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. TendoAchilles 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 Plantar fascia Calcaneus Bursa Physis (growth plate) Achilles tendon 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.​

 

Conditions

Bunion

What Is a Bunion?

Bunions are often described as a bump on the side of the big toe but more than just being a bump is is actually a misalignment of the bone structure of the forefoot. Bunions are a common foot deformity and there are many misconceptions about them. People often suffer with painful bunions for years before seeking treatment. The misalignment of the foot bones involves the big toe leaning toward the second toe, as opposed to pointing straight ahead. Bunions are a progressive disorder.They begin with a mild angulation of the big toe but often progress into a severe misalignment and subsequently pain and arthritis may insue. People may or may not have symptoms secondary to a bunion deformity, but usually the severity of deformity correlates with pain symptoms.

 

What Causes a Bunion?

Bunions are mainly an inherited malalignment of the bones in the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion. Wearing tight fitting shoes don’t actually cause bunions, but this sometimes makes the deformity worse. 

 

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

  • Numbness
     

Other conditions which may appear with bunions include hammertoes, 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.

  • Activity modifications. Avoid activity that causes bunion pain, including standing for long periods of time.

  • Medications. Nonsteroidal anti-inflammatory 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 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 likely time to discuss surgical options with your foot and ankle 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 foot and ankle 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.

Hammertoes

 

What Is a Hammertoe?

A 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 and can cause pain symptoms 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 but essentially the same as a corn just a different location) 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. After pain symptoms start, hammertoes usually never get better without some kind of intervention.

 

What Causes Hammertoes?

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, tight-fitting shoes can actually cause the contracture that defines a 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, hammertoes are 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.

  • Changes in shoegear. 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.

  • Splinting/strapping. Splints or small straps may be applied by the podiatric surgeon to realign the bent toe.

 

When Is Surgery Needed?

In many cases 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 number of toes involved, your activity level, your age, and the severity of the hammertoe. The two most common surgical procedures performed to correct hammertoes are a flexor tenotomy or a proximal interphangeal joint arthrodesis. Hammertoes that are flexible may be treated with a flexor tenotomy which is a minimally invasive procedure which involves releasing the bottom tendons in the toe in order to straighten the toe and correct the hammertoe.  Rigid hammertoes are usually treated with a procedure called a proximal interphangeal joint arthrodesis.  This procedure involves 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.

Heel Pain

 

Heel pain is most often caused by plantar fasciitis.  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 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 standing after a period of rest

  •  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 patients continue to have heel pain after an extended treatment period, surgery will often be considered. Your 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.

Morton’s Neuroma

 

What Is a Neuroma?

A neuroma 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 is 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.

  •  Often 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 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 foot and ankle 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. Lateral plantar nerve Medial plantar nerve Neuroma Common digital nerves 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 shoegear. 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, the surgical approach involves removing the neuroma. Regardless of whether you’ve undergone surgical or nonsurgical treatment, your foot and ankle 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.

Ingrown Toenail

 

What Is an Ingrown Toenail?

When a toenail is ingrown, the nail is curved downward and grows into the skin, usually at the nail borders (the sides of the nail). This “digging in” of the nail irritates the skin, often creating pain, redness, swelling, and warmth in the toe. If an ingrown nail causes a break in the skin, bacteria may enter and cause an infection in the area, which is often marked by drainage and a foul odor. However, even if your toe isn’t painful, red, swollen, or warm, a nail that curves downward into the skin can progress to an infection.

 

What Causes an Ingrown Toenail?

Ingrown toenails can develop for various reasons. In many people, the tendency to have this common disorder is inherited. In other cases, an ingrown toenail is the result of trauma, such as stubbing your toe, having an object fall on your toe, or engaging in activities that involve repeated pressure on the toes, such as kicking or running.  Another cause of ingrown toenails is wearing shoes that are tight or short. Certain nail conditions are often associated with ingrown toenails. For example, if you have had a toenail fungal infection or if you have lost a nail through trauma, you are at greater risk for developing an ingrown toenail.

 

Treatment

Sometimes initial treatment for ingrown toenails can be safely performed at home. However, home treatment is strongly discouraged if you suspect you have an infection, or if you have a medical condition that puts your feet at high risk—for example, diabetes, nerve damage in the foot, or poor circulation. Home care: If you don’t have an infection or any of the above conditions, you can soak your foot in room-temperature water (add Epsom’s salt if you wish), and gently massage the side of the nail fold to help reduce the inflammation. Avoid attempting “bathroom surgery.” Repeated cutting of the nail can cause the condition to worsen over time. If your symptoms fail to improve, it’s time to see a foot and ankle surgeon.

