Utilizing a couple of illuminating case studies, these authors look at the role improper shoe gear can play in compressive neuropathy and discuss treatment options.
Shapiro and Gibbs originally described vamp disease as a commonly occurring problem in which the patient can develop inflammatory swelling on the dorsal aspect of the base of the hallux, secondary to the irritation from the vamp of the shoe.1 This can cause painful callus formation, irritating the extensor hallucis longus tendon with potential to cause infection in the area.
A second type of vamp disease can occur at the first or second metatarsocuneiform joint or under the inferior extensor retinaculum. The problem can also involve the region under the extensor hallucis brevis muscle belly. Compression from the vamp of the shoe or lacing issues on the deep or superficial peroneal nerve results in pain for the patient. Kopell and Thompson referred to this compression as anterior tarsal tunnel syndrome.2,3
In regard to the etiology of the metatarsocuneiform exostosis that can compress the nerve from shoe pressure, there are several possible mechanisms. Ankle sprains, trauma, tight fitting shoes, ski boots and faulty biomechanics are reportedly inciting factors.3,4 Neurologic conditions often occur in joggers and dancers, and can even be implicated in injuries resulting from athletes doing sit-ups with their feet hooked under a metal bar.4 The presence of edema, ganglion and a bony hyperostosis can also cause nerve compression.4
The hypermobile, pronated foot can also be contributory to neuropathy in athletes.4 The maximally dorsiflexed portion of the metatarsal creates a jamming effect, which can result in the development of a subchondral bone and marginal exostosis formation. In the cavus foot, the structural abnormality leads more often to the hyperostosis. The plantarflexed first ray leads to compensation at the midtarsal and subtalar joints, which is more of a secondary cause of the exostosis rather than a primary pes cavus foot.4 An enlarged extensor hallucis brevis muscle belly can also cause irritation.
However, we believe the major aggravating factor to nerve compression is the vamp of the shoe and a tight shoelace. We will refer to this as vamps disease II.5
How Tight Lacing And Incorrect Shoe Size Can Trigger Vamp Disease
The vamp of the shoe covers the dorsum of the foot and includes the tongue. The throat of the shoe is the central portion of the vamp proximal to the toebox. The throat of the shoe dictates the maximal girth permitted by the shoe itself. The eyelets are on each side of the throat and will extend to the top of the collar. The eyelets in many athletic shoes extend onto the collar itself.6
In an informal office study, after measuring the shoe size of approximately 100 men and 100 women, we found that the majority of women wear shoes that are too small, causing abnormal pressure on the dorsum of the foot.7 We found that generally, men wear shoes that are too large. This can present a problem in both cases. Both sexes have a tendency to lace the shoes too tight, creating a strangulation of the superficial and deep peroneal nerves in both cases.
Case Study One: Treating A ‘Generalized Ache’ From Shoe Gear
A 17-year-old male presented with a bump on the dorsum of his foot of several years’ duration. He stated the pain was worse over the last three years and described the pain as a generalized ache, especially in certain types of shoe gear.
Direct palpation of the dorsal midfoot exostosis elicited the patient’s primary pain. The patient's musculoskeletal exam was normal with the exception of a prominence on the dorsal aspect of the second metatarsocuneiform area. Vascular, neurological and dermatological exams were normal. X-rays revealed an intermetatarsal angle of 13 degrees and tibial sesamoid position of a three with a mild bilateral hammertoe of the second digit. A bilateral exostosis was also present on the X-ray at the second metatarsocuneiform joint area.
We offered the patient conservative care but he requested surgical intervention after the failure of orthotics, anti-inflammatories and shoe therapy including loosening his laces. We performed a midfoot exostectomy with no complications reported postoperatively.
Case Study Two: When A Runner Notices Growing “Bumps” On Her Foot And Sharp Pain With Ambulation
The patient was a 32-year-old female who had been running for nine months. She noted “bumps” on the top of her foot that seemed to be growing with time. The patient also reported numbness and pain that could radiate up to a level of 8/10 on the visual analogue scale with ambulation and running. She described the pain as a sharp sensation with tingling that radiated into the toes.
Vascular and neurological exams were normal with the exception of deep peroneal nerve pain on palpation. The musculoskeletal exam was normal with the exception of a dorsal midfoot exostosis at the first and second metatarsocuneiform joint areas. Dermatological examination showed erythema at the second metatarsocuneiform area superficial to the exostosis itself. The biomechanical exam revealed increased pronation with posterior tibial dysfunction and an os tibiale externum. X-rays showed a decreased calcaneal inclination angle, an anteriorly broken cyma line and a bilateral midfoot exostosis. The patient was also wearing a shoe that was too narrow for her foot.
Conservative care included injection therapy, a donut pad, taping, anti-inflammatories, shoe therapy (including re-lacing and an appropriate width shoe), home physical therapy and orthotic devices. Following the failure of conservative care, the patient had surgical intervention including a midfoot exostectomy and a Kidner procedure. The patient healed uneventfully.
Pertinent Insights On Deep Peroneal Nerve Entrapment
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.
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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 .
7. Study says patients often misjudge shoe size. Podiatry Today. 2001; 14(11):13.
8. Beltran LS, Bencardino J, Ghazihanian V, Beltran J. Entrapment neuropathies III: lower limb. Semin Musculoskel Radiol.. 2010; 14(5):501-11.
9. Kennedy JG, Baxter DE. Nerve disorders in dancers. Clin Sports Med. 2008; 27(2):329-334.