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tests/Surgeries
Tests
Diagnostic tests that may be performed include the following:
• Blood differential
• dorsiflexion-eversion
• Electromyography
• Joint x-rays
• MRI
• Muscle biopsy
• Nerve biopsy
• Nerve conduction velocity
• Synovial biopsy
• Synovial fluid analysis (shows uric acid crystals)
• X-ray
• Uric acid- blood
• Uric acid – urine
Surgeries
• Arthrodesis
• Bunionectomy
• Exostetectomy
• Osteotomy
• PIP arthroplasty
• Tendon and Ligament Repair
• Instep plantar fasciotomy
Non-Surgical Treatments
A bunion is a deformity that usually occurs at the head of one of the five long bones (the metatarsal bones) that extend from the arch and connect to the toes. A bunion typically develops in the
following way:
• Most often it occurs in the first metatarsal bone (the one that attaches to the big toe). A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone),
in which case it is known as a bunionette or tailor's bunion.
• A bunion begins to form when the big or little toe is forced in toward the rest of the toes, causing the head of the metatarsal bone to jut out and rub against the side of the shoe.
• The underlying tissue becomes inflamed, and a painful bump forms.
• As this bony growth develops, the bunion is formed as the big toe is forced to grow at an increasing angle towards the rest of the toes. One important bunion deformity, hallux valgus, causes
the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it.
Bunions can be caused by several conditions:
• Narrow high-heeled shoes with pointed toes can put enormous pressure on the front of the foot.
• Injury in the joint may cause a bunion to develop over time.
• Genetics play a role in 10 - 15% of all bunions.
Flat feet, gout, arthritis, and occupations (such as ballet) that place undue stress on the feet can also increase the risk for bunions.
Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can be relieved by wearing appropriate shoes, such as the following:
• Soft, wide, low-heeled leather shoes that lace up
• Athletic shoes with soft toe boxes
• Open shoes or sandals with straps that don't touch the irritated area
A thick doughnut-shaped, moleskin pad can protect the protrusion. In some cases, an orthotic can help redistribute weight and take pressure off the bunion. Nonsteroidal anti-inflammatory drugs
(NSAIDs) or corticosteroid injections may offer some pain relief.
Surgery. If discomfort persists, surgery may be necessary particularly for more serious conditions, such as hallux valgus. There are over 100 surgical variations ranging from removing the bump
to realigning the toes.
The most common surgery, an office procedure known as bunionectomy, involves shaving down the bone of the big toe joint. In one procedure the surgeon uses a very small incision, through which the
bone-shaving drill is inserted. The physician shaves off the bone, guided by feel or x-ray. It is not a cure, but patient satisfaction is high and results are long-lasting.
More extensive surgeries may be required to realign the toe joint. Although there are variations of each, they generally involve one or more of the following:
• Osteotomy (cutting and realigning the joint). Long-term studies on osteotomies report that 90% or more of patients are satisfied with the procedure.
• Exostetectomy (removal of the large bony growth. Only useful when there is no shift in the toe bone itself).
• Arthrodesis (removal of damaged portion of the joint, followed by implantation of screws, wires, or plates to hold the bones together until they heal.) This is the gold standard for very severe
cases or when previous procedures have failed. Good results have been reported in most patients.
• Arthroplasty (removal of damaged portion of the joint with the goal of achieving a flexible scar). This offers symptom relief and faster rehabilitation than arthrodesis, but has risk for deformity
and some foot weakness. It tends to be used in older patients. Biologic or synthetic implants for supporting the toes are showing promise as part of this procedure.
• Tendon and Ligament Repair. If tendons and ligaments have become too loose, the surgeon may tighten them.
In severe cases, surgeons are testing bone grafts to restore bone length in patients who have had previous bunion surgeries or when damage from osteoarthritis has occurred.
Complications, though uncommon in even the most complex procedures, can include:
• Continued pain
• Infection
• Possible numbness
• Irritation from implants used to support the bone
• Sometimes, the metatarsal bone is excessively shortened.
