Sunday, March 31, 2013

Treatment of Foot Problems Pt.3


A muscle imbalance or abnormal bone length can make one or more small toes buckle under, causing their joints to contract.  This in turn, causes the tendons to shorten.  Corns (build-ups of dead skin cells where shoes press and rub) often form on the contracted joint, and may become irritated and infected.
Flexible Hammertoes
When hammertoes are flexible, you can straighten the buckled joint with your hand.  Flexible hammertoes may progress to rigid hammertoes over time.  Corns, irritation, and pain are common symptoms.   Function is often limited as well.
Rigid Hammertoes
A rigid hammertoe is fixed; you can no longer straighten the buckled joint with your hand.  Corns, irritation, pain, and loss of function may be more severe for rigid hammertoes than for flexible ones.

Curled Fifth Toe
The little toe may curl inward underneath its neighbor so that the nail faces outward.  With this inherited problem, the fat pad on the bottom of the toe (normally used for walking) loses contact with the ground.  Corns and pain may result.

Plantar Calluses

Second Metatarsal Plantar Callus
When the second metatarsal bone is longer or lower than the others, it hits the ground first - and with more force than it is equipped to handle at every step.  As a result, the skin under this bone thickens.   Like a rock in your shoe, the callus causes irritation and pain.  The treatment for this is an osteotomy.  The second metatarsal bone is cut, and the end of the bone is then "lifted" and aligned with the other bones.

Heel Spurs
A heel spur is a bony overgrowth on your heel bone (see Plantar Fascitis).  It may be stimulated by muscles that pull from the heel bone along the bottom of the foot.  High-arched feet are especially apt to have too-tight muscles here.  Heel spurs may cause pain  when the foot bears weight.  They can be treated first with an injection, anti-inflammatory medication, as well as arch supports if indicated.  If this fails, they can then be treated with surgical excision and a plantar release.  The band of tight muscles is released to relieve the abnormal stress.  The bone spur is surgically removed.

When a nerve is pinched between two metatarsal bones (usually the third and forth metatarsals), enlargement of the nerve may occur.  Abnormal bone structure contributes to the cause, but too-tight shoes can aggravate the condition.  You may experience sharp pain in your toes that may become severe enough to keep you from walking.
Excision: A small portion of the nerve is removed.  As a result of this, a small area is usually permanently numbered, but this is preferable to pain.
Follow-up Care
You can usually bear weight right away, but you must return to have your dressing changed.  Keep your incision dry until the stitches are removed.

High-Arched Feet (Pes Cavus)
The shape of your foot often determines the kinds of foot problems you will have.  Your feet may have unusually high arches due to an imbalance of muscles and nerves, which is usually inherited.   Too high arches can cause various problems - tired or aching feet; and calluses.   High arches are not usually investigated with surgery but most often treated with arch supports.

Flat Feet (Pes Planus)
Flat feet can be hereditary and are caused by a muscle imbalance.  Feet with low, relaxed arches may bring on such problems as hammertoes and bunions; arch, foot, and leg fatigue; calf pain; and an overly tight heel cord (which makes the foot even flatter).  Loose joints move to freely, causing pain and instability.  Flat feet are also usually treated with arch supports.

Orthotics (also called orthoses or orthotic devices) are prescribed, custom0made arch supports.  They fit inside most shoes and "bring the floor up to your feet."
A podiatrist may prescribe them to help correct such problems as high arches and flat feet.  Also, following some foot surgeries, orthotics can help support the correction that was achieved.
To be fitted with orthotics, your podiatrist will first take an impression of your feet.  Your orthotics are then fashioned from leather, plastic, or other materials.  Their fit is checked at an office visit and adjustments can be made as you wear them.  Expect an initial "breaking-in" period; you may need to build up wearing time gradually (as you would with contact lenses).

Surgery Decision
If your bunions or hammertoes are bad enough, they may need surgical correction.  This is a gratifying operation that can provide both pain relief and improved appearance.
All surgery carries risks including stiffness, persistent pain and swelling, recurrence of problem, damage to nerves, hardware breakage, blood clots in the legs, anesthetic problems, inability to correct the problem, etc.  Make sure you understand the risks and alternatives prior to surgery.

Post-Operative Tips
Your recovery, like your foot problem and surgery, is as unique as you are.  In addition to the previous tips given on follow-up care for each surