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Ingrown toenails

Ingrown toenails are a common and painful condition in which the edge of a toenail grows into the surrounding skin, most often on the big toe. Effective treatment ranges from simple self‑care at home to minor surgical procedures in a clinic, depending on how severe the problem is and whether infection is present.

What is an ingrown toenail?

An ingrown toenail occurs when the nail plate curves and presses or pierces into the adjacent skin of the nail fold. This causes local inflammation, redness, swelling and tenderness, and can progress to infection with pus and overgrowth of tissue if not managed. People who trim nails too short or rounded, wear tight shoes, or have naturally curved/thick nails are particularly prone to the problem. Recurrent episodes are common if the underlying cause is not corrected.

Mild cases and home treatment

For early or mild ingrown toenails, conservative treatment at home is often sufficient. The aim is to reduce inflammation, relieve pressure from the nail edge, and guide the nail to grow straight out rather than into the skin. A typical first step is to soak the foot in warm water for 15 to 20 minutes several times a day, sometimes with Epsom salt or mild soap to soften the skin and nail and to help reduce discomfort. After soaking, gently drying the foot and using a clean cotton bud to nudge the swollen skin away from the nail edge can help free the nail margin.

Some people place a tiny wisp of cotton or dental floss under the very edge of the nail after soaking. This lifts the nail slightly away from the skin so it can grow over, rather than into, the nail fold. The material must be changed daily and kept clean to reduce the risk of infection. During this period, it is important to wear roomy footwear or open‑toed sandals so that there is no extra pressure on the affected toe. Simple pain relievers such as paracetamol or ibuprofen can be used if needed, provided there are no medical reasons to avoid them.

When medical care is needed

If pain is significant, the nail fold looks very red or swollen, there is pus, or home care fails over a few days, professional treatment is recommended. A doctor or podiatrist can confirm the diagnosis and rule out other problems such as fungal nail disease, trauma or, in people with diabetes, more serious infections. They may gently lift the ingrown edge and place a small piece of cotton, dental floss or a specialized splint beneath it to keep it elevated. Sometimes a topical corticosteroid cream is prescribed to reduce inflammation around the nail once the toe has been soaked.

Infected ingrown toenails can require additional measures. If there is spreading redness, warmth extending beyond the toe, or systemic symptoms such as fever, oral antibiotics may be indicated. However, for many localized infections, proper drainage, removal of the offending nail edge and good local wound care are the most important components of treatment. People with poor circulation, diabetes, or immune problems should seek medical help early, as even a minor ingrown toenail can lead to serious complications in these groups.

Surgical treatment options

Moderate to severe or recurrent ingrown toenails are often best managed with minor surgical procedures under local anaesthetic. The most common method is partial nail avulsion, in which the clinician removes a narrow strip from the side of the nail that is growing into the skin. This immediately relieves pressure and allows inflamed tissue to settle. In many cases, this procedure is combined with destruction of the corresponding part of the nail matrix (the root that produces the nail) so that the removed strip does not grow back.

Matrix destruction can be performed chemically, most often by applying phenol, or mechanically by cutting out the matrix tissue or using electrocautery or laser. Chemical matricectomy with phenol after partial nail avulsion has been shown to reduce the risk of the ingrown edge recurring, although it may slightly increase short‑term drainage and risk of minor infection compared with simple excision. Alternative technologies such as radiofrequency or carbon dioxide laser aim to achieve the same result with less bleeding and possibly quicker recovery.

Aftercare and recovery

After a surgical procedure, the toe is usually dressed with a sterile bandage, and patients are advised to rest and keep the foot elevated for the first day. Mild bleeding and oozing can continue for a few days as the area heals. The dressing is typically changed daily or as instructed, with gentle cleaning in warm water and re‑application of a clean, dry bandage. Most people can resume normal walking within a day or two, but tight or restrictive footwear should be avoided until tenderness and swelling subside.

Pain after partial nail avulsion is usually modest and can be controlled with oral pain relievers. The remaining nail often looks slightly narrower than before but generally functions normally and grows out in a way that avoids the previous problem side. It is important to attend any recommended follow‑up appointments so the clinician can check healing and address any early signs of infection or recurrence.

Prevention and long‑term care

Preventing future ingrown toenails is an important part of treatment, especially for those who have had repeated episodes. Correct nail‑cutting technique is central: toenails should be trimmed straight across, with the corners left visible rather than cut into a curve, and not cut excessively short. Using clean, sharp clippers and avoiding tearing or ripping the nail reduces the chance of leaving sharp spikes that can penetrate the skin. Good foot hygiene, including keeping the feet dry and changing socks regularly, helps lower the risk of infection.

Footwear choice also matters. Shoes with a wide toe box that do not compress the toes together, and avoiding high heels or narrow shoes for long periods, can significantly lower pressure on the nails. People engaged in sports that involve repeated toe trauma, such as football, running or ballet, may need specially fitted shoes or protective padding. Those with conditions that impair sensation or circulation, such as diabetes, should have regular foot checks by a health professional and seek early advice at the first sign of nail problems.

In summary, ingrown toenails can usually be treated effectively with a combination of self‑care, conservative clinical measures and, when necessary, minor surgical procedures. Understanding how they develop, knowing when to escalate from home remedies to professional care, and following sound preventive habits are key to reducing pain, infection and recurrence over the long term.

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HyProCure for Flat Feet

HyProCure is a minimally invasive surgical option for selected patients with symptomatic flat feet (pes planus), aimed at correcting pathological talotarsal joint motion rather than simply supporting the arch externally. It involves placing a titanium stent into the sinus tarsi to stabilise the subtalar joint, with the goal of improving alignment, reducing pain, and enhancing function while preserving joint motion.

Pathomechanics of flat feet and treatment rationale

Symptomatic flat feet are often associated with excessive or prolonged pronation driven by instability at the subtalar or talotarsal joint rather than just “low arches” in isolation. When the talus excessively plantarflexes and adducts on the calcaneus, the medial longitudinal arch collapses, the heel everts, and the forefoot abducts, altering the kinetic chain through the foot, ankle, knee, hip, and lower back. This can contribute to plantar fasciopathy, posterior tibial tendon overload, medial knee stress, and compensatory proximal symptoms, even though many flat feet remain asymptomatic.

Conservative management—such as custom orthoses, physical therapy, and footwear modification—aims to control pronation and redistribute load but does not change the underlying joint structure. For patients who remain symptomatic despite appropriate conservative care, surgical options range from osteotomies and tendon procedures to subtalar arthroereisis, of which HyProCure is a specific extra‑osseous talotarsal stabilisation (EOTTS) system.

Surgical technique and mechanism of action

HyProCure uses a small, threaded titanium stent inserted into the sinus tarsi, the naturally occurring canal between talus and calcaneus, via a small incision on the lateral aspect of the foot. The device sits extra‑osseously in this space, so there is no drilling or cutting of bone, and the surrounding joint surfaces remain intact. Functionally, the implant acts like a “doorstop” to excessive subtalar motion, limiting the pathologic pronatory excursion that allows the talus to collapse medially and the arch to flatten, while still permitting physiological inversion–eversion.

Once placed, the stent immediately realigns and stabilises the hindfoot, bringing the talus back over the calcaneus and improving the orientation of the ankle and midfoot. This restores a more normal heel‑to‑toe progression, improves the timing and magnitude of pronation–supination during gait, and can rebalance ground reaction forces through the medial and lateral columns. Because bone is not cut, the surgery is typically performed as a day procedure, often under local or regional anaesthesia, and the implant is designed as a long‑term or permanent solution but can be removed if necessary.

Indications, patient selection, and postoperative course

HyProCure is generally considered for patients with flexible, symptomatic pes planus or overpronation in whom conservative measures have failed, including both children and adults. In paediatric patients, it is often positioned as an intermediate option when orthoses are insufficient yet full reconstructive surgery would be disproportionately invasive. Adults with chronic pain in the feet, ankles, knees, or lower back related to talotarsal malalignment may also benefit, provided that the deformity is flexible and there is no advanced degenerative joint disease or rigid flatfoot.