Recovery from more invasive procedures, such as arthrodesis or osteotomy, may take 6 - 8 weeks before a patient can put full weight on the foot. In such cases, patient will need to wear a cast
or use crutches. Elderly patients may need wheelchairs.
A hammertoe is a permanent deformity of the toe joint in which the toe bends up slightly and then curls downward, resting on its tip. When forced into this position long enough, the tendons of
the toe contract, and it stiffens into a hammer- or claw-like shape.
Hammertoe is most common in the second toe but may develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased
when the toes are already crowded by the pressure of a bunion. Lying down for long periods, diabetes, and various diseases that affect the nerves and muscles put people at risk.
Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it causes can usually be relieved by putting a toe pad, which are sold in drug stores, into the shoe. To help prevent and
ease existing discomfort from hammertoes, shoes should have a deep, wide toe area. As the tendon becomes tighter and the toe stiffens, other treatments, including exercises, splints, and custom-made
shoe inserts (orthotics) may help redistribute weight and ease the position of the toe.
Surgery. Surgery may be needed in some severe cases. If the toe is still flexible, only a simple procedure that releases the tendon may be involved. Such procedures sometimes only require a single
stitch and a Band-Aid. If the toe has become rigid, surgery on the bone is necessary, but it can still be performed in the doctor's office. A procedure called PIP arthroplasty involves releasing
the ligaments at the joint and removing a small piece of toe bone, which restores the toe to its normal position. The toe is held in this position with a pin for about 3 weeks then the pin is removed.
A 2000 study reported that after 5 years, 92% of patients who had arthroscopy were still pain free.
Forefoot Pain
The incidence of forefoot pain and deformity increases with age. With early diagnosis, conservative therapy is often successful in treating common disorders of the forefoot. When a cause cannot
be determined, any pain on the ball of the foot is generally referred to as metatarsalgia. It is most likely caused by improper footwear, particularly high heels, or by high-impact activities.
Calluses are composed of the same material as corns, hardened patches of dead skin cells. Calluses, however, develop on the ball or heel of the foot. The skin on the sole of the foot is ordinarily
about 40 times thicker than skin anywhere else on the body, but a callus can even be twice as thick. A protective callus layer naturally develops to guard against excessive pressure and chafing
as people get older and the padding of fat on the bottom of the foot thins out. If calluses get too big or too hard, they may pull and tear the underlying skin.
Risk factors for calluses include the following:
• Poorly fitting shoes
• Walking regularly on hard surfaces
• Flat feet
Of note, in people with diabetes, the presence of calluses is a strong predictor of ulceration, particularly in those who have a history of foot ulcers.
A neuroma usually means a benign tumor of a nerve. However, Morton’s neuroma, also called interdigital neuroma, is not actually a tumor. It is a thickening of the tissue surrounding the nerves
leading to the toes. Morton’s neuroma usually develops when the bones in the third and fourth toes pinch together, compressing a nerve. It can also occur in other locations. The nerve becomes enlarged
and inflamed. The inflammation causes a burning or tingling sensation and cramping in the front of the foot. Tight, poorly-fitting shoes, injury, arthritis, or abnormal bone structure may also
cause this condition.
Treatment for Neuromas. Pain from Morton's neuroma can be reduced by massaging the affected area. Roomier shoes (box-toe shoes), pads of various sorts, and cortisone injections in the painful area
are also helpful. A combination of cortisone injections and shoe modifications provides better immediate relief than changes in footwear alone.
If these treatments are not effective, the enlarged area may need to be surgically removed. In one long-term study of one surgeon's experience, 85% of patients reported satisfaction as being good
to excellent nearly six years after surgery. About 65% were pain free. Some numbness is common afterward but it rarely bothers patients. Occasionally, the nerve tissue may re-grow and form another
neuroma.
A stress fracture in the foot, also called fatigue or march fracture, usually results from a break or rupture in any of the five metatarsal bones (mostly the second or third). These fractures are
caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics. Women are at higher risk than men are. A fracture in the first metatarsal bone, which leads to the big
toe, is uncommon because of the thickness of this bone. If it occurs, however, it is more serious than a fracture in any of the other metatarsal bones because it dramatically changes the pattern
of normal walking and weight bearing.
