Toe Pain Research Articles

Adverse To Converse

Toe Pain--- Cross-Country HISTORY: A 12 year-old female cross country runner presented to the pediatric sports medicine clinic with 3 months of right second toe pain. Initially, the pain started after stubbing her toe. She developed a constant dull ache that was present at rest and worsened with prolonged walking and during cross country. She noted that her symptoms gradually worsened with time, and she was having no improvement with rest, icing and anti-inflammatories. PHYSICAL EXAMINATION: Overlying skin with no rashes or lesions. Tenderness along the plantar surface of her right second metatarsophalangeal (MTP) joint. ROM was limited in both passive and active flexion and extension of the affected joint. Sensation was intact, and strength with flexion and extension of the toe was normal, however there was significant pain with testing. MT squeeze test was negative. Varus and valgus stress to MTP joint elicited no laxity, and “drawer test” of MTP joint showed mild instability. DIFFERENTIAL DIAGNOSIS: 1. Sprain of plantar plate 2. Metatarsal fracture/stress fracture 3. Osteochondrosis of the metatarsal head 4. Metatarsalgia 5. Lisfranc injury 6. Intermetatarsal neuroma TEST RESULTS: X-ray R foot: --- Flattening of the second metatarsal head. MRI R foot without contrast: --- Flattening/collapse of the 2nd metatarsal head/distal epiphysis with prominent marrow edema of the 2nd metatarsal head and neck. Mild MTP joint space narrowing. FINAL/WORKING DIAGNOSIS: Osteochondrosis of the metatarsal head (Freiberg Disease) - Stage 4 TREATMENT AND OUTCOMES: 1. Placed in short leg walking boot with protected weight-bearing, ice 1-2 times daily, Foot/Ankle Surgery consultation with discussion of conservative care vs surgical (chondral drilling and/or chondroplasty). Patient opted for conservative care. 2. At 4-week follow-up, patient’s pain significantly reduced. Continued walking boot additional 4 weeks with transition into stiff-soled shoe. 3. At 8-weeks post treatment, follow-up MRI showed no progression of disease. Clinically with almost complete resolution of pain. 4. By 10 weeks, transitioned into a custom foot orthotic with added support to float 2nd MTP joint. Restrictions included low impact sports only with plan for repeat MRI at 6 months.

Toe Pain - Softball

HISTORY: An 18-year-old collegiate softball player started noticing right great toe pain in March of her freshmen season. Pain was unrelenting throughout the day but temporarily responded to anti-inflammatories. She denied fevers, chills, night sweats, or unexpected weight loss. She did not report her pain to the team physician. However, after seeing an outside physician for continued pain, she was placed in a walking boot and provided a bone stimulator. After an additional three weeks of pain despite these therapies, she presented to the training room for re-evaluation of her toe. PHYSICAL EXAMINATION: Examination revealed exquisite tenderness to palpation of the dorsal-fibular aspect of the proximal portion of the distal phalanx of the right first toe, with mild swelling but no plantar tenderness. There was full passive and active range of motion of the MTP and IP joints. Skin of the right foot was intact, without erythema or induration. Tendon function was intact. The foot was neurovascularly intact. DIFFERENTIAL DIAGNOSIS: 1. Stress Reaction of right first toe distal phalanx 2. Subacute/Chronic Osteomyelitis 3. Bony Tumor TEST AND RESULTS: Right toe AP, lateral, and oblique radiographs- bony alignment is unremarkable, no acute fracture; joint spaces well preserved. MRI of right foot without contrast - diffuse marrow edema throughout the first distal phalanx; no corresponding focal signal hyperintensity in the distal phalanx.Nuclear medicine bone marrow imaging - mild increased radiotracer uptake in the region of the distal first phalanx suggesting increased regional blood flow. The above studies were reviewed by the team physicians and there was a concern for bony mass of the proximal portion of the dorsal fibular distal phalanx. MRI with contrast confirmed this suspicion. CT right foot without contrast with 3D reconstruction - ill-defined sclerosis in the medial aspect of the base of the first distal phalanx measuring 7 mm x 4 mm x 5 mm with faint lucency proximal to the sclerosis. FINAL WORKING DIAGNOSIS:Osteoid Osteoma TREATMENT AND OUTCOMES: 1. Continued anti-inflammatories with COX2 inhibitors for symptomatic treatment. 2. Surgical curettage and excisional biopsy of the 7 mm x 4 mm x 5 mm nidus; deferment of radiofrequency ablation due to proximity to the joint. 3. Anticipated return to play in 4-6 weeks.

