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What is an Achilles Tendon Rupture?

An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause a tear. An injury to the tendon can also result from falling or tripping.

Achilles tendon ruptures are most often seen in “weekend warriors”—typically, middle-aged people participating in sports in their spare time. Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures.

Signs and Symptoms

A person with a ruptured Achilles tendon may experience one or more of the following:

  • Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf—often subsiding into a dull ache
  • A popping or snapping sensation
  • Swelling on the back of the leg between the heel and the calf
  • Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes

These symptoms require prompt medical attention to prevent further damage. Until the patient is able to see a doctor, the RICE method should be used. This involves:

  • Rest. Stay off the injured foot and ankle, since walking can cause pain or further damage.
  • Ice. Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
  • Compression. Wrap the foot and ankle in an elastic bandage to prevent further swelling.
  • Elevation. Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.

Diagnosis

In diagnosing an Achilles tendon rupture, the foot and ankle surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms. The surgeon will examine the foot and ankle, feeling for a defect in the tendon that suggests a tear. Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle. If the Achilles tendon is ruptured, the patient will have less strength in pushing down (as on a gas pedal) and will have difficulty rising on the toes.

The diagnosis of an Achilles tendon rupture is typically straightforward and can be made through this type of examination. In some cases, however, the surgeon may order an MRI or other advanced imaging tests.

Treatment

Treatment options for an Achilles tendon rupture include surgical and nonsurgical approaches. The decision of whether to proceed with surgery or nonsurgical treatment is based on the severity of the rupture and the patient’s health status and activity level.

Nonsurgical Treatment

Nonsurgical treatment, which is generally associated with a higher rate of rerupture, is selected for minor ruptures, less active patients and those with medical conditions that prevent them from undergoing surgery. Nonsurgical treatment involves use of a cast, walking boot or brace to restrict motion and allow the torn tendon to heal.

Surgery

Surgery offers important potential benefits. Besides decreasing the likelihood of re rupturing the Achilles tendon, surgery often increases the patient’s push-off strength and improves muscle function and movement of the ankle.

Various surgical techniques are available to repair the rupture. The surgeon will select the procedure best suited to the patient.

Following surgery, the foot and ankle are initially immobilized in a cast or walking boot. The surgeon will determine when the patient can begin weightbearing.

Complications such as incision-healing difficulties, rerupture of the tendon or nerve pain can arise after surgery.

Physical Therapy

Whether an Achilles tendon rupture is treated surgically or nonsurgically, physical therapy is an important component of the healing process. Physical therapy involves exercises that strengthen the muscles and improve range of motion in the foot and ankle.

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What Is an Ankle Fracture?

A fracture is a partial or complete break in a bone. Fractures in the ankle can range from the less serious avulsion injuries (small pieces of bone that have been pulled off) to severe shattering-type breaks of the tibia, fibula or both.

Ankle fractures are common injuries most often caused by the ankle rolling inward or outward. Many people mistake an ankle fracture for an ankle sprain, but they are quite different and therefore require an accurate and early diagnosis. They sometimes occur simultaneously.

Symptoms

An ankle fracture is accompanied by one or all of these symptoms:

  • Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
  • Significant swelling, which may occur along the length of the leg or may be more localized.
  • Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
  • Bruising that develops soon after the injury.
  • Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
  • Change in the appearance of the ankle—it will look different from the other ankle.
  • Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

Diagnosis

Following an ankle injury, it is important to have the ankle evaluated by a foot and ankle surgeon for proper diagnosis and treatment. If you are unable to do so right away, go to the emergency room and then follow up with a foot and ankle surgeon as soon as possible for a more thorough assessment.

The affected limb will be examined by the foot and ankle surgeon who will touch specific areas to evaluate the injury. In addition, the surgeon may order x-rays and other imaging studies, as necessary.

