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Plantar Fasciitis — Full Clinical Guide (UK Podiatry)

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1. Definition

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2. Pathophysiology

Mechanical mechanism

Tissue response

• Microtear → attempted repair → further microtear at the same site
• Histologically: collagen fibre disorganisation, mucoid degeneration, angiofibroblastic hyperplasia (similar to other insertional tendinopathies)
• Absence of classic inflammatory cells in chronic specimens — hence the preferred term fasciosis or fasciopathy in the research literature
• Over time, a traction osteophyte (heel spur) may develop at the calcaneal origin — though this is a consequence, not a cause, and is present in asymptomatic individuals

The Windlass Mechanism

• Raises the longitudinal arch
• Supinates the subtalar joint
• Provides a rigid lever for propulsion

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3. Risk Factors

Intrinsic (patient-related)

Extrinsic (activity/environment-related)

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4. Gait Analysis & Deviations

Stance Phase Deviations

• Excessive calcaneal eversion at initial contact — subtalar joint pronates beyond normal (~4–6°), increasing medial fascial tension
• Prolonged pronation through midstance (when the foot should be resupinating) — delays windlass activation and keeps the fascia under load

• Medial arch collapse — loss of the normal arch during weight acceptance; flattening increases strain at the calcaneal origin
• Abducted foot progression angle — toe-out gait pattern; associated with rearfoot valgus and compensatory pronation
• Antalgic gait — shortened stance phase on the affected side; reduced heel contact time as the patient avoids loading the painful insertion

• Early heel lift — to avoid painful dorsiflexion of the ankle at terminal stance; this reduces the normal windlass activation and redistributes force onto the forefoot
• Reduced push-off power — weakness or avoidance of full plantarflexion; decreased hallux dorsiflexion
• In-toe or out-toe gait — compensatory strategies to offload the medial heel

Swing Phase

• Generally less affected, though hip abductor weakness and pelvic drop (Trendelenburg) may contribute to subtalar pronation during stance and should be assessed

Specific Gait Observations

• Windlass test (Jack's test): passive dorsiflexion of the hallux with the patient weight-bearing — failure to form a clear arch (insufficient windlass) correlates with PF and excessive pronation
• Silfverskiöld test: differentiates true equinus (gastrocnemius contracture vs. gastro-soleus contracture) — critical as isolated gastrocnemius tightness is a major modifiable driver

Pedobarograph Findings

• Elevated peak plantar pressures medially and beneath the calcaneus
• Lateral column underloading in pes cavus
• Medial column overloading in pes planus

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5. Assessment

History

• Site: plantar heel, medial calcaneal region
• Character: sharp, stabbing — classically post-static dyskinesia (worst with first steps in the morning or after prolonged sitting, easing with activity, worsening again with sustained activity)
• Duration: often months before presentation
• Aggravating: barefoot walking, stairs, hard surfaces, prolonged standing
• Bilateral in ~30% of cases; may coexist with PTTD (posterior tibial tendon dysfunction)

Physical Examination

Differential Diagnoses to Exclude

• Calcaneal stress fracture
• Fat pad atrophy / syndrome
• Baxter's neuritis (first branch of lateral plantar nerve — more medial tenderness over abductor hallucis)
• Tarsal tunnel syndrome
• Seronegative spondyloarthropathy
• Calcaneal tumour / Paget's disease (in older patients)

Investigations

• X-ray (weight-bearing): mandatory first step — rules out stress fracture, bone tumour, enthesophytes; heel spurs alone have no diagnostic value
• Ultrasound: demonstrates plantar fascial thickening (>4 mm pathological), hypoechogenicity at origin — useful for guided injection
• MRI: most sensitive; shows fascial thickening and perilesional oedema; not routinely required but useful in refractory cases

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6. Management

Conservative (First-Line — NHS Podiatry Standard)

• Relative rest — reduce high-impact loading; avoid barefoot walking and flat shoes
• Graduated return to activity