Man With Foot Pain

A 40-year-old man with no medical history presented to the emergency department with bilateral toe pain, which developed during 2 to 3 days. He was afebrile and denied associated complaints. Physical examination was significant for erythematous, tender regions over the toes of both feet (Figures 1 and 2). The patient subsequently had a positive test result for coronavirus disease 2019 (COVID-19).

Hallux valgus severity, great toe pain, and plantar pressures during gait: A cross-sectional study of community-dwelling adults.

Hallux valgus (HV) is a common disabling condition affecting 36% of adults aged 65 years and over. Identifying whether the severity of the deformity alters weight-bearing patterns during walking may assist clinicians optimize offloading interventions. Therefore, we examined how plantar pressure distributions during walking are affected by HV severity. Plantar pressures and maximum forces in ten regions of the foot were obtained from 120 participants (40 men, 80 women) aged ≥50 years using a pressure platform (RSscan® International, Olen, Belgium). HV severity was documented using a validated line-drawing instrument with participants separated into four groups: none (n = 30), mild (n = 30), moderate (n = 30) and severe (n = 30). Pressure and force values were compared across HV severity, stratified by the presence or absence of great toe pain. Participants with severe HV were more likely to have great toe pain. More severe HV was associated with significant reductions in peak pressure and maximum force under the hallux but not at other sites of the foot. This association appeared strongest in those reporting great toe pain. Greater HV severity is associated with great toe pain and reduced loading under the hallux when walking. These observed changes in plantar pressure and maximum force may reflect a pain avoidance mechanism.

P28 Marfan syndrome? Think again!

Abstract Background A 21 year old male was referred to the adult hypermobility clinic from the local rheumatologist with a suspected diagnosis of Marfan syndrome, based on his body habitus although he had presented to his GP with painful toes. Methods He had a background of autism,learning difficulties and was wearing glasses due to amblyopia. He had a history of dental crowding with two previous teeth extractions. There was no family history of note. On examination, his arm span was not greater than his height, there was no arachnodactyly, his palate was normal, but he had gum hypertrophy. His skin texture was normal, with no abnormal scarring or bruising, but there was presence of striae. His Beighton score was 4/9 and he had flat feet. There was reduced muscle mass and hypotonia, which was felt to be the cause of his hypermobility, rather than increased ligamentous laxity. There was evidence of gynaecomastia and lack of facial hair. The working diagnosis was Klinefelter syndrome due to his tall stature, gynaecomastia and absence of secondary male characteristics. Subsequently, the patient was referred to endocrinology and for genetic testing. Results The endocrinology team recognised the clinical features of male hypogonadism with small phallus (Tanner stage 2/3) and small testes, confirmed also by ultrasound. The patient reported absence of early morning erections. Blood tests confirmed hypergonadotropic hypogonadism (high luteinizing hormone, low testosterone) and the patient was commenced on testosterone therapy. His bone mineral density values lied within the expected range for age. Karyotype analysis confirmed the presence of 48,XXYY which is a chromosomal condition characterized by the presence of an extra X and Y chromosome in males. In terms of management, he attended our Outpatient Hypermobility Exercise Programme and was given advice on footwear. He was provided with extensive written information about this condition by the Rare Chromosome Disorder Support Group, Unique. Conclusion Our case report illustrates the importance of considering 48,XXYY syndrome in patients with typical body habitus and joint hypermobility. Marfanoid habitus is associated with connective tissue diseases, like hypermobile Ehlers-Danlos syndrome and Marfan syndrome, but also described in homocystinuria and Klinefelter syndrome. 48,XXYY was considered previously as a variant of Klinefelter syndrome, but now it is regarded as a separate syndrome with overlapping features with the Klinefelter syndrome. As in our case, the classical phenotypic characteristicsinclude gynaecomastia, small testes and tall stature. Most affected individuals are infertile. This syndrome is also associated with behavioural problems, learning difficulties, congenital heart defects, bone abnormalities, tremor, obesity, type 2 diabetes and/orrespiratory problems. Patients have an essentially normal life expectancy but require regular medical follow-up. Disclosures A. Madenidou None. V. Choida None. V. Reddy None. H. Kazkaz None.

