What is the Achilles Tendon?
The Achilles tendon-the the longest tendon in the body-runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the “heel cord,” the Achilles tendon facilitates walking by helping to raise the heel off the ground.
Achilles Tendonitis and Achilles Tendonosis
Two common disorders that occur in the heel cord are Achilles tendonitis and Achilles tendonosis. Achilles tendonitis is an inflammation of the Achilles tendon. If treated this inflammation does not typically last very long. However, long-standing pathology can lead to a degeneration of the tendon (tendonosis), in which the tendon loses its organized structure and is likely to develop microscopic tears. This degeneration can involve the site where the Achilles tendon attaches to the heel bone or just proximal to the insertion.
Symptoms Associated with Tendonitis or Tendonosis
Pain-aching, stiffness, soreness, or tenderness may occur anywhere along the tendon’s path. Often pain appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity. When a degeneration is present the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.
Causes
Achilles tendonitis and tendonosis are usually caused by a sudden increase in repetitive activity. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibers. Due to this ongoing stress on the tendon, the body is unable to repair the injured tissue. Athletes are at high risk for developing disorders of the Achilles tendon. It is also common in individuals whose work puts stress on their ankles and feet as well as in “weekend warriors”- those who are less conditioned and participate in athletics only on weekends or infrequently. In addition, people with excessive pronation (flattening of the arch) have a tendency to develop Achilles tendonitis and tendonosis due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their over-pronation could further aggravate the Achilles tendon.
Diagnosis
In diagnosing Achilles tendonitis or tendonosis, the surgeon will examine the patient’s foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with x-rays, ultrasound, or MRI.
Treatment
Treatment approaches for Achilles tendonitis or tendonosis are selected on the basis of how long the injury has been present and the degree of damage to the tendon.
Prevention
To prevent Achilles tendonitis or tendonosis from recurring after surgical or non-surgical treatment, the foot and ankle surgeon may recommend strengthening and stretching of the calf muscles through daily exercises.
An ankle fracture is a break of one or more of the bones that make up the ankle. The ankle is a hinge-type joint that connects the leg to the foot and consists of three bones: tibia, fibula, and talus. These bones are supported by strong ligaments.
Ankle fractures result when the ankle is forced beyond its normal range of motion. This can occur when a jumping or running athlete lands on an uneven surface or when the foot is firmly planted and the body gets twisted. Equipment and surface conditions may also play a role.
The diagnosis of an ankle fracture is considered when a patient gives a history of “turning” or “rolling” his or her ankle accompanied by sudden pain and swelling. The physical exam will reveal tenderness over the involved bones. X-rays are needed to confirm the fracture and plan for treatment. Occasionally, a CT or MRI is ordered to evaluate the. cartilage or tendons around the ankle.
Nonoperative: Less severe ankle fractures can be treated by nonoperative means. Typically, a cast or splint is used to stabilize the ankle for several weeks. After the period of immobilization, a course of physical therapy to strengthen the muscles around the ankle is needed to complete the recovery process.
Operative: Surgery is often needed to stabilize ankle fractures. Usually, the surgery involves the placement of screws and plates. The patient then is placed in a cast or splint after surgery to ensure proper healing. This may take 4-8 weeks depending on the severity of the fracture.
Definition
Ankle sprains are injuries to the ligaments typically on the outside of the ankle joint; usually brought on by twisting of the ankle.
The ankle ligaments usually involved in an ankle sprain are also known as the lateral collateral ligaments which help to stabilize the ankle mortise. The lateral collateral ligaments of the ankle are comprised of the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament.
The function of the Lateral (outside) Ankle Ligaments
The lateral collateral ligaments provide stability to the ankle throughout the gait cycle as the foot bends up and down. Therefore, total lateral stability of the ankle is provided by these three ligaments. Rolling in of the foot (inversion), with the sole of the foot towards the opposite leg, is defined as a lateral ankle sprain and can injure the ligaments.
The most anterior (front) and most frequently injured of these ligaments is the anterior talofibular ligament. This ligament is intracapsular, which means it is contiguous with the lining of the ankle capsule.
The main function of the anterior talofibular ligament is the prevention of axial or rotational instability of the ankle. Along with the calcaneofibular ligament (CFL) and posterior talofibular ligament, the ATF prevents inversion or rolling in of the foot. Irregularity of the ground, or laterally directed force, can cause the foot to twist.
Recurrent injuries to the lateral ankle ligaments can cause long-standing or chronic injuries to the lateral ankle ligaments. This chronic ankle instability means that the lateral ankle ligaments no longer provide the ability to stop ankle twisting and to hold the Talus within the ankle joint. As you walk or run with an unstable ankle, the talus can twist within the joint. This abnormal movement redirects force to the outside of the joint which causes the foot to roll to the inside producing further tearing of the ligament and further injury.
Treatment
Conservative treatment for this condition usually begins with RICE (rest, ice, compression elevation) is the standard initial treatment. Allowing the ligaments to heal in the correct position and at the correct length depends on how quickly treatment is initiated and the severity of the injury.
Surgical Treatment
Surgical treatment of the ankle ligaments is performed when instability develops and the condition can no longer be treated by conservative means. Sometimes this involves imbrication (overlapping) of the injured ligaments or reconstruction with the help of the tendons of the lateral ankle (peroneal tendons).
Hallux valgus is the medical term for a bunion deformity involving the large toe joint. As the head of the 1 metatarsal protrudes more medially the joint capsule undergoes a series of changes. These changes increase the deformity and cause a partial dislocation of the great toe joint. So as the big toe progressively dislocates towards the small toes, the head of the 1st metatarsal becomes more prominent. The functionality of the joint is compromised the greater this dislocation.
