Common Foot and Ankle Disorders: The Role of Cumulative Industrial Trauma Kurt Rongstad, md

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Common Foot and Ankle Disorders: The Role of Cumulative Industrial Trauma

Kurt Rongstad, MD

Dept. of Orthopedic Surgery

University of Wisconsin

Work Related Diseases

  • Repetitive Occupational Exposure

  • Coal Miners’ Lung

  • Lung Cancer in Uranium Miners

  • Asbestosis in Shipyard Workers

  • Multiple Bone Infarcts in Caisson Workers

Repetitive Work as cause of Musculoskeletal Disorders

  • “Overuse Syndrome” - Fry, 1988

  • “Cumulative Stress Disorder”

  • “Repetitive Stress Injury”

  • “Cumulative Trauma Disorder”

  • Medical and Legal Interest: Focused on Upper Extremity

Research: Foot & Ankle and Cumulative Trauma

  • 1995: Dr. Roger Mann - Medline Search

  • Dec. 2000: Foot & Ankle International

  • Guyton, Mann, Kreiger, Mendel, Kahan:

  • “Cumulative Industrial Trauma as an Etiology of Seven Common Disorders in the Foot and Ankle: What is the Evidence?”

Etiology of Disease: Koch’s Postulates

  • Postulate 1: The disease is found to be excessive in a class of workers.

  • Postulate 2: The etiologic agent (work) must be able to be separated from other agents.

  • Postulate 3: The work exposure should cause disease to a normal person.

Hypothenar Hammer Syndrome: Koch’s Postulates

  • Postulate 1: Condition is confined to a small well defined group of laborers.

  • Postulate 2: Mechanical stimulus to hand is isolated from other exposures.

  • Postulate 3: No patients reported symptoms prior to starting occupation.

Common Foot and Ankle Disorders

  • Hallux Valgus (Bunions)

  • Lesser Toe Deformity (Hammertoes)

  • Interdigital (Morton’s) Neuroma

  • Tarsal Tunnel Syndrome

  • Heel Pain (Plantar Fasciitis)

  • Flatfoot Deformity

  • Ankle and Foot Arthritis

Bunions: Hallux Valgus

  • Enlargement of medial base of great toe

  • Angulation of big toe towards 2nd toe

  • Pain often associated with pressure from shoes

  • Fairly common

Bunions: Causes

  • Constrictive shoewear !!!

  • Hereditary

  • Ligamentous laxity

  • Muscle imbalance

  • Inflammatory arthritis

  • Occupational repetitive trauma: Not even a hint in the literature

Bunions: My experience

  • Fix about 75-100 bunions per year

  • One W.C. related bunion repair in 10 years (acute trauma)


  • Flexion deformity of the lesser toes at the proximal joint

  • Often associated with a callous or sore spot

  • Most common foot deformity

Hammertoes: Causes

  • Constrictive shoewear

  • Neurologic

  • Examples: Nerve or Muscle diseases, Stroke

  • Increasing age

  • Female: Male - about 7:1

Hammertoes: Work related?

  • Study by Lamberinudi, England, 1938:

  • Industrial workers: no higher incidence of toe deformities

  • Study by Hewitt, England, 1954

  • Study by Hung, Hong Kong, 1985:

  • Lower incidence of toe deformities in heavy laborers

  • Only correlation: elderly women

Morton’s Neuroma

  • Described by Thomas Morton, 1876

  • Entrapment of interdigital nerve

  • Nerve enlarges

  • Usually between base of 3rd-4th toes

  • Burning or tingling symptoms

Morton’s Neuroma -- Causes

  • Compression of nerve by intermetatarsal ligament

  • Medial – lateral compression (tight shoes)

  • Pressure on forefoot (high heels)

  • Anatomic variance – small space between metatarsal heads or enlarged nerve

  • No evidence of occupational exposure etiology

  • Great majority of patients with neuroma report normal ambulation patterns. {Postulate 1 not satisfied}

Bunions/Hammertoes/Neuromas: Caused by Work Shoes?

