Keys To Identifying And Treating Vamp Disease
In both cases, shoe gear exacerbated the patients' symptoms. In vamps disease II, the deep peroneal and superficial nerve entrapment exists. Deep peroneal nerve entrapment occurs as the nerve travels deep to the extensor retinaculum and deep to the extensor hallucis longus tendon at the level of the talonavicular joint. It can also be entrapped as it travels beneath the extensor hallucis brevis belly between the first metatarsal and second tarsometatarsal joint. The superficial peroneal nerve, because of its subcutaneous location, can also be compressed as it splits into the medial and intermediate branches. Both nerves can be injured due to ankle instability, trauma, a hypertrophic extensor hallucis brevis or an os intermetatarseum.
However, we feel the most common causes for this type of nerve compression is a “double crush” scenario of a degenerative exostosis and overlying shoe pressure from lacing issues or improper fit, creating compression of the nerve.8,9
Key Pointers On Effective Treatment
One should direct the treatment of vamps disease II based upon its etiology. Shoe therapy is the best treatment for conservative care. The patient should have a shoe measurement and a discussion with a demonstration of proper lacing protocol. Clinicians should not only discuss loosening the laces but demonstrate how to lace around the prominence as well.
We will also, at times, remove the lace from the top eyelets due to the compression upon dorsiflexion of the foot. We have found that if patients can place a finger underneath the top laces after tying the shoe, the shoe is tied properly.
Other treatment options include: a donut pad over the exostosis, anti-inflammatories, cortisone injections, orthotics to stabilize the foot and surgery. Surgery usually involves decompressing the nerve and removing the exostosis or other etiological factors, such as a ganglion cyst, and sectioning the overlying extensor hallucis brevis tendon. Removal of the exostosis invariably requires tedious displacement of the neurovascular bundle during dissection.4
Vamps disease II is a compressive neuropathy on the dorsal aspect of the foot with multiple etiologies. We believe the main reason for the compression occurs due to improper shoe gear and lacing issues. If conservative care is ineffective, then one should consider surgical management.
Dr. Mozena is in private practice at the Town Center Foot Clinic in Portland, Ore. He is a Fellow of the American College of Foot and Ankle Surgeons and is board certified in foot and ankle surgery. He is a Clinical Assistant Professor of Surgery at Western University of Health Sciences.
Dr. Jones is in private practice at the Town Center Foot Clinic in Portland, Ore. He is a Clinical Assistant Professor of Surgery at Western University of Health Sciences.
1. Shapiro L, Gibbs RC. Vamp disease. Arch Derm. 1970; 102(6):661-664.
2. Donovan A, Rosenberg ZS, Cavalcanti CF. MR Imaging of entrapment neuropathies of the lower extremity. Radiographics. 2010;30(4):1001-17.
3. Reed SR, Wright S. Compression of the deep branch of the peroneal nerve by the extensor halluxis brevis muscle: a variation of the anterior tarsal tunnel syndrome. Can J Surg. 1995; 38(6):545-6.
4. Schon LC, Baxter DE. Neuropathies of the foot and ankle in athletes. Clin Sports Med. 1990; 9(2):489-509.
5. Tobin R, Krych S, Harkless LB. First metatarsal-cuneiform dorsal exostosis: its anatomical relation with the medial dorsal cutaneous nerve. J Foot Ankle Surg. 1989; 28(5):442-444.
6. Available at http://allaboutshoes-toeslayer.blogspot.com/2009/10 .