 

Physician care:

The foot and ankle surgeon will examine your toe and select the treatment best suited for you. Treatment may include:

  •  Oral antibiotics. If an infection is present, an oral antibiotic may be prescribed.

  •  Surgery. A simple procedure, often performed in the office, is commonly needed to ease the pain and remove the offending nail. Surgery may involve numbing the toe and removing a corner of the nail, a larger portion of the nail, or the entire nail.

  •  Permanent removal. Various techniques may be used to destroy or remove the nail root. This treatment prevents the recurrence of an ingrown toenail. Your surgeon will determine the most appropriate procedure for you. Normal nail Ingrown nail Following nail surgery, a light bandage will be applied. Most people experience very little pain after surgery and may resume normal activity the next day. If your surgeon has prescribed an oral antibiotic, be sure to take all the medication, even if your symptoms have improved. Preventing Ingrown Toenails Many cases of ingrown toenails may be prevented by following these two important tips:

  •  Trim your nails properly. Cut your toenails in a fairly straight line, and don’t cut them too short. You should be able to get your fingernail under the sides and end of the nail.

  •  Avoid poorly-fitting shoes. Don’t wear shoes that are short or tight in the toe box. Also avoid shoes that are loose, because they too cause pressure on the toes, especially when you run or walk briskly.

Tailors Bunions

 

What Is a Tailor’s Bunion?

Tailor’s bunion, also called a bunionette, is an enlargement of the fifth metatarsal bone at the base of the little toe. The metatarsals are the five long bones of the foot. The enlargement that characterizes a tailor’s bunion occurs at the metatarsal “head,” located at the far end of the bone where it meets the toe. Tailor’s bunions are not as common as bunions, which occur on the inside of the foot, but both are similar in symptoms and causes. The symptoms of tailor’s bunions include redness, swelling, and pain at the site of the enlargement. These symptoms occur when wearing shoes that rub against the enlargement, irritating the soft tissues underneath the skin and producing inflammation.

 

Why do we call it “Tailor’s bunion”?

The deformity received its name centuries ago, when tailors sat crosslegged all day with the outside edge of their feet rubbing on the ground. This constant rubbing led to a painful bump at the base of the little toe.

 

Causes of a Tailor’s Bunion

Often a tailor’s bunion is caused by an inherited faulty mechanical structure of the foot. In these cases, changes occur in the foot’s bony framework that result in the development of an enlargement. The fifth metatarsal bone starts to protrude outward, while the little toe moves inward. This shift creates a bump on the outside of the foot that becomes irritated whenever a shoe presses against it. Sometimes a tailor’s bunion is actually a bony spur (an outgrowth of bone) on the side of the fifth metatarsal head. Heredity is the main reason that these spurs develop. Regardless of the cause, the symptoms of a tailor’s bunion are usually aggravated by wearing shoes that are too narrow in the toe, producing constant rubbing and pressure. In fact, wearing shoes with a tight toe box can make the deformity get progressively worse.

Diagnosis

Tailor’s bunion is easily diagnosed because the protrusion is visually apparent. X-rays may be ordered to help the foot and ankle surgeon determine the cause and extent of the deformity.

 

Treatment: Non-surgical Options

Treatment for tailor’s bunion typically begins with non-surgical therapies. Your foot and ankle surgeon may select one or more of the following options:

  • Shoe modifications. Wearing the right kind of shoes is critical. Choose shoes that have a wide toe box, and avoid those with pointed toes or high heels.

  • Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help relieve the pain and inflammation.

  • Injection therapy. Injections of corticosteroid are commonly used to treat the inflamed tissue around the joint. Tailor’s bunion (bunionette) Tailor’s bunion (bunionette)

  • Padding. Bunionette pads placed over the area may help reduce pain. These pads are available from your foot and ankle surgeon or at a drug store.

  • Icing. An ice pack may be applied to reduce pain and inflammation. Wrap the pack in a thin towel rather than placing ice directly on your skin.

 

When Is Surgery Needed?

Surgery is often considered when pain continues despite the above approaches. Surgery is highly successful in the treatment of tailor’s bunions. In selecting the procedure or combination of procedures for your particular case, the foot and ankle 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.

Tarsal Tunnel

 

What Is the Tarsal Tunnel?

The tarsal tunnel is a narrow space that lies on the inside of the ankle next to the ankle bones. The tunnel is covered with a thick ligament (the flexor retinaculum) that protects and maintains the structures contained within the tunnel—arteries, veins, tendons, and nerves. One of these structures is the posterior tibial nerve, which is the focus of tarsal tunnel syndrome.
 

What Is Tarsal Tunnel Syndrome?