Nonsurgical Treatment

Treatment of ankle fractures depends on the type and severity of the injury. At first, the foot and ankle surgeon will want you to follow the RICE protocol:

  • Rest: Stay off the injured ankle. Walking may cause further injury.
  • Ice: Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
  • Compression: An elastic wrap should be used to control swelling.
  • Elevation: The ankle should be raised slightly above the level of your heart to reduce swelling.

Additional treatment options include:

  • Immobilization. Certain fractures are treated by protecting and restricting the ankle and foot in a cast or splint. This allows the bone to heal.
  • Prescription medications. To help relieve the pain, the surgeon may prescribe pain medications or anti-inflammatory drugs.

When Is Surgery Needed?

For some ankle fractures, surgery is needed to repair the fracture and other soft tissue-related injuries, if present. The foot and ankle surgeon will select the procedure that is appropriate for your injury.

Follow-Up Care

It is important to follow your surgeon’s instructions after treatment. Failure to do so can lead to infection, deformity, arthritis and chronic pain.

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Foot and Ankle Injuries

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What Is Chronic Ankle Instability?

Chronic ankle instability is a condition characterized by a recurring giving way of the outer (lateral) side of the ankle. This condition often develops after repeated ankle sprains. Usually, the giving way occurs while walking or doing other activities, but it can also happen when you’re just standing. Many athletes, as well as others, suffer from chronic ankle instability.

People with chronic ankle instability often complain of:

  • A repeated turning of the ankle, especially on uneven surfaces or when participating in sports
  • Persistent (chronic) discomfort and swelling
  • Pain or tenderness
  • The ankle feeling wobbly or unstable

Causes

Chronic ankle instability usually develops following an ankle sprain that has not adequately healed or was not rehabilitated completely. When you sprain your ankle, the connective tissues (ligaments) are stretched or torn. The ability to balance is often affected. Proper rehabilitation is needed to strengthen the muscles around the ankle and retrain the tissues within the ankle that affect balance. Failure to do so may result in repeated ankle sprains.

Repeated ankle sprains often cause—and perpetuate—chronic ankle instability. Each subsequent sprain leads to further weakening (or stretching) of the ligaments, resulting in greater instability and the likelihood of developing additional problems in the ankle.

Diagnosis

In evaluating and diagnosing your condition, the foot and ankle surgeon will ask you about any previous ankle injuries and instability. Then s/he will examine your ankle to check for tender areas, signs of swelling and instability of your ankle as shown in the illustration. X-rays or other imaging studies may be helpful in further evaluating the ankle.

 

Nonsurgical Treatment

Treatment for chronic ankle instability is based on the results of the examination and tests, as well as on the patient’s level of activity. Nonsurgical treatment may include:

  • Physical therapy. Physical therapy involves various treatments and exercises to strengthen the ankle, improve balance and range of motion and retrain your muscles. As you progress through rehabilitation, you may also receive training that relates specifically to your activities or sport.
  • Bracing. Some patients wear an ankle brace to gain support for the ankle and keep the ankle from turning. Bracing also helps prevent additional ankle sprains.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed to reduce pain and inflammation.

When Is Surgery Needed?

In some cases, the foot and ankle surgeon will recommend surgery based on the degree of instability or lack of response to nonsurgical approaches. Surgery usually involves repair or reconstruction of the damaged ligament(s). The surgeon will select the surgical procedure best suited for your case based on the severity of the instability and your activity level. The length of the recovery period will vary, depending on the procedure or procedures performed.

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What Is an Ankle Sprain?

An ankle sprain is an injury to one or more ligaments in the ankle, usually on the outside of the ankle. Ligaments are bands of tissue—like rubber bands—that connect one bone to another and bind the joints together. In the ankle joint, ligaments provide stability by limiting side-to-side movement.

Some ankle sprains are much worse than others. The severity of an ankle sprain depends on whether the ligament is stretched, partially torn or completely torn, as well as on the number of ligaments involved. Ankle sprains are not the same as strains, which affect muscles rather than ligaments.

