BUNIONS
Even though bunions are a common foot deformity, there are misconceptions about them. Many people may unnecessarily suffer the pain of bunions for years before seeking treatment.
What Is a Bunion?
Bunions are often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. With a bunion, the big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment producing the bunion's bump. Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which continues to become increasingly prominent. Usually the symptoms of bunions appear at later stages, although some people never have symptoms.
What Causes a Bunion?
Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion. Although wearing shoes that crowd the toes won't actually cause bunions in the first place, it sometimes makes the deformity get progressively worse. That means you may experience symptoms sooner.
Symptoms
Symptoms occur most often when wearing shoes that crowd the toes, shoes with a tight toe box or high heels. This may explain why women are more likely to have symptoms than men. In addition, spending long periods of time on your feet can aggravate the symptoms of bunions. Symptoms, which occur at the site of the bunion, may include:
- Pain or soreness
- Inflammation and redness
- A burning sensation
- Perhaps some numbness
Other conditions which may appear with bunions include calluses on the big toe, sores between the toes, ingrown toenail, and restricted motion of the toe.
Diagnosis
Bunions are readily apparent, you can see the prominence at the base of the big toe or side of the foot. However, to fully evaluate your condition, the podiatric foot and ankle surgeon may take x-rays to determine the degree of the deformity and assess the changes that have occurred. Because bunions are progressive, they don't go away, and will usually get worse over time. But not all cases are alike, some bunions progress more rapidly than others. Once your podiatric surgeon has evaluated your particular case, a treatment plan can be developed that is suited to your needs.
Treatment
Sometimes observation of the bunion is all that's needed. A periodic office evaluation and x-ray examination can determine if your bunion deformity is advancing, thereby reducing your chance of irreversible damage to the joint. In many other cases, however, some type of treatment is needed. Early treatments are aimed at easing the pain of bunions, but they won't reverse the deformity itself.
These options include:
Changes in shoewear.
Wearing the right kind of shoes is very important. Choose shoes that have a wide toe box and forgo those with pointed toes or high heels which may aggravate the condition.
Padding.
Pads placed over the area of the bunion can help minimize pain. You can get bunion pads from your podiatric surgeon or purchase them at a drug store.
Activity modifications.
Avoid activity that causes bunion pain, including standing for long periods of time.
Medications.
Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, may help to relieve pain.
Icing.
Applying an ice pack several times a day helps reduce inflammation and pain.
Injection therapy.
Although rarely used in bunion treatment, injections of corticosteroids may be useful in treating the inflamed bursa (fluid-filled sac located in a joint) sometimes seen with bunions.
Orthotic devices.
In some cases, custom orthotic devices may be provided by the podiatric surgeon.
When Is Surgery Needed?
When the pain of a bunion interferes with daily activities, it's time to discuss surgical options with your podiatric surgeon. Together you can decide if surgery is best for you. Recent advances in surgical techniques have led to a very high success rate in treating bunions.
A variety of surgical procedures are performed to treat bunions. The procedures are designed to remove the "bump" of bone, correct the changes in the bony structure of the foot, as well as correct soft tissue changes that may also have occurred. The goal of these corrections is the elimination of pain.
In selecting the procedure or combination of procedures for your particular case, the podiatric surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.
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INSTRUCTIONS FOR USING CRUTCHES
It takes some coordination to get around on crutches. To make sure you use your crutches correctly,
please read these instructions and follow them carefully.
Sizing Your Crutches
Even if you've already been fitted for crutches, make sure your crutch pads and handgrips are set at the proper distance, as follows:
Crutch pad distance from armpits: The crutch pads (tops of crutches) should be 11/2" to 2" (about two finger widths) below the armpits, with the shoulders relaxed.
Handgrip: Place it so your elbow is flexed about 15 to 30 degrees–enough so you can fully extend your elbow when you take a step.
Crutch length (top to bottom): The total crutch length should equal the distance from your armpit to about 6" in front of a shoe.
Begin in the "Tripod Position".
The tripod position is the position you stand in when using crutches. It is also the position you begin walking in. To get into the tripod position, place the crutch tips about 4" to 6" to the side and in front of each foot. Stand on your "good" foot (the one that is weight-bearing).
Walking with Crutches
(Non-weight-bearing) If your podiatric foot and ankle surgeon has told you to avoid ALL weight-bearing, it is important to follow these instructions carefully. You will need sufficient upper body strength to support all your weight with just your arms and shoulders.
- Begin in the tripod position–and remember, keep all your weight on your "good" (weightbearing) foot.
- Advance both crutches and the affected foot/leg.
- Move the "good" weight-bearing foot/leg forward (beyond the crutches).
- Advance both crutches, and then the affected foot/leg.
- Repeat steps #3 and #4.
Managing Chairs with Crutches
To get into and out of a chair safely:
- Make sure the chair is stable and will not roll or slide, and it must have arms and back support.
