Conditions

The Achilles tendon is the largest tendon in the human body and can withstand forces of 1,000 pounds or more. But it also the most frequently ruptured tendon.

Both professional and weekend athletes can suffer from Achilles tendonitis, a common overuse injury and inflammation of the tendon.
Events that can cause Achilles tendonitis may include:

• Hill running or stair climbing.
• Overuse resulting from the natural lack of flexibility in the calf muscles.
• Rapidly increasing mileage or speed.
• Starting up too quickly after a layoff.
• Trauma caused by sudden and/or hard contraction of the calf muscles when putting out extra effort such as in a final sprint.

Achilles tendonitis often begins with mild pain after exercise or running that gradually worsens. Other symptoms include:

• Recurring localized pain, sometimes severe, along the tendon during or a few hours after running.
• Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to the heel bone.
• Sluggishness in your leg.
• Mild or severe swelling.
• Stiffness that generally diminishes as the tendon warms up with use.

Treatment Normally Includes:

• A bandage specifically designed to restrict motion of the tendon.
• Non-steroidal anti-inflammatory medication.
• Orthoses, which are devices to help support the muscle and relieve stress on the tendon such as a heel pad or shoe insert.
• Rest and switching to another exercise, such as swimming, that does not stress the tendon.
• Stretching, massage, ultrasound and appropriate exercises to strengthen the weak muscle group in front of the leg and the upward foot flexors.

In extreme cases, surgery is performed to remove the fibrous tissue and repair any tears.

According to the American Academy of Orthopaedic Surgeons, doctors have noticed an increase in the number and severity of broken ankles since the 1970s, due, in part, to the Baby Boomer generation being active throughout every stage of their lives.
The ankle has two joints, one on top of the other, and three bones. A broken ankle can involve one or more of the bones, as well as injury to the surrounding connecting tissues or ligaments.
There are a wide variety of causes for broken ankles, most commonly a fall, an automobile accident, or sports-related trauma. Because a severe sprain can often mask the symptoms of a broken ankle, every ankle injury should be examined by a physician.

Symptoms of a broken ankle include:

• Bruising.
• Swelling.
• Immediate and severe pain.
• Inability to put any weight on the injured foot.
• Tenderness to the touch.
• Deformity, particularly if there is a dislocation or a fracture.

The treatment for a broken ankle usually involves a leg cast or brace if the fracture is stable. If the ligaments are also torn, or if the fracture created a loose fragment of bone that could irritate the joint, surgery may be required to secure the bones in place so they will heal properly.

• Ankle sprains are caused by an unnatural twisting or force on the ankle bones of the foot, which may result in excessive stretching or tearing of one or more ligaments on the outside of the ankle. The severity of the sprain can impact the degree of damage as well as the type and duration of treatment. If not properly treated, ankle sprains may develop into long-term problems.
• Primary symptoms of ankle sprains are pain following a twist or injury, swelling, and bruising.
• Treatment includes resting and elevating the ankle and applying ice to reduce swelling. Compressive bandages also may be used to immobilize and support the injury during healing. Serious ankle sprains, particularly among competitive athletes, may require surgery to repair and tighten the damaged ligaments.
• To prevent ankle sprains, try to maintain strength, balance, and flexibility in the foot and ankle through exercise and stretching, and wearing well-fitted shoes.

Arthritis is a disabling and occasionally crippling disease afflicting almost 40 million Americans. In some forms, it appears to be hereditary. While the prevalence of arthritis increases with age, all people from infancy to middle age are potential victims. People over 50 are the primary targets.

Arthritis is an inflammation and swelling of the cartilage and lining of the joints, generally accompanied by an increase in the fluid in the joints.

It is often a part of complex diseases that may involve more than 100 disorders. If the feet seem more susceptible to arthritis than other parts of the body, it is because each foot has 33 joints that can be afflicted, and there is no way to avoid the pain of the tremendous weight-bearing load on the feet.

Arthritic feet can result in loss of mobility and independence, but that may be avoided with early diagnosis and proper medical care.

Symptoms:

• Early morning stiffness.
• Limitation in motion of joint.
• Recurring pain or tenderness in any joint.
• Redness or heat in a joint.
• Skin changes, including rashes and growths.
• Swelling in one or more joints.

Forms of Arthritis

Osteoarthritis is the most common form of arthritis. It is frequently called degenerative joint disease or “wear and tear” arthritis. Aging usually brings on a breakdown in cartilage, and pain gets progressively more severe, although it can be relieved with rest. Dull, throbbing nighttime pain is characteristic, and it may be accompanied by muscle weakness or deterioration.

Overweight people are particularly susceptible to osteoarthritis. The additional weight contributes to the deterioration of cartilage and the development of bone spurs.

Rheumatoid arthritis is a major crippling disorder, and perhaps the most serious form of arthritis. It is a complex, chronic inflammatory group of diseases, often affecting more than a dozen smaller joints during its course, and frequently in both ankles, or the index fingers of both hands.

Arthritis can be treated in many ways, including:

• Physical therapy and exercise.
• Medication.
• Orthoses or specially prescribed shoes.

Here are some tips for athletic foot care:

1. Wash your feet every day, and dry thoroughly.
2. Wear only good quality, well-fitting cotton socks.
3. Always use the correct shoe for each sport and surface.

