|Ankle (Foot) Surgery -
According to the Greek myth, Achilles was vulnerable only at his heel. It's a trait that he must have passed down to all other humans when he gave his name to the Achilles tendon, which connects the calf muscles to the heel bone.
The Achilles tendon is the largest tendon in the human body and can withstand forces of 1,000 pounds or more. But it is also the most frequently ruptured tendon, and both professional and weekend athletes can suffer from Achilles tendinitis, a common overuse injury and inflammation of the tendon.
Any number of events may trigger an attack of Achilles tendinitis, including:
- rapidly increasing your running mileage or speed
- adding hill running or stair climbing to your training routine
- starting up too quickly after a layoff
- trauma caused by sudden and/or hard contraction of the calf muscles when putting out extra effort such as in a final sprint
- overuse resulting from the natural lack of flexibility in the calf muscles
Symptoms of Achilles tendinitis fall into a common pattern.
- Mild pain after exercise or running that gradually worsens
- A noticeable sense of sluggishness in your leg
- Episodes of diffuse or localized pain, sometimes severe, along the tendon during or a few hours after running
- Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to the heel bone
- Stiffness that generally diminishes as the tendon warms up with use
- Some swelling
Because several conditions such as a partial tendon tear and heel bursitis have similar symptoms, you need to see your orthopaedic surgeon for a proper diagnosis.
Treatment depends on the degree of injury to the tendon, but usually involves
- Rest, which may mean a total withdrawal from running or exercise for a week, or simply switching to another exercise, such as swimming, that does not stress the Achilles tendon
- Nonsteroidal anti-inflammatory medication
- Orthoses, which are devices to help support the muscle and relieve stress on the tendon such as a heel pad or shoe insert
- A bandage specifically designed to restrict motion of the tendon
- Stretching, massage, ultrasound and appropriate exercises to strengthen the weak muscle group in front of the leg and the upward foot flexors
Surgery is often an option of last resort. If friction between the tendon and its covering sheath makes the sheath thick and fibrous, surgery to remove the fibrous tissue and repair any tears may be the best treatment option. Recovery is slow, may require a temporary cast and includes a rehabilitation program to avoid weakness.
You may not be able to prevent Achilles tendinitis, but here are six steps to reduce your risk of incurring an attack:
- Choose your running shoes carefully. They should provide sufficient cushion for the heel strike. Using a prescribed orthotic to change the position of a poorly aligned heel bone may also help. Perhaps the best precaution is to know your limits and to follow a sensible program when you exercise.
- Walk and stretch to warm up gradually before running. It's better to spend few minutes warming up than to spend months on the sidelines with a ruptured Achilles tendon.
- Focus on stretching and strengthening the muscles in the calf.
- Increase your running distance and your speed gradually, in increments no greater than 10% a week.
- Avoid unaccustomed strenuous sprinting, hill running and the like.
- Cool down properly after exercise.
ACHILLES TENDON RUPTURE
For a tendon rupture, the area of the rupture is often swollen, tender, bruised (ecchymotic), and may actually have a palpable gap in the tendon. X-rays, although they do not show the tendon reliably, do show the calcaneus. When doing the x-ray, the physician is checking to see if the bone to which the Achilles tendon attached (calcaneus) has been injured. In some cases, the tendon will not tear; but instead, it will literally pull a piece of calcaneal bone off of the rest of the calcaneus. Although this is repairable, the technique is different then merely sewing the two ends of a ruptured tendon together. If the tendon has not ruptured, then the patient may have sustained only a pulling injury to the tendon. This type of injury results in a stretch injury to the tendon which is called tendonitis. Although this often heals without surgery, until completely healed, the tendon is structurally weaker then normal and is at an increased risk for tearing with continued athletic activity or additional injury producing situations. The most reliable diagnostic study for a suspected rupture of the Achilles' tendon is the Thompson test. This is a test performed during the physical exam. When then test is abnormal, the probability of a ruptured tendon being present is extremely high.
Side View of Ruptured Achilles' Tendon. Notice depression at site of rupture
The treatment options for a complete rupture of the tendon include surgery followed by casting, or casting alone. There are advantages and disadvantages to each technique and the options should be discussed with your physician. With surgery, the tendon is either reattached to the calcaneal bone (if it has been pulled off or avulsed) or the two ends are sewn together is the tendon has been torn in two.In most people, a cast is applied after surgery until healing is complete. Each patient must be considered individually. There are many reasons why a person may not be a suitable candidate for a surgical repair of the injury. These include, but are not limited to: poor circulation, presence of skin problems at the site of the injury, age, a sedentary lifestyle, other medical conditions that make the person a poor candidate for surgery (such as heart or lung problems). If the injury is treated non-operatively, then a cast is applied until healing is complete. The length of time required for healing is highly variable. Often it may take as long as six months for complete healing to occur.
Arthritis of the Foot and Ankle
There are more than 100 different types of arthritis. But when most people talk about arthritis, they are usually referring to the most common form, osteoarthritis ("osteo" means bone). Osteoarthritis develops as we age and is often called "wear-and-tear" arthritis. Over the years, the thin covering (cartilage) on the ends of bones becomes worn and frayed. This results in inflammation, swelling, and pain in the joint.
An injury to a joint, even if treated properly, can cause osteoarthritis to develop in the future. This is often referred to as traumatic arthritis. It may develop months or years after a severe sprain, torn ligament or broken bone.
There are 28 bones and over 30 joints in the foot. Tough bands of tissue, called ligaments, hold the bones and joints in place. If arthritis develops in one or more of these joints, your balance and walk may be affected. The foot joints most commonly affected by arthritis include:
- the ankle (tibiotalar joint), where the shinbone (tibia) rests on the uppermost bone of the foot (the talus)
- the three joints of the hindfoot: the subtalar or talocalcaneal joint, where the bottom of the talus connects to the heel bone (calcaneus); the talonavicular joint, where the talus connects to the inner midfoot bone (naviculus) and the calcaneocuboid joint, where the heel bone connects to the outer midfoot bone (cuboid)
- the midfoot (metatarsocunieform joint), where one of the forefoot bones (metatarsals) connects to the smaller midfoot bones (cunieforms)
- the great toe (first metatarsophalangeal joint), where the first metatarsal connects to the toe bone (phalange); this is also where bunions usually develop
Signs and symptoms
Signs and symptoms of arthritis of the foot vary, depending on which joint is affected. Common symptoms include pain or tenderness, stiffness or reduced motion, and swelling. Walking may be difficult.
Diagnosing arthritis of the foot and ankle
Your doctor will begin by getting your medical history and giving you a physical exam. Among the questions you may be asked are:
- When did the pain start? Is it worse at night? Does it get worse when you walk or run? Is it continuous, or does it come and go?
- Have you ever had an injury to your foot or ankle? What kind of injury? When did it occur? How was it treated?
- Is the pain in both feet or just one? Where is the pain centered?
- What kinds of shoes do you normally wear? Are you taking any medications?
