Forefoot disorders are often seen in clinical practice. Forefoot deformity and pain can deteriorate gait function and decrease quality of life. This review presents common forefoot disorders and conservative treatment using an insole or orthosis. Metatarsalgia is a painful foot condition affecting the metatarsal (MT) region of the foot. A MT pad, MT bar, or forefoot cushion can be used to alleviate MT pain. Hallux valgus is a deformity characterized by medial deviation of the first MT and lateral deviation of the hallux. A toe spreader, valgus splint, and bunion shield are commonly applied to patients with hallux valgus. Hallux limitus and hallux rigidus refer to painful limitations of dorsiflexion of the first metatarsophalangeal joint. A kinetic wedge foot orthosis or rocker sole can help relieve symptoms from hallux limitus or rigidus. Hammer, claw, and mallet toes are sagittal plane deformities of the lesser toes. Toe sleeve or padding can be applied over high-pressure areas in the proximal or distal interphalangeal joints or under the MT heads. An MT off-loading insole can also be used to alleviate symptoms following lesser toe deformities. Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve that leads to a painful condition affecting the MT area. The MT bar, the plantar pad, or a more cushioned insole would be useful. In addition, patients with any of the above various forefoot disorders should avoid tight-fitting or high-heeled shoes. Applying an insole or orthosis and wearing proper shoes can be beneficial for managing forefoot disorders.
Animals ; Congenital Abnormalities ; Foot ; Foot Orthoses ; Gait ; Hallux ; Hallux Limitus ; Hallux Rigidus ; Hallux Valgus ; Hammer Toe Syndrome ; Head ; Hoof and Claw ; Humans ; Joints ; Metatarsal Bones ; Metatarsalgia ; Metatarsophalangeal Joint ; Neuroma ; Orthotic Devices ; Quality of Life ; Shoes ; Splints ; Toes

PURPOSE: Toe ulcers have been implicated as a causative factor in diabetic foot amputation. The aim of this study was to evaluate the outcomes of percutaneous needle flexor tenotomies of diabetic claw toes with ulcers or pending ulcers. MATERIALS AND METHODS: The authors undertook a retrospective chart review between January 2014 and June 2016 to identify those patients who underwent a percutaneous needle flexor tenotomy for diabetic claw toe deformities. We evaluated 54 toes in 42 patients. Twenty-four patients were female and the mean age at the time of operation was 57 years. The mean follow-up time was 11 months. Thirty-four patients (46 toes) had tip toe ulcers or pending ulcers and 8 patients (8 toes) had dorsal pending ulcers. All patients had palpable pulses and good capillary refill. RESULTS: Forty-three of 46 tip toe ulcers (93.5%) healed without significant complications and 8 dorsal ulcers showed no specific changes within 5 weeks. There were no recurrent ulcers at final follow-up. Four patients developed transfer lesion of the adjacent toe and needed subsequent tenotomy. CONCLUSION: Percutaneous needle tenotomy in an outpatient clinic was an effective and safe method for treating toe ulcers in neuropathic patients to offload the tip of the toe so that ulcer healing could occur.
Ambulatory Care Facilities ; Amputation ; Animals ; Capillaries ; Congenital Abnormalities* ; Diabetic Foot ; Female ; Follow-Up Studies ; Hammer Toe Syndrome* ; Hoof and Claw* ; Humans ; Methods ; Needles ; Outpatients* ; Retrospective Studies ; Tenotomy* ; Toes ; Ulcer*

