Gout is a disease in which tissue deposition of monosodium urate crystals occurs in and about the joints with acute or chronic arthritis. It initially is seen in men aged thirty to sixty years. In women it usually occurs after menopause. But, gouty attacks can be precipitated by trauma, certain foods, alcohol intake, diuretics, and kidney failure. Kidney excretion is the major route of uric acid disposal.

Gout may be divided into the following phases: asymptomatic, acute gouty arthritis, intercritical gout (follows acute attack), and chronic tophaceous gout manifested by monosodium urate crystal (tophi) deposited in the soft tissues of the body.

Classifications of gout include primary-elevated serum urate levels or urate deposition appears to be a consequence of disorders of uric acid metabolism not associated with another acquired disorder, secondary-gout is a minor feature secondary to a genetic or acquired process, uric acid overproduction-about 10% of patients excrete excessive amounts of uric acid into the urine, and uric acid undersecretion-the majority of patients show a relative deficit in the renal excretion of uric acid.

Clinical features include acute gouty arthritis most commonly at the 1st metatarsophalangeal joint of the big toe. 10% of the patients have no recurrence, but up to 60% of patients experience a second attack in less than a year. The ankle, tarsal area and knee are commonly affected. Affected joints are usually red, hot, swollen, and extremely tender. Diffuse erythema is present. A patient may be awakened at night from the pain. High grade fever may be associated with acute attacks. The most common sites for tophi are the base of the great toe, Achilles tendon, elbow, knees, wrists, and hands. About 10-20% of patients with primary hyperuricemia develop uric acid kidney stones. Renal disease is the most common complication of gout except for the arthritis.

On x-ray one may see soft tissue swelling, and joint effusions, rat-bite erosions, cyst-like or punched-out erosions. Many lesions are expansile with overhanging margins(Martel's sign) that are displaced away from the axis of the bone. Joint spaces are preserved until late in the disease. Ankylosis and joint subluxation may occur in advanced cases. Gouty tophi (white, chalky crystals) may be seen within soft tissues.

The diagnosis of gout is confirmed by the presence of strongly negatively birefringent monosodium urate crystals identified on joint aspiration.

Treatment for acute gout includes colchincine, NSAIDS(indomethacin, sulindac, naprosyn, ketoprofen), corticosteroids, and glucocorticoids.

Treatment for chronic gout includes colchicines, allopurinol, and probenecid and sulfinpyrazone.

Prevention of recurrence can be obtained by avoiding foods high in purines like anchovies, organ meat, liver, spinach, mushrooms, asparagus, oatmeal, cocoa, sweetbreads, shellfish, beans, peas, and lentils as well as avoiding alcohol, aspirin, and diuretics.

Bibliography

• Banks, Alan S., et al McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia:Lippincott Williams and Wilkins, 2001.
• Ferri, Fred F., The Care of the Medical Patient.Philadelphia:Mosby, 2001.

In order to ensure fewer nail problems, the shoe selection is important. The shoes must be wide and tall enough to accommodate your feet. If you trim your own nails, try to cut the nails straight across without going into the corners. If you have circulation problems or diabetes, please see your podiatrist before doing any self-care.

Ingrown Toenails

An ingrown toenail, or onychocryptosis, occurs when the nail grows down into the skin instead of outward (happening most often to the big toe). It can cause the toe to become infected and may be very painful. Redness, irritation, swelling, and an uncomfortable feeling of warmth are associated with an ingrown toenail. The best ways to prevent ingrown toenails include trimming your nails properly, guarding your feet from trauma, and wearing shoes that provide adequate room for your toes.

What causes Ingrown Toenails?
Many things can cause ingrown toenails.

The following are a few of the most common causes:

• Cutting toenails incorrectly
• Toenails are too large
• Toes curl, either congenitally or from diseases such as arthritis
• Frequent stubbing of the toes
• Wearing shoes that are too tight

What treatments are available?
As soon as an ingrown toenail is noticed it should be treated. If the toenail is not infected, you may find relief in these simple steps:

• Soak your feet in warm salt water
• Dry them with a clean towel
• Rub on an antiseptic solution
• Cover the toe with a bandage

If there are no signs of infection, your doctor will cut the ingrown portion out. Depending on the severity and the presence or absence of infection, the side of the nail may need to be removed back to the level of the cuticle. Antibiotics may also be required if infected.