• Plantar fascia-specific stretch: seated, ankle dorsiflexed, toes manually dorsiflexed — confirm tension on plantar surface; 3 × 10 repetitions before first steps in the morning
• Achilles/gastrocnemius stretching: wall stretches with knee straight (gastrocnemius) and bent (soleus); sustained 30-second holds
• Silfverskiöld-guided stretching: if isolated gastroc contracture, focus calf stretches on knee-extended position

• Heel-cushioned trainers with good arch support
• Avoid flat shoes and barefoot walking
• Heel raises (temporary) to reduce Achilles and fascial tension

• Dorsiflexion night splint (AFO-type) holds ankle at neutral/slight dorsiflexion overnight
• Maintains passive stretch during sleep; reduces post-static dyskinesia in the morning
• Particularly effective when equinus is a driver

• NSAIDs: short course for analgesic effect (chronic PF has minimal inflammation)
• Ice/ice massage to plantar heel after activity

• Eccentric loading protocols, shockwave therapy, taping

• Short-term pain relief (~1 month); ultrasound guidance preferred
• Risks: plantar fascia rupture (risk increases with multiple injections — mean 2.67 injections associated with rupture), fat pad atrophy
• Should be counselled thoroughly before proceeding

Second-Line / Refractory

• Extracorporeal shockwave therapy (ESWT): growing evidence base; NICE-approved for refractory PF; particularly low-intensity protocols
• Platelet-rich plasma (PRP) injection: emerging evidence; reduces inflammatory cytokines and promotes fascial healing
• Walking boot / short-leg cast: offloads fascia in severe/refractory cases

Surgical (< 5% of patients)

• Only after ≥6–12 months of failed conservative management
• Limited plantar fasciotomy (medial half only): complete release risks lateral column overload, metatarsal stress fractures
• Gastrocnemius recession: for patients with clear isolated gastrocnemius contracture without Baxter's neuritis
• Deep fascia release of abductor hallucis: if Baxter's neuritis (lateral plantar nerve entrapment) is coexistent

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7. Prescribed Orthotics

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Prescription 1 — Functional Semi-Rigid Orthosis for PF with Excessive Pronation / Pes Planus

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Prescription 2 — Accommodative Cushioned Orthosis for PF with Pes Cavus / Rigid High-Arched Foot

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UK Podiatric Orthotic Prescription Notes

• Casting: UK podiatrists cast in subtalar neutral (STN), partial weight-bearing or non-weight-bearing; digital scanning (e.g. INFOOT, RS Scan) increasingly standard
• Labs: common UK orthotic laboratories include Algeos, Canonbury, and Hospital Appliances (HAL)
• Material shorthand: PPT = polyurethane protective tissue; EVA = ethylene vinyl acetate (Shore hardness specifies firmness); Poron = medical-grade polyurethane foam
• Review: both prescriptions should be reviewed at 6–8 weeks with gait reassessment and patient feedback on comfort and symptom relief; modifications (grinding, additions, top cover replacement) are routine

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Hallux Rigidus — Full Clinical Guide (UK Podiatry)

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1. Definition

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2. Pathophysiology

Articular Cartilage Degeneration

• Subchondral bone becomes exposed → reactive sclerosis and cyst formation
• Synovial inflammation develops secondary to cartilage particle abrasion — resulting in synovitis, joint effusion, and pain
• Osteophyte formation occurs at the dorsal metatarsal head and proximal phalangeal base — initially as a mechanical response to altered load distribution, but progressively impinges on available dorsiflexion range

Mechanical Mechanism

• Dorsal osteophytes physically block dorsiflexion, reducing joint ROM progressively
• Reduced dorsiflexion impairs windlass activation → loss of propulsive efficiency → compensatory gait deviations (see Section 4)
• As cartilage loss progresses centrally, pain occurs throughout the arc of motion, not just at the extremes