Your doctor may do a gait analysis. This shows how the bones in your leg and foot line up as you walk, measures your stride, and tests the strength of your ankles and feet. You may also need some diagnostic tests. X-rays can show changes in the spacing between bones or in the shape of the bones themselves. A bone scan, computed tomography (CT) scan, or magnetic resonance image (MRI) may also be used in the evaluation.
Treating your arthritis
Depending on the type, location and severity of your arthritis, there are many types of treatment available. Nonsurgical treatment options include:
- Taking pain relievers and anti-inflammatory medication to reduce swelling
- Putting a pad, arch support or other type of insert in your shoe
- Wearing a custom-made shoe, such as a stiff-soled shoe with a rocker bottom
- Using an ankle-foot orthosis (AFO)
- Wearing a brace or using a cane
- Participating in a program of physical therapy and exercises
- Controlling your weight or taking nutritional supplements
- Getting a dose of steroid medication injected into the joint
If your arthritis doesn't respond to such conservative treatments, surgical options are available. The type of surgery that's best for you will depend on the type of arthritis you have, the impact of the disease on your joints, and the location of the arthritis. Sometimes more than one type of surgery will be needed. The primary surgeries performed for arthritis of the foot and ankle are:
Arthroscopic debridement. Arthroscopic surgery may be helpful in the early stages of arthritis. A pencil-sized instrument (arthroscope) with a small lens, a miniature camera and a lighting system is inserted into a joint. This projects three-dimensional images of the joint on a television monitor, enabling the surgeon to look directly inside the joint and identify the trouble. Tiny probes, forceps, knives and shavers can then be used to clean the joint area by removing foreign tissue and bony outgrowths (spurs).
Arthrodesis, or fusion. This surgery eliminates the joint completely by welding the bones together. Pins, plates and screws or rods through the bone are used to hold the bones together until they heal. A bone graft is sometimes needed. Your doctor may be able to use a piece of your own bone, taken from one of the lower leg bones or the hip, for the graft. This surgery is normally quite successful. A very small percentage of patients have problems with wound healing. These complications can be addressed by bracing or additional surgery.
Arthroplasty, or joint replacement. In rare cases, your doctor may recommend replacing the ankle joint with artificial implants. However, total ankle joint replacement is not as advanced or successful as total hip or knee joint replacement. The implant may loosen or fail, resulting in the need for additional surgery.
Outcomes and rehabilitation
Initially, foot and ankle surgery can be quite painful, so you will be given pain relievers both in the hospital and after you are released. After surgery, you will have to restrict activities for a time. You may have to wear a cast and use crutches, a walker, or a wheelchair, depending on the type of surgery you had. Keeping your foot elevated above the level of your heart will be very important for the first week or so.
You will not be able to put any weight on your foot for at least four to six weeks, and full recovery takes four to nine months. You may also need to participate in a physical therapy program for several months to regain strength in the foot and restore range of motion. Usually, you can return to ordinary daily activities in three to four months, although you may have to wear special shoes or braces. In the vast majority of cases, surgery brings pain relief and makes it easier for you to do daily activities.
If the joint that connects your big toe to your foot has a swollen, sore bump, you may have a bunion. More than half the women in America have bunions, a common deformity often blamed on wearing tight, narrow shoes, and high heels. Bunions may occur in families, but many are from wearing tight shoes. Nine out of ten bunions happen to women. Nine out of ten women wear shoes that are too small. Too-tight shoes can also cause other disabling foot problems like corns, calluses and hammertoes.
With a bunion, the base of your big toe (metatarsophalangeal joint) gets larger and sticks out. The skin over it may be red and tender. Wearing any type of shoe may be painful. This joint flexes with every step you take. The bigger your bunion gets, the more it hurts to walk. Bursitis may set in. Your big toe may angle toward your second toe, or even move all the way under it. The skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe. An advanced bunion may make your foot look grotesque. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic and you may develop arthritis.
Relief from bunions
Most bunions are treatable without surgery. Prevention is always best. To minimize your chances of developing a bunion, never force your foot into a shoe that doesn't fit. Choose shoes that conform to the shape of your feet. Go for shoes with wide insteps, broad toes and soft soles. Avoid shoes that are short, tight or sharply pointed, and those with heels higher than 2 1/4 inches. If you already have a bunion, wear shoes that are roomy enough to not put pressure on it. This should relieve most of your pain. You may want to have your shoes stretched out professionally. You may also try protective pads to cushion the painful area.
If your bunion has progressed to the point where you have difficulty walking, or experience pain despite accomodative shoes, you may need surgery. Bunion surgery realigns bone, ligaments, tendons and nerves so your big toe can be brought back to its correct position. Orthopaedic surgeons have several techniques to ease your pain. Many bunion surgeries are done on a same-day basis (no hospital stay) using an ankle-block anesthesia. A long recovery is common and may include persistent swelling and stiffness.
Your young teenager (especially girls aged 10-15) may develop an adolescent bunion at the base of his or her big toe. Unlike adults with bunions, a young person can normally move the affected joint. Your teenager may have pain and trouble wearing shoes. Try having your child's shoes stretched and/or getting wider shoes. Surgery to remove an adolescent bunion is not recommended unless your child is in extreme pain and the problem does not get better with changes in shoe wear. If your adolescent has bunion surgery, particularly before they are fully grown, there is a strong chance his or her problem will return.
If you have a painful swollen lump on the outside of your foot near the base of your little toe, it may be a bunionette (tailor's bunion). You may also have a hard corn and painful bursitis in the same spot. A bunionette is very much like a bunion. Wearing shoes that are too tight may cause it. Get shoes that fit comfortably with a soft upper and a roomy toe box. In cases of persistent pain or severe deformity, surgical correction is possible.
Chronic Lateral Ankle Pain
Recurring or persistent (chronic) pain on the outer (lateral) side of the ankle often develops after an injury such as a sprained ankle. However, several other conditions may also cause chronic ankle pain.
Signs and symptoms
- Pain, usually on the outer side of the ankle. The pain may be so intense that you have difficulty walking or participating in sports. In some cases, the pain is a constant, dull ache.
- Difficulty walking on uneven ground or in high heels
- A feeling of giving way (instability)
- Repeated ankle sprains
Possible causes for chronic lateral ankle pain
The most common cause for a persistently painful ankle is incomplete healing after an ankle sprain. When you sprain your ankle, the connecting tissue (ligament) between the bones is stretched or torn. Without thorough and complete rehabilitation, the ligament or surrounding muscles may remain weak, resulting in recurrent instability. As a result, you may experience additional ankle injuries. Other causes of chronic ankle pain include:
- An injury to the nerves that pass through the ankle. The nerves may be stretched, torn, injured by a direct blow, or pinched under pressure (entrapment).
- A torn or inflamed tendon
- Arthritis of the ankle joint
- A break (fracture) in one of the bones that make up the ankle joint
- An inflammation of the joint lining (synovium)
- The development of scar tissue in the ankle after a sprain—The scar tissue takes up space in the joint, thus putting pressure on the ligaments.