Stroke is a leading cause of disability in the elderly. Among complications of stroke, musculoskeletal problems are common, thereby causing improper gait biomechanics, development of pain, and limitation in performing activities of daily living. Post-stroke hip fractures and greater trochanteric pain syndrome are common complication near hip joint. Knee osteoarthritis can be accelerated by altered biomechanics of post-stroke period, that is associated with ambulation levels. Stiff knee gait and genu recurvatum can be developed after stroke and usually contribute to abnormal gait patterns, due to weakness or spasticity of various muscles, and they need to control or compensate affected muscle activities. In case of ankle and foot problems, foot varus deformity is caused by imbalance between muscles that control ankle movement, while claw toes and the persistent extension of the great toe are mainly due to overactivity of muscles that moves toes, and mainstay of treatment is to control inappropriate activities of affected muscles. It is important to make the exact therapeutic decision and establish the rehabilitation plan through the early evaluation of lower extremity musculoskeletal problems that affect the mobility and ambulation.
Activities of Daily Living ; Aged ; Ankle ; Congenital Abnormalities ; Femur ; Foot ; Gait ; Hammer Toe Syndrome ; Hip Fractures ; Hip Joint ; Humans ; Knee ; Lower Extremity* ; Muscle Spasticity ; Muscles ; Osteoarthritis, Knee ; Rehabilitation ; Stroke* ; Toes ; Walking

OBJECTIVE: To determine the optimal injection site in the flexor digitorum longus (FDL) muscle for effective botulinum toxin injection. METHODS: Fourteen specimens from eight adult Korean cadavers were used in this study. The most proximal medial point of the tibia plateau was defined as the proximal reference point; the most distal tip of the medial malleolus was defined as the distal reference point. The distance of a line connecting the proximal and distal reference points was defined as the reference length. The X-coordinate was the distance from the proximal reference point to the intramuscular motor endpoint (IME), or motor entry point (MEP) on the reference line, and the Y-coordinate was the distance from the nearest point from MEP on the medial border of the tibia to the MEP. IME and MEP distances from the proximal reference point were evaluated using the raw value and the X-coordinate to reference length ratio was determined as a percentage. RESULTS: The majority of IMEs were located within 30%-60% of the reference length from the proximal reference point. The majority of the MEPs were located within 40%-60% of the reference length from the proximal reference point. CONCLUSION: We recommend the anatomical site for a botulinum toxin injection in the FDL to be within a region 30%-60% of the reference length from the proximal reference point.
Adult ; Botulinum Toxins* ; Cadaver ; Hammer Toe Syndrome ; Humans ; Tibia

PURPOSE: Charcot-Marie-Tooth disease type 2A (CMT2A) is caused by mutations in the mitofusin 2 (MFN2) genes associated with variable central nervous system (CNS) involvement. The authors report a case of a middle-aged woman with genetically confirmed CMT type 2 (CMT2), combined with delayed-onset bilateral optic neuropathy. CASE SUMMARY: A 47-year-old woman presented with complaints of subacute decrease of visual acuity in both eyes. Her corrected visual acuity was 20/200 in the right eye and 20/320 in the left eye. Fundus photographs revealed bilateral disc pallor and diffuse retinal nerve fiber layer defects. No papillomacular bundle defect was observed. Goldmann perimetry showed central scotoma in both eyes. She had suffered from muscle wasting of the legs and foot deformities such as high arches and hammer toes since childhood and required a wheelchair for ambulation. A series of CMT gene mutation tests revealed an MFN2 gene mutation, c.617C>T (p.Thr206Ile), and the patient was diagnosed with CMT2A. CONCLUSIONS: Charcot-Marie-Tooth disease is a common inherited neuromuscular disorder and CMT2A, an axonal CMT neuropathy, is associated with bilateral optic neuropathy. Therefore, suspecting CMT and testing for gene mutations as part of the work-up in patients with subacute bilateral optic neuropathy associated with peripheral neuropathy is critical.
Axons ; Central Nervous System ; Charcot-Marie-Tooth Disease* ; Female ; Foot Deformities ; Hammer Toe Syndrome ; Humans ; Leg ; Middle Aged ; Nerve Fibers ; Optic Nerve Diseases* ; Pallor ; Peripheral Nervous System Diseases ; Retinaldehyde ; Scotoma ; Visual Acuity ; Visual Field Tests ; Walking ; Wheelchairs

