Cartilage mapping might offer some prediction in regard to long-term outcomes of first toe pathology or so Thomas Roukis (2005) suggests. This paper considers the evidence that might support this hypothesis. All clinicians desire to help patients and there are no reasons why earlier interventions should not be the goal to prevent surgery being required.
Not every patient with a hallux valgus or hallux rigidus requires surgery if symptoms can be allayed. The primary question relates to the prediction of a strategy related to the location of osteochondral lesions. Are specific criteria such as hallux valgus angle and the articular angle of the metatarsal head together with long or short metatarsal lengths useful as criteria for intervention." Often unstated, the metatarsal-sesamoid joint relationship creates the highest focus when studies start to analyse zones affecting this joint complex. To exclude the sesamoid apparatus from assessment could lead to some patients being disappointed.
Many papers on hallux valgus concentrate on surgery with little evidence on conservative care. Deformity plays less of a role in why patients come to us (Tollafield 2019). Dayton (2018) cites others suggesting that pain arises from the medial eminence (70-75%) and from intractable plantar keratoma (IPK) and metatarsalgia (40-48%). Secondary features generally drive patients to seek assistance (Table 1, opposite).
Deformity and arthritis of the first toe joint did not determine joint pain as much as general health, educational attainment and level of physical activity (Hurn el al, 2014). The statistics covering pain (62%) and deformity (37%) were derived from the database PASCOM-10, a tool used by the College of Podiatry covering 1030 responses with 571 statements. The data is skewed toward surgical consultations. Referrals arise in the main from medical practitioners with the purpose of surgical discussion in mind. Pain, discomfort and difficulties with walking and wearing shoes are placed into the 60% group of the complainants for this first toe condition (Tollafield 2019).
The idea of using RICE, the mnemonic for rest, ice, compression and elevation, might appear ideal but this is not always practical for patients who do not have acute pain, except maybe for gout or turf toe injury. But what of pain associated with the chronic condition? RICE can still be applied but managing pressure and stabilising the joint forms the key management strategy. Metatarsalgia can be arrested depending upon patient footwear considerations in relation to orthoses and insole prescriptions.
What are the objectives of treatment?
There is probably little doubt that surgical papers predominantly refer to cartilage damage in passing without meaningful conclusion. One should ask, does it matter? The podiatrist needs to know how to use the information reliably to inform patients of prognosis.
Should a patient have an intervention and what intervention is best?
Protecting soft tissue should be paramount as in footwear, local padding or devices suited to protecting the first toe prominence. Splints and taping all have a part to play but no-one has studied the effect on hallux valgus degeneration emanating from erosions within the conservative...