Postoperatively, protocols vary, but patients typically weightbear in a protective boot shortly after surgery, transitioning to normal shoes within weeks as swelling resolves and gait adapts. There is usually a short period of altered walking as the neuromuscular system adjusts to the corrected alignment, with full adaptation commonly reported over the first year. Many patients experience improved tolerance for walking, running, and jumping as load distribution normalises and painful overuse of soft tissues reduces.

Outcomes and benefits

Published clinical and industry-reported data suggest high success and satisfaction rates with HyProCure for flatfoot deformity and talotarsal instability. Reports describe approximately 94–95 percent success in achieving durable correction and symptom relief, with over 97 percent of patients rating outcomes as good or excellent at around one year post‑procedure. The realignment of the subtalar joint reduces abnormal stresses not only in the foot but along the kinetic chain, and many patients report reductions in pain at the knees, hips, and lower back together with improved mobility and quality of life.

An important advantage is that HyProCure aims to treat the underlying structural cause of hyperpronation rather than compensating for it with external devices, potentially removing or reducing the need for long‑term orthotic use. The procedure preserves joint motion, avoids bone cuts, and is considered minimally invasive, which may lead to shorter operative times, less soft tissue disruption, and quicker recovery compared with traditional osteotomies. Furthermore, the implant is removable, and removal does not necessarily lead to loss of all correction, offering a degree of reversibility if complications or intolerance occur.

Risks, complications, and limitations

Despite these benefits, HyProCure is not without risk, and complication rates differ markedly between children and adults. In a 2024 clinical study on flatfoot patients in China, overall complication incidence was reported at about 10.6 percent, but only 5.1 percent in children and adolescents compared with 28.8 percent in adults. Documented complications include sinus tarsi pain, peroneal muscle spasm, increased tension in the Achilles–triceps surae complex, and reduced muscle strength, sometimes necessitating implant removal.

The same study reported overall implant removal rates of about 4.4 percent, with just over 1 percent in children and approximately 15 percent in adults, underscoring the higher risk profile in mature, stiffer feet. Persistent sinus tarsi pain is a leading indication for removal and may relate to device size, positioning, or patient-specific anatomy. Flat feet themselves are often asymptomatic, so careful selection is essential to ensure that the patient’s symptoms actually arise from talotarsal malalignment and not from other pathologies; otherwise, expectations may not be met despite technically successful surgery.

HyProCure is also limited in rigid deformities, advanced arthritis, or cases where significant soft tissue reconstruction or bony realignment is required, in which case osteotomies or fusions may be more appropriate. As with any implant-based procedure, long‑term outcomes depend on factors such as body weight, activity level, neuromuscular control, and adherence to rehabilitation, and there is still ongoing research to refine patient selection criteria and implant sizing strategies.

Taken together, HyProCure represents a targeted subtalar arthroereisis option that can offer meaningful structural correction and symptom relief for well‑selected patients with flexible, symptomatic flat feet who have not responded to conservative therapy. For clinicians, it occupies a niche between orthotic management and more invasive reconstructive surgery, with the advantages of a minimally invasive approach and reversible implant, but it requires thoughtful assessment of biomechanics, comorbidities, and patient expectations to optimise outcomes and minimise complications, particularly in adults.

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Interdigital maceration

Interdigital maceration of the foot is a common but often under‑appreciated condition in podiatric practice, with important implications for skin integrity, infection risk and patient comfort. It represents a disruption of the normal balance of moisture in the interdigital spaces, leading to a characteristic “white and soggy” appearance of the skin and predisposing to secondary bacterial or fungal infection.

Definition and pathophysiology

Interdigital maceration refers to softening and breakdown of the epidermis between the toes due to prolonged exposure to excessive moisture and impaired evaporation. In physiological conditions, the stratum corneum maintains a balance between hydration and barrier function, allowing flexibility while preventing penetration of pathogens and irritants. When moisture is excessive, water accumulates within the stratum corneum, the corneocyte cohesion is reduced, and the mechanical strength of the skin falls. In the tight, poorly ventilated interdigital spaces this leads to whitening, over‑hydration, surface breakdown and alteration of the local microbiome. The resulting loss of barrier function facilitates fissuring, erosions and overgrowth of bacteria and fungi, turning an initially simple moisture problem into an infectious process.

Aetiology and risk factors

The fundamental driving factor is prolonged moisture in a confined space, whether from excessive production (sweating) or reduced evaporation. Plantar hyperhidrosis is a major contributor, with sweat accumulating between closely apposed toes where air circulation is minimal. Poor foot hygiene, particularly failure to dry carefully between the toes after bathing, is frequently implicated and is a modifiable risk factor. External moisture sources such as swimming, foot spas and occlusive dressings can produce similar over‑hydration of the stratum corneum. Footwear factors are critical: prolonged use of closed, non‑breathable shoes or boots, tight toe boxes and synthetic socks all reduce evaporation and raise local humidity. Anatomical crowding, oedema and digital deformity can increase toe‑to‑toe contact pressure, further limiting air flow and maintaining a persistently damp environment. The application of emollient creams between the toes is another iatrogenic risk, as these products can trap moisture in skin that already has limited capacity to dry. Systemic factors such as diabetes, obesity and peripheral vascular disease may not cause maceration directly but predispose to persistent moisture, delayed healing and transition to secondary infection.

Clinical features

Clinically, interdigital maceration presents as white, grey‑white or translucent, “soggy” skin in the web spaces, often with superficial peeling or shredding of the stratum corneum. The tissue may be softened to the point that it can be gently wiped away, revealing erythematous or eroded underlying skin. A malodorous smell is common, particularly once bacterial colonisation has developed, and patients may report embarrassment or concern about foot odour. Subjective symptoms vary: uncomplicated maceration is often only mildly uncomfortable, but once erosions or infection occur, patients describe burning, stinging or tenderness on weight‑bearing and during toe splay. In more advanced cases, there may be fissuring at the base of the web space, exudative erosions and extension of inflammation onto the plantar or dorsal aspects of the digits. Importantly, simple moisture‑related maceration is typically non‑pruritic, in contrast to classic interdigital tinea pedis which often presents with itch and more obvious erythematous scaling.

Differential diagnosis and microbiology

A careful differential diagnosis is essential because several dermatoses can mimic interdigital maceration and may coexist. Interdigital tinea pedis remains the key differential; chronic intertriginous tinea can produce macerated toe webs with scaling borders and erythema, often involving the lateral three toes. Soft corns (heloma molle), typically located on the apposed surfaces of adjacent toes, present as focal macerated hyperkeratotic lesions rather than diffuse web‑space involvement. Interdigital erythrasma, psoriasis alba, scabies and erosio interdigitalis blastomycetica are among other listed differentials and may be suggested by associated lesions elsewhere or by characteristic colour and distribution. The interdigital spaces normally harbour polymicrobial flora, including coagulase‑negative staphylococci, micrococci, coryneform organisms and gram‑negative rods. When maceration impairs the barrier, gram‑negative toe web infection can develop, most commonly due to Pseudomonas aeruginosa, but also Enterobacteriaceae and less often gram‑positive cocci such as Staphylococcus and Streptococcus. Dermatophyte infection (for example Trichophyton rubrum or Trichophyton mentagrophytes) frequently coexists, and dermatophytes themselves may alter local microbial ecology through production of antibiotic substances.

Complications

The major complication of persistent interdigital maceration is progression to infectious foot intertrigo with painful, exudative erosions and significant malodour. Once erosions are present, portals of entry are created for deeper bacterial infection, increasing the risk of cellulitis, lymphangitis and, in high‑risk patients, osteomyelitis. In individuals with diabetes, peripheral neuropathy or peripheral arterial disease, these apparently minor web‑space lesions can therefore act as precursors to more serious ulceration and limb‑threatening infection. Recurrent fissuring and chronic discomfort can also impair gait, limit activity and reduce quality of life, particularly in occupations requiring prolonged standing in occlusive footwear. From a podiatric perspective, ongoing maceration compromises the success of local treatments such as digital orthoses, corn enucleation and nail surgery, as persistent moisture impairs tissue resilience and healing.