Causes

Sprained ankles often result from a fall, a sudden twist or a blow that forces the ankle joint out of its normal position. Ankle sprains commonly occur while participating in sports, wearing inappropriate shoes or walking or running on an uneven surface.

Sometimes ankle sprains occur because a person is born with weak ankles. Previous ankle or foot injuries can also weaken the ankle and lead to sprains.

Symptoms

The symptoms of ankle sprains may include:

  • Pain or soreness
  • Swelling
  • Bruising
  • Difficulty walking
  • Stiffness in the joint

Ankle fractures are common injuries most often caused by the ankle rolling inward or outward. Many people mistake an ankle fracture for an ankle sprain, but they are quite different and therefore require an accurate and early diagnosis. They sometimes occur simultaneously.

Why Prompt Medical Attention Is Needed

There are four key reasons why an ankle sprain should be promptly evaluated and treated by a foot and ankle surgeon:

  • An untreated ankle sprain may lead to chronic ankle instability, a condition marked by persistent discomfort and a giving way of the ankle. Weakness in the leg may also develop.
  • A more severe ankle injury may have occurred along with the sprain. This might include a serious bone fracture that, if left untreated, could lead to troubling complications.
  • An ankle sprain may be accompanied by a foot injury that causes discomfort but has gone unnoticed thus far.
  • Rehabilitation of a sprained ankle needs to begin right away. If rehabilitation is delayed, the injury may be less likely to heal properly.

Diagnosis

In evaluating your injury, the foot and ankle surgeon will obtain a thorough history of your symptoms and examine your foot. X-rays or other advanced imaging studies may be ordered to help determine the severity of the injury.

Nonsurgical Treatment

When you have an ankle sprain, rehabilitation is crucial—and it starts the moment your treatment begins. Your foot and ankle surgeon may recommend one or more of the following treatment options:

  • Rest. Stay off the injured ankle. Walking may cause further injury.
  • Ice. Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
  • Compression. An elastic wrap may be recommended to control swelling.
  • Elevation. The ankle should be raised slightly above the level of your heart to reduce swelling.
  • Early physical therapy. Your doctor will start you on a rehabilitation program as soon as possible to promote healing and increase your range of motion. This includes doing prescribed exercises.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation. In some cases, prescription pain medications are needed to provide adequate relief.

When Is Surgery Needed?

In more severe cases, surgery may be required to adequately treat an ankle sprain. Surgery often involves repairing the damaged ligament or ligaments. The foot and ankle surgeon will select the surgical procedure best suited for your case based on the type and severity of your injury as well as your activity level.

After surgery, rehabilitation is extremely important. Completing your rehabilitation program is crucial to a successful outcome. Be sure to continue to see your foot and ankle surgeon during this period to ensure that your ankle heals properly and function is restored.

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Arthritis is a general term for a group of more than 100 diseases. Arthritis means “joint inflammation.” When it affects the ankle joint, it can produce swelling and pain and may eventually result in deformity, loss of joint function and decreased ability to walk.

The most common form of ankle arthritis is osteoarthritis. Similar symptoms may be caused by another form of arthritis, rheumatoid arthritis.

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.

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. X-rays may be ordered to evaluate the extent of the disease.

Non-surgical Treatment

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.
  • 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?

When osteoarthritis has progressed substantially or failed to improve with non-surgical treatment, surgery may be recommended. In advanced cases, surgery may be the only option. 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.

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Athlete’s foot is a skin infection caused by fungus. A fungal infection may occur on any part of the body; on the foot, it is called athlete’s foot, or tinea pedis. Fungus commonly attacks the feet because it thrives in a dark, moist and warm environment, such as a shoe.

Fungal infections are more common in warm weather when feet tend to sweat more.  Fungus thrives in damp areas, such as swimming pools, showers and locker rooms.  Athletes often have sweaty feet and use the facilities where fungus is commonly found, thus the term “athlete’s foot.”