Pain may be along the side that the nail is ingrown or even throughout the entire toe. Walking seems to make the pain worse. To evaluate the problem, your podiatrist will evaluate the toe around the affected area.

Fungal nails

Fungal nails tend to be thick, crumbly, and discolored. Fungal nails can be very difficult to trim without the assistance of a podiatrist.

You will need to talk to your podiatrist regarding treatment of fungal nails. Treatment can include solutions, creams, removal of problematic nails, or even oral medications.

Toenails can have changes similar to the ones that are present in fungal nails without the presence of a fungus. Your foot doctor can examine the nails to determine if a fungus is present or if there is another underlying condition.

Black and blue nails

Black and blue nails are most often caused by a traumatic event. Many times this happens from sport activities or a heavy object falling onto the toe. There could be pain associated with this discoloration if the injury is sudden.

Your podiatrist should examine the nail and the rest of your foot to ensure that there is no infection present. Treatment can include doing nothing, drilling a hole into the nail plate to relieve the pressure, or removal of the entire nail plate.

You should discuss the treatment choices with your podiatrist.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Have you ever gone over someone's house and been ashamed to take off your shoes? Ever gone to the beach and buried your feet in the sand? Do you wear closed toed shoes because you are ashamed of toenails? Don't worry, you are not alone. This is what millions of Americans experience. If you have dry, yellow, brittle, and discolored toenails, you may have Onychomycosis, better known as fungus nail. With Onychomycosis, the nail has been penetrated by bacteria or some type of fungi. In this article we will discuss Onychomycosis and treatment options.

How would you know if you had onychomycosis? Your podiatrist will be able to diagnose your condition. In order to do so, debridement of the nail plate saving the most proximal section is advised. Three tests can be performed on the nail clippings. The most accurate diagnostic test of onychomycosis is the PAS test. PAS is very specific and less operator dependent. Onychomycosis usually doesn't affect children and is increasingly common as one gets older.

In order to manage Onychomycosis, your podiatrist can suggest three treatment options; debridement of the nail, oral therapy, and topical therapy. Debridement of the nail is going to give the patient satisfaction temporarily because the fungus nail can and will possibly grow back. Oral therapy requires the patient to follow a pill regimen and may have drug reactions with other medications that a patient is taking. Oral medications may also irritate your liver. Topical therapies cause no harm to the patient. They can be taken with other medications without harm to the liver.

There are many nonprescription treatments for onychomycosis. Natural oils have been shown to be effective in its control. Camphor, menthol, eucalyptus oil, cedar leaf, nutmeg oil, thymol, clove, and tea tree oil have all been used. The way these over the counter products work is that they kill fungus on the surface of the nail where the discoloration, brittleness, and dryness occur. Many podiatrist have topical products which contain the essential ingredients. These ingredients not only clear up the current fungus on the nail but promote healthy nail growth. One such topical antifungal is NailEsse. NailEsse can be used on both hands and feet. Daily use on requires daily application on the hands for 6-8 months and 8-12 month period for toenails. The current fungus on the nail will be killed and the new nail that grows will be fungus free. This product should be available at your local podiatrist office.

The key to treating fungus nail is to make sure that you visit your podiatrist so you can accurately be diagnosed and treated. Just because you have an abnormal nail, it may not necessarily be onychomycosis. Home remedies are not effective as treatment your podiatrist can provide. The correct combination of oils in topical antifungals is key to effective treatment.

A shock wave is the resultant acoustic energy wave of an explosion. For kidney stones, the shock wave must be focused to specifically apply the energy wave to the desired area as well as in the foot.

ESWT offers improvement in pain relief of Plantar Fasciitis (inflammation of the plantar fascia) and functional restoration with negligible (few) complications. It is a safe procedure and has lack of risks and complications. The cost is very expensive and the cost of ESWT is not covered by all insurances and the patient is forced to pay out of pocket. The procedure can cause micro-fractures of the calcaneus (heel bone). Also, some patients require several treatments.

Indications for ESWT include plantar fasciitis, chronic heel pain, avascular degeneration, and where conservative treatment has not prevailed and the condition still persists.

The OSSATRON is indicated for use in patients with chronic proximal plantar fasciitis who have failed to respond to conservative treatment such as physical therapy and stretching exercises, orthotics, night splints, NSAIDS, (non-steroidal anti-inflammatory drugs), cortisone injections, or previous surgery.