Tarsal tunnel syndrome is a compression, or squeezing, on the posterior tibial nerve that produces symptoms anywhere along the path of the nerve. The posterior tibial nerve runs along the inside of the ankle into the foot. Tarsal tunnel syndrome is similar to carpal tunnel syndrome, which occurs in the wrist. Both disorders arise from the compression of a nerve in a confined space. Although tarsal tunnel syndrome may not be as well known as carpal tunnel syndrome, it is nevertheless a cause of foot and ankle pain in adults.

 

Symptoms

Patients with tarsal tunnel syndrome experience one or more of the following symptoms:

  • Tingling, burning, or a sensation similar to an electrical shock

  • Numbness

  • Pain, including shooting pain

 

The symptoms are typically felt on the inside of the ankle and/or on the bottom of the foot. In some people, a symptom may be isolated and occur in just one spot. In others, it may extend to the heel, arch, toes, and even the calf. Sometimes the symptoms of the syndrome appear suddenly. Often they are brought on or aggravated by overuse of the foot—such as in prolonged standing, walking, exercising, or beginning a new exercise program. It is very important to seek early treatment if any of the symptoms of tarsal tunnel syndrome occur. If left untreated, the condition progresses and may result in permanent nerve damage. In addition, because the symptoms of tarsal tunnel syndrome can be confused with other conditions, proper evaluation is essential so that a correct diagnosis can be made. Causes Tarsal tunnel syndrome is caused by anything that produces compression on the posterior tibial nerve, such as:

  • A person with flat feet is at risk for developing tarsal tunnel syndrome, because the outward tilting of the heel that occurs with “fallen” arches can produce strain and compression on the nerve.

  •  An enlarged or abnormal structure that occupies space within the tunnel can compress the nerve. Some examples include a varicose vein, ganglion cyst, swollen tendon, and arthritic bone spur.

  •  An injury, such as an ankle sprain, may produce inflammation and swelling in or near the tunnel, resulting in compression of the nerve.

  •  A person who is overweight may be prone to experiencing pressure on the posterior tibial nerve.

  •  Systemic diseases such as diabetes or arthritis can cause swelling, thus compressing the nerve.

 

Diagnosis

The foot and ankle surgeon will examine the foot to arrive at a diagnosis and determine if there is any loss of feeling. During this examination, the Posterior tibial nerve Flexor retinaculum Ankle cross section Posterior tibial nerve Flexor retinaculum surgeon will position the foot and tap on the nerve to see if the symptoms can be reproduced. He or she will also press on the area to help determine if a small mass is present. Sometimes an MRI is ordered, usually if a mass is suspected or in cases where initial treatment does not reduce the symptoms. In addition, special studies used to evaluate nerve problems—electromyography and nerve conduction velocity (EMG/NCV)—may be ordered if the condition shows no improvement with non-surgical treatment.

 

Treatment

A variety of treatment options, often used in combination, are available to treat tarsal tunnel syndrome. These include:

  • Rest. Staying off the foot prevents further injury and encourages healing.

  • Ice. To reduce swelling in the tarsal tunnel, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.

  • Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.

  • Immobilization. Restricting movement of the foot by wearing a cast is sometimes necessary to enable the nerve and surrounding tissue to heal.

  • Physical therapy. Ultrasound therapy, exercises, and other forms of physical therapy may be prescribed to reduce symptoms. • Injection therapy. Injections of a local anesthetic provide pain relief, and an injected corticosteroid may be useful in treating the inflammation.

  • Orthotic devices. Custom shoe inserts may be prescribed to help maintain the arch and limit excessive motion that can cause compression on the nerve.

  • Shoes. Supportive shoes, as recommended by your foot and ankle surgeon, may prove helpful.

  • Bracing. Patients with flatfoot or those with severe symptoms and nerve damage may be fitted with a brace to reduce the amount of pressure on the foot.

  • Surgery. Sometimes surgery is the best option for treating tarsal tunnel syndrome. The foot and ankle surgeon will determine if surgery is necessary and will select the appropriate procedure or procedures based on the cause of the condition

Puncture Wound

 

What Is a Puncture Wound?

Puncture wounds and cuts are not the same. A puncture wound has a small entry hole caused by a pointed object — for example, a nail that you step on. In contrast, a cut is an open wound that doesn’t produce a “hole” but rather a long tear in the skin. Puncture wounds require different treatment from cuts because these small holes in the skin can disguise serious injury. Puncture wounds are common in the foot, especially in warm weather when people go barefoot. But even though they occur frequently, puncture wounds of the foot are among the most inadequately treated conditions. That’s a big concern, because if not properly treated, infection or other complications can develop. Getting proper treatment within the first 24 hours is especially important with puncture wounds because they carry the danger of embedding the piercing object (“foreign body”) under the skin. Research shows that complications of puncture wounds could be prevented if the patient seeks professional treatment right away.