Aetiology of Joint Damage

• Repetitive microtrauma — particularly in athletes and those with hypermobility of the first ray
• Post-traumatic — following intra-articular fractures, osteochondral lesions, or "turf toe" (acute hyperextension)
• Metabolic — gout (monosodium urate crystal deposition) and pseudogout can accelerate or mimic HR
• Inflammatory — rheumatoid arthritis and seronegative spondyloarthropathies (psoriatic arthritis, reactive arthritis) may involve the 1st MTPJ as an enthesopathy or erosive arthritis
• Genetic/structural predisposition — elevated first ray, long first metatarsal, metatarsus primus elevatus, and hypermobile first ray all increase joint loading

Radiological Hallmarks

• Significantly narrowed joint space (dorsal > diffuse with progression)
• Subchondral sclerosis
• Subchondral cysts
• Osteophytes along the dorsal osteochondral junction
• In advanced disease, periarticular bone loss and deformity

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3. Risk Factors

Intrinsic Factors

Extrinsic Factors

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4. Gait Analysis & Deviations

Stance Phase Deviations

• Often relatively normal in early HR; the compensation begins as the foot approaches midstance and the MTPJ is asked to dorsiflex

• Early heel lift — the patient lifts the heel prematurely to avoid achieving the MTPJ dorsiflexion required during terminal stance; this is one of the most consistent gait deviations
• Reduced velocity and cadence — shortened step length on the affected side

• Insufficient push-off — the hallmark gait deviation; loss of normal 1st MTPJ dorsiflexion means the windlass mechanism cannot fully activate; propulsive force is markedly reduced
• Transfer of weight to the lateral forefoot — the patient rolls off the lateral digits (2nd–5th toes) rather than the hallux to avoid the blocked joint; this can lead to secondary metatarsalgia, corns, and callus under the 2nd and 3rd metatarsal heads
• In-toe or out-toe gait modification — abducting the foot (toe-out) during propulsion bypasses the blocked dorsiflexion axis and allows lateral roll-off; alternatively, some patients adopt an in-toe position to engage plantarflexors as compensators
• Bouncing gait — a short, bouncing propulsive pattern results from inability to smoothly roll over the hallux; listed explicitly in orthopaedic gait abnormality tables as associated with HR at the midstance-to-preswing phase
• Hallux interphalangeal (IP) joint hyperextension — the IP joint may hyperdorsiflex as the patient attempts to achieve some push-off movement; can lead to IP joint OA over time

• Subtalar overpronation — compensatory pronation in midstance attempts to plantarflex the first ray and improve MTPJ dorsiflexion availability; however, this increases medial column stress
• Hip external rotation — rotating the limb outward shifts the propulsive axis away from the blocked MTPJ
• Knee hyperextension — to compensate for poor push-off drive
• Antalgic (pain-avoidance) gait — shortened stance phase on the affected side; reduced heel-to-toe progression

Pedobarograph / Pressure Plate Findings

• Reduced peak pressures under the hallux/1st MTPJ
• Elevated peak pressures beneath the 2nd and 3rd metatarsal heads (lateral transfer)
• Prolonged lateral forefoot contact time
• Asymmetric propulsive phase with reduced impulse under the medial forefoot

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5. Assessment

History

• Site: dorsal and/or diffuse first MTPJ; may refer to the plantar sesamoid region
• Character: aching at rest progressing to sharp pain with activity; worse on stairs, slopes, and push-off
• Onset: typically insidious and gradual over years; may follow acute trauma
• Aggravating: barefoot walking, inclines, running, squatting, wearing flat shoes
• Relieving: rest, stiff-soled footwear, elevation
• Bilateral: common when hereditary; check contralateral side
• Associated features: visible/palpable dorsal bony lump; dorsal skin irritation from shoe pressure; secondary metatarsalgia

Physical Examination

Clinical Grading (Coughlin & Shurnas — widely used in UK podiatry/orthopaedics)

