Hallux Limitus or Hallux Rigidus

If Mortons Toe Extension and Anti-Inflammatories, perhaps even following total rest for a couple of weeks, is unsuccessful, then treat with a cheilectomy for resistant forms of osteoarthritis.

Grade 1 can be seen on an MRI, and even picked up usually with a technetium scan.

Grade 2 is about a 3 mm. maximum diameter lesion, which can usually be removed with an arthroscope; however, this is probably overkill, since it can usually be done with an open procedure without too much difficulty and not too much longer recovery.

Grade 3 is greater than 3 mm. in diameter and requires an open cheilectomy. When doing an excision, this can be done in the office, and involves the excising the dorsal one-third of the head of the metatarsal.

Grade 4 shows severe degenerative joint disease, and the best treatment for which is a fusion, which should be done is slight dorsiflexion.

Tarsal Tunnel Syndrome

Ninety-three percent of the posterior tibial nerves branch within the retinaculum, and seven percent proximal to it. Sometimes the compression is by way of varicosities.

Thirty percent have EMGs positive, with normal NCVs.

Anterior Ankle Impingement Syndrome

These especially become symptomatic following use of Stairmasters. The symptoms are frequently described as "weakness" and sometimes with pain. To diagnose it, you really need to get lateral x-rays in both maximum flexion and extension. Bone scans are usually hot. Sometimes these can be removed with the arthroscope, and this can be facilitated using the osteotome from the lateral portal and there is usually more easily done without using the distractor.

Lateral Heel Pain

The flexor digitorum brevis is attached to the area from which the spur forms, with the plantar fascia actually attached to an area more inferiorly and posteriorly than to the spur itself.

Hyperpronation with heel pain and with the Tinel's sign at the lateral heel indicates compression of Baxter's nerve, which may need to be decompressed.

Usually after decompression, the patient can walk immediately in a post-op shoe with soft dressing. Baxter also resects a part of the plantar fascia, and one almost always has to release more of the plantar fascia in the cavus-type foot. If one chooses to do a subcalcaneal endoscopic fasciectomy, use a 4 mm. arthroscope, after at least 3 or 4 months of conservative care. This should include at least stretching not only the calf muscles, but also the toe flexors, as well.

Ankle Sprain Rehabilitation

Use "comfortable" modalities such as ultrasound under water, massage, etc. to help with the range of motion. In the later stages of rehabilitation, use contrast baths or paraffin, and always support the arch with orthoses. They must stay out of curved-lasted shoes, especially with hyperpronators.

Second Metatarso-phalangeal Joint Instability

Frequently caused by high-heeled shoes, rheumatoid arthritis, and in athletes. The pathognomonic sign is the drawer sign which produces exquisite pain at the MTPJ.

These can usually be treated with tape, properly fitting shoes, and sometimes orthoses.

If surgery is needed, you need to reef up the loose ligament, lengthen the extensor digitorum longus tendon, possibly do a dorsal capsulotomy of the MTPJ, and then transfer the flexor digitorum longus to the dorsal aspect of the proximal phalanx, deep to the neurovascular bundles.

With incompetent first rays, especially with heel pain, always need to increase the strength of the peroneal muscle.

With patients with arch pain, especially with posterior tibial attenuation and/or potential attenuation, and particularly those that are hyperpronated, the only football shoe that does so is the Tanel 360 which has cleats in a circular pattern on the sole which, also, reportedly, helps prevent knee injuries, as well.

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