As the 1 MPJ progressively moves out of place, it can cause increasing pain, local swelling, and redness due to irritation from shoes. There also may be an associated “burning” sensation due to the fact that one of the nerves in the area gets pressed up against the prominent bone from shoe gear.
Causes
There are several attributing factors that can lead to asymptomatic bunion deformity. Heredity plays an important role in the development of this deformity as well as the abnormal mechanical function of the foot. Statistically, more women have symptomatic bunion deformities than men.
As this deformity progresses the big toe will eventually underlap the 2 toes which will result in hammertoe deformities of these digits. This process can continue and lead to hammertoe formation of the 3 digits.
Shoe gear also plays an important role in the symptomatology of bunion deformities. High-heeled shoes, pointed shoes, shoes that are too short or too narrow will severely aggravate a bunion deformity. However, shoes do not cause bunion deformities but simply aggravate deformities that are developing or already exist.
Treatment
Appropriate history and physical examination, bio-mechanical evaluation, and x-ray evaluation are necessary to make an accurate diagnosis and to be able to recommend an appropriate treatment plan to the patient.
Conservative options include shoe modifications, foot padding, anti-inflammatory medication, and orthotics. Occasionally, injections may be recommended to a patient in an attempt to diminish or eliminate their painful symptoms. Splints or digital wedges will not be effective in realigning the joint. None of these conservative treatments will change the structural position of the joint.
Your Podiatric surgeon may discuss and recommend surgical treatment. The exact type of procedure depends heavily on the degree of deformity of the bunion and associated pathology.
Following surgery, you will have to wear protective shoe gear such as a surgical shoe or CAM boot. Some bunion deformities allow postoperative weight-bearing. However, more severe deformities and subsequent surgical treatment demand non-weight bearing.
As a general rule, bunion surgical procedures are performed on an out-patient basis in approved Surgical Centers or in a Hospital. Following bunion surgery, an individual can expect a gradual return to normal function and gradual reduction of the localized swelling, which is a normal part of the healing process.
Charcot foot is a progressive degenerative condition that affects the metatarsal, tarsometatarsal, and tarsal joints in the feet. Nerve damage (neuropathy) often accompanies this deformity and decreases the body’s ability to sense pain. As a result, the joints in the feet are subjected to repeated trauma and injury, causing progressive damage to the ligaments, cartilage, and bones.
Incidence and Prevalence
It occurs at the same rate in men and women and develops in both feet in approximately 20% of cases.
Charcot foot occurs most often in people with diabetes mellitus. According to the American Diabetes Association, 60-70% of people with diabetes develop peripheral nerve damage that can lead to Charcot foot and about 0.5% of these patients develop the condition. Typically, onset occurs after the age of 50, and after the patient has had diabetes for 15 to 20 years.
Signs and Symptoms
The progression of Charcot can occur in a matter of weeks or months. Minor trauma, such as twisting the foot, can initiate the process and the loss of pain perception and the sense of foot position can result in repeated joint injuries. Also, increased midfoot pressure due to a tight heel cord can result in a deforming force leading to a joint breakdown.
Symptoms of Charcot foot include the following:
Subluxation initiates the process of degenerative joint disease (arthropathy).
Deformity of the foot is caused by joint displacement and/or dislocation which may include bone fractures. If not stabilized the altered joints may lead to osteophytes protruding from the top or bottom of the foot as the body forms new bone to replaces bone loss.
Fractures may cause the tarsal bones to collapse, resulting in an outward bowing of the arch (called “rocker foot”). Complications of Charcot foot include calluses and ulcers, which occur when bony protrusions rub inside the shoes and may become infected.
Diagnosis
Diagnosis is based on medical history (i.e., history of diabetes), symptoms, imaging tests (e.g., x-rays, MRI).
X-rays are used to detect joint effusions, osteophytes, fractures, and joint misalignment and/or dislocation.
Treatment
The goal of treatment is to stabilize the affected joints. Limiting the amount of weight on the foot for at least 8 weeks may help to prevent further damage. Offloading modalities including casting, walking boots, or rolling walkers are typically used.
Surgery may be necessary to treat severe deformities and re-establish a stable construct. Also, recurring ulcers, often caused by bony prominences, are contoured to allow skin healing.
After treatment, most patients with Charcot foot can resume regular activities but should be monitored to ensure reoccurrence does not occur.
Crossover toe occurs when the second toe moves closer and eventually crosses over and lies on top of the big toe. Although it can occur at any age, it is most often seen in adults and occurs over a long period of time.
Symptoms
Pain can be experienced on the ball of the foot or on top of the toe as it rubs in shoe gear. As the condition worsens it can lead to increase pain and, sometimes, dorsal (top) ulceration of the skin due to continual irritation of the shoe”s toe box.
Crossover toe is a progressive disorder. In the very early stages, the best time to treat crossover toe-a patient may have pain but no crossover of the toe. Without treatment, the condition usually worsens to dislocation of the joint, so it is very beneficial to have a foot and ankle surgeon evaluate the foot soon after pain first occurs.
Causes
Crossover toe is a result of increased pressure on the second toe joint which can lead to the weakening of the supportive ligaments. Eventually, this leads to a failure of the joint to stabilize the toe resulting in the toe crossing over the big toe.
Often a bunion deformity accompanies the deformity and can expedite its progression.