Evaluation and diagnosis
The first step in identifying the cause of chronic ankle pain is taking a history of the condition. Your doctor may ask you several questions, including:
- Have you previously injured the ankle? If so, when?
- What kind of treatment did you receive for the injury?
- How long have you had the pain?
- Are there times when the pain worsens or disappears?
Because there are so many potential causes for chronic ankle pain, your doctor may do a number of tests to pinpoint the diagnosis, beginning with a physical examination. Your doctor will feel for tender areas and look for signs of swelling. He or she will have you move your foot and ankle to assess range of motion and flexibility. Your doctor may also test the sensation of the nerves, and may administer a shot of local anesthetic to help pinpoint the source of the symptoms.
Your doctor may order several x-ray views of your ankle joint. You may also need to get x-rays of the other ankle so the doctor can compare the injured and noninjured ankles. In some cases, additional tests such as a bone scan, computed tomography (CT) scan, or magnetic resonance image (MRI) may be needed.
Treatment will depend on the final diagnosis and should be personalized to your individual needs. Both conservative (nonoperative) and surgical treatment methods may be used. Conservative treatments include:
- Anti-inflammatory medications such as aspirin or ibuprofen to reduce swelling
- Physical therapy, including tilt-board exercises, directed at strengthening the muscles, restoring range of motion, and increasing your perception of joint position
- An ankle brace or other support
- An injection of a steroid medication
- In the case of a fracture, immobilization to allow the bone to heal
If your condition requires it, or if conservative treatment doesn't bring relief, your doctor may recommend surgery. Many surgical procedures can be done on an outpatient basis. Some procedures use arthroscopic techniques; other require open surgery. Rehabilitation may take 6 to 10 weeks to ensure proper healing. Surgical treatment options include:
- Removing (excising) loose fragments
- Cleaning (debriding) the joint or joint surface
- Repairing or reconstructing the ligaments or transferring tendons
Almost half of all people who sprain their ankle once will experience additional ankle sprains and chronic pain. You can help prevent chronic pain from developing by following these simple steps:
- Follow your doctor's instructions carefully and complete the prescribed physical rehabilitation program.
- Do not return to activity until cleared by your physician.
- When you do return to sports, use an ankle brace rather than taping the ankle. Bracing is more effective than taping in preventing ankle sprains.
- If you wear hi-top shoes, be sure to lace them properly and completely.
Parents know immediately if their newborn has a clubfoot. Some will even know before the child is born, if an ultrasound was done during the pregnancy. A clubfoot occurs in approximately one in every 1000 births, with boys slightly outnumbering girls. One or both feet may be affected.
The appearance is unmistakable: the foot is turned to the side and it may even appear that the top of the foot is where the bottom should be. The involved foot, calf and leg are smaller and shorter than the normal side. It is not a painful condition. But if it is not treated, clubfoot will lead to significant discomfort and disability by the teenage years.
Risk Factors / Prevention
Doctors still aren't certain why it happens, though it can occur in some families with previous clubfeet. In fact, your baby's chance of having a clubfoot is twice as likely if you, your spouse or your other children also have it. Less severe infant foot problems are common and are often incorrectly called clubfoot.
Stretching and casting. Treatment should begin right away to have the best chance for a successful outcome without the need for surgery. Over the past 5 to 10 years, more and more success has been achieved in correcting clubfeet without the need for surgery. A particular method of stretching and casting, known as the Ponseti method, has been responsible for this. With this method, the doctor changes the cast every week for several weeks, always stretching the foot toward the correct position. The heel cord is then released followed by one more cast for three weeks. Once the foot has been corrected, the infant must wear a brace at night for two years to maintain the correction. This has been extremely effective but requires the parents to actively participate in the daily care by applying the braces. Without the parents' participation, the clubfoot will almost certainly recur. That's because the muscles around the foot can pull it back into the abnormal position.
The goal of this, and any treatment program, is to make your newborn's clubfoot (or feet) functional, painless and stable by the time he or she is ready to walk. (Note: Anytime your baby wears a cast, watch for changes in skin color or temperature that may indicate problems with circulation.)
Treatment Options: Surgical
Surgery if needed. On occasion, stretching, casting and bracing are not enough to correct your baby's clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to12 months of age, surgery corrects all of your baby's clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still while it heals. It's still possible for the muscles in your child's foot to try to return to the clubfoot position, and special shoes or braces will likely be used for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgical treatment, particularly as the years pass by.
Without any treatment, your child's clubfoot will result in severe functional disability. With treatment, your child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however. You should expect it to stay 1 to 1 1/2 sizes smaller and somewhat less mobile than the normal foot. The calf muscles in your child's clubfoot leg will also stay smaller.
Every day, the average person spends several hours on their feet and takes several thousand steps. Walking puts pressure on your feet that's equivalent to 2-3 times your body weight. No wonder your feet hurt!
Actually, most foot problems can be blamed not on walking but on your walking shoes. Corns, for example, are calluses that form on the toes because the bones push up against the shoe and put pressure on the skin. The surface layer of the skin thickens and builds up, irritating the tissues underneath. Hard corns are usually located on the top of the toe or on the side of the small toe. Soft corns resemble open sores and develop between the toes as they rub against each other.
Causes of corns
- Shoes that don't fit properly. If shoes are too tight, they squeeze the foot, increasing pressure. If they are too loose, the foot may slide and rub against the shoe, creating friction.
- Toe deformities, such as hammer toe or claw toe.
- High heeled shoes because they increase the pressure on the forefoot.
- Rubbing against a seam or stitch inside the shoe.
- Socks that don't fit properly.
Diagnosis and treatment
Corns can usually be easily seen. They may have a tender spot in the middle, surrounded by yellowish dead skin. Treating foot problems like corns is a team effort. You will need to work with your physician to ensure that problems don't recur.
During your office visit :
- To restore the normal contour of the skin and relieve pain, your doctor may trim the corn by shaving the dead layers of skin off with a scalpel. This procedure should be done by a professional, and not by yourself, particularly if you have poor circulation, poor eyesight, or a lack of feeling in your feet.
- If the doctor discovers an underlying problem, such as a toe deformity, he or she can correct it. Most surgeries can be done on an outpatient basis.
At home :
- You can soak your feet regularly and use a pumice stone or callus file to soften and reduce the size of corns and calluses.
- Wearing a donut-shaped foam pad over the corn will also help relieve the pressure. Use non-medicated corn pads; medicated pads may increase irritation and result in infection.
- Use a bit of lamb's wool (not cotton) between your toes to help cushion soft corns.
- Wear shoes that fit properly and have a roomy toe area.
Foot pain in the "ball of your foot," that area between your arch and the toes, is generally called metatarsalgia (met'-a-tar-sal'-gee-a). The pain usually centers on one or more of the five bones (metatarsals) in this mid-portion of the foot.
