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Toes




The toes, particularly your big toe, help you move and keep your balance. Playing sports, running, and receiving a blow to the foot can damage your toes. Wearing shoes that are too loose or too tight can also cause toe problems. Certain diseases, such as severe arthritis, can cause toe problems and pain. Gout often causes pain in the big toe.

Common toe problems include

  • Corns and bunions
  • Ingrown toenails
  • Toe joint sprains and dislocations
  • Hammer toes
  • Crossover toe
  • Fractured toe bones

Treatments for toe injuries and disorders vary. They might include shoe inserts or special shoes, padding, taping, medicines, rest, and in severe cases, surgery.

Corns and Bunions

Bunions are often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. With a bunion, the big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment, producing the bunion's "bump." Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which continues to become increasingly prominent. Usually the symptoms of bunions appear at later stages, although some people never have symptoms.

Sometimes observation of the bunion is all that's needed. A periodic office evaluation and x-ray examination can determine if your bunion deformity is advancing, thereby reducing your chance of irreversible damage to the joint. In many other cases, however, some type of treatment is needed.

Early treatments are aimed at easing the pain of bunions, but they won't reverse the deformity itself.
These options include:

  • Changes in shoewear. Wearing the right kind of shoes is very important. Choose shoes that have a wide toe box and forgo those with pointed toes or high heels which may aggravate the condition.
  • Padding. Pads placed over the area of the bunion can help minimize pain. You can get bunion pads from your foot and ankle surgeon or purchase them at a drug store.
  • Activity modifications. Avoid activity that causes bunion pain, including standing for long periods of time.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help to relieve pain.
  • Icing. Applying an ice pack several times a day helps reduce inflammation and pain.
  • Injection therapy. Although rarely used in bunion treatment, injections of corticosteroids may be useful in treating the inflamed bursa (fluid-filled sac located in a joint) sometimes seen with bunions.
  • Orthotic devices. In some cases, custom orthotic devices may be provided by the foot and ankle surgeon.
Corns can usually be easily seen. They may have a tender spot in the middle, surrounded by yellowish dead skin. Treating foot problems like corns is a team effort. You will need to work with your physician to ensure that problems don't recur.

Actually, most foot problems can be blamed not on walking but on your walking shoes. Corns, for example, are calluses that form on the toes because the bones push up against the shoe and put pressure on the skin. The surface layer of the skin thickens and builds up, irritating the tissues underneath. Hard corns are usually located on the top of the toe or on the side of the small toe. Soft corns resemble open sores and develop between the toes as they rub against each other.

Treatment
  • You can soak your feet regularly and use a pumice stone or callus file to soften and reduce the size of corns and calluses.
  • Wearing a donut-shaped foam pad over the corn will also help relieve the pressure. Use non-medicated corn pads; medicated pads may increase irritation and result in infection.
  • Use a bit of lamb's wool (not cotton) between your toes to help cushion soft corns.
  • Wear shoes that fit properly and have a roomy toe area.
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Ingrown Toenails

If you trim your toenails too short, particularly on the sides of your big toes, you may set the stage for an ingrown toenail. Like many people, when you trim your toenails, you may taper the corners so that the nail curves with the shape of your toe. But this technique may encourage your toenail to grow into the skin of your toe. The sides of the nail curl down and dig into your skin. An ingrown toenail may also happen if you wear shoes that are too tight or too short.

Ingrown nails may develop for many reasons. Some cases are congenital-the nail is just too large for the toe. Trauma, such as stubbing the toe or having the toe stepped on, may also cause an ingrown nail. However, the most common cause is tight shoe wear or improper grooming and trimming of the nail.

Nonsurgical Treatment

Ingrown toenails should be treated as soon as they are recognized. If they are recognized early (before infection sets in), home care may prevent the need for further treatment:

  • Soak the foot in warm water 3-4 times daily like foot massager.
  • Keep the foot dry during the rest of the day.
  • Wear comfortable shoes with adequate room for the toes. Consider wearing sandals until the condition clears up.
  • You may take ibuprofen or acetaminophen for pain relief.
  • If there is no improvement in 2-3 days, or if the condition worsens, call your doctor.

You may need to gently lift the edge of the ingrown toenail from its embedded position and insert some cotton or waxed dental floss between the nail and your skin. Change this packing every day.

Surgical Treatment

If excessive inflammation, swelling, pain and discharge are present, the toenail is probably infected and should be treated by a physician (see left image below). You may need to take oral antibiotics and the nail may need to be partially or completely removed (see middle image below). The doctor can surgically remove a portion of the nail, a portion of the underlying nail bed, some of the adjacent soft tissues and even a part of the growth center

Unless the problem is congenital, the best way to prevent ingrown toenails is to protect the feet from trauma and to wear shoes and hosiery (socks) with adequate room for the toes. Nails should be cut straight across with a clean, sharp nail trimmer without tapering or rounding the corners. Trim the nails no shorter than the edge of the toe. Keep the feet clean and dry at all times.

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Hammer Toes

Hammertoe is a contracture-or bending-of one or both joints of the second, third, fourth, or fifth (little) toes. This abnormal bending can put pressure on the toe when wearing shoes, causing problems to develop. Corns and calluses can be painful and make it difficult to find a comfortable shoe. But even without corns and calluses, hammertoes can cause pain because the joint itself may become dislocated.