Treatment for Stress Fractures. Patients should seek treatment if pain persists for 3 weeks. In a study of young athletes, treatment after that time was associated with a lower chance for returning
to their sport. Surgery may be needed if conservative measures fail. In most cases, however, stress fractures heal by themselves if rigorous activities are avoided. It is best to wear low-heeled
shoes with stiff soles. Some physicians recommend moderate exercise, particularly swimming and walking. Occasionally, a physician may recommend wearing a special wooden shoe and a compressive wrap
to make walking more comfortable.
Sesamoiditis is an inflammation of the tendons around the small, round bones that are embedded in the head of the first metatarsal bone, which leads to the big toe. Sesamoid bones bear much stress
under ordinary circumstances; excessive stress can strain the surrounding tendons. Often there is no clear-cut cause, but sesamoid injuries are common among people who participate in jarring, high-impact
activities, such as ballet, jogging, and aerobic exercise.
Treatment for Sesamoiditis. Rest and reducing stress on the ball of the foot are the first lines of treatment for sesamoiditis. A low-heeled shoe with a stiff sole and soft padding inside is all
that is usually required. In severe cases, surgery may be necessary.
Heel Pain
The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects 2 million Americans every year. It can occur in the front, back, or bottom of the heel. General treatment
guidelines are as follows:
• The American Orthopaedic Foot and Ankle Society (AOFAS) www.aofas.org suggests shoe inserts, medications, and stretching as a first line of therapy
for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after 8 weeks.
• If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy.
• Heel surgery to relieve pain may be performed for heel spurs, plantar fasciitis, bursitis, or neuroma.
• Surgery is not recommended until nonsurgical methods have failed for at least 6 months and preferably up to 12 months. Nonsurgical treatments for heel pain are effective in 90% of patients.
Plantar Fasciitis and Heel Spurs. Plantar fasciitis is a common foot problem that accounts for 1 million office visits per year. Plantar fasciitis occurs from small tears and inflammation in the
wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps to serve as a shock
absorber for the body. The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body. Most people with plantar fasciitis experience pain in the heel
with their first steps in the morning. The pain also often spreads to the arch. The condition can be temporary or may become chronic if the problem is ignored. In such cases, resting provides relief,
but only temporarily.
Heel spurs are calcium deposits that can develop under the heel bone as result of the inflammation that occurs with plantar fasciitis. Heel spurs and plantar fasciitis are sometimes blamed interchangeably
for pain, but plantar fasciitis can occur without heel spurs, and spurs commonly develop without causing any symptoms at all.
Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It is usually associated with overuse during high-impact exercise and sports and accounts for up to 9% of all running
injuries. Because the condition often occurs in only one foot, however, factors other than overuse are likely to responsible in many cases. Other causes of this injury include poorly-fitting shoes,
lack of calf flexibility, or an uneven stride that causes an abnormal and stressful impact on the foot.
Treatment Goals. The three major treatment goals for plantar fasciitis are:
• Reducing inflammation and pain
• Reducing pressure on the heel
• Restoring strength and flexibility
Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads as needed reduces the risk for future surgery. Pain that is not relieved by NSAIDs may require more
intensive treatments, including leg supports and even surgery.
Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:
• Put the hands on a wall and lean against them.
• Place the uninjured foot on the floor in front of the injured foot. The injured foot in back should have the heel off the floor.
• Stretch the back leg and foot gently.
With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such
as walking, swimming, or cycling) also seems to be beneficial.
Medications to Relieve Pain and Reduce Inflammation.
• NSAIDs. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil).
• Corticosteroids. Corticosteroids, or steroids, are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as xylocaine) may provide relieve in severe cases
of plantar fasciitis. (Steroid injections are not used for pain that is only due to heel spurs). For athletes or performers who need immediate relief, an effective method is to administer the steroid
dexamethasone using a procedure called iontophoresis, which introduces the drug into the foot's tissue using an electrical current.