 

Foreign Bodies in Puncture Wounds

A variety of foreign bodies can become embedded in a puncture wound. Nails, glass, toothpicks, sewing needles, insulin needles, and seashells are some common offenders. In addition, pieces of your own skin, sock, and shoe can be forced into the wound during a puncture, as well as dirt and debris from the object. By their nature, all puncture wounds are dirty wounds because they involve penetration of an object that isn’t sterile. Regardless of what the foreign body is, anything that remains in the wound increases your chances of developing other problems, either in the near future or down the road.

 

Severity of Wounds

There are different ways of determining the severity of a puncture wound. Depth of the wound is one way to evaluate how severe the wound is. The deeper the puncture, the greater the likelihood that complications, such as infection, will develop. Many patients cannot judge how far their puncture extends into the foot. Therefore, if you’ve stepped on something and the skin was penetrated, seek treatment as soon as possible. The type and the “cleanliness” of the penetrating object also determine the severity of the wound. Larger or longer objects can penetrate deeper into the tissues, possibly causing more damage. The dirtier an object, such as a rusty nail as opposed to a sewing needle, the more dirt and debris are dragged into the wound, which may increase the chance of infection. Another thing that can determine wound severity is whether you were wearing socks and shoes or were barefoot. Particles of socks and shoes can get trapped in a puncture wound.
 

Treatment of Puncture Wounds

The key to proper treatment is this: A puncture wound must be cleaned properly and monitored throughout the healing process to avoid complications. Even if you have gone to an emergency room for immediate treatment of your puncture wound, see a foot and ankle surgeon for a thorough cleaning and careful follow-up. The sooner you do this, the better — within 24 hours after injury, if possible. The foot and ankle surgeon is trained to properly care for these injuries and will make sure your wound is properly cleaned and no foreign body remains. He or she may numb the area, thoroughly clean inside and outside the wound, and monitor your progress. In some cases, x-rays may be ordered to determine whether something remains in the wound or if bone damage has occurred.

 

To treat or prevent infection, antibiotics may be prescribed. Once you return home, be sure to carefully follow the foot and ankle surgeon’s instructions to prevent complications (see “Puncture Wounds: What You Should Do”).

 

Avoiding Complications

Infection is a common complication of puncture wounds that can lead to serious consequences. Sometimes a minor skin infection evolves into a bone or joint infection, so you should be aware of signs to look for. A minor skin infection may develop in 2 to 5 days after injury. The signs of a minor infection that show up around the wound include soreness, redness, and possibly drainage, swelling, and warmth. You may also develop a fever. If these signs have not improved, or if they reappear in 10 to 14 days, a serious infection in the joint or bone may have developed. Other complications that may arise from inadequate treatment of puncture wounds include painful scarring in the area of the wound or a hard cyst where the foreign body has remained in the wound. Although the complications of puncture wounds can be quite serious, early proper treatment can play a crucial role in preventing them.

PTTD

 

What Is PTTD?

Posterior tibial tendon dysfunction (PTTD) is an inflammation and/or overstretching of the posterior tibial tendon in the foot. An important function of the posterior tibial tendon is to help support the arch. But in PTTD, the tendon’s ability to perform that job is impaired, often resulting in a flattening of the foot. The posterior tibial tendon is a fibrous cord that extends from a muscle in the leg. It descends the leg and runs along the inside of the ankle, down the side of the foot, and into the arch. This tendon serves as one of the major supporting structures of the foot and helps the foot to function while walking. PTTD is often called “adultacquired flatfoot” because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse — especially if it isn’t treated early.

 

Symptoms of PTTD

The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change. For example:

  • When PTTD initially develops, typically there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen.

  • Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward.

  • As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle.The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle.

 

What Causes PTTD?

Overuse of the posterior tibial tendon is frequently the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs. Treatment: Non-surgical Approaches Because of the progressive nature of PTTD, it’s best to see your foot and ankle surgeon as soon as possible. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be arrested. In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities. In many cases of PTTD, treatment can begin with non-surgical approaches that may include:

  •  Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle stirrup brace or a custom orthotic device that fits into the shoe.

  •  Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weightbearing for a while. Posterior tibial tendon

  •  Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.

  •  Medications. Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.

  •  Shoe modifications. Your foot and ankle surgeon may advise you on changes to make with your shoes and may provide special inserts designed to improve arch support.

 

When Is Surgery Needed?

In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Surgical treatment may include repairing the tendon, realigning the bones of the foot, or both. Your foot and ankle surgeon will determine the best approach for your specific case.

Peroneal Tendons

 

What Are the Peroneal Tendons?