  • No causation of toe deformities

  • May increase symptoms if deformity present

  • High Fashion Women’s Footwear:

  • Clearly associated as a cause of toe deformities

  • Almost always a “self inflicted wound”

Tarsal Tunnel Syndrome

  • Compression Neuropathy of the Tibial Nerve in the Tarsal Tunnel

  • Numbness, burning into the heel and arch

  • Not common, poorly understood

  • Best surgical results when a mass present in the tunnel

Tarsal Tunnel Syndrome: Industrial Cumulative Trauma

  • Forst: Sewing machine operator with Tarsal Tunnel Syndrome (unsuccessful release)

  • Lam: “no significant common factor concerning occupation…except jockeys may be at increased risk.”

  • No other literature references

  • Tarsal Tunnel Syndrome is NOT the lower extremity equivalent of Carpal Tunnel Syndrome

Heel Pain

  • Most common foot or ankle problem

  • Often due to microtrauma to the origin of the plantar fascia

  • Morning pain, end of day pain in medial heel common

  • Pain may be central or even burning in quality

Heel Pain: Causes

  • Obesity: Highest correlation of all causes

  • Middle age

  • Tight heel cords

  • Recent increase in activity

  • High arches/ low arches

  • Running athletes

  • Treatment aimed at cause

Heel Pain: Industrial Causes

  • Scant data: most series do not list occupation as a cause, other studies contradictory

  • Gill: Survey, 1996: Patients with heel pain self report jobs with more walking on hard surfaces than patients with other orthopedic complaints

  • Davis: Study: 103 of 105 patients with plantar fasciitis reported sedentary type jobs

Adult Acquired Flatfoot

  • Gradual falling of the arch

  • Pain can be medial ankle, arch or even lateral ankle

  • Multiple underlying processes: Posterior Tibial Tendon dysfunction most common

  • Treated with arch supports, braces, or surgery

Adult Acquired Flatfoot - Causes

  • Associated with obesity

  • Lifelong flatfeet [increase stresses]

  • Female more common than male

  • Isolated trauma to medial ankle rare

  • Great majority of patients report normal lifelong walking patterns

  • No literature association to occupation


  • Arthritis: extensive research, yet poorly understood in terms of cause

  • Foot joints arthritis: in mild forms, fairly common in general population

  • Ankle joint arthritis: surprisingly rare in general population without acute traumatic event

  • Knee arthritis: quite common even without prior specific acute trauma


  • Knee Arthritis:

  • Higher incidence in professional athletes (soccer)

  • No higher incidence in recreational runners – several studies

  • Higher incidence in obese

  • Higher incidence in miners and dock workers than age-matched controls [Partridge, 1968]

  • Ankle/Foot Arthritis:

Occupational Cumulative Trauma

  • Does it exist in the Foot/Ankle at all?

  • Probably:

  • Dancers

  • Professional Athletes

  • Military Recruits

Cumulative Occupational Trauma: Koch’s Postulates

  • Postulate 1: The disorder must be higher in a group of workers as compared to control group.

  • No evidence in any of our common foot and ankle disorders.

  • Heel pain: Very common in industrial workers; Very common in general population.

  • Tarsal Tunnel Syndrome: Not common in either group.

Cumulative Occupational Trauma: Koch’s Postulates

  • Postulate 2: The work exposure must be able to be isolated from other exposures.

  • Unable to isolate work activities, floor quality, or even types of work shoes from everyday living.

  • Only spend 25% of our awake time at work.

  • Everyday foot demands vary little from work demands.

  • ***(Recreational demands often exceed work demands!)

Cumulative Occupational Trauma: Koch’s Postulates

  • Postulate 3: A normal host is exposed to the work exposure and develops the disease.

  • This would require a prospective cohort study.

  • Scant (at best) retrospective data in literature to support the existence of cumulative industrial foot trauma.

  • Highly unlikely study to be pursued.

Foot/Ankle Cumulative Work Trauma

  • Are we not looking hard enough for its existence?

  • Has previous literature simply neglected to look at this subject?

  • Maybe: Heel pain and arthritis as work related disorders seem to make sense.

  • Not disproven. Just cannot be proven at this time.

Foot/Ankle Cumulative Work Trauma

  • Absence of proof does not surprise me.

  • Foot evolved for the demands of repetitive stresses.

Thank You!

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