Foot Problems in Middle-Aged Patients: Keeping Active People Up to Speed
Catherine M. Coady, MD; Nina Gow, MD; William Stanish, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 5 - MAY 2021
In Brief: Most of the common foot problems that bother active middle-aged people are self-limiting and easily treated if detected early. Reviewed here are the causes, symptoms, diagnosis, and treatment of hallux valgus and rigidus, lesser-toe deformities, corns, Morton's neuroma, metatarsal stress fractures, plantar fasciitis, posterior tibialis tenosynovitis and rupture, acquired pes planus, tarsal tunnel syndrome, and foot problems related to rheumatoid arthritis and diabetes. In most cases, conservative treatment will enable patients to return to activity relatively quickly.
Middle-aged men and women are participating in varied levels of exercise and athletic activities more than ever before. As a result, they are more vulnerable to foot and foot-related injuries. Fortunately, most foot ailments are minor and can be treated conservatively. Early diagnosis and treatment are keys to returning these active people expeditiously and safely to their sports. This article reviews current concepts in the management of foot problems common in active middle-aged individuals.
Pathologic changes can lead to angulation of the great toe into valgus, enlargement of the medial portion of the first metatarsal, and thickening over the medial bursa. The causes of hallux valgus include heredity, metatarsus primus varus, pes planus, rheumatoid arthritis, and neurologic disorders. However, the most common cause is wearing poorly fitted shoes with a narrow toe box. Most patients affected by symptomatic hallux valgus are middle-aged women.
Athletes often have pain over the first metatarsophalangeal (MTP) joint and difficulty wearing shoes because of the medial prominence and associated toe deformities. The great toe should be evaluated for an adduction contracture, degree of pronation, deformity, and mobility; the more severe the deformity, the greater likelihood it will require surgery. The presence of lesser-toe or other foot abnormalities such as pes planus should also be noted.
Radiographs with the patient standing should include anteroposterior (AP) and lateral views. The AP view should be evaluated for the angle created by the first metatarsal and the proximal phalanx (metatarsophalangeal angle) and the angle between the first and second metatarsal shafts (intermetatarsal angle) (figure 1). These are used to classify the severity of the deformity and to determine the type of correction required in the event of surgery.
Treatment of hallux valgus must be individualized, since the degree of deformity is not always consistent with the severity of symptoms. In fact, many patients with a severe deformity are asymptomatic. Footwear that fits properly is important in the initial management. Wide, soft shoes with a broad toe box and sufficient insole padding are recommended to make the patient more comfortable in athletic and nonathletic activities. Orthoses that support the longitudinal arch and redistribute the pressure areas may give some relief of symptoms. Such conservative management is often successful. However, if it fails, surgery may be contemplated (1).
Degenerative arthritis in the first MTP joint associated with pain and diminished range of motion is known as hallux rigidus. Sports that include running or jumping may predispose an individual to this ailment.
Patients typically present with pain, loss of motion, and difficulty wearing their shoes. Forced dorsiflexion of the great toe, which occurs in many sports, is very painful when this condition is significant. Another hallmark of this condition is restricted dorsiflexion caused by a ridge of osteophytes that can easily be palpated along the dorsal aspect of the metatarsal head.
Radiographic signs of hallux rigidus (figure 2) are joint degenerative changes including joint space narrowing, sclerosis, cysts, and dorsal and lateral osteophytes.
Athletes who have hallux rigidus should wear low-heeled shoes with adequate width and depth to accommodate the increased bulk of the joint. Patients may also benefit from using a Morton's extension to their orthosis or a rigid insole or shoe to reduce the stress across the symptomatic MTP joint. Such conservative measures are usually given a 6-month trial.
If conservative management fails—failure is usually high in runners and jumpers—a cheilectomy may be performed to remove the dorsal osteophytes causing the impingement. This procedure often gives good pain relief and improves or maintains the mobility of the toe. If the disease has progressed so far as to eliminate a viable joint space radiographically, arthrodesis (figure 3), excisional arthroplasty, or prosthetic replacement may be advised (2).
Lesser-toe deformities that are common and may be asymptomatic in the middle-aged athlete include claw toe, hammer toe, and mallet toe deformities (figure 4). Claw toe refers to a digit that is hyperextended at the MTP joint and flexed at the proximal and distal interphalangeal joints. A hammer toe is extended at the MTP joint, flexed at the proximal interphalangeal joint, and hyperextended at the distal interphalangeal joint. A mallet toe is in neutral at the MTP and proximal interphalangeal joints, but flexed at the distal interphalangeal joint. These deformities are caused by a variety of factors, such as heredity, neuromuscular diseases, arthritides, and trauma.
Conservative care for these deformities is often successful if initiated early. Simple treatments that involve corn padding, metatarsal cushioning, toe crest splints, and wearing a shoe with a large toe box can provide significant relief of symptoms.
Unfortunately, if not initiated early, conservative measures are often disappointing. If an active person continues to have significant discomfort despite these modalities, soft-tissue surgery that involves tendon lengthening, capsulotomy, and/or ligament release may be required. For more significant deformities, a bony procedure, such as shortening osteotomy or arthrodesis, is necessary.