Causes of foot pain
Sometimes, the foot pain is caused by a callus that forms on the bottom of your foot. A callus is a build-up of skin that forms in response to excessive pressure over the bone. Normally, a callus is not painful, but the build-up of skin can increase the pressure and eventually make walking difficult.
Shoes that don't fit properly because they are too tight or too loose can cause foot pain. Tight shoes squeeze the foot and increase pressure; loose shoes let the foot slide and rub, creating friction.
Pain on the underside of the foot may indicate a torn ligament or inflammation of the joint. Your orthopedic surgeon can do some simple tests to assess joint stability.
Treating foot pain
Most of the time, practical measures can help ease foot pain.
- Your doctor may recommend that you use a shoe insert (orthosis) as a kind of shock absorber, or that you wear a different kind of shoe.
- Sometimes, simply buying shoes that fit properly can solve the problem. Shoes should have a wide toe box that doesn’t cramp your foot. Heels should never be higher than 2-1/4" high.
- Soaking your feet to soften calluses, then removing some of the dead skin with a pumice stone or callus file will also ease pressure.
- Occasionally, surgery may be necessary to remove a bony prominence or correct a deformity.
Every mile you walk puts 60 tons of stress on each foot. Your feet can handle a heavy load, but too much stress pushes them over their limits. When you pound your feet on hard surfaces playing sports or wear shoes that irritate sensitive tissues, you may develop heel pain, the most common problem affecting the foot and ankle. A sore heel will usually get better on its own without surgery if you give it enough rest. However, many people try to ignore the early signs of heel pain and keep on doing the activities that caused it. When you continue to use a sore heel, it will only get worse and could become a chronic condition leading to more problems. Surgery is rarely necessary.
Evaluation and treatment
Heel pain can have many causes. If your heel hurts, see your doctor right away to determine why and get treatment. Tell him or her exactly where you have pain and how long you've had it. Your doctor will examine your heel, looking and feeling for signs of tenderness and swelling. You may be asked to walk, stand on one foot or do other physical tests that help your doctor pinpoint the cause of your sore heel. Conditions that cause heel pain generally fall into two main categories: pain beneath the heel and pain behind the heel.
Pain beneath the heel
If it hurts under your heel, you may have one or more conditions that inflame the tissues on the bottom of your foot:
- Stone bruise: When you step on a hard object such as a rock or stone, you can bruise the fat pad on the underside of your heel. It may or may not look discolored. The pain goes away gradually with rest.
- Plantar fasciitis (subcalcaneal pain): Doing too much running or jumping can inflame the tissue band (fascia) connecting the heel bone to the base of the toes. The pain is centered under your heel and may be mild at first but flares up when you take your first steps after resting overnight. You may need to do special exercises, take medication to reduce swelling and wear a heel pad in your shoe.
- Heel spur: When plantar fasciitis continues for a long time, a heel spur (calcium deposit) may form where the fascia tissue band connects to your heel bone. Your doctor may take an X-ray to see the bony protrusion, which can vary in size. Treatment is usually the same as for plantar fasciitis: rest until the pain subsides, do special stretching exercises and wear heel pad shoe inserts.
Pain behind the heel
If you have pain behind your heel, you may have inflamed the area where the Achilles tendon inserts into the heel bone (retrocalcaneal bursitis). People often get this by running too much or wearing shoes that rub or cut into the back of the heel. Pain behind the heel may build slowly over time, causing the skin to thicken, get red and swell. You might develop a bump on the back of your heel that feels tender and warm to the touch. The pain flares up when you first start an activity after resting. It often hurts too much to wear normal shoes. You may need an X-ray to see if you also have a bone spur.
Treatment includes resting from the activities that caused the problem, doing certain stretching exercises, using pain medication and wearing open back shoes.
- Your doctor may want you to use a 3/8" or 1/2" heel insert.
- Stretch your Achilles tendon by leaning forward against a wall with your foot flat on the floor and heel elevated with the insert.
- Use nonsteroidal anti-inflammatory medications for pain and swelling.
- Consider placing ice on the back of the heel to reduce inflammation.
The plantar fascia is a thick, broad, inelastic band of fibrous tissue that courses along the bottom (plantar surface) of the foot. It is attached to the heel bone (calcaneus) and fans out to attach to the bottom of the metatarsal bones in the region of the ball of the foot. Because the normal foot has an arch, this tight band of tissue (plantar fascia) is at the base of the arch. In this position, the plantar fascia acts like a bowstring to maintain the arch of the foot.
Plantar fasciitis refers to an inflammation of the plantar fascia. The inflammation in the tissue is the result of some type of injury to the plantar fascia. Typically, plantar fasciitis results from repeated trauma to the tissue where it attaches to the calcaneus.
This repeated trauma often results in microscopic tearing of the plantar fascia at or near the point of attachment of the tissue to the calcaneus. The result of the damage and inflammation is pain.
If there is significant injury to the plantar fascia, the inflammatory reaction of the heel bone may produce spike-like projections of new bone called heel spurs. The spurs are not the cause of the initial pain of plantar fasciitis, they are the result of the problem. Most heel spurs are painless. Occasionally, they are associated with pain and discomfort and require medical treatment or even surgical removal
Plantar fasciitis (heel-spur syndrome) is a common problem among people active in sports, especially runners. It typically starts as a dull, intermittent pain in the heel and may progress to sharp, constant pain. Often, it is usually worse in the morning or after sitting, and then decreases as the patient begins to walk around. In addition, the pain usually increases after standing or walking for long periods of time, and at the beginning of a sporting activity.
Often people who develop plantar fasciitis have several risk factors for doing so. They include:
- Flat feet
- High arched, rigid feet
- Increasing age and family tendency
- Running on toes, hills or very soft surfaces (sand)
- Poor arch support in shoes
- Rapid change in activity level
Fortunately, the majority of cases of plantar fasciitis respond favorably to non-operative treatment. However, the recovery time varies tremendously from patient to patient. While some patients may be healed after 6 weeks of treatment, others may require 6 months or longer for recovery. In addition, the methods of treatment that may work for one patient, may not be successful in another patient. Typically, the methods of treatment that are attempted include anti-inflammatory mediation, icing, stretching, activity modification, and heel inserts.
In addition, it is necessary to avoid the activities that are known to aggravate the fasciitis. This includes any activity that involves repeated impact of the heel on a hard surface, such as running. Sometimes, cortisone injections are necessary to achieve satisfactory healing.
If the pain persists, it may be necessary to run additional diagnostic studies to rule other, less common, causes of heel pain such as stress fractures, nerve compression injuries, or collagen disorders of the skin.
Rarely, surgical treatment is necessary. However, when the nonsurgical treatments have been tried and they have failed, surgery may be indicated for the relief of heel pain. Most of these surgical procedures can be completed on an outpatient basis in less than one hour. The surgery can be accomplished under local anesthesia or minimal sedation administrated by a trained anesthesiologist.
Surgical treatment options include:
- Surgical removal/release of the fascia. A small incision is made on the inside of the heel and the inflamed tissue is removed or released.
