28. | Manual of Rheumatology and Outpatient Orthopedic Disorders (LB Spiral Manuals)

Chapter 21 Ankle and Foot Pain

Manual of Rheumatology and Outpatient Orthopedic Disorders

Chapter 21 Ankle and Foot Pain

David S. Levine and Gordon A. Brody

Anatomy
History
Physical examination
Additional investigations
Common foot problems

I. Anatomy

The joints of the foot and ankle can be divided into two groups: essential joints, whose motion is required for normal foot function, and nonessential joints, which have little appreciable motion and are largely responsible for providing stability.
1. Essential joints
  1. The tibiotalar (ankle) joint maintains an axis through the malleoli such that dorsiflexion and external foot rotation are coupled. Similarly, plantar flexion and internal foot rotation are coupled motions . Surrounding ligamentous structures limit inversion or eversion through the ankle joint.
  2. The talocalcaneal (subtalar) joint is responsible for hindfoot inversion and eversion. Motion occurs around an axis inclined 15 degrees lateral to the longitudinal axis of the foot. Along with the ankle joint, the subtalar joint forms a universal joint enabling the hindfoot to accommodate to uneven ground.
  3. The talonavicular and calcaneocuboid (transverse tarsal) joints function to link the mobile hindfoot to the mobile forefoot.
  4. The metatarsophalangeal (MTP) joints of the forefoot have significant dorsiflexion and plantar flexion capability, which enables the center of gravity of the body to be propelled forward efficiently in terminal stance phase.
2. Nonessential joints such as the navicular-cuneiform, intercuneiform, and tarsometatarsal joints have little motion as a consequence of stout ligamentous reinforcement. These joints serve to provide a rigid lever during weight transfer from the hindfoot to the forefoot.
Ligaments
1. The deltoid ligament is the prime stabilizer of the medial side of the ankle joint. It runs from the medial malleolus to the talus, calcaneus, and navicular. Its deep portion resists lateral translation of the talus within the ankle joint. The superficial portion blends with other capsular and ligamentous structures over the medial hindfoot.
2. The lateral collateral ligaments consist of the anterior and posterior talofibular ligaments and the calcaneofibular ligament. As a group , these ligaments are the prime stabilizers of the lateral side of the ankle joint. The anterior talofibular is the most frequently injured ligament, especially during plantar flexion of the foot. With increasing energy or when the foot is in a neutral position or in slight dorsiflexion, the calcaneofibular ligament may also be injured.
3. The medial talocalcaneonavicular (spring) ligament has been increasingly noted to be important in supporting the head of the talus and preventing loss of medial longitudinal arch height.
4. The plantar intertarsal (interosseous) ligaments stabilize the bones of the midfoot, thereby maintaining their static contribution to the medial longitudinal arch.
Muscles . Dorsiflexion of the foot and ankle (tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius). Plantar flexion of the foot and ankle (gastrocnemius, soleus). Hindfoot inversion (posterior tibialis, gastrocnemius). Hindfoot eversion (peroneus brevis, peroneus longus). The intrinsic muscles of the foot contribute to the bulk and padding of the sole, help to maintain the architecture of the transverse and longitudinal arches, and influence the alignment of the toes. The toes are flexed and extended by their long flexors and extensors.
Fascia. The plantar fascia originates on the posteromedial tubercle of the calcaneus and inserts into the bases of the proximal phalanges via the plantar plate and flexor tendon sheaths. It maintains a static support of the longitudinal arch via a windlass mechanism.
The blood supply of the ankle and foot comes principally from the dorsalis pedis artery (an extension of the anterior tibialis artery), which is palpable between the first and second metatarsal bases on the dorsum of the foot, and the posterior tibialis artery, palpable about one finger's breadth posterior and inferior to the medial malleolus. Communicating branches from the peroneal artery provide an inconsistent anastomosis with the above-named arteries.
Innervation of the foot and ankle is from the superficial and deep peroneal nerves, which supply the dorsum of the foot. The medial and lateral plantar nerves provide sensation to the plantar surface of the foot and innervate the intrinsic muscles. The sural nerve provides sensation to the outer border of the heel and the dorsolateral border of the foot. The saphenous nerve, a terminal branch of the femoral nerve , provides sensation to the medial border of the ankle and foot.