Because the OSSATRON has not been tested on subjects with the following conditions, it's safety and effectiveness is unknown: diabetic neuropathy, ankle or foot fracture, Peripheral Vascular Disease (poor circulation), skeletally immature patients, pregnancy, severe osteoarthritis, rheumatoid arthritis, osteoporosis, metabolic disorders, osteomyelitis (bone infection), and systemic infection.

There are no known contraindications to ESWT with the OSSATRON for treatment of chronic proximal plantar fasciitis.

Patients with bleeding disorders that may prolong clotting time may be at risk for bleeding following OSSATRON. Anesthesia should be administered prior to the procedure.

Between April 1998 and November 1999, 302 patients were treated for chronic proximal plantar fasciitis using OSSATRON ESWT. 260 received active or placebo. 42 were not randomized. Pain scale was 5-10 with10 being severe. Evaluations were obtained at 4, 8, 12 weeks post-treatment.

234 randomized patients showed a statistically significant difference in treatment versus placebo groups. Following one OSSATRON ESWT, 62% of patients met with success. 76% of all patients who received treatment, had acceptable results after 1 treatment and no longer required long term treatment or surgery. 38 complications were reported of 302 subjects.

The patient should be instructed to discontinue any medication containing aspirin or an NSAID for 3 days prior to ESWT to minimize bleeding. Patient should bring running shoes to wear home as weight bearing is allowed after the procedure. ESWT should be performed with anesthesia local or regional since the procedure is painful. Position the OSSATRON perpendicular to the patient table with the therapy arm in the horizontal position, and the coupling membrane near the plantar surface of the affected foot. The head may be placed in the vertical position, coupling membrane up, for the affected side aligned with the membrane. A total of 1500 shocks are delivered for effective treatment of chronic heel pain syndrome. Total OSSATRON treatment time is 13-15 minutes for delivery of 1500 shocks at 2.0 Hz. Upon discharge, patients are advised not to participate in stressful activity for the affected heel for 4 weeks. Orthotics are encouraged.

What is extracorporeal shock wave (ESW) treatment?

"Extracorporeal" means "outside the body". Shock waves are created by very strong acoustic (sound) energy.
Your ESW treatment will be performed with a device called OssaTron.

The OssaTron is a shock wave generator very similar to the shock wave devices used to treat kidney stones without surgery. The shock waves are created by a spark plug that is enclosed in a soft plastic dome filled with water. During ESW treatment, this dome is placed close against the heel so that the shock waves pass through the dome to the heel. ESW treatment has recently been found to be effective for treating chronic proximal plantar fasciitis, a condition that causes pain in the heel of the affected foot and is sometimes called "heel spurs".

Who should not have ESW treatment for proximal plantar fasciitis?

• Anyone taking medications that may prolong or interfere with blood clotting should not have ESW treatment.
• Anyone with a history of bleeding problems should not have ESW treatment.
• Children should not have ESW treatment.
• Pregnant women should not have ESW treatment.

Because the OssaTron has not been tested on people who have the following conditions, its effect, safety, and effectiveness on someone who has one of the following conditions is unknown:

• Tarsal tunnel syndrome or other nerve entrapment disorders (damage or pressure on the nerves to the foot)
• Diabetic neuropathy (nerve damage due to diabetes)
• Fracture of the foot or ankle
• Significant peripheral vascular disease (problems with the circulation in the blood vessels in the legs)
• Severe osteoarthritis
• Rheumatoid arthritis
• Osteoporosis
• Metabolic disorders
• Malignancies
• Paget's disease
• Osteomyelitis
• Systemic infection

Your doctor can provide you with additional information about these and other conditions and how they might affect the decision to perform ESW treatment.

What side effects and complications could happen?

• The ESW treatment may cause skin reddening or bruising of the treated foot. This usually clears within a few days.
• The ESW may cause numbness or tingling in the treated foot.
• The ESW procedure may cause the plantar fascia to tear.
• The ESW treatment may not help heel pain in your case. You may have episodes of pain similar to the pain you had before treatment. The pain may continue for a few days to several weeks after treatment.
• Shock waves directed at large blood vessels or major nerves may cause damage to these structures. Misdirected ESW may result in nerve or blood vessel injury.

What will happen on the day of the ESW treatment?

Your doctor will probably ask you to come the hospital or surgery center a few hours before your ESW treatment is scheduled. You should wear shorts or lose fitting clothing that can easily be rolled up to the knee of your affected leg. Otherwise, you may be asked to change from your own clothes into a hospital gown. The staff may take your temperature, pulse and blood pressure and ask you some questions about your general health. They also will make sure you have signed a consent form for the ESW treatment.