Athlete’s foot usually produces itchy, dry, scaling skin. It is commonly seen on the soles of the feet and in between the toes. In advanced cases, inflammation, cracks and blisters may form; an infection caused by bacteria can also result. The fungus can spread to other areas of the body, including toenails.

Avoiding walking barefoot combined with good foot hygiene can help reduce the spread of the fungus. Feet should be washed every day with soap and water and thoroughly dried, including between the toes. Feet should be kept as dry as possible. If your feet sweat a lot you may need to change your socks during the day. Antifungal powders, sprays and/or creams are often used to treat athlete’s foot. Your foot and ankle surgeon will recommend the best treatment for you.

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Even though bunions are a common foot deformity, there are misconceptions about them. Many people may unnecessarily suffer the pain of bunions for years before seeking treatment.

What Is a Bunion?

A bunion (also referred to as hallux valgus) is often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. The big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment—producing the bunion’s bump.

Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which becomes increasingly prominent. Symptoms usually appear at later stages, although some people never have symptoms.

Causes

Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited but certain foot types that make a person prone to developing a bunion.

Although wearing shoes that crowd the toes will not actually cause bunions, it sometimes makes the deformity get progressively worse. Symptoms may therefore appear sooner.

Symptoms

Symptoms, which occur at the site of the bunion, may include:

  • Pain or soreness
  • Inflammation and redness
  • A burning sensation
  • Possible numbness

Symptoms occur most often when wearing shoes that crowd the toes, such as 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.

Diagnosis

Bunions are readily apparent—the prominence is visible at the base of the big toe or side of the foot. However, to fully evaluate the condition, the 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 do not go away and will usually get worse over time. But not all cases are alike—some bunions progress more rapidly than others. Once your surgeon has evaluated your bunion, a treatment plan can be developed that is suited to your needs.

Nonsurgical Treatment

Sometimes observation of the bunion is all that is needed. To reduce the chance of damage to the joint, periodic evaluation and x-rays by your surgeon are advised.

In many other cases, however, some type of treatment is needed. Early treatments are aimed at easing the pain of bunions, but they will not reverse the deformity itself. These 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.
  • Padding. Pads placed over the area of the bunion can help minimize pain. These can be obtained from your surgeon or purchased at a drug store.
  • Activity modifications. Avoid activity that causes bunion pain, including standing for long periods of time.
  • Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
  • 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 (fluid-filled sac located around a joint) sometimes seen with bunions.
  • Orthotic devices. In some cases, custom orthotic devices may be provided by the foot and ankle surgeon.

When Is Surgery Needed?

If nonsurgical treatments fail to relieve bunion pain and when the pain of a bunion interferes with daily activities, it is time to discuss surgical options with a foot and ankle surgeon. Together you can decide if surgery is best for you.

A variety of surgical procedures is available to treat bunions. The procedures are designed to remove the bump of bone, correct the changes in the bony structure of the foot and correct soft tissue changes that may also have occurred. The goal of surgery is the reduction of pain and deformity.

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.

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A callus is a thickened area of skin on the foot caused by pressure and repeated rubbing, such as from a shoe or sock. The rubbing causes the skin to produce a layer of protective skin (a callus). Calluses vary in size and can become painful.

There are a number of treatments for painful calluses. People who have calluses are cautioned against performing “bathroom surgery,” as this can lead to cuts and infection. A foot and ankle surgeon can evaluate the cause of the calluses and recommend the treatment most appropriate for your condition. However, if the underlying cause of the callus is not treated or removed, the callus may return.

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A corn is a small circular thickened lesion in the skin of the foot. It usually forms due to repeated pressure on the skin, such as the rubbing of a shoe. The name “corn” comes from its resemblance to a kernel of corn. A corn is different from a callus in that it has a central core of hard material.

People with foot deformities, such as hammertoes, often suffer from corns because the tops of the bent toes rub against the tops of shoes.