II. History

Pain
1. Exact localization, radiation.
2. Aggravating, alleviating factors.
3. Associated findings.
4. Acute or insidious onset (traumatic or atraumatic).
5. Intensity.
6. Quality. Radiating pain with an electric quality may be consistent with neuroma.
Footwear
1. Recent alterations in usual footwear.
2. Attitude toward footwear influences expectations.
3. Barefoot activities associated with increased or decreased symptoms.
Past medical history. Numerous conditions, including gout, rheumatoid arthritis (RA), neoplasm, peripheral vascular disease, diabetes mellitus, congenital deformity, and neurologic conditions, can all contribute to foot or ankle dysfunction. Similarly, the altered gait pattern related to foot and ankle dysfunction can contribute to other musculoskeletal complaints, such as low back pain and medial knee pain.
Past surgical history. Any prior history of surgical procedures on the foot and ankle should be thoroughly discussed.

III. Physical examination

Gait and alignment should be evaluated with the patient in shoes and barefoot.
1. At heel-strike, the hindfoot should assume a valgus attitude, allowing shock absorption through the flexible hindfoot. Weight is transferred forward during foot-flat. At heel-rise, the hindfoot is inverted (by the tibialis posterior muscle). The transverse tarsal joint becomes rigid when the hindfoot is inverted, enabling the body weight to be transferred via the rigid midfoot to the metatarsophalangeal joints preparing for toe-off. The swing phase then completes the gait cycle.
2. An antalgic gait involves a shortened stance phase, which signifies a painful limb.
3. A steppage gait involves hip and knee flexion to clear the foot during swing phase in the setting of a drop foot (e.g., after a peroneal nerve palsy).
4. Observe the patient from behind. Physiologic hind foot valgus should be readily apparent. Excessive valgus (as in a flat foot) or hindfoot varus (as in clubfoot sequelae or cavovarus foot) should be noted.
5. Heel-rise should be associated with hindfoot inversion (tibialis posterior).
6. Total limb alignment should be evaluated from the hips to the toes.
7. Rotational deformities such as internal tibial torsion or excessive femoral anteversion are best evaluated with the patient prone.
Range of motion should be compared with that of the contralateral extremity . Both active and passive range of motion should be evaluated.
1. Ankle dorsiflexion must be examined with the hindfoot in the neutral position. Dorsiflexion with the knee in extension versus flexion should be noted to differentiate tendoachilles from gastrocnemius contracture.
2. The subtalar joint is assessed by inverting and everting the heel while stabilizing the tibia.
3. Forefoot inversion (supination) and eversion (pronation) as well as abduction and adduction are assessed by holding the heel in the cup of the hand to lock the subtalar joint and grasping the forefoot.
4. Active and passive motion of the MTP and interphalangeal joints
  1. Hammertoes are lesser toes having a fixed or flexible flexion contracture of the proximal interphalangeal (PIP) joints.
  2. If MTP hyperextension coexists, the term claw toe is used.
  3. A mallet toe exists with a fixed or flexible flexion contracture of the distal interphalangeal (DIP) joints of the lesser toes.
Tenderness. The point of maximal tenderness is of critical importance to establishing a correct diagnosis. Systematically palpate the foot to localize tenderness and evaluate bony and soft- tissue asymmetry.
1. Tenderness over a prominent medial eminence of the hallux MTP joint is commonly seen in hallux valgus.
2. Tenderness over the lateral ankle ligaments is seen commonly after an inversion ankle sprain.
3. Tenderness over the MTP joint of the hallux may be seen in gout and degenerative arthrosis.
4. Metatarsalgia is signified by tenderness along the plantar surfaces of the metatarsal heads.
5. Medial hindfoot or posterolateral hindfoot tenderness is often associated with acute or chronic posterior tibial tendon insufficiency, respectively.
Swelling may be nonspecific or the manifestation of a systemic disease (i.e., RA, congestive heart failure or venous obstructive outflow disease).
1. Dorsal forefoot swelling together with pain on weight- bearing suggests a metatarsal stress fracture.
2. Swelling anterior to the distal fibula indicates an anterior talofibular ligament sprain.
3. Swelling distal to the medial malleolus along with inability to invert the heal is consistent with posterior tibial tendon insufficiency.
4. Swelling, especially when associated with pain and erythema, is consistent with musculoskeletal infection, or it may be seen in severe flares of inflammatory disease such as RA or gout.
Skin
1. Callosities (keratoses) are areas of thickened skin that reflect areas of increased weight-bearing. Calluses under the second and third metatarsal heads may represent lesser metatarsal overload secondary to a hypermobile first ray.
2. Corns. A hard corn (clavus durum) is frequently seen over the dorsolateral aspect of the PIP joint of the fifth toe where it contacts the shoe upper. A soft corn (clavus mollum), caused by moisture, is most frequently seen in the fourth web space.
3. Ulceration may be the consequence of underlying bony prominences, altered protective sensation as in diabetic neuropathy, or systemic vascular insufficiency.
Neurologic and vascular examinations, including evaluation of sensation, motor function, reflexes, position sense, skin temperature, pulses , and capillary refill, should be performed carefully .
1. Charcot's arthropathy may develop in diabetics with peripheral neuropathy. The resulting destruction of normal foot architecture leads to deformity and ulceration.
2. Skin breakdown resulting from vascular disease with arterial insufficiency may be amenable to vascular bypass surgery to improve inflow.
3. Footwear should be examined. Insufficient insole support may contribute to posterior tibial tendinitis. The wear pattern of the sole of the shoe may provide insight into the overall alignment of the foot. A constrictive toe box may aggravate a hallux valgus or deformity of the lesser toes. Insole wear patterns can provide insight into points of high pressure during weight-bearing.

