John V. Vanore

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010.

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 1: Hallux valgus.

Hallux rigidus is a progressive disorder of the first MTP joint, characterized by a diminished range of motion (ROM) and degenerative alterations of the joint (1–9). Because some degree of movement is generally available, the term hallux limitus (7) has been used to describe the condition, although the pathologic process is one of progressive degenerative joint disease secondary to biomechanical disturbance or local pathology (Fig. 1). Generally, a cyclic deterioration of the articulation and the reduction of motion occur, and ultimately, ankylosis with virtual absence of joint movement results (3, 10).

Diagnosis and treatment of First Metatarsophalangeal Joint Disorders. Section 6: Other disorders ☆ ☆☆

If clinical examination and radiographs allow for definitive diagnosis, treatment should be directed accordingly. Nondisplaced or mildly displaced fractures, symptomatic partitions, and avascular necrosis may be initially treated with immobilization and offloading techniques. If these measures fail, or if a markedly displaced fracture is encountered, excision of the affected sesamoid(s) may be indicated. Degenerative/arthritic changes may be treated with offloading techniques, orthotics, anti-inflammatory nonsteroidal drugs, or localized injection. Surgery may be indicated if nonsurgical care is unsuccessful (2,14). Excision of a sesamoid(s) may result in a variety of postoperative problems including hallux varus, valgus, hammertoe, and/or extensus; the patient must be evaluated carefully (15).

The diagnosis and treatment of heel pain

Mechanical heel pain is one of the most frequent conditions presented to foot and ankle specialists. Plantar heel pain is responsible for the majority of mechanical heel pain cases. Plantar heel pain is defined as insertional heel pain of the plantar fascia with or without a heel spur (Fig. 1). The most common cause cited for plantar heel pain is biomechanical abnormalities that lead to pathologic stress to the plantar soft tissues (1–7). Localized nerve entrapment of the medial calcaneal or muscular branch off the lateral plantar nerve may be a contributing factor (8–11). Patients usually present with isolated plantar heel pain upon initiation of weightbearing, either in the morning upon arising or after sitting for a period of rest. The pain tends to decrease after a few minutes, then returns as the day proceeds and time on the feet increases. Associated significant findings may include high body mass index, tightness of the Achilles tendon, pain upon palpation of the inferior heel, and inappropriate shoe wear (12–14). Many patients will have attempted self-remedies before seeking medical advice. A careful history is important, including time(s) of day when pain occurs, current shoe wear, activity level both at work and at leisure, and history of trauma. An appropriate physical examination of the lower extremity includes range of motion of the ankle with special attention to decreased range of motion of dorsiflexion of the ankle, palpation of the inferior medial aspect of the heel, palpation of the medial aspect of the heel, the occurrence of bilateral symptoms, and angle and base of gait evaluation. Following physical evaluation, appropriate radiographs may be considered. Radiographic identification of a plantar heel spur indicates that the condition has been present for at least 6–12 months, whether having been symptomatic or not (Fig. 2). As a rule, the longer the duration of heel pain symptoms, the longer the period to final resolution of the condition. Initial treatment options may include nonsteroidal antiinflammatory drugs (NSAIDs), padding and strapping of the foot, and corticosteroid injections for appropriate patients. Patient-directed treatments seem to be as important in resolving symptoms. They include regular stretching of the calf muscles, avoidance of flat shoes and barefoot walking, use of cryotherapy directly to the affected part, over-the-counter arch supports and heel cushions, and limitation of extended physical activities. Patients usually have a clinical response within 6 weeks of initiation of treatment. If improvement is noted, the initial therapy program is continued until symptoms are resolved. If no improvement is noted, the patient should be referred to a podiatric foot and ankle surgeon. The second phase of treatment for the referred patient includes continuation of the initial treatment options with considerations for additional therapy: the use of custom orthotic devices, especially in the biomechanically malaligned patient, the use of night splints to

Diagnosis and Treatment of Forefoot Disorders. Section 3. Morton's Intermetatarsal Neuroma

Nerve pathologies are a common cause of forefoot pain and include diverse conditions with similar symptoms. The symptoms are characteristic of sensory nerve disorders and differ from other musculoskeletal conditions. Morton’s intermetatarsal neuroma is a compression neuropathy of the common digital nerve (Fig. 1). It is most commonly seen in the third intermetatarsal space, but it also can be seen in other intermetatarsal spaces (Fig. 2). A neuroma may occur in more than one intermetatarsal space and may be bilateral. Neuromas are more prevalent in adults beginning in the third decade of life, and are more common in females than males (1-7).