A tendon is a band of tissue that connects a muscle to a bone. In the foot, there are two peroneal tendons. They run side-by-side behind the outer ankle bone. One peroneal tendon attaches to the outer part of the midfoot, while the other tendon runs under the foot and attaches near the inside of the arch. The main function of the peroneal tendons is to stabilize the foot and ankle and protect them from sprains.

 

Types of Peroneal Tendon Injuries

Peroneal tendon injuries may be acute (occurring suddenly) or chronic (developing over a period of time). They most commonly occur in individuals who participate in sports that involve repetitive ankle motion. In addition, people with higher arches are at risk for developing peroneal tendon injuries. Basic types of peroneal tendon injuries are tendonitis, tears, and subluxation. Tendonitis is an inflammation of one or both tendons. The inflammation is caused by activities involving repetitive use of the tendon, overuse of the tendon, or trauma (such as an ankle sprain). Symptoms of tendonitis include:

  • Pain

  • Swelling

  • Warmth to the touch Acute tears are caused by repetitive activity or trauma.
     

Immediate symptoms of acute tears include:

  • Pain

  • Swelling

  • Weakness or instability of the foot and ankle
     

As time goes on, these tears may lead to a change in the shape of the foot, in which the arch may become higher. Degenerative tears (tendonosis) are usually due to overuse and occur over long periods of time—often years. In degenerative tears, the tendon is like taffy that has been overstretched until it becomes thin and eventually frays. Having high arches also puts you at risk for developing a degenerative tear. The signs and symptoms of degenerative tears may include:

  • Sporadic pain (occurring from time to time) on the outside of the ankle

  • Weakness or instability in the ankle

  • An increase in the height of the arch

  • Subluxation – one or both tendons have slipped out of their normal position.
     

In some cases, subluxation is due to a condition in which a person is born with a variation in the shape of the bone or muscle. In other cases, subluxation occurs following trauma, such as an ankle sprain. Damage or injury to the tissues that stabilize the tendons (retinaculum) can lead to chronic tendon subluxation. The symptoms of subluxation may include:

  • A snapping feeling of the tendon around the ankle bone

  • Sporadic pain behind the outside ankle bone

  • Ankle instability or weakness
     

Early treatment of a subluxation is critical, since a tendon that continues to sublux (move out of position) is more likely to tear or rupture. Therefore, if you feel the characteristic snapping, see a foot and ankle surgeon immediately.

 

Peroneal Tendons Diagnosis

Because peroneal tendon injuries are sometimes misdiagnosed and may worsen without proper treatment, prompt evaluation by a foot and ankle surgeon is advised. To diagnose a peroneal tendon injury, the surgeon will examine the foot and look for pain, instability, swelling, warmth, and weakness on the outer side of the ankle. In addition, imaging studies such as an MRI or ultrasound may be needed to fully evaluate the injury. An ankle sprain may sometimes accompany a peroneal tendon injury. The surgeon is trained to look for signs of this and other related injuries. Proper diagnosis is important because prolonged discomfort after a simple sprain may be a sign of additional problems.
 

Treatment

  • Treatment depends on the type of peroneal tendon injury. Options include:

  • Immobilization. A cast or splint may be used to keep the foot and ankle from moving and allow the injury to heal.

  • Medications. Oral or injected anti-inflammatory drugs may help relieve the pain and inflammation.

  • Physical therapy. Ice, heat, or ultrasound therapy may be used to reduce swelling and pain. As symptoms improve, exercises can be added to strengthen the muscles and improve range of motion and balance.

  • Bracing. The surgeon may provide a brace to use for a short while or during activities requiring repetitive ankle motion. Bracing may also be an option when a patient is not a candidate for surgery.

  • Surgery. In some cases, surgery may be needed to repair the tendon or tendons and perhaps the supporting structures of the foot. The foot and ankle surgeon will determine the most appropriate procedure for the patient’s condition and lifestyle. After surgery, physical therapy is an important part of rehabilitation.

Pediatric Flatfoot

 

What Is Pediatric Flatfoot?