Achieving the Quadruple Aim: Treating Patients as People by Screening for and Addressing the Social Determinants of Health

Achieving the Quadruple Aim: Treating Patients as People by Screening for and Addressing the Social Determinants of Health

Patient Knowledge of Provider Training Background and Preferences for Treatment of Foot and Ankle Conditions

Category:Professional, Patient CareIntroduction/Purpose:Differences exist in the training backgrounds of medical providers who treat foot and ankle disorders. Considerable overlap and similarities also exist between podiatric and orthopaedic surgeons, though patients may be unaware of the differences. It is not known to what extent professional training influences how patients seek care. The purpose of this study is to understand patients’ knowledge of the differences in professional training background between podiatry and orthopedic surgery and to determine which factors are important to patients when selecting a provider.Methods:Patient survey data was gathered from Froedtert Memorial Lutheran Hospital and the Mayo Clinic. A 27-question survey was administered to new patients who were referred to the foot and ankle service in an orthopedic department at both institutions. Survey questions included data on patient demographics, patient opinion, and knowledge of differences between podiatry, orthopedics, and other foot and ankle providers. Patients were grouped by provider preference. Univariate and multivariate regressions were used to characterize the study population and determine provider preference. Significance was determined through t-tests, Fisher’s Exact test, and chi-square tests.Results:Of the 169 patients who completed the entire survey, 99 chose “orthopedic surgeon” as their provider of preference for any foot or ankle injury. Between the groups, there was no significant difference in age, healthcare affiliation, previous podiatric visits, level of education, and perceived knowledge about the differences between the two specialties (Table 1). For patients who listed podiatry as their preference, they were less likely to expect their doctor to have completed residency (76.2% vs. 90.7-94.9%, p=0.03). Patients preferred an orthopedic surgeon over a podiatrist for ankle (63.3% vs. 9.5%, p<0.001) and knee injuries (82.8% vs. 5.8%, p<0.001), while they preferred a podiatrist for toe pain (42.6% vs. 27.8%, p<0.001). 76.3% of patients thought orthopaedic surgeons and podiatrist undergo the same professional training.Conclusion:Foot and ankle patients have poor understanding of the different medical and surgical training backgrounds between a podiatrist and orthopedic surgeon. The majority of patients believe podiatrist and orthopaedic surgeons have the same professional training. However, patients also believed orthopaedic surgeons have a longer training period, though it was still underestimated by three years. Patients preferred care for podiatrist with conditions affecting the toes and orthopaedic surgeons for all other conditions.

RECESSIVE MULTIPLE EPIPHYSEAL DYSPLASIA: A CASE REPORT

Multiple epiphyseal dysplasia (MED) is characterized by abnormal bone and cartilage development particularly affecting epiphysis of long bones. Individuals with MED present during childhood presents with hip pain, knee pain and waddling gait. The autosomal recessive MED is differentiated from the dominant type by the presence of hands, knees and feet malformations with scoliosis. We present here, a case of autosomal recessive MED, an eleven and half years old boy who presented with pain in knees, difficulty walking, abnormal fingers and abnormal toes. The radiographs of hands, knees and pelvis were suggestive of an abnormal epiphyseal development. After diagnosis, patient was counseled and he was advised analgesics and different exercises.

Does Hallux Valgus Correction Reduce the Width of the Forefoot?

Background: Hallux valgus has been associated with a widened forefoot. Most surgical procedures for the correction of hallux valgus have the potential to reduce forefoot width. Success after hallux valgus surgery is correlated with relief of toe pain in conventional shoes and improvement in the appearance of the foot. Therefore, reduction in forefoot width, referred to as metatarsal span (MS), likely correlates with both criteria and may be a reliable radiographic indicator of success after hallux valgus surgery. Methods: Preoperative and postoperative radiographs of 52 patients who underwent correction of hallux valgus with a distal Chevron osteotomy and Akin osteotomy were evaluated by 4 observers. The observers measured the hallux valgus angle (HVA), the intermetatarsal first and second angle (IMA), and the MS. Results: Preoperative HVA ranged from 14° to 48°, IMA ranged from 6° to 25°, and MS ranged from 74.2 to 110.6 mm. The average HVA improvement was 19.4°, IMA improvement was 6.7°, and MS reduction was 8.7 mm. No correlation was identified with regard to correction of the HVA or IMA to MS. Conclusion: Digital radiographic linear measurements were easily and reliably made. Therefore, linear measurements as described in this article can be used as a tool to evaluate if clinical outcomes correlate with reduction of MS. A distal Chevron with an Akin osteotomy has the potential to reduce forefoot width. Levels of Evidence: Level IV: Case series.