- Stand with the backs of your legs touching the front of the seat.
- Place both crutches in one hand, grasping them by the handgrips.
- Hold on to the crutches (on one side) and the chair arm (on the other side) for balance and stability while lowering yourself to a seated position, or raising yourself from the chair if you're getting up.
Managing Stairs without Crutches
The safest way to go up and down stairs is to use your seat, not your crutches.
To go up stairs:
- Seat yourself on a low step.
- Move your crutches upstairs by one of these methods:
- If distance and reach allow, place the crutches at the top of the staircase.
- If this isn't possible, place crutches as far up the stairs as you can, then move them to the top as you progress up the stairs.
- In the seated position, reach behind you with both arms.
- Use your arms and weightbearing foot/leg to lift yourself up one step.
Repeat this process one step at a time. (Remember to move the crutches to the top of the staircase if you haven't already done so.)
To go down stairs:
- Seat yourself on the top step.
- Move your crutches downstairs by sliding them to the lowest possible point on the stairway, then continue to move them down as you progress down the stairs.
- In the seated position, reach behind you with both arms.
- Use your arms and weightbearing foot/leg to lift yourself down one step.
- Repeat this process one step at a time. (Remember to move the crutches to the bottom of the staircase if you haven't already done so.)
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DIABETIC FOOT CARE GUIDELINES
Diabetes can be dangerous to your feet, even a small cut could have serious consequences. Diabetes may cause nerve damage that takes away the feeling in your feet. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection. Because of these problems, you might not notice a pebble in your shoe, so you could develop a blister, then a sore, then a stubborn infection that might cause amputation of your foot or leg.
To avoid serious foot problems that could result in losing a toe, foot, or leg, be sure to follow these guidelines.
- Inspect your feet daily. Check for cuts, blisters, redness, swelling, or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.
- Wash your feet in lukewarm (not hot!) water. Keep your feet clean by washing them daily. But only use lukewarm water, the temperature you'd use on a newborn baby.
- Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or patting, and make sure to carefully dry between the toes.
- Moisturize your feet, but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But DON'T moisturize between the toes, this could encourage a fungal infection.
- Cut nails carefully, and straight across. Also, file the edges. Don't cut them too short, since this could lead to ingrown toe nails.
- Never trim corns or calluses. No "bathroom surgery", let your doctor do the job.
- Wear clean, dry socks. Change them daily.
- Avoid the wrong type of socks. Avoid tight elastic bands (they reduce circulation). Don't wear thick or bulky socks (they can fit poorly and irritate the skin).
- Wear socks to bed. If your feet get cold at night, wear socks. NEVER use a heating pad or hot water bottle.
- Shake out your shoes and inspect the inside before wearing. Remember, you may not feel a pebble, so always shake out your shoes before putting them on.
- Keep your feet warm and dry. Don't get your feet wet in snow or rain. Wear warm socks and shoes in winter.
- Never walk barefoot. Not even at home! You could step on something and get a scratch or cut.
- Take care of your diabetes. Keep your blood sugar levels under control.
- Don't smoke. Smoking restricts blood flow in your feet.
- Get periodic foot exams. See your podiatric foot and ankle surgeon on a regular basis for an examination to help prevent the foot complications of diabetes.
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FLEXIBLE FLATFOOT
What Is Flatfoot? Flatfoot is often a complex disorder, with diverse symptoms and varying degrees of deformity and disability. There are several types of flatfoot, all of which have one characteristic in common, partial or total collapse (loss) of the arch.
Other characteristics shared by most types of flatfoot include:
- Toe drift, where the toes and front part of the foot point outward
- The heel tilts toward the outside and the ankle appears to turn in.
- Ashort Achilles tendon, which causes the heel to lift off the ground earlier when walking and may act as a deforming force
Bunions and hammertoes may occur in some people with flatfeet. Health problems such as rheumatoid arthritis or diabetes sometimes increase the risk of developing flatfoot. In addition, adults who are overweight frequently have flatfoot.
Flexible Flatfoot
Flexible flatfoot is one of the most common types of flatfoot. It typically begins in childhood or adolescence and continues into adulthood. It usually occurs in both feet and generally progresses in severity throughout the adult years. As the deformity worsens, the soft tissues (tendons and ligaments) of the arch may stretch or tear and can become inflamed.
The term "flexible" means that while the foot is flat when standing (weight-bearing), the arch returns when not standing. In the early stages of flexible flatfoot arthritis is not restricting motion of the arch and foot, but in the later stages arthritis may develop to such a point that the arch and foot become stiff.