1. • Bunions are often described as a large protrusion to the side of the big toe, but this is incorrectly over simplified. The visual bump we all see is an extension of the underlying problem, which actually involves a complicated ligamentous and tendonous imbalance along with some inherent bony pathology. This is why the big toe points toward the second toe rather than straight forward. Bunions are progressive, which means the longer you leave a bunion without treatment the worse it will get with time. Usually the symptoms of the bunion will appear in late stages.
   • Most often a bunion can be caused by an inherited trait leading to abnormal mechanics of the foot and ankle. This leads to a structural problem in the entire foot. The foot type is the trait passed on from your ancestors, rather than the actual bunion deformity. Shoe types can cause the bunion to worsen, but will not actually cause the bunion.
   • Symptoms occur most often when wearing shoes that crowd the toes. Long bouts of ambulation or standing can aggravate the bunion. This can cause pain, soreness, inflammation, redness, burning and even numbness. Treatment for bunion deformities should initially consist of shoe changes along with orthotics therapy for biomechanical control. X-rays should be taken during the initial evaluation for future review when the Bunion deformity is thought to be progressing. Also injection therapy, icing and oral anti-inflammatory can be utilized to reduce swelling or pain. If these treatments don’t resolve the pain or the continued progression of the bunion is noted then surgery is most likely necessary. Some bunion deformities can be very progressed on initial evaluation and may require surgical correction immediately to prevent further joint damage. A variety of procedures can be performed for the numerous stages and diagnostic criteria for a bunion. We will consider all these criteria including x-ray findings, age, and activity level in selecting the correct procedure for each individual patient. The radiographs will demonstrate some bunion deformities that have been repaired through surgical intervention.
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2. Tailor’s Bunion

What is a Tailor’s Bunion?

Tailor’s bunion, also called a bunionette, is a prominence of the fifth metatarsal bone at the base of the little toe. The metatarsals are the five long bones of the foot. The prominence 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 they are similar in symptoms and causes.

Why is it called a tailor’s bunion? The deformity received its name centuries ago, when tailors sat cross-legged 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

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, resulting 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.

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.

Symptoms

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.

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.

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

• Shoe modifications. Choose shoes that have a wide toe box, and avoid those with pointed toes or high heels.
• Padding. Bunionette pads placed over the area may help reduce pain.
• Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help relieve the pain and inflammation.
• 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.
• Injection therapy. Injections of corticosteroid may be used to treat the inflamed tissue around the joint.
• Orthotic devices. In some cases, custom orthotic devices may be provided by the foot and ankle surgeon.

When is Surgery Needed?
Surgery is often considered when pain continues despite the above approaches. In selecting the procedure or combination of procedures for your 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.

When your feet become numb, they are at risk for becoming deformed. One way this happens is through ulcers. Open sores may become infected. Another way is the bone condition Charcot (pronounced “sharko”) foot. This is one of the most serious foot problems you can face. It warps the shape of your foot when your bones fracture and disintegrate, and yet you continue to walk on it because it doesn’t hurt. Diabetic foot ulcers and early phases of Charcot fractures can be treated with a total contact cast.

The shape of your foot molds the cast. It lets your ulcer heal by distributing weight and relieving pressure. If you have Charcot foot, the cast controls your foot’s movement and supports its contours if you don’t put any weight on it. To use a total contact cast, you need good blood flow in your foot. The cast is changed every week or two until your foot heals. A custom-walking boot is another way to treat your Charcot foot. It supports the foot until all the swelling goes down, which can take as long as a year. You should keep from putting your weight on the Charcot foot. Surgery is considered if your deformity is too severe for a brace or shoe.

Overlapping toes are characterized by one toe lying on top of an adjacent toe. The fifth toe is the most commonly affected. Overlapping toes may develop in the unborn fetus. Passive stretching and adhesive taping is most commonly used to correct overlapping toes in infants, but the deformity usually recurs. Sometimes they can be surgically corrected by releasing the tendon and soft tissues about the joint at the base of the fifth toe. In some extreme cases, a pin may be surgically inserted to hold the toe in a straighten position. The pin, which exits the tip of the toe, may be left in place for up to three weeks.

Underlapping toes usually involve the fourth and fifth toes. (A special form of underlapping toes is called congenital curly toes). The cause of underlapping toes is unknown. It is speculated that they may be caused by an imbalance in muscle strength of the small muscles of the foot. If deformed toes are flexible, a simple release of the tendon in the bottom of the toe will allow for them to straighten. If the deformity is rigid, surgery may be needed to remove a small portion of the bone in the toe.

According to the American Diabetes Association, about 15.7 million people (5.9 percent of the United States population) have diabetes. Nervous system damage (also called neuropathy) affects about 60 to 70 percent of people with diabetes and is a major complication that may cause diabetics to lose feeling in their feet or hands.

Foot problems are a big risk in diabetics. Diabetics must constantly monitor their feet or face severe consequences, including amputation.

With a diabetic foot, a wound as small as a blister from wearing a shoe that’s too tight can cause a lot of damage. Diabetes decreases blood flow, so injuries are slow to heal. When your wound is not healing, it’s at risk for infection. As a diabetic, your infections spread quickly. If you have diabetes, you should inspect your feet every day. Look for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, scratches, cuts and nail problems. Get someone to help you, or use a mirror.