Reducing Pressure on the Heel. Several approaches can relieve pressure on the heel, including:
• Sturdy Shoes and Insoles. It is important to wear comfortable but sturdy shoes that have thick soles, rubber heels, and a sole insole to relieve pressure. (An insole with an arch support might
also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support the rest of the heel while relieving pressure on the painful spot
itself. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics. A 2001 study
indicated, however, that patients may comply better with custom-made orthotics.
• Night Splints. Some evidence suggests that splints worn at night may be helpful for some people. One device, for example, uses an Ace bandage and an L-shaped fiberglass splint to keep the foot
stretched while the patient is sleeping. This allows the muscle to heal. One study reported that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients.
Although patient compliance may be better with custom-made prescribed orthotics than with tension night splints, one study has found they are equally effective in improving pain.
• Elevated Heels. Some people report that mild symptoms may be relieved with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is
not recommended for anyone with a moderate to severe condition. (Heel cups have not been proven to be very useful.)
Extracorporeal Shock Wave Therapy. In 2002, the FDA approved extracorporeal shock wave therapy (ESWT) for treatment of plantar fasciitis. ESWT is increasingly being used as an alternative to surgery
for patients who have not responded to other treatments. The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which triggers healing of the tissues that are causing
the pain. ESWT is performed at an outpatient surgical facility and involves local anesthesia and conscious sedation. Several long-term studies have shown benefits lasting a year or more, although
other short-term studies have suggested that the treatment is ineffective. Results are not usually seen until at least 3 months after treatment.
Surgery. Surgery is appropriate in about 5% of patients, typically those who have disabling heel pain for at least a year that does not respond to other treatments. A typical surgery is called
instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing and therefore releasing part of the plantar fascia.
The standard procedure uses a large incision and takes about 2 months to resume complete normal activity. A less invasive variant uses a procedure called endoscopy that employs small incisions
and is proving to be effective.
For either approach, some studies report good to excellent pain relief in 80 - 90% of patients. In one study, however, half of the patients were dissatisfied because the procedure didn't work or
because recovery took too long. In another 2000 study, about 15% of the patients reported long-lasting complications, including pain from scar tissue and continued heel pain. Pain is more likely
when more than half of the plantar fascia was released during surgery.
Wearing a below-the-knee walking cast after the operation for two weeks may reduce the need for pain relief and speed recovery time compared to use of crutches.
Botox. Research shows that injections of botulinum toxin (Botox), a protein used to temporarily paralyze certain muscles, reduces pain and improves patient's ability to walk.
Bursitis of the heel is an inflammation of the bursa, a small sack of fluid, beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) and steroid
injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.
Haglund's deformity, known medically as posterior calcaneal exostosis, is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe repeatedly
rubs against the back of the heel, aggravating the tissue and the underlying bone. It is commonly called pump bump because it frequently occurs with high heels. (It can also develop in runners,
however.)
Treatment for Haglund's Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil)
will also reduce pain. Your doctor may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.
In severe cases, surgery may be necessary to remove or reduce the bony growth. According to one study, however, surgery was not effective for over 30% of patients and, in fact, 14% experienced
a worse condition afterward. A more recent study reported that surgery cured 90% of cases, but full recovery required 6 months to 2 years. Experts advise patients to try all conservative measures
before choosing surgery.
Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury and is most common in people
who engage in high-impact exercise, particularly jogging, racquetball, and tennis.
People at highest risk for this disorder from these activities are those with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and may bounce when they
walk. A shortened tendon can be due to an inborn structural abnormality, or it can develop from regularly wearing high heels.
Evidence is uncertain about the best way to treat either acute or chronic Achilles tendinitis. Some approaches include:
Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) may help to ease pain and reduce inflammation. It is also
helpful to apply ice four or five times a day for 20 to 30 minutes. (Note: Corticosteroid injections are sometimes used, although evidence suggests they don't help very much, while also posing
a risk for rupture of the tendon.)
Gentle Stretching. Gentle calf muscle stretches may also help reduce the pain and spasms. If the calf is swollen, elevating the leg is recommended. Exercise is safe when the heel is no longer swollen
or tender, even if pain is still present. If pain increases with exercise, stop immediately.
Laser Therapy. Low-level laser therapy that emits energy directed at pain trigger points has helped some patients. No strong evidence supports its use to date, however.
