Metatarsalgia - hillingdongp.org.uk
Transcription
Metatarsalgia - hillingdongp.org.uk
Metatarsalgia Htwe Zaw FRCS (Tr&Orth) Orthopaedic Foot & Ankle Consultant Hillingdon Hospitals NHS Foundation Trust Painful foot • common in general population (17.4% Hill et al. J Foot and Ankle Research 2008 ) • more common in women • Steven Raikin MD (Rothman Institute, Philadelphia) – 1” heels: 22% forefoot pressure – 2” heels: up to 57% – 3” heels: up to 76% Metatarsalgia • • • • ‘pain in the forefoot’ multiple aetiology pain under metatarsal heads pain between heads footwear advice (1st line treatment) orthotics chiropody physiotherapy steroid injection surgery Assessment • Symptoms – – – – mechanical vs non-mechanical neuropathic shoewear related functional deficit (e.g. stairs) • Examination – – – – – site of maximal tenderness dorsal/plantar callosities hammer/mallet/claw toes & subluxed MTPJ mid/hindfoot malalignment (flatfeet, high arch) gastroc-soleus tightness (Silfverskiold’s test) Gastrocnemius-soleus complex Imaging • Weight-bearing views (AP, lateral, oblique) Treatment • dependent on aetiology footwear education - high & wide toe box shoes orthotics – offloading insoles & splints chiropody – regularly shave callosities physiotherapy - eccentric stretches ultrasound-guided steroid injection surgical correction Shoe modification • ‘high & wide toe box’ • bespoke orthotic shoes • high street brands (Ecco, Clarks, Hotters, Coolers) • rocker-bottom shoes (MBT, Sketchers) • supportive sandals (Birkenstock, FitFlop) offloading orthotics • • • • ‘metatarsal shelf/dome’ +/- heel raise +/- arch support +/- hindfoot correction Nighttime splints Ankle dorsiflexion splint Strassburg sock US-guided injections • • • • steroid + LA ultrasound-guided: diagnostic & therapeutic avoid alcohol/sclerosants ?pulsed RF ablation Ian Garnham et al. A Prospective Study on Ultrasound-guided Steroid injections for Morton’s Neuroma: Does the Size of the Lesion Matter? J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XLIII 4 Henry Slater et al. Effectiveness of Ultrasound-Guided Corticosteroid Injection in the Treatment of Morton's Neuroma. Foot & Ankle International May 2008 vol. 29 no. 5 483-487 (Sydney) Aetiology Hallux metatarsalgia Lesser metatarsalgia hallux valgus hallux rigidus sesamoiditis forefoot overload cavus turf toe gout interdigital (Morton’s) neuroma intermetatarsal bursitis MTPJ pathology (capsulitis/subluxn) forefoot overload transfer lesions Freiberg’s stress fracture Morton’s Neuroma • • • • • • ‘perineural fibrosis’ mechanical irritation of plantar digital nerves pain, burning, numbness, tingling typically females (4:1), unilateral, 3/4 webspace better barefoot, worse in constrictive shoes Mulder’s click (compression test) wide toe box shoes, offloading insoles, us-guided steroid injection, surgical excision Mulder’s click Plantar MTPJ pain plantar fat pad displacement (e.g. hammertoes) S Bus, M Maas, P Cavanagh, R Michels, M Levi (AMC), Diabetes Care 27:2376 –2381, 2004 Dorsal MTPJ pain MTPJ instability/capsulitis/Freiberg’s/tenosynovitis Lachman test: Transfer Lesions • • • • • relatively long lesser MTs defunctioned 1st ray (e.g. HV) iatrogenic (post-surgical) neurological conditions Charcot arthropathy What to look for • Check for gastrocnemius tightness? – eccentrics, dorsiflexion splints/socks OR ?heel raise • Lesser metatarsalgia (mtpj vs webspace) – eccentrics, offloading insole, chiropody, consider USS ± injection • Hallux metatarsalgia – refer early (hallux valgus, rigidus, sesamoid, turf toe, cavus) – eccentrics, offloading insoles, rocker-bottom/wide toe-box shoes When to refer failed conservative Mx pt wants to consider surgery pain is primary symptom lesser toe deformities impending or active ulceration hallux metatarsalgia associated mid/hindfoot deformities previous surgery (altered biomechanics) Thank you