People with diabetes are prone to having foot problems, often because of two complications of diabetes: nerve damage (neuropathy) and poor circulation. Neuropathy causes loss of feeling in your feet, taking away your ability to feel pain and discomfort, so you may not detect an injury or irritation. Poor circulation in your feet reduces your ability to heal, making it hard for even a tiny cut to resist infection.
Having diabetes increases the risk of developing a wide range of foot problems. Furthermore, with diabetes, small foot problems can turn into serious complications.

Diabetes-Related Foot and Leg Problems

• Infections and ulcers (sores) that don’t heal. An ulcer is a sore in the skin that may go all the way to the bone. Because of poor circulation and neuropathy in the feet, cuts or blisters can easily turn into ulcers that become infected and won’t heal. This is a common – and serious – complication of diabetes and can lead to a loss of your foot, your leg, or your life.
• Corns and calluses. When neuropathy is present, you can’t tell if your shoes are causing pressure and producing corns or calluses. Corns and calluses must be properly treated or they can develop into ulcers.
• Dry, cracked skin. Poor circulation and neuropathy can make your skin dry. This may seem harmless, but dry skin can result in cracks that may become sores and can lead to infection.
• Nail disorders. Ingrown toenails (which curve into the skin on the sides of the nail) and fungal infections can go unnoticed because of loss of feeling. If they are not properly treated, they can lead to infection.
• Hammertoes and bunions. Nerve damage affecting muscles can cause muscle weakness and loss of tone in the feet, resulting in hammertoes and bunions. If left untreated, these deformities can cause ulcers.
• Charcot foot. This is a complex foot deformity. It develops as a result of loss of sensation and an undetected broken bone that leads to destruction of the soft tissue of the foot. Because of neuropathy, the pain of the fracture goes unnoticed and the patient continues to walk on the broken bone, making it worse. This disabling complication is so severe that surgery, and occasionally amputation, may become necessary.
• Poor blood flow. In diabetes, the blood vessels below the knee often become narrow and restrict blood flow. This prevents wounds from healing and may cause tissue death.

What Your Foot and Ankle Surgeon Can Do

Your foot and ankle surgeon can help wounds heal, preventing amputation. There are many new surgical techniques available to save feet and legs, including joint reconstruction and wound healing technologies. Getting regular foot checkups and seeking immediate help when you notice something can keep small problems from worsening. Your foot and ankle surgeon works together with other health care providers to prevent and treat complications from diabetes.

Your Proactive Measures

You play a vital role in reducing complications. Follow these guidelines and contact your foot and ankle surgeon if you notice any problems:

• Inspect your feet daily. If your eyesight is poor, have someone else do it for you. Inspect for:
• Skin or nail problems: Look for cuts, scrapes, redness, drainage, swelling, bad odor, rash, discoloration, loss of hair on toes, injuries, or nail changes (deformed, striped, yellowed or discolored, thickened, or not growing).
• Signs of fracture: If your foot is swollen, red, hot, or has changed in size, shape, or direction, see your foot and ankle surgeon immediately.
• Don’t ignore leg pain. Pain in the leg that occurs at night or with a little activity could mean you have a blocked artery. Seek care immediately.
• Nail cutting. If you have any nail problems, hard nails, or reduced feeling in your feet, your toenails should be properly trimmed.
• No “bathroom surgery.” Never trim calluses or corns yourself, and don’t use over-the-counter medicated pads.
• Keep floors free of sharp objects. Make sure there are no needles, insulin syringes, or other sharp objects on the floor.
• Don’t go barefoot. Wear shoes, indoors and outdoors.
• Check shoes and socks. Shake out your shoes before putting them on. Make sure your socks aren’t bunched up.
• Have your circulation and sense of feeling tested. Your foot and ankle surgeon will perform tests to see if you’ve lost any feeling or circulation.

When is Amputation Necessary?

Even with preventative care and prompt treatment of infection and complications, there are instances when amputation is necessary to remove infected tissue, save a limb, or even save a life.

Here’s some basic advice for taking care of your feet:

1. Always keep your feet warm.
2. Don’t get your feet wet in snow or rain.
3. Don’t put your feet on radiators or in front of the fireplace.
4. Don’t smoke or sit cross-legged. Both decrease blood supply to your feet.
5. Don’t soak your feet.
6. Don’t use antiseptic solutions, drugstore medications, heating pads or sharp instruments on your feet.
7. Trim your toenails straight across. Avoid cutting the corners. Use a nail file or emery board. If you find an ingrown toenail, contact our office.
8. Use quality lotion to keep the skin of your feet soft and moist, but don’t put any lotion between your toes.
9. Wash your feet every day with mild soap and warm water.
10. Wear loose socks to bed.
11. Wear warm socks and shoes in winter.
12. When drying your feet, pat each foot with a towel and be careful between your toes.
13. Buy shoes that are comfortable without a “breaking in” period. Check how your shoe fits in width, length, back, bottom of heel and sole. Avoid pointed-toe styles and high heels. Try to get shoes made with leather upper material and deep toe boxes. Wear new shoes for only two hours or less at a time. Don’t wear the same pair everyday. Inspect the inside of each shoe before putting it on. Don’t lace your shoes too tightly or loosely.
14. Choose socks and stockings carefully. Wear clean, dry socks every day. Avoid socks with holes or wrinkles. Thin cotton socks are more absorbent for summer wear. Square-toes socks will not squeeze your toes. Avoid stockings with elastic tops.

