Patient Resources.

Ingrown Toe Nail

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 isn’t 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 don’t have an infection or any of the above medical conditions, you can soak your foot in room-temperature water (adding Epsom’s 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’s 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 don’t cut them too short. You should be able to get your fingernail under the sides and end of the nail.
• Well-fitted shoes and socks. Don’t 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
• Don’t cut a notch in the nail. Contrary to what some people believe, this does not reduce the tendency for the nail to curve downward.
• Don’t repeatedly trim nail borders. Repeated trimming does not change the way the nail grows, and can make the condition worse.
• Don’t 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 don’t correct the underlying problem.

Ankle Sprain

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

The symptoms of ankle These symptoms may vary in intensity, depending on the severity of the sprain. Sometimes pain and swelling are absent in people with previous ankle sprains. Instead, they may simply feel the ankle is wobbly and unsteady when they walk. Even if there is no pain or swelling with a sprained ankle, treatment is crucial. Any ankle sprain – whether it’s your first or your fifth – requires prompt medical attention.

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.

Non-surgical 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.

Flexible Flatfoot

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 (weight-bearing), the arch returns when not standing.

Symptoms

Symptoms, which 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 (over-pronation)
• 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 severity of the disorder. If you are diagnosed with flexible flatfoot but you don’t have any symptoms, your surgeon will explain what you might expect in the future.

Non-surgical Treatment

If you experience symptoms with flexible flatfoot, the surgeon may recommend non-surgical 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 weight-bearing.
• 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.

When is Surgery Necessary?

In some patients whose pain is not adequately relieved by other treatments, surgery may be considered. A variety of surgical techniques is 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.

Achilles Tendon

What Is the Achilles Tendon?

A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the “heel cord,” the Achilles tendon facilitates walking by helping to raise the heel off the ground.

Achilles Tendonitis and Achilles Tendonosis

Two common disorders that occur in the heel cord are Achilles tendonitis and Achilles tendonosis.

Achilles tendonitis is an inflammation of the Achilles tendon. This inflammation is typically short-lived. Over time, if not resolved, the condition may progress to a degeneration of the tendon (Achilles tendonosis), in which the tendon loses its organized structure and is likely to develop microscopic tears. Sometimes the degeneration involves the site where the Achilles tendon attaches to the heel bone. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.

Causes

As “overuse” disorders, Achilles tendonitis and tendonosis are usually caused by a sudden increase of a repetitive activity involving the Achilles tendon. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibers. Due to this ongoing stress on the tendon, the body is unable to repair the injured tissue. The structure of the tendon is then altered, resulting in continued pain.

Athletes are at high risk for developing disorders of the Achilles tendon. Achilles tendonitis and tendonosis are also common in individuals whose work puts stress on their ankles and feet, such as laborers, as well as in “weekend warriors” -those who are less conditioned and participate in athletics only on weekends or infrequently.

In addition, people with excessive pronation (flattening of the arch) have a tendency to develop Achilles tendonitis and tendonosis due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their over-pronation could further aggravate the Achilles tendon.

Symptoms

The symptoms associated with Achilles tendonitis and tendonosis include:

• Pain—aching, stiffness, soreness, or tenderness—within the tendon. This may occur anywhere along the tendon’s path, beginning with the tendon’s attachment directly above the heel upward to the region just below the calf muscle. Often pain appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
• Tenderness, or sometimes intense pain, when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.
• When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.

Diagnosis

In diagnosing Achilles tendonitis or tendonosis, the surgeon will examine the patient’s foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with x-rays or other imaging modalities.

Treatment

Treatment approaches for Achilles tendonitis or tendonosis are selected on the basis of how long the injury has been present and the degree of damage to the tendon. In the early stage, when there is sudden (acute) inflammation, one or more of the following options may be recommended

• Immobilization. Immobilization may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon and promote healing.
• Ice. To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
• Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation in the early stage of the condition.
• Orthotics. For those with over-pronation or gait abnormalities, custom orthotic devices may be prescribed.
• Night splints. Night splints help to maintain a stretch in the Achilles tendon during sleep.
• Physical therapy. Physical therapy may include strengthening exercises, soft-tissue massage/mobilization, gait and running re-education, stretching, and ultrasound therapy.

