0:00

And as we consider the topics of metatarsal

0:03

and heel pain, I'm showing you, uh, these two, um,

0:08

algorithms, uh, really just to, um, emphasize the fact

0:12

that there are complex problems

0:14

and we have to really think about things

0:16

with differential sets of consideration.

0:19

And based on our limitations in time, we're gonna pick

0:21

and choose a few of these things, uh, really to, uh,

0:25

emphasize with respect to our time together

0:27

and the imaging findings.

0:29

So let's begin with the differential considerations

0:32

of metatarsalgia.

0:33

First, a definition pain in the forefoot under one

0:37

or more of the metatarsal heads.

0:40

And as you can imagine, that can be difficult with respect

0:43

to assessing patients clinically to identify whether

0:45

that's really based at the metatarsals

0:48

or moving a bit more proximally, uh,

0:50

into the metatarsal shafts.

0:52

When we're considering the metatarsal fe nal joints,

0:55

we really divide the first

0:57

MTP away from what's been referred to as the lesser

1:01

or central metatarsals.

1:02

That's second through fifth.

1:04

And when we consider the set of differential considerations,

1:08

we've got the primary here listed.

1:11

Many of the anatomic variations we're going to focus on

1:16

valgus the secondary, these more systemic in nature.

1:20

In some cases with the arties, more localized.

1:24

When we're thinking about neuroma trauma, we're going

1:27

to focus on plantar plate and turf toe in our time together.

1:31

And of course, iatrogenic the result

1:33

of reconstructive procedures.

1:35

As we're considering Some of these causes realize

1:39

that at the base, many times we're dealing

1:41

with altered mechanics in the foot.

1:44

That takes away the balance of structure

1:47

and, uh, the overall stability of articulations.

1:50

And then of course, dealing

1:52

with stresses on osseo structures as well.

1:56

Beginning with Hal Valgas, this is something

1:59

that when you're reading plain films

2:01

and looking at studies on a daily basis,

2:03

you're seeing them throughout the entire day.

2:06

As we consider Hal Valgas alignment, remember,

2:09

we're usually referring to weight, weight-bearing films.

2:12

And so in some cases,

2:13

as we're looking at non-weight-bearing studies, CT

2:16

and Mr, we still reference this possibility,

2:20

but of course are looking at the plain films

2:22

for the final diagnosis of weight-bearing.

2:25

As we consider the diagnosis,

2:26

you're looking at an angle based on the long axis

2:29

of the first metatarsal with respect to the long axis

2:32

of the proximal phx.

2:34

Generally, when that's over 15 degrees, we're thinking about

2:37

how ex valgus alignment.

2:39

We can also consider the orientation of the first metatarsal

2:43

with respect to the medial QA formm, of course,

2:45

that metatarsus Primus varus.

2:48

And looking at the angle between the first

2:50

and the second metatarsals, if

2:52

that's greater than 10 degrees, usually considered

2:55

to be abnormal when we start to have Hal valgus alignment.

2:59

We're also looking for secondary degenerative changes at the

3:03

MTP as well as sesamoid arthropathy.