Common Disorders
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Did you know the foot has 28 bones, 37 joints, 107 ligaments, 19 muscles, and numerous tendons? These parts all work together to allow the foot to move in a variety of ways while balancing your weight and propelling you forward or backward on even or uneven surfaces. It is no wonder that most Americans will experience a foot problem that will require the care of a specialist at one point or another in their lifetime.

Metatarsus adductus is a congenital deformity of the foot where there is increased curvature of the forefoot. This gives the foot the appearance of a "C" shape. This deviation of the metatarsals or visual effect of in-toeing is a deformity that occurs at the midfoot of the foot. The diagnosis of metatarsus adduction is relatively straightforward and is predominantly a clinical diagnosis. The exact cause of metatarsus adductus is not fully understood but is considered to be caused by intrauterine position and pressures. There may also be a genetic component to the deformity.

Diagnosis

The diagnosis of metatarsus adductus is made by physical examination and has certain characteristics:

  • the foot has an inward position as compared to the lower leg
  • the foot has a concave border medially and a convex border laterally
  • the metatarsus adductus foot may appear with a high arch
  • there is usually a separation of the big toe from the lesser toes

Treatment

Kohler's Disease is a spontaneous loss of blood supply to a bone in the foot called the Navicular bone. Dr. Kohler described it in 1908. The spontaneous loss of blood supply to a bone is called osteochondrosis. In later years Dr. Kohler was also associated with another osteochondrosis of the foot known as Freiberg's disease. Some texts refer to this condition as Kohler's II.

Clinical features and Treatment

Clinically, the presentation of Kohler's disease may be an incidental x-ray finding. Often, however, localized pain or a painful gait is noted. Occasionally mild swelling is seen. It is seen most commonly in males and most cases only affect one foot. Biopsy of the bone to make the diagnosis is not necessary.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toesoverlapping toesflexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes

Amniotic band syndrome (ABS) is an uncommon, congenital fetal abnormality with multiple disfiguring and disabling manifestations. A wide spectrum of clinical deformities are encountered and range from simple ring constrictions to major head, face and internal organ defects. Lower extremity limb malformations are extremely common and consist of asymmetric digital ring constrictions, distal atrophy, congenital intrauterine amputations, and clubfoot. Although debated, early amnion rupture with subsequent entanglement of fetal parts (mostly limbs and appendages) by amniotic strands is the primary theory of pathogenesis.

Amniotic band syndrome is associated with an excessive number of synonyms and acronyms such as congenital constriction band syndrome, Streeter's dysplasia, Simonart's bands, amniotic band disruption complex, congenital annular defects, congenital ring constrictions, ADAM (Amniotic Deformity, Adhesion, Mutilations) complex, TEARS (The Early Amnion Rupture Spectrum) of defects, and fetal disruption complex. The overabundance of synonyms/acronyms used to describe the congenital malformations in ABS attest partly to the confusion surrounding its etiology.

There are several causes of pain in the arch of the foot and heel region. The type of pain and its location help the doctor in determining the cause of the pain and helps to direct them in the best treatment for the patient.

The most common pain in the bottom of the foot is heel pain. This pain tends to be worse first thing in the morning or after rest. It is associated with a tight ligament in the bottom of the foot called the plantar fascia. X-rays will often reveal a spur on the bottom of the heel. (See plantar fasciitis and heel spurs) Pain in the back of the heel can be due to bony enlargements (Hagland's deformity), spurring in the Achilles tendon or Achilles tendonitis. Burning pain in the bottom of the foot may be caused by a condition called tarsal tunnel syndrome or it may be due to peripheral neuropathy. People with diabetes frequently experience burning in the bottom of the feet. Pain in the middle of the arch of the foot that is also associated with small, hard knots may be due to plantar fibromatosis.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toesoverlapping toesflexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes

There are several causes of pain in the ball of the foot. The type of pain and its location help the doctor in determining the cause of the pain and helps to direct them in the best treatment for the patient.

Calluses on the bottom of the foot can be painful. These calluses are caused by an abnormal alignment of the bones behind the toes called metatarsal bones. When there is an abnormal alignment of one or more of these bones, they will experience excessive weight and pressure. The skin thickens in response to this pressure forming the callus. Treatment consists of periodic trimming or shaving the callus, padding the shoes to remove the pressure, functional shoe orthotics, or surgery. Surgery should not be contemplated until the use of orthotics has been determined to have failed. The surgery consists of fracturing the involved metatarsal bone to realign it (See metatarsal surgery). Following the surgery, the patient should wear an orthotic to prevent the occurrence of new areas of callus. People with diabetes should not trim or shave these areas or use over the counter corn removers.

Pain in the ball of the foot not associated with calluses can be a result of inflammation of a tendon into the toe, inflammation of the joint, or due to a pinched nerve called a Neuroma. A neuroma will also often cause a burning pain into one or more toes. Another cause of pain in the ball of the foot is arthritis. Arthritis will usually affect multiple joints in the ball of the foot. Common types of arthritis are rheumatoid arthritis, osteoarthritis and degenerative arthritis. Degenerative arthritis most commonly affects the big toe joint. The big toe joint is often stiff causing jamming (Hallux Limitus). Over time the jamming of the joint will cause an enlargement on the top of the joint.

The most common cause of pain in the ball of the foot, in the area of the big toe joint, is sesamoiditis. Sesamoiditisis an inflammation of two small bones under the big toe joint. On occasion, a stress fracture can occur in one of these bones. Severe pain with sudden onset about the big toe joint may be gout.

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the heel of a child the most likely cause is due to injury of the growth plate in the heel bone. This is called Sever's disease. A condition that may mimic Seiver's disease is Achilles tendonitis. Achilles tendonitis is inflammation of the tendon attached to the back of the heel. A tight Achilles tendon may contribute to Seiver's disease by pulling excessively on the growth plate of the heel bone. This condition is most common between the ages of 8 - 15 years of age and boys tend to be affected more than girls. It is frequently seen in the active soccer, football or baseball player. Sport shoes with cleats seem to aggravate the condition. It is believed that the condition is due to an underlying mechanical problem with the way the foot functions.

Treatment

Home treatment consists of calf muscle stretching exercises, heel cushions in the shoes, and/or oral anti-inflammatory medications like Tylenol or Advil. Icing the area may provide some temporary relief. If the condition persists the child should be evaluated by a podiatrist for abnormal foot function. In severe cases a below the knee walking cast may be required. Treatment may require the use of custom-made shoe inserts called orthotics.Orthotics work by correcting foot function and will fit into most normal shoes.