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Finding out about your foot problems on the internet

Whilst the Internet provides information, there are caveats.  Much medical information on the Internet is anecdotal or biased .  An important consideration is that the “facts” about disease or medical practice need to be interpreted in context, and this interpretation is the prime value of the medical professional. 

Searching the Internet can be complex and many of the scientific databases  are not easily reached through the algorhythms available in the popular search engines.  

Probably the most valid source of health information is the website of the United States National Institute for Health.  This can be searched via PubMed.  See also the attached link to the Journal of Bone and Joint Surgery. Even in these publications there are complexities of terminology and interpretation which could led to incorrect conclusions. 

Information about corrective surgery on the forefoot reveals surprisingly few retrospective analyses and these are not encouraging. 

 

One reasonably objective (and discouraging) retrospective analysis is a meta-analysis in the Cochrane Database, in italics below:

Intervention for treating hallux valgus (abductovalgus) and bunions.

Ferrarid, HigginsJP, Williams RL

A summary of this Cochrane Database report as follows in italics:

The (available) methodological quality of the twelve included trials was poor and trial sizes were small.

Conclusion: There is insufficient evidence…to determine…the most appropriate (treatment) for hallux valgus. It is notable that…patients remaining dissatisfied were consistently high (25 – 33%) even when the hallux valgus angle and pain had improved.

The poor outcomes that this database records relates only to the great toe – hallux valgus (“bunion”). If the other long-term toe and foot abnormalities are taken into account the results are far worse. Correction of the great toe alone is only a partial solution, and if unattended to a sequence of further problems can be predicted. Make sure your surgeon has an overall conceptio of foot abnormalities, and doesn’t leap only at the immediate and obvious.

That there are many different approaches in the management of forefoot deformities illustrates that individualism of surgeon and the patient is important.  It also demonstrates that there is, as yet, no single, agreed optimum form of surgical management.

Most information on the internet will relate to “conventional” surgery, partly because this has been in place for the longest period and partly because this is what is performed by most surgeons. 

 

General websites include  the American Orthopaedic Foot and Ankle Society (www.aofas.org.) One purpose of this website seems to be to keep the market within the “orthopaedic” domain, and exclude podiatrists. This site expresses firmly the “conventional” approach to the abnormalities of the forefoot.  However, you will recognise that “faulty footwear” is used to explain the cause of these abnormalities, which is a significant error.  Knowing the cause of the deformities is clearly fundamental to the management strategies of any medical condition, unless the aim is purely cosmetic, anatomical endeavour. 

A number of papers on the Internet are produced by podiatrists, predominately in the United States.  Podiatrists are not trained as orthopaedic surgeons and the extent to which they are allowed to practice (surgery) varies  with state and country.  Podiatrists are sometimes called chiropodists  and in many countries are not permitted to perform open surgery. 

 

One characteristic of the podiatrists’ literature is the liberal use of “jargoneering”.  This means the bandying of technical terms, to give the impression of comprehensive knowledge.  By its very nature “jargoneering” is difficult for the layman to place in perspective, or interpret relative and balanced values.  Any perplexing terms which you come across on the Internet should be discussed with an appropriate health professional – which could include your family practitioner – to gain a full understanding of their contextual applicability. 

 

Some entries on the Internet are astonishingly mis-informative.  One would think the Mayo Clinic Website (Bunions.MayoClinic.com) would offer the ultimate opinion on the forefoot abnormalities. That is not the case. Mayo gives the cause of bunions as “wearing shoes which are too tight”. This conclusion has no scientific support, and is invalid.

Harvard Medical School’s source of authority, the American Foot and Ankle Society  (website http:www.afoas.org ) says (in italics below)

A bunion is a firm, painful bump that forms over a bony bulge at the base of the big toe. In most cases, the big toe joint also is enlarged and has degenerative arthritis. Bunions tend to be inherited, but they also are common in the following groups:

       Women who wear high heels

       People who wear shoes that are too narrow or too pointed

       People with flatfeet

All of these situations force the big toe to drift toward the little toes, and this can cause bunions to form. Another error is that the joint in hallux valgus virtually never exhibits arthritis (unless damaged by previous surgery), and is not enlarged

There is no justification for any of these explanations, which are, frankly, totally incorrect. “Bunions” and the other disorders of the forefoot also occur in men, young people and in primitive people who have never worn shoes.

Flat feet, far from causing “bunions”, are a result of the various changes which occur in the forefoot abnormalities.

 

The following authors concede they have not found an explanation the forefoot abnormalities of ageing.

            The prevalence of foot problems in older women: a cause for concern. J Public Health Med. 2002 Jun;24(2):77-84.

Dawson J, Thorogood M, Marks SA, Juszczak E, Dodd C, Lavis G, Fitzpatrick R.

OCHRAD, School of Health Care, Oxford Brookes University, Oxford. jdawson@brookes.ac.uk

BACKGROUND: Painful feet are an extremely common problem amongst older women. Such problems increase the risk of falls and hamper mobility. The aetiology of painful and deformed feet is poorly understood.

CONCLUSION: Most women in this age-group have been exposed to high-heeled shoes over many years, making aetiological research difficult in this area. Foot pain and deformities are widespread. The relationship between footwear, occupational activities and foot problems is a complex one that deserves considerably more research.

The following newspaper article, outwardly “authoritative” is replete with unverified and incorrect assumptions: http://www.independent.co.uk/news/uk/home-news/high-heel-injuries-cost-pound29m-a-year-947823.html

A more general reference is the following. Unfortunately it requires a subscription.

Orthopaedic Information: How to Find It Fast on the Internet
J. Sybil Biermann, Gregory J. Golladay, J.F. Myles Clough, Steven R. Schelkun, and A. Herbert Alexander
J Bone Joint Surg Am. 2006;88:1134-1140. [Full Text] [PDF]

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