Foot & Ankle

The Ankle
The ankle is a complex mechanism which is actually composed of two joints: the subtalar joint and the true ankle joint. The subtalar joint consists of the talus and the calcaneus, and allows side-to-side motion of the foot. The true ankle joint is composed of 3 bones, the tibia, fibula, and talus, and is responsible for the up and down motion of the foot. The ankle is stabilized and supported by three groups of ligaments, while movement is made possible by muscles and tendons.

The Foot
The foot itself contains 26 bones, 33 joints, 107 ligaments, and 19 muscles. In fact, a quarter of all the bones in the human body are located in the feet. The tarsal bones of the foot work together as a group, locking together to form a rigid structure when the foot is twisted in one direction, and unlocking to conform to a contacted surface when twisted in another. These bones are connected to the 5 long bones of the foot called the metatarsals. The bones of the toes are called phalanges, and the joints that connect them to the metatarsals are called phalangeal joints. These joints form the ball of the foot, and their movement is very important for a normal walking pattern.

Arthritis
The foot and ankle are subject to several types of arthritis, including gout, ankylosing spondylitis, psoriatic arthritis, Reiter's syndrome, Lyme disease, degenerative arthritis, and rheumatoid arthritis (to name a few). Arthritis in the foot and ankle can be very disabling.

Gout is rather common in the foot, especially at the base of the great toe (in the "metatarsophalangeal joint). It is caused by the deposition of sodium urate crystals in the joints. It occurs more frequently in men than women, and symptoms occur suddenly. Attacks are recurrent, and often occur after the stress of a surgical procedure. Diagnosis is made from physical exam, laboratory tests, and identification of the crystals under a microscope. Acute attacks are treated with rest and elevation of the foot and medication (colchicine or other anti-inflammatory medications.) Chronic gout results in large deposits of crystals called "tophi". These tophi often need to be removed surgically.

Degenerative arthritis, also known as "osteoarthritis" is the "wear and tear" form of arthritis. It usually occurs in middle-aged and elderly persons, but can also occur in younger patients. It can result from trauma, but obesity and excessive levels of physical activity can also contribute to its cause. It can occur in any joint of the foot and ankle. Treatment is conservative initially, consisting of activity modification, anti-inflammatory medication, shoe modifications, orthotics, bracing, and injections. Surgery is a last resort, and is indicated when the pain is disabling, or when there is a significant deformity.

Rheumatoid arthritis often affects the joints of the hands and feet first. It is diagnosed by physical exam, laboratory tests, and x-rays. It is progressive, and can result in severe deformities, and significant disability. Treatment is directed toward pain relief and prevention of deformity first. As the condition progresses, treatment is directed toward correction of deformity, restoration of function, and preservation of function. Treatment consists of medications and orthopedic appliances in the early stages, and surgery in the later stages of the disease. Patients with rheumatoid arthritis have a higher incidence of complications related to surgery. Complications include recurrence of the deformity, infection, wound healing problems, and failure of the bone to heal.

Psoriatic arthritis, Reiter's syndrome, ankylosing spondylitis, and Lyme disease are other forms of arthritis that can involve the feet. These diseases are treated medically, and rarely, if ever, require surgical treatment. Patients with these and other types of arthritis, with the possible exception of osteoarthritis, should be under the care of a rheumatologist, as well as an orthopedic surgeon.

Bunions
Bunions are a rather common foot deformity where the great toe deviates toward the lesser toes, resulting in a prominence at the base of the great toe on the inside of the foot (the area known as the "first metatarsophalangeal joint".) The medical term for this problem is "hallux valgus". It is a condition which is much more common in women, and seems to be related to shoe wear, although heredity might also be a factor. It can occur in young people, as well as adults. The "juvenile" form of the condition is much more difficult to deal with surgically, and has poorer results from surgery.

Bunions are not always painful, but pain is the most common complaint related to this deformity. A bunion that is not painful usually needs no treatment, as surgery merely for "cosmetic" reasons might very well result in a painful foot, with or without improvement in the appearance. The first line of treatment for a bunion is shoe modifications, bunion pads, splints, and other conservative measures. When conservative treatment fails, surgery can be considered.