Management principles

Management of interdigital maceration centres on restoring dry, intact skin and addressing underlying predisposing factors. Basic foot hygiene measures are foundational: patients should be instructed to wash the feet daily with a mild cleanser, rinse thoroughly and meticulously dry between the toes using a thin towel or similar implement to reach narrow spaces. Once adequately dry, topical agents that reduce moisture, such as methylated or surgical spirits, may be applied between the toes; these act as astringents, assisting evaporation and helping the macerated tissue to resolve. In those with hyperhidrosis, additional strategies such as topical antiperspirants or astringent soaks (for example aluminium salt solutions) can be helpful to reduce sweating and prevent recurrence. Footwear advice is crucial: patients should be encouraged to use breathable shoes, rotate pairs to allow drying, avoid excessively tight toe boxes and select moisture‑wicking socks, changing them when damp.

Where clinical features suggest concomitant fungal infection—itch, erythematous scaling beyond the web spaces, unilateral predominance or typical plantar involvement—topical antifungal therapy is indicated in addition to moisture control. Agents such as azole or allylamine creams, gels or sprays are commonly used, with treatment often required for several weeks to months to fully eradicate tinea pedis. If gram‑negative toe web infection is suspected because of marked malodour, greenish exudate or failure of simple measures, microbiological sampling and, in some cases, topical or systemic antibacterial therapy (for example flucloxacillin or ciprofloxacin, depending on culture and extent) may be necessary. Mechanical measures such as the use of lamb’s wool or other toe spacers can help separate digits, promote air flow and reduce skin‑on‑skin moisture retention while the area heals. In all cases, clinicians should educate patients about avoiding creams between the toes, recognising early signs of recurrence and seeking prompt review if pain, spreading erythema or systemic symptoms develop.

Interdigital maceration of the foot exemplifies how a seemingly minor moisture imbalance can have disproportionate clinical consequences when combined with occlusive footwear, anatomical crowding and systemic risk factors. For the podiatric practitioner, careful assessment to distinguish simple maceration from tinea pedis and gram‑negative intertrigo, coupled with meticulous attention to moisture control, footwear modification and treatment of coexistent infection, is central to effective care. Early identification and management not only relieve discomfort and odour but can prevent progression to serious soft tissue and osseous infection in vulnerable patients.

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Iselin’s disease

Iselin’s disease is a traction apophysitis of the base of the fifth metatarsal, producing lateral foot pain in skeletally immature, typically athletic children and adolescents. It is an overuse injury of the apophyseal growth plate at the styloid process where peroneus brevis inserts, and is usually self‑limiting with conservative management.

Definition and epidemiology

Iselin’s disease, also called apophysitis of the fifth metatarsal base or Iselin’s osteochondrosis, is an osteochondrosis of the secondary ossification centre at the tuberosity of the fifth metatarsal. The apophysis lies within the insertion of the peroneus brevis tendon, and radiographically appears around age 10 in girls and 12 in boys, fusing by roughly 11 and 14 years respectively. Because it is linked to growth plate physiology and traction, the condition is almost exclusively seen in active children aged about 9–14 years engaged in sports involving running, cutting, and jumping such as football, basketball, and ballet. It is considered relatively uncommon but probably under‑recognised in primary care and general musculoskeletal practice.

Pathophysiology and aetiology

The underlying pathology is traction‑induced inflammation and microtrauma of the cartilaginous apophysis at the base of the fifth metatarsal. Repetitive loading of the peroneus brevis tendon during activities that involve rapid inversion–eversion, push‑off, and lateral cutting produces shear forces across the open growth plate. Over time, this mechanical stress leads to oedema and fragmentation within the apophysis, visible on imaging as irregularity and sclerosis. Contributory biomechanical factors include overuse from high training volumes, muscular tightness or weakness (for example tight gastrocnemius–soleus complex or weak lateral stabilisers), and footwear that fails to provide adequate lateral support and cushioning. Because the growth plate cartilage is softer and less resilient than mature bone, it is more susceptible to this repetitive traction until physeal closure occurs.

Clinical presentation

Children typically report insidious onset pain along the outer border of the foot centred on the base of the fifth metatarsal, aggravated by activity and relieved by rest. Symptoms often flare with running, jumping, tip‑toeing, or sports training sessions and settle between activities, at least in early stages. Parents and clinicians may observe a limp or a tendency to walk on the medial border of the foot to unload the symptomatic lateral apophysis. On examination, there is focal tenderness at the widest part of the lateral midfoot over the styloid process, frequently accompanied by localised swelling, erythema, or a palpable “lump” at the fifth metatarsal base. Pain is reproduced with direct palpation and often with resisted eversion or passive inversion that tensions peroneus brevis; in more irritable cases, range of motion of the foot and ankle may be limited by discomfort and the child may struggle to participate fully in sport.

Diagnosis and differential diagnosis

Diagnosis is primarily clinical, based on the characteristic history of activity‑related lateral foot pain in a skeletally immature athlete and focal tenderness at the fifth metatarsal base. Plain radiographs are not always required but can assist in excluding acute fractures and in demonstrating typical apophyseal changes when indicated. Radiographic features include a longitudinally oriented, irregular apophysis with sclerosis and possible fragmentation that remains in continuity with the metatarsal base, distinguishing it from a transverse avulsion (pseudo‑Jones) fracture or more proximal Jones fracture. Other important differentials are os vesalianum (an accessory ossicle lateral to the fifth metatarsal), stress fracture, peroneal insertional tendinopathy, and less commonly infection or neoplasm in atypical presentations. In equivocal or refractory cases, MRI can demonstrate bone marrow oedema within the apophysis and adjacent metatarsal base and associated soft‑tissue oedema, confirming the diagnosis and excluding other pathology.

Management

Management of Iselin’s disease is almost always conservative and directed at load modification and symptom control. Initial treatment emphasises relative rest from provoking activities, particularly high‑impact running and jumping, along with ice and simple analgesia or non‑steroidal anti‑inflammatory medication as required. Short‑term immobilisation in a walking boot or stiff‑soled shoe may be useful in more severe cases to reduce traction forces and allow the inflamed apophysis to settle. Addressing underlying biomechanical contributors is equally important and may include calf and peroneal stretching, strengthening of intrinsic and peroneal musculature, and correction of any foot posture issues with supportive footwear or orthoses to offload the lateral border. A graded return‑to‑sport programme is then implemented, increasing activity volume and intensity only as symptoms permit and ensuring the child can run, cut, and jump pain‑free before full competition. Surgery is not indicated; contemporary paediatric orthopaedic and sports medicine sources emphasise that operative treatment is unnecessary and that outcomes with conservative care are excellent.

Prognosis and clinical significance

Prognosis for Iselin’s disease is favourable, with symptoms generally resolving as the apophysis matures and fuses once mechanical loading is optimally managed. Most children return to full activity without long‑term sequelae when diagnosis is timely and activity modification implemented early. Persistent pain is usually related to continued overuse, poor adherence to rest or rehabilitation, or misdiagnosis of a true fracture or other pathology. The main clinical importance of recognising Iselin’s disease lies in distinguishing it from avulsion or Jones fractures of the fifth metatarsal, which require different management and have different risks, and in avoiding unnecessary investigations or immobilisation in a condition that is self‑limiting when managed appropriately. For clinicians in paediatric sports and foot health, awareness of this entity and its biomechanical underpinnings supports targeted load management, education, and rehabilitation strategies that allow young athletes to maintain participation while protecting the vulnerable apophysis.

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The incisura fibularis

The incisura fibularis is a key anatomical feature of the distal tibia that plays a central role in the stability, biomechanics, and injury patterns of the ankle mortise, with growing relevance to podiatric practice and contemporary imaging‑guided management of ankle trauma. This essay will outline its anatomy, morphological variability, radiological assessment, and clinical significance, particularly in relation to syndesmotic injury, posterior malleolar fractures, and recurrent lateral ankle sprain.