PURPOSE: The objective of this study was to examine the clinical results and effectiveness of resection arthroplasty for correction of lesser toe deformity. MATERIALS AND METHODS: From January 2000 to November 2012, 92 cases of resection arthroplasty for lesser toe deformity were reviewed. Hammer toe was the most common type of deformity, accounting for 44 toes (33 patients). Hallux valgus was the most common comorbid illness. Second toe was the most commonly affected toe and proximal interphalangeal joint was the most common location of resection arthroplasty (69 toes, 75.0%). We also analyzed the alignment of phalanges using the last follow-up weight bearing radiographic image. The analysis included clinical evaluation with American Orthopaedic Foot and Ankle Society (AOFAS) score as well as subjective satisfaction. RESULTS: Flexor tenotomy (19 cases) was the most common combined surgery. Floating toe (4 cases) was the most common complication. The last follow-up alignment of phalanges was better than good in 71 toes (77.2%) in anteroposterior view and in 69 toes (75.0%) in lateral view. Sixty one cases (85.9%) resulted in better satisfaction than 'good' and the final average AOFAS score was 87.4. CONCLUSION: Resection arthroplasty is a valuable surgical option for treatment of lesser toe deformity, with high patient satisfaction, easy surgical technique and remarkable correction of deformity.
Ankle ; Arthroplasty* ; Congenital Abnormalities* ; Follow-Up Studies ; Foot ; Hallux Valgus ; Hammer Toe Syndrome ; Joints ; Patient Satisfaction ; Tenotomy ; Toes* ; Weight-Bearing

In hallux valgus, one of the most common conditions affecting the forefoot, the first metatarsophalangeal joint is progressively subluxed due to lateral deviation of the hallux and medial deviation of the first metatarsal. Patients usually complain of medial prominence pain, commonly referred to as "bunion pain," plantar keratotic lesions, and lesser toe deformities such as hammer toe or claw toe deformities. The etiology of hallux valgus is multifactorial. Narrow high-heeled shoes or excessive weight-bearing have been suggested to be extrinsic factors contributing to the condition, and many other intrinsic factors also exist, such as genetics, ligamentous laxity, metatarsus primus varus, pes planus, functional hallux limitus, sexual dimorphism, age, metatarsal morphology, first-ray hypermobility, and tight Achilles tendon. When we evaluate patients with hallux valgus, careful history taking and meticulous examination are necessary. On the radiographic evaluation, we routinely measure the hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle, which are valuable parameters in decision making for bunion surgery. To prevent the development and progression of hallux valgus, a soft leather shoe with a wide toe box is usually recommended. The use of a toe separator or bunion splint may help in relieving symptoms. The purpose of hallux valgus surgery is to correct the deformity and maintain a biomechanically functional foot. When we decide on an adequate surgical option, we should consider the patient's subjective symptoms, the expectations of the patient, the degree of the de-formity, and the radiographic measurements in order to correct the deformity and prevent complications after surgery.
Achilles Tendon ; Congenital Abnormalities ; Decision Making ; Diagnosis ; Flatfoot ; Foot ; General Surgery ; Genetics ; Hallux Limitus ; Hallux Valgus* ; Hallux* ; Hammer Toe Syndrome ; History ; Humans ; Intrinsic Factor ; Ligaments ; Metatarsal Bones ; Metatarsophalangeal Joint ; Shoes ; Splints ; Toes ; Weight-Bearing

Lesser toe deformities such as mallet toe, hammer toe and claw toe are annoying problems not only to patients but also to orthopaedic surgeons because they are not easy to manage or treat. Though they occupy very small portion in whole body, they are notorious for unpredictable surgical results. It can make clinical results better to understand these deformities more comprehensively and to make strategic surgical plan for each target deformity.
Congenital Abnormalities ; Hammer Toe Syndrome ; Humans ; Toes