Surgery for correction of bunion deformities is usually done as outpatient surgery. Depending on the exact surgery performed, most patients will be non-weight bearing for 4 to 6 weeks following surgery. If the problem is present in both feet, it is usually recommended to do only one side at a time. Sometimes the surgery can be done under a local anesthetic with sedation, but most often a regional or general anesthetic is used. After surgery, frequent follow up visits with the surgeon are necessary to change dressings and evaluate the progression of healing. Swelling can persist for several months or even a year after surgery. Complications can occur, and include recurrence of the deformity, wound healing problems, persistent pain and swelling, infection, over-correction, and arthritis. Because of these risks, surgical correction of this problem should never be taken lightly, and should be a last resort.

Bursitis
"Bursitis" is inflammation of a bursa (a structure in the body that functions as a "cushion" to protect joints and also to reduce friction between the skin or tendons and a bony prominence). There are several areas in the foot and ankle where bursae are located. These bursae can become inflamed from pressure, trauma, infection, or disease (gout or rheumatoid arthritis). When they become inflamed, they are usually painful, and require some type of treatment. Most types of bursitis can be treated conservatively with pressure relief (shoe modifications, pads, etc.), anti-inflammatory medications, aspiration (drainage) of the fluid, or injections. Infected bursae require antibiotic treatment. When conservative treatment fails, surgery is usually indicated, especially in the case of an infected bursa.

Flatfoot Deformity
Flatfoot deformity can be divided into two basic types: congenital and acquired. The congenital type is one you are born with, and the acquired type is one that develops later in life. Another term for flatfoot is "pes planus".

The congenital type of flatfoot deformity is further divided into asymptomatic flexible flatfoot, symptomatic flexible flatfoot, and tarsal coalition with peroneal spastic flatfoot. Asymptomatic flexible flatfoot is basically a normal condition, and requires no treatment. The symptomatic flatfoot is usually treated conservatively with appropriate shoe wear and/or arch supports. Occasionally surgery might be indicated when conservative measures fail. The foot with a tarsal coalition (where some of the small bones of the foot are fused together) often requires surgical intervention to get rid of the symptoms.

The acquired type of flatfoot deformity has several causes, including damage to the posterior tibial tendon, arthritis, trauma, diabetes, neuromuscular disorders, and tumors. The treatment for these various types of flatfoot deformities depends on the cause of the deformity and the severity of symptoms. However, in general, conservative measures are tried before surgery is considered.

Foot Ganglion
A ganglion is a fluid filled mass associated with a joint capsule or a tendon sheath. Ganglion cysts can occur many places on the body, and are very common on the foot. Ganglions usually appear as a firm nodule under the skin. They may be symptom free, or can be painful, and may change in sizeperiodically. It is important to know that ganglion cysts are NOT CANCER and will never become cancerous (malignant). If the cyst is large or painful, treatment might consist of aspiration of the fluid with a needle. The recurrence rate with this treatment is 70%, however. A more definitive treatment is surgical excision, which can also have up to a 30% recurrence rate. Therefore, surgery should be considered only if the cyst is symptomatic. "Skillful neglect" (leaving it alone) is always a good option in treating this condition, as many times the cyst will go away on its own without any treatment.

Hammer Toe Deformity
"Hammer toe" deformity is a term used to describe a toe that is "clawed" or curved. There are actually several names used to specifically describe these deformities, including "hammer toe", "claw toe", and "mallet toe". However the distinction between these can be confusing, and therefore the term "hammer toe" is used most often to describe this condition.

Shoes generally have a significant role in causing hammer toe deformities. Occasionally these deformities are the result of tight tendons, neuromuscular diseases, inflammatory arthritis, or other diseases. Sometimes no cause can be identified. These deformities are often present in multiple toes, and result in painful calluses or sores on the tops of the toes due to pressure from shoes. When the hammer toe is flexible, conservative treatment consisting of shoe modifications, taping and padding might be successful. However, if the deformity is rigid (or fixed), surgery is usually recommended to correct the deformity and relieve the pressure off the toe.

Surgery for this condition usually has good results, with rare complications. However, as with any surgery, complications can and do occur. Some of these problems include persistent swelling, mild recurrence of the deformity, persistent discomfort, and infection. With this in mind, surgery should be considered only after conservative treatment has failed.