Anatomy and basic function

Anatomy Standard - Drawing Anatomy of tibia in situ ...

Tibia anatomy diagram

The incisura fibularis (fibular notch) is a triangular depression on the posterolateral aspect of the distal tibia that receives the distal fibula. Together with the distal fibula and the distal tibiofibular ligaments, it forms the distal tibiofibular syndesmosis, which is crucial for maintaining the congruence of the ankle mortise around the talus.

Bony congruity between the medial surface of the fibula and the walls of the incisura provides an important component of syndesmotic stability, complementing the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, interosseous ligament, and transverse tibiofibular ligament. The geometry of the notch constrains fibular translation and rotation, thereby influencing talar position under load and the distribution of forces across the tibiotalar joint.

Morphological variability

Morphometry studies have demonstrated substantial anatomical variability in incisura depth, height, width, and orientation, with some evidence of gender‑related differences. Descriptions commonly distinguish shallow versus deep notches and note variations in version (anteverted, neutral, retroverted) and in how well the fibula “engages” within the notch.

Three broad distal tibial surface shapes have been described on CT and 3D models: a “C‑shaped” configuration producing a crescent‑shaped syndesmosis, a “1‑shaped” configuration with a relatively shallow incisura, and a “G‑shaped” configuration with a deeper notch and more prominent anterior or posterior tibial tubercles. These morphotypes appear to correlate with different patterns of fibular seating, posterior malleolar fracture morphology, and propensity to ligamentous versus bony injury.

Radiological assessment

Radiologically, the incisura fibularis has become a central landmark for intra‑ and postoperative assessment of syndesmotic reduction following ankle fracture or high‑ankle sprain. On mortise view radiographs, the lateral border of the talus normally aligns closely with a line projected from the proximal incisura down to the tibial plafond, reflecting mortise congruence.

In ankles without fracture, dislocation, or syndesmotic disruption, the alignment between the incisura and the lateral talar border is typically within 1 mm; a deviation of 1 mm or more has been proposed to indicate mortise incongruence and possible syndesmotic instability or talar shift. CT‑based measurements of incisura depth, rotation, width, and fibular engagement have also been used to validate syndesmotic reduction, with small side‑to‑side differences in depth and rotation when the syndesmosis is anatomically restored.

Relationship to injury patterns

A growing body of work links incisura morphology to specific ankle injury patterns. A shallow, retroverted, or “disengaged” incisura appears more frequently in patients with ligamentous syndesmotic injury and recurrent lateral ankle sprain, suggesting reduced bony constraint and greater reliance on soft tissues for stability. In such individuals, inversion injuries may preferentially overload the anterior talofibular ligament and syndesmotic structures rather than resulting in straightforward malleolar fractures.

Conversely, deeper, more constraining notches may predispose to particular posterior malleolar fracture configurations when axial load and rotational forces are transmitted through the tibiofibular complex. A recent retrospective CT‑based study of posterior malleolus fractures reported significant associations between incisura depth, version, width, fibular engagement, and the pattern of posterior malleolar involvement, including statistically significant relationships between incisura width and fracture type and between fibular engagement and fracture pattern.

Surgical and intraoperative relevance

Intraoperatively, the incisura fibularis is used as a bony reference for anatomic reduction of the distal fibula, particularly in syndesmotic fixation after malleolar fractures. Malreduction, especially excessive external rotation or lateral translation of the fibula relative to the incisura, is a recognised cause of poor outcomes, and its prevention depends on understanding the patient‑specific notch anatomy.

Techniques that allow direct visualization and manipulation of the incisura—such as posterior approaches that expose the distal tibial plafond and tibiofibular junction—permit more accurate restoration of the fibula into the notch before definitive fixation. For isolated distal tibiofibular arthritis or chronic syndesmotic instability, fusion procedures rely on preparing the joint surfaces within the incisura–fibula interface to achieve solid arthrodesis while preserving overall ankle alignment and mortise geometry.

Implications for podiatric practice

For podiatrists and foot and ankle clinicians, awareness of incisura fibularis morphology has several practical implications. First, when interpreting ankle radiographs or cross‑sectional imaging after sprain or fracture, recognising a congenitally shallow or retroverted notch can help explain recurrent instability or atypical injury patterns and inform discussions about prognosis. Second, in patients with chronic symptoms after “adequately treated” ankle fractures, subtle syndesmotic malreduction relative to the incisura may underlie persistent pain, dysfunction, or early degenerative change.

Finally, as CT‑based classification systems and morphometric analyses become more integrated into surgical planning, podiatric practitioners collaborating in multidisciplinary teams need a clear conceptual model of how the incisura contributes to distal tibiofibular stability and to posterior malleolar fracture morphology. This knowledge supports more nuanced rehabilitation strategies, targeted protection of at‑risk ankles, and more accurate communication of radiological findings and surgical objectives in the management of complex ankle injuries.

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The Ipswich Touch Test (IpTT)

The Ipswich Touch Test (IpTT) is a simple, equipment‑free screening tool designed to detect loss of protective sensation in the feet of people with diabetes, supporting early identification of those at risk of ulceration and amputation.

Background and Rationale

Diabetic peripheral neuropathy (DPN) is one of the most important risk factors for diabetic foot ulceration and subsequent amputation, making early detection of sensory loss a central goal of foot screening programs. Standard tools such as the 10 g Semmes–Weinstein monofilament and vibration perception threshold testing are well established, but they require equipment, may not always be available, and are underused in busy or resource‑limited settings. The IpTT was developed by Rayman and colleagues at Ipswich Hospital (UK) after they observed inadequate foot screening of inpatients with diabetes, which was associated with preventable heel ulcers. Their aim was to design a safe, quick, low‑cost test that could be performed by any health‑care worker at the bedside, thereby embedding foot protection into routine inpatient care.

Test Procedure and Interpretation

The Ipswich Touch Test involves light touch of specific toes and relies on patient perception rather than instrument‑based stimulation. With the patient lying or sitting and eyes closed, the examiner uses the index finger to lightly touch the tips of the first, third, and fifth toes on each foot (six sites in total) for approximately 1–2 seconds, taking care not to press harder if the patient does not initially respond and touching each site only once. After each touch, the patient is asked to say when and where they feel the stimulus; their responses are recorded as “felt” or “not felt” at each site. Loss of protective sensation is generally defined as two or more insensate sites out of the six tested, a cut‑off that has been used in multiple validation studies and correlates with elevated risk of ulceration.

The simplicity of the procedure confers several practical advantages. The examiner’s finger is always available, easily cleaned, and does not bend or wear out like monofilaments, eliminating the need for replacement or calibration. Only brief training is needed to standardise touch pressure and timing, allowing nurses, care assistants, and even family members to learn and perform the test reliably. This low barrier to implementation is particularly valuable on general hospital wards, in primary care, and in remote or resource‑limited settings where specialised equipment may be unavailable.

Evidence on Diagnostic Performance

Rayman et al. originally compared the IpTT with the 10 g monofilament and vibration perception threshold (VPT) ≥ 25 V as a reference standard in 265 individuals with diabetes. Using a threshold of at least two insensate sites, they reported IpTT sensitivity of 77% and specificity of 90% for identifying feet at risk, compared with monofilament sensitivity of 81% and specificity of 91%; agreement between IpTT and monofilament was almost perfect, with a kappa of 0.88. Inter‑rater agreement for the IpTT itself was substantial (kappa 0.68), supporting its reliability when performed by different examiners. Subsequent studies have broadly confirmed these performance characteristics, though reported sensitivity varies, reflecting differences in populations, reference standards, and settings.