Corns are hyperkeratotic lesions caused by abnormal pressure over bony prominences. The pressure leads to proliferation of the stratum corneum or horny layer of the skin.
Corns are classified as hard or soft. Hard corns usually occur on the phalangeal condyles on the lateral side of the little toe and/or on the dorsal surface of the other toes. Soft corns are usually interdigital and form over the phalangeal condyles between the toes. The keratosis is similar to hard corns, but the overlying tissue becomes macerated because of its location, and the callosity may eventually ulcerate.
Hard corns are managed by wearing shoes with a larger toe box size and using padding to reduce pressure and friction. These corns can also be pared down with a pumice stone. Conservative management is generally effective. However, if corn-related problems continue and lesser-toe deformities are identified as the cause of the hard corns, surgical correction may be beneficial.
Treatment of soft corns includes keeping the affected area clean and decreasing friction by using gauze or lamb's wool between the toes. If conservative management fails, the involved phalangeal condyles may be surgically excised (3).
Morton's neuroma is a common source of forefoot pain, especially in middle-aged women, and is bilateral 15% of the time, according to the experience of one of the authors (W.S.). It is caused by abnormal pressure on the plantar digital nerves, which results in perineural fibrosis and myxoid degeneration. It typically occurs at the web space between the third and fourth metatarsals and, to a lesser extent, at the web space between the second and third metatarsals (figure 5).
Active people often describe a sensation of having a stone in their shoe. They commonly feel pain and numbness in the toe area that worsens with activities such as running. The pain subsides when they stop activity, especially after removing the shoe. In fact, the desire to remove the shoe and massage the foot is a classic indication of a neuroma. The clinician may be able to palpate a discrete, painful mass and can elicit pain by direct palpation between the metatarsal heads or a palpable click by lateral compression of the metatarsal heads.
If Morton's neuroma is recognized early, symptoms may be minimized if patients wear appropriate footwear and avoid the aggravating activity. A broad, soft-soled shoe with a low heel and a metatarsal pad is often helpful. An injection of cortisone and lidocaine without epinephrine into the affected web space may be both diagnostic and therapeutic. If conservative management is unsuccessful, the neuroma may be surgically excised.
Metatarsal Stress Fractures
Metatarsal stress fractures are the result of repetitive microtrauma in the metatarsal when bone resorption outpaces replacement. They are particularly common in middle-aged people who have recently become active or have suddenly increased or altered their training regimen. Long-distance runners and walkers and ballet dancers are particularly prone to metatarsal stress fractures.
The patient who has sustained such a fracture reports pain in the dorsal surface of the forefoot, usually around the second or third metatarsal. He or she describes it as a dull ache that becomes suddenly severe during exercise. If the aggravating activity is continued, pain may persist when the patient is at rest. There is tenderness on direct palpation of the fracture.
A fracture callus is usually not visible radiographically until 3 weeks after the initial insult, and then the fracture is typically seen in the diaphyseal or neck region. Though initial radiographs are usually not diagnostic, a bone scan will be positive early.
The athlete should avoid activities that cause pain. If there is pain with ambulation, cast immobilization may be necessary. After the fracture heals—typically in 4 to 6 weeks—the patient may progressively resume sports activities. Swimming and cycling are excellent activities for maintaining fitness during the recovery period.
Plantar fasciitis, an inflammation of the plantar fascia at its calcaneal attachment, is a troublesome condition that commonly interferes with exercise during middle age. It may occur as a result of repetitive forces in combination with biomechanical abnormalities, anatomic variants, or training errors.
An active individual will typically report a gradual onset of heel pain at the origin of the plantar aponeurosis and along the medial arch (figure 6). The pain is felt during initial weightbearing in the morning and is exacerbated by prolonged running or jumping.
Clinically, patients have discomfort on palpation of the fascial band, and their pain may increase with passive dorsiflexion of the MTP joints. They should be evaluated for overpronation or a cavus foot, both of which increase the load on the plantar fascia. Radiographs, if they are taken, may show spurring of the calcaneal tuberosity. Other potential causes of heel pain should be ruled out, including inflammatory arthropathies such as Reiter's syndrome and rheumatoid arthritis, calcaneal stress fracture, nerve entrapments, and sacroiliac radiculopathy (4).
Treatment of plantar fasciitis includes rest, avoidance of running and jumping, stretching, and the use of anti-inflammatory medications. Adding a small heel raise and a soft heel pad can often be helpful. Taping and night splints in the acute phase may provide some symptomatic relief. Orthoses may also be necessary, especially if an athlete has an excessively pronated or cavus foot. If the above modalities do not relieve the symptoms, no more than two cortisone injections into the plantar fascia aponeurosis are of value in some patients. In refractory cases, operative fascial release may be indicated.
Posterior Tibialis Tenosynovitis and Rupture
In middle-aged athletes, the tibialis posterior (figure 7) is the foot tendon most at risk for tenosynovitis and possible rupture. The diagnosis is frequently missed because progressive pronation is insidious and relatively painless.