Symptoms, which may occur in some persons with flexible flatfoot, include:
Pain in the heel, arch, ankle, or along the outside of the foot
- "Turned-in" ankle
- Pain associated with a shin splint
- General weakness/fatigue in the foot or leg
Diagnosis of Flexible Flatfoot
In diagnosing flatfoot, the podiatric foot and ankle surgeon examines the foot and observes how it looks when you stand and sit. X-rays are usually taken to determine the severity of the disorder. If you are diagnosed with flexible flatfoot but you don't have any symptoms, your podiatric surgeon will explain what you might expect in the future.
Treatment Options
If you experience symptoms with flexible flatfoot, the podiatric surgeon may recommend various treatment options, including:
Activity modifications. Cut down on activities that bring you pain and avoid prolonged walking and standing to give your arches a rest.
Weight loss. If you are overweight, try to lose weight. Putting too much weight on your arches may aggravate your symptoms.
Orthotic devices. Your podiatric surgeon can provide you with custom orthotic devices for your shoes to give more support to the arches.
Immobilization. In some cases, it may be necessary to use a walking cast or to completely avoid weight-bearing.
Medications. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, help reduce pain and inflammation.
Physical therapy. Ultrasound therapy or other physical therapy modalities may be used to provide temporary relief.
Shoe modifications. Wearing shoes that support the arches is important for anyone who has flatfoot.
Surgery. In some patients whose pain is not adequately relieved by other treatments, surgery may be considered.
Flatfoot Surgery
A variety of surgical techniques is available to correct flexible flatfoot. Your case may require one procedure or a combination of procedures. All of these surgical techniques are aimed at relieving the symptoms and improving foot function. Among these procedures are tendon transfers or tendon lengthening procedures, realignment of one or more bones, joint fusions, or insertion of implant devices.
In selecting the procedure or combination of procedures for your particular case, the podiatric surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other factors.
The length of the recovery period will vary, depending on the procedure or procedures performed.
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TOE AND METATARSAL FRACTURES
The structure of your foot is complex, consisting of bones, muscles, tendons, and other soft tissues. Of the 26 bones in your foot, 19 are toe bones (phalanges) and metatarsal bones (the long bones in the midfoot). Fractures of the toe and metatarsal bones are common and require evaluation by a specialist.A podiatric foot and ankle surgeon should be seen for proper diagnosis and treatment, even if initial treatment has been received in an emergency room.
What Is a Fracture?
A fracture is a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.
Traumatic fractures (also called acute fractures) are caused by a direct blow or impact like seriously stubbing your toe. Traumatic fractures can be displaced or nondisplaced. If the fracture is displaced, the bone is broken in such a way that it has changed in position (dislocated). Treatment of a traumatic fracture depends on the location and extent of the break and whether it is displaced. Surgery is sometimes required.
Signs and symptoms of a traumatic fracture include:
- You may hear a sound at the time of the break.
- "Pinpoint pain" (pain at the place of impact) at the time the fracture occurs and perhaps for a few hours later, but often the pain goes away after several hours.
- Deviation (misshapen or abnormal appearance) of the toe.
- Bruising and swelling the next day.
- It is not true that "if you can walk on it, it's not broken." Evaluation by the podiatric surgeon is always recommended.
Stress fractures are tiny, hairline breaks that are usually caused by repetitive stress. Stress fractures often afflict athletes who, for example, too rapidly increase their running mileage. Or they may be caused by an abnormal foot structure, deformities, or osteoporosis. Improper footwear may also lead to stress fractures. Stress fractures should not be ignored, because they will come back unless properly treated.
Symptoms of stress fractures include:
- Pain with or after normal activity
- Pain that goes away when resting and then returns when standing or during activity
- "Pinpoint pain" (pain at the site of the fracture) when touched
Swelling, but no bruising Sprains and fractures have similar symptoms, although sometimes with a sprain, the whole area hurts rather than just one point. Your podiatric surgeon will be able to diagnose which you have and provide appropriate treatment. Certain sprains or dislocations can be severely disabling. Without proper treatment they can lead to crippling arthritis.
Consequences of Improper Treatment
Some people say that "the doctor can't do anything for a broken bone in the foot." This is usually not true. In fact, if a fractured toe or metatarsal bone is not treated correctly, serious complications may develop. For example:
- Adeformity in the bony architecture which may limit the ability to move the foot or cause difficulty in fitting shoes
- Arthritis, which may be caused by a fracture in a joint (the juncture where two bones meet), or may be a result of angular deformities that develop when a displaced fracture is severe or hasn't been properly corrected
- Chronic pain and long-term dysfunction
- Non-union, or failure to heal, can lead to subsequent surgery or chronic pain.
Treatment of Toe Fractures
Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:
Rest. Sometimes rest is all that is needed to treat a traumatic fracture of the toe.
Splinting. The toe may be fitted with a splint to keep it in a fixed position.
Rigid or stiff-soled shoe. Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned.
"Buddy taping" the fractured toe to another toe is sometimes appropriate, but in other cases itmay be harmful.