Non-surgical Treatment
Ideally, the best time to treat crossover toe is before the toe starts to drift toward the big toe. At that time, non-surgical approaches can be used to stabilize the joint and reduce the symptoms and address the underlying cause of the condition.
Surgical Treatment
Your Podiatric foot and ankle surgeon will select the appropriate procedure to address the amount of deformity. However, after the digit has crossed over the big toe surgery is necessary to reduce the contracture.
Diabetics are at increased risk for foot problems. However, consistent visits with your Podiatric Foot and Ankle surgeon can decrease the chance for infection or problems to develop. Infection is often preceded by neuropathy or decreased nerve function. Neuropathy causes loss of feeling in your feet, taking away your ability to feel pain and discomfort, so you may not detect an injury or irritation. Furthermore, in diabetes, small foot problems can turn into serious complications.
Common Diabetic Complications in the Foot
1. Infections and ulcers (sores) that don”t heal. Together with decreased nerve function, poor circulation in the feet can prolong the healing time of ulcers. The longer it takes a wound to heal the greater the chance for infection to develop. This is a common and serious complication of diabetes and can lead to a loss of your foot or your leg.
2. Corns and calluses. When neuropathy is present, you can”t tell if your shoes are causing pressure and producing corns or calluses. Corns and calluses must be properly treated or they can develop into ulcers.
3. Dry, cracked skin. Poor circulation can make your skin dry which can lead to cracking and possible infection.
4. Nail disorders. Ingrown toenails and fungal infections can go unnoticed because of loss of feeling. If not treated and left to progress ulcers can develop.
5. Hammertoes, bunions, and bony prominences. Any bony prominence that may lead to skin irritation, especially in shoe gear, can progress to skin breakdown.
6. Charcot’s foot. This is a complex foot deformity that develops as a result of loss of sensation and leads to the destruction of the soft tissue of the foot. Typically, patients do not notice the presence of a sore because of neuropathy. The sore goes unnoticed as the patient continues to walk on the bony prominence worsening the sore. Often bony remodeling and amputation are necessary.
Treatment Objectives
The ultimate goal of your Podiatric Physician is to prevent amputation and loss of function. There are many new surgical techniques available to save feet and legs, including
joint reconstruction and wound healing technologies. Getting regular foot checkups and seeking immediate help when you notice something can keep small problems from worsening. Your foot and ankle surgeon works together with other health care providers to prevent and treat complications from diabetes.
What You Can Do
Follow these guidelines and contact your foot and ankle surgeon if you notice any problems:
1. Inspect your feet daily. Look for any open sores, injuries, redness or swelling.
2. Changes in circulation. Pay attention to the color of your toes. Purplish discoloration in the toes may be a sign of decreased blood flow. Also, pain in the leg that occurs when walking or at rest can be a vascular blockage. Seek care immediately.
3. Nail trimming. If you have thick nails, hard nails, or reduced feeling in your feet, your toenails should be trimmed professionally.
4. No bathroom surgery. Never trim calluses or corns yourself and don”t use over-the-counter medicated pads.
5. Don”t go barefoot. Wear shoes, indoors and outdoors. Keep floors free of sharp objects. Make sure there are no needles, insulin syringes, or other sharp objects on the floor.
6. Have your sense of feeling tested. Your foot and ankle surgeon will perform various tests to see if you’ve lost any feeling.
What is Flatfoot?
Flatfoot is often a complex disorder that can occur in several planes (transverse, sagittal, frontal). It is characterized by a low arch which puts increased stress on the ligaments and tendons on the inside of the foot and ankle. There are several types of flatfoot of which flexible flatfoot is one.
Flexible Flatfoot
Flexible flatfoot is one of the most common types of flatfoot which typically begins in childhood or adolescence and continues into adulthood. The term “flexible” means that the foot is flat when standing and the arch is not visible. However, the arch returns when not standing.
The early stages of flexible flatfoot are associated with a good range of motion in the foot and ankle with little or no arthritic changes. As the deformity worsens, the soft tissues (tendons and ligaments) of the arch may stretch or tear and degeneration of joints occurs. Symptoms include weakness in the foot or leg, pain in the heel, arch, or ankle.
Treatment
Your Podiatric Foot and Ankle surgeon will examine your feet in both non-weight bearing and weight-bearing positions, including x-rays to determine a course of treatment.
Conservative treatment may include custom functional inserts designed to support the foot and bring the ground to your arch.
Flatfoot Surgery
A variety of surgical techniques are available to correct flexible flatfoot. The goal of the surgical techniques is to relieve the symptoms and improve foot function. These procedures include tendon transfers or tendon lengthening procedures, realignment of one or more bones, joint fusions, or insertion of implant devices.
Foot and Ankle Anatomy
The foot is made up of 26 bones, 19 are located in the toes (phalanges), 5 are the long bones of the foot (metatarsals). The midfoot has several small bones that form the medial and lateral arches. The rearfoot consists of the heel bone (calcaneus) and ankle joint bone (talus).
The ankle joint, or mortise, consists of the tibia and fibula. Each of these bones has corresponding ligaments that attach the foot to the ankle.
What is a Fracture?
A fracture is defined as a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.
Traumatic Fractures
Traumatic fractures are caused by a direct injury to a bone and are classified as either displaced or non-displaced. If a bone breaks but is in good anatomic alignment, often casting, and not surgery is the recommended treatment. However, 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:
Incorrect Myth: “if you can walk on it, it’s not broken.” Evaluation by the foot and ankle surgeon is always recommended.
