Interrogation, examination, palpation
Static forefoot deformities are complex pathologies and that’s why the decision on the type of surgery must be based on multilateral and full examination of every case. First of all the medical history and major complaints of the patient are found out. The most painful spots in the first and other metatarsophalangeal joints and causes of pain and its duration are detected. It is also very important to determine whether certain footwear, peculiarities of foot structure or condition or high physical activity cause pain. The patient’s age is also an important factor as one must think of a long-lasting favorable functional and cosmetic outcome of surgery. Beside that it is necessary to take into account the condition of the vascular system, musculoskeletal system, skin and extremity neurology. The main goal of pre-surgical examination is selection of the most suitable surgical method in every single case. Quite often complaints are related to a severe transverse foot deformity (gravity, nagging pain especially at the end of the day, in the forefoot, in projections of talar and navicular bones, heavy lower shin) which makes it necessary to differentiate problems depending on the type of flat foot).
Visual examination helps detect localization of a deformity, degree of the deformity, presence of any skin modifications and other static pathologies. Examination results and palpation are closely connected and the latter helps detect degree of foot flexibility, the most painful spots, range of motion in certain joints, presence of contractures, subluxations and dislocations in metatarsophalangeal and interphalangeal joints, hypermobility of the medial metatarsal cuneiform joint. Foot flexibility is detected by compressing the foot by sides at the heads of metatarsal bones the following way:
Groups of complaints upon pathologies of the first toe:
- Related to dislocation of the head of the first metatarsal bone which causes discomfort upon wearing shoes, pain, quite often – exacerbating bursitis in the first toe head;
- Related to first toe dislocation (Hallux valgus) – its outward deviation, rotation, shifting under or on the second toe which causes pain by wearing footwear, quite often on walking and it is also a cosmetic defect;
- Related to first toe deformity (Hallux valgus interphalangeus) – outward deviation of a nail phalanx which is more a cosmetic defect;
- Related to dislocation of sesamoid bones which is accompanied by pain under the head of the first metatarsal bone on walking;
- Related to arthrosis of the first metatarsophalangeal joint which is accompanied by pain upon movement in this joint and movement limitation;
- Related to hypermobility or arthrosis of the medial metarsal cuneiform joint which is accompanied by pain while walking or standing.
Examination of the foot itself starts with palpation of tissues in the region of the first metatarsophalangeal joint in order to detect the most painful spots and localization of exostoses. If there is pain by intense movement in the metatarsophalangeal joint, one can suggest that the synovial membrane or articular cartilage is damaged.
Standard assessment of the patient’s foot condition with hallux valgus for selecting a surgical technic includes the following parameters:
Assessment parameters for foot condition:
- Type of foot flexibility.
- Presence of any exostoses on the interior surface of the first metatarsal head.
- Presence of inflammated bursal sac.
- Type of lateral first toe dislocation, position of the second toe to the first toe.
- Type of valgus rotation of the first toe.
- Presence of crepitation, exudate or pain.
Presence of movement limitation: whether there is pain in the medial part of the first metatarsal head by normal position of the first toe or movements are limited. Assessment of movement in the metatarsal cuneiform joint, Assessment of articular instability. Normal range of motion in the first metatarsophalangeal joint is from 65˚ of dorsiflexion to 15˚ of plantarflexion. Any decrease in the articular range of motion (hallux limitus or hallux rigidus) testifies to arthrotic or arthritic modifications. Significant modifications, especially arthritic ones, of the articular bone ends make almost all reconstructive surgeries ineffective. Examination of range of motion has a less practical value as it is more important to detect any hyperkeratosis on the plantar and dorsal foot surfaces. Callosities on the planta testify to lowering of heads of corresponding metatarsal bones and fixed toe deformities. Any signs of metatarsalgia must be taken into account while selecting type of surgery as a range of technics allows correcting this pathology by means of a standard surgery with some modifications.Roentgenography and roentgenometry
Standard roentgen examination of the foot allows detecting all parameters necessary for selection of a type and volume of surgery. Dorsoplantar andlateral projections under load give an objective functional demonstration of deformity and allow measuring when necessary. Axial projection of the forefoot is rarely used. It detects type of dislocation of sesamoid bones, their degenerative modifications and also rotation of the first metatarsal bone. Oblique medial projection under 45˚ angle allows visualizing exostoses of the first metatarsal head, damage in articular ends and also absence of parallelism between the first and second metatarsal bones. Practically dorsiplantar projection is more current. Orthopedic surgeons must concentrate on basic roentgenologic parameters which must be taken into consideration by examining standard foot X-rays as neglecting some of these factors leads to fatal mistakes by foot surgery.
The dorsiplantar projection is to be performed under load as the difference in measurements can reach 20%. Besides at the focal distance of 1 meter the X-ray beam must have a 15-20˚ inclination which allows accurate measurement of absolute dimensions and distances by planning a surgery and also visualizing the shape of articular bone ends and direction of articular space.
Plantography is one of the simplest and most informative ways of foot examination by a plantar imprint which allows detecting not only flat foot but also load distribution on certain extremities. In case of obese people or obvious fat pads in the fore plantar part, plantograms cannot be regarded as an accurate representation of load distribution and they don’t give much information.
Plantography: on the left and in the center – making imprints, on the right – foot imprints on paper
Different authors suggest a lot of methods of getting necessary imprints, most of them have proved efficiency of the method by studying the results of treatment of foot injuries and conditions. In recent years the method has developed after the photocamera (photoplantography) and computer (computer photoplantography and podometry) were implemented in the method. Plantography and podometry detecting not the degree of bone arch formation but a number of.
The aim of these methods is providing objective results of surgical treatment and making a decision on further use of orthotic devices. After the surgeon detects and assesses the above roentgenologic and clinical parameters, it is possible to select an objective method of surgical treatment.
Clinical picture – deformity analysis
By now a lot of various classifications of hallux valgus types have been suggested but we consider some of them too complicated as for parameters used and are of no practical use. We developed a simple and practical classification which distinguishes three degrees of first toe deformities.
|1st degree||2nd degree||3rd degree|
|HV < 25°||HV >=25°||HV > 35°|
|IM < 12°||IM <=18°||IM>18°|
negative or subluxation in
or subluxation in
-+/- first toe
-+/- first toe
-+/- first toe
Use of analyzed parameters allows detecting surgical volume but it is the surgeon who decides on additional surgeries or correction of basic procedures. At any stage a surgery must include procedures aimed at restoring capsular-ligamentous balance ( ) in the metatarsophalangeal joint (medial exostosectomy, lateral release, medial capsulography).