Surgery. If the break is badly displaced or if the joint is affected, surgery may be necessary. Surgery often involves the use of fixation devices, such as pins.
Treatment of Metatarsal Fractures
Breaks in the metatarsal bones may be either stress or traumatic fractures. Certain kinds of fractures of the metatarsal bones present unique challenges. For example, sometimes a fracture of the first metatarsal bone (behind the big toe) can lead to arthritis. Since the big toe is used so frequently and bears more weight than other toes, arthritis in that area can make it painful to walk, bend, or even stand.
Another type of break, called a Jones fracture, occurs at the base of the fifth metatarsal bone (behind the little toe). It is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments.Your podiatric surgeon is an expert in correctly identifying these conditions as well as other problems of the foot.
Treatment of metatarsal fractures depends on the type and extent of the fracture, and may include:
Rest. Sometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
Avoid the offending activity. Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
Immobilization, casting, or rigid shoe. A stiff-soled shoe or other form of immobilization may be used to protect the fractured bone while it is healing.
Surgery. Some traumatic fractures of the metatarsal bones require surgery, especially if the break is badly displaced.
Follow-up care. Your podiatric foot and ankle surgeon will provide instructions for care following surgical or non-surgical treatment. Physical therapy, exercises and rehabilitation may be included in a schedule for return to normal activities.
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HALLUX RIGIDUS
Each day, with every step you take, your big toe bears a tremendous amount of stress, a force equal to about twice your body weight. Most of us don't realize how much we use our big toe. We tend to take it for granted, unless a problem develops. One problem that afflicts the big toe is called hallux rigidus, a condition where movement of the toe is restricted to varying degrees. This disorder can be very troubling and even disabling, since we use the all-important big toe whenever we walk, stoop down, climb up, or even stand. If you have pain and/or stiffness in your big toe, you may have this condition.
What Is Hallux Rigidus?
Hallux rigidus is a disorder of the joint located at the base of the big toe. It causes pain and stiffness in the big toe, and with time it gets increasingly harder to bend the toe. "Hallux" refers to the big toe,while "rigidus" indicates that the toe is rigid and cannot move.
Hallux rigidus is actually a form of degenerative arthritis (a wearing out of the cartilage within the joint that occurs in the foot and other parts of the body). Because hallux rigidus is a progressive condition, the toe's motion decreases as time goes on. In its earlier stage, motion of the big toe is only somewhat limited, at that point, the condition is called "hallux limitus."
But as the problem advances, the toe's range of motion gradually decreases until it potentially reaches the end stage of "rigidus", where the big toe becomes stiff, or what is sometimes called a "frozen joint." Other problems are also likely to occur as the disorder progresses.
Early signs and symptoms include:
- Pain and stiffness in the big toe during use (walking, standing, bending, etc.)
- Pain and stiffness aggravated by cold, damp weather
- Difficulty with certain activities (running, squatting)
- Swelling and inflammation around the joint
As the disorder gets more serious, additional symptoms may develop, including:
- Pain, even during rest
- Difficulty wearing shoes because bone spurs (overgrowths) develop. Wearing high-heeled shoes can be particularly difficult.
- Dull pain in the hip, knee, or lower back due to changes in the way you walk
- Limping,in severe case
What Causes Hallux Rigidus?
Common causes of hallux rigidus are faulty function (biomechanics) and structural abnormalities of the foot that can lead to osteoarthritis in the big toe joint. This type of arthritis, the kind that results from "wear and tear",often develops in people who have defects that change the way their foot and big toe functions. For example, those with fallen arches or excessive pronation (rolling in) of the ankles are susceptible to developing hallux rigidus.
In some people, hallux rigidus runs in the family and is a result of inheriting a foot type that is prone to developing this condition. In other cases, it is associated with overuse, especially among people engaged in activities or jobs that increase the stress on the big toe, such as workers who often have to stoop or squat. Hallux rigidus can also result from an injury, even from stubbing your toe. Or it may be caused by certain inflammatory diseases, such as rheumatoid arthritis or gout. Your podiatric foot and ankle surgeon can determine the cause of your hallux rigidus and recommend the best treatment.
Diagnosis of Hallux Rigidus
The sooner this condition is diagnosed, the easier it is to treat. Therefore, the best time to see a podiatric surgeon is when you first Normal Function Limited Motion Rigid Deformity notice that your big toe feels stiff or hurts when you walk, stand, bend over, or squat. If you wait until bone spurs develop, your condition is likely to be more difficult to manage. In diagnosing hallux rigidus, the podiatric surgeon will examine your feet and manipulate the toe to determine its range of motion. X-rays are usually required to determine how much arthritis is present as well as to evaluate any bone spurs or other abnormalities that may have formed.
Treatment: Non-Surgical Approaches
If your condition is caught early enough, it is more likely to respond to less aggressive treatment. If fact, in many cases, early treatment may prevent or postpone the need for surgery in the future. That's why it is important to see your podiatric surgeon when you first begin to notice symptoms.