Flatfoot is common in both children and adults. When this deformity occurs in children, it is referred to as “pediatric flatfoot,” a term that actually includes several types of flatfoot. Although there are differences between the various forms of flatfoot, they all share one characteristic — partial or total collapse of the arch. Most children with flatfoot have no symptoms, but some children have one or more symptoms. When symptoms do occur, they vary according to the type of flatfoot. Some signs and symptoms may include:

  •  Pain, tenderness, or cramping in the foot, leg, and knee

  •  Outward tilting of the heel

  •  Awkwardness or changes in walking

  •  Difficulty with shoes

  •  Reduced energy when participating in physical activities

  •  Voluntary withdrawal from physical activities
     

Flatfoot can be apparent at birth or it may not show up until years later, depending on the type of flatfoot. Some forms of flatfoot occur in one foot only, while others may affect both feet. Types of Pediatric Flatfoot Various terms are used to describe the different types of flatfoot. For example, flatfoot is either asymptomatic (without symptoms) or symptomatic (with symptoms). As mentioned earlier, the majority of children with flatfoot have an asymptomatic condition. Symptomatic flatfoot is further described as being either flexible or rigid. “Flexible“ means that the foot is flat when standing (weightbearing), but the arch returns when not standing. “Rigid” means the arch is always stiff and flat, whether standing on the foot or not. Several types of flatfoot are categorized as rigid. The most common are:

  • Tarsal coalition. This is a congenital (existing at birth) condition. It involves an abnormal joining of two or more bones in the foot. Tarsal coalition may or may not produce pain. When pain does occur, it usually starts in preadolescence or adolescence.

  • Congenital vertical talus. Because of the foot’s rigid “rocker bottom” appearance that occurs with congenital vertical talus, this condition is apparent in the newborn.
     

Symptoms begin at walking age, since it is difficult for the child to bear weight and wear shoes. There are other types of pediatric flatfoot, such as those caused by injury or some diseases.

 

Diagnosis

In diagnosing flatfoot, the foot and ankle surgeon examines the foot and observes how it looks when the Pediatric flatfoot Normal pediatric foot child stands and sits. The surgeon also observes how the child walks and evaluates the range of motion of the foot. Because flatfoot is sometimes related to problems in the leg, the surgeon may also examine the knee and hip. X-rays are often taken to determine the severity of the deformity. Sometimes an MRI study, CT scan, and blood tests are ordered.
 

Treatment:

Non-surgical Approaches If a child’s flatfoot is asymptomatic, treatment is often not required. Instead, the condition will be observed and re-evaluated periodically by the foot and ankle surgeon. Custom orthotic devices may be considered for some cases of asymptomatic flatfoot. In symptomatic pediatric flatfoot, treatment is required. The foot and ankle surgeon may select one or more approaches, depending on the child’s particular case. Some examples of non-surgical options include:

  •  Activity modifications. The child needs to temporarily decrease activities that bring pain as well as avoid prolonged walking or standing.

  •  Orthotic devices. The foot and ankle surgeon can provide custom orthotic devices that fit inside the shoe to support the structure of the foot and improve function.

  •  Physical therapy. Stretching exercises, supervised by the foot and ankle surgeon or a physical therapist, provide relief in some cases of flatfoot. • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to help reduce pain and inflammation.

  •  Shoe modifications. The foot and ankle surgeon will advise you on footwear characteristics that are important for the child with flatfoot.
     

When Is Surgery Needed?

In some cases, surgery is necessary to relieve the symptoms and improve foot function. Foot and ankle surgeons perform a variety of techniques to treat the different types of pediatric flatfoot. The surgical procedure or combination of procedures selected for your child will depend on his or her particular type of flatfoot and degree of deformity.

Osteoarthritis

 

What Is Osteoarthritis?

Osteoarthritis is a condition characterized by the breakdown and eventual loss of cartilage in one or more joints. Cartilage—the connective tissue found at the end of the bones in the joints—protects and cushions the bones during movement. When cartilage deteriorates or is lost, symptoms develop that can restrict one’s ability to easily perform daily activities. Osteoarthritis is also known as degenerative arthritis, reflecting its nature to develop as part of the aging process. As the most common form of arthritis, osteoarthritis affects millions of Americans. Many people refer to osteoarthritis simply as arthritis, even though there are more than 100 different types of arthritis. Osteoarthritis appears at various joints throughout the body, including the hands, feet, spine, hips, and knees. In the foot, the disease most frequently occurs in the big toe, although it is also often found in the midfoot and ankle. Signs and Symptoms People with osteoarthritis in the foot or ankle experience, in varying degrees, one or more of the following:

  • Pain and stiffness in the joint

  • Swelling in or near the joint

  • Difficulty walking or bending the joint Some patients with osteoarthritis also develop a bone spur (a bony protrusion) at the affected joint.
     