There are a number of treatment options for corns. When corns get hard enough to cause pain, a foot and ankle surgeon will recommend the treatment option most appropriate for you. However, if the underlying cause of the corn is not treated or removed, the corn may return. It is important to avoid trying to remove a corn at home or using medicated corn pads, as serious infection may occur.

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What Is Diabetic Peripheral Neuropathy?

Diabetic neuropathy is nerve damage caused by diabetes. When it affects the arms, hands, legs and feet, it is known as diabetic peripheral neuropathy. Diabetic peripheral neuropathy is different from peripheral arterial disease (poor circulation), which affects the blood vessels rather than the nerves.

Three different groups of nerves can be affected by diabetic neuropathy:

  • Sensory nerves, which enable people to feel pain, temperature and other sensations
  • Motor nerves, which control the muscles and give them their strength and tone
  • Autonomic nerves, which allow the body to perform certain involuntary functions, such as sweating

Diabetic peripheral neuropathy doesn’t emerge overnight. Instead, it usually develops slowly and worsens over time. Some patients have this condition long before they’re diagnosed with diabetes. Having diabetes for several years may increase the likelihood of having diabetic neuropathy. The loss of sensation and other problems associated with nerve damage make a patient prone to developing skin ulcers (open sores) that can become infected and may not heal. This serious complication of diabetes can lead to loss of a foot, a leg or even a life.

Causes

The nerve damage that characterizes diabetic peripheral neuropathy is more common in patients with poorly managed diabetes. However, even diabetic patients who have excellent blood sugar (glucose) control can develop diabetic neuropathy. There are several theories as to why this occurs, including the possibilities that high blood glucose or constricted blood vessels produce damage to the nerves.

As diabetic peripheral neuropathy progresses, various nerves are affected. These damaged nerves can cause problems that encourage development of ulcers. For example:

  • Deformities (such as bunions or hammertoes) resulting from motor neuropathy may cause shoes to rub against toes, creating a sore. The numbness caused by sensory neuropathy can make the patient unaware that this is happening.
  • Because of numbness, a patient may not realize that s/he has stepped on a small object and cut the skin.
  • Cracked skin caused by autonomic neuropathy, combined with sensory neuropathy’s numbness and problems associated with motor neuropathy, can lead to developing a sore.

Motor Neuropathy (Deformity) + Ill-fitting shoes + Sensory Neuropathy (numbness) = Ulcers (sores)

Symptoms

Depending on the type(s) of nerves involved, one or more symptoms may be present in diabetic peripheral neuropathy.

For sensory neuropathy:

  • Numbness or tingling in the feet
  • Pain or discomfort in the feet or legs, including prickly, sharp pain or burning feet

For motor neuropathy:

  • Muscle weakness and loss of muscle tone in the feet and lower legs
  • Loss of balance
  • Changes in foot shape that can lead to areas of increased pressure

For autonomic neuropathy:

  • Dry feet
  • Cracked skin

Diagnosis

To diagnose diabetic peripheral neuropathy, the foot and ankle surgeon will obtain the patient’s history of symptoms and will perform simple in-office tests on the feet and legs. This evaluation may include assessment of the patient’s reflexes, ability to feel light touch and ability to feel vibration. In some cases, additional neurologic tests may be ordered.

Treatment

First and foremost, treatment of diabetic peripheral neuropathy centers on control of the patient’s blood sugar level. In addition, various options are used to treat the painful symptoms.

Medications are available to help relieve specific symptoms, such as tingling or burning. Sometimes a combination of different medications is used.

In some cases, the patient may also undergo physical therapy to help reduce balance problems or other symptoms.

Prevention

The patient plays a vital role in minimizing the risk of developing diabetic peripheral neuropathy and in preventing its possible consequences. Some important preventive measures include:

  • Keep blood sugar levels under control.
  • Wear well-fitting shoes to avoid getting sores.
  • Inspect your feet every day. If you notice any cuts, redness, blisters or swelling, see your foot and ankle surgeon right away. This can prevent problems from becoming worse.
  • Visit your foot and ankle surgeon on a regular basis for an examination to help prevent the foot complications of diabetes.
  • Have periodic visits with your primary care physician or endocrinologist. The foot and ankle surgeon works together with these and other providers to prevent and treat complications from diabetes.