When is Surgery Needed?

If non-surgical approaches fail to restore the tendon to its normal condition, surgery may be necessary. The foot and ankle surgeon will select the best procedure to repair the tendon, based upon the extent of the injury, the patient’s age and activity level, and other factors.

Prevention

To prevent Achilles tendonitis or tendonosis from recurring after surgical or non-surgical treatment, the foot and ankle surgeon may recommend strengthening and stretching of the calf muscles through daily exercises. Wearing proper shoes for the foot type and activity is also important in preventing recurrence of the condition.

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 toenail, at the end of the toe. 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 specialist can diagnose the cause of toenail problems and recommend treatments.

Bunions (Hallux Abducto Valgus)

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 or hallux abducto 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 won’t 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 don’t 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.

Non-Surgical Treatment

Sometimes observation of the bunion is all that’s 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 won’t 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 creating 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 non-surgical treatments fail to relieve bunion pain and when the pain of a bunion interferes with daily activities, it’s time to discuss surgical options with a foot and ankle surgeon. Together you can decide if surgery is best for you.

Heel Pain (Plantar Fasciitis)

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 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 non-supportive 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 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

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

Non-Surgical 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 and strapping. Placing pads in the shoe softens the impact of walking. Strapping helps 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 non-surgical treatment, a small percentage of patients may require surgery. If, after several months of non-surgical 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.

Morton's Neuroma (Intermetatarsal Neuroma)

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’s 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 avoid surgery.

Non-surgical Treatment

In developing a treatment plan, your foot and ankle surgeon will first determine how long you’ve 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 non-surgical 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’ve 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.

Hammertoe

What Is Hammertoe?

Hammertoe is a contracture (bending) 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 non-surgical 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) changes in the foot that occur over time in some people.

Hammertoes may be aggravated by shoes that don’t 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 upon 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 don’t 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.

Non-surgical Treatment

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

A number of non-surgical 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 toe box 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.

Osteoarthritis of the Foot and Ankle

What Is Osteoarthritis?

Osteoarthritis is a condition characterized by the breakdown and eventual loss of cartilage in one or more joints. Cartilage (the connective tissue found at the end of the bones in the joints) protects and cushions the bones during movement. When cartilage deteriorates or is lost, symptoms develop that can restrict one’s ability to easily perform daily activities.

Osteoarthritis is also known as degenerative arthritis, reflecting its nature to develop as part of the aging process. As the most common form of arthritis, osteoarthritis affects millions of Americans. Some people refer to osteoarthritis simply as arthritis, even though there are many different types of arthritis. Osteoarthritis appears at various joints throughout the body, including the hands, feet, spine, hips, and knees. In the foot, the disease most frequently occurs in the big toe, although it is also often found in the midfoot and ankle.

Causes

Osteoarthritis is considered a “wear and tear” disease because the cartilage in the joint wears down with repeated stress and use over time. As the cartilage deteriorates and gets thinner, the bones lose their protective covering and eventually may rub together, causing pain and inflammation of the joint.

An injury may also lead to osteoarthritis, although it may take months or years after the injury for the condition to develop. For example, osteoarthritis in the big toe is often caused by kicking or jamming the toe, or by dropping something on the toe. Osteoarthritis in the midfoot is often caused by dropping something on it, or by a sprain or fracture. In the ankle, osteoarthritis is usually caused by a fracture and occasionally by a severe sprain.

Sometimes osteoarthritis develops as a result of abnormal foot mechanics such as flat feet or high arches. A flat foot causes less stability in the ligaments (bands of tissue that connect bones), resulting in excessive strain on the joints, which can cause arthritis. A high arch is rigid and lacks mobility, causing a jamming of joints that creates an increased risk of 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.