Shoe pressure may cause pain at the site of a bone spur, and in some cases blisters or calluses may form over its surface. Bone spurs can also limit the movement of the joint. Causes Osteoarthritis is considered a “wear and tear” disease because the cartilage in the joint wears down with repeated stress and use over time. As the cartilage deteriorates and gets thinner, the bones lose their protective covering and eventually may rub together, causing pain and inflammation of the joint. An injury may also lead to osteoarthritis, although it may take months or years after the injury for the condition to develop. For example, osteoarthritis in the big toe is often caused by kicking or jamming the toe, or by dropping something on the toe. Osteoarthritis in the midfoot is often caused by dropping something on it, or by a sprain or fracture. In the ankle, osteoarthritis is usually caused by a fracture and occasionally by a severe sprain. Sometimes osteoarthritis develops as a result of abnormal foot mechanics. People who have flat feet or high arches are at increased risk for developing osteoarthritis in the foot. A flat foot causes less stability in the ligaments (bands of tissue that connect bones), resulting in excessive strain on the joints, which can cause arthritis. A high arch is rigid and lacks mobility, causing a jamming of joints that creates an increased risk of arthritis.

 

Diagnosis

In diagnosing osteoarthritis, the foot and ankle surgeon will examine the foot thoroughly, looking for swelling in the joint, limited mobility, and pain with movement. In some cases, deformity and/or enlargement (spur) of the joint may be noted. In addition to the foot examination, x-rays may be ordered to help the doctor diagnose osteoarthritis and evaluate the extent of the disease in the foot and ankle.
 

Treatment:

Non-surgical Options To help relieve symptoms, the surgeon may begin treating osteoarthritis with one or more of the following non-surgical approaches:

  • Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are often helpful in reducing the inflammation and pain. Occasionally a prescription for a steroid medication is needed to adequately reduce symptoms. In addition, certain nutritional supplements may provide some longer-term benefit.

  • Orthotic devices. Custom orthotic devices (shoe inserts) are often prescribed to provide support to improve the foot’s mechanics or cushioning to help minimize pain.

  • Bracing. Bracing, which restricts motion and supports the joint, can reduce pain during walking and help prevent further deformity.

  • Immobilization. Protecting the foot from movement by wearing a cast or removable cast-boot may be necessary to allow the inflammation to resolve.

  • Steroid injections. In some cases, steroid injections are applied to the affected joint to deliver anti-inflammatory medication.

  • Physical therapy. Exercises to strengthen the muscles, especially when the osteoarthritis occurs in the ankle, may give the patient greater stability and help avoid injury that might worsen the condition.
     

When Is Surgery Needed?

If non-surgical treatment fails to adequately reduce the pain associated with osteoarthritis, surgery may be recommended. The goal of surgery is to decrease pain and improve function. The foot and ankle surgeon will consider a number of factors when selecting the procedure best suited to the patient’s condition and lifestyle.

Gout

What Is Gout?

Gout is a disorder that results from the build-up of uric acid in the tissues or a joint—most often the joint of the big toe. An attack of gout can be miserable, marked by the following symptoms:

  •  Intense pain that comes on suddenly—often in the middle of the night or upon arising

  •  Redness, swelling, and warmth over the joint—all of which are signs of inflammation

 

What Causes Gout?

Gout attacks are caused by deposits of crystallized uric acid in the joint. Uric acid is present in the blood and eliminated in the urine, but in people who have gout, uric acid accumulates and crystallizes in the joints. Uric acid is the result of the breakdown of purines, chemicals that are found naturally in our bodies and in food. Some people develop gout because their kidneys have difficulty eliminating normal amounts of uric acid, while others produce too much uric acid. Gout occurs most commonly in the big toe because uric acid is sensitive to temperature changes. At cooler temperatures, uric acid turns into crystals. Since the toe is the part of the body that is furthest from the heart, it’s also the coolest part of the body—and, thus, the most likely target of gout. However, gout can affect any joint in the body. The tendency to accumulate uric acid is often inherited. Other factors that put a person at risk for developing gout include: high blood pressure, diabetes, obesity, surgery, chemotherapy, stress, and certain medications and vitamins. For example, the body’s ability to remove uric acid can be negatively affected by taking aspirin, some diuretic medications (“water pills”), and the vitamin niacin (also called nicotinic acid). While gout is more common in men aged 40 to 60 years, it can occur in younger men and also occurs in women. Consuming foods and beverages that contain high levels of purines can trigger an attack of gout. Some foods contain more purines than others and have been associated with an increase of uric acid, which leads to gout. You may be able to reduce your chances of getting a gout attack by limiting or avoiding the following foods and beverages: shellfish, organ meats (kidney, liver, etc.), red wine, beer, and red meat.

 

Diagnosis

In diagnosing gout, the foot and ankle surgeon will take your personal and family history and examine the affected joint. Laboratory tests and x-rays are sometimes ordered to determine if the inflammation is caused by something other than gout.

 

Treatment

Initial treatment of an attack of gout typically includes the following:

  •  Medications. Prescription medications or injections are used to treat the pain, swelling, and inflammation.

