Crooked toes can be straightened with surgery

27. October 2014

Orthopaedist Vahur Metsna says that the foot forms part of a whole and any complaints related to feet may actually be an expression of the symptoms of another disease.Three different parts are terminologically differentiated in the case of foot problems:the back of the hindfoot (heel), the midfoot and the forefoot (metatarsus and toes).

How should feet be examined? Metsna says the room should be big enough to observe the person walking. Both feet should be examined comparatively: the patient must take off their socks and bare their legs up to their knees. “The way a patient walks can be evaluated as soon as they walk in the door,” he says. “You can also take a look at their footwear, to see where the shoes ‘pinch’.” In some cases it may be necessary to examine the patient when they are seated, on their back or on their stomach. “You should check whether the person is limping, whether both sides of the body are working symmetrically and how the metatarsus is held, which is to say whether it is bent inwards or outwards,” adds Metsna. He says that examining the patient’s footwear is extremely important. It is necessary to observe how high the heels are, the medial or lateral wear on the sole, impressions on the insole of the footwear and the round traces of wear on the sole of the shoe. “If the sole of one of the shoes is more worn on the outside, that’s a very important detail,” Metsna explains. “It’s also good to compare the shape of the shoe and the shape of the foot.” For example, part of the tip of the shoe may have risen in the case of hammertoe.

The examination can continue from the front when the patient is standing. “The patient should stand with their legs together and their legs should be visible from the knees to the ankles,” says Metsna. ”The kneecaps should be examined to see whether they face directly ahead or are turned inwards, and whether there is any asymmetry in the leg muscles. The shape and position of the toes must also be checked.” Rehabilitation specialists sometimes note that one of the patient’s legs is, for example, 2 cm shorter than the other. “It’s actually very difficult to judge this just by looking, as it depends largely on the position of the pelvis,” says Metsna. “If there are doubts, the axes of the legs should be x-rayed. Looking from the front, it’s also possible see the medial longitudinal arch of the foot – if it’s collapsed, the foot turns inwards and flatfoot develops.”

Patients with flat feet in particular should be examined from behind – how the heel is positioned or whether it has collapsed. “In theory, people say that when someone has flatfoot, their toes stick out from the lateral side when the foot is viewed from behind, but it actually depends largely on how the person positions their feet,” says Metsna. If flatfoot is suspected, the patient should be asked to rise up on the toes of the foot which is thought to be affected. The heel must turn inwards. If the heel does not do so, this is the main sign of adult-acquired flatfoot. Most patients who suffer from adult-acquired flatfoot are women over the age of 50.

The best way to examine a patient’s feet is when the patient sits down and the doctor sits in front of them and takes the patient’s foot in their lap. Metsna adds that a physician can also take the pulse on the foot, especially if the patient has ulcers, and see any muscle atrophy. Noting changes in the skin is also important. The metatarsus may often become fixed in the wrong position in the case of flatfoot. Morton’s neuroma is a relatively frequent condition – symptoms include pain and burning between the third and fourth toes of the foot and sometimes the toes swell up by evening, explains Metsna. “In the case of such patients, it’s necessary to identify the places in the joints that hurt,” he says. “Does it hurt when you put a finger under the metatarsus between the third and the fourth toes? Or does it hurt when the foot is squeezed together sideways? The toes may look OK from the outside.” Patients whose feet are deformed and who have ulcers should make an appointment with an orthopaedist. Diabetics should definitely have the sensitivity of their feet regularly checked by their family doctor.

Orthopaedist means surgery

Patients whose feet are severely deformed require surgery, says Metsna. “Or if the orthopaedist has tried all conservative treatment methods, such as in the case of hammertoe – arch support insoles, spacious shoes and braces – but they haven’t worked,” he says. “Also, if a patient has been complaining about pain in their foot for a long time.” If a patient has crooked toes but refuses to have surgery, there is no point in seeing an orthopaedist, he adds: all an orthopaedist can recommend in such cases is the same thing a family doctor would already have mentioned, such as soft and spacious shoes and arch support insoles. If a patient feels that they will be unable to tolerate the pain for much longer, they should think about surgery. Flatfoot is not surgically treated unless the patient has been wearing arch support insoles for at least six months. Surgery is considered if wearing them has had no effect. Support insoles are not necessary if the flatfoot is asymptomatic – they only become necessary when the patient has complaints, Metsna explains.

Surgery does not give you a new foot

Metsna says that patients must have realistic expectations regarding surgery. An operation alleviates a condition but does not provide patient with a new foot. “A third of patients can’t wear their old footwear and they won’t regain their previous physical capacity,” said Metsna. Recovery is long, lasting up to six months. “Only then is it possible to assess how the surgery went,” Metsna says. “The foot remains swollen for a long time and relapses are possible in 16% of cases.” He insists that follow-up treatment after toe surgery is at least as important as the surgery itself. Recovering from surgery takes a long time, and the foot may remain swollen for up to a year. “Patients aren’t able to work for a long time, as much as two to three months, unless they’re driven to and from the office,” says the orthopaedist. “Driving is only possible after six to eight weeks, and the same applies to the use of public transport.” Patients can start wearing ordinary footwear after a couple of months, but they must be a couple of sizes bigger than usual. “Shoes in the patient’s regular size can be worn after about three months,” he adds. He also gives some shoe advice for the future: lots of space for the toes, a soft upper, sole arch support and a 3-5 cm heel.

The patient is given painkillers when they are discharged from hospital and they have a helper on their way home. The patient must spend the first few days in bed with their feet up, using ice packs and painkillers for relief. Ice packs must be used, but not all the time, as they may otherwise cause necrosis of the skin. Special walking boots must be used which place the burden on the heel and which must be taken off at night.

Exertion must be avoided, as the plantar plates may otherwise break. Bandaging is also difficult according to Metsna. “It’s best to have a specialist do it, and it should be done as infrequently as possible,” he advises. The ends of the wire rods must be covered with the bandage. The bandage also keeps the toes in the right position in addition to covering the surface of the wound. When a toe support is prescribed, it must be worn 24 hours a day for six weeks. It may only be taken off for exercise and washing. The wires are removed four weeks after surgery. It is then recommended to tape the toes for four weeks using a new plaster every day. A sea salt bath is a good idea if time permits. Therapeutic exercise is also very important according to the orthopaedist. It is important to know which joints to exercise and when. The patient can start exercising a week after the first time their feet are bandaged.


Source: Terviseuudised