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What Is Flatfoot?

Flatfoot is often a complex disorder, with diverse symptoms and varying degrees of deformity and disability. There are several types of flatfoot, all of which have one characteristic in common: partial or total collapse (loss) of the arch. Other characteristics shared by most types of flatfoot include toe drift, in which the toes and front part of the foot point outward. The heel tilts toward the outside and the ankle appears to turn in. A tight Achilles tendon, which causes the heel to lift off the ground earlier when walking and may make the problem worse, bunions and hammertoes may develop as a result of a flatfoot.

Flexible Flatfoot

Flexible flatfoot is one of the most common types of flatfoot. It typically begins in childhood or adolescence and continues into adulthood. It usually occurs in both feet and progresses in severity throughout the adult years. As the deformity worsens, the soft tissues (tendons and ligaments) of the arch may stretch or tear and can become inflamed. The term “flexible” means that while the foot is flat when standing (weightbearing), the arch returns when not standing.

Symptoms

Symptoms that may occur in some persons with flexible flatfoot include:

  • Pain in the heel, arch, ankle or along the outside of the foot
  • Rolled-in ankle (overpronation)
  • Pain along the shin bone (shin splint)
  • General aching or fatigue in the foot or leg
  • Low back, hip or knee pain

Diagnosis

In diagnosing flatfoot, the foot and ankle surgeon examines the foot and observes how it looks when you stand and sit. X-rays are usually taken to determine the disorder’s severity. If you are diagnosed with flexible flatfoot, but you do not have any symptoms, your surgeon will explain what you might expect in the future.

Nonsurgical Treatment

If you experience symptoms with flexible flatfoot, the surgeon may recommend nonsurgical treatment options, including:

  • Activity modifications. Cut down on activities that bring you pain and avoid prolonged walking and standing to give your arches a rest.
  • Weight loss. If you are overweight, try to lose weight. Putting too much weight on your arches may aggravate your symptoms.
  • Orthotic devices. Your foot and ankle surgeon can provide you with custom orthotic devices for your shoes to give more support to the arches.
  • Immobilization. In some cases, it may be necessary to use a walking cast or to completely avoid weightbearing.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce pain and inflammation.
  • Physical therapy. Ultrasound therapy or other physical therapy modalities may be used to provide temporary relief.
  • Shoe modifications. Wearing shoes that support the arches is important for anyone who has flatfoot.
  • Ankle Foot Orthoses (AFO) devices. Your foot and ankle surgeon may recommend advanced bracing to modify your walking and to support your arches.

When Is Surgery Necessary?

In some patients whose pain is not adequately relieved by other treatments, surgery may be considered. Many surgical techniques are available to correct flexible flatfoot, and one or a combination of procedures may be required to relieve the symptoms and improve foot function. 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.

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A fungus is an organism that lives in warm moist areas. Fungus of the toenails is a common problem that can affect people of all ages, although it most commonly affects individuals who are older.

Toenail fungus often begins as an infection in the skin called tinea pedis (also known as athlete’s foot). The fungus often starts under the nail fold at the end of the nail. Over time, it grows underneath the nail and causes changes to its appearance, such as a yellow or brownish discoloration. It can also cause thickening and deformity of the toenail.

Many people have difficulty with their toenails and need assistance in caring for them. A foot and ankle surgeon can diagnose the cause of toenail problems and recommend treatments.

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What Is Hammertoe?

Hammertoe is a contracture (bending) deformity 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, causing problems to develop.

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 nonsurgical treatment.

Because of the progressive nature of hammertoes, they should receive early attention. Hammertoes never get better without some kind of intervention.