IV. Additional investigations

Results of blood testing to evaluate the white cell count, erythrocyte sedimentation rate, and C-reactive protein level may support a diagnosis of infection or RA. Measurements of rheumatoid factor and uric acid levels and human leukocyte antigen (HLA) testing may be helpful in suspected cases of inflammatory arthropathies.
Joint aspiration in the presence of an effusion with culture, cell counts, and analysis of glucose , protein, and crystals should be performed to rule out a septic joint, RA, or a crystal-induced arthropathy such as gout or pseudogout.
Radiographs provide a confirmation of the suspected diagnosis after the history and physical examination have been performed. All radiography should be performed during weight-bearing whenever possible.
1. The ankle series consists of anteroposterior, mortise (30-degree internal rotation), and lateral views of the ankle. The joint space, alignment, and distal tibia-fibula syndesmosis as well as bony structures themselves should be carefully evaluated. Contralateral radiographs are often useful for evaluating asymmetries.
  1. Ankle fractures are usually readily apparent. The presence of a medial malleolar fracture without a concomitant lateral malleolar fracture necessitates a full-length radiograph of the fibula.
  2. Osteochondral fractures of the talar dome are often not visible on films of initial injuries. Repeated films obtained when symptoms persist should be carefully scrutinized.
  3. Chronic lateral ankle instability, seen after 20% of ankle sprains, may be further assessed with stress radiographs. Talar tilt (mortise) and anterior drawer (lateral) views must be compared with those of the contralateral, uninjured limb.
2. The foot series consists of weight-bearing anteroposterior and lateral radiographs. Joint spaces, bone density, alignment, and presence of deformity should be noted.
  1. Forefoot, midfoot, and hindfoot relationships cannot be evaluated in the non “weight-bearing condition.
  2. An oblique radiograph may provide additional information about the midfoot bony architecture (e.g., Lisfranc's fracture-dislocation) and about a suspected tarsal coalition (calcaneonavicular).
  3. Broden's views (taken with the ankle in 30 degrees of internal rotation and in a neutral position, with varying degrees of tilt to the x-ray beam) provide information about the congruity of the posterior talocalcaneal facet after calcaneus fractures.
  4. Canale's view (taken with the ankle in plantar flexion, the foot internally- rotated 15 degrees, and the x-ray beam tilted 15 degrees cranially) profiles the talar neck after talus fractures.
  5. A sesamoid view of the forefoot demonstrates the sesamoid-first metatarsal articulation for arthrosis, fracture, and subluxation.
Computed tomography (CT) provides high-resolution anatomic detail of the cortical and cancellous structures of the foot and ankle. Computer-assisted reconstruction can provide images in planes other than that actually imaged . Arthrosis of the tarsal bones, coalitions, and osteochondral lesions are well seen with this modality. In addition, the complex fracture patterns of the talus, calcaneus, and midfoot structures are well delineated on CT, which enables improved preoperative planning and management.
Magnetic resonance imaging (MRI) provides exquisite anatomic detail of the soft-tissue elements of the foot and ankle, such as the ankle ligaments (after suspected talofibular ligament tear), tendons (e.g., a diseased posterior tibial tendon), skin, and subcutaneous structures. In addition, the condition of the articular chondral surfaces can be well visualized on certain sequences. The extent of soft-tissue involvement of a neoplastic lesion can be more accurately assessed on MRI.
Technetium bone scanning provides information about the metabolic activity of the bones of the foot and ankle. Increased activity as seen diffusely in RA and locally in a stress fracture is visualized as a hot spot. However, low specificity makes the differentiation of the multiple diagnostic possibilities difficult without additional clinical information.

