Initial treatment is by adding padding to shoes, changing the type of footwear used, and taking anti-inflammatory drugs. Some patients may need surgery to correct the deformity and realign the toe.
In the clinic
The plantar aponeurosis is a flat band of connective tissue that supports the arch of the sole of the foot. It runs from the calcaneal tuberosity to the base of the toes. Overuse and increased strain on the plantar aponeurosis, such as excessive running and standing, and increased body weight, can lead to micro-tears and degeneration within the aponeurosis at the heel with disorganization of the collagen fibers. Patients typically present with mild to severe heel pain, which appears thickened on imaging (Fig. 6.121). It is usually successfully treated with intense physiotherapy, but may require image-guided injection therapies. In severe cases, the diseased section of the fascia needs to be surgically removed.
In the clinic
A Morton’s neuroma is an enlarged common plantar nerve, usually in the third interspace between the third and fourth toes. In this region of the foot the lateral plantar nerve often unites with the medial plantar nerve. As the two nerves join, the resulting nerve is typically larger in diameter than those of the other toes. Also, it is in a relatively subcutaneous position, just above the fat pad of the foot close to the artery and the vein. Above the nerve is the deep transverse metatarsal ligament, which is a broad strong structure holding the metatarsals together. Typically, as the patient enters the “push-off” phase of walking the interdigital nerve is sandwiched between the ground and the deep transverse metatarsal ligament. The forces tend to compress the common plantar nerve, which can be irritated, in which case there is usually some associated inflammatory change and thickening.
Typically, patients experience pain in the third interspace, which may be sharp or dull and is usually worsened by wearing shoes and walking.
Treatment may include injection of anti-inflammatory drugs, or it may be necessary to surgically remove the lesion.
In the clinic
Clubfoot is a congenital deformity in which babies are born with one or both feet pointing inward and downward. It is treated with gentle manipulation of the affected foot and with plaster casts to straighten the foot, which is usually followed by a minor surgical procedure where the calcaneal tendon is cut to release the foot into a better position.
A young man was enjoying a long weekend skiing at a European ski resort. While racing a friend he caught an inner edge of his right ski. He lost his balance and fell. During his tumble he heard an audible “click.” After recovering from his spill, he developed tremendous pain in his right knee. He was unable to carry on skiing for that day, and by the time he returned to his chalet, his knee was significantly swollen. He went immediately to see an orthopedic surgeon.
The orthopedic surgeon carefully reviewed the mechanism of injury.
The man was skiing down the slope with both skis in parallel. The ankles were held rigid in the boots and the knees were slightly flexed. A momentary loss of concentration led to the skier catching the inner edge of his right ski. This effect was to force the boot and calf into external rotation. Furthermore, the knee was forced into a valgus position (bowed laterally away from the midline) and the skier tumbled. Both skis were detached from the boots as the bindings released them.
A series of structures within the knee joint were damaged sequentially.
As the knee went into external rotation and valgus, the anterior cruciate ligament became taut, acting as a fulcrum. The tibial collateral ligament was stressed and the lateral compartment of the knee compressed. As the force increased, the tibial collateral ligament was torn (Fig. 6.139A,B), as was the medial meniscus (Fig. 6.140C). Finally, the anterior cruciate ligament, which was taut, gave way (Fig. 6.140A,B).
The joint became swollen some hours afterward.