Causes

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) or neurological changes in the foot that occur over time in some people.

Hammertoes may be aggravated by shoes that do not fit properly. A hammertoe may result if a toe is too long and is forced into a cramped position when a tight shoe is worn. Occasionally, hammertoe is the result of an earlier trauma to the toe. In some people, hammertoes are inherited.

Symptoms

Common symptoms of hammertoes include:

  • Pain or irritation of the affected toe when wearing shoes.
  • Corns and calluses (a buildup of skin) on the toe, between two toes or on the ball of the foot. Corns are caused by constant friction against the shoe. They may be soft or hard, depending on their location.
  • Inflammation, redness or a burning sensation
  • Contracture of the toe
  • In more severe cases of hammertoe, open sores may form.

Diagnosis

Although hammertoes are readily apparent, 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 may attempt to reproduce your symptoms by manipulating your foot and will study the contractures of the toes. In addition, the foot and ankle surgeon may take x-rays to determine the degree of the deformities and assess any changes that may have occurred.

Hammertoes are progressive—they do not go away by themselves and usually they will get worse over time. However, not all cases are alike—some hammertoes progress more rapidly than others. Once your foot and ankle surgeon has evaluated your hammertoes, a treatment plan can be developed that is suited to your needs.

Nonsurgical Treatment

There is a variety of treatment options for hammertoe. The treatment your foot and ankle surgeon selects will depend on the severity of your hammertoe and other factors.

A number of nonsurgical measures can be undertaken:

  • Padding corns and calluses. Your foot and ankle surgeon can provide or prescribe pads designed to shield corns from irritation. If you want to try over-the-counter pads, avoid the medicated types. Medicated pads are generally not recommended because they may contain a small amount of acid that can be harmful. Consult your surgeon about this option.
  • Changes in shoewear. 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 toebox and heels no higher than two inches.
  • Orthotic devices. A custom orthotic device placed in your shoe may help control the muscle/tendon imbalance. Injection therapy. Corticosteroid injections are sometimes used to ease pain and inflammation caused by hammertoe.
  • Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation. Splinting/strapping. Splints or small straps may be applied by the surgeon to realign the bent toe.

When Is Surgery Needed?

In some cases, usually when the hammertoe has become more rigid and painful or when an open sore has developed, surgery is needed.

Often, patients with hammertoe have bunions or other foot deformities corrected at the same time. 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, the number of toes involved, your age, your activity level and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.

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Heel pain is most often caused by plantar fasciitis, a condition that is sometimes also called heel spur syndrome when a spur is present. 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 able to distinguish between all the possibilities and to 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.

Causes

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 nonsupportive footwear on hard, flat surfaces puts abnormal strain on the plantar fascia and can also lead to plantar fasciitis. This is particularly evident when one’s job requires long hours on the feet. Obesity and overuse may also contribute to plantar fasciitis.

Symptoms

The symptoms of plantar fasciitis are:

  • Pain on the bottom of the heel
  • Pain in the arch of the foot
  • Pain that is usually worse upon arising
  • Pain that increases over a period of months
  • Swelling on the bottom of the heel

People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they have 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.

Diagnosis

To arrive at a diagnosis, the foot and ankle surgeon will obtain your medical history and examine your foot. Throughout this process, the surgeon rules out all possible causes for your heel pain other than plantar fasciitis.

In addition, diagnostic imaging studies, such as x-rays or other imaging modalities, 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.

Nonsurgical Treatment

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 20 minutes several times a day helps reduce inflammation. Place a thin towel between the ice and your heel; do not apply ice directly to the skin.
  • 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.
  • Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.

If you still have pain after several weeks, see your foot and ankle surgeon, who may add one or more of these treatment approaches:

  • Padding, taping and strapping. Placing pads in the shoe softens the impact of walking. Taping and strapping help 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.

When Is Surgery Needed?