- Removal of bone spurs. During the same operation that is used to separate the connective tissue from the heel bone, the offending heel spur can be removed.
A joint is formed where the bones come together. The bones are held together by tissue called ligaments. The ligaments allow for motion of the boned at the joint, but only within certain ranges of motion. Sprains occur when the ligaments are stretched more then normal. This results in a partial tear or complete tear of the ligament. This ligament damage results in the development of abnormal motion at the joint due to the loss of stability.
The term sprain merely indicates that a ligament has been damaged. Sprains are divided into several groups depending on the severity of damage to the involved ligament.
Grade I Sprain
A Grade I (First Degree) sprain is the most common and requires the least amount of treatment and recovery. The ligaments connecting the ankle bones are often over-stretched, and damaged microscopically, but not actually torn. The ligament damage has occurred without any significant instability developing.
Grade II Sprain
A Grade II (Second Degree) injury is more severe and indicates that the ligament has been more significantly damaged, but there is no significant instability. The ligaments are often partially torn.
Grade III Sprain
A Grade III (Third Degree) sprain is the most severe. This indicates that the ligament has been significantly damaged, and that instability has resulted. A grade III injury means that the ligament has been torn.
The lateral ligaments are the most commonly injured. On the lateral side, the ligaments are typically damaged in a direction that goes from the front to the back, with the most severe injury being in the front (anterior) and the least severe being in the back (posterior). Therefore, the most commonly damaged ligament is the anterior talo-fibular ligament and the least commonly damaged is the posterior talofibular ligament.
The sprain occurs when the ankle is turned unexpectedly in any direction that is further than he ligaments are able to tolerate. Typically, the sprain occurs with running, jumping, sharp direction changes, or stepping on uneven ground. The risk factors for having an ankle sprain include, uneven ground, previous untreated ankle injuries, being overweight, or using poorly fitting or worn out shoes.
Diagnosis of the injury is determined by examination of the location of the bruising (ecchymosis), swelling, and tenderness. It is also necessary to perform stress testing of the ligaments to determine whether the ligament has been torn. Stress testing of the ligaments is done by pushing on the ankle and attempting to determine if there is any abnormal motion at the joint which would indicate that a ligament has been torn. In addition, x-rays are often performed to check for the possibility of a chipped bone or fracture.
When performing a stress test of the ligaments, a posteriorly directed force is applied to the front of the tibia (shin bone). If the ankle ligaments are completely torn, the tibia will visibly shift backwards at the ankle joint. When the force is removed, the tibia will snap back into its proper position at the ankle joint. When this abnormal motion occurs, the anterior talo-fibular ligament (ATFL) has been torn.
Depending on the severity of the sprain, treatment may range from simply wearing a supportive brace, to using a walking cast, or even having the ankle operated on. The type of treatment depends on several factors including severity of injury, presence of associated injuries, the routine stresses that are placed upon the ankle, and the general medical condition of the injured patient. At some point,
- Compression, and
(RICE) is used in the treatment program. As the healing progresses, the exercises that may be involved include range of motion exercises, strengthening exercises, and exercises developed to restore balance and agility.
Each injury is different and the time to return to full activity depends upon the severity of the injury and the restoration of motion and strength. As a general rule, the minimum time required for satisfactory healing is 6 weeks.
RESIDUAL ANKLE INSTABILITY
Occasionally, when the ligaments heal, they are weaker or looser then prior to the injury. This results in an ankle that is more likely to be unstable and twist more easily. When this happens, PT often allows the adjacent muscles to strengthen and stabilize that joint. Sometimes, it is necessary to wear a brace when walking on uneven ground or during sports to support the ankle. Rarely, it is necessary to surgically reconstruct the ligaments. However, when it does become necessary to reconstruct the torn ligaments, the reconstruction may be done in several ways. One of the methods of reconstruction involves harvesting a portion of the peronus brevis tendon at the lateral aspect of the ankle, and then placing several drill holes around the bones of the ankle. The harvested tendon is then passed through the drill holes to reconstruct the damaged ligaments. Post operatively, a short leg cast is usually applied for approximately 6 weeks. Following this, physical therapy is initiated to rehabilitate the ankle.
Lisfranc (Midfoot) Fracture
Have you ever dropped a heavy box on the top of your foot? Or accidentally stepped in a small hole and fallen, twisting your foot? These two common accidents can result in a Lisfranc fracture-dislocation of the midfoot. This fracture gets its name from the French doctor who first described the injury.
Lisfranc injuries occur at the midfoot, where a cluster of small bones forms an arch on top of the foot between the ankle and the toes. From this cluster, five long bones (metatarsals) extend to the toes. The second metatarsal also extends down into the row of small bones and acts as a stabilizing force. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.
Signs and symptoms
Lisfranc fracture-dislocations are often mistaken for sprains. The top of the foot may be swollen and painful. There may be some bruising. If the injury is severe, you may not be able to put any weight on the foot. Lisfranc injuries are often difficult to see on X-rays. Unrecognized Lisfranc injuries can have serious complications such as joint degeneration and compartment syndrome, a build-up of pressure within muscles that can damage nerve cells and blood vessels. If the standard treatment for a sprain (rest, ice and elevation) doesn't reduce the pain and swelling within a day or two, ask your doctor for a referral to an orthopaedic specialist.
The orthopaedist will examine your foot for signs of injury. He may hold your heel steady and move your foot around in a circle. This motion produces minimal pain with a sprain, but severe pain with a Lisfranc injury. If your initial X-ray did not show an injury, the orthopaedist may request several other views, including comparison views of the uninjured foot and stress or weightbearing X-rays. In some cases, a computed tomography (CT) scan or magnetic resonance image (MRI) may be necessary to confirm the diagnosis.
Treatment for a Lisfranc injury depends on the severity of the injury. If the bones have not been forced out of position, you will probably have to wear a cast and refrain from putting weight on the foot for about six weeks. When the cast is removed, you may have to wear a rigid arch support. Your orthopaedist will also recommend foot exercises to build strength and help restore full range of motion.
Often, operative treatment is needed to stabilize the bones and hold them in place until healing is complete. Pins, wires or screws may be used. Afterwards, you will have to wear a cast and limit weightbearing on the foot for six to eight weeks. A walking brace may be prescribed when the fixation devices are removed. You may also have to wear an arch support and a rigid soled shoe until all symptoms have disappeared. In some cases, if arthritis develops in these joints, the bones may have to be fused together.
It is important to follow your doctor's orders and refrain from activities until you are given the go-ahead. If you return to activities too quickly, you may easily suffer another injury, resulting in damage to the blood vessels, the development of painful arthritis and an even longer healing time.
Toe and Forefoot Fractures
Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken (fractured) bone in your forefoot (metatarsals) or in one of your toes (phalanges) is often painful but rarely disabling. Most of the time, these injuries heal without operative treatment.