Treatment for mild or moderate cases of hallux rigidus may include one or more of these strategies:
Shoe modifications. Shoes that have a large toe box should be worn, because they put less pressure on your toe. Stiff or rocker-bottom soles may also be recommended. Most likely, you'll have to stop wearing high heels.
Orthotic devices. Custom orthotic devices may improve the function of your foot.
Medications. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed to help reduce pain and inflammation. Supplements such as glucosamine-chondroitin sulfate and some vitamins and minerals may also be helpful.
Injection therapy. Injections of corticosteroids in small amounts are sometimes given in the affected toe to help reduce the inflammation and pain.
Physical therapy. Ultrasound therapy or other physical therapy modalities may be undertaken to provide temporary relief.
When Is Surgery Needed?
In some cases, surgery is the only way to eliminate or reduce pain. There are several types of surgery that can be undertaken to treat hallux rigidus. These surgical procedures fall into two categories:
Some procedures reconstruct and "clean up" the joint. The surgeon removes the arthritic damage from the joint as well as any accompanying bone spurs, and then alters the position of one or more bones in the big toe. These procedures are designed to preserve and restore normal alignment and function of the joint as well as reduce or eliminate pain.
More aggressive procedures are used when the joint cannot be preserved. These may involve fusing the joint, or removing part or all of the joint and, in some cases, replacing it with an implant, such as is done for the hip or knee. These procedures eliminate painful motion in the joint and provide a stable foot. The procedure that is used to correct hallux rigidus depends on many factors, including the cause of the condition and the severity, as well as the patient's age, occupation and activity level. Your podiatric surgeon is trained to select a surgical procedure best suited to your particular condition and needs. If surgery is performed, the length of the recovery period will vary, depending upon the procedure or procedures performed.
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HAMMERTOE
What Is Hammertoe? Hammertoe is a contracture or bending, of one or both joints of the second, third, fourth, or fifth (little) toes. This abnormal bending can put pressure on the toe when wearing shoes, causing problems to develop.
- Common symptoms of hammertoes include:
- Pain or irritation of the affected toe when wearing shoes.
- Corns (a buildup of skin) on the top, side, or end of the toe, or between two toes. Corns are caused by constant friction against the shoe. They may be soft or hard, depending upon their location.
- Calluses (another type of skin buildup) on the bottom of the toe or on the ball of the foot. Corns and calluses can be painful and make it difficult to find a comfortable shoe. But even without corns and calluses, hammertoes can cause pain because the joint itself may become dislocated.
Hammertoes usually start out as mild deformities and get progressively worse over time. In the earlier stages, hammertoes are flexible and the symptoms can often be managed with noninvasive measures. But if left untreated, hammertoes can become more rigid and will not respond to non-surgical treatment.
Corns are more likely to develop as time goes on, and corns never really go away, even after trimming. In more severe cases of hammertoe, open sores may form. Because of the progressive nature of hammertoes, they should receive early attention. Hammertoes never get better without some kind of intervention.
What Causes Hammertoe?
The most common cause of hammertoe is a muscle/tendon imbalance. This imbalance, which leads to a bending of the toe, results from mechanical (structural) changes in the foot that occur over time in some people.
Hammertoes are often aggravated by shoes that don't fit properly, for example, shoes that crowd the toes. And in some cases, ill-fitting shoes can actually cause the contracture that defines hammertoe. For example, a hammertoe may develop if a toe is too long and is forced into a cramped position when a tight shoe is worn.
Occasionally, hammertoe is caused by some kind of trauma, such as a previously broken toe. In some people, hammertoes are inherited.
Treatment: Non-Surgical Approaches
There are a variety of treatment options for hammertoe. The treatment your podiatric foot and ankle surgeon selects will depend upon the severity of your hammertoe and other factors. A number of non-surgical measures can be undertaken:
Trimming corns and calluses. This should be done by a healthcare professional. Never attempt to do this yourself, because you run the risk of cuts and infection. Your podiatric surgeon knows the proper way to trim corns to bring you the greatest benefit.
Padding corns and calluses. Your podiatric surgeon can provide or prescribe pads designed to shield corns from irritation. If you want to try over-the-counter pads, avoid the medicated types.Medicated pads are generally not recommended because they may contain a small amount of acid that can be harmful. Consult your podiatric surgeon about this option. Normal Toes Hammertoes
- Changes in shoewear. Avoid shoes with pointed toes, shoes that are too short, or shoes with high heels, conditions that can force your toe against the front of the shoe. Instead, choose comfortable shoes with a deep, roomy toe box and heels no higher than two inches.
- Orthotic devices. A custom orthotic device placed in your shoe may help control the muscle/ tendon imbalance.