PURPOSE: This study was performed to evaluate the impact of the lesser toe operation on the overall clinical outcomes, and to analyze the clinical results of concomitant surgery for hallux valgus and lesser toe deformities. MATERIALS AND METHODS: Forty-six cases underwent surgery for hallux valgus with concomitant lesser toe deformities were followed up for at least 1 year. Lesser toe deformities consisted of 9 crossover toes, 10 claw toes, 12 hammer toes and 15 bunionettes. Clinical evaluation was performed according to AOFAS (American Orthopaedic Foot and Ankle Society) score, patient's satisfaction score, and pain VAS (visual analogue scale) score. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and period to union were measured. Preoperative expectation about lesser toe deformities, postoperative satisfaction, complication rate, hospitalization period, medical expenses, and frequency of outpatient follow-up were analyzed. RESULTS: AOFAS score, VAS score, HAV and IMA had improved significantly. On preoperative expectation of patients, correction of lesser toe deformities was ranked third, following the improvement of big toe(bunion) pain and the correction of hallux valgus. Patient's satisfaction score was average 92.8 points, and the importance of lesser toe operation was 30.2%. When compared to hallux valgus operation only, there were average 2.5 days of additional hospitalization, 2.4 times of additional outpatient follow-up, 386000 won of additional medical expenses. CONCLUSION: Combined operation for hallux valgus and concomitant lesser toe deformities showed good clinical results. When compared to hallux valgus operation only, there were longer hospitalization, more frequent follow-up, more medical expenses, more complications. However, lesser toe deformity correction in patients underwent hallux valgus operation is considerable, because of high preoperative expectation and postoperative satisfaction.
Animals ; Ankle ; Bunion, Tailor's ; Congenital Abnormalities ; Follow-Up Studies ; Foot ; Hallux ; Hallux Valgus ; Hammer Toe Syndrome ; Hospitalization ; Humans ; Outpatients ; Toes

PURPOSE: The purpose of this study is to evaluate the effect of axial shortening metatarsal osteotomy on the treatment of advanced rheumatoid arthritis patients with severe hallux valgus and claw toe deformity of lesser toes which is used for preserving the metatarsophalangeal joint. MATERIALS AND METHODS: From January 2005 to June 2009, 18 cases of axial shortening metatarsal osteotomy in advanced rheumatoid arthritis were reviewed ; all of them followed up for more than 2 years after surgical procedures and the mean follow up period was 3.4 years. We performed axial shortening Scarf osteotomy and Akin osteotomy for hallux valgus and Weil osteotomy with soft tissue release for claw toe of lesser toes, respectively. We measured preoperative and postoperative hallux valgus angle, each metatarsal shortening length and the range of motion of the metatarsophalangeal joints through radiographic and clinical examination and compared them each other. Clinical results were evaluated by American Orthopedic Foot and Ankle Society (AOFAS) score and subjective satisfaction of the patients. RESULTS: The hallux valgus angle was reduced from the preoperative mean value of 44.8 degree to 9.0 degree postoperatively and the range of motion of the metatarsophalangeal joint of great toe and lesser toes was increased from the mean of 21.7 degree and 11.0 degree preoperatively to 38.0 degree and 32.5 degree, respectively at postoperation. Also, the mean AOFAS score was improved from 26.5 points to 67.4 points. CONCLUSION: Axial shortening osteotomy is a useful method to correct the deformity and preserve the metatarsophalangeal joint for severe hallux valgus and claw toe deformity in advanced rheumatoid arthritis.
Animals ; Ankle ; Arthritis, Rheumatoid ; Congenital Abnormalities ; Follow-Up Studies ; Foot ; Hallux ; Hallux Valgus ; Hammer Toe Syndrome ; Hoof and Claw ; Humans ; Joints ; Metatarsal Bones ; Metatarsophalangeal Joint ; Orthopedics ; Osteotomy ; Range of Motion, Articular ; Toes