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Forefoot, Midfoot and Hindfoot Conditions

Forefoot Conditions

Bunions

A bunion is a bony protuberance that appears on the external surface of the big toe when it angles toward the adjacent toe. It is an extra bone and a fluid-filled sac that grows at the base of the big toe.

Causes of bunions:

Bunions are common in women and tend to run in families (heredity). The major cause of bunions is prolonged wearing of ill-fitting shoes like tight, narrow, and high-heeled shoes which compress the toes and exerts excessive pressure while walking. The condition gets worsen and more painful as the bump grows bigger in size. Certain conditions such as rheumatoid arthritis and gout may also cause bunions.

Symptoms:

  • Swelling
  • Pain and tenderness around the big toe
  • Turning of big toe towards the adjacent toe
  • Change in the shape of the foot
  • A bony mass at the joint surface of the big toe
  • Pain and discomfort while walking
  • Restricted movements of big toe

Diagnosis:

Your orthopaedic surgeon diagnoses a bunion based on the following:

  • Medical history to rule out any diabetic conditions, hypertension, circulatory disorders
  • Physical examination to evaluate the nature of bunion
  • Foot or ankle X-rays to determine the bone and soft tissue damage

Treatment:

A bunion may be treated either by non-surgical or surgical methods.

The non-surgical treatment options include:

  • Medications to help alleviate pain and associated symptoms
  • Wear broad-toed and deep shoes that fit properly to reduce the compression of the toes
  • Use of bunion pads, cushions and splints to protect and alleviate painful foot bunions
  • Select properly fitted shoes that match the shape of your feet

Surgery:

The surgical method of removal or excision of a bunion is known as bunionectomy. The goal of bunion surgery is to relieve pain and restore the normal position and function of the big toe.

Some of the surgical complications include infection, blood clot formation, recurrence of the bunion, damage to nerves, bleeding, unrelieved pain and stiffness.

Prognosis:

Always try to take care of the bunion at the initial stage by wearing accommodative shoes. In very few cases, post-surgical complications may interrupt the healing of the bunion. If left untreated it may cause bursitis, gait abnormalities, arthritis and other serious health problems.

Prevention:

Avoid wearing poorly fitted shoes to prevent irritation and compression of the toes which may lead to the growth of a bunion.

Hammertoe

A hammertoe is a deformity of a lesser toe (second through fifth toes), where the toe gets bent upward at the toe’s middle joint, resembling a hammer. The bent portion may rub against a shoe causing pain, irritation and development of corns. It is caused by wearing shoes that are too tight or narrow near the toes, when the second toe is larger than the first, and as a complication of arthritis and certain neuromuscular conditions.

Early stages of hammertoe are flexible and may be treated by conservative measures such as strapping, padding and wearing appropriate footwear. In more severe cases and when conservative treatment does not help, surgical correction is indicated. Surgery may include a tendon transfer procedure, where a tendon is rearranged from the lower side of the toe to the top, to pull the bent joint down and straighten the toe.

Stiff or fixed hammertoes may be corrected by joint resection or joint fusion (permanent straightening of the toe), which involves cutting tendons and ligaments of the joint and removing part of the bone to help straighten the joint. The straightened toe is held by pins for 3-4 weeks following surgery.

There may be some swelling, redness, and stiffness following surgery. A special shoe may be provided to help with walking. As with any surgical procedure, hammertoe correction may be associated with a few risks including infection, bleeding, nerve injury or poor alignment of the toe.

Ingrown Toenails

Ingrown toenail is a very common and painful condition of the toe. It occurs when the sides or corner of the nail grow inwards and penetrates the skin of the toe. Pain is often accompanied by swelling and redness. It is often seen in adults rather than children and is more common in men than women.

The conservative measures to treat a mild ingrown toenail include soaking the foot regularly in warm water, antibiotics to treat infection, pain relievers, and wearing open-toed shoes or sandals.

Untreated it may lead to an infection or even an abscess that necessitates surgical treatment. Matricectomy is a technique of removal of all or part of the base nail portion (nail matrix) using chemical, electrical, or surgical method. Matricectomy is of two types-complete and lateral matricectomy.