The most common cause of hammertoe is a muscle/tendon imbalance. This imbalance, which leads to a bending of the toe, results from mechanical (structural) changes in the foot that occur over time in some people.

Hammertoes are often aggravated by shoes that don't fit properly-for example, shoes that crowd the toes. And in some cases, ill-fitting shoes can actually cause the contracture that defines hammertoe. For example, a hammertoe may develop if a toe is too long and is forced into a cramped position when a tight shoe is worn.

Occasionally, hammertoe is caused by some kind of trauma, such as a previously broken toe. In some people, hammertoes are inherited.

There are a variety of treatment options for hammertoe. The treatment your foot and ankle surgeon selects will depend upon the severity of your hammertoe and other factors.

A number of non-surgical measures can be undertaken:

  • Trimming corns and calluses. This should be done by a healthcare professional. Never attempt to do this yourself, because you run the risk of cuts and infection. your foot and ankle surgeon knows the proper way to trim corns to bring you the greatest benefit.
  • Padding corns and calluses. your foot and ankle surgeon can provide or prescribe pads designed to shield corns from irritation. If you want to try over-the-counter pads, avoid the medicated types. Medicated pads are generally not recommended because they may contain a small amount of acid that can be harmful. Consult your foot and ankle surgeon about this option.
  • Changes in shoewear. Avoid shoes with pointed toes, shoes that are too short, or shoes with high heels-conditions that can force your toe against the front of the shoe. Instead, choose comfortable shoes with a deep, roomy toe box and heels no higher than two inches.
  • Orthotic devices. A custom orthotic device placed in your shoe may help control the muscle/tendon imbalance.
  • Injection therapy. Corticosteroid injections are sometimes used to ease pain and inflammation caused by hammertoe.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are often prescribed to reduce pain and inflammation.
  • Splinting/strapping. Toe Splints or small straps may be applied by the foot and ankle surgeon to realign the bent toe.
In some cases, usually when the hammertoe has become more rigid, surgery is needed to relieve the pain and discomfort caused by the deformity. Your foot and ankle surgeon will discuss the options and select a plan tailored to your needs. Among other concerns, he or she will take into consideration the type of shoes you want to wear, the number of toes involved, your activity level, your age, and the severity of the hammertoe.

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Crossover Toe

Crossover toe is a condition in which the second toe drifts toward the big toe and eventually crosses over and lies on top of the big toe. Crossover toe is a common condition that can occur at any age, although it is most often seen in adults.

Some people confuse crossover toe with a hammertoe, probably because both conditions involve a toe that does not lie in the normal position. However, crossover toe is entirely different from a hammertoe-and much more complex.

Crossover toe is a progressive disorder. In the very early stages-the best time to treat crossover toe-a patient may have pain but no crossover of the toe. Without treatment, the condition usually worsens to dislocation of the joint, so it is very beneficial to have a foot and ankle surgeon evaluate the foot soon after pain first occurs.

It is generally believed that crossover toe is a result of abnormal foot mechanics, where the ball of the foot beneath the second toe joint takes an excessive amount of weight- bearing pressure. This pressure eventually leads to weakening of the supportive ligaments and a failure of the joint to stabilize the toe, resulting in the toe crossing over.

Certain conditions or characteristics can make a person prone to experiencing excessive pressure on the ball of the foot. These most commonly include a severe bunion deformity, a second toe longer than the big toe, an arch that is structurally unstable and a tight calf muscle.

The foot and ankle surgeon may select one or more of the following options for early treatment of crossover toe:

  • Rest and ice. Staying off the foot and applying ice packs help reduce the swelling and pain. Apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
  • Oral medications. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, may help relieve the pain and inflammation.
  • Immobilization. Sometimes the foot is immobilized for a while so that the injured tissue can heal.
  • Taping/splinting. It may be necessary to tape the toe so that it will stay in the correct position. This helps relieve the pain and prevent further drifting of the toe.
  • Stretching. Keeping the calf muscles stretched is important in patients who have tight calf muscles.
  • Shoe modifications. Supportive shoes with stiff soles are recommended because they control the motion and lessen the amount of pressure on the ball of the foot.
  • Orthotic devices. Custom shoe inserts are often very beneficial. These include arch supports or a metatarsal pad that distributes the weight away from the joint.
Once the second toe starts moving toward the big toe, it will never go back to its normal position unless surgery is performed. The foot and ankle surgeon will select the procedure or combination of procedures best suited to the individual patient.

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Fractured Toe Bones

A fracture is a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.

Traumatic fractures (also called acute fractures) are caused by a direct blow or impact-like seriously stubbing your toe. Traumatic fractures can be displaced or nondisplaced. If the fracture is displaced, the bone is broken in such a way that it has changed in position (dislocated). Treatment of a traumatic fracture depends on the location and extent of the break and whether it is displaced. Surgery is sometimes required.

Treatment of Toe Fractures
Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

  • Rest. Sometimes rest is all that is needed to treat a traumatic fracture of the toe.
  • Splinting. The toe may be fitted with a splint to keep it in a fixed position.
  • Rigid or Stiff-Soled Shoe. Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned.
  • "Buddy Taping." "Buddy taping" the fractured toe to another toe is sometimes appropriate, but in other cases it may be harmful.
  • Surgery. If the break is badly displaced or if the joint is affected, surgery may be necessary. Surgery often involves the use of fixation devices, such as pins.
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Information obtained from National Institute of Health
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