ACHING FEET – ORTHOPAEDIC CAUSES AND TREATMENT METHODS

Hallux valgus, also known as bunion or big toe, is a deformity of the big toe of the foot. Regardless of its aesthetic appearance, hallux valgus often causes pain. However, once the deformity of the big toe has developed, its further development can only be delayed, but can hardly be corrected without surgery. The development is often hereditary and most sufferers already have splayfoot. It is noticeable that women in particular suffer from this deformity. This is not only due to incorrect footwear. The particularly soft connective tissue of the female sex favours the deformation. The likelihood also increases after pregnancy or rheumatism.

The misalignment of the toes in hallux valgus is caused by the first metatarsal bone with the head shifting towards the inside of the foot. This causes the big toe, which is actually straight, to bend and shift towards the second and third toes. The second and third toes can then bend under the pressure, resulting in a claw toe or hammer toe. There are five different degrees of severity, ranging from a normal position to a mild, moderate, mild to moderate or severe deformity.

To prevent hallux valgus, it is advisable to strengthen the inner muscles of the foot. Pads or insoles can also counteract a widening of the forefoot. Night splints and supports can be used to keep the big toe in a normal position. This delays the further development of hallux valgus. Soft tissue padding and special shoes can prevent the development of painful calluses. Unfortunately, however, conservative methods can only delay the development of hallux valgus, but cannot correct it.

Only surgical interventions can help here. To find out which surgical measure can be considered, the foot is x-rayed under load.

The surgical options
For mild to moderate hallux valgus, chevron osteotomy or scarf osteotomy are established procedures to treat the malposition of the toes by bony correction of the first metatarsal bone away from the body. While the chevron osteotomy is suitable for mild deformities, the scarf osteotomy is used for mild to moderate deformities. In the case of severe hallux valgus, bony correction is performed on the first metatarsal bone close to the body by means of an opening osteotomy or a tarsal correction or stiffening of the first tarsometatarsal joint (lapidus arthrodesis).

If the big toe is also bony deformed, an Akin osteotomy can be performed. Reconstruction of the joint capsule and the tendon close to the joint is mandatory.

If the claw toe is also in need of correction, resection or fusion surgery of the metatarsophalangeal joint close to the body should be discussed. In some cases, correction can also be achieved by a shortening osteotomy of the metatarsophalangeal joint. The fixation is carried out with wires, which are removed again after approx. four weeks, or with titanium screws.

After the operation, it is important to keep calm. A forefoot relief shoe should be worn. The big toe is mobilised immediately afterwards with the help of physiotherapy. The transition to normal weight-bearing is possible again after approx. six weeks. The screws and plates usually do not need to be removed.

Hallux rigidus refers to osteoarthritis of the metatarsophalangeal joint of the big toe. The disease is particularly noticeable due to pain when rolling the big toe or stabbing pain when walking. The degenerative disease is rare, but there are several factors that can trigger it. These include hallux valgus deformity, predisposition, incorrect loading, injuries, but also diseases such as gout, rheumatism or diabetes. The treatment of osteoarthritis in the metatarsophalangeal joint of the big toe depends on the stage of development of the hallux rigidus.

Stage I: The toe hurts under load, mobility is reduced by 20 to 50 %. The joint space is not noticeable, but small bony protrusions may have already formed.

Treatment: In some cases, pain relief can now be achieved with special insoles with a rigidus spring or roll-off aid. Injections, e.g. with hyaluronic acid, can delay the progression of osteoarthritis by protecting the remaining cartilage. In the case of inflammation, injections or medication with anti-inflammatory agents are recommended. Mobility can be improved with the help of physiotherapy.

Stage II: The range of movement is limited both passively and actively, the toe is sometimes very painful. X-rays show a narrowing of the joint space and the formation of bone spurs. The metatarsal head of the metatarsophalangeal joint may be flattened.

Stage III: In particular, upward movement of the toe is hardly possible. Pain is almost permanent. The joint space is severely narrowed and bone cysts can sometimes be recognised. Bone spurs are clearly visible. Sometimes the metatarsophalangeal joint makes an unpleasant crunching noise.