A key piece of evidence is the systematic review and meta‑analysis by Hu et al., which pooled data from five studies using the 10 g monofilament as the reference. They found pooled sensitivity of 0.77 and specificity of 0.96, with an area under the summary receiver‑operating characteristic curve of 0.897, indicating high overall diagnostic accuracy for detecting loss of protective sensation. When compared against VPT ≥ 25 V, IpTT sensitivity ranged from 76–100% and specificity from 90–96.6%, again suggesting strong agreement with more equipment‑dependent measures. Other individual studies have reported sensitivities spanning roughly 51–93% and specificities in the 90–98% range when benchmarked against monofilament, pinprick, and neuropathy disability scores, reinforcing the view that a positive IpTT is highly specific for neuropathy even where sensitivity may be more modest

Home‑based and lay‑person application has also been studied. In one cohort of 331 patients, 25.1% had at least two insensate sites on monofilament testing; a home‑performed IpTT achieved sensitivity of 78.3%, specificity of 93.9%, positive predictive value of 81.2%, and negative predictive value of 92.8% for detecting “at‑risk” feet. Another study reported 100% agreement between IpTT performed at home by a friend or family member and clinical testing, highlighting the potential for self‑monitoring and community‑based screening models. More recent work continues to support good specificity (often above 95%) but notes that sensitivity can be relatively low in some series, making the IpTT better at confirmatory identification of neuropathy than at ruling it out in isolation.

Clinical Applications and Advantages

In clinical practice, the Ipswich Touch Test can be integrated into diabetic foot assessment across multiple settings. In hospital, it provides an immediate, no‑equipment method to identify inpatients needing pressure relief and close monitoring, helping reduce the incidence of heel ulcers and other iatrogenic lesions. In primary care and diabetes clinics, it serves as a rapid screening tool that can be routinely applied by nurses or podiatrists, prompting more detailed neurological assessment and preventive interventions when abnormal. Its ease of teaching also makes it attractive for structured self‑care programs, where patients and carers are encouraged to perform regular home checks in between professional visits.

The main advantages of the IpTT are its simplicity, negligible cost, portability, and minimal training requirements. It is inherently infection‑control friendly, as the examiner’s hands can be washed or gloved, contrasting with reusable tuning forks or shared monofilaments that may require more specific decontamination processes. In many low‑ and middle‑income settings where monofilaments, tuning forks, or biothesiometers are unavailable or unaffordable, the IpTT offers a pragmatic way to introduce neuropathy screening and begin risk‑stratified foot care. Even in well‑resourced environments, its speed and convenience lower the threshold for screening, potentially raising coverage among people with diabetes who might otherwise be missed.

Limitations and Role in Comprehensive Assessment

Despite these strengths, several limitations must be acknowledged. The IpTT is inherently subjective, relying on patient report and examiner consistency, and it does not quantify threshold intensity or distinguish between small‑ and large‑fiber neuropathy in the way that more detailed neurological testing can. Variability in sensitivity across studies suggests that a normal Ipswich Touch Test, especially when performed by non‑specialists, does not fully exclude neuropathy, and therefore it should not replace 10 g monofilament testing or VPT where these are available. Some comparative data indicate that monofilaments may detect neuropathy earlier or more comprehensively, leading several authors to conclude that Ipswich Touch Test is best regarded as an ideal alternative in the absence of monofilaments rather than a superior test.

For podiatrists and multidisciplinary diabetic foot teams, the Ipswich Touch Test should therefore sit within a broader assessment framework. A comprehensive foot exam will typically combine visual inspection, vascular assessment, monofilament or VPT testing, evaluation of deformity and footwear, and assessment of previous ulcer or amputation history, with Ipswich Touch Test functioning as an adjunct or backup. In resource‑limited contexts, using IpTT as a primary screen, possibly combined with another simple neurological sign such as ankle reflex or vibration, may enhance sensitivity while preserving the benefits of a low‑cost approach. Ultimately, the value of the Ipswich Touch Test lies less in technological sophistication and more in its capacity to democratise neuropathy screening and embed foot protection into everyday care for people with diabetes.

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Heel fat pad atrophy

Heel fat pad atrophy is an increasingly recognised cause of plantar heel pain, especially in older or high‑impact populations, and is frequently misdiagnosed as plantar fasciopathy. It involves structural and functional failure of the calcaneal fat pad, resulting in reduced shock absorption, focal overloading of the calcaneus, and characteristic bruised, central heel pain with weightbearing.

Anatomy and biomechanics of the heel fat pad

The plantar calcaneal fat pad (corpus adiposum) is a specialised fibro‑adipose structure that overlies the inferior surface of the calcaneus. It is organised into elastic fat chambers separated by fibrous septa that anchor to the periosteum, designed to resist shear and dissipate vertical ground reaction forces during gait. In a healthy adult, heel pad thickness is typically around 1–2 cm, with ultrasound studies reporting unloaded thickness close to 18–20 mm and significant but controlled compressibility under load. During walking, the heel can be exposed to forces of approximately 110% of body weight, rising to around 200% during running, which the fat pad normally attenuates. This mechanical role explains why subtle structural change can produce disproportionate symptoms.

Pathophysiology and aetiology

Heel fat pad atrophy reflects thinning, fragmentation, or displacement of the corpus adiposum accompanied by loss of elasticity and hydration. Micromechanical failure of the fibrous septa is thought to reduce structural integrity, impairing shock absorption and allowing higher peak plantar pressures directly over the calcaneus. Over time, repetitive high‑impact loading, such as running or jumping, and prolonged standing on hard surfaces drive cumulative microtrauma and wear, particularly when combined with inadequate footwear or barefoot loading on rigid substrates.

Multiple intrinsic and extrinsic factors contribute. Ageing leads to reduced collagen elasticity, loss of soft‑tissue moisture, and thinning or displacement of the fat pad, making heel fat pad syndrome more prevalent in older adults. Biomechanical factors, including altered arch alignment, high arches, and abnormal gait patterns, shift load toward the posterior calcaneus and increase local stress. A history of corticosteroid injection into or near the heel has been associated with fat pad breakdown, presumably via catabolic effects on collagen and adipose tissue. Systemic factors such as obesity and certain medical conditions further compromise tissue integrity and may accelerate thinning. Less commonly, acute trauma or a single episode of excessive heel strike can precipitate symptomatic structural failure.

Clinical presentation and differential diagnosis

Clinically, patients typically describe a deep, dull, “bruised” pain centred under the heel that is provoked by weightbearing and worsens on hard surfaces or when walking barefoot. Standing or walking for prolonged periods aggravates symptoms, whereas non‑weightbearing usually provides rapid relief. On examination, there is focal tenderness beneath the posterior‑central calcaneus, often slightly lateral to the midline, corresponding to the main weightbearing point at heel strike. The pad may feel thinned or less resilient on palpation compared to the contralateral side, and compressive testing may reproduce pain.

Differentiating heel fat pad atrophy from plantar fasciopathy is clinically important, as management priorities differ. Plantar fasciitis usually presents with medial calcaneal and proximal fascial tenderness and pronounced “first‑step” pain after rest, whereas fat pad pain is more central/posterior, often maximal during prolonged standing or impact and particularly severe when barefoot on firm ground. Radiology and ultrasound can assist: imaging in heel fat pad syndrome may demonstrate reduced fat pad thickness, altered echotexture, septal defects, fibrosis, or oedema within or around the pad, whereas plantar fasciopathy shows fascial thickening and entheseal changes. A scoping review suggests heel fat pad syndrome may be the second most common cause of plantar heel pain, yet is frequently overlooked or conflated with plantar fasciopathy in the literature and in practice.

Investigations

Although heel fat pad atrophy is primarily a clinical diagnosis, imaging can provide objective corroboration and help exclude other pathology. Ultrasound offers a practical method to quantify heel pad thickness in unloaded and loaded states and to assess compressibility, with studies reporting abnormal thinning and altered compressibility indices in symptomatic patients. MRI can demonstrate changes such as focal atrophy, fibrosis, oedema, and septal defects, alongside assessment of surrounding soft tissues and bone marrow. Radiographs may be useful to assess calcaneal spurs or other bony pathology but are less informative regarding fat pad quality. Objective measurement can be valuable in tracking progression and response to interventions in both clinical and research settings.