- Injection therapy. Corticosteroid injections are sometimes used to ease pain and inflammation caused by hammertoe.
- Medications. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, are often prescribed to reduce pain and inflammation.
- Splinting/strapping. Splints or small straps may be applied by the podiatric surgeon to realign the bent toe.
When Is Surgery Needed?
In some cases, usually when the hammertoe has become more rigid, surgery is needed to relieve the pain and discomfort caused by the deformity. Your podiatric surgeon will discuss the options and select a plan tailored to your needs. Among other concerns, he or she will take into consideration the type of shoes you want to wear, the number of toes involved, your activity level, your age, and the severity of the hammertoe. The most common surgical procedure performed to correct a hammertoe is called arthroplasty. In this procedure, the surgeon removes a small section of the bone from the affected joint.
Another surgical option is arthrodesis, which is usually reserved for more rigid toes or severe cases, such as when there are multiple joints or toes involved. Arthrodesis is a procedure that involves a fusing of a small joint in the toe to straighten it. A pin or other small fixation device is typically used to hold the toe in position while the bones are healing. It is possible that a patient may require other procedures, as well, especially when the hammertoe condition is severe. Some of these procedures include skin wedging (the removal of wedges of skin), tendon/muscle rebalancing or lengthening, small tendon transfers, or relocation of surrounding joints. Often patients with hammertoe have bunions or other foot deformities corrected at the same time. The length of the recovery period will vary, depending on the procedure or procedures performed.
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HEEL PAIN
Heel pain is most often caused by plantar fasciitis; a condition that is sometimes also called heel spur syndrome when a spur is present. Heel pain may also be due to other causes, such as a stress fracture, tendonitis, arthritis, nerve irritation, or, rarely, a cyst. Because there are several potential causes, it is important to have heel pain properly diagnosed. A podiatric foot and ankle surgeon is best trained to distinguish between all the possibilities and determine the underlying source of your heel pain.
What Is Plantar Fasciitis?
Plantar fasciitis is an inflammation of the band of tissue (the plantar fascia) that extends from the heel to the toes. In this condition, the fascia first becomes irritated and then inflamed; resulting in heel pain. The symptoms of plantar fasciitis are:
- Pain on the bottom of the heel
- Pain that is usually worse upon arising
- Pain that increases over a period of months
People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they've been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people the pain subsides but returns after spending long periods of time on their feet.
Causes of Plantar Fasciitis
The most common cause of plantar fasciitis relates to faulty structure of the foot. For example, people who have problems with their arches, either overly flat feet or high-arched feet, are more prone to developing plantar fasciitis.
Wearing non-supportive footwear on hard, flat surfaces puts abnormal strain on the plantar fascia and can also lead to plantar fasciitis. This is particularly evident when a person's job requires long hours on their feet. Obesity also contributes to plantar fasciitis.
Diagnosis
To arrive at a diagnosis, the podiatric foot and ankle surgeon will obtain your medical history and examine your foot. Throughout this process the surgeon rules out all the possible causes for your heel pain other than plantar fasciitis.
In addition, diagnostic imaging studies such as x-rays, a bone scan, or magnetic resonance imaging (MRI) may be used to distinguish the different types of heel pain. Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.
Treatment Options
Treatment of plantar fasciitis begins with first-line strategies, which you can begin at home:
Stretching exercises. Exercises that stretch out the calf muscles help ease pain and assist with recovery.
Avoid going barefoot. When you walk without shoes, you put undue strain and stress on your plantar fascia.
Ice. Putting an ice pack on your heel for 10 minutes several times a day helps reduce inflammation.
Limit activities. Cut down on extended physical activities to give your heel a rest.
Shoe modifications. Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia. Your shoes should provide a comfortable environment for the foot.
Medications. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, may help reduce pain and inflammation.
Lose weight. Extra pounds put extra stress on your plantar fascia.
If you still have pain after several weeks, see your podiatric surgeon, who may add one or more of these approaches:
Padding and strapping. Placing pads in the shoe softens the impact of walking. Strapping helps support the foot and reduce strain on the fascia.
Orthotic devices. Custom orthotic devices that fit into your shoe help correct the underlying structural abnormalities causing the plantar fasciitis.
Injection therapy. In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain.
Removable walking cast. A removable walking cast may be used to keep your foot immobile for a few weeks to allow it to rest and heal.
Night splint. Wearing a night splint allows you to maintain an extended stretch of the plantar fascia while sleeping. This may help reduce the morning pain experienced by some patients.
Physical therapy. Exercises and other physical therapy measures may be used to help provide relief.
Although most patients with plantar fasciitis respond to non-surgical treatment, a small percentage of patients may require surgery. If, after several months of non-surgical treatment, you continue to have heel pain, surgery will be considered.Your podiatric foot and ankle surgeon will discuss the surgical options with you and determine which approach would be most beneficial for you.