Types of fractures
Stress fractures frequently occur in the bones of the forefoot that extend from your toes to the middle of your foot. Stress fractures are like tiny cracks in the bone surface. They can occur with sudden increases in training (such as running or walking for longer distances or times), improper training techniques or changes in training surfaces. Most other types of fractures extend through the bone. They may be stable (no shift in bone alignment) or displaced (bone ends no longer line up). These fractures usually result from trauma, such as dropping a heavy object on your foot, or from a twisting injury. If the fractured bone does not break through the skin, it is called a closed fracture.
Several types of fractures occur to the forefoot bone on the side of the little toe (fifth metatarsal). Ballet dancers may break this bone during a misstep or fall from a pointe position. A ankle-twisting injury may tear the tendon that attaches to this bone and pull a small piece of the bone away. A more serious injury in the same area is a Jones fracture, which occurs near the base of the bone and disrupting the blood supply to the bone. This injury may take longer to heal or require surgery.
Signs and symptoms
Pain, swelling, and sometimes bruising are the most common signs of a fracture in the foot. If you have a broken toe, you may be able to walk, but this usually aggravates the pain. If the pain, swelling, and discoloration continue for more than two or three days, or if pain interferes with walking, something could be seriously wrong; see a doctor as soon as possible. If you delay getting treatment, you could develop persistent foot pain and arthritis. You could also change the way you walk (your gait), which could lead to the formation of painful calluses on the bottom of your foot or other injuries.
The doctor will examine your foot to pinpoint the central area of tenderness and compare the injured foot to the normal foot. You should tell the doctor when the pain started, what you were doing at the time, and if there was any injury to the foot. X-rays will show most fractures, although a bone scan may occasionally be needed to identify stress fractures. Usually, the doctor will be able to realign the bone without surgery, although in severe fractures, pins or screws may be required to hold the bones in place while they heal.
See a doctor as soon as possible if you think that you have a broken bone in your foot or toe. Until your appointment, keep weight off the leg and apply ice to reduce swelling. Use an ice pack or wrap the ice in a towel so it does not come into direct contact with the skin. Apply the ice for no more than 20 minutes at a time. Take an analgesic such as aspirin or ibuprofen to help relieve the pain. Wear a wider shoe with a stiff sole.
Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for three to four weeks. Substitute another activity that puts less pressure on the foot, such as swimming. Gradually, you will be able to return to activity. Your doctor or coach may be able to help you pinpoint the training errors that caused the initial problem so you can avoid a recurrence.
The bone ends of a displaced fracture must be realigned and the bone kept immobile until healing takes place. If you have a broken toe, the doctor will "buddy-tape" the broken toe to an adjacent toe, with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed. Remove or replace the tape if swelling increases and the toes feel numb or look pale. If you are diabetic or have peripheral neuropathy (numbness of the toes), do not tape the toes together. You may need to wear a rigid flat-bottom orthopaedic shoe for two to three weeks.
If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace, or a rigid, flat-bottom shoe. It could take six to eight weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, the doctor may request another set of X-rays to ensure that the bones remain properly aligned. As symptoms subside, you can put some weight on the leg. Stop if the pain returns.
|Surgery is rarely required to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success.
If you sometimes feel that you are "walking on a marble," and you have persistent pain in the ball of your foot, you may have a condition called Morton's neuroma.
A neuroma is a benign tumor of a nerve. Morton's neuroma is not actually a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes. It occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. Morton's neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma or excessive pressure. The incidence of Morton's neuroma is 8 to 10 times greater in women than in men.
Signs and Symptoms
- Normally, there are no outward signs, such as a lump, because this is not really a tumor.
- Burning pain in the ball of the foot that may radiate into the toes. The pain generally intensifies with activity or wearing shoes. Night pain is rare.
- There may also be numbness in the toes, or an unpleasant feeling in the toes.
Runners may feel pain as they push off from the starting block. High-heeled shoes, which put the foot in a similar position to the push-off, can also aggravate the condition. Tight, narrow shoes also aggravate this condition by compressing the toe bones and pinching the nerve.
Diagnosis and Treatment
During the examination, your physician will feel for a palpable mass or a "click" between the bones. He or she will put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot.
Initial therapies are nonsurgical and relatively simple. They can involve one or more of the following treatments:
- Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.
- Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.
- Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.
Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton's Neuroma. If conservative treatment does not relieve your symptoms, your orthopaedic surgeon may discuss surgical treatment options with you. Surgery can resect a small portion of the nerve or release the tissue around the nerve, and generally involves a short recovery period.
Rheumatoid Arthritis of the Foot and Ankle
Rheumatoid arthritis (RA) is a systemic disease that attacks multiple joints throughout the body. About 90% of the people with rheumatoid arthritis eventually develop symptoms related to the foot or ankle. Usually, symptoms appear in the toes and forefeet first, then in the hindfeet or the back of the feet, and finally in the ankles. Other inflammatory types of arthritis that affect the foot and ankle include gout, ankylosing spondylitis, psoriatic arthritis, and Reiter's syndrome.
The exact cause of RA is unknown, but there are several theories. Some people may be more likely to develop RA because of their genes. However, it usually takes a chemical or environmental "trigger" to activate the disease. In RA, the body's immune system turns against itself. Instead of protecting the joints, the body produces substances that attack and inflame the joints.
Signs and symptoms
The most common symptoms of RA in the foot are pain, swelling, and stiffness. Symptoms usually appear in several joints on both feet. You may feel pain in the joint or in the sole or ball of your foot. The joint may be warm and the way you walk may be affected. You may develop corns or bunions, and your toes can begin to curl and stiffen in positions called claw toe or hammer toe.
If your hindfoot (back of the foot) and ankle are affected, the bones may shift position in the joints. This can cause the long arch on the bottom of your foot to collapse (flatfoot), resulting in pain and difficulty walking.
Because RA affects your entire system, you may also feel feverish, tire easily, and lose your appetite. You may develop lumps around your joints, particularly by the elbow.
Sometimes, arthritis symptoms in the foot are the first indication that you have RA. Your doctor will ask you about your medical history, your occupation, and your recreational activities, as well as any other persistent or previous conditions in your feet and legs. The appearance of symptoms in the same joint on both feet or in several joints is an indication that RA might be involved. Your doctor will also request X-rays to see how much damage there is to the joints. Blood tests will show whether you are anemic or have an antibody called the rheumatoid factor, which is often present with RA. If you've already been diagnosed with RA, you and your doctor should be aware that the disease will probably spread to your feet and ankles. Watch for early signs such as swelling and foot pain.
Many people with RA can control their pain and the disease with medication and exercise. Some medications, such as aspirin or ibuprofen, help control pain. Others, including methotrexate, prednisone, sulfasalazine, and gold compounds, help slow the spread of the disease itself. In some cases, an injection of a steroid medication into the joint can help relieve swelling and inflammation.
Your doctor may also prescribe special shoes. If your toes have begun to stiffen or curl, you should wear a shoe with an extra deep toe box. You may also need to use a soft arch support with a rigid heel. In more severe cases, you may need to use a molded ankle-foot orthotic device, canes, or crutches.