Conservative management

Management is initially conservative and centres on reducing peak plantar pressures while optimising overall foot biomechanics. Activity modification is foundational: patients are advised to reduce or temporarily cease high‑impact activities such as distance running and court sports, substituting with lower‑impact exercise where possible. Footwear education is crucial, emphasising supportive shoes with firm heel counters, appropriate arch support, and adequate heel cushioning; walking barefoot or in thin‑soled footwear on hard surfaces is discouraged. External devices—including cushioned socks, silicone or gel heel cups, and custom or semi‑custom insoles—aim to increase cushioning and, importantly, to contain and centralise the fat pad under the calcaneus.

Clinical taping techniques can be used to “cup” and reposition the pad beneath the heel, providing symptomatic relief and serving as a predictor of orthotic response. Physiotherapy or podiatry‑led rehabilitation often includes strengthening of intrinsic and extrinsic foot and ankle musculature, improving load sharing and dynamic stability, as well as targeted mobilisation of the rearfoot, talocrural joint, and plantar fascia to restore normal motion patterns. Adjunctive measures, such as short periods of icing and judicious use of oral or topical non‑steroidal anti‑inflammatories, may assist during acute exacerbations, although they do not address the underlying structural deficit. Importantly, repeated corticosteroid injection into the heel should be avoided in this population because of its association with further fat pad compromise.

Emerging interventional approaches and evidence gaps

For patients who remain significantly symptomatic despite optimised conservative care, several interventional strategies have been explored, though the evidence base remains limited. These include injectable fillers and heel fat pad augmentation via autologous fat grafting, which aim to restore volume and shock‑absorbing capacity. Clinical trial protocols investigating autologous fat transfer suggest that improving plantar cushioning may reduce peak plantar pressures, potentially lowering the risk of ulceration in high‑risk groups such as individuals with diabetes and bony prominence. Early case series and small studies report imaging‑confirmed changes in fat pad morphology, including atrophy, fibrosis, and oedema, but there remains a “glaring absence” of robust controlled trials evaluating the long‑term efficacy and durability of commonly used conservative and surgical interventions.

Consequently, current best practice emphasises accurate diagnosis, comprehensive mechanical off‑loading, and optimisation of global foot function, while recognising that definitive regenerative solutions are still under investigation. From a clinical perspective, heel fat pad atrophy underscores the importance of viewing plantar heel pain as a heterogeneous symptom complex rather than a monolithic “plantar fasciitis” entity, demanding careful localisation of pain, biomechanical assessment, and tailored intervention.

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Rigid carbon plates for treating hallux rigidus

Rigid carbon plates are a key non‑operative option for reducing first metatarsophalangeal joint (1st MTPJ) pain and improving function in patients with hallux rigidus by limiting painful dorsiflexion while preserving overall gait efficiency. Their use is supported by clinical studies on rigid and carbon‑based insoles, as well as growing clinical experience and commercial device design focused on targeted forefoot motion control.

Pathophysiology of hallux rigidus

Hallux rigidus is a degenerative arthropathy of the 1st MTPJ characterised by progressive cartilage loss, dorsal osteophyte formation, and reduced sagittal plane range of motion, particularly dorsiflexion. The loss of joint congruency and osteophyte impingement elevates joint reaction forces during propulsion, producing pain, stiffness, and altered push‑off mechanics.

As dorsiflexion becomes limited and painful, patients commonly compensate by externally rotating the foot, transferring load laterally to lesser metatarsal heads, or shortening step length, which can lead to secondary metatarsalgia, midfoot overload, and reduced walking speed. Conservative interventions therefore aim to reduce painful dorsiflexion moments at the 1st MTPJ while maintaining sufficient forefoot stability for efficient gait

Rationale for rigid carbon plates

Rigid orthoses have long been used to “splint” the first ray and limit 1st MTPJ motion as a primary strategy in conservative management of hallux rigidus. A systematic review of non‑operative care reports that footwear modifications and rigid custom insoles are effective in roughly half of patients, supporting their role as first‑line therapy.

Carbon fibre is particularly suited to this task because it offers very high stiffness at minimal thickness and weight, allowing substantial motion restriction with relatively low bulk. By stiffening the forefoot region of the shoe, carbon plates reduce bending at the ball of the foot so that the big toe joint does not need to dorsiflex as much during terminal stance, thereby decreasing joint loading and pain.

Design characteristics of carbon plates

Rigid carbon plates for hallux rigidus are usually thin (around 1.0–1.2 mm) and flat or slightly contoured, with minimal flex across the metatarsal heads. Their stiffness is achieved using high‑strength carbon (often combined with glass fibres) embedded in a polymer matrix, producing a durable, fatigue‑resistant structure that tolerates repetitive forefoot loading.

Two main geometries are commonly employed:

  • Morton’s extension plates: extend under the hallux and first metatarsal, allowing more normal motion of the lateral metatarsophalangeal joints while specifically splinting the first ray.carboneaze+1
  • Full‑width forefoot plates: span the entire forefoot, limiting motion at both the 1st MTPJ and lesser MTPJs and creating a more global rocker effect.

Choice of design is typically dictated by whether isolated first‑ray control is desired or whether broader forefoot immobilisation and rocker function are clinically advantageous.

Clinical evidence for carbon‑based insoles

Although many traditional devices used polypropylene or other rigid plastics, carbon fibre has increasingly been adopted as a base material for rigid 1st ray splinting orthoses. A randomized controlled trial comparing flexible carbon fibre insoles with a rigid Morton’s extension in patients with unilateral 1st MTPJ arthritis found that flexible carbon insoles produced significantly greater reductions in pain interference and pain intensity scores at 6 and 12 weeks, with higher comfort and better compliance.

Specifically, the flexible carbon group demonstrated larger median improvements in PROMIS pain interference and pain intensity scales, while the more rigid Morton’s extension did not achieve similar gains despite also restricting motion. The authors concluded that carbon‑based insoles which balance mechanical shielding with some preserved motion may provide superior symptom relief and patient adherence compared with very rigid orthoses.

Beyond this trial, a broader review of conservative hallux rigidus care notes that custom insoles fabricated from rigid materials, including carbon fibre, reduce symptoms in a substantial proportion of patients and carry a moderate level of evidence within an evidence‑based framework. Emerging work in related forefoot and midfoot pathologies also suggests that full‑length carbon insoles can reduce forefoot loading and alter muscle activation patterns in ways that may support pain reduction and gait efficiency.

Mechanisms of symptom relief

Rigid carbon plates treat hallux rigidus primarily through mechanical modification of the 1st MTPJ environment:

  • Motion restriction: By limiting dorsiflexion at the 1st MTPJ, plates decrease peak articular cartilage stress and dorsal osteophyte impingement during propulsion.
  • Load redistribution: The stiffened forefoot encourages a more rocker‑like gait, shifting load proximally and to adjacent structures rather than concentrating it at the arthritic joint.
  • Capsular protection: In conditions such as turf toe and big‑toe arthritis, carbon plates protect the joint capsule from excessive dorsiflexion and repetitive microtrauma.

These mechanical effects collectively reduce pain, dampen inflammatory flares, and may slow progression of degenerative change by limiting repeated high‑stress motion at the affected joint.

Integration with footwear and orthoses

Successful use of rigid carbon plates depends heavily on shoe compatibility and integration with existing orthotic therapy. Many clinicians either place the plate directly under the insole in a suitable shoe, or incorporate it into a custom device to avoid excess bulk and maintain foot position control. Full‑length plates often work best in footwear with adequate depth and a relatively stiff outsole, further enhancing the rocker function created by the plate.

Layering a carbon plate beneath a functional orthotic can be particularly useful in hallux rigidus, with the plate restricting painful toe motion while the orthosis addresses rearfoot and midfoot mechanics and redistributes plantar pressures. However, excessive stack height from combining OTC inserts with separate plates can compromise fit and comfort, so careful device selection and shoe testing are important.