The ESW treatment my cause some pain or discomfort, so an anesthetic is commonly given before the procedure. Usually, this is a local anesthetic or a regional anesthetic called a heel block. During the ESW treatment you will be asked to rest comfortably on your back while your doctor holds your foot up to the OssaTron shock head.

An ESW treatment for chronic proximal plantar fasciitis usually takes about 30 minutes. The ESW treatment is performed as an outpatient procedure. No overnight hospital stay is necessary.

What will happen after the ESW treatment?

Immediately after treatment, you will stay at the hospital or surgery center until the anesthetic wears off enough that it is safe for you to walk. Your doctor will probably ask you to restrict "stressful activity" involving the treated foot for four weeks after treatment. "Stressful activity" may include running or jogging, doing heavy housework or yard work, and participating in sports.

Some patients need a mild pain medication following ESW treatment. Although some patients in the clinical study felt immediate relief from pain after the ESW treatment, it is more common for it take up to six weeks for pain relief to begin.

What are the expected results from ESW treatment?

In the OssaTron clinical study, patients with chronic proximal plantar fasciitis were graded "Success" or "Fail" according to four measurements: 1) The doctor graded the amount of pain with pressure on the heel: 2) the patient graded the amount of pain during walking first thing in the morning: 3) the patient graded the time and distance he or she could walk without pain and 4) the patient reported the amount of pain medication he or she needed for the heel pain.

Percentage of Patients with Successful Outcome at 12 Weeks

Your doctor will ask you to return to the office for a follow up visit, six or eight weeks after your OssaTron treatment. Please check with your doctor about this follow up visit.

I have more questions about ESW treatment for heel pain. How can I get more information?

Talk to your doctor. In order to use the OssaTron to treat chronic proximal plantar fasciitis, your doctor had to complete a specialized training program. The training program not only allowed your doctor to learn how to perform the ESW treatment, but it also included information about shock wave energy in general, and information from the OssaTron clinical study. Therefore, your doctor is the best person to talk with if you have any questions or concerns about ESW treatment for chronic proximal plantar fasciitis with the OssaTron.

What other treatments are available for treating chronic proximal plantar fasciitis?

Doctors know that many people who have heel pain get better with time, even with no treatment. Many other people get better after trying one or several conservative treatments, which include:

• Rest from excessive or abusive activity and the application of heat or cold.
• Physical conditioning exercises
• Use of a shoe insert or heel cup
• Physical therapy, including ultrasound therapy
• Over-the-counter pain relievers, such as aspirin or Tylenol (acetaminophen)
• Prescription pain relievers
• Non-steroidal anti-inflammatory medications (NSAIDs), such as Advil (ibuprofen) or Aleve (naproxen)
• Steroid injections (cortisone)

Apply Biofreeze during the day to cool those hot, inflamed and swollen bones & joints.

In difficult cases of chronic proximal plantar fasciitis, open or arthroscopic surgery may be performed.

Who should consider having ESW treatment for proximal plantar fasciitis?

ESW treatment with the OssaTron is for patients who have had heel pain for at least six months and who have tried other methods for treating their heel pain. In the OssaTron clinical study, the treated patients had failed to respond to at least three attempts at conservative treatment: two prior courses of non-invasive treatment, including physical therapy and the use of an orthotic device: and one prior course of pharmacological treatment.

ESW treatment with the OssaTron is for patients who can tolerate anesthesia prior to the ESW procedure. ESW treatment with the OssaTron is painful.

ESW treatment with the OssaTron is for patients who can tolerate hearing protection to reduce the risk of hearing impairment due to the sound of the OssaTron.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Reflex Sympathetic Dystrophy (Complex Regional Pain Syndrome)

In 1598, Pare first recorded awareness of the condition. Then, later during the American Civil War, Reflex Sympathetic Dystrophy (RSD) was recognized and described. The hallmark of Complex Regional Pain Syndrome (CRPS) is severe, spontaneous pain associated with local features of autonomic dysfunction that occurs after trauma or operation to a limb. It is defined as a disordered response by an extremity to a noxious (hurtful) stimulus.

The exact cause is unknown.