Investigations

• Weight-bearing X-ray (DP + lateral): mandatory — demonstrates joint space narrowing, subchondral sclerosis, cysts, and osteophyte size/distribution; grading is radiographic + clinical
• Ultrasound: identifies dorsal osteophytes, joint effusion, synovitis, and soft tissue changes; useful for guided injection
• MRI: most sensitive for cartilage assessment and osteochondral lesions; used when surgical planning is required or diagnosis is unclear
• Blood tests: if systemic arthritis or gout suspected — uric acid, CRP, ESR, rheumatoid factor, anti-CCP

Differential Diagnoses

• Hallux valgus (often coexists)
• Gout / pseudogout
• Sesamoiditis
• Turf toe (acute)
• Rheumatoid/psoriatic arthritis
• Osteochondral defect of 1st metatarsal head
• Freiberg's disease (avascular necrosis of metatarsal head — typically 2nd)

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6. Management

Conservative (First-Line — NHS Podiatry Standard)

• Explanation of degenerative nature; importance of footwear and load management
• Avoid activities requiring extreme MTPJ dorsiflexion (uphill running, jumping, squatting)
• Gradual, low-impact exercise (swimming, cycling — where MTPJ load is reduced)

• Wide, deep toe box — reduces dorsal osteophyte pressure and skin irritation
• Stiff/rigid-soled shoes — limits MTPJ bending moments
• Low, broad heel — keeps the foot in a more neutral position
• Avoid flat, flexible shoes (flip-flops, ballet pumps) which maximise MTPJ stress
• Rocker-bottom shoe modifications (see orthotic prescriptions): moves the pivot point proximal to the MTPJ, allowing toe-off without joint bending

• Core conservative intervention in UK podiatry
• Reduces joint loading, redirects pressure, accommodates deformity

• NSAIDs: oral (short course) or topical — reduce synovitis and pain
• Ice/contrast bathing for acute flares

• Intra-articular: useful for short-term pain relief, particularly in active inflammatory phases
• Ultrasound guidance improves accuracy
• Temporary — does not alter structural progression; limited to 2–3 injections per year

• Joint mobilisation (grades I–II Maitland) — some benefit in early HR to maintain available ROM
• Intrinsic foot muscle strengthening
• Gait re-education

• If plantar sesamoid pain coexists, a dancer's pad or sesamoid aperture pad may be incorporated

Second-Line / Adjunct

• Hyaluronic acid (viscosupplementation) injection: emerging evidence; may delay surgical intervention in grade II–III
• PRP injection: limited evidence; may reduce synovitis
• Toe spacers / silicone digital props: if secondary IP joint issues develop

Surgical (Grades I–II: Joint-Preserving; Grades III–IV: Fusion)

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7. Prescribed Orthotics

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Prescription 1 — Functional Rigid/Semi-Rigid Orthosis with Morton's Extension (HR Grades I–II, Active Patient)

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Prescription 2 — Accommodative Full-Contact Orthosis with Rocker Profile (HR Grades II–III, Older / Less Active Patient or Post-Arthritic Painful Forefoot)

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UK Podiatric Orthotic Notes for HR

• Carbon fibre orthoses: preferred for Morton's extension in active/athletic patients — ultra-thin, rigid, and tolerated in standard training shoes
• Morton's extension vs. Kinetic Wedge: the Kinetic Wedge design (cut-out beneath the 1st MTH that tapers proximally under the hallux) is an alternative to the full Morton's extension; it allows some 1st MTH plantarflexion while still reducing MTPJ loading
• Shoe selection: wide toe box + rigid or semi-rigid sole is non-negotiable; the orthosis is ineffective in flexible, flat footwear
• Review: 6–8 weeks post-fitting with pressure analysis if available; adjust Morton's extension length/thickness and rearfoot posting based on symptom response and gait findings

