Presented by: Kenneth Hunt, MD
Assistant Professor, Orthopaedic Surgery
Stanford University Medical Center
March 23, 2011
The foot is extremely complex, made up of 26 bones, 33 joints, more than 100 ligaments, and 19 muscles and tendons. In fact, 25 percent of the bones in your body are found in this heavily worked, often neglected appendage. And since most people will put approximately 80,000 miles on their feet in a lifetime, it’s especially important to prevent problems that can potentially lead to pain or immobility.
Some of the problems affecting the forefoot (the front part of the foot) are bunions, arthritis, toe malformations like hammertoe or claw toe, and hallux rigidus (stiffness in the big toe).
For many people, foot problems stem from ill-fitting footwear. Almost 90 percent of women wear shoes that are too small, which is associated with bunions. These bone deformities that can lead to pain, weakness, reduced joint mobility, falls, and loss of the ability to do the activities you love to do.
There’s a lot of demand put on the forefoot,” said Kenneth Hunt, MD, an assistant professor of orthopaedic surgery, who spoke at a presentation sponsored by the Stanford Health Library. Dr. Hunt focused on ankle problems at a previous Health Library presentation. “Healthy feet keep you active, keep your other organs healthy, and essentially keep you young. That’s why it’s most important to prevent deformities before they affect your function. Don’t let small aches and pains become big ones.”
Proper footwear should fit in the front and back; have a low, broad heel; a firm heel collar; an adjustable fastening device; an upper made of breathable material; and have comfortable, nonslip soles.
When problems do develop, there are multiple options before committing to surgery. “The goal of surgery is to improve alignment, reduce pain, and improve function,” Dr. Hunt said. “Surgery should not be a first choice for most people, but it can be a useful option.”
The most common problem in the forefoot are bunions. A bunion causes an enlargement at the base of the big toe, usually in combination with a misalignment in which the big toe shifts from pointing straight forward to leaning toward the smaller toes (hallux valgus). The enlarged joint (the metatarsophalangeal joint) can become inflamed and painful as extra bone and tissue swelling grow at the base of the big toe.
“The tendons pull in one direction like a bow and arrow, and pull the phalanx laterally (to the outside),” Dr. Hunt said. “From there we often see the toe rotate and shift laterally: When the big toe shifts, the other toes have to get out of the way.”
The condition tends to be more common in women. The primary external cause of bunions is wearing narrow-toed, high-heeled shoes, he said. There also seem to be genetic factors that predispose some people to the development of bunions. People with flat feet or wide feet (hypermobility) and older people, whose tissue may be stretched out from years of use, also develop the condition.
To determine the extent of the damage, physicians will first do an X-ray of the foot and look at the angle between the first and second metatarsals (the intermetatarsal angle) which should be 9 degrees or less, and at the angle of the big toe toward the rest of the toes, which normally should be less than 15 degrees. They will also look for arthritis—a deterioration of the cartilage that causes nerve-sensitive bone to rub together.
Treatment is always conservative to start, he said. First steps involve avoiding heels, stretching shoes, wearing heel pads or orthotics, or splinting the toe. Anti-inflammatory medication can also help. “There’s no way to reverse the process, but many times these steps can reduce the pain sufficiently,” he said. “We can’t truly correct the bone condition without surgery.”
Surgical procedures typically involve removing the bony growth of the bunion while realigning the big toe. Surrounding tissue may be too loose on the one side and too tight on the other, so a procedure called soft tissue release can correct the angle by stretching the distal end of the metatarsal.
There are several strategies for an osteotomy, a technique to break and realign the bone (bones are then held in place with small screws). For severe cases, fusing bones together can correct the deformity and improve function.
Hallus rigidus is a condition at the base of the big toe that causes it to stiffen and become rigid. It often leads to bone spurs and osteoarthritis. It’s the second most common forefoot problem (after bunions) and is usually caused by trauma or overuse. As it progresses, it can cause a prominent bump at the base of the toe and affect your gait since the toe doesn’t lift properly.
The condition is first treated with over-the-counter drugs for inflammation, and rest is recommended to relieve pain. Shoes should have stiff insoles and arch support. In some cases, cortisone shots can be helpful, but the relief is usually short term.
For early stages, a surgical procedure called a dorsal cheilectomy can remove the bone spurs through an incision at the top of the toe. Advanced stages are treated by fusing the bone, and an osteotomy may help when the toe is pointed in the wrong direction.
Lesser Toe Deformities
The muscles that control your toes can get out of balance and cause the smaller toes to bend into an odd position at the joint. These conditions include claw toe, in which a toe curves up; hammertoe, which is bent pointing downwards; and mallet toe, when just the tip points down.
Mallet toe is almost always associated with poor-fitting shoes. If a toe is forced to stay in a bent position for too long, the muscles tighten and the tendons contract; over time they lose the ability to straighten. Dr. Hunt pointed out that feet continue to grow even as an adult, so it’s important to check your shoe size regularly to accommodate the foot comfortably. Hammertoe is usually associated with bunions, and claw toe is often caused by neurological problems.
In cases of small toe deformities, physicians will take X-rays and look first at the big toe to determine if there is dislocation. Nonsurgical remedies are the first approach; surgical procedures can include tendon release to reverse the tight and loose tendons, or proximal interphalangeal (PIP) fusion.
Though there are some complications associated with surgery (such as numbness or poor alignment), studies have shown that more than 90 percent of the people who select surgery are satisfied with the result. Dr. Hunt said the key is to have realistic expectations and to try everything else before deciding on surgery.
“We try to address all the problems at once, so you don’t have to deal with foot problems again,” said Dr. Hunt. “Our goal is to eliminate pain, reduce swelling, and help you return to full function. For patients who need surgery, we want the first operation to be the only operation they need.”
About the Speaker
Kenneth Hunt, MD, is a specialist in foot and ankle reconstruction and in treating lower extremity trauma and deformity. He received his MD from the University of Utah School of Medicine and completed his internship and residency at the University of Utah. He did his fellowship training in foot and ankle reconstruction at Orthocarolina and Carolinas Medical Center in Charlotte, North Carolina. Dr. Hunt joined Stanford in 2009.
For More Information:
About Dr. Hunt
Stanford Orthopaedic Surgery & Sports Medicine
American Academy of Orthopaedic Surgeons