The five major signs and symptoms are:

• Pain out of proportion to the injury
• Edema
• Autonomic dysfunction
• Movement disorder, and
• Trophic changes

Causes of CRPS include accidental trauma. Injury may be the result of fractures, dislocations or sprains, amputations, crush injuries or even minor cuts of the toes or feet. Other etiologic (causative) factors include surgical procedures, diabetes mellitus, hemiparesis, venipuncture, and infections. It usually results from incomplete nerve trauma or soft tissue injury, and most commonly affects the hands and feet.

Genant proposed criteria for diagnosis of RSD which included pain and tenderness in the extremity, soft-tissue swelling, decreased motor function, trophic skin changes, vasomotor instability and patchy oteoporosis.

Histological findings on synovial biopsies characteristic for RSD that Kozin noted include proliferation and disarray of synovial lining cells, increased numbers of small blood vessels, mild perivascular inflammatory infiltrate and synovial edema.

Stages of RSD (CRPS)

1. STAGE I occurs between 1-3 months. The foot displays soft, puffy edema, antalgic guarding of the part, pronounced pain, allodynia(hyperesthesia to light touch-pressure), hyperhidrosis(excessive perspiration); spotty osteoporosis on radiographic inspection; pain aggravated by movement and emotional stress.
2. STAGE II occurs between 3-6 months. Edema is still present, range of motion decreases, dystonia (impairment of muscle tone), mottled or cyanotic coloration, and progressive spotty bone demineralization noted radiographically. Hair growth is decreased, nails are brittle, and there is muscle wasting causing limited joint mobility.
3. STAGE III occurs between 6-9 months. There is a cool, dry foot with pallor;with the skin slightly taut, waxy and thin; stiffness and disability are pronounced, marked disuse atrophy of bone (Sudek's atrophy).

Techniques to confirm clinical diagnosis

Plethysmography(the determination of changes in volume by using an instrument for recording variations in volume of an organ, part, or limb) and venous blood gas measurement for determination of vasoconstriction.

Thermography or videothermogram to evaluate near-surface blood flow. A positive thermogram will show significant coolness in the affected extremity.

Xenon clearance or laser Doppler to measure peripheral blood flow.

Serologic tests, such as antinuclear antibody and rheumatoid factor (are usually negative).

Plain film radiographic examination reveals patchy osteoporosis, which may progress to a diffuse ground-glass appearance.

Three-phase Technetium bone scan, showing diffuse uptake in the blood flow, pool and delayed phase. In the delayed phase, periarticular uptake is noted in the affected part.

Other studies include electromyography(the recording and study of the electrical properties of skeletal muscle) and nerve conduction velocity studies, arteriography(radiography of an artery or arterial system after injection of a contrast medium into the blood stream), and erythrocyte sedimentation rate. The results of these studies are negative. Quantitative bone density testing is also used.

Pharmaceutical treatment for CRPS is Prednisone, Elavil, Procardia, NSAIDS(Non-Steroidal Anti-Inflammatory Drugs), Neurontin, Dilantin

PHYSICAL THERAPY treatment may be administered including, massage, ultrasound, ROM(range of motion) exercises, splint, hydrotherapy and contrast baths, transcutaneous electrical nerve stimulation (TENS), trigger point electrical stimulation, acupuncture.

Other forms of treatment include chemical sympathectomy, epidural block, lidocaine, morphine pump, and amputation

References

• Banks, Alan S., et al McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia:Lippincott Williams and Wilkins, 2001.
• Kozin F. Reflex sympathetic dystrophy syndrome:a review. Clin Exp Rheumatol 1992;10:401-409.
• Schwartzman RJ, McLellan TL. Reflex sympathetic dystrophy.Arch Neurol 1987;44:555-561.
• Schwartzman RJ. Reflex sympathetic dystrophy. Curr Opin Neurol Neurosurg 1993;6:531-536.
• Stanton-Hicks MD. Upper and lower extremity pain. In: Raj P, ed. Practical Management of pain. St. louis:Mosby-Year-Book, 1992:312-328.
• Bej MD, Schwartzman RJ. Abnormalities of cutaneous blood flow regulation in patients with reflex sympathetic dystrophy as measured by laser Dopler fluxmetry. Arch Neurol 1991;48:912-915.
• Amadio PC, Mackinnon SE, Merritt WH, et al. Reflex sympathetic dystrophy syndrome:consensus report on an ad hoc committee of the American Association for Hand Surgery on the definition of reflex sympathetic dystrophy syndrome. Plast Reconstr Surg 1991;87:371-375.
• Schwartzman RJ. The diagnosis and staging of RSD: an overview of the problem. Reflex sympathetic dystrophy: current strategies in diagnosis and treatment. Paper presented at Jefferson Medical College, Philadelphia, April 10, 1992.