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Morton's Neuroma — Full Clinical Guide (UK Podiatry)

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1. Definition

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2. Pathophysiology

Anatomical Basis

• The lateral branch of the medial plantar nerve frequently communicates with a branch of the lateral plantar nerve, producing a larger-calibre nerve trunk with less room to accommodate swelling
• The nerve lies close to the ground, covered only by a thin fat pad
• The DTML above acts as an unyielding roof during dorsiflexion

Mechanical Compression

• The metatarsal heads to splay apart slightly
• Simultaneous tightening of the DTML
• The digital nerve is compressed between the DTML dorsally and the ground plantarly — a "nutcracker" mechanism

Tissue Response and Histology

1. Endoneural oedema → early, reversible
2. Perineural fibrosis → fibroblast proliferation around the nerve sheath; may be seen on imaging as a well-defined ovoid mass
3. Demyelination → in established neuromas; produces the characteristic burning, electric, and neuropathic pain symptoms
4. Axonal degeneration → in severe/longstanding cases; produces numbness and permanent sensory deficit

• Intermetatarsal bursitis — an inflamed intermetatarsal bursa may coexist with or precede neuroma formation (these lie dorsal to the nerve and must be distinguished on imaging)
• Ischaemic changes — local microvascular compromise from repetitive compression
• Traction injury — hyperpronation forces the forefoot into abduction, applying tension to the interdigital nerve around the DTML

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3. Risk Factors

Intrinsic Factors

Extrinsic Factors

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4. Gait Analysis & Deviations

Stance Phase Deviations

• Generally unremarkable; pain is not typically reproduced during heel strike or loading

• Increased pronation — hyperpronation is both a risk factor and a compensation; increased midstance pronation abducts the forefoot, applies traction on the interdigital nerve, and promotes forefoot splay
• Forefoot adduction compensation — some patients adopt a slight in-toe position to reduce transverse plane shear on the affected web space

• Antalgic deviation of push-off — the hallmark gait change; the patient avoids full propulsion through the affected interspace; they may roll off the medial forefoot (to avoid the 3rd space) or lateral forefoot (to avoid the 2nd space) depending on which interspace is affected
• Shortened stride length on the affected side — reduced push-off force
• Early heel lift followed by rapid toe-off — to minimise the period of DTML compression at full dorsiflexion; reduces time the nerve is maximally compressed
• Forefoot abductory twist (FAT) — excessive abduction of the forefoot in late stance, visible as medial whipping of the heel; a key sign of hyperpronation-driven neuroma; increases traction on the nerve
• Transfer loading — peak pressures shift to adjacent interspaces or metatarsal heads; may produce secondary metatarsalgia at adjacent MTHs

• Reduced velocity and cadence — pain-avoidance reduces walking speed
• Lateral weight shift — leaning away from the affected side, reducing medial column loading
• Toe-out (abducted) gait pattern — reduces the dorsiflexion-supination stress at push-off; very commonly observed

Pedobarograph / Pressure Plate Findings

• Reduced peak pressure and impulse at the affected intermetatarsal web space
• Elevated peak pressures at adjacent MTH (e.g., 2nd MTH if 3rd space neuroma — lateral transfer)
• Shortened forefoot contact time on the affected side
• Possible increased medial arch loading if hyperpronation is a contributor

Footwear Assessment

• Inspection of footwear: look for asymmetric wear patterns at the forefoot; narrowed toe box; worn insoles with focal indentation at the metatarsal heads

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5. Assessment

History

• Site: plantar forefoot in the affected web space; typically 3rd > 2nd interspace
• Character: burning, cramping, aching, lancinating, electric shock-type pain; often described as a "pebble in the shoe" or "bunched-up sock"
• Radiation: frequently radiates into the adjacent toes (>60% of patients); numbness in the toes reported by ~40%
• Onset: worse with weight-bearing activity; resolves with rest and removal of shoes; worse in narrow/high-heeled footwear; classically better in sandals (no medial compression)
• Severity: progressive; may become constant in longstanding cases
• Bilateral: can affect multiple interspaces; bilateral involvement possible but less common