Complete matricectomy is a technique where the entire nail matrix is removed and it results in permanent nail loss. Lateral matricectomy is surgical removal of a portion of the nail bed. This procedure is considered as a choice for treatment of chronic or recurrent ingrown toe nails.

Ingrown toenail surgery is the best option to prevent the condition from recurring. The surgery should be considered when other local treatments have failed. The infection or abscess is drained from the end of the toe and extra tissue grown around the nail is removed.  The ingrown toe nail is cut along the edge and is pulled out. A  liquid solution is applied to the exposed part of the nail bed to prevent the regrowth of the toe nail again into the skin. This procedure is called nail ablation.

The surgery may cause permanent nail deformity or may give a poor cosmetic appearance.

Instructions after surgery may include:

  • Every two days remove the old dressing. If the dressing is stuck to toe, soak foot with dressing on to soften. The toe willoften look a bit messy at this stage.
  • Add two tablespoons of salt to a bowl of warm but not hot water. Soak foot no longer than 5 minutes.
  • Dry toe and wipe wound with gauze, It is helpful to wipe away as much of the discharge as possible when cleaning.
  • Cover tow with a sterile adhesive dressing such as Mepore. In order to fit the dressing around the toe it can be helpful to make a diagonal cut in each corner.
  • Between redressings keep the dressing on and dry- should it come off or become wet or dirty simply redress.
  • Monitor the toe for signs of infection, the symptoms to look out for include: increased warmth, swelling, increase in exudate and increased pain.
  • If you notice signs of infection then contact your GP or practice nurse immediately.

Sesamoiditis

Sesamoiditis is an inflammation of the sesamoid bone and the associated tendons. It is commonly seen in ballet dancers, sprinters and basketball players. It is an overuse injury caused by an increased pressure over the sesamoid bones resulting in a chronic inflammation.

Sesamoids are a special type of bone that are found in the knee, wrist and behind the big toe. Unlike other bones of the body, these bones do not articulate with other bones but are present under the tendons or embedded in the muscles. They provide a smooth surface over which the tendon can glide, increasing their ability to transmit muscle force. The knee cap or patella is the largest sesamoid bone in the body. Two small sesamoid bones are found on the underside of the big toe.

Causes

Trauma or injury is the most common cause of sesamoiditis; an injury to the soft tissues around the big toe joint and the sesamoid bone can result in sesamoiditis. Any acute injury such as muscle pull, ligament sprain, fracture of the sesamoid or the surrounding bones and a dislocation of the neighbouring joints can result in sesamoiditis. Repetitive stress or chronic overuse can result in a stress fracture of the sesamoid bone which can be a cause of persistent pain. Sometimes a condition called osteonecrosis, caused by a lack of blood supply to the bone, can give rise to sesamoiditis. Frequent use of high heel shoes can aggravate the condition.

Symptoms

A dull, longstanding pain is the predominant symptom of sesamoiditis. Usually the pain is gradual in onset but in cases of fracture the onset of pain is sudden. Pain is aggravated by movement of the affected body part or any pressure over it. In some cases, swelling and bruising may be present.

Diagnosis

A thorough physical examination is essential for the diagnosis of sesamoiditis. Your physician will check for tenderness and aggravation of pain on movement. The examination helps evaluate the type and cause of the injury.  X-rays may be ordered to confirm the diagnosis. In case an X-ray is inconclusive your physician may order a MRI scan.

Treatment

Usually the treatment of sesamoiditis is non-surgical. In very rare cases, surgery is considered when the non-surgical approach fails to provide any benefit.

The non-surgical treatment options include

Immobilization: Take adequate rest and place the foot in a removable cast. Avoid activities which cause pain. Crutches may be used to avoid weight bearing on the affected bone.

Padding and strapping: A pad may be used to cushion the inflamed area. Strapping can be used to relieve the muscle tension around the inflammation.

Physical therapy: Some exercises such as range of motion exercises and strengthening exercises may be advised to improve the condition. Ultrasound therapy can also be helpful in relieving pain.

Orthotic devices: Some orthotic devices such as special shoes that cushion the injured area can relieve the pressure over the affected sesamoid.

Oral medications: Non-steroidal anti-inflammatory (NSAIDs) medications may be used for the reduction of pain and inflammation.

