As Published in TGForum and
Transgender Community News

The medical problems of the feet caused by the wearing of high-heeled shoes with a narrow toe box and thin soles are all well known to our community.  But after a generation of bunions, hammer toes and neuromas caused by fashionable shoes designed by men, the younger female generation has caused a swing in fashion to lower heels, wider toe boxes and thicker soles. But those of us, who have endured and love the longer leg gained with 3-4 inch heels have paid the price with toe deformities which become painful with time.
The foot is a complex system of 26 bones and 114 tendons, which support the entire weight bearing load of the body. Irregardless of your size, as the height of the heel increases, the load is placed on an ever smaller area of the front foot thus increasing the angle of the toes to the foot and decreasing the support. Since the ball of the foot is composed of the Metatarsal bones connected to the toes or Phalanges, this all important Joint is referred to as the MPJ. The constant friction at this joint caused by walking in high-heeled, narrow shoes has been determined to cause the problems I am about to discuss. If you never wear high-heeled shoes, you may stop here. But everyone else, "Are you with me�"
    The deformity of the Big toe caused by pointed shoes is called a Hallux (Large Toe) Valgus (Pointing Lateral) Deformity. This occurs 10 times more frequently in women than men and with time can approach an angle greater than 40 degrees. The head of the first metatarsal becomes inflamed and enlarged with further rubbing against the shoe. This is called a Bunion and on the fifth toe it is called a Bunionette. While this occurs slowly over time the conservative approach has been to pad the bunion to decrease callous formation and ulceration and occasionally to inject steroids to quiet inflammation if anti-inflammatory drugs are ineffective. As the angle increases, the second toe either overlaps or occasionally underlaps the Big Toe and the body support shifts to the second MPJ where the most common complaint becomes pain or "metatarsalgia" of the ball of the foot. This can usually be alleviated by switching to a broad, soft-soled shoe or MPJ pad.  But since we are not to forego walking fashionably, surgery may be considered if all of the above do not work. Using corrective surgery, the toes and joints may be properly realigned to start the process all over again. Approximately two-thirds of the operative population may return to unrestricted shoe wear, but the one-third with wider feet may need to wear wider shoes. Now in discussing surgery with your Orthopedist or Operating Podiatrist, you must realize that there are myriad procedures, all of which remove a wedge of deformed bone and sometimes fix the toes with a metallic pin or temporary wire. The best procedure for you is determined by your x-rays and the level of your deformity. The goal of your surgery is to straighten the big toe and restore mobility to the MPJ, which will give you the highest level of activity. The MPJ is not to be fused as was once very common.  Recovery may be up to 8 weeks in an open-toed wide shoe. The most common complication is incomplete correction of the deformity followed by stiffening of the MPJ, both of which will limit your mobility. Severe complications are less than 2%. But as many as 10% of surgeries need to be redone.
    Deformities of the lesser toes are among the most common of all foot disorders. They are 5 times more common in women than men, being attributed to shoes that are too short or too narrow. As the cramped toes buckle, the fascial plate weakens and the lower tendons of the small toes tighten causing the toe to curl in an elevated position. This resembles the piano key hammer, where the elevated toe constantly rubs against the top of the shoe and enlarges. This may be seen in all small toes, but most commonly in the second toe in association with Hallux Valgus. Correction early on may be performed with orthotics and proper fitting shoes, but as the deformity increases so does the rigidity. Surgery then involves cutting and elongating the extensor tendons and occasionally cutting the bone to straighten the toe. Recovery is usually 4-6 weeks and may involve prolonged swelling of the toe lasting up to 6 months.
 The nerves providing sensation to the toes run along the sole of the foot between the metatarsal heads and split in the interdigital web to supply feeling to two adjoining toes. Morton in 1876 described pain associated with these nerves at the point of the split extending into the toes. This has been termed a "Morton's Neuroma" and is associated with the stretching of the nerve and chronic friction caused by walking on the ball of the foot in high heels.  Surgical exploration reveals a nerve entrapped in a narrow sheath similar to carpal tunnel syndrome. Releasing the nerve often releases the pain, but may leave permanent changes in sensation. In conclusion, the best advice is to change shoes, when the pain emerges and use anti-inflammatory drugs to decrease the inflammation so that you may walk another day in those beautiful pumps.

Best of Luck in Your New Future,
Cerise Richards, M.D.