V. Common foot problems

Achilles tendinitis is a common condition of the Achilles tendon that presents with pain either at or just proximal to its insertion into the calcaneal tuberosity. It is frequently caused by overuse related to athletic participation. Degenerative changes within the tendon itself may be the cause in older persons. Occasionally, inflammatory disorders such as gout or Reiter's syndrome may precipitate such a condition.
1. Physical examination. The tendon itself may be thickened approximately 2 to 3 cm proximal to the insertion. Local tenderness is frequently present. A palpable bony prominence may be noted at the calcaneal insertion. An overlying adventitial bursa may be present as well. Active ankle plantar flexion may reveal subtle weakness in comparison with the contralateral extremity. The Thompson test (squeezing the calf) causes ankle plantar flexion, thereby ruling out a rupture of the tendon.
2. Radiography may demonstrate a soft-tissue thickening at the level of the tendinopathy. Alternatively, a degenerative spur may be seen growing up into the tendon at its insertion.
3. The treatment of an acute tendinitis revolves around reducing the associated inflammation . A brief period of rest in a walking boot or cast may result in significant resolution of symptoms. Antiinflammatory medications, judicious use of cryotherapy, and gentle physiotherapy on the resumption of athletic activity are valuable adjuncts. Steroid injection can lead to tendon rupture. Particular attention should be paid to gastrocnemius equinus contracture, which is frequently present in recalcitrant cases. Chronic tendinitis unresponsive to conservative measures frequently will benefit from surgical debridement of the diseased tendon with excision of a bony spur, if present. Should considerable weakness exist in the degenerative condition or if insufficient tendon remains after debridement, augmentation with the flexor hallucis longus tendon is particularly useful.
Plantar heel pain is one of the most common disorders seen by physicians who manage foot and ankle problems. Plantar fasciitis, an irritation of the plantar fascia at its origin on the posteromedial tubercle of the calcaneus, is the most common cause of plantar heel pain. Atrophy of the normal plantar fat pad may result in difficulty walking because of plantar heel pain. Entrapment of branches of the posterior tibial nerve as they cross in close proximity to the heel may also result in plantar heel pain. Inflammatory arthropathies (psoriatic arthritis and Reiter's syndrome » RA) frequently present with plantar heel pain, often before the systemic nature of these diseases is appreciated.
1. Physical examination may reveal tenderness at the origin of the plantar fascia. Dorsiflexion of the MTP joints may exacerbate the tenderness because this stretches the fascia. Start-up pain during the first step in the morning or after prolonged sitting is common. Gastrocnemius equinus contracture (continuous with the plantar fascia) is frequently present.
2. Radiographic findings are frequently normal. An incidental traction spur at the origin of the flexor digitorum brevis muscle may be present. This is rarely, however, the source of the discomfort.
3. Treatment should be directed at unloading the heel with soft cushioning in the shoe, vigorous stretching of the plantar fascia-gastrocnemius complex, and administering nonsteroidal antiinflammatory medications. Occasional night splinting is helpful in the persistent case. Patients should be counseled about the often-prolonged nature of the disorder . In more than 95% of cases, symptoms will resolve within 12 months. In the presence of significant tendoachilles or gastrocnemius contracture, tendon release and lengthening are often curative.
Pes planus deformity and posterior tibial tendon insufficiency have received considerable attention recently. A flat foot, in and of itself, is not pathologic. However, when associated with progressive pain and deformity, it warrants intervention. Static factors contributing to the integrity of the medial longitudinal arch include the plantar fascia, the spring ligament, and the capsular and ligamentous structures associated with the bones of the medial column of the foot. The dynamic factor most commonly associated with the maintenance of the medial arch is the posterior tibial muscle and its tendon. When overloaded (e.g., by a gastrocnemius equinus contracture), the posterior tibial tendon fails. The hindfoot remains in valgus. Eventually, the static supports of the longitudinal arch fail and a sag is noted in the midfoot. The foot assumes a pronated posture and exacerbates the hindfoot valgus, which increases the gastrocnemius contracture. Eventually, degenerative changes occur in the midfoot and hindfoot joints if the problem is left untreated.
