Chapter 6
Chronic/Overuse Conditions of the Foot and Ankle

  1. Plantar Fasciitis

    1. Classifications:
      1. Systemic
      2. Degenerative
      3. Traumatic
      4. Mechanical (overuse)

    2. Mechanical and Degenerative forms most often treated. Commonly seen in patients:
      1. Participating in endurance sports
      2. Occupations requiring prolonged standing or walking
      3. Change in life style

    3. Symptoms include:
      1. Morning pain
      2. Slow reduction in pain as attempt activity, but with increasing pain as activity continues throughout day
      3. Anterior-medial heel pain

    4. Treatment
      1. Short Term Goals (aimed at decreasing symptoms)
        1. Anti-inflammatory drugs (oral and injection)
        2. Physical therapy
      2. Long Term Goals (to prevent mechanical stress)
        1. Shoewear with taping or foot orthoses

  2. Metatarsalgia

    1. Defined as pain in the anterior segment of foot
    2. Symptoms include: pain & tenderness of the plantar surface of metatarsal heads; development of callus under prominent metatarsal heads; increased pain during midstance and propulsion phases of walking.
    3. Etiology: Rheumatoid Arthritis; neurological and/or vascular disease; alteration of normal biomechanics of forefoot, secondary to abnormal subtalar joint pronation.
    4. Abnormal subtalar joint pronation prevents normal conversion of foot from mobile to rigid structure. Thus, as weight shifted from lateral to medial aspect of foot prior to toe-off, first ray cannot accept weight and moves vertically. This causes increased weight load on the second, third, and fourth metatarsal heads.
    5. This differs from a Mortons toe or Mortons neuroma which are also classified as metatarsalgia.
    6. Treatment:
      1. More than 55 years of age.
        1. Extra-depth shoe with full length insole (Plastazote II and Spenco). Metatarsal bar if required.
      2. Less than 55 years of age and mechanical problem: functional orthotic with forefoot post (rearfoot post is questionable).
      3. Proper shoes important with either treatment.

  3. Hallux Limitus/Rigidus

    1. Defined as restriction in first MTP extension. Normally, requires 55 to 65 degrees of MTP extension for walking.
    2. Other terms used to describe degenerative arthritis of first MTP joint; hallus flexus and hallux non-extensus. Hallus rigidus refers to ankylosis of the first MTP joint.
    3. Etiology: any condition which prevents the first metatarsal head from moving below transverse plane of the lesser metatarsal heads. Most commonly caused by trauma, degenerative changes secondary to hallux abducto valgus or rheumatoid arthritis, as well as congenital.
    4. Normal mechanics during propulsion require the first ray to move posteriorly while weight is being supported primarily on the hallux and 2nd and 3rd metatarsal heads. As heel lift occurs, posterior motion of the first metatarsal becomes possible as the first metatarsal glides backward upon the sesamoids. This posterior gliding of the first metatarsal head on the sesamoids enables the first metatarsal to move below the common transverse plane of the lesser metatarsals, allowing full dorsiflexion of hallux.

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