• Flat feet are a common condition of the foot structure. In infants and toddlers, prior to walking, the longitudinal arch is not developed and flat feet are normal. Most feet are flexible and an arch appears when children begin standing on their toes. The arch continues to develop throughout childhood, and by adulthood most people have developed normal arches.
• Flat feet are generally associated with pronation, a leaning inward of the ankle bones toward the center line. Shoes of children who pronate, when placed side by side, will lean toward each other (after they have been worn long enough for the foot position to remodel their shape).
• Many people with flat feet do not experience pain or other problems. When pain in the foot, ankle, or lower leg does occur, especially in children, the feet should be evaluated.
• Painful progressive flatfoot, otherwise known as tibialis posterior tendonitis or adult-acquired flatfoot, refers to inflammation of the tendon of the tibialis posterior. This condition arises when the tendon becomes inflamed, stretched, or torn. Left untreated, it may lead to severe disability and chronic pain. People are predisposed to tibialis posterior tendonitis if they have flat feet or an abnormal attachment of the tendon to the bones in the midfoot.
• Nonsteroidal anti-inflammatory medications, icing, physical therapy, supportive taping, bracing, and orthotics are common treatments for painful progressive flatfoot. Note: Please consult your physician before taking any medications. In some cases, a surgery may need to be performed to repair a torn or damaged tendon and restore normal function. In the most severe cases, surgery on the midfoot bones may be necessary to treat the associated flatfoot condition.

• Gout (also known as gouty arthritis) is a condition caused by a buildup of the salts of uric acid (a normal byproduct of the diet) in the joints. A single big toe joint is the most commonly affected area, possibly because it is subject to so much pressure in walking. Attacks of gouty arthritis are extremely painful. Men are more likely to be afflicted than women. Diets heavy in red meat, rich sauces, shellfish, and brandy have been linked to gout. However, other protein compounds in foods, such as lentils and beans, may play a role.
• The main symptom of gout is waking up in the middle of the night with an acute throbbing pain in the big toe, which is swollen. The pain lasts for around three or four hours and then subsides. However, pain in the same toe usually returns within a few months.
• Gout can be controlled by with prescription medications and diet. Note: Please consult with your physician before taking any medications. The application of ice or cooling lotions helps alleviate pain and swelling during an acute phase. In some cases, specially-made shoes are prescribed to relieve the pain associated with gout.

Hammertoe is a deformity of the second, third, or fourth toes. In this condition, the toe is bent at the middle joint, causing it to resemble a hammer. Left untreated, hammertoes can become inflexible and require surgery. People with hammertoe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.

The primary causes of hammertoe include improperly fitting shoes and muscle imbalance.

Treatment for the condition typically involves wearing shoes with soft, roomy toe boxes and toe exercises to stretch and strengthen the muscles. Commercially available straps, cushions, or nonmedicated corn pads may also relieve symptoms.

In severe cases, hammertoe surgery may be recommended to correct the deformity.

Heel pain may be due to many conditions, such as a stress fracture, tendonitis, arthritis, nerve irritation, Plantar Fasciitis or, a bone spur. Because there are several potential causes, it is important to have heel pain properly diagnosed. East Penn Foot and Ankle Associates are well trained to distinguish between all the possibilities and determine the underlying source of your heel pain.

1. Plantar Fasciitis is an inflammation of the band of tissue (the plantar fascia) that extends from the heel to the toes.
   

   Symptoms

   • Pain on the bottom of the heel or arch.
   • Pain that is usually worse upon arising.
   • Pain that increases over a period of months.
   • Pain with first step in the morning or after rest.
   • Pain decrease with activity.

   Causes

   The most common cause of plantar fasciitis relates to faulty structure of the foot such as overly flat feet or high-arched feet.

   Overuse syndrome such as wearing non-supportive footwear on hard, flat surfaces for prolong periods puts abnormal strain on the plantar fascia and can also lead to plantar fasciitis.

   Obesity also contributes to plantar fasciitis.

   Diagnosis
   To arrive at a diagnosis, East Penn Foot and Ankle Associates will obtain a thorough medical history and examine your foot.

   Diagnostic imaging studies such as x-rays, a bone scan, or magnetic resonance imaging (MRI) or Ultrasound may be used to distinguish the different types of heel pain.

   Treatment

   • Stretching exercises.
   • Avoid going barefoot.
   • Ice.
   • Shoe modifications.
   • Medications.
   • Lose weight.
   • Padding and strapping.
   • Orthotic Devices.
   • Injection therapy.
   • Removable walking cast.
   • Night splint – Can be purchased at our online store.
   • Physical Therapy – Rehabilitation program with Robbins Rehabilitation

   Although most patients with plantar fasciitis respond to non-surgical treatment, if after several months of non-surgical treatment, you continue to have heel pain, surgery will be considered.

   Long-Term Care
   For all patients, wearing supportive shoes and using custom orthotic devices are the mainstay of long-term treatment for plantar fasciitis.