Treatment in stages II and III: Surgical joint smoothing can alleviate pain. The foot surgeon will remove the bony protrusions pointing upwards.

Stage IV: The big toe is stiffened and almost immobile. Those affected suffer constant pain even when at rest. This is because bone is now really rubbing against bone. At this advanced stage, hallux rigidus shows an almost non-existent joint space, which may also contain free joint bodies. The joint is clearly deformed.

Treatment: If the osteoarthritis has already destroyed the entire joint, an operation to stiffen the joint should be discussed. In this so-called arthrodesis, the big toe is positioned in a slightly hyperextended position to enable postoperative rolling. Fixation is achieved with screws or special plates. This may seem like a rigorous step, but the case numbers show that fusion of the metatarsophalangeal joint of the big toe in cases of severe osteoarthritis is one of the most successful operations on the foot – with a high level of patient satisfaction. After an operation to stiffen the metatarsophalangeal joint, the foot must be immobilised for six weeks to allow the bones to strengthen. After a successful X-ray check, weight-bearing can then begin, sometimes with the use of a roll-off aid on the shoe. Sporting activities, including jogging and ball sports, are usually possible again after eight to twelve weeks.

In contrast, treatment with joint prostheses in stage IV has not been able to establish itself in the treatment of hallux rigidus. This often leads to renewed stiffening of the joint with persistent pain.

Our ankle joint is a perfectly sophisticated system. Anatomically, the upper ankle joint is a hinge joint that enables us to raise and lower our foot. It is formed by the tibial malleolus and fibular malleolus, the tibia and the talus. A strong inner and outer ligament apparatus ensures stability. The lower ankle joint is located in the hindfoot between the talus and calcaneus as well as the talus and navicular bone. It enables inward and outward tilting. Due to the immense strain that our ankle joint is exposed to on a daily basis, injuries or illnesses to the ankle joint can be particularly painful. Torn ankle ligaments and bone necrosis are among the most common.

Treatment of torn ligaments: Torn ankle ligaments can occur quickly as a result of a twist, fall or accident. The only thing that often helps is to put your feet up and cool them. Supportive bandages can provide relief. In the past, doctors used to operate on torn ankle ligaments. Today, however, this is only done if there is chronic instability and conservative methods have not been successful. However, specialists recommend surgery if the outer ligaments have been damaged by the ligament tear. An MRI provides information about the condition and helps to determine the treatment methods.

Treatment for bone necrosis in the ankle joint: Bone necrosis in the ankle joint is usually characterised by severe pain in the ankle joint. As a rule, bone necrosis of the ankle is very rare. Young adults, adolescents and children who are active in sports are particularly affected. There is no need for acute trauma; bone necrosis of the ankle joint can also occur without any recognisable cause. It is usually the result of circulatory disorders and congenital malalignment of the joint surfaces.

Bone necrosis of the ankle leads to load-dependent symptoms. In some cases, this is accompanied by joint swelling due to water retention. X-ray images and magnetic resonance imaging findings provide the orthopaedic specialist with information about the stage of bone necrosis in the ankle joint. The therapy is based on these results.

In the early stages, when the bone necrosis manifests itself with bone oedema without signs of loosening, conservative treatment can be used. This involves protecting the ankle joint in combination with measures to promote blood circulation. However, if the bone necrosis indicates a detachment of the bone area, an arthroscopy is recommended. As part of the arthroscopic procedure, the foot specialist will inspect the bone area and perform either an anterograde or retrograde drilling. In severe cases, the necrotic area may become detached and a joint mouse may form. This joint mouse is then refixed arthroscopically using special anchors. If this is not possible, cartilage and bone-stimulating measures are initiated in the area of the necrosis after removal of the free joint body. If cartilage reconstruction measures have been carried out, a longer period of rest of at least six weeks must be observed. During this time, the joint is mobilised but must not be subjected to any stress. Jogging or other ball sports can be resumed after three months at the earliest. Jumping sports are only possible after about six months. However, if only one joint mouse has been removed, the foot can be fully loaded again after just a few days.