A patient will usually present with pain, tenderness, and swelling behind the medial malleolus, often accompanied by an aching discomfort along the medial longitudinal arch of the foot. If the tendon subsequently ruptures, a progressive flatfoot deformity will result.
Early treatment includes avoiding activities that cause the symptoms and using anti-inflammatories and a medial shoe wedge. If necessary, no more than two cortisone injections into the tendon sheath may help. Formal physiotherapy may be needed to strengthen the foot and ankle once the inflammation has resolved. In refractory cases, a tenosynovectomy may be required.
If the tendon does go on to rupture, the athlete may be treated with an ankle-foot orthosis. Should this treatment fail, a reconstructive procedure such as a free tendon transplant from the peroneous longus should be considered. If the deformity is more severe, a talonavicular or triple fusion may be necessary.
Acquired Pes Planus
Pes planus is the loss of the normal medial longitudinal arch. The most common cause of adult acquired pes planus is a rupture of the posterior tibialis tendon (figure 7); other causes include previous midfoot fracture, inflammatory arthritis, neuropathic foot, and osteoarthritis of the talonavicular or tarsometatarsal joints.
A patient may present with an abnormal gait and pain along the medial border of the foot or under the metatarsal heads. The majority of adults with acquired pes planus can participate in sports if they wear well-cushioned shoes and medial arch supports. An orthosis may be necessary in some individuals. If symptoms are disabling, a limited tarsal fusion or triple arthrodesis may be indicated (5).
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome occurs when the posterior tibial nerve or one of its branches becomes constricted beneath the fibrous roof of the flexor retinaculum (figure 7).
Clinically, the patient will complain of paresthesias on the medial plantar aspect of the foot. If there is entrapment of the lateral plantar nerve, the patient may present with heel pain. One of the most reliable diagnostic findings in tarsal tunnel syndrome is a positive Tinel's sign (tingling elicited by tapping along the course of the nerve).
If tarsal tunnel syndrome is suspected clinically, electromyographic studies may be helpful in confirming the diagnosis. Magnetic resonance imaging may be useful to evaluate for a mass or anatomic variant, which may be causing the patient's tarsal tunnel syndrome.
Initial conservative treatment entails activity modification and the use of anti-inflammatory medications and orthoses, especially in athletes with overpronation. A one-time injection of cortisone and lidocaine without epinephrine into the tarsal tunnel may be given for diagnostic and therapeutic reasons. If the symptoms persist and other causes of heel pain are eliminated, surgical release may be necessary.
Rheumatoid arthritis affects small joints, and the foot is therefore vulnerable. Although any foot joint may be affected, the talonavicular and MTP joints are particularly susceptible. Arthritic deformities in the MTP joints include hallux valgus and lesser-toe subluxation and dislocation. A patient typically presents with a painful inflammatory synovitis affecting these joints.
Initial measures should focus on the optimal use of medication to manage the disease and reduce the pain and synovitis. Wearing shoes that provide extra depth in the toe box, padding bony prominences, and using arch supports are also important. Judicious administration of intra-articular cortisone injections may also be helpful.
In patients who have advanced rheumatoid arthritis, an arthrodesis is indicated for the talonavicular joint. The Hoffman procedure, a resection arthroplasty of the second to fifth metatarsal heads with fusion of the great-toe MTP joint, may be necessary for severe involvement of the MTP joints (6).
Diabetic patients are encouraged to participate in sports to improve their health and help control their disease. However, sports participation may compromise the health of both type 1 and type 2 diabetics, because their feet can be vulnerable to the stresses of exercise. The primary cause of diabetic foot problems is a peripheral neuropathy that allows excessive pressure to go undetected, resulting in soft-tissue lesions and eventually bony disorders. Diabetics also have coexisting circulatory impairment, which delays healing.
Since diabetics' foot problems range from mild insensitivity to more serious problems such as neuropathic plantar ulceration, circulatory disturbances, and neuroarthropathy, educating diabetic patients about potential foot complications is extremely important. They should be instructed to wear wide, well-padded shoes without ridges and socks that wick moisture away; they also should wash their feet with mild soaps and dry them completely. An interdisciplinary approach that emphasizes prevention and early treatment can minimize the effects of diabetes, reduce sports-related complications, and allow patients to remain active (7).
Early Detection to Preserve Fitness
The number of middle-aged men and women who are physically active or competitively athletic has increased. When injured, they are no more willing than younger active adults to give up their exercise routines or sports participation. Foot ailments are common in middle age, and many problems, if detected early, are easily treated with simple, conservative measures. Patient education, wearing proper shoes, using orthoses when necessary, and sensible exercise routines are all key measures to ensure that middle-aged patients continue a lifetime of physical activity and fitness.
Dr Coady is an orthopedic surgeon at Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. Dr Gow is a fellow in sports medicine and Dr Stanish a professor of surgery at Dalhousie University in Halifax, Nova Scotia. Drs Coady and Stanish are fellows of the Royal College of Surgeons of Canada. Address correspondence to Catherine M. Coady, MD, 1796 Summer St, Suite 4872, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada B3H 3A7; e-mail to [email protected].
Copyright (C) 192021. The McGraw-Hill Companies. All Rights Reserved