Advantages and limitations

Rigid carbon plates offer several practical advantages in managing hallux rigidus:

  • High stiffness with low profile and weight, improving shoe fit compared with many traditional rigid insoles.
  • Reversible, non‑invasive intervention compatible with other conservative measures such as NSAIDs, intra‑articular injections, and physiotherapy.
  • Versatility in design (Morton’s extension vs full‑width) to tailor motion restriction to the individual’s pathology and activity demands.

Conversely, limitations include potential discomfort from excessive rigidity, difficulty fitting plates into fashion or low‑volume footwear, and patient reluctance to accept changes in shoe feel or forefoot rocker mechanics. Over‑restriction of forefoot motion may transfer stress to proximal joints or lesser MTPJs, and plates may not adequately control pain in advanced cases where surgical options such as cheilectomy, arthrodesis, or arthroplasty are more appropriate.

Place in overall management

Within the broader conservative algorithm for hallux rigidus—alongside pharmacologic therapy, intra‑articular injections, activity modification, and footwear changes—rigid carbon plates occupy a central role as a mechanical pain‑relief strategy that can delay or obviate surgery for many patients. Evidence indicates that about half of patients achieve meaningful symptom control with such conservative measures, justifying early and systematic use of these devices.

Contemporary research comparing rigid Morton’s extensions with flexible carbon fibre insoles suggests that optimal plate design for hallux rigidus may require a nuanced balance between sufficient rigidity to shield the joint and enough flexibility to preserve comfort and normal mechanics. For clinicians and patients, rigid and semi‑rigid carbon plates therefore represent a valuable, adaptable tool in the non‑operative management of hallux rigidus, particularly when carefully matched to footwear, orthotic strategy, and the individual’s functional goals.

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Treating hallux rigidus

Hallux rigidus is a degenerative arthritis of the first metatarsophalangeal (MTP) joint that leads to pain and progressive loss of dorsiflexion of the hallux, ultimately impairing gait and limiting activities that require push‑off. Treatment revolves around symptom relief, preservation of joint motion where possible, and restoration of function, using a stepwise approach from conservative care to surgery depending on disease severity, patient demands, and radiographic changes.

Principles and goals of treatment

The primary goals of treating hallux rigidus are to relieve pain, maintain or improve range of motion, and allow patients to walk and perform daily activities without significant limitation. Management must be individualized by considering the clinical stage (e.g. mild, moderate, or advanced arthritis), alignment of the first ray, patient age, activity level, and expectations regarding joint motion. In early stages, joint‑preserving strategies are typically preferred, whereas in end‑stage disease, procedures that sacrifice motion in exchange for reliable pain relief, such as arthrodesis, are often indicated.

Conservative management

Non‑operative treatment is recommended as first‑line management and can provide meaningful relief in approximately half of patients, particularly those with mild to moderate disease. Pharmacological measures include non‑steroidal anti‑inflammatory drugs (NSAIDs) to reduce synovitis and pain, although these rarely provide complete or lasting symptom control when used alone. Intra‑articular corticosteroid injections can produce short‑term pain relief—often on the order of weeks to a few months—with diminishing returns in more advanced grades, and intra‑articular hyaluronic acid has demonstrated a reduction in pain and improved function several months after injection in some series.

Footwear modification and orthoses represent key elements of conservative care. Stiff‑soled shoes, rocker‑bottom soles, and shoes with a higher toe box limit painful dorsiflexion at the first MTP joint and reduce pressure over dorsal osteophytes. Custom insoles or orthotics can offload the first MTP joint, support the medial longitudinal arch, and sometimes incorporate a Morton’s extension or carbon fiber plate to further reduce joint motion during push‑off. Collectively, footwear changes, insoles, and injections are among the most effective conservative strategies according to evidence‑based reviews, with moderate‑grade recommendations.

Physical and manual therapy approaches, while supported by relatively low‑level evidence, aim to optimize joint mechanics and muscular support. Interventions may include great toe mobilization, long‑axis traction of the MTP joint, mobilization of the sesamoids, stretching of capsular and tendon structures, and strengthening of the flexor hallucis longus and intrinsic foot muscles to improve the pulley mechanism and dynamic stabilization. Dynamic splinting to encourage first MTP extension has been reported to significantly increase active range of motion post‑operatively and could theoretically reduce progression from hallux limitus to rigidus, though robust randomized data are limited. Overall, conservative programs are best viewed as comprehensive packages that combine medication, injections, footwear modification, and targeted rehabilitation rather than single isolated modalities.

Joint‑sparing surgical options

When conservative measures fail, and especially in grades I–III disease where some dorsiflexion remains and joint surfaces are not completely destroyed, joint‑sparing operations are considered. The most established of these is cheilectomy, which consists of resecting dorsal osteophytes and a portion of the dorsal metatarsal head to improve dorsiflexion and reduce impingement. For early stages, cheilectomy alone has demonstrated excellent pain relief and functional outcomes, and even in some grade III cases, series have shown substantial improvement in visual analogue scale pain scores with low revision rates.

Cheilectomy can be combined with proximal phalanx osteotomy, such as a Moberg dorsal closing‑wedge osteotomy, to further increase dorsiflexion by shifting the arc of motion. In a cohort of high‑grade hallux rigidus, the combination of cheilectomy and Moberg osteotomy led to improved dorsiflexion, high patient satisfaction, and a low conversion rate to arthrodesis at mid‑term follow‑up, suggesting this is a reasonable option for active patients with residual motion pre‑operatively. Arthroscopic techniques allow debridement and dorsal cheilectomy through small portals and have been described mainly for grade I–II disease, offering potential benefits in terms of soft‑tissue preservation and recovery, though long‑term outcome data remain limited.

Interpositional arthroplasty is another joint‑sparing strategy mainly reserved for moderate to severe hallux rigidus in patients who strongly wish to preserve motion. Classic procedures such as Keller resection arthroplasty remove a portion of the base of the proximal phalanx, often combined with soft‑tissue interposition, but excessive resection can lead to toe weakening, shortening, and transfer metatarsalgia. Modern interpositional techniques may use capsular flaps, tendon graft, or synthetic materials as spacers to maintain joint space and allow painless motion, but outcomes can be more variable and less predictable than arthrodesis. Synthetic cartilage implants, such as polyvinyl alcohol hydrogel spacers, have shown short‑term results comparable to arthrodesis in terms of pain and function at around two years, with the advantage of preserving motion and a reported failure rate near 10%, though longer‑term durability is still under investigation.

Joint‑sacrificing procedures

In end‑stage hallux rigidus with severe cartilage loss, large osteophytes, and minimal remaining motion, joint‑sacrificing procedures are most commonly used. Arthrodesis of the first MTP joint is widely regarded as the gold standard for advanced disease because it reliably eliminates arthritic pain and provides a stable, plantigrade toe for push‑off. The procedure involves removal of the residual cartilage, preparation of subchondral bone, and fusion of the proximal phalanx to the metatarsal using screws and/or plates, with union rates typically high and long‑term satisfaction favorable. The trade‑off is permanent loss of first MTP motion, which can limit certain activities (e.g. kneeling, sprinting, high‑heeled shoes), but many patients adapt well with proper alignment of the fusion.

Implant arthroplasty, using metallic or silastic prostheses, aims to maintain joint motion while resurfacing arthritic surfaces. However, concerns exist about implant loosening, subsidence, and revision complexity over time, and evidence has not consistently shown superiority to arthrodesis in terms of pain relief and durability. For low‑demand or elderly patients reluctant to accept a fusion, implant arthroplasty or interpositional arthroplasty may still be considered, but careful counselling regarding risks, potential for failure, and need for eventual conversion to arthrodesis is essential.

Treatment selection and future directions

Choosing among the available treatments requires a structured assessment that integrates clinical staging, radiographic findings, and patient‑specific goals. In practice, early disease is often managed with a combination of footwear modification, orthoses, NSAIDs, injections, and possibly manual therapy, progressing to cheilectomy (with or without proximal phalanx osteotomy) if symptoms persist. For intermediate disease in active individuals with some preserved motion, extended cheilectomy, Moberg osteotomy, or interpositional/synthetic cartilage arthroplasty may be appropriate, while advanced cases with near‑complete cartilage loss are usually best served by first MTP arthrodesis.