Physical Examination

Differential Diagnoses

Investigations

• Clinical diagnosis is primary in UK podiatric practice
• Weight-bearing X-ray: excludes bony pathology, stress fracture, Freiberg's; may show splaying of adjacent metatarsals
• Ultrasound (first-line imaging in UK): demonstrates a well-defined, ovoid, hypoechoic mass in the plantar web space, parallel to the metatarsals; can be compressed/displaced with forefoot squeeze during the scan; distinguishes from intermetatarsal bursitis (which lies dorsal to the nerve); preferred as it is dynamic and allows real-time correlation with symptoms; also facilitates guided injection
• MRI: most sensitive; shows the neuroma as a low-signal mass on T1 (fibrotic nature) between metatarsal heads; short-axis orientation most useful; used when US is equivocal or surgical planning is required
• Nerve conduction studies/EMG: occasionally useful in atypical presentations to exclude proximal nerve pathology or tarsal tunnel syndrome
• Diagnostic nerve block: common digital nerve block with local anaesthetic — if symptoms resolve, confirms the diagnosis and the specific interspace

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6. Management

Conservative (First-Line — NHS Podiatry Standard)

• Wide, deep toe-box footwear — decompresses the intermetatarsal space by allowing metatarsals to splay naturally
• Low heel (≤25 mm) — reduces forefoot loading and DTML pressure
• Flexible upper with sufficient depth — avoids direct dorsal compression of the web space
• Avoidance of pointed-toe shoes, high heels, and tight athletic shoes
• Classically, symptoms do not occur in sandals — confirming the role of shoe compression

• Metatarsal pads/domes to offload the MTH region and widen the intermetatarsal space
• Custom functional orthotics to control hyperpronation

• Temporary adhesive metatarsal dome applied proximal to affected MTH region
• Interdigital wedge/prop to splay adjacent toes and widen the web space
• Low-dye strapping may assist if hyperpronation is a driver

• NSAIDs (oral or topical) for acute flares
• Ice post-activity to reduce perineural inflammation

• Ultrasound-guided injection into the affected interspace: corticosteroid + local anaesthetic
• Evidence is mixed: ~50–80% report short-term improvement; corticosteroid injection alone is not statistically superior to footwear modification at 1 year (Roberts and Hedges)
• Repetitive injections carry a risk of hammer-toe deformity (fat atrophy, ligament weakening around the MTPJ)
• Typically limited to 2–3 injections per interspace

• Not recommended — not demonstrated to be effective; associated with complications

• Intrinsic foot muscle strengthening (improves intermetatarsal arch)
• Gait re-education to reduce FAT and hyperpronation

Second-Line

• Radiofrequency ablation / cryotherapy: emerging interventional options for refractory neuromas prior to surgical consideration; limited but growing evidence base in UK podiatric practice
• Hyaluronidase injection: used in some centres to attempt to break down perineural fibrosis
• Walking assessment and biomechanical review: if all conservative measures have failed without addressing the gait driver, revisit the biomechanical assessment

Surgical

• Neurectomy should be at least 2–3 cm proximal to the DTML to ensure the stump retracts and does not form a traction neuritis
• Most common complication of dorsal approach: stump neuroma (caused by inadequate proximal resection or failure of the nerve to retract)
• Silicone or metallic implants not used — neurectomy is definitive

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7. Prescribed Orthotics

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Prescription 1 — Functional Semi-Rigid Orthosis with Metatarsal Dome for Morton's Neuroma with Hyperpronation (2nd or 3rd Interspace)

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Prescription 2 — Accommodative Full-Contact Orthosis with Metatarsal Bar and Forefoot Offloading (Bilateral or Rigid/Older Foot Type)