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2. Pediatric Heel pain is a warning sign that a child has a condition that deserves attention. Heel pain in children is often caused by injury to the growth plate commonly referred to as Calcaneal Apophysitis or Sever’s Disease. A growth plate is an area of growing tissue within the bone that determines the future length and shape of the bone. Growth plate injuries of the heel are usually caused by overuse. However, pediatric heel pain may be the sign of many other problems, and can occur at younger or older ages.
   

   Symptoms

   • Pain in the back or bottom of the heel
   • Limping
   • Walking on the toes
   • Difficulty participating in normal activities or sports

   Why Does Pediatric Heel Pain Differ from Adult Heel Pain?
   During these ages (8 to 14 years old), the bones are growing faster than the tendons. This means that the heel cord is relatively short when compared to the leg bone, causing the tendon to pull on the growth plate of the heel. When this is the case, a great deal of tension is put on the heel bone causing irritation and pain. Also, during this time frame the bone is still immature and is more prone to injury.
   Pediatric heel pain usually does not improve with activity. In fact, walking around typically makes the pain worse. Where adult heel pain improves with activity.

   Causes

   • Calcaneal Apophysitis is heel pain in children caused by injury to the growth plate in the heel bone
   • Tendo-Achilles Bursitis - Inflammation of the fluid-filled sac (bursa) located between the Achilles tendon (heel cord) and the heel bone. Can be associated with certain diseases such as juvenile rheumatoid arthritis
   • Overuse Syndrome
   • Fractures - Sometimes heel pain is caused by a break in the bone such as Stress Fractures

   Diagnosis
   To diagnose the underlying cause of your child’s heel pain, East Penn Foot and Ankle Associates will first obtain a thorough medical history and ask questions about recent activities. A thorough examine of 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

   • Reduce activity
   • Cushion the heel
   • Medications - Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
   • Physical Therapy - Rehabilitation program with Robbins Rehabilitation
   • Custom Foot Orthotic Devices
   • Immobilization
   • Surgery - There are some instances when surgery may be required to lengthen the tendon or correct other problems
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3. 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

   • 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

   Causes

   • Heredity may play a role in Haglund’s deformity. People can inherit a type of foot structure that makes them prone to developing this condition.
   • 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.
   • Tight Achilles tendon, 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.

   Diagnosis

   • X-Rays will be ordered to help us evaluate the structure of the heel bone
   • MRI or Ultrasound may also be ordered if further evaluation is needed

   Treatment
   The goal is to reduce the inflammation of the bursa. While these approaches can resolve the bursitis, they will not shrink the boney protrusion.

   Non-Surgical Approaches:

   • Medication - Anti-inflammatory medications may help reduce the pain and inflammation
   • Ice - 20 minutes of each waking hour. Do not put ice directly against the skin
   • Exercises - Stretching exercises help relieve tension from the Achilles tendon
   • Heel lifts
   • Heel Pads
   • Shoe Modifications
   • Physical Therapy -Rehabilitation program with Robbins Rehabilitation
   • 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

   • 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

Hallux limitus is a condition that results in stiffness of the big toe joint. It is normally caused by an abnormal alignment of the long bone behind the big toe joint, called the first metatarsal bone. Left untreated, Hallux Limitus can cause other joint problems, calluses, and/or diabetic foot ulcers. Painful bone spurs also can develop on the top of the big toe joint.

Anti-inflammatory medications, cortisone injections, and/or functional orthotics are some of the common treatments for stiff big toe. Note: Please consult your physician before taking any medications. Surgery may be required if spurring around the joint becomes severe.

An unmovable big toe, known as Hallux Rigidus, is the most common form of arthritis in the foot. Hallux Rigidus occurs as a result of wear-and-tear injuries, which wear down the articular cartilage, causing raw bone ends to rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The resulting stiff big toe can make walking painful and difficult.

Symptoms

• A bump, like a bunion or callus, that develops on the top of the foot.
• Pain in the joint when active, especially as you push-off on the toes when you walk.
• Stiffness in the big toe and an inability to bend it up or down.
• Swelling around the joint.

Pain relievers and anti-inflammatory medications are often prescribed to reduce swelling and ease the pain. Note: Please consult your physician before taking any medications. Applying ice packs or soaking the foot in contrast baths (alternating cold and hot water) may also help reduce inflammation and control symptoms for a short period of time.

A stiff-soled shoe with a rocker or roller bottom design and possibly a steel shank or metal brace in the sole can help alleviate the symptoms. These types of shoes add greater support when walking and reduce the amount of bend in the big toe.

When damage is more severe, a surgical procedure may be performed to remove the bone spurs, as well as a portion of the foot bone, and allow the toe more room to bend.

Ingrown nails, the most common nail impairment, are nails whose corners or sides dig painfully into the soft tissue of nail grooves, often leading to irritation, redness, and swelling. Usually, toenails grow straight out. Sometimes, however, one or both corners or sides curve and grow into the flesh. The big toe is usually the victim of this condition but other toes can also become affected.

Ingrown toenails may be caused by:

• Improperly trimmed nails (Trim them straight across, not longer than the tip of the toes. Do not round off corners. Use toenail clippers.)
• Heredity.
• Shoe pressure; crowding of toes.
• Repeated trauma to the feet from normal activities.