Digital Fractures
Toe fractures can usually occur when the foot strikes a hard object, either dropping an object onto the foot or kicking an object. Non-displaced fractures of the toes do not typically require a cast and can be immobilized with the use of a surgical shoe, boot or buddy splinted to an adjacent toe.
Metatarsal Fractures
Similar to digital fractures, metatarsal fractures can be described as being displaced or non-displaced. If the fracture is displaced, the bone is broken in such a way that the fracture fragment is mal-aligned with respect to the remaining metatarsal. 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 swelling, redness, bruising, and pain (often pinpoint).
Stress Fracture
A stress fracture occurs because of too much stress across the outside lining of the bone (cortical surface). Typically, this occurs when a person walks or runs excessively. Characteristics include pain, tender with swelling without bruising which is painful with activity and goes away with rest. When a developing stress fracture is recognized early, the person should stop activities that aggravate the fracture. The fracture should be treated properly to prevent a through and through a break of the bone, prolonging the healing time. In more advanced and severe cases, crutches and a cast are necessary.
Treatment of Toe Fractures
Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the type of fracture but rarely requires surgery.
Treatment of Metatarsal Fractures
Metatarsal fractures may be caused by trauma or chronic fatigue leading to a stress fracture. Stress fractures often require immobilization and/or a bone stimulator to heal. Displaced traumatic fractures of the foot require surgical correction.
A ganglion is a gelatinous fluid-filled, out-pouching of the lining of a joint or tendon. Typically, ganglion cysts grow slowly and occur on the foot or ankle. Historically, ganglion cysts have been referred to as a bible cyst; referring to the practice of hitting the cyst with a book, or bible, to flatten the cyst. However, because the cyst is well encapsulated, the cyst usually reappears.
Causes
Often minor trauma or repetitive trauma can irritate the lining of a joint or tendon sheath and cause a ganglion cyst to develop.
Symptoms
Ganglions develop and grow with little or no symptoms. However, if located along a bony prominence pain can develop. Tingling or numbness can also occur if the ganglion cyst overlies the course of a nerve.
Diagnosis is often made by your Podiatric Foot and Ankle Surgeon during a physical examination. Several soft tissue masses present in a similar fashion but can be ruled out based on their defining characteristics. Other diagnostic tools include a needle biopsy or an MRI which are used to confirm a diagnosis.
Treatment
Non-surgical treatment, including needle aspiration and padding, may temporarily relieve symptoms. However, if the encapsulated cyst is not removed in its entirety the cyst will reform. Therefore, ganglion cysts are often difficult to treat without surgery.
Surgical treatment is designed to remove the cyst and a small amount of the surrounding tissue to decrease the likelihood that the cyst will return.
Gout, or a gouty attack, is caused by an increase in the amount of uric acid crystals in the body.
Symptoms
Redness, swelling, and intense pain characterize what most people experience during an acute gouty attack. Often the light touch of bedsheets can elicit pain. In the foot, pain and swelling usually occur in the great toe joint; which is the furthest joint (coolest) from the heart, or the body’s core heat.
Causes
Many foods contain high levels of purines of which uric acid is a byproduct. These foods would include red meat, shellfish, red wine, and alcoholic beverages as a group. Two other inherited causes for a gouty attack include (1) the body’s overproduction of uric acid crystals and (2) the body’s inability to excrete normal amounts of uric acid crystals. Medication, such as high blood pressure medication (water pills), can lead to a build-up of uric acid crystals.
In the past, gout has been referred to as “the rich man’s disease”. This is because during the middle ages only the wealthy people were able to afford to eat these ”rich” foods. Consuming foods and alcoholic beverages that may contain high levels of purines may contribute to an attack of gout.
Diagnosis
Your Podiatric Physician can usually make this diagnosis after a thorough history and physical. In certain cases, x-rays and blood tests are often ordered to confirm the increase in uric acid and to determine whether or not there is another cause of the inflammation.
Treatment
Treatment typically begins with prescription oral anti-inflammatory medication. This, together with a change in your diet, can reduce the symptoms of a gouty attack. However, a significant reduction in the amount of gout-producing foods including shellfish, red wine, red meat, etc. is necessary. Severe acute attacks may require oral steroids or a steroid injection to the affected joint to allow for immediate relief. If you experience repeated gout attacks your Podiatric Physician may refer you to your primary care physician for long-term uric acid management. In cases where high levels of uric acid crystals are allowed to build up within a joint (tophi), surgical removal may be indicated.
Definition
Haglund’s deformity is a bony enlargement on the back of the heel. Usually, the enlarged bone causes increased pressure on the soft tissue of the posterior heel leading to bursitis or an inflammation of a fluid-filled sac between the tendon and bone. Often described as a ‘pump bump’, the bursa sac becomes irritated when the bony enlargement rubs against the hard heel counter of ‘pump’ type shoes, men’s dress shoes, or ice skates. It most often develops in women but does present in men.
Symptoms
Symptoms include a prominent bump on the outside or inside of the heel at the attachment of the Achilles tendon to the heel bone. Other signs include pain, redness, and swelling (usually associated with an inflamed bursa sac).
Causes
Foot structure is the leading cause of asymptomatic Haglund’s deformity. A high arched foot causes increased pressure on the insertion of the Achilles tendon to the heel bone; squeezing of the bursa that lies between the tendon and the bone. Consistent irritation at this site can lead to an inflamed bursa and bony prominence.