Emerging options such as biologic injections (platelet‑rich plasma, bone marrow aspirate) and novel implant materials are being explored, but current evidence is insufficient to draw firm conclusions about their long‑term efficacy in hallux rigidus. High‑quality randomized controlled trials are still needed, particularly in the domain of physiotherapy and manual therapy, to clarify which conservative protocols offer the greatest benefit. For now, a graded, evidence‑informed approach that starts with conservative measures and progresses to well‑selected surgical procedures offers the best chance of restoring pain‑free function for patients with this common and disabling condition.

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Haglund’s deformity

Haglund’s deformity is a posterosuperior bony prominence of the calcaneus that irritates the overlying soft tissues, especially the retrocalcaneal bursa and Achilles tendon insertion, leading to posterior heel pain and functional limitation. Treatment focuses first on relieving mechanical irritation and inflammation with conservative measures, and then, if symptoms persist, on surgical reshaping of the heel and addressing associated tendon and bursal pathology.

Pathophysiology and treatment goals

The bony enlargement in Haglund’s deformity increases pressure between the calcaneus, the Achilles tendon, and the retrocalcaneal bursa, especially in closed‑back shoes and during activities that load the tendon. Repeated friction and compression provoke bursitis, tendon degeneration, and sometimes partial tearing at the Achilles insertion, which together generate pain, swelling, and stiffness at the back of the heel. The overarching goals of treatment are to reduce mechanical stress on the area, control inflammation and pain, restore calf–Achilles flexibility and strength, and, when necessary, remove the offending bony prominence while preserving or restoring tendon function.

Conservative (non‑operative) management

Non‑operative care is the first‑line approach and is often continued for at least several months before surgery is considered. It combines activity modification, footwear changes, physical therapies, and pharmacologic strategies aimed at both symptoms and underlying biomechanics.

Key conservative measures include:

  • Footwear modification: Patients are advised to avoid rigid heel counters and tight shoes that rub over the posterior heel, and instead use softer, backless, or open‑heeled footwear when possible. Padding around the heel and using shoes with a slightly higher heel can further decrease direct pressure on the deformity.
  • Heel lifts and orthoses: Heel lifts elevate the calcaneus, reducing dorsiflexion at the ankle and therefore strain and compression at the Achilles insertion and retrocalcaneal bursa. Custom foot orthotics can correct contributing alignment issues such as excessive pronation and help redistribute plantar loads, which may lessen traction on the posterior heel and reduce the likelihood of recurrence.
  • Activity modification and rest: Reducing or temporarily stopping high‑impact activities that load the Achilles tendon, such as running and jumping, can allow inflamed tissue to settle. A graded return to activity is then guided by symptoms, often with cross‑training using low‑impact exercise like cycling or swimming.
  • Physical therapy: Stretching of the gastrocnemius and soleus muscles, and eccentric strengthening of the Achilles, are central components of physiotherapy programs. Improved calf flexibility decreases tension at the insertion, while progressive loading of the tendon can enhance its capacity and reduce pain in many insertional tendinopathies. Therapists may also use modalities such as ultrasound, manual mobilization, and proprioceptive exercises to support recovery.
  • Anti‑inflammatory strategies: Nonsteroidal anti‑inflammatory drugs (NSAIDs) are often used for short‑term pain and swelling control. Ice, compression, elevation, and topical anti‑inflammatory gels can be added to reduce local inflammation. Some centres also use extracorporeal shockwave therapy to address chronic insertional Achilles symptoms related to Haglund’s deformity.
  • Injections: Corticosteroid injections around the inflamed bursa may be considered to relieve pain, but they are used cautiously near the Achilles tendon because of the risk of tendon weakening or rupture. When used, they are typically targeted to the bursa under imaging or careful palpation to minimize intratendinous spread.

Many patients improve with this combination, especially when footwear and load management are optimized, but a substantial group continues to have pain despite several months of comprehensive conservative care. Persistent pain that limits daily activities or sport, despite such management, is the main indication to consider surgery.

Surgical treatment options

Surgery aims to remove the posterosuperior calcaneal prominence, excise the inflamed retrocalcaneal bursa, and debride any diseased Achilles tendon while preserving or reconstructing the tendon attachment. The two broad categories of procedures are open surgery and endoscopic (minimally invasive) calcaneoplasty, and both have shown good clinical results in appropriately selected patients

Open procedures

Open surgery can be performed through several approaches, including lateral, medial, or a central tendon‑splitting incision through the Achilles. Through these approaches, the surgeon typically:

  • Excises the retrocalcaneal bursa.
  • Resects the Haglund’s bony prominence using an osteotome or burr.
  • Debrides degenerative Achilles fibres, and, if necessary, detaches and then reattaches part of the tendon using suture anchors.

In some cases, a dorsal closing‑wedge calcaneal osteotomy is used to change the orientation of the calcaneal tuberosity and reduce impingement. Systematic review data show that open procedures lead to substantial improvements in outcome scores such as the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, with mean gains of over 30 points in many series. However, complications can include wound healing problems, superficial infection, altered sensation around the incision, hypertrophic scarring, persistent pain from inadequate resection, stiffness, and rarely Achilles tendon rupture.

Endoscopic calcaneoplasty

Endoscopic techniques use one to three small portals placed around the Achilles tendon to access the retrocalcaneal space. Under endoscopic visualization, the surgeon removes the inflamed bursa and shaves down the posterosuperior calcaneal prominence, similar in principle to open surgery but with less soft tissue disruption. Several series report excellent or good results in most patients, with AOFAS score improvements comparable to those of open surgery and very low complication rates.

Benefits of endoscopic surgery include smaller scars, shorter operative times, lower incidence of wound complications, and often quicker return to work and sport. The main limitations are a steep learning curve and the need for precise anatomical understanding to avoid iatrogenic injury; high‑quality comparative trials remain limited, so current recommendations are graded cautiously.

Indications and patient selection

Surgery is usually reserved for patients with:

  • Persistent posterior heel pain attributable to Haglund’s deformity that has failed at least six months of structured conservative treatment.
  • Radiographic confirmation of a prominent posterosuperior calcaneus with corresponding clinical findings.
  • Functional limitation in daily or sporting activities that the patient considers unacceptable.

Patients with high risk of wound healing problems (for example, smokers, individuals with poorly controlled diabetes or peripheral vascular disease) must be counselled carefully, and in some cases surgery may be discouraged or modified. The choice between open and endoscopic techniques depends on surgeon expertise, the extent of Achilles degeneration, and patient‑specific anatomy and goals.

Postoperative rehabilitation and outcomes

Postoperative protocols differ depending on whether the Achilles tendon was detached and repaired, but they generally involve protected weight‑bearing and progressive mobilization. After isolated bony resection without significant tendon repair, patients often use a boot with heel elevation and progress from toe‑touch to full weight‑bearing over several weeks. When the tendon has been split or reattached, non‑weight‑bearing in a boot or cast with the ankle in plantarflexion for about four weeks is common, followed by gradual progression to weight‑bearing and neutral ankle position.

Physiotherapy focuses on restoring ankle range of motion, managing swelling and scar tissue, and then gradually rebuilding calf strength and functional gait. Full recovery, including return to high‑impact sports, may take six months or more, especially after open surgery or extensive tendon work. Overall, both open and endoscopic procedures yield high patient satisfaction and marked pain relief, with endoscopic surgery offering similar functional gains and potentially fewer complications, though definitive superiority has not been established due to limited high‑level evidence

In summary, treatment of Haglund’s deformity of the heel progresses from carefully optimized conservative care—emphasizing footwear, load management, orthoses, and physiotherapy—to surgical removal of the bony prominence with bursal excision and tendon management in resistant cases, using either open or endoscopic methods that, when appropriately applied and rehabilitated, can restore comfortable function for most patients.