1. Physical examination demonstrates a complex deformity with varying degrees of hindfoot valgus and midfoot pronation and abduction. Early on in the disorder, tenderness is noted along the posterior tibial tendon below the medial malleolus. However, in the advanced case, pain along the posterolateral hindfoot predominates because of calcaneofibular impingement. The too many toes sign may be viewed from behind with excessive hindfoot valgus. The inability to perform a single-limb heel-rise or invert the heel may be noted. Claw toes and a hallux valgus deformity may develop secondarily.
2. Radiography should always be performed during weight bearing. The lateral radiograph will often demonstrate a sag in the longitudinal arch of the foot and an increase in the talocalcaneal angle. The anteroposterior radiograph will similarly demonstrate an increase in the talocalcaneal angle as well as loss of coverage of the talar head by the navicular. In long-standing cases, degenerative arthrosis may be noted in the hindfoot, particularly the subtalar joint.
3. Treatment depends on the stage of the disease.
  1. Stage 1 disease, marked by posterior tibial tendinitis (without deformity), is treated by immobilization of the foot to allow the posterior tibial tendinitis to resolve, followed by use of a supportive insole orthosis. Lengthening of a contracted tendoachilles complex, when present, is particularly helpful in arresting progression.
  2. Stage 2 disease, marked by tendon insufficiency and flexible pes planus deformity, is best treated surgically with tendoachilles lengthening, posterior tibial tendon augmentation, and medial column stabilization via arthrodesis of the nonessential joints of the midfoot.
  3. Stage 3 disease is characterized by either fixed pes planus deformity or degenerative arthrodesis of one or more of the essential hindfoot joints (i.e., the subtalar joint). However, the significant limitation of normal gait mechanics that results warrants early, aggressive intervention when the deformity is flexible and hindfoot arthrodesis can be avoided.
Metatarsalgia represents a condition characterized by pain under the weight-bearing surfaces of the metatarsal heads. Its many causes include hypermobility of the first ray with compensatory overload of the lesser metatarsals, claw toes (in which the plantar fat pad is drawn distally to expose the plantar metatarsal heads), and a rigid cavovarus foot and tendoachilles-gastrocnemius equinus contracture. It may be prominent in RA.
1. On palpation of the plantar forefoot, prominence of the metatarsal heads may be noted. The plantar metatarsal fat pad may be displaced distally in the presence of hammer toe or claw toe deformities. A hypermobile first ray with overload of the lesser toes will present with plantar keratoses beneath the second (and third) metatarsal heads. Gastrocnemius equinus contracture and claw toes routinely coexist in this syndrome.
2. Radiography. Claw toe deformities may be demonstrated on weight-bearing lateral radiographs. A forefoot cavus posture may be evident as well. The anteroposterior radiograph will demonstrate a long, hypertrophied second metatarsal in the hypermobile first-ray syndrome.
3. Treatment is directed at unloading the excessive plantar pressure beneath the metatarsal heads. Various nonoperative measures that are particularly helpful include placing a metatarsal pad just proximal to the metatarsal heads. Accommodative inserts can also provide unloading of the metatarsal heads. Surgical correction of lesser claw toe deformities can replace the plantar fat pad beneath the metatarsal heads. Stabilization of the hypermobile first ray can redistribute plantar weight-bearing forces. Gastrocnemius equinus contracture can be relieved through tendoachilles or gastrocnemius tendon lengthening.
(Morton's) neuroma is the presence of pain in the web space between the third and fourth toes caused by irritation of the common plantar interdigital nerve at this location. Many etiologies are thought to contribute to this disorder, including constrictive shoes with a narrow toe box, forefoot overload with metatarsalgia, and gastrocnemius equinus contracture. Patients typically complain of a numbness or burning sensation radiating into the toes that is promptly relieved by removing the shoes and rubbing the feet.
1. Symptoms may be reproduced during compression of the metatarsal heads by the examiner . A palpable mass may be appreciated in the appropriate web space.
2. Radiographic findings are routinely normal. MRI can be helpful when the diagnosis is uncertain .
3. Treatment includes wearing appropriate shoes to accommodate the natural width of the forefoot. A metatarsal pad may serve to splay the metatarsal heads and provide symptom relief. In recalcitrant cases, local steroid injection or surgical excision is warranted.
Inversion ankle injuries (sprains) are among the most common musculoskeletal injuries seen by the physician . Recall that the talus is wider anteriorly than posteriorly, which renders it particularly susceptible to inversion injury in the plantar-flexed position. Approximately 20% of ankle sprains will progress to varying degrees of chronic ankle instability.