  •  Dietary restrictions. Foods and beverages that are high in purines should be avoided, since purines are converted in the body to uric acid.

  •  Fluids. Drink plenty of water and other fluids each day, while also avoiding alcoholic beverages, which cause dehydration.

  •  Immobilize and elevate the foot. Avoid standing and walking to give your foot a rest. Also, elevate your foot (level with or slightly above the heart) to help reduce the swelling.

The symptoms of gout and the inflammatory process usually resolve in three to ten days with treatment. If gout symptoms continue despite the initial treatment, or if repeated attacks occur, see your primary care physician for maintenance treatment that may involve daily medication. In cases of repeated episodes, the underlying problem must be addressed, as the build-up of uric acid over time can cause arthritic damage to the joint.

 

When Is Surgery Needed?

In some cases of gout, surgery is required to remove the uric acid crystals and repair the joint. Your foot and ankle surgeon will determine the procedure that would be most beneficial in your case.

 

Haglund’s Deformity

 

What Is Haglund’s Deformity?

Haglund’s deformity is a bony enlargement on the back of the heel that most often leads to painful bursitis, which is an inflammation of the bursa (a fluid-filled sac between the tendon and bone). In Haglund’s deformity, the soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. Haglund’s deformity is often called “pump bump” because the rigid backs of pump-style shoes can create pressure that aggravates the enlargement when walking. In fact, the deformity is most common in young women who wear pumps.

 

Symptoms

Haglund’s deformity can occur in one or both feet. The signs and symptoms include:

  •  A noticeable bump on the back of the heel

  •  Pain in the area where the Achilles tendon attaches to the heel

  •  Swelling in the back of the heel

  •  Redness near the inflamed tissue
     

What Causes Haglund’s Deformity?

To some extent, heredity plays a role in Haglund’s deformity. People can inherit a type of foot structure that makes them prone to developing this condition. For example, high arches can contribute to Haglund’s deformity. The Achilles tendon attaches to the back of the heel bone, and in a person with high arches, the heel bone is tilted backward into the Achilles tendon. This causes the uppermost portion of the back of the heel bone to rub against the tendon. Eventually, due to this constant irritation, a bony protrusion develops and the bursa becomes inflamed. It is the inflamed bursa that produces the redness and swelling associated with Haglund’s deformity. A tight Achilles tendon can also play a role in Haglund’s deformity, causing pain by compressing the tender and inflamed bursa. In contrast, a tendon that is more flexible results in less pressure against the painful bursa. Another possible contributor to Haglund’s deformity is a tendency to walk on the outside of the heel. This tendency, which produces wear on the outer edge of the sole of the shoe, causes the heel to rotate inward, resulting in a grinding of the heel bone against the tendon. The tendon protects itself by forming a bursa, which eventually becomes inflamed and tender.
 

Diagnosis

After evaluating the patient’s symptoms, the foot and ankle surgeon will examine the foot. In addition, x-rays will be ordered to help the surgeon evaluate the structure of the heel bone.

Treatment:

Non-surgical Approaches Non-surgical treatment of Haglund’s deformity is aimed at reducing the inflammation of the bursa. While these approaches can resolve the bursitis, they will not shrink the bony protrusion. Non-surgical treatment can include one or more of the following:

  • Medication. Anti-inflammatory medications may help reduce the pain and inflammation. Some patients also find that a topical pain reliever, which is applied directly to the inflamed area, is beneficial.

  • Ice. To reduce swelling, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.

  • Exercises. Stretching exercises help relieve tension from the Achilles tendon. These exercises Bony enlargement Bursa are especially important for the patient who has a tight heel cord.

  • Heel lifts. Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel.

  • Heel pads. Placing pads inside the shoe cushions the heel and may help reduce irritation when walking.

  • Shoe modification. Wearing shoes that are backless or have soft backs will avoid or minimize irritation.

  • Physical therapy. Inflammation is sometimes reduced with certain forms of physical therapy, such as ultrasound therapy.

  • Orthotic devices. These custom arch supports are helpful because they control the motion in the foot, which can aggravate symptoms.

  • Immobilization. In some cases, casting may be necessary to reduce symptoms.
     

When Is Surgery Needed?

If non-surgical treatment fails to provide adequate pain relief, surgery may be needed. The foot and ankle surgeon will determine the procedure that is best suited to your case. It is important to follow the surgeon’s instructions for post-surgical care. Prevention A recurrence of Haglund’s deformity may be prevented by:

  •  Wearing appropriate shoes; avoid pumps and high-heeled shoes

  •  Using arch supports or orthotic devices

  •  Performing stretching exercises to prevent the Achilles tendon from tightening

  •  Avoiding running on hard surfaces and running uphill​
     

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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