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UK Podiatric Orthotic Notes for Morton's Neuroma

• Metatarsal dome vs. metatarsal bar: the dome is preferred for single-space involvement with precise targeting; the bar is preferred for bilateral or multi-space involvement, or when broad forefoot offloading is needed
• Metatarsal pad placement is critical: position is always proximal to the MTH row — confirmed by patient feedback with the foot weighted; if placed too distally (under the heads), it worsens compression
• Top cover bonding: ensure the dome/bar is bonded firmly beneath the top cover to prevent pad migration — a common clinical failure point
• Toe spacers: silicone interdigital props between the affected toes complement the orthosis by passively maintaining web space width throughout the gait cycle
• Review: 4–6 weeks post-fitting; reassess metatarsal dome position with pressure plate if available; patient should notice symptom relief particularly in enclosed footwear within 2–4 weeks

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🦶 PODIATRY CHEAT SHEET — PLANTAR FASCIITIS

Pathophysiology (quick recall)

• Microtears at calcaneal origin → collagen disorganisation → angiofibroblastic hyperplasia
• Windlass mechanism disrupted → reduced arch rise at propulsion
• Gastrocnemius tightness + pronation = two biggest mechanical drivers
• Heel spur = consequence, not cause

Risk Factors

Gait Deviations

• Early heel lift (avoids DF load)
• Antalgic gait — shortened stance on affected side
• Prolonged pronation through midstance
• Reduced push-off — windlass not activating
• Abducted foot progression (toe-out gait)

Assessment

Management Ladder

Orthotics at a Glance

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🦶 PODIATRY CHEAT SHEET — HALLUX RIGIDUS

Pathophysiology (quick recall)

• Cartilage loss begins dorsally (highest shear stress at push-off)
• Dorsal osteophytes → physical block to DF → impingement pain
• Windlass disrupted → propulsive insufficiency
• Synovitis from cartilage particle abrasion → effusion + worsening destruction
• Triggers: trauma, gout, RA, metatarsus primus elevatus, hypermobile 1st ray

Risk Factors

Grading (Coughlin & Shurnas)

Gait Deviations

• Insufficient push-off — hallmark deviation (MTP 6-phase gait abnormality table)
• Early heel lift — avoids terminal stance DF demand
• Lateral forefoot roll-off — avoids 1st MTPJ, loads 2nd/3rd MTH → metatarsalgia
• Toe-out / hip external rotation — shifts propulsive axis away from blocked joint
• IP joint hyperextension — compensatory push-off via IP joint
• Bouncing gait — abbreviated, painful propulsion
• Subtalar overpronation — attempts to plantarflex 1st ray and improve available DF

Assessment

Management Ladder

Orthotics at a Glance

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🦶 PODIATRY CHEAT SHEET — MORTON'S NEUROMA

Pathophysiology (quick recall)

• Nerve compressed between DTML (above) + ground (below) during push-off = "nutcracker" mechanism
• 3rd interspace: medial + lateral plantar nerve branches may converge → larger nerve trunk → less tolerance for swelling
• Sequence: endoneural oedema → perineural fibrosis → demyelination → axonal degeneration
• Histology: thickened perineurium, endoneural fibrosis, degenerated axons — compressive neuropathy
• Intermetatarsal bursitis may coexist (lies dorsal to nerve — differentiate on USS)

Risk Factors

Gait Deviations

• Antalgic avoidance of push-off through affected interspace
• Lateral or medial roll-off (around the painful web space)
• Forefoot abductory twist (FAT) — visible medial heel whip; hyperpronation sign
• Toe-out gait — reduces DF-supination stress at push-off
• Shortened stride + reduced cadence on affected side
• Rapid toe-off — minimises time of DTML compression at peak DF
• Transfer metatarsalgia — elevated pressure at adjacent MTHs (pressure plate finding)

Assessment

Differential Diagnoses (quick recall)

Management Ladder

Orthotics at a Glance

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