Steroid injection: Sometimes a steroid injection may be used to reduce the pain.

Prevention

A recurrence of the sesamoiditis can be prevented by following a few simple measures which include:

  • Use appropriate shoes with proper padding.
  • Follow physical therapy for improving gait and strength.
  • Avoid the use of high heel shoes and other activities associated with aggravation of pain. 

Hallux Valgus

Hallux Rigidus

Hallux rigidus is an arthritic condition characterized by stiffness and rigidity of the big toe. Arthritis of the foot commonly occurs at the big toe base. The condition can be quite painful as the big toe must bend with every step you take.

The condition may occur due to age related wear and tear or an injury sustained at the joint between the big toe and the foot (metatarsophalangeal joint).  This can lead to loss of the cartilage from the joint which provides a cushioning effect and allows smooth movement and flexibility of the big toe. The bones may rub against each other causing pain and the development of bone spurs that further restrict toe movement. Hence, the toe becomes stiff and walking is painful. Hallux rigidus usually occurs between 30 and 60 years of age. It may be more common with certain types of foot anatomy which place more stress on the big toe joint.

Pain is present at the base of the first toe especially when pushing off as you walk. It may be associated with swelling around the joint, a bony bump on the top portion of the foot as well as rigidity and inability to bend the toe.

If you find that your toe is painful and stiff causing you to bear weight on the outside of your foot, you might be suffering from hallux rigidus. It is recommended that you get it evaluated during the initial stages of the disease before any bone spurs develop.

Your doctor is highly qualified to examine, diagnose, and treat arthritic conditions of the foot such as hallux rigidus. He will discuss your symptoms in detail and perform a physical examination to accurately diagnose the extent and stage of your condition. X-rays will be ordered to look for any bone changes and loss of joint space that may have occurred.

Nonsurgical treatment in the form of pain-relieving medication and anti-inflammatories will be prescribed to reduce pain and swelling. Changing your shoe to one with a broader toe area and a stiff or rocker-bottom sole may help reduce pressure on the toe.

If these non-surgical treatment modalities do not provide relief, then Mr Shaikh will discuss your surgical options which may include:

  • Cheilectomy: Removal of bone spurs as well as a small portion of the bone from the foot to allow more toe movement. It is usually recommended in mild forms of the disease.
  • Arthrodesis: Fusing the toe to the foot. It is usually recommended if the cartilage is severely eroded and movement of the toe is very painful.
  • Arthroplasty: Replacement of the metatarsophalangeal joint with an artificial one. It is usually performed in older patients with few functional demands.

Metatarsalgia

This condition is discomfort in the forefoot due to overloading or inflammation in the lesser (2nd to 5th) metatarsophalangeal joints. It is commonly misdiagnosed as a neuroma. After clinical examination , xrays are performed to look at the bony anatomy. A cause for the metatarsalgia (for example, long metatarsals) is identified  and treated accordingly.

Initial management involves a insole with a bar/dome to off-load the joints. In addition physiotherapy helps. Surgical options include osteotomies to shorten and elevate the bones.

Midfoot Conditions

Lisfranc Fracture

Bone spurs

Bone spurs, also called osteophytes, are bony projections that develop along the edges of a bone or in the area where muscles, tendons, and ligaments are attached. Bone spurs are often found in joints and in the bones of the spine.

Causes

The main cause of bone spurs is from disease conditions such as osteoarthritis. Other factors which can exacerbate bone spurs include being overweight, poor posture, past injuries, and ill-fitting shoes.

Symptoms

Most bone spurs cause no signs or symptoms and are often undiagnosed until an x-ray reveals the growths. In some cases, bone spurs, can cause pain and loss of motion in the affected joints. Specific symptoms depend on where the bone spurs are located. Bone spurs in the spine can cause stenosis (narrowing of the spinal cord) resulting in neurological symptoms in the patient due to pressure on the nerves. Bone spurs that press against tendons or ligament can cause a tear to occur.

Diagnosis

Diagnosis starts with a physical examination of the affected area and x-rays shows the actual condition responsible for producing the symptoms. If required other imaging techniques such as CT scan or MRI scan may be ordered by the doctor if there are complications to surrounding structures affected by the bone spur.