Decompression and gutter splint techniques to prevent recurrence in ingrowing toenails

Ingrowing toenails (IT) is puncture of periungual skin by its surrounding nail plate. IT most frequently occurs in males aged 10-30 years. Pathogenesis of IT is multifactorial. Patients most commonly present with toe pain and may also complain erythema, swelling, or discharge from the nail edge. The clinical presentation of IT has been divided into three stages; stage I or inflammatory stages, stage II or abcess formation, and stage III or granulation tissue formation. IT is a nail disease with high reccurences that commonly seen in daily practice. Several treatment approaches ranging from conservative therapy (gutter splint) to surgical treatment (decompression technique). We report a case of IT in a 13-year-old boy that treated with decompression and gutter splint technique. The combination of this technique provides good results for IT and there was no recurrences after two months of observation.

Hallux valgus in Riyadh, Saudi Arabia: Prevalence, characteristics, and its associations

Objectives: Hallux valgus (HV) is a common forefoot deformity encountered in orthopedic clinics. Little is known about the condition in Saudi Arabia due to the deficiency of studies investigating its characteristics in the general population. Epidemiological studies documenting HV prevalence are of paramount importance. This study aimed to estimate the prevalence of HV and identify its characteristics among the Saudi population residing in the capital city, Riyadh. Methods: An interview-based and self-reported cross-sectional study was conducted at four commercial centers and three universities in Riyadh, Saudi Arabia. Data were collected between December 2017 and February 2018. For estimation of the prevalence of HV, the Manchester scale was used. Multivariate logistic regression was used to test the relationship between HV and possible risk factors. Bivariate analysis, using cross-tabulation, was used to identify the odds ratios (ORs) of HV and Chi-square to calculate statistical significance. Results: A total of 420 participants (140 males and 280 females) were included in the study. The overall prevalence of HV for all participants was 43% (n = 181). The prevalence of HV in males and females was 30.7% (n = 43) and 49.2% (n = 138), respectively. Severe degree of HV was noted in 0.95% of the participants. The incidence of HV was more prevalent in participants who reported a positive family history (OR = 2.144; P = 0.001), big toe pain (OR = 2.97; P = 0.001), and female gender (OR = 2.039; P = 0.003). Conclusion: In the Saudi Arabian population, HV is a prevalent foot deformity that is associated with big toe pain, positive family history, and female gender.

Scarf and Weil osteotomy for symptomatic hallux valgus does not fully remove second toe residual metatarsalgia

Category: Bunion Introduction/Purpose: Patients with hallux valgus (HV) often experience concurrent second toe metatarsalgia due to altered forefoot biomechanics. Additional second toe Weil osteotomy has been performed to reduce transfer metatarsalgia as some studies have highlighted the presence of second toe pain after isolated HV correction. 1, 2 There is a paucity of literature evaluating residual second toe pain after these procedures . We hypothesize that combined Scarf/Weil osteotomy will result in less residual second toe pain while achieving good functioning outcome. The aim of this study was to evaluate the presence of second toe pain after isolated scarf osteotomy versus combined Scarf/Weil osteotomy. Methods: Between January 2007 and June 2012, 439 patients underwent a scarf osteotomy for symptomatic hallux valgus at a tertiary hospital. Patients who underwent isolated scarf osteotomy were matched 1:1 to patients who had both Scarf and second toe Weil osteotomy. The following functional outcome scores were prospectively collected preoperatively and postoperatively at 6 and 24 months: American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal (MTP-IP) Scale, Visual Analog Scale (VAS), SF36-Physical Component Score (PCS) and Mental Component Score (MCS). Radiological outcomes such as the Hallux Valgus Angle (HVA) and Intermetatarsal Angle (IMA) were measured. Statistical analysis was performed using SPSS® 20.0 and significance was defined as a p-value = 0.05. The Student’s unpaired t-test was used to compare the radiological and functional outcomes between the two groups of patients, while the paired t-test was used to analyze improvement in pre- and postoperative outcomes within each group. Results: 94.4% of the patients were female and no difference in BMI. In the Scarf/Weil group, the HVA and IMA improved by 21.2 ± 10.2 and 8.2 ± 4.7 degrees respectively (both P&lt;0.001). At 2 years, the AOFAS-hallux score improved by 26.6 ± 20.9 (p=0.034), AOFAS-second toe by 29.3 ± 20.9, VAS-hallux by 3.1 ± 3.4 (p&lt;0.001), VAS-second toe by 3.6 ± 3.2 (p&lt;0.001). In the Scarf group, the HVA and IMA improved by 17.1 ± 8.0 and 5.8 ± 4.3 degrees respectively (both p&lt;0.001). At 2 years, the AOFAS-hallux score improved by 32.2 ± 21.2 (p=0.034), AOFAS-second toe by 13.0 ± 16.3 (p &lt;0.001), VAS-hallux by 4.4 ± 3.3 (p&lt;0.001), VAS-second toe by 1.2 ± 2.4 (p&lt;0.001). Conclusion: A significant finding is that at 6 months and 2 years, the VAS-2nd toe score in the isolated Scarf group was 1 ± 0 point lower than the other group (p&lt;0.001). All other functional outcome scores were comparable between the two groups at 6 months. Our findings suggest that shortening second toe Weil osteotomy for large HV deformity may not fully resolve second toe metatarsalgia in the short-term, providing useful information for preoperative counselling.

