Page 136 - ASOP ROT Study Guide

14 . 6 Neuromas

The cutaneous nerves to the toes may become trapped or irritated between the metatarsal heads
giving rise to a neuroma (Morton's neuroma). The cause is uncertain except that it is almost
certainly secondary to repetitive trauma and may be therefore associated with metatarsal head
prolapse as described above.

The condition is difficult to diagnose with certainty although the pain is characteristically dull and
throbbing, often with sharp exacerbations which are accompanied by tingling of the toes. It is
equally difficult to localize. Classically, sideways compression of the foot produces a palpable
click, reproducing the symptoms.

Treatment by excision may be accompanied by subsequent sensory disturbance to the affected toes.
Recurrence is common even with care and patients should be warned about this.

14 . 7 Ingrowing Toe-nails

Although a minor disorder this very uncomfortable or painful condition causes much distress. The
cause is unclear but is often associated with poor nail care. The curved nail grows into the nail fold
and digs in. The trauma to the nail fold skin may lead to a secondary infection. This then becomes
a self perpetuating and long term nagging infection with acute and very painful flare ups. It can also
lead to secondary blood borne infections, which can have serious consequences if the sufferer has
prosthetic joints or heart valves

Careful nail care and straight cutting usually will control the condition. However, it may be
necessary to remove the nail to clear up chronic infection. Definitive treatment can be problematic
as the condition tends to recur. Wedge resection of the nail bed may retain the toe nail and
remove the problem. The surest way of relieving the problem is to remove the nail bed using
phenol after removing the nail, but some cosmetic surgery may also be necessary.

14 . 8 Plantar Fascitis

The plantar fascia is a tough layer of fibrous tissue which runs from the os calcis to each toe base.
The term plantar fascitis includes a number of vague, but nevertheless very incapacitating painful
disorders of the foot. The cause is entirely obscure and it originates spontaneously with a fairly
sudden onset.

Patients characteristically complain of a soreness of the instep, often worse first thing on rising, or
after sitting for a few hours. The symptoms are rninimally relieved by walking but then persist as a
debilitating ache, often exacerbated by a change of direction, or walking on rough ground. Most
cases settle spontaneously (ie. they are self-limiting) although the symptoms may last a few months
or even years. On examination there may be tenderness at a point on the hindfoot, at the origin of
the plantar fascia medially. Discomfort is often more diffuse.

There is no specific cure and the many, varied methods of relieving symptoms are less than
satisfactory. Patients should be reassured that the condition will tend to get better. Insoles that are
hollowed out under the tender area may help, but may cause discomfort around the edge of the
hollow. Soft shoes and insoles, particularly modern sports trainers, can be of considerable value in
relieving symptoms.

If there is a marked tender point, a local injection of steroids and long acting local anesthetic can be
very effective, although rather painful to administer. Some sufferers demand a surgical
solution, and surgical stripping of the fascia from the os calcis is practiced. The results of this are
entirely unpredictable.

14 . 9 Neuropathic Feet

Feet without sensation (sensory neuropathy) are prone to developing sores caused by the inability
to perceive minor trauma from rubbing or treading on objects. Such problems are most common in
areas where leprosy is normally seen, particularly in the far east. In the western world the