Treatment

The conservative treatment for bone spurs includes pain medications, rest and orthotics. Depending on the location and the severity of the pain and inflammation, steroids injection may be recommended.

In severe cases, surgical removal of the bone spur may be recommended as an option.

Arthritis

Hindfoot Conditions

Plantar Fasciitis

The plantar fascia is a long, thin ligament present along the bottom of the foot that creates the arch of the foot. It extends from the heel bone, and then splits and fans out to attach itself to the toes.

Plantar fasciitis is a condition where the plantar fascia becomes inflamed from overstretching or overuse, causing pain in the heel and bottom of the foot. It can occur in one or both feet due to excessive standing and is one of the most common orthopaedic complaints, especially in active men between 40 and 70 years of age.

Causes

Plantar fasciitis occurs when you strain or irritate the plantar fascia ligament. Repeated strain can result in tiny tears in the ligament, leading to pain and swelling, which can make walking difficult.

Strains can occur due to:

  • High or low foot arch
  • Obesity or sudden weight gain
  • Tight Achilles tendon which connects the calf muscles to the heel
  • Starting a new activity or increasing the intensity of an activity
  • Wearing improper shoes with soles that are too soft, do not fit well or offer poor arch support

Symptoms

The major complaint of plantar fasciitis is pain and stiffness in the heel and foot. The pain associated with this condition becomes more intense:

  • In the morning when you step out of bed
  • Walking after sitting or standing for some time
  • Climbing stairs
  • After exercise

Diagnosis

Your doctor diagnoses plantar fasciitis after reviewing your medical history and conducting a physical examination of the foot to check for tenderness, stiffness or redness of the sole. Your doctor may watch how you stand and walk, and evaluate related conditions such as high arches.

X-rays of the foot can be taken if your doctor suspects a stress fracture, a hairline fracture in the bone, or other related conditions such as a heel spur, which is extra calcium deposit on the heel bone.

Treatment

Treatment involves conservative measures to resolve the condition. Conservative treatment measures include:

  • Rest: Rest is the first step that is considered for reducing pain and preventing further damage to the ligament. Weight reduction helps reduce stress on the fascia and is highly recommended.
  • Ice: Rolling your foot over ice can be very effective in reducing swelling, and is recommended for 20 minutes, 3-4 times a day
  • Medications: NSAIDs (non-steroidal anti-inflammatory drugs) may be prescribed for relief of pain and inflammation
  • Exercise: calf stretches and plantar fascia stretches are effective in relieving pain
  • A steroid injection may be administered into the plantar fascia for reducing pain and inflammation
  • Supportive shoes and orthotics may also be recommended to reduce the pain while walking or standing
  • Night splints can be suggested by your doctor to help stretch the plantar fascia while sleeping
  • Physical therapy may be recommended for instruction on stretching exercises, massage and ice treatments
  • PT may use extracorporeal shockwave therapy (ESWT), which uses high-energy shockwave impulses to stimulate healing of the damaged plantar fascia tissues
  • Protein Rich Plasma injections can be considered to help healing.

Surgery

Surgical treatment is considered only if conservative therapy does not provide effective relief after 12 months.  There are two surgeries your surgeon may perform and will depend on your situation.

  • Gastrocnemius recession- Tight calf muscles or gastrocnemius muscles can strain the plantar fascia. To release this stress, your surgeon will surgically lengthen the calf muscle, and increase the motion of the ankle. The surgery can be performed by open incision or endoscopically through a small incision by using an endoscope, which is a long instrument with a small camera attached.
  • Plantar fascia release- If you have normal range of ankle motion, but continue to have heel pain, a partial release procedure is recommended. Your surgeon will partially cut the plantar fascia ligament to relieve the tension. The surgery can be performed endoscopically but open incision is easier to perform and is associated with lower risk of nerve damage.

Risks and Complications

Complications are rare following surgery to treat plantar fasciitis, but as with any surgical procedure, they can occur.  Some complications include:

  • Infection
  • Nerve Damage
  • Unresolved Pain

Achilles Tendonitis

The Achilles tendon is one of the longer tendons in the human body which stretches from the heel bone to the calf muscles. It appears as a band of tissue at the back of the ankle and above the heel. It is used when you walk, run or jump. It is the largest tendon in the body and can withstand great stresses; however, overuse or degeneration can occur resulting in inflammation called tendonitis or tendinosis.tendinitis.