Long-term Care
No matter what kind of treatment you undergo for plantar fasciitis, the underlying causes that led to this condition may remain. Therefore, you will need to continue with preventive measures. If you are overweight, it is important to reach and maintain an ideal weight. For all patients, wearing supportive shoes and using custom orthotic devices are the mainstay of long-term treatment for plantar fasciitis.
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MORTON'S NEUROMA
What Is a Neuroma? Aneuroma is a thickening of nerve tissue that may develop in various parts of the body. The most common neuroma in the foot is a Morton's neuroma, which occurs at the base of the third and fourth toes. It is sometimes referred to as an intermetatarsal neuroma. "Intermetatarsal" describes its location, in the ball of the foot between the metatarsal bones (the bones extending from the toes to the midfoot).Neuromas may also occur in other locations in the foot.
The thickening, or enlargement, of the nerve that defines a neuroma is the result of compression and irritation of the nerve. This compression creates swelling of the nerve, eventually leading to permanent nerve damage.
Symptoms of a Morton's Neuroma
If you have a Morton's neuroma, you will probably have one or more of these symptoms where the nerve damage in occurring:
- Tingling, burning, or numbness
- Pain
- A feeling that something is inside the ball of the foot, or that there's a rise in the shoe or a sock is bunched up
The progression of a Morton's neuroma often follows this pattern:
The symptoms begin gradually. At first they occur only occasionally, when wearing narrow-toed shoes or performing certain aggravating activities. The symptoms may go away temporarily by massaging the foot or by avoiding aggravating shoes or activities. Over time the symptoms progressively worsen and may persist for several days or weeks. The symptoms become more intense as the neuroma enlarges and the temporary changes in the nerve become permanent.
What Causes a Neuroma?
Anything that causes compression or irritation of the nerve can lead to the development of a neuroma. One of the most common offenders is wearing shoes that have a tapered toe box, or high-heeled shoes that cause the toes to be forced into the toe box.
People with certain foot deformities, bunions, hammertoes, flatfeet, or more flexible feet, are at higher risk for developing a neuroma. Other potential causes are activities that involve repetitive irritation to the ball of the foot, such as running or racquet sports. An injury or other type of trauma to the area may also lead to a neuroma.
Diagnosis
To arrive at a diagnosis, the podiatric foot and ankle surgeon will obtain a thorough history of your symptoms and examine your foot. During the physical examination, the doctor attempts to reproduce your symptoms by manipulating your foot. Other tests may be performed. The best time to see your podiatric surgeon is early in the development of symptoms. Early diagnosis of a Morton's neuroma greatly lessens the need for more invasive treatments and may avoid surgery.
Treatment
In developing a treatment plan, your podiatric surgeon will first determine how long you've had the neuroma and evaluate its stage of development. Treatment approaches vary according to the severity of the problem.
For mild to moderate cases of neuroma, treatment options include:
Padding. Padding techniques provide support for the metatarsal arch, thereby lessening the pressure
on the nerve and decreasing the compression when walking.
Icing. Placing an icepack on the affected area helps reduce swelling.
Orthotic devices. Custom orthotic devices provided by your podiatric surgeon provide the support needed to reduce pressure and compression on the nerve.
Activity modifications. Activities that put repetitive pressure on the neuroma should be avoided until the condition improves.
Changes in shoewear. It's important to wear shoes with a wide toe box and avoid narrow-toed shoes or shoes with high heels.
Medications. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
Injection therapy. If there is no significant improvement after initial treatment, injection therapy may be tried.
When Is Surgery Needed?
Surgery may be considered in patients who have not received adequate relief from other treatments.
Generally, there are two surgical approaches to treating a neuroma, the affected nerve is either removed or released. Your podiatric surgeon will determine which approach is best for your condition.
The length of the recovery period will vary, depending on the procedure or procedures performed. Regardless of whether you've undergone surgical or nonsurgical treatment, your podiatric surgeon will recommend long-term measures to help keep your symptoms from returning. These include appropriate footwear and modification of activities that cause repetitive pressure on the foot.
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PEDIATRIC HEEL PAIN
What Is Pediatric Heel Pain? Heel pain is a common childhood complaint. That doesn't mean, however, that it should be ignored, or that parents should wait to see if it will "go away." Heel pain is a symptom, not a disease. In other words, heel pain is a warning sign that a child has a condition that deserves attention.
Heel pain problems in children are often associated with these signs and symptoms:
- Pain in the back or bottom of the heel
- Limping
- Walking on toes
- Difficulty participating in usual activities or sports
The most common cause of pediatric heel pain is a disorder called calcaneal apophysitis (see below),which usually affects 8 - to 14 -year olds. However, pediatric heel pain may be the sign of many other problems, and can occur at younger or older ages.
What Is the Difference Between Pediatric and Adult Heel Pain?