Diagnosis
Your Podiatric Foot and Ankle Surgeon will examine the foot and ankle and evaluate the extent to which the Achilles tendon and bone are involved. Often, x-rays will be ordered to visualize the extent of the bony prominence. Sometimes bony in-growth may occur within the Achilles tendon (enthesis).
Treatment
Definition
Hallux Rigidus is an arthritic condition often leading to pain and stiffness within the big toe joint. This condition is recognized when there is decreased motion in the joint causing a gradual wearing away of the smooth surface (cartilage) of the joint.
Symptoms
The symptoms are gradually progressive and increase in severity with increased activity. Difficulty walking up and downstairs, running, or even walking can occur. Usually, it is more difficult to bend the big toe in an upward direction as the problem advances.
As the disorder progresses, the movement of the great toe will decrease and bony growth around the joint development.
Causes
There are different causes of Hallux Rigidus including trauma, biomechanics, and your foot structure. For instance, people with a flat 1 metatarsal head are more likely to experience jamming of the great toe joint as opposed to a 1 metatarsal head that is round in shape. Activity level also plays a role. The average person takes over 5000 steps per day. With each step, you take you to put up to two times your bodyweight upon your feet. The more motion across a predisposed joint, the more likely jamming and a wearing away of the joint’s cartilage will occur.
Diagnosis
Clinical diagnosis by your Podiatric Foot and Ankle Surgeon involves a detailed history and physical examination. Biomechanical evaluation of the great toe joint along with X-rays can diagnose the grade or severity of the condition. However, the longer the condition is present, the greater likelihood there is that there will be damage within the joint and the development of bone spurs or pieces of bone within the joint.
Treatment
Non-Surgical Treatment: These include a modification of shoes, oral anti-inflammatory medication, or custom inserts made by your foot and ankle surgeon to reduce the stress across the affected joint.
Surgical Treatment: The severity of the condition will determine the level of surgical intervention. If little joint damage is detected then the excess bone may need to be removed. More extensive joint damage may require a procedure to increase the amount of joint space or replacement of the entire joint (implant).
Your Podiatric Foot and Ankle Surgeon will review all aspects of your condition, including the procedure and post-operative period, in order to return you to a more normal lifestyle.
Heredity and biomechanics play an important role in the development of hammertoes.
During the gait cycle if an abnormal amount of force is misdirected, (the arch is too low or the foot being too unstable) the toes must over grip and increase their actions. Often times this leads to a muscular imbalance causing deformity to the toes.
If a hammertoe deformity progresses it can lead to irritation in shoe gear and to the development of a corn or bursa. A large development of keratinized skin of the outer layer (stratum corneum) builds up to prevent further irritation of the epidermis. Often, a small fluid-filled sac between the bone and the skin tries to cushion the bone, usually to no avail and with the development of further pain.
Hammertoe deformity can be congenital (such as in polydactyly and syndactyly) or developmental such as in adductor Varus deformity, flexor stabilization, or flexor substitution.
In congenital development, abnormal development of the bones, skin, or insertion of the tendon has occurred which produces an abnormal position of the toe.
In the developmental development of hammertoe deformity, muscular imbalance with progressive shortening of the flexor tendons (the deforming force) and the extensor tendons (the holding force). The result is an angular malposition of the toe causing rubbing in shoes with pain.
Conservative treatment for hammertoes includes deeper shoes and padding. Surgical treatment of a hammertoe deformity is addressed by lengthening the contracted tendon and joint capsule and by removing a piece of the joint (knuckle) to allow the toe to straighten. Pins are often used to stabilize the toe during the healing period.
Heel pain can encompass several different problems depending on the exact location and quality of the pain (ie. tendonitis, stress fracture). However, plantar fasciitis is the most common diagnosis associated with heel pain. The plantar fascia is a band of soft tissue that extends from the heel bone to the toes; the function of which is to provide support to the arch when ambulating.
Definition
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.
Symptoms
Common symptoms include pain on the bottom of the heel. Most often this pain occurs when getting out of bed in the morning or after sitting for a long period 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
The most common cause of plantar fasciitis is foot structure. People with high or low arch height can predispose the plantar fascia to increased stress. Shoe gear with little or noarch support combined with a job that requires several hours of walking can also impart additional stress on the fascia band.
Diagnosis
The pain associated with plantar fasciitis can usually be elicited and diagnosed by your Podiatric Foot and Ankle Surgeon during a routine clinic visit. Additionally, heel spurs are commonly identified but rarely cause discomfort. Other imaging modalities that might be utilized include magnetic resonance imaging (MRI) or x-rays.
Treatment
Your Podiatric Physician can offer you several conservative options to relieve plantar fasciitis. In fact, plantar fasciitis is successfully treated by conservative therapy 9/10 times. However, if non-surgical treatment does not reduce or relieve the discomfort surgery will be considered. Your foot and ankle surgeon will discuss the surgical options with you and determine which approach would be most beneficial for you.
Do I have an Ingrown Toenail?
Ingrown toenails occur when the skin of your toe grows over the nail, usually on the big toe. They can cause redness, swelling, and serious pain. If left untreated, the toe can become badly infected. If you suspect your toe has become infected, you should seek professional treatment.
What causes ingrown toenails?
Ill-fitting footwear can put pressure on the nail, pushing it into the skin. Any activity that can cause damage to nails, like running or kicking, increases your chance of getting an ingrown nail. Poor nail-trimming is another common culprit, if a nail is cut too short or too infrequently, it can become ingrown.
How do I fix an ingrown toenail?
Some ingrown nails resolve themselves within a few days. Keep your feet clean and dry, except to soak them in warm water a few times a day. Wear shoes that do not put pressure on your toe. If you are bothered by pain, try acetaminophen or ibuprofen.