If you suspect an infection due to an ingrown toenail, immerse the foot in a warm salt water soak, or a basin of soapy water, then apply an antiseptic and bandage the area.

People with diabetes, peripheral vascular disease, or other circulatory disorders must avoid any form of self treatment and seek podiatric medical care as soon as possible.

Other “do-it-yourself” treatments, including any attempt to remove any part of an infected nail or the use of over-the-counter medications, should be avoided. Nail problems should be evaluated and treated by your podiatrist, who can diagnose the ailment, and then prescribe medication or another appropriate treatment.

A podiatrist will resect the ingrown portion of the nail and may prescribe a topical or oral medication to treat the infection. If ingrown nails are a chronic problem, your podiatrist can perform a procedure to permanently prevent ingrown nails. The corner of the nail that ingrows, along with the matrix or root of that piece of nail, are removed by use of a chemical, a laser, or by other methods.

Foot pain in the “ball of your foot,” the area between your arch and the toes, is generally called metatarsalgia. The pain usually centers on one or more of the five bones (metatarsals) in this mid-portion of the foot.

Also known as “dropped metatarsal heads,” metatarsalgia can cause abnormal weight distribution due to over-pronation.

Metatarsalgia causes one of metatarsal joints to become painful or inflamed. People often develop a callus under the affected joint. Metatarsalgia can also be caused by arthritis, foot injury (sports, car accidents, repeated stress), hard surfaces (cement or tile floors) and specific footwear (rigid soled work boots). Inappropriate shoes will only aggravate the condition.

A simple change of shoes may solve the problem. In more severe cases, full-length custom-molded foot inserts may need to be prescribed.

A morton’s neuroma is an enlarged benign growths of nerves, most commonly between the third and fourth toes. They are caused by tissue rubbing against and irritating the nerves. Pressure from ill-fitting shoes or abnormal bone structure can also lead to this condition. Treatments include orthoses (shoe inserts) and/or cortisone injections, but surgical removal of the growth is sometimes necessary.

1. Fungal infection of the nail, or onychomycosis, is often ignored because the infection can be present for years without causing any pain. The disease is characterized by a progressive change in a toenail’s quality and color, which is often ugly and embarrassing.

   In reality, the condition is an infection underneath the surface of the nail caused by fungi. When the tiny organisms take hold, the nail often becomes darker in color and foul smelling. Debris may collect beneath the nail plate, white marks frequently appear on the nail plate, and the infection is capable of spreading to other toenails, the skin, or even the fingernails. If ignored, the infection can spread and possibly impair one’s ability to work or even walk. This happens because the resulting thicker nails are difficult to trim and make walking painful when wearing shoes. Onychomycosis can also be accompanied by a secondary bacterial or yeast infection in or about the nail plate.

   Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are especially vulnerable around damp areas where people are likely to be walking barefoot, such as swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more susceptible to all types of infection, including fungal infection. Those who suffer from chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails. Other contributing factors may be a history of athlete’s foot and excessive perspiration.

2. Laser Treatment for Nail Fungus

What is Neuropathy?
No matter what caused the neuropathy, the symptoms are the same. Neuropathy initially manifests itself as a tingling in the toes which gradually spreads up the feet or hands and worsens into a burning pain. The sensations, whether tingling or pain, can be either constant or periodic. A person with neuropathy can also experience muscle weakness or numbness.

Diabetic Neuropathy Neuropathy is among the one of the most common complications of diabetes. Over time, diabetic neuropathy may occur in up to 50% of diabetics, despite controlling blood sugar. Once it occurs and without treatment, it almost always gets worse.
Diabetic neuropathy usually affects the feet first and then the hands. It starts with sensory changes such as numbness or tingling in the toes. At first these symptoms come and go, but then they become constant. Over a long period of time, the person may experience such a loss of sensation that he might not feel how tight his shoes are, know whether the bath water is hot or cold, or whether or not he has injured himself.

Changes in muscle strength also occur, possibly causing the diabetic to fall or the arches of his feet to collapse. Diabetic neuropathy is the leading cause of ulcerations and infections in the feet, and in advanced cases, amputation.

New testing and treatment has revolutionized care for diabetic neuropathy. The main methods of treatment, until now, have been rigorous control of blood sugar levels, meticulous care of the feet and the use of pain medication. The new testing procedures and specially-developed treatment procedures can slow and even reverse the progress of this.

Testing Procedure Sensory Testing (QST): Neurosensory and Motor Testing (NMT). It will tell the doctor the stage of a person’s neuropathy so that appropriate treatment can be done. It also accurately diagnoses other conditions that have similar symptoms to neuropathy so the correct treatment can be performed.

The American Diabetic Association recommends yearly testing for diabetics.

New Treatment for Neuropathy Conservative methods of treatment, such as special shoe inserts, nerve blocks or anodyne treatments (infrared light) can be used when neuropathy is in its early stages. If the neuropathy has progressed to the point where there is numbness and tingling throughout the day and weakness interferes with daily activities, then the person might be a candidate for Oral Medication like Lyrica or a surgical procedure like peripheral nerve decompression surgery. This is particularly suited to the treatment of tarsal tunnel (like carpal tunnel in the wrist but it is in the foot) neuropathy, with about an 80-90% improvement rate. Ideally, surgery is done before there is no feeling left in the nerve and before the condition has worsened to the point of ulcerations.

