Forefoot pathologies

Red flag screening

• Sinister pathology
• Emergency conditions such as acute tendon rupture or fracture
• Osteomyeltis/infection.

Consider

• Mechanism of injury
• Duration and severity in symptoms
• Change in symptoms
• Limitation of function
• Swelling pattern and severity
• Development of structural changes in the toes.

• Assess passive and active range of motion, bony tenderness, muscle power.
• Assess for tightness in triceps surae.
• Pain on compression of intermetatarsal space.
• Digital drawer test to assess integrity of plantar plate and joint capsule.

• X-ray if suspected bone pathology
• Diagnostic ultrasound for capsular or inflammatory pathologies
• Blood work if inflammatory arthropathy or infection indicated.

• Neuroma
• Synovitis
• Bursitis
• Capsule injury
• Infection
• Stress fracture
• Avascular necrosis
• Plantar plate injury
• Joint changes related to systemic disease (i.e. R/A, O/A)

Patient education and self-management advice, with supporting literature including:

• Weight management advice if appropriate
• Activity modification and management advice
• Analgesia & non-steroidal anti inflammatory drugs as appropriate.
• Exercise prescription
• Footwear advice
  • Increased width and depth of toe box, low heel height with more rigid rocker.

• Failure of first line treatment
• Ambiguous diagnosis
• Worsening symptoms.