If the issue does not resolve itself or you suspect it is infected, seek professional help. We treat ingrown toenails every day at Pinnacle Foot & Ankle Clinics. With help from our friendly podiatrists, you’ll be on your feet and pain-free in no time! Request an appointment at one of our three convenient Twin Cities locations here.
Lisfranc joint injuries are rare and often misdiagnosed. Typical signs and symptoms include pain, swelling, and the inability to bear weight. Clinically, these injuries vary from mild sprains to fracture-dislocations. On physical examination, swelling is found primarily over the midfoot region. Pain is elicited with palpation along the tarsometatarsal joints. Radiographs are necessary are often show a diastasis of the normal architecture and confirm the presence of dislocation or fracture. Patients with fractures and fracture dislocations should be referred for surgical management.
The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc (1790-1847), a field surgeon in Napoleon”s army. Lisfranc described an amputation performed through this joint because of gangrene that developed after an injury incurred when a soldier fell off a horse with his foot caught in the stirrup. The incidence of Lisfranc joint fracture-dislocations is less than 1 percent of all fractures.
Lisfranc joint complex injury can occur as a result of direct or indirect trauma. Direct trauma occurs when an external force strikes the foot. With indirect trauma, force is transmitted to the stationary foot so that the weight of the body becomes a deforming force by torque, rotation, or compression.
Lisfranc joint fracture-dislocations and sprains can be caused by a variety of high-energy forces including motor vehicle crashes, industrial accidents and falls from high places. Occasionally, these injuries result from a less stressful mechanism, such as a twisting fall. Since Lisfranc joint fracture-dislocations and sprains carry a high risk of chronic disability consulting your Podiatric Physicians is important to avoid long-term discomfort. Key characteristics that should not be ignored are foot injuries characterized by marked swelling, tarsometatarsal joint tenderness, and the inability to bear weight.
Early diagnosis of a Lisfranc joint injury is imperative for proper management and the prevention of a poor functional outcome.
Definition
Malignant Melanoma is a cancer of the skin and is defined as an out-of-control growth of the skin cells that produce the melanin. Normal skin cells, called melanocytes, contain melanin which provides color to our skin. The more melanin present in the skin, the darker the skin. Melanin provides protection against UV waves from the sun and their damaging effect. Melanoma is usually from overexposure to UV waves of the sun.
Literature suggests there are approximately 160,000 new cases of malignant melanoma are diagnosed each year and approximately 48,000 deaths are attributed to melanoma each year.
Classification
Malignant Melanoma’s severity is based on the depth of penetration into the epidermis and dermis. The depth of severity is defined by two classification systems:
1. Clark”s classification describes the depth of penetration one sees on a histological slide. The depths are classified from 1-5 depending on the level progressing from superficial epidermis (level 1) to deep dermis/subcutaneous tissue (level 5).
2. Breslow’s classification stages the tumor based on the measured depth of penetration of the growth from the epidermis into the dermis/subcutaneous tissue. The measurement is from level 1 (.75mm) to level 5 (Greater than 4mm).
The malignancy can spread via the bloodstream to other parts of the body and settle in the liver and lung.
Characteristics
Malignant melanoma presents as a dark or discolored lesion. Other characteristics included a raised surface, friability (easy to bleed), pain, or burning. In general, soft tissue masses, and melanoma, can be best described based on the ABCD”s:
A: Asymmetry, or unevenly shaped with one side larger than the other.
B: Boarders, irregular which present jagged and not smooth.
C: Color, changes from the normal skin color with usually a mix of color.
D: Diameter, a melanoma will enlarge over time whereas a “beauty mark” will remain the same size.
There are four types of Melignant Melanoma:
1. Superficial spreading melanoma (70% of diagnosed cases)
2. Nodular melanoma (15% of diagnosed cases)
3. Lentigo maligna melanoma (10% of diagnosed cases)
4. Acral lentiginous melanoma (5% of diagnosed cases)
Treatment
Biopsy of the skin lesion is the only definitive diagnosis for malignant melanoma. Once submitted to pathology an accurate diagnosis can be performed. Following the staging of the lesion, your Podiatric Physician can coordinate appropriate treatment.
Morton’s neuroma is a painful fibrotic enlargement of one of the common digital nerves. The majority of neuromas are benign but can be cancerous. The term “neuroma” actually means a “tumor of a nerve”. Initially described by a British physician, the problem most often occurs between the bases of the 3rd and 4th toes.
Causes
Irritation to the nerve proper occurs as it courses between the metatarsal heads. During normal foot movement, the nerve can become irritated by a ligament beneath the metatarsal heads. This irritation can lead to a build-up of scar tissue (fibrosis), or “perineural fibrosis,” around the small nerves. This scar tissue becomes enlarged and causes compression on the nerve, which results in decreased blood and oxygen to the affected nerve segment, resulting in pain.
Symptoms
Some people experience a feeling of walking on a ‘lump’ or ‘bump’ under the forefoot. People often associate this feeling with their sock being bunched-up in their shoe, which it is not. Also described is a feeling of sharp pain, numbness or tingling which can radiate into the toes.
Treatment
A thorough physical exam is necessary to properly diagnose and recommend a course of treatment. Several conditions can mimic the symptoms of a neuroma. These would include capsulitis, tendonitis, or arthritis. In a minority of conditions, an MRI may be necessary to further evaluate the foot.