Floating toe

Category: Midfoot/Forefoot Introduction/Purpose: The Weil osteotomy (WO) is frequently used for treating metatarsalgia and metatarsophalangeal (MTP) instability. Nevertheless, it presents complications, being the floating toe the most frequent one. A modification has been proposed to decrease the beforementioned complication, removing a slice from the osteotomy (modified Weil osteotomy, MWO). Additionally, it has been proposed that stabilizing the toe interphalangeal joints when treating hammer toes may contribute to decrease the floating toe complication, given that all flexors contribute to MTP flexion. The objective of this research is to describe complications and functional score in patients operated with MWO with and without interphalangeal stabilization. Methods: 110 patients (250 toes) treated for metatarsalgia and hammer toe deformity were retrospectively collected and prospectively followed for 66 months (SD 15). 2 groups were studied, 45 adults with isolated MWO and 65 adults with MWO with toe stabilization. Average age 55. Patients with Diabetes, previous surgeries and infections were excluded. LEFS, AOFAS and satisfaction index were recorded. A physical examination looking for floating toe, MTP instability and metatarsalgia was performed. Statistical analysis included logistic regression spearmen correlation test, Mann-Whitney test and student T test. Results: LEFS and AOFAS scores were 70 and 73 respectively, with no differences between patients operated with isolated MWO or with toe stabilization. Satisfaction index average result was “minor reservations”. Floating toe incidence was 24%, with no difference between groups. There was no difference in functional scores and satisfaction index if floating toe was present or absent. There was no correlation between functional scores and satisfaction index. Metatarsalgia was present in 31% of patients, and there is a direct correlation of floating toe occurrence and pain (4 times more chance to have pain). Conclusion: There was no clinical significant consequence of floating toe on LEFS, AOFAS or satisfaction. There was no difference in complication rate, functional scores and patient satisfaction if the interphalangeal joint was fixed or not. Although floating toe didn’t influence on functional scores, it was associated with pain. It can be suggested that the scores utilized were not able to detect the negative influence of floating toe on every patient. The high prevalence of floating toe using the MWO should make us look for additional factors which we may be overlooking when treating metatarsalgia, such as plantar plate damage.

Case Report: Tibial and fibular osteochondroma as an unusual cause of popliteal artery entrapment syndrome

Background: Osteochondroma, or osteocartilaginous exostosis, is the most common benign neoplasm of bone, and accounts for 20-50% of all benign tumors. Vascular complications associated with osteochondromas are rare, and include pseudoaneurysm formation, vessel occlusion and vessel displacement. To date, only two cases of popliteal artery entrapment syndrome (PAES) caused by an isolated fibular osteochondroma have been reported. Case Report: This report describes a unique case of PAES. A 33-year-old woman had a history of multiple osteochondroma, including of the proximal tibia and fibula on the left, diagnosed at age two years and monitored clinically by an orthopedist. The patient presented at our facility with a one-year history of a progressive intermittent claudication, left-sided toe pain and pallor in cold weather. After a complete evaluation, we diagnosed an arterial occlusion of the left popliteal artery. We tried several attempts of revascularization, by different forms, without success. The case went to amputation surgery. Conclusion: We consider this an important case because, although the association of osteochondroma and PAES is rare, physicians should consider it early to avoid acute vascular complications. Moreover, to date, we believe this is the first description of a PAES related with multiple osteochondroma.