Peripheral Nerve Decompression Surgery Diabetic & Non-Diabetic Neuropathy: The Theory
Dr. Lee Dellon, Professor of Neurosurgery and Plastic Surgery, John Hopkins University, made the discovery in 1988 that nerves were subject to compression and swelling in areas that were anatomically tight-such as the inside of the ankle thus causing symptoms of neuropathy.

With Diabetics there are two reasons why a diabetic’s nerves are subject to compression. The first reason is the propensity of a diabetic’s nerves to swelling. Sugar from the blood enters into the nerve to give the nerve energy; this sugar, glucose, is converted into another sugar, called sorbitol. Sorbitol’s chemical formula makes it attract water molecules and water is drawn into the nerve causing the nerves in a diabetic to be swollen. If a nerve swells in a place that is already tight, then the nerve becomes pinched, or compressed.

The second reason is related to the transport systems within the diabetic nerve. It is believed that proteins are transported to the nerve to keep it functioning normally. This mechanism does not work well in diabetics because of compression on the nerve in the nerve tunnels. The flow of proteins to repair the nerve is impeded. Opening the nerve tunnel allows the flow of proteins to resume.

In the case of non-diabetic neuropathy, the neuropathy may or may not be caused by swelling nerves, but is thought to be caused by tight nerve tunnels. Surgery may be effective in many cases where the neuropathy is unrelated to diabetes. Success rates in non-diabetic neuropathy are equal to those in diabetic neuropathy patients.

Peripheral Nerve Decompression Surgery: What to Expect The surgery that is done for neuropathy is similar to the surgery commonly done for nerve compression in the wrist (carpal tunnel syndrome) and the ankle (tarsal tunnel syndrome). The surgery opens the tight area through which the affected nerve passes by, dividing a ligament that crosses the nerve. This opening gives the nerve more room, allows blood to flow better in the nerve and permits the nerve to glide with movements of nearby joints.

The surgery can be done in a Surgery Center and takes about one hour, with one hour of recovery. (Times vary for individual patients}

A long-acting local anesthetic will be put into the incisions so that once awake you will feel very little pair, along with numbness in your foot that wears off in 12-24 hours. Many surgical patients have noted restoration of sensation and reduction of pain immediately after anesthesia wears off.

When the nerves that have been “asleep” awaken, you may temporarily experience hot or cold or shooting pain in your toes. This is a good indication of recovery, but there still may be some discomfort to the patient. There is medication available that can help with this discomfort.

How does this type of surgery help diabetic neuropathy? Most recent studies show that 80-90% of those diabetic patients who have had a nerve decompressed have had decreased pain and improved sensory and motor function with improved balance.

The surgery to decompress the nerve does not change the basic, underlying metabolic (diabetic) neuropathy that made the nerve susceptible to compression in the first place. When the surgical decompression is done early in the course of nerve compression and nerve fibers have begun to die, decompression of the nerve will actually permit the diabetic nerve to regenerate or re-grow.

These patients with advanced neuropathy (ulcerations or lost toes} may recover less sensation because damage to the nerve has become irreversible. In this case, a consultation can determine how much help you can get from the surgery.

What Is PTTD?
The posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. Posterior tibial tendon dysfunction (PTTD) is a condition caused by changes in the tendon, impairing its ability to support the arch. This results in flattening of the foot.

PTTD is often called “adult acquired 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.
Causes
Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs.

Symptoms

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, 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.

Non-surgical Treatment

Because of the progressive nature of PTTD, early treatment is advised. 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 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 weight-bearing for a while.
• Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization.
• Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
• Shoe modifications. Your foot and ankle surgeon may advise 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. Your foot and ankle surgeon will determine the best approach for you.

Shin splints refer to pain on either side of the leg bone that is caused by muscle or tendon inflammation. The problem is usually related to a collapsing arch, but may be caused by a muscle imbalance between opposing muscle groups in the leg.

Proper stretching before and after exercise and sports, corrective shoes, or orthotics (corrective shoe inserts) can help prevent shin splints.

• Tarsal coalition is a bone condition that causes decreased motion or absence of motion in one or more of the joints in the foot. The bones found at the top of the arch, the heel, and the ankle are referred to as the tarsal bones. A tarsal coalition is an abnormal connection between two of the tarsal bones in the back of the foot or the arch. This abnormal connection between two bones is most commonly an inherited trait.
• The lack of motion or absence of motion experienced in a tarsal coalition is caused by abnormal bone, cartilage, or fibrous tissue growth across a joint. When excess bone has grown across a joint, it may result in restricted or a complete lack of motion in that joint. Cartilage or fibrous tissue growth can restrict motion of the affected joint to varying degrees, causing pain in the affected joint and/or in surrounding joints.
• Symptoms usually include an aching sensation deep in the foot near the ankle or arch, accompanied by muscle spasms on the outside of the affected leg. Nonsurgical treatments, such as corrective shoes or custom orthotics, physical therapy, and anti-inflammatory medication, are the first courses of action. Note: Please consult your physician before taking any medications. Surgery is sometimes performed in severe cases to allow for more normal motion between the bones or to fuse the affected joint or surrounding joints.

