Is a visual/physical exam enough to diagnose soft tissue issues in toes and feet? No pain, but 2nd toe is drifting over toward big toe, and it feels like there’s a visible thickness under the second toe. Podiatrist wants to go straight to surgery.Are there any tests that’d typically be run first?
Typically when a patient complains of a drifting second toe associated with a corn or callus, surgery is the first thing that pops to mind. However, getting a history of how the deformity developed, performing a physical evaluation, and obtaining radiographic information is first and foremost. Having a toe that is or is becoming crossed over may seem to be a cosmetic issue, especially if the patient denies pain. However, I find in my practice, which is 95% female, that most women do not realize they may be experiencing pain. I find this may be due to one of two things: 1) the ladies have drastically changed their shoe type to accommodate for the pain 2) in my opinion, that women have a higher threshold for pain, particularly when it is in regards to their feet.
First the history taking involves very specific questions, including but not limited to, how long has the patient had the condition, how painful is it issue at hand, what has the patient done to try to correct the problem or relieve the pain and since doing any conservative treatment (if any at all) is the problem getting better, worse or is it consistent? Second, is the physical evaluation which includes determining if the toe is flexible or rigid by putting the digit through a range of motion, verifying if the appearance of the toe changes during weight bearing verses non-weight bearing, assessing of all associated skin changes such as the presence of corns or calluses, and establishing if pain or tenderness accompanies the irregularity. Lastly, a review of the X-rays will yield further insight if the condition has a bony component, which is classically related with drifting toes. Years of clinical and surgical experience is the doctors best arsenal to determine if additional soft tissue disruption are present. However, if there is any doubt, further studies like an ultrasound or a MRI can be ordered.
After the history, physical and studies have been perform there should be a thorough consultation. Traditionally, for the condition you are describing, surgery is one of the options, especially if conservative treatment has already been exhausted. If there are further noninvasive alternatives, they should be offered first, but with the notion that in the future surgery may be required if the problem persist, gets worse and becomes painful.
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