Surgery vs. Nonsurgical Treatment. If pain continues, the ruptured tendon will require a cast and perhaps surgery. Although some experts believe a cast is sufficient in many cases, without an operation,
the tendon has a 38% chance of rupturing again. Some experts suggest surgery for active persons and nonsurgical treatment for older people.
Surgery requires a long incision with a postoperative period of immobilization that can average 6 weeks. Complications can include a significant surgical scar, infection, and muscle atrophy, although
surgery reduces pain and preserves foot function in the long term. Less invasive techniques are being tested. In one study, selected patients with ruptured tendons were hospitalized for about 5
days and fitted with special footgear (Variostabil that continuously raised the back of the foot). The footgear was effective for most patients, and the tendon ruptured again in only 5% of these
cases.
Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and
pull the fascia. It can cause not only heel pain, but also hip, knee, and lower back problems.
Arch Pain
Tarsal tunnel syndrome results from compression of a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It can cause pain anywhere along the bottom of the foot.
It is often associated with diabetes, back pain, or arthritis. It may also be caused by injury to the ankle or by a growth, abnormal blood vessels, or scar tissue that press against the nerve.
Magnetic resonance (MR) imaging and the dorsiflexion-eversion test are being used to diagnose this syndrome.
Treatment for Tarsal Tunnel Syndrome. Pain from tarsal tunnel syndrome may be relieved by treatment with orthotics, specially designed shoe inserts, to help redistribute weight and take pressure
off the nerve. Corticosteroid injections may also help. Surgery is sometimes performed, particularly if symptoms persist for more than a year, although its benefits are under some debate. Tarsal
tunnel syndrome caused by known conditions, such as tumors or cysts, may respond better to surgery than when the cause is not known. Recovery from this surgery can take months before a person can
resume normal activity. It should be performed by only experienced surgeons.
Flat foot, or pes planus, is a defect of the foot that eliminates the arch. The condition is most often inherited. Arches, however, can also fall in adulthood, in which case the condition is sometimes
referred to as posterior tibial tendon dysfunction (PTTD). This occurs most often in women over 50, but it can occur in anyone. The following are risk factors for PTTD:
• Wearing high heels for long periods of time is a particular risk for flat feet. In such cases, over the years, the Achilles tendon in the back of the calf shortens and tightens, so the ankle
does not bend properly. The tendons and ligaments running through the arch then try to compensate. Sometimes they break down, and the arch falls.
• Some studies have indicated that the earlier one starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet later on.
• Other conditions that can lead to PTTD include obesity, diabetes, surgery, injury, rheumatoid arthritis, or use of corticosteroids.
Some research suggests that flat feet in adults can, over time, actually exert abnormal pressure on the ankle joint that can cause damage. One indirect complication of flat arches may be urinary
incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence. Nevertheless, whether flat feet
pose any significant problems in adults is unknown. For example, a 2002 study on athletes with flat feet indicated that they had no higher risk for leg or foot injuries than athletes with normal
arches.
Treatment for Flat Feet in Children. Children with flat feet often outgrow them, particularly tall, slender children with flexible joints. One expert suggests that if an arch forms when the child
stands on tip-toes, then the child will probably outgrow the condition. For certain children, minimally invasive surgery to implant temporary corrective screws into the arch may be an option.
Treatment for Flat Feet in Adults. In general, conservative treatment for flat feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain relief and insoles or custom-made orthotics
to support the foot and prevent progression.
In severe cases, surgery may be required to correct the foot posture, usually with procedures called osteotomies or arthrodesis, which typically lengthen the Achilles tendon and adjusting tendons
in the foot. One procedure uses an implant to support the arch. These procedures have potential complications and conservative methods should be tried first.
An overly-high arch (hollow foot) can cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least.
Contrary to the general impression, the hollow foot is much more common than the flat foot.
Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but can also occur when muscles in the foot contract or become
unbalanced due to nerve or muscle disorders.
Reviewed By: Andrew L. Chen, M.D., M.S., Orthopedist, The Alpine Clinic, Littleton, NH. Review provided by VeriMed Healthcare Network.
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