Case Report: Bilateral Ainhum in a 6-year-old Black African Male child

Background: Ainhum is an uncommon surgical condition and rarer still in children, and is gradually disappearing due to improved socioeconomic condition of the populace. This has consequently led to paucity of literature on the lesion, making it relatively unknown and may be unrecognized by many. This case report describes the clinical features of this relatively uncommon condition occurring in a black African child, in order to facilitate recognition and appropriate management. Case Summary: The patient was a 6year old child born to a polygamous family, that presented with complains of bilateral progressive pain and swelling in the 5th little toes for about 5months. Attendance to other health facilities including traditional medications has not yielded any improvement. A bilateral constriction at the base of both fifth toes was found on examination. A diagnosis of bilateral Ainhum of the 5th digits was made followed by bilateral amputation at the metatarsophalangeal joint after counseling and due investigations. He had uneventful recovery. Conclusion: Ainhum may occur in children ultimately leading to mutilation, and amputation being the only viable option of treatment. Socio-demographic factors play an important role in the changing pattern of surgical diseases, more ostensibly in Africa, these needs to be considered in the planning of health services.

Identification of Clusters of Foot Pain Location in a Community Sample.

To identify foot pain clusters according to pain location in a community-based sample of the general population. This study analyzed data from the North West Adelaide Health Study. Data were obtained between 2004 and 2006, using computer-assisted telephone interviewing, clinical assessment, and self-completed questionnaire. The location of foot pain was assessed using a diagram during the clinical assessment. Hierarchical cluster analysis was undertaken to identify foot pain location clusters, which were then compared in relation to demographics, comorbidities, and podiatry services utilization. There were 558 participants with foot pain (mean age 54.4 years, 57.5% female). Five clusters were identified: 1 with predominantly arch and ball pain (26.8%), 1 with rearfoot pain (20.9%), 1 with heel pain (13.3%), and 2 with predominantly forefoot, toe, and nail pain (28.3% and 10.7%). Each cluster was distinct in age, sex, and comorbidity profile. Of the two clusters with predominantly forefoot, toe, and nail pain, one of them had a higher proportion of men and those classified as obese, had diabetes mellitus, and used podiatry services (30%), while the other was comprised of a higher proportion of women who were overweight and reported less use of podiatry services (17.5%). Five clusters of foot pain according to pain location were identified, all with distinct age, sex, and comorbidity profiles. These findings may assist in the identification of individuals at risk for developing foot pain and in the development of targeted preventive strategies and treatments.

Implementation and Validation of Anatomic Triplane Hallux Abducto Valgus Classification

Category: Bunion Introduction/Purpose: The most common classification system for HAV deformity is based on two-dimensional radiographs. This system relies upon measurements taken of the transverse plane. (IMA and HVA) to classify and deploy surgical options based on the severity of these angles [1]. Recently, the understanding of HAV deformity as a three-dimensional problem has been described. A study by Kim et al. [2] utilized WB-CT to describe a frontal plane rotational component in 87% HAV cases. To develop a better understanding of HAV, a unique anatomic classification system (see figure) was proposed. The aims of this study were: (1) To use traditional WB radiographs to confirm the findings of Kim’s WB-CT study. (2)To use inter-observer and intra-observer analysis to validate the classification of HAV into this new system. Methods: An Institutional Review Board approved multi-center retrospective study was performed utilizing four view WB radiographs (Anterior-Posterior, Oblique, Lateral and Axial Sesamoid) on patients presenting to the clinic for “bunion,” Hallux Valgus, HAV, Hallux Rigidus or “great toe pain.” The data were analyzed for the presence of frontal/coronal plane rotation of the first metatarsal, subluxation of the sesamoids, metatarsus adductus and degenerative joint disease of the first MTP (metatarsophalangeal) joint (Hallux Rigidus); these findings were compared to Kim’s study. Additionally, these data were used to categorize HAV deformities into a new 3D classification scheme and were tested for inter-observer and intra-observer reliability. Results: The results established the presence of frontal/coronal plane rotation and subluxation in similar ratios as reported by Kim et al. thus confirming the utility of a four-view WB radiograph series in recognition of 3D deformity of HAV. The results also confirmed good reliability of the classification from both the inter-observer and intra-observer standpoint. Conclusion: These data suggest that new protocols and tools are reliable in helping the surgeon recognize and better identify the three-dimensional components of HAV.