Exercise is very important in the treatment of RA. Your doctor or physical therapist may recommend stretching as well as functional and range of motion exercises.
Surgery can correct several of the conditions, such as bunions and hammer toes, associated with RA of the foot and ankle. In many cases, however, the most successful surgical option is fusion (arthrodesis). Fusion is often performed on the great toe, in the midfoot, in the heel, and in the ankle. In this procedure, the joint cartilage is removed; in some cases, some of the adjacent bone is also removed. The bones are held in place with screws, plates and screws or a rod through the bone. The surgeon may then implant a bone graft from the hip or leg. Eventually, the bones unite, creating one solid bone. There is loss of motion, but the foot and ankle remain functional and generally pain-free. Replacing the ankle joint with an artificial joint (arthroplasty) may be possible. However, this is a relatively new surgical technique. Whether it will be as successful in the long term as hip or knee replacement surgery is not yet known.
As in all surgeries, there is some risk. Infections, failure to heal, and loosening of the devices are the most common problems. Intravenous antibiotics and/or repeat surgery may be needed. Severe complications may require amputation, but this is rare.
Recovery and rehabilitation
Your doctor will prescribe pain medication for your use after the surgery. Before you leave the hospital, you will be taught how to use crutches. It takes a long time to recover from foot surgery. Here are some things to consider as part of your recovery:
- Ask friends or family for help in preparing meals and doing other activities of daily living.
- For the first week or so after surgery, keep your foot elevated above the level of your heart as much as possible.
- Be sure to do the prescribed physical therapy exercises. They will help you regain strength, motion, and the ability to walk.
- You won't be able to put all your weight on your foot for several weeks, and you may need to wear a special shoe or a cast for several months.
- You will probably be able to resume ordinary daily activities 3 to 4 months after surgery.
RA is a progressive disease that currently has no cure. However, medications, exercises, and surgery can help lessen the effects of the disease and may slow its progress.
Most bones in the human body are connected to each other at joints. But there are a few bones that are not connected to any other bone. Instead, they are connected only to tendons or are embedded in muscle. These are the sesamoids. The kneecap (patella) is the largest sesamoid. Two other very small sesamoids (about the size of a kernel of corn) are found in the underside of the forefoot near the great toe, one on the outer side of the foot and the other closer to the middle of the foot.
Sesamoids act like pulleys. They provide a smooth surface over which the tendons slide, thus increasing the ability of the tendons to transmit muscle forces. The sesamoids in the forefoot also assist with weightbearing and help elevate the bones of the great toe. Like other bones, sesamoids can break (fracture). Additionally, the tendons surrounding the sesamoids can become irritated or inflamed. This is called sesamoiditis and is a form of tendinitis. It is common among ballet dancers, runners and baseball catchers.
Signs and symptoms
- Pain is focused under the great toe on the ball of the foot. With sesamoiditis, pain may develop gradually; with a fracture, pain will be immediate.
- Swelling and bruising may or may not be present.
- You may experience difficulty and pain in bending and straightening the great toe.
Examination and diagnosis
During the examination, the physician will look for tenderness at the sesamoid bones. Your doctor may manipulate the bone slightly or ask you to bend and straighten the toe. He or she may also bend the great toe up toward the top of the foot to see if the pain intensifies.
Your physician will request X-rays of the forefoot to ensure a proper diagnosis. In many people, the sesamoid bone nearer the center of the foot (the medial sesamoid) has two parts (bipartite). Because the edges of a bipartite medial sesamoid are generally smooth, and the edges of a fractured sesamoid are generally jagged, an X-ray is useful in making an appropriate diagnosis. Your physician may also request X-rays of the other foot to compare the bone structure. If the X-rays appear normal, the physician may request a bone scan.
Treatment is generally nonoperative. However, if conservative measures fail, your physician may recommend surgery to remove the sesamoid bone.
- Stop the activity causing the pain.
- Take aspirin or ibuprofen to relieve the pain.
- Rest and ice the sole of your feet. Do not apply ice directly to the skin, but use an ice pack or wrap the ice in a towel.
- Wear soft-soled, low-heeled shoes. Stiff-soled shoes like clogs may also be comfortable.
- Use a felt cushioning pad to relieve stress.
- Return to activity gradually, and continue to wear a cushioning pad of dense foam rubber under the sesamoids to support them. Avoid activities that put your weight on the balls of the feet.
- Tape the great toe so that it remains bent slightly downward (plantar flexion).
- Your doctor may recommend an injection of a steroid medication to reduce swelling.
- If symptoms persist, you may need to wear a removable short leg fracture brace for 4 to 6 weeks.
- Fracture of the sesamoid
- You will need to wear a stiff-soled shoe or a short, leg-fracture brace.
- Your physician may tape the joint to limit movement of the great toe.
- You may have to wear a J-shaped pad around the area of the sesamoid to relieve pressure as the fracture heals.
- Pain relievers such as aspirin or ibuprofen may be recommended.
- It may take several months for the discomfort to subside.
- Cushioning pads or other orthotic devices are often helpful as the fracture heals.
Stiff Big Toe (Hallux Rigidus)
The most common site of arthritis in the foot is at the base of the big toe. This joint is called the metatarsophalangeal, or MTP joint. It's important because it has to bend every time you take a step. If the joint starts to stiffen, walking can become painful and difficult.
In the MTP joint, as in any joint, the ends of the bones are covered by a smooth articular cartilage. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe, or hallux rigidus.
Hallux rigidus usually develops in adults between the ages of 30 and 60 years. No one knows why it appears in some people and not others. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint.
Signs and symptoms
- Pain in the joint when you are active, especially as you push-off on the toes when you walk
- Swelling around the joint
- A bump, like a bunion or callus, that develops on the top of the foot
- Stiffness in the great toe and an inability to bend it up or down
Diagnosing the problem
If you find it difficult to bend your toe up and down or find that you are walking on the outside of your foot because of pain in the toe, see your doctor right away. Hallux rigidus is easier to treat when the condition is caught early. If you wait until you see a bony bump on the top of your foot, the bone spurs will have already developed and the condition will be more difficult to treat.
Your physician will examine your foot and look for evidence of bone spurs. He or she may move the toe around to see how much motion is possible without pain. X-rays will show the location and size of any bone spurs, as well as the degree of degeneration in the joint space and cartilage.
Nonoperative treatment options
Pain relievers and anti-inflammatory medications such as ibuprofen may help reduce the swelling and ease the pain. Applying ice packs or taking contrast baths (described below) may also help reduce inflammation and control symptoms for a short period of time. But they aren't enough to stop the condition from progressing. Wearing a shoe with a large toe box will reduce the pressure on the toe, and you will probably have to give up wearing high heels. Your doctor may recommend that you get a stiff-soled shoe with a rocker or roller bottom design and possibly even a steel shank or metal brace in the sole. This type of shoe supports the foot when you walk and reduces the amount of bend in the big toe.