Achilles tendonitis also called Achilles tendinitis may be caused by a sudden increase in activity which overstrains the tendon, tight calf muscles, and bony overgrowths. It is characterized by pain, irritation, swelling or thickening. Pain or stiffness is usually worse in the morning or after activity.

Tendonitis may affect the part of the tendon inserted in the heel bone (insertional tendonitis) or the middle portion of the tendon (non-insertional tendonitis). Damaged tendon fibres may calcify or harden. Bony overgrowths may form because of tendonitis and irritate the tendon further. Non-insertional tendonitis is more common in young active people while insertional tendonitis may occur in any age group.

Your doctor will review your symptoms and examine your foot and ankle looking for pain, tenderness, swelling, bony overgrowths and loss of range of motion. Imaging studies such as an X-ray, ultra-sound or MRI are ordered to identify the calcified or damaged areas of tendon and to plan treatment.if necessary to plan surgery.

Achilles tendonitis is first treated conservatively by resting the ankle, applying ice, administering pain and anti-inflammatory medication and strengthening and stretching the calf muscles. Steroid injections may be recommended to reduce inflammation. Special shoes or shoe inserts may help reduce strain and irritation. Shockwave therapy and protein rich plasma injections are also helpful. Pain usually takes a few months to subside. If pain persists longer than 6 months and there is minimal improvement, surgery may be necessary. Surgery depends on the type of tendonitis and the amount of tendon damage and may involve lengthening of the calf muscle, removing damaged portions of tendon or bony overgrowths, and reinforcing the remaining tendon with sutures, bone anchors or nearby tendons.

Heel Pain

The heel is a cushion of fat tissue at the back part of the human foot that protects the structure of muscles, ligaments and the heel bone (calcaneous). Heel pain is a common foot condition, seen in one out of 10 people with at least one episode in their life time. It is essential to make a correct diagnosis of the cause of heel pain to direct a person for appropriate treatment.

Causes

Heel pain is often due to tenderness in the heel and can be caused by obesity, abnormal walking style, standing or walking or running on hard surfaces and wearing ill-fitting shoes. Heel pain is rarely caused by injury. The conditions that are related to heel pain are –

  • Plantar fasciitis, inflammation of the ligament that connects the heal bone to the toes
  • Bursitis, swelling of a bursa at the back of the heel
  • Achilles tendinitis, swelling of the Achilles tendon that connects calf muscle and heel
  • Bone spurs in heel
  • Calcaneus fracture, fracture of heel bone
  • Haglund’s deformity, bone enlargement at the back of heel
  • Tarsal Tunnel Syndrome, nerve enlargement at the back of the foot
  • Arthritis, swelling of joints

Symptoms

The common symptoms are chronic heel pain mostly during walking, jogging and running. Sharp and stabbing pain when you first stand up early in the morning and stand after sitting for long hours may also occur.

Diagnosis

The cause of the heel pain is diagnosed by studying your medical history. The doctor will examine your heel by observing and feeling for signs of swelling and tenderness. The doctor might perform a diagnostic X-ray if necessary.

Treatment

Treatment of heel pain completely relies on the causes. The conventional treatments are

  • Rest from activities that causes stress on the heel
  • Applying ice packs to help pain and inflammation
  • Regular exercise and foot massage
  • Wearing proper shoes, heel cups, professional heel straps and night splints

Other treatments include –

  • Ultrasound therapy/Shockwave therapy
  • Anti-inflammatory drugs (topical or oral)
  • Analgesics
  • Surgery may be recommended in cases of heel spurs, bursitis and fracture of heel bone.

Prevention

Following are the few steps to avoid heel pain –

  • Wearing proper fitting shoes
  • Reduce weight if you are obese
  • Using shoe inserts

  • British Orthopaedic Foot & Ankle Society
  • Royal College Of Surgeon
  • BMI Healthcare
  • London Musculoskeletal Centre
  • Hillingdon Hospital
  • Princess Grace Hospital