Learning Objectives
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Learn the common causes of foot pain.
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Develop an understanding of the unique anatomy of the fifth metatarsophalangeal joint.
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Develop an understanding of the causes of bunionette.
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Develop an understanding of the differential diagnosis of bunionette.
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Learn the clinical presentation of bunionette.
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Learn how to examine the foot.
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Learn how to use physical examination to identify bunionette.
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Develop an understanding of the treatment options for bunionette.
Miranda Halliday
Miranda Halliday is a 24-year-old fashion designer with the chief complaint of, “My left little toe is killing me.” Miranda stated that she was traveling to a fashion show in New York about 3 weeks ago when she did something “really stupid.” She packed several pairs of new Christian Louboutin high heels that a supplier had given her to wear on the trip. Miranda must have noticed the blank look on my face, and she said, “You know, Doctor, the ones with the red bottoms?” I nodded as convincingly as I could, and said, “So what about these shoes caused your foot pain?” She said, “Doctor, have you ever worn high heels that were a size too small for 15 hours a day? Let me tell you, it’s something you really, really, really do not want to do. I should have packed some more comfortable shoes, but I was in a hurry to catch my flight—really, really, really stupid.” She called an Uber to take her to her hotel and told the driver to take her to the Hilton, but they took her to the wrong Hilton. “I got to the front desk and they couldn’t find my reservation. They called around and saw that I was actually staying at the New York Hilton Midtown, not the Hilton Times Square where the Uber dropped me off. The desk clerk said it was an easy walk, so off I went. Because, as you can see, I am really fit, a 20-block walk seemed like no biggie. I made it about 10 blocks when my left foot really started to hurt. I just figured that my feet had swollen on the plane, and once I put my feet up, I would be fine. I know, I know, I have a bad habit of wearing shoes that are a little small, but who wants a girl with size 9 feet?”
I asked Miranda about any antecedent foot trauma, and she shook her head no, but went on to say that over the last 6 months, she had noticed that her left little toe was looking a little funny. She also noted that she was getting some calluses on the tops of her other toes ( Fig. 10.1 ). When she went to get a pedicure, the girl told her that her shoes were rubbing on the top of her toes, but high heels are a part of her job, her look, her brand narrative. Usually after a couple of Extra-Strength Tylenols and a glass of wine or two, she was good to go. This time, the pain just wouldn’t go away. Miranda said she felt that her left little toe was starting to go sideways and asked, “What was that all about?” She said that after a day on her feet, the little toe and the side of her foot were kind of swollen and “squishy,” and felt irritated and warm to touch. I asked Miranda what made her pain worse, and she said wearing some pairs of shoes was worse than others, and long days on her feet, like during Fashion Week, were the worst. “Sometimes a heating pad will help, but I really don’t like that my little toe is going all cattywompus on me. Before this, I actually had nice-looking feet. I now have to wear tennis shoes when I walk to work! Doctor, can you believe it?”
I asked Miranda to point with one finger to show me where it hurt the most. She pointed to the lateral aspect of the left little toe and said, “It’s really the whole side of my foot that hurts.” She cupped the lateral side of her left foot with her right palm for emphasis.
On physical examination, Miranda was afebrile. Her respirations were 18, and her pulse was 64 and regular. Her blood pressure was 119/68. Miranda’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the left foot revealed findings consistent with a bunionette. There was some swelling over the fifth metatarsophalangeal joint on the left. The toe was warm but did not appear to be infected. The left foot felt slightly edematous on palpation, and there was tenderness over the joint. Palpation of the little toe on the left exacerbated Miranda’s pain. Range of motion of the metatarsophalangeal joint also caused an increase in pain. I appreciated some crepitus when I dorsiflexed the toe. The right foot examination was normal, other than some callus formation over the dorsum of the third through fifth toes. Examination of her other major joints revealed no evidence of inflammatory arthropathy. A careful neurologic examination of the lower extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.
Key Clinical Points—What’s Important and What’s Not
The History
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History of wearing high heels that were too tight for a long period of time
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No fever or chills
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Swelling of the left little toe
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Deformity of the left little toe
The Physical Examination
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Patient is afebrile
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Medial angulation of the little toe on the left
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Callus formation on the dorsa of the second through fourth toes
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Tenderness to palpation of the left little toe
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Palpation of lateral aspect of the left foot reveals warmth to touch
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Mild swelling in the foot
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No evidence of infection
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Pain on range of motion
Other Findings of Note
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper extremity neurologic examination, motor and sensory examination
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Examination of joints other than the left foot were normal other than callus formation on the dorsa of the third through fifth toes on the right
What Tests Would You Like to Order?
The following tests were ordered:
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Plain radiographs of the foot
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Ultrasound of the left foot
Test Results
The plain radiographs of the left foot lateral splaying of the distal fifth metatarsal are consistent with tailor’s bunion (bunionette) (see Fig. 10.1 ).
Clinical Correlation—Putting it all Together
What is the diagnosis?
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Bunionette (tailor’s bunion)
The Science Behind the Diagnosis
Anatomy
The metatarsophalangeal joints of the toes are condyloid joints characterized by the articulation of the rounded articular surfaces of the metatarsal heads into the shallow concavities of the articular surfaces of the proximal end of the first phalanges ( Fig. 10.2 ). Each joint is lined with synovium, and the ample synovial space allows for intraarticular placement of needles for injection and aspiration. The metatarsophalangeal joints have dense joint capsules and strong plantar and collateral ligaments, although fracture and subluxation may still occur. The metatarsophalangeal joints of the toes are also susceptible to overuse and misuse injuries with resultant inflammation and arthritis.
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