A contrast bath uses alternating cold and hot water to reduce inflammation. You'll need two buckets, one with water as cold as you can tolerate and the other with water as warm as you can tolerate. Immerse your foot in the cold water for 30 seconds, then immediately place it in the hot water for 30 seconds. Continue to alternate between cold and hot for five minutes, ending in the cold water. You can do contrast baths up to three times a day. However, be careful to avoid extreme temperatures in the water, especially if your feet aren't very sensitive to heat or cold.
Cheilectomy This surgery is usually recommended when damage is mild or moderate. It involves removing the bone spurs as well as a portion of the foot bone, so the toe has more room to bend. The incision is made on the top of the foot. The toe and the operative site may remain swollen for several months after the operation, and you will have to wear a wooden-soled sandal for at least two weeks after the surgery. But most patients do experience long-term relief.
Arthrodesis Fusing the bones together (arthrodesis) is often recommended when the damage to the cartilage is severe. The damaged cartilage is removed and pins, screws, or a plate are used to fix the joint in a permanent position. Gradually, the bones grow together. This type of surgery means that you will not be able to bend the toe at all. However, it is the most reliable way to reduce pain in these severe cases.
For the first six weeks after surgery, you will have to wear a cast and then use crutches for about another six weeks. You won't be able to wear high heels, and you may need to wear a shoe with a rocker-type sole.
Arthroplasty Older patients who place few functional demands on the feet may be candidates for joint replacement surgery. The joint surfaces are removed and an artificial joint is implanted. This procedure may relieve pain and preserve joint motion.
POSTERIOR TIBIAL TENDON INJURIES
An acquired flatfoot deformity usually occurs when the posterior tibial tendon fails to function properly. The posterior tibial tendon lies within the calf of the foreleg. The tendon passes behind the medial malleolus of the ankle and attaches to a bone in the foot called the navicular bone.
Normal anatomy and arch as seen in this view of the left ankle from the medial side.
The navicular bone is a key structural component in the formation of the arch of the foot. When this bone is in the proper position, the arch is maintained. However, if this bone moves out of position, towards the bottom of the foot (plantar surface), then the arch begins to sag and disappear. As this occurs, the patient develops a flatfoot deformity.
|Abnormal anatomy and falling arch as seen in this view of the left ankle from the medial side. Compare position of navicular bone in figure 1 with figure 2.
The posterior tibial tendon is essential to the normal functioning of the foot by maintaining the navicular bone in the proper position. By doing so, the arch of the foot is maintained. However, if the posterior tibial tendon fails to function properly, the navicular bone begins to drop, the arch falls and a flatfoot deformity begins to develop. When this occurs, the foot may develop pain with weight bearing.
The posterior tibial tendon injuries appear to fall into 2 categories: traumatic and degenerative. A traumatic injury usually occurs suddenly, as with a blow to the medial side of the ankle or with a twisting injury that results in a complete or partial tear of the tendon. A chronic tear develops over a period of time and is usually related to a slowly developing degenerative tearing (or stretching) of the tendon. When the tendon is damaged, the damage may result in a complete tear, a partial tear, or a stretching type of injury that allows the tendon to remain in one piece, but it becomes functionally too long, and thereby loses the ability to perform properly.
Predisposing factors to degenerative posterior tibial tendon insufficiency (tearing) include: diabetes mellitus, hypertension, obesity, trauma or surgery to the medial aspect of the ankle and steroid injections. In addition, other inflammatory conditions such as rheumatoid arthritis, seronegative arthropathy and infection may also lead to degeneration of the posterior tibial musculotendinous unit.
The chronic degenerative tear of the posterior tibial tendon usually occurs in a patient who is a female, 40+ years of age, without a history of injury, and who does prolonged periods of standing and walking.
The physical exam consists of examination of the ankle for areas of swelling, tenderness, and abnormal positioning of the foot, arch, and medial aspect of the ankle. In addition, attention is paid to the forefoot and to the position of the heel. Palpation of the posterior tibial tendon allows for localization of the pain to the tendon, for identification of localized swelling in and around the tendon, and for palpation of the tendon to determine if a gap in the tendon can be felt.
Performing a single limb toe raise and checking the ability of the patient to stand on his/her toes tests the strength of the PTT.
Inspection of the foot allows for identification of abnormal positioning of the forefoot and toes, the medial aspect of the ankle, and the position of the heel. In addition, it is also possible to check the arch height. When doing these tests, they must be performed in the weight bearing position with the patient standing in bare feet.
One of the classic signs of posterior tibial tendon insufficiency is a "splaying" of the forefoot. This means that the medial aspect of the ankle rolls to the inside causing increased prominence of the medial malleolus. At the same time, as the arch drops, the forefoot moves to the outside (laterally). When this occurs, the abnormality is best seen by viewing the patient's feet while the patient is standing. When viewed from the backside, the affected foot will appear to turn to the outside and "too many toes will be seen".
Figure 1: In this figure, the left side is normal and the right side (red markings) is abnormal. As viewed from the backside, the inside of the right ankle (medial side) appears to roll toward the opposite ankle (red arrow). At the same time, both the 4th and 5th toes may be seen on the right (red circle), while only the 5th toe may be seen on the left foot (blue circle).
Although the tendon cannot be seen on x-ray, alteration in the normal position of the bones of the foot may be seen. The MRI scan is an excellent way of visualizing the tendon to identify tendonitis, partial tears, or complete tears. Unfortunately, like most medical tests, the MRI is not 100% accurate.
Posterior tibial tendonitis represents an inflammation of the posterior tibial tendon. Initially, in degenerative injuries, the tendon starts out with an area of inflammation, which then begins to degenerate. As it deteriorates, the tendon may begin to have microscopic tearing. This results in a structural weakening of the tendon. As the tendon weakens, it begins to stretch out, causing further tearing. During this process, the area around the tendon becomes painful and swollen. As the tendon stretches and weakens, it becomes unable to support the arch of the foot. As the arch decreases, the normal relationship between the bones of the foot changes. This allows the arch to collapse, which further stretches the tendon causing more damage and tearing. At this point, the medical description of the injury is called: posterior tibial tendonitis, dysfunctional posterior tibial tendon, partial tear of the PTT, or a tear in continuity of the PTT. Without proper treatment, or sometimes, even with proper treatment, the damage is so advanced that healing fails to occur and the tendon ruptures.
The treatment options in this disease process include both operative and several different types of operative treatment. The choice of treatment usually depends on how long the problem has been going on and on the response of the patient to a particular type of treatment. Initially, treatment often consists of physical therapy, icing, NSAID, and activity restriction. Sometimes orthotics are used initially. Occasionally, it is necessary to use a cast.
In more severe situations, or if the problem fails to improve with non-operative treatment, then surgery may be indicated. Usually this consists of some type of reconstruction/repair of the PTT. In more advanced cases, it is necessary to fuse the bones of the foot together to reestablish the normal relationship of the bones of the foot to each other.