conditions have the symptoms of irritation, redness, and enlargement at or near the base of Achilles tendon, Haglund’s deformity is painful only when pressed and has redness and swelling that does not spread further than the prominence itself.

X-ray images help to diagnose Haglund’s deformity and MRI can show its outline.

To help with the pain upon pressure and reduce the strain on Achilles tendon, one can wear shoes without heels or with stretched, cushioned or softer heel counters. Also, the heels of the shoes can be modified with a 6 mm heel-raise, which can be done by a certified pedorthist.

The common treatment is PRICEMM: Protection, relative Rest, Ice, Compression, Elevation, Medication, and rehabilitation exercise Modalities. It’s also useful to complete an eccentric strengthening program and perform soleus and gastrocnemius stretching. If this treatment has not helped, after 6 months surgery may be recommended.

Ankle Ligament Sprains

Ankle ligaments hold the joint and bones together in a joint called a talocrural joint. The bones that are held together here are lower tibia and fibula of the lower legs, as well as talus, a small bone that fits between them. This joint is like a hinge: it moves allowing the toes to lift off the ground (dorsiflexion) and swings down to plant the foot firmly on the ground (plantarflexion). The list of ligaments of the foot that are commonly injured can be found in the previous blog entry. If the foot is rotated outward during a sprain, it’s called an eversion sprain. It comprises 5-10% of all ankle sprains and takes much longer to heal than an inversion sprain. An inversion sprain is much more common.

 Ankle sprains are classified into Grades 1, 2, & 3, depending on their severity. Grade 1 is a mild sprain. There is some pain and very little swelling because the ligament has been stretched but there is no deformity; return to normal function can be expected in 2 weeks. Grade 2 is when the ligament is partially torn. Some bleeding and bruising can occur and is often lower than the injury site due to gravity. Here rehabilitation is necessary and the person can return to normal activities within 2-6 weeks. Grade 3 sprain is a complete tear of a ligament. Pain is severe at first but then subsides quicker than a Grade 2 sprain. Surgery could be necessary and return to activity can take as long as 6 weeks or more.

Common testing includes Ottawa ankles rules: if pain is present near the malleoli (the two bones protruding on the inside and outside of the ankle) and the person cannot walk for 4 steps after injury, an X-ray should be ordered. Treatment includes avoiding HARM (heat, alcoholic beverages, running, and massage). Ultrasound can be indicated to reduce swelling only if the person is 18 years old or older. Casting a sprained ankle is not recommended. Use the acronym PRICE (protection, rest, ice, compression, and elevation).

There are many different types of ankle braces that can provide protection. An ankle can be taped to provide support short-term. If there is a severe sprain, a short-leg cast or a walking boot can be used to partially immobilize the leg but not completely. Elevate the ankle and apply ice-packs wrapped in a wet towel for 15-20 minutes every 2 hours for the first 2-3 days. Compressive wrap should be applied correctly to ensure adequate blood flow to the toes. Once the swelling begins to subside, your MD will refer you to a physiotherapist whose advice the client should follow as precisely as possible. Gradually begin to move the ankle 48 hours after the sprain as part of rehabilitation. Make sure footwear is roomy enough to accommodate swelling and it gives enough ankle support through a wide stable base. The soles of the shoes should not be worn down especially at the heel causing ankle instability.

Chronic Ankle Instability (CAI)

Clients describe CAI as a feeling of “giving way” and instability resulting in swelling, prolonged pain, increased or (if ankle sprain has previously occurred) limited range of motion. CAI often leads to ankle injuries and, most commonly, ankle sprains. The three most common ankle sprains are: inversion sprains (the sole of the foot is rotated inward to face the other foot), eversion sprains (the rotation is outward and usually affects deltoid ligaments), and high ankle sprains (harm to the syndesmotic ligaments). 75% of all ankle injuries are sprains and 85% of all ankle sprains are inversion sprains, which tend to recur. People most affected by CAI are usually physically active. Those that tend to have lax ankle ligaments (mechanical issue) and have an active lifestyle (functional issue) tend to suffer from CAI the most. Those with a cavus foot (high arch of the sole of the foot) are also more likely to have CAI, particularly, lateral ankle instability. If the joint is stable, intact and ligaments are strong, injury is less likely to occur.

Anterior talofibular ligament is the most commonly injured and also the weakest ankle ligament. ATFL inversion sprain can occur when a foot is inverted and plantarflexed (the position of the foot when toes are pointed out) while the leg is externally rotated (leg is turned to point to the side). The next most common sprain is a tear in the calcaneofibular ligament (CFL) often followed by a tear of the AFTL. A sprain of the posterior talofibular ligament (PTFL) of the outer side of the ankle is least common of the three because it’s the third weakest ligament. The medial (inner or facing the midline) ligaments are: tibiocalaneal, tibionavicular, superficial tibiotalar, and posterior tibiotalar ligaments and are least likely to be sprained.