Although most patients with plantar fasciitis respond to nonsurgical treatment, a small percentage of patients may require surgery. If, after several months of nonsurgical treatment, you continue to have heel pain, surgery will 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. Wearing supportive shoes, stretching and using custom orthotic devices are the mainstay of long-term treatment for plantar fasciitis.

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What Is an Ingrown Toenail?

When a toenail is ingrown, it is curved 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 the toe is not painful, red, swollen or warm, a nail that curves downward into the skin can progress to an infection.

Causes

Causes of ingrown toenails include:

  • Heredity. In many people, the tendency for ingrown toenails is inherited.
  • Trauma. Sometimes 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.
  • Improper trimming. The most common cause of ingrown toenails is cutting your nails too short. This encourages the skin next to the nail to fold over the nail.
  • Improperly sized footwear. Ingrown toenails can result from wearing socks and shoes that are tight or short.
  • Nail conditions. Ingrown toenails can be caused by nail problems, such as fungal infections or losing a nail due to trauma.

Treatment

Sometimes initial treatment for ingrown toenails can be safely performed at home. However, home treatment is strongly discouraged if an infection is suspected or for those who have medical conditions that put feet at high risk, such as diabetes, nerve damage in the foot or poor circulation.

Home Care

If you do not have an infection or any of the above medical conditions, you can soak your foot in room-temperature water (adding Epsom salt may be recommended by your doctor) 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 is time to see a foot and ankle surgeon.

Physician Care

After examining the toe, the foot and ankle surgeon will select the treatment best suited for you. If an infection is present, an oral antibiotic may be prescribed.

Sometimes a minor surgical procedure, often performed in the office, will ease the pain and remove the offending nail. After applying a local anesthetic, the doctor removes part of the nail’s side border. Some nails may become ingrown again, requiring removal of the nail root.

Following the nail procedure, 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:

  • Proper trimming. Cut toenails in a fairly straight line, and do not cut them too short. You should be able to get your fingernail under the sides and end of the nail.
  • Well-fitting shoes and socks. Do not wear shoes that are short or tight in the toe area. Avoid shoes that are loose because they too cause pressure on the toes, especially when running or walking briskly.

What You Should Know About Home Treatment

  • Do not cut a notch in the nail. Contrary to what some people believe, this does not reduce the tendency for the nail to curve downward.
  • Do not repeatedly trim nail borders. Repeated trimming does not change the way the nail grows and can make the condition worse.
  • Do not place cotton under the nail. Not only does this not relieve the pain, it provides a place for harmful bacteria to grow, resulting in infection.
  • Over-the-counter medications are ineffective. Topical medications may mask the pain, but they do not correct the underlying problem.

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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 between 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. 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 enlargement of the nerve, eventually leading to permanent nerve damage.

Causes

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 court sports. An injury or other type of trauma to the area may also lead to a neuroma.

Symptoms

If you have a Morton’s neuroma, you may 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
  • A feeling that there is something 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 removing the shoe, massaging the foot or by avoiding aggravating shoes or activities.
  • 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.

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 or imaging studies 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 help you avoid surgery.

Nonsurgical Treatment

In developing a treatment plan, your foot and ankle surgeon will first determine how long you have had the neuroma and evaluate its stage of development. Treatment approaches vary according to the severity of the problem.

For mild to moderate neuromas, treatment options may 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 foot and ankle 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.
  • Shoe modifications. Wear shoes with a wide toe box and avoid narrow-toed shoes or shoes with high heels.
  • Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
  • Injection therapy. Treatment may include injections of cortisone, local anesthetics or other agents.

When Is Surgery Needed?

Surgery may be considered in patients who have not responded adequately to nonsurgical treatments. Your foot and ankle surgeon will determine the approach that is best for your condition. The length of the recovery period will vary, depending on the procedure performed.

Regardless of whether you have undergone surgical or nonsurgical treatment, your surgeon will recommend long-term measures to help keep your symptoms from returning. These include appropriate footwear and modification of activities to reduce the repetitive pressure on the foot.

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