Pediatric heel pain differs from the most common form of heel pain experienced by adults (plantar fasciitis) in the way pain occurs. Plantar fascia pain is intense when getting out of bed in the morning or after sitting for long periods, and then it subsides after walking around a bit. Pediatric heel pain usually doesn't improve in this manner. In fact, walking around typically makes the pain worse.
Heel pain is so common in children because of the very nature of their growing feet. In children, the heel bone (the calcaneus) is not yet fully developed until age 14 or older. Until then, new bone is forming at the growth plate (the physis), a weak area located at the back of the heel. Too much stress on the growth plate is the most common cause of pediatric heel pain.
Causes of Pediatric Heel Pain
There are a number of possible causes for a child's heel pain. Because diagnosis can be challenging, a podiatric foot and ankle surgeon is best qualified to determine the underlying cause of the pain and develop an effective treatment plan.
Conditions that cause pediatric heel pain include:
Calcaneal apophysitis. Also known as Sever's disease, this is the most common cause of heel pain in children.Although not a true "disease," it is an inflammation of the heel's growth plate due to muscle strain and repetitive stress, especially in those who are active or obese. This condition usually causes pain and tenderness in the back and bottom of the heel when walking, and the heel is painful when touched. It can occur in one or both feet.
Tendo-Achilles bursitis. This condition is an inflammation of the fluid-filled sac (bursa) located between the Achilles tendon (heel cord) and the heel bone. Tendo- Achilles bursitis can result from injuries to the heel, certain diseases (such as juvenile rheumatoid arthritis), or wearing poorly cushioned shoes.
Overuse syndromes. Because the heel's growth plate is sensitive to repeated running and pounding on hard surfaces, pediatric heel pain often reflects overuse. Children and adolescents involved in soccer, track, or basketball are especially vulnerable. One common overuse syndrome is Achilles tendonitis. This inflammation of the tendon usually occurs in children over the age of 14. Another overuse syndrome is plantar fasciitis, which is an inflammation of the band of tissue (the plantar fascia) that runs along the bottom of the foot from the heel to the toes.
Fractures. Sometimes heel pain is caused by a break in the bone. Stress fractures, hairline breaks resulting from repeated stress on the bone, often occur in adolescents engaged in athletics, especially when the intensity of training suddenly changes. In children under age of 10, another type of break, "acute fractures" can result from simply jumping 2 or 3 feet from a couch or stairway.
Diagnosis of Pediatric Heel Pain
To diagnose the underlying cause of your child's heel pain, the podiatric surgeon will first obtain a thorough medical history and ask questions about recent activities. The surgeon will also examine the child's foot and leg. X-rays are often used to evaluate the condition, and in some cases the surgeon will order a bone scan, a magnetic resonance imaging (MRI) study, or a computerized tomography (CT or CAT) scan. Laboratory testing may also be ordered to help diagnose other less prevalent causes of pediatric heel pain.
Treatment Options
The treatment selected depends upon the diagnosis and the severity of the pain. For mild heel pain, treatment options include:
Reduce activity. The child needs to reduce or stop any activity that causes pain.
Cushion the heel. Temporary shoe inserts are useful in softening the impact on the heel when walking, running, and standing.
For moderate heel pain, in addition to reducing activity and cushioning the heel, the podiatric surgeon may use one or more of these treatment options:
Medications. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, help reduce pain and inflammation.
Physical therapy. Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed tissue.
Orthotic devices. Custom orthotic devices prescribed by the podiatric surgeon help support the foot properly.
For severe heel pain, more aggressive treatment options may be necessary, including:
Immobilization. Some patients need to use crutches to avoid all weight-bearing on the affected foot for a while. In some severe cases of pediatric heel pain, the child may be placed in a cast to promote healing while keeping the foot and ankle totally immobile.
Follow-up measures. After immobilization or casting, follow-up care often includes use of custom orthotic devices, physical therapy, or strapping.
Surgery. There are some instances when surgery may be required to lengthen the tendon or correct other problems.
Can Pediatric Heel Pain Be Prevented?
The chances of a child developing heel pain can be reduced by following these recommendations:
- Avoid obesity
- Choose well-constructed, supportive shoes that are appropriate for the child's activity
- Avoid, or limit, wearing cleated athletic shoes
- Avoid activity beyond a child's ability
If Symptoms Return
Often heel pain in children returns after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of the initially diagnosed condition, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with your podiatric surgeon.
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This information has been prepared by the Consumer Education Committee of the American College of Foot and Ankle Surgeons, a professional society of 5,700 podiatric foot and ankle surgeons. Members of the College are Doctors of Podiatric Medicine who have received additional training through surgical residency programs.
The mission of the College is to promote superior care of foot and ankle surgical patients through education, research and the promotion of the highest professional standards.
Copyright © 2004,American College of Foot and Ankle Surgeons www.acfas.org
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