Conditions We Treat


By Dr. Brann


Foot and Ankle Pain

Achilles Tendon

Deformities

Diabetes

Injuries

Fractures

Fungus & Infections

Joint Disorders

Nerve Disorders

Pediatric Conditions

Conditions

BUNIONS

DEFINITION

Bunions are a very common, often painful, condition of the forefoot also known as Hallux Valgus. The word bunion describes a bony enlargement or bump on the side of the great toe. The deformity is the result of misalignment of the joint at the base of the great toe. As the deformity progresses, the big toe gradually moves toward the adjacent toes, creating apparent enlargement of the bump and crowding of the other toes. Bunions affect women more often than men because of their frequent use of tight-fitting, pointed/confining, or high heeled shoes. Bunions are typically caused by faulty mechanics or abnormal function of the foot. People with flat feet (low arches) are especially prone to develop bunions. Injuries such as fractures or joint sprains, as well as various forms of arthritis, can also lead to the development of bunions.

COMMON PROBLEMS

Pain is the most common symptom associated with the bunion deformity. However for many individuals the deformity also a cosmetic problem. Pressure from shoes over the bunion leads to irritation of the soft tissues and underlying bone resulting in swelling, inflammation, and pain. Patients frequently report difficulty in finding comfortable, appropriate shoewear that doesn't aggravate their symptoms. As the big toe continues to drift toward the other toes, the bunion deformity increases in size so that even small amounts of pressure can be extremely painful and disabling. In addition, with increasing deformity of the great toe, the second toe begins to displace upward creating a painful Hammertoe deformity. This alters the function of the second toe often leading to a condition known as Metatarsalgia (pain over the metatarsal head). Misalignment of the great toe joint can also lead to premature wearing out of the articular cartilage (joint surfaces) and the development of early arthritis. Other symptoms associated with bunions include toenail problems and the formation of corns and calluses. Increasing deformity and symptoms tend to progress more rapidly in younger patients.

DIAGNOSIS

Initial evaluation includes a history and physical examination. X-rays of the feet, usually in the standing position, are also taken. This allows your doctor to measure certain angles which are important in assessing the deformity and determining the best treatment plan.

TREATMENT OPTIONS

Treatment for bunions varies with the age of the patient,the nature and severity of symptoms, and the degree of deformity. Coexisting medical conditions are also carefully considered in determining the most appropriate treatment. Initially, efforts should be directed at relieving pressure over the bunion which is most easily accomplished by obtaining a proper fitting shoe with a broader toebox to accommodate the deformity. Stiff leather shoes can be stretched or altered .Various splints or padding may also aid in reducing symptoms. Shoes with tight or constrictive toeboxes and high heels should be avoided. Orthotic devices also play an important role in improving faulty mechanics which may slow progression of the deformity. Antiinflammatory medication is sometimes used to decrease acute symptoms. While these treatments may relieve pain in some patients, they do not address the structural deformity or functional deficit and therefore their beneficial effects are frequently only temporary. In more severe cases or in those individuals for whom conservative measures fail, surgery may be necessary. There are over 100 different surgical procedures available today for the correction of bunion deformities. As these disorders are often complex, a combination of several procedures may be required to address all components of a particular deformity. The procedures your surgeon selects will depend on the type and severity of your bunion as well as any associated secondary changes such as arthritis. The goals of surgery are to remove the painful enlargement and to reestablish correct alignment of the joint so that normal function can be restored. Surgery is usually performed on an outpatient basis under either local anesthesia with sedation (foot block),spinal or general anesthesia.

HAMMERTOES

DEFINITION

The term hammertoe refers to a flexion deformity or buckling of the joints within the toes. Depending on which joint or joints are affected, similar conditions known as mallet toes or clawtoes can also occur. These conditions are frequently painful and usually cause considerable difficulty in obtaining comfortable footwear.

COMMON PROBLEMS

As the joint assumes a flexed position, a deformity results which creates a bony prominence that is vulnerable to pressure from the shoe. Constant, repetitive pressure, especially from ill-fitting or constrictive shoes leads to pain over the deformed joint. Symptoms typically occur over the interphalangeal joint (between bones in the toe) but can also occur at the tip of the toe or beneath a metatarsal head (ball of the foot). Over time, the skin adjacent to the prominent bone becomes irritated leading to the formation of corns and calluses. These are thickenings of the outer layer of skin, which form in an attempt to protect the underlying structures from pressure. In severe cases, inflammation, ulceration, and infection can result, further complicating the condition.

DIAGNOSIS

A history and physical exam is needed to make the diagnosis of hammertoe deformity. Foot X-rays while the patient is standing also provide useful information in evaluating the deformity.