As part of the assessment, the physician would often order stress radiographs and X-rays. To estimate loss or return of functional ankle control and predict future ankle injury postural control is used. Postural control is one’s ability to keep centre of mass centred over one single foot. Most commonly, to improve postural control taping, bracing, and orthotics are used. In extreme cases, the physician may recommend reconstructive surgery of the ankle.

Meniscal Injuries, etc… What is a Meniscus, anyway?

Meniscus, also called semi-lunar cartilage (rubber-like padding around bones where they join together), is knee-joint cartilage which grows inward from the joint capsule and forms pads or discs. These discs are situated within the knee to cushion the contact between femur (the bone of upper leg) and tibia (the biggest bone of the lower leg). They deepen tibia’s surface and provide a larger and more stable surface area for the femur to join with. Their function is shock absorption, reducing friction, and stabilization of the knee joint.

Half of all knee ligament and meniscal injuries are sports injuries. There are chronic and acute meniscal tears. Chronic degenerative tears rarely cause any dysfunction or pain since they are caused by many episodes of minimal trauma. When constant shearing forces act on the inner meniscus, it may lead to detachment, pain, instability, and momentary locking. Horizontal cleavage tears are chronic in nature and are due to degenerative changes in the back inner part of the knee.

The three acute tears are: longitudinal, bucket-handle, and parrot-beak, and are classified by their shape. The most common are longitudinal tears and happen when the knee is twisted while flexed and the foot is fixed in one place. Bucket-handle tears have 40% frequency of incidence. They happen when an entire longitudinal segment of meniscus is displaced toward the center of the tibia, often leading to the knee locking in place when flexed. Parrot-beak tears are often found in adolescents and involve the mid-outer meniscus developing two tears in a parrot-beak shape.

Immediate treatment includes RICE (rest, ice, compression, elevation), non-steroidal anti-inflammatory medications (NSAIDs), and crutches to keep the weight off the injured knee. See your family health professional immediately if the knee is locked in place or if excessive joint effusion (abnormal accumulation of fluid in a joint) is present. Physiotherapy, surgery, and/or orthoses (braces or other devices that support and correct joint alignment) may be prescribed by family doctor or nurse practitioner.

Quality Foot Care for Those with Morton’s Neuroma

 If you are a fashion-minded woman ages 30 to 60, you are at a high risk of developing Morton’s Neuroma. This is a type of nerve pain that often occurs in the third intermetatarsal space (in the space where the 3rd and 4th toes join together) but can occur in other intermetatarsal spaces also. The frequency of Morton’s Neuroma is directly related to how one walks and by the anatomical structure of the foot. The pain is caused by a lesion or injury to one of the common digital (toe) nerves due to repeated trauma or compression, often when wearing high-heeled and narrow shoes. That’s why, this condition is more common in women. The pain is often worse when walking but can occur at rest. Another symptom is loss of sensation in the involved toes and affected toes may be splayed.

   The most effective initial treatment is, commonly, a Neuroma Pad placed in shoes with large enough toe-box. Make sure to wear footwear with deep and wide toe-box, low heels, and stiff soles. If a neuroma pad does not provide enough pain relief, use of professional orthotics is recommended. In extreme cases, Morton’s Neuroma can be treated with ultrasound or laser treatment.

Osteoarthritis

It’s a degenerative disease of joints that involves cartilage, bone, and synovia. With wear and friction, cartilage that surrounds the bones at a joint thins, becomes rough, and causes pain, deformity, and instability. Unstable joints often buckle or lock in place, especially the knee. Tenderness, stiffness, and pain of the joint, not getting relief from over-the-counter medications, pain changes with weather, joint swelling, restricted movement, creaking and grating, and bony enlargement are common symptoms. Pain in the joint develops gradually, worsens with use and is relieved with rest.  Pain and stiffness increase with damp weather and low air pressure because nerve fibres in the capsule of the knee are sensitive to changes in atmospheric pressure. An X-ray is used to diagnose osteoarthritis. It affects more women than men. Mild to moderate pain can be treated with non-steroidal anti-inflammatory drugs, such as aspirin or ibuprofen. Other treatments may include surgical and non-surgical therapies, such as orthotics, well-cushioned shoes, and physiotherapy. A family doctor would make the diagnosis and may refer the client to a podiatrist or chiropodist.

Women’s Plantar Fasciitis Orthotic Insole (at Mark’s Work Warehouse)

Did you know? If you have Plantar Fasciitis,  inflammation of the plantar fascia, you can: use RICE (rest, ice, compression, elevation) and tape the afflicted area for 1 to 5 days to achieve pain relief and support. Then, wean  into orthotics and/or shoes with good arch support. Also, support pes planus or pes cavus and use anti-inflammatory medications for pain. The use of TENS and ultrasound are also recommended.

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