Heel Spurs
It is a common misconception that people with heel pain have "heel spurs". Heel pain actually has many causes, and is only sometimes related to a spur (bony projection) on the calcaneus (heel bone). Heel pain can be caused by inflammation of the plantar fascia ("plantar fasciitis"), arthritis, nerve damage, and stress fractures. Heel spurs have never been proven to be the cause of heel pain. In fact, many people who have heel pain don't have heel spurs, and many people with heel spurs don't have heel pain. Heel pain is a difficult problem to cure, and can take many months, even years, to cure.

The most common cause of heel pain is plantar fasciitis. The treatment of plantar fasciitis is always conservative at first. A correct diagnosis must be made, and can be done with a good exam and x-rays in most instances. Occasionally a bone scan, MRI or EMG/nerve conduction study might be needed to rule out some other cause of the heel pain. Conservative treatment includes activity modification, anti-inflammatory medications, orthotics, heel cups, stretching, physical therapy, and injections. If a long trial of conservative treatment fails, surgery is considered as a last resort.

Morton's Neuroma
"Morton's neuroma" is a disease of a specific nerve in the foot. It is a swelling and inflammation of the small nerve located between the base of the third and fourth toes. The symptoms of this condition are pain in between the third and fourth toes, and on the bottom of the foot in the same area. There may also be numbness between the 3rd and 4th toes. Causes include trauma, abnormal anatomy, and tight fitting shoes. Diagnosis is made by symptoms and physical exam. Treatment is usually conservative, and includes shoe modifications, pads, anti-inflammatory medications, activity modification, and injections. If conservative treatment fails, surgery can be considered, and consists of removing the neuroma. This most often results in permanent numbness in the web space between the 3rd and 4th toes. Neuromas can occur in other areas of the foot, and are diagnosed and treated much the same as a Morton's neuroma. As always, surgery should be considered only after an adequate trial of conservative treatment has failed.

Sprains, Strains, Dislocations, and Fractures
Sprains, strains, dislocations and fractures are common injuries in the foot and ankle. A "sprain" is an injury of a ligament (a fibrous band of tissue that connects one bone to another). When someone sprains their ankle, they have done something to injure one of the ligaments of that joint. You can also injure ligaments in the foot. Usually sprains are the result of a twisting type mechanism, but can also result from direct impact, such as in a car wreck from pushing hard on the brake pedal or on the floorboard at the time of impact. Sprains are usually treated without surgery, but a severe sprain might very well need surgery. Most sprains of the foot and ankle are treated with rest, ice, compression, and elevation. Sometimes a cast is needed. You should never assume that an injury is "just a sprain", as it is difficult to determine if an injury is a sprain or a fracture without an x-ray.

A "strain" is a stretching injury to a muscle or tendon. It is always treated conservatively with rest, ice, anti-inflammatory medications, etc. Most strains will get better with rest, but sometimes physical therapy might be needed to speed healing. The most common strains related to the foot and ankle are strains of the Achilles' tendon, or of the gastrocnemius muscle (calf muscle). A strain should not be confused with a frank tear of a muscle or tendon. Such injuries most often need surgery or more intensive treatment than a strain would require.

A "dislocation" is an injury where a joint is totally disrupted. Many of these injuries of the foot and ankle require surgery, as they result in significant damage to ligaments and other soft tissues, which in turn leads to instability of the joint. Dislocations in the foot and ankle are often associated with fractures as well. Dislocations are the result of a much more intense force than that required to cause a sprain or a "reduced" (put back into place) as soon as possible. It is not advisable to reduce a dislocation on your own. These injuries are best handled by trained medical personnel, and under an anesthetic.

A "fracture" is a broken bone, whether it be a non-displaced "hair-line" fracture, or a completely displaced fracture. Fractures are diagnosed with x-rays. There are 26 bones in the foot, plus two more to form the ankle joint. Any of these bones can be broken, but probably the most common ones are the fibula (the small bone that makes the "bump" on the outside of the ankle), and the metatarsals (the longer bones that make up the arch area of the foot). Many times fractures of the foot and ankle can be treated without surgery, using casts, post-operative shoes, and/or crutches, but sometimes surgery is required to put the broken bones back in place and hold them while they heal. It usually takes bones 6 to 8 weeks to heal, but often pain persists longer due to swelling and the damage to the soft tissues. Surgery does not speed up or slow down the healing process as a general rule, but rather allows the bone to heal in the correct position.

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