The structure of the foot is complex, consisting of bones, muscles, tendons and other soft tissues. Of the 26 bones in the foot, 19 are toe bones (phalanges) and metatarsal bones (the long bones in the midfoot). Fractures of the toe and metatarsal bones are common and require evaluation by a specialist. A foot and ankle surgeon should be seen for proper diagnosis and treatment, even if initial treatment has been received in an emergency room.

What is a Fracture?

A fracture is a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.

Traumatic fractures (also called acute fractures) are caused by a direct blow or impact, such as seriously stubbing your toe. Traumatic fractures can be displaced or non-displaced. If the fracture is displaced, the bone is broken in such a way that it has changed in position (dislocated).

Signs and symptoms of a traumatic fracture include:

• You may hear a sound at the time of the break.
• “Pinpoint pain” (pain at the place of impact) at the time the fracture occurs and perhaps for a few hours later, but often the pain goes away after several hours.
• Crooked or abnormal appearance of the toe.
• Bruising and swelling the next day.
• It is not true that “if you can walk on it, it’s not broken.” Evaluation by a foot and ankle surgeon is always recommended.

Consequences of Improper Treatment
Some people say that “the doctor can’t do anything for a broken bone in the foot.” This is usually not true. In fact, if a fractured toe or metatarsal bone is not treated correctly, serious complications may develop. For example:

• A deformity in the bony architecture which may limit the ability to move the foot or cause difficulty in fitting shoes
• Arthritis, which may be caused by a fracture in a joint (the juncture where two bones meet), or may be a result of angular deformities that develop when a displaced fracture is severe or hasn’t been properly corrected
• Chronic pain and deformity
• Non-union, or failure to heal, can lead to subsequent surgery or chronic pain.

Treatment of Toe Fractures
Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

• Rest. Sometimes rest is all that is needed to treat a traumatic fracture of the toe.
• Splinting. The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoe. Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned.
• “Buddy taping” the fractured toe to another toe is sometimes appropriate, but in other cases it may be harmful.
• Surgery. If the break is badly displaced or if the joint is affected, surgery may be necessary. Surgery often involves the use of fixation devices, such as pins.

Treatment of Metatarsal Fractures
Breaks in the metatarsal bones may be either stress or traumatic fractures. Certain kinds of fractures of the metatarsal bones present unique challenges.

For example, sometimes a fracture of the first metatarsal bone (behind the big toe) can lead to arthritis. Since the big toe is used so frequently and bears more weight than other toes, arthritis in that area can make it painful to walk, bend, or even stand.
Another type of break, called a Jones fracture, occurs at the base of the fifth metatarsal bone (behind the little toe). It is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments. Your foot and ankle surgeon is an expert in correctly identifying these conditions as well as other problems of the foot.

Treatment of metatarsal fractures depends on the type and extent of the fracture, and may include:

• Rest. Sometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
• Avoid the offending activity. Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe. A stiff-soled shoe or other form of immobilization may be used to protect the fractured bone while it is healing.
• Surgery. Some traumatic fractures of the metatarsal bones require surgery, especially if the break is badly displaced.
• Follow-up care. Your foot and ankle surgeon will provide instructions for care following surgical or non-surgical treatment. Physical therapy, exercises and rehabilitation may be included in a schedule for return to normal activities.

Most foot warts are harmless, even though they may be painful. They are often mistaken for corns or calluses, which are layers of dead skin that build up to protect an area which is being continuously irritated. A wart, however, is caused by a viral infection which invades the skin through small or invisible cuts and abrasions. Foot warts are generally raised and fleshy and can appear anywhere on the foot or toes. Occasionally, warts can spontaneously disappear after a short time, and then, just as frequently, they recur in the same location. If left untreated, warts can grow to an inch or more in circumference and can spread into clusters of warts. Children, especially teenagers, tend to be more susceptible to warts than adults.

Plantar warts, also known as verrucas, appear on the soles of the feet and are one of several soft tissue conditions that can be quite painful. Unlike other foot warts, plantar warts tend to be hard and flat, with a rough surface and well-defined boundaries. They are often gray or brown (but the color may vary), with a center that appears as one or more pinpoints of black. Plantar warts are often contracted by walking barefoot on dirty surfaces or littered ground. The virus that causes plantar warts thrives in warm, moist environments, making infection a common occurrence in public pools and locker rooms.
Like any other infectious lesion, plantar warts are spread by touching, scratching, or even by contact with skin shed from another wart. The wart may also bleed, another route for spreading. Plantar warts that develop on the weight-bearing areas of the foot (the ball or heel of the foot) can cause a sharp, burning pain. Pain occurs when weight is brought to bear directly on the wart, although pressure on the side of a wart can create equally intense pain.

To prevent the spread of warts, follow these tips:

• Avoid direct contact with warts, both from other persons or from other parts of the body.
• Avoid walking barefoot, except on sandy beaches.
• Change your shoes and socks daily.
• Check your children’s feet periodically.
• Keep your feet clean and dry.

It is important to note that warts can be very resistant to treatment and have a tendency to reoccur. Over-the-counter foot wart treatments are usually ineffective because their use can inadvertently destroy surrounding healthy tissue. Please contact our office for help in effectively treating warts. Our practice is expert in recommending the best treatment for each patient, ranging from prescription ointments or medications to, in the most severe cases, laser cautery.