Static forefoot changes, pes planus, and pes cavus and their impact on driving

Static forefoot changes

A pathological static foot is one that departs from the reference foot, defined by its intermediate plantar print, morphology with no excessive projections, and a good position in relation to the leg.

• Hallux abductus valgus (HAV):
  • Pain is the most important symptom of outward deviation of the first toe, and is due to repeated friction in each step and to irritation of the nerve running under the bulging bunion.
  • Pain may also be caused by degeneration of the metatarsophalangeal joint caused by osteoarthritis, and by an inadequate load transfer of the first metatarsal bone, inducing overload on the intermediate metatarsal bones.
  • If bunion bursitis also exists, friction will allow the condition to evolve to inflammation, infection, and fistulisation, thus gradually increasing local pain, with the resultant risk for safe driving.
  • Conservative treatment focuses on shoes.
  • Surgical treatment using arthroplasty causes incapacity to drive for approximately four weeks, and if joint preservation techniques (osteotomy) are used, at least two months should elapse for adequate fracture union.
• Hallux limitus or rigidus:
  • This is a form of osteoarthritis localised in the metatarsophalangeal joint of the first toe that may be of a rheumatic, gouty, congenital, osteodystrophic, osteochondritic, or surgical origin, or result from an intraarticular fracture.
  • Movement causes pain, that is no longer felt when total ankylosis has occurred.
  • Treatment is initially conservative, consisting of infiltrations, adapted insoles, and footwear corrections.
  • Surgery ranges from joint toilette and arthroplasty to arthrodesis in a physiological position. The first two procedures will require a month of recovery before driving, while two months should elapse after arthrodesis.
• Claw toe:
  • This is caused by muscle imbalance and lack of harmony in metatarsal length, but also occurs over time as a result of flat forefoot and pes cavus, and is enhanced in almost all cases by short footwear.
  • When claw may be reduced, it is improved by some conservative treatments.
  • Ankylosis and pain caused by footwear generally lead to surgery, that usually causes incapacity to drive for up to six weeks.
• Insufficiency of first radius:
  • This is mainly due to congenital or surgical shortness of the first metatarsal, or to musculoskeletal imbalance, and may lead to HAV or dystrophy of the second metatarsal head.

Tips

• Hallux abductus valgus (HAV):
  • Severe pain in the first metatarsophalangeal joint caused by HAV requires use in pedals of some support to avoid pain. This entails a risk of accident by impairing control of clutch, throttle, and brake pedals.
  • The specialist should advise against driving during acute pain episodes. Once treatment has been started, driving will be allowed when pain has subsided and if there is an adequate functional capacity of the foot.
  • Surgical treatment sometimes requires long recovery periods during which driving is not permitted.
  • The specialist will tell when driving may be safely resumed based on complete functional recovery of the foot and absence of pain.
• Hallux limitus or rigidus, Claw toe and Insufficiency of first radius:
  • The specialist should advise against driving during acute pain episodes. Once treatment has been started, driving will be allowed when pain has subsided and if there is an adequate functional capacity of the foot.
  • Surgical treatment sometimes requires long recovery periods during which driving is not permitted.
  • The specialist will tell when driving may be safely resumed based on complete functional recovery of the foot and absence of pain.

Pes planus

• Pain caused by this condition is not continuous, often occurring following a venous disorder or strenuous physical activity. 
• Osteoarthritis is a recurrent cause of pain. A short Achilles tendon may also result in calf, talar, or metatarsal pain.
• Conservative treatment ranges from correction of triggering factors to kinesitherapy and plantar orthosis.
• Acute sustained pain or functional discomfort may require a surgical solution such as arthrodesis. 
• The outcome of surgery is uncertain, and a six-month work leave is mandatory, during which driving is not permitted.

Tips

• Pes planus treated with orthopaedic measures usually allows for unrestricted driving.
• Surgical treatment requires long recovery periods during which driving is not permitted.
• The specialist will tell when driving may be safely resumed based on complete functional recovery of the foot with a good support and no pain.

Pes cavus

Pes cavus is more common and bothersome than pes planus, and makes it difficult to find adequate footwear because of a narrow heel and wide forefoot.

The ankle is usually poorly stable and often experiences repeated sprains.

Hyperkeratosis is a constant, because pes cavus rests upon a decreased plantar surface.

Surgery is performed when deformities interfering with use of shoes evolve, or conservative treatment cannot relieve pain.

Incapacity to drive will range from two months for metatarsodigital cases to longer than six months in cases where tarsectomy or dual arthrodesis is performed.

Tips

• Driving is allowed when pes cavus is treated with orthopaedic measures to achieve adequate pedal control.
• The specialist will advise patients with deformities preventing use of adequate shoes to achieve a good plantar surface not to drive.
• Patients with extensive hyperkeratosis making pedal control difficult must also be advised against driving.
• Surgical treatment requires long recovery periods during which driving is not permitted.
• The specialist will tell when driving may be safely resumed based on complete functional recovery of the foot with a good support and no pain.
• In non-surgical cases or cases with a poor result of foot support on pedals, the vehicle may be adapted based on a detailed report of deficiencies by the specialist, so that the patient may drive with any appropriate restrictions in each case.