TREATMENT OPTIONS

Several options are available for the treatment of a hammertoe deformity. The treatment depends on the nature and severity of the specific condition and the factors that caused it. In the early stages, avoidance of ill-fitting , constrictive footwear, especially high heel shoes, may be effective in reducing symptoms. Periodic trimming of corns and calluses provides temporary relief of discomfort. Various types of accommodative padding or shoes with deeper toe boxes may decrease pressure over bony prominences. Biomechanical abnormalities such as excessive pronation should be evaluated and treated with appropriate orthotic devices. For many patients however these conservative treatments provide only partial or temporary relief of symptoms as they do not correct the deformity. If conservative methods fail or in more advanced cases, surgery is usually necessary to eliminate symptoms, correct the deformity, and restore function and stability to the toe. Today many good surgical procedures are available for the correction of hammertoes. The specific procedures required will depend on the type and severity of the individual deformity. Hammertoe repair is usually performed on an outpatient basis under local anesthesia with intravenous sedation.

MORTON'S NEUROMA

DEFINITION

A Morton's Neuroma is a painful condition affecting the forefoot caused by repetitive irritation of one of the common digital nerves.

COMMON PROBLEMS

The pain is usually located at the base of the 3rd and 4th toes. Frequently patients describe a cramping sensation that is relieved by removing the shoe and massaging the foot. There also may be burning pain radiating into the toes, sometimes associated with numbness. Some people experience a clicking sensation while walking and others report a sharp tingling or electric shocks, much like hitting your funny bone.

DIAGNOSIS

The diagnosis of Morton's Neuroma is based on the history and physical examination. X-rays are taken to rule out other causes for the symptoms. In cases where the diagnosis is in question, ultrasound or MRI (magnetic resonance imaging) may be recommended.

TREATMENT OPTIONS

As with many foot problems, treatment usually begins with changing footwear. A well-cushioned shoe with a broad toebox is advised. High heel, pointed toe shoes should be advoided. Biomechanical factors should be evaluated and controlled with appropriate orthotic devices. If this is inadequate, an injection of a local anesthetic with cortisone may reduce swelling and inflammation of the affected nerve. If these measures fail to resolve the symptoms, surgical excision of the nerve is recommended. This is typically done on an outpatient basis under local anesthesia with intravenous sedation.

PLANTAR FASCIITIS

DEFINITION

Plantar fasciitis , also known as heel spur syndrome, is one of the most common disorders affecting the foot and ankle. It is a painful, overuse condition of the heel usually caused by chronic, repetitive strain or stretching of the muscles and ligaments that support the arch. Although it can affect anyone, it is most often seen in people who stand or walk for prolonged periods of time each day. It is especially common in active individuals who like to walk or run for exercise on a regular basis.

COMMON PROBLEMS

It usually begins with a gradual onset of sharp pain on the bottom of the heel which tends to progress over time. Typically symptoms are worse when first standing in the morning or after periods of rest. The pain usually improves as the day goes on only to worsen again at the end of the day. Symptoms are usually relieved with rest. As the chronic inflammatory process continues, a heel spur may develop in some individuals.

DIAGNOSIS

The diagnosis of plantar fasciitis is established with the history and physical examination. Certain common foot deformities such as fallen arches (flatfeet) or high arches may predispose individuals to plantar fasciitis. Weight bearing x-rays of the affected foot are usually taken to evaluate the bony architecture of the foot as well as to rule out a stress fracture of the calcaneus (heel bone) and also to determine if a heel spur is present.

TREATMENT OPTIONS

The treatment goals are to reduce the inflammation, which decreases the pain, and to control those factors which led to the development of the condition. Initial measures include relative rest and avoidance of excessive walking and / or running. Ice massage of the affected heel 10-15 minutes two to three times daily helps to decrease the inflammation. Antiinflammatory medications may also be prescribed. Certain biomechanical abnormalities such as excessive pronation should be controlled with custom orthotic devices appropriate for the specific disorder. These devices limit abnormal motions and forces which can lead to or aggravate plantar fasciitis. A calf stretching program is frequently recommended to improve flexibility and limit excessive stress on the inflammed tissues. Night splinting may also be helpful for some patients. A cortisone injection is sometimes necessary to reduce inflammation and pain. Physical therapy modalities such as ultrasound may be required in more resistant cases. Although plantar fasciitis may become a chronic condition, most patients will improve significantly with the treatment measures outlined above and will usually be able to return to their preinjury activity level without any residual disability. Surgery is therefore only indicated in those patients whose symptoms fail to resolve with conservative treatment. Surgical treatment usually involves release of the plantar fascia from the heel bone and removing the bone spur if present. In some cases there can be impingement of one of the small nerves that courses adjacent to the plantar fascia which may need to be released. This type of surgery is usually done as an outpatient with either general anesthesia or regional anesthesia (spinal block or local foot block).

Plantar Fasciitis Stretching Exercises