Conservative treatment options include metatarsal pads to offload the forefoot and decrease pressure on the MPJ’s and anti-inflammatory medication. Steroid injections and alcohol sclerosing injections are designed to reduce inflammation and decrease nerve function respectively.
Surgical excision of a neuroma will be addressed by your Podiatric surgeon if conservative options have not proven effective.
Definition
Pediatric flatfoot occurs when there is a partial or total collapse of the arch of the foot.
Most children have some degree of flat feet at birth and most who present to a podiatrist do not need treatment. However, some conditions progress and do require intervention. There is also a difference between a ‘flexible’ and a ‘rigid’ flatfoot. Flexible flatfoot is noted when the arch seems to collapse while the child is standing and the arch is visible when not standing. The diagnosis of a rigid flatfoot is made when the arch is not present whether the child is standing or not.
Symptoms
Diagnosis
Your podiatrist will examine the child while standing and take x-rays to determine the severity of the condition.
Treatment
An asymptomatic or minimally symptomatic foot may not require treatment. Sometimes a custom orthotic may provide enough support to decrease symptoms and prevent the development of potential problems.
Surgical treatment is rarely indicated for a true flexible flatfoot. There are a variety of techniques to treat the painful pediatric flatfoot, depending on the foot type and degree of deformity.
Definition
There are two tendons that make up the peroneal tendons, brevis, and longus. By definition, a tendon is a band of tissue that connects muscle to bone. The peroneal brevis tendon attaches to the base of the 5 metatarsal and the peroneal longus travels under the foot and attaches to the 1 metatarsal. The peroneal tendons function to evert (outward movement) the foot.
Peroneal Tendon Injuries
Peroneal tendon injuries vary from minimally debilitating to severe pain. Three common injuries include:
1. Tendonitis: Defined as an inflammation of one or both tendons caused by repetitive use of the tendons. This would also include ankle sprains. Symptoms often include pain and swelling.
2. Tears: A tear within the tendon can occur as a result of direct trauma or chronic, the repetitive motion causing injury. Symptoms are usually more pronounced than tendonitis and can lead to ankle instability.
3. Tendonosis (degeneration): Degeneration of the tendon follows a long period of overuse. This is a change in the physical make-up of the tendon which leads to an overall structural weakening of the tendon.
4. Subluxation: Both peroneal tendons begin above the ankle and course down toward the lateral (outside) ankle joint bone (fibula). Subluxation occurs when one or both of the tendons move out of the natural groove in the fibula. Often symptoms include feeling a ‘popping’ or noticing the tendon move over the ankle joint bone.
Diagnosis
Your Podiatric Foot and Ankle Surgeon will evaluate for any weakness, pain, or instability around the ankle joint. Based on the severity of the injury a treatment plan will be recommended. This may or may not include an MRI to further access the pathology.
Treatment
Low-grade injuries such as tendonitis typically respond well to R.I.C.E. (Rice, Ice, Compression, Elevation). However, long-standing injuries or traumatic injuries may require physical therapy or surgical repair.
Definition
Puncture wounds occur when a foreign object, such as a nail, glass, or piece of wood, enters the skin and causes a hole. These types of wounds require immediate treatment because they often cut deep into the skin. Unlike superficial cuts or abrasions, puncture wounds can cause serious injury and infection.
In the feet, puncture wounds occur most often on the plantar (bottom) surface. They can occur when wearing or not wearing shoes. However, if wearing shoes or socks the material can get pushed into the foot by the foreign body. By their nature, all puncture wounds are dirty wounds because they involve penetration of an object that isn’t sterile.
Signs and Symptoms of Infection
If left untreated, puncture wounds can cause an infection. The initial signs of infection include redness and increased pain from the site. Sometimes a minor skin infection can spread into a more serious skin infection (cellulitis). More serious signs of infection include widespread redness, warmth, swelling, and drainage from the site. If the wound tracks, or spreads to deep tissues, the infection can spread to the bone.
Treatment
Puncture wounds are best treated within the first 24 to 48 hours after the injury by a Podiatric Foot and Ankle Surgeon. Inspection and cleaning of the wound along with prescribing the appropriate antibiotic are essential. Even if you have gone to an emergency room for immediate treatment you should follow up with a Podiatric Physician.
Definition
Rheumatoid arthritis (RA) is a disease caused by an autoimmune response. The body does not recognize certain cells and the immune system attack healthy joints. The onset of RA is typically between ages 20 to 50 and affects women more than men (3:1).
Symptoms
RA usually begins with achy or stiff joints. This is caused by inflammation of the lining (synovium) of joints of the hands and feet. Other signs of inflammation can include pain, swelling, and a feeling of warmth around affected joints. Prolonged joint inflammation can lead to joint damage, joint deformity, and destruction.
In the foot and ankle, RA usually presents in the ball of the foot (metatarsal-phalangeal joints). The joint synovium thickens and produces an excess of joint fluid which can damage the joint”s cartilage and bones. The long-standing disease can produce rheumatoid nodules or a collection of soft tissue around joints. In the foot, these nodules can cause pain with walking. Also, hammertoes (contracture) of the toes can occur.
Diagnosis
RA is diagnosed on the basis of a clinical examination and blood tests. The Podiatric Foot and Ankle Surgeon may order x-rays or an MRI to further access joint involvement.
Treatment
The medical management of RA is determined by the primary care doctor or rheumatologist. However, a Podiatric Physician can address the problems associated with the foot and ankle. This would include proper shoe gear and surgical intervention to reduce joint contractures.