Management of Hallux Rigidus in Athletes

Hallux rigidus can be a major limiting factor for athletes due to pain, stiffness, and weakness. Any sporting activity that requires significant dorsiflexion of the hallux to perform at peak level will be negatively impacted by a painful stiff toe due to limited push-off strength and propulsive power. There are reasonably good nonsurgical options to help an athlete to extend their activities and career, and should be exhausted before indicating for surgery. Once nonoperative measures are no longer able to meet the satisfaction of the patient, several surgical options are available. The surgical choice depends upon the grade of disease and expectations of the athlete. In running sports, the initial goal is always to increase and maintain range of motion, while reducing pain. This is easier to achieve in early stages of hallux rigidus. In later stages of hallux rigidus, it might be possible to increase range of motion, but the underlying degenerative changes of the joint might continue to cause pain with activities. An arthrodesis is the most reliable way to achieve pain relief, but will also have most impact on the ability to play certain sports.

Turf Toe: 40 Years Later and Still a Problem

“Turf toe,” originally described in literature by Bowers and Martin in 1976, is an injury to the capsuloligamentous complex of the first metatarsophalangeal joint. This injury is common in football players. Up to 45% of National Football League (NFL) players have suffered from turf toe during their professional career. Turf toe injuries have been attributed to playing on hard, artificial surfaces with soft, flexible cleats; 83% of the turf toe injuries occurred on artificial turf. For most turf toe injuries, nonoperative treatment is the preferred approach, even in some cases with associated fracture of the sesamoids. Operative intervention should be considered after nonoperative management has failed or in cases of clear instability or sesamoid retraction. Good functional outcomes with high rates of return to play can be expected with appropriate management. Despite this, persistent symptoms of stiffness and great toe pain are not uncommon following initial injury, surgery or both. Due to limited availability of high-level evidence regarding the outcomes of turf toe injuries, particularly for surgical management of high-level athletes, this article will combine what is available with level V evidence based on the senior author’s experience over 34 years and his discussions with other experts in the unique subspecialty of foot and ankle sports medicine.

Six-year multi-centre, observational, post-marketing surveillance of the safety of the HPV-16/18 AS04-adjuvanted vaccine in women aged 10-25years in Korea.

PurposeTo evaluate the safety of HPV‐16/18 AS04‐adjuvanted vaccine when administered as per the PI in Korea.MethodsA total of 3084 women aged 10–25 years were enrolled in this post‐marketing surveillance from 2008 to 2014. Subjects were invited to receive three doses of the vaccine (0, 1 and 6 months), and participants who received at least one dose were included in the analysis. Adverse events (AEs), adverse drug reactions (ADRs) and serious AEs (SAEs) were recorded after each dose. All AEs, ADRs and SAEs were presented with exact 95% confidence intervals (CI) (NCT01101542).ResultsInjection‐site pain was the most frequent AE and ADR reported by 322 subjects (10.4% [95%CI: 9.4–11.6]); the local pain was transient and lasted 4–7 days in most cases. Dysmenorrhoea and vaginitis were the most common unexpected AEs reported by 30 (1.0% [95%CI: 0.7–1.4]) and 16 subjects (0.7% [95%CI: 0.3–0.8]), respectively. Pain (toe pain, leg pain and body pain [one case each]; foot pain [two cases]) was the most common unexpected ADR reported by five subjects (0.2% [95%CI: 0.1–0.4]). Four subjects reported a single SAE (one case each of exostosis, gastroenteritis, abortion and tonsillitis); none were fatal. All SAEs were assessed as unlikely to be related to vaccination; gastroenteritis, exostosis and tonsillitis resolved during the study period.ConclusionsThis is the first post‐marketing surveillance study in Korea that provides 6‐year safety data for HPV‐16/18 AS04‐adjuvanted vaccine. The vaccine showed an acceptable safety profile and favourable benefit/risk ratio when given to women aged 10–25 years in Korea. © 2017 The Authors. Pharmacoepidemiology & Drug Safety Published by John Wiley & Sons Ltd.