Diagnosis and Treatment of Forefoot Disorders. Section 4. Tailor's Bunion

Tailor’s bunion (also called bunionette) involves deformity of the fifth metatarsophalangeal joint (MPJ), much like a bunion that occurs medially. Although tailor’s bunion typically involves deformity with lateral prominence of the fifth metatarsal head, both lateral and plantar clinical pathology will be discussed in this document. Numerous factors can contribute to the development of a tailor’s bunion. Structural causes include a prominent lateral condyle, a plantarflexed fifth metatarsal, a splay foot deformity, lateral bowing of the fifth metatarsal, or a combination of these deformities (1-5). In addition, there may be hypertrophy of the soft tissues over the lateral aspect of the metatarsal head (6). Other contributing factors may include a varus fifth toe, hallux valgus with abnormal pronation of the fifth metatarsal, hindfoot varus, and flatfoot (7). Tailor’s bunion is seen most commonly in adolescents and adults. It has been reported that the mean age of presentation of tailor’s bunion is 28 years (range, 16–57 years) (8), with a female-to-male ratio greater than 2:1 (1). Significant History (Pathway 5, Node 1)

Diagnosis and Treatment of Forefoot Disorders. Section 2. Central Metatarsalgia

This clinical practice guideline (CPG) is based upon consensus of current clinical practice and review of the clinical literature. The guideline was developed by the Clinical Practice Guideline Forefoot Disorders Panel of the American College of Foot and Ankle Surgeons. The guideline and references annotate each node of the corresponding pathways. Central Metatarsalgia (Pathway 3) Central metatarsalgia involves pathology of the second, third, and fourth metatarsals and their respective metatarsophalangeal joints (MPJs). Metatarsal pathology may be secondary to a variety of problems including trauma, length abnormalities, structural deformity, and others. Pathology of the central MPJs is also secondary to numerous different etiologies and encompasses both osseous and soft tissue conditions. Osseous changes may be secondary to arthritis, whereas soft tissue conditions can be complex, often leading to instability of the MPJ and resultant multiplanar deformities. Systemic inflammatory conditions may produce both osseous and soft tissue abnormalities in the areas of the central MPJs.

Diagnosis and Treatment of Forefoot Disorders. Section 5. Trauma

Trauma to the toes, lesser metatarsals, and their respective joints involves various mechanisms and injury types (1, 2). These include a history of both direct and indirect trauma. Patients may exhibit symptoms acutely at the time of trauma or at a later onset. Symptoms include pain, swelling, discoloration, loss of joint motion, and difficulty standing and/or walking. An accurate history of the inciting traumatic event should be elicited.

Clinical Practice GuidelineDiagnosis and treatment of First Metatarsophalangeal Joint Disorders. Section 4: Sesamoid disorders☆☆☆

If clinical examination and radiographs allow for definitive diagnosis, treatment should be directed accordingly. Nondisplaced or mildly displaced fractures, symptomatic partitions, and avascular necrosis may be initially treated with immobilization and offloading techniques. If these measures fail, or if a markedly displaced fracture is encountered, excision of the affected sesamoid(s) may be indicated. Degenerative/arthritic changes may be treated with offloading techniques, orthotics, anti-inflammatory nonsteroidal drugs, or localized injection. Surgery may be indicated if nonsurgical care is unsuccessful (2,14). Excision of a sesamoid(s) may result in a variety of postoperative problems including hallux varus, valgus, hammertoe, and/or extensus; the patient must be evaluated carefully (15).