Definition
A Tailor’s Bunion, or bunionette, is an enlargement of the bone on the outside of the foot (5 metatarsal). The bony prominence can cause increased pressure in shoes which results in pain, redness, and swelling. In addition, the joint can become irritated (capsulitis) or the soft tissue around the joint can become inflamed.
Historically, the tailor’s bunion gets its name from medieval times when tailors sat all day cross-legged with the outside portion of their feet resting on the ground. This repetitive position resulted in the irritation of the 5th metatarsal head causing local redness and pain.
Causes
The development of a Tailor’s bunion is the result of the structural development of the 5 metatarsal, which is a hereditary condition. There are three main causes of Tailor’s Bunions:
1. Enlarged 5 metatarsal head
2. Lateral (outside) bowing of the 5 metatarsal
3. Increase in the spacing between the 4 metatarsals and 5
Tight shoes or shoes that are too narrow in the toe box can cause excess pressure on the 5 metatarsal head and lead to irritation.
Treatment
Conservative treatment would include possible shoe modification, orthotics, padding, or anti-inflammatory medication. However, x-rays and a physical exam are necessary to determine the type of deformity.
Surgical treatment can address the prominence of the 5 metatarsal heads. The exact procedure and post-op course depend on the type and the severity of the Tailor’s bunion. In general, the surgical procedures recommended by your Podiatric Surgeon will be designed to reduce irritation and re-align the joint.
Definition
A tarsal coalition is a bridge between two or more bones of the midfoot and/or rearfoot. “Tarsal” refers to the bones in the midfoot and rearfoot; while the term “coalition” refers to the abnormal connection between bones.
The most commonly affected bone is the heel bone (calcaneus) and the abnormal connections it makes to the talus (talocalcaneal) and navicular (calcaneonavicular). Tarsal coalitions occur congenitally (present since birth) because of a failure of the bones to separate. Incidence is about 1% of all people and equally affects one foot or both feet.
Coalitions are categorized based on the type of tissue that bridges two or more bones.
1. Bony coalition- Synostosis
2. Fibrous coalition- Syndesmosis
3. Cartilaginous coalition- Synchondrosis
Symptoms
Although present since birth, the pain from a tarsal coalition may not arise until adolescence or later. Some individuals with tarsal coalition do not experience any pain.
The abnormal connection between two bones in a tarsal coalition prevents what would otherwise be normal movement between the two bones. As consequence, the hindfoot and/or midfoot usually are stiff and immobile in a foot affected by a tarsal coalition. As a person ages, the abnormal connection becomes bonier and stiffer, which is why the pain from a tarsal coalition usually arises in adolescence (when the bones of the foot complete their bone formation) or later. Because of the restricted movement between two bones affected by a tarsal coalition, the joints around the coalition are functionally impaired and can develop painful degenerative arthritis as the person ages. In some cases, an injury can disrupt and aggravate a previously non-painful tarsal coalition.
A person affected by a tarsal coalition is often flat-footed on the foot in which the tarsal coalition exists. Pain is usually present just below the ankle area and is made worse with weight-bearing activities. In some cases, the muscles on the outside of the leg will spasm.
Tarsal coalitions can often be diagnosed simply with an examination and standard radiographs (x-rays). However, special imaging techniques (CT scan or MRI) are also used to confirm the diagnosis and determine both, the extent of the coalition (abnormal connection) and whether the degenerative joint disease is present in the nearby joints.
Non-surgical treatment is directed at allowing the person affected by a tarsal coalition to live a pain-free life but does not correct existing malalignment of the foot. Surgery to remove the abnormal connection can be performed, but its success depends on a number of factors, including the person”s age, the extent of the abnormal connection, and whether there is degenerative arthritis in the nearby joints. When the predicted outcome of removal of the abnormal connection (resection of the coalition) is poor, then surgical fusion of the two involved bones is performed.
Foot and Ankle Anatomy
The foot is made up of 26 bones, 19 are located in the toes (phalanges), 5 are the long bones of the foot (metatarsals). The midfoot has several small bones that form the medial and lateral arches. The rearfoot consists of the heel bone (calcaneus) and ankle joint bone (talus).
The ankle joint, or mortise, consists of the tibia and fibula. Each of these bones has corresponding ligaments that attach the foot to the ankle.
What is a Fracture?
A fracture is defined as a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.
Traumatic Fractures
Traumatic fractures are caused by a direct injury to a bone and are classified as either displaced or non-displaced. If a bone breaks but is in good anatomic alignment, often casting, and not surgery is the recommended treatment. However, 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:
Incorrect Myth: “if you can walk on it, it’s not broken.” Evaluation by the foot and ankle surgeon is always recommended.
Stress Fractures
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:
Is it a Fracture, or a Sprain?
Sprains and fractures have similar symptoms, although sometimes with a sprain, the whole area hurts rather than just one point. Your foot and ankle 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:
Treatment of Toe Fractures
Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself.
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.
Definition
A wart is a small growth on the skin that develops when the skin is infected by a virus. Plantar warts are caused by direct contact with the human papillomavirus (HPV). This is the same virus that causes warts on other areas of the body and is acquired in public places where people go barefoot, such as locker rooms and swimming pools. It can also be acquired at home if other family members have the virus. Warts can develop anywhere on the foot but usually occur on the bottom (plantar) of the foot. Plantar warts most commonly occur in children, adolescents, and the elderly.
Common warts found on the feet include plantar warts, solitary warts, and mosaic warts.
What to look for:
Characteristics of warts include:
Treatment
Treatment options include topical acid (stronger than over-the-counter) and prescription medication.