Hallux limitus describes a condition in which there is limitation of motion of the 1st metatarsal phalangeal joint in the sagittal plane.

Hallux limitus is the inability of the hallux to dorsiflex at the 1st MPJ. This limited range of motion results in jamming of the 1st metatarsal phalangeal joint (1st MPJ).

Over time, repetitive jamming will contribute to arthritis of the 1st MPJ. The most characteristic sign of hallux limitus is a bump (exostosis) on top of the head of the 1st metatarsal. In fact, many doctors also refer to hallux limitus as a dorsal bunion.

Incidence

Ages 30 to 50 years old, men and women equally. Tends to occur in the pronated foot.

Pathogenesis

Hallux limitus is caused by four contributing factors. These factors include the following:

1. A long 1st metatarsal.
2. An elevated 1st metatarsal. (Metatarsus primus elevatus)
3. An impaction injury (trauma) of the 1st MPJ resulting in an osteochondral defect (OCD) of the joint.
4. Systemic diseases that cause injury to the joint such as rheumatoid arthritis, lupus, or gout.

Clinical Presentation

Patient usually presents with pain in the bottom of the 1st MPJ where a callous can develop due to the toe not bending upward enough. Another consequence of the jamming of the 1st MPJ is the development of spurs on the top of the joint, which can become painful as a result of shoe pressure. Evaluation of the range of motion of the 1st MPJ can be performed in two positions; relaxed and functional. In a relaxed position, with no resistance exerted by the calf, the 1st MPJ shows normal range of motion without pain. In a functional position, when resistance is applied by the calf, the range of motion of the 1st MPJ changes and hallux limitus can be more appropriately assessed. The term functional hallux limitus is applied to cases that have normal range of motion in a relaxed position, but decreased range of motion in a functional position.

Joint Fluid Analysis Findings

Non-inflammatorty, but can be used to rule out differentials

Useful Lab Tests/Studies

Diagnosis is made by performing a physical exam of the foot and the use of x-rays. Physical exam will reveal pain and limitation in motion of the 1st MPJ. The motion at the 1st MPJ is less than 65 degrees dorsiflexion. There is commonly mild swelling and bony prominences associated with the 1st MPJ. X-rays of the foot will reveal the true severity of the patient's condition. It will allow the physician to evaluate the joint for bone spurs, decrease in joint space, flattening of joint surfaces, and loose bodies in the joint. X-rays can also reveal the cause of hallux limitus such as an elongated or elevated 1st metatarsal.

Radiographic Findings

Uneven joint space narrowing, at the site of abnormal applied force. Subcondral sclerosis (Eburnation) adjacent to the site of the joint space narrowing, can be more diffuse in severe cases. Osteophytosis, typically at the margins of the affected joint, can be an isolated finding absent of joint space narrowing or subchondral sclerosis. Subchondral cyst in affected joint. Loose osseous body in affected joint. The loose body appears as a bone fragment or ossicle within the joint. It can be the initiating factor and caused by trauma, or it could be a fractured osteophyte in an already existing osteoarthritic joint. These 5 finds are also found in osteoarthritis which is essentially what hallux limitus is.

Morphological Changes

Narrowing of joint spaces and break down of cartilage, formations of cysts and exostosis of the bone around areas of cartilage that have been broken down due to increased pressure. Sclerosis of subchondral bone in response to increased pressure on an area. Progressively get worse as the disease progresses to hallux rigidus.

Differential Diagnosis

Osteoarthritis, Gout, Pseudogout, Rheumatoid arthritis, Lupus, septic arthritis, sesamoiditis, and sesamoid fractures.

Impact of Disease

Patient will have decreased ambulation due to the pain and limitation of motion at the 1st MPJ and therefore have a decreased quality of life.

Treatment

Conservative- anti-inflammatories, physical therapy, ice, MPJ ROM exercises once painful symptoms resolve, strapping to reduce motion of joint, padding, shoe gear with stiff soles, orthotic control. Long term conservative treatment is usually not very effective. Patients who do not respond to conservative treatment (especially patients with Hallux Rigidus) require surgery. One example of surgery preformed is a bunionectomy with an implant. The arthritic part of the bone and joint is removed and replaced with an implant.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.