1. Physical examination shortly following an inversion ankle injury reveals swelling located over the anterolateral aspect of the ankle joint. Ecchymoses may be present. Tenderness over the anterior talofibular ligament will be noted on palpation. Involuntary guarding and apprehension to attempted inversion maneuvers will be evident. Depending on the severity of the injury, weight-bearing may not be possible. Additional findings on the medial portion of the ankle indicate a higher-energy injury. Manual stress testing with anterior drawer and talar tilt maneuvers, if tolerated, may reveal asymmetry in comparison with the uninjured extremity.
2. Radiographs should always be obtained to rule out a fracture of the fibula or medial malleolus. Small avulsion fractures of the distal fibula are frequently seen and require no specific treatment. As mentioned previously, anteroposterior and lateral stress radiographs comparing the injured and uninjured extremities may prove helpful in subtle cases.
3. Treatment initially is largely supportive. Immobilization, elevation, cryotherapy, and nonsteroidal antiinflammatory medications are instituted until the patient is comfortable. Organized physical therapy to restore normal muscle strength and proprioception is essential for a good outcome. Weight-bearing in a light-weight orthosis that controls inversion and eversion is particularly helpful. Normal activities can gradually be resumed when strength in the injured ankle is equal to that in the uninjured extremity. Chronic ankle instability is most often associated with premature return to athletic activities and early reinjury. Long-term use of a protective orthosis may provide symptomatic relief to those with chronic ankle instability. Surgical repair or reconstruction of elongated lateral ankle ligaments is helpful in those cases in which nonoperative therapy has failed.
Hallux valgus is a common condition whose cause is likely multifactorial. Tight and constrictive shoes, ligamentous laxity with muscle imbalance, and hereditary predisposition all contribute to a lateral deviation of the hallux on the first metatarsal. Hallux valgus may often be a part of a larger deformity ”namely, the planovalgus foot with a pronated midfoot that gradually stretches the medial capsule of the hallux MTP joint into valgus.
1. Physical examination reveals a lateral deviation of the hallux phalanges, often with impingement of the lesser toes that causes an overlapping second-toe deformity (claw toes). Prominence of the medial aspect of the hallux metatarsal head may cause local paresthesias or ulceration of the overlying soft tissues. Bursal swelling can occur and can become infected. Gastrocnemius equinus contracture and a hypermobile first ray may often be present.
2. Radiography will demonstrate an increased hallux valgus angle and an increased intermetatarsal angle (metatarsus primus varus). Second metatarsal overload may be present. Lateral radiographs may reveal claw toe deformities of the lesser toes. Loss of medial column height (sag) may be noted as well.
3. Treatment should be based on the severity of the deformity and degree of functional limitation and should be directed at the cause of the deformity. Nonoperative measures include accommodative shoes with a wide toe box and insole orthoses to support a flexible pes planus deformity associated with hallux valgus. Operative intervention, when nonoperative measures are not successful, should be directed at the restoration of soft-tissue and osseous stability. Operative intervention is largely successful in appropriately selected patients.
Hallux rigidus is a painful condition characterized by a limitation of hallux dorsiflexion. It often coincides with degenerative arthrosis to varying degrees. Remote injuries to the hallux MTP joint may be recalled. Alternatively, an elevated first ray causes the hallux proximal phalanx to jam into the first metatarsal head rather than glide over it in a smooth arc.
1. Physical examination reveals restricted dorsiflexion at the hallux MTP joint. Prominent osteophytes may be readily palpable, especially over the dorsolateral aspect of the joint.
2. Radiography may reveal varying degrees of osteoarthrosis, from osteophyte formation to joint space narrowing. An elevated first ray may be noted on the lateral radiograph.
3. Treatment in which a steel rocker bar is used in the sole of a shoe to relieve motion at the MTP joint can be quite effective. Surgical intervention, including cheilectomy, is of limited short-term value. In intractable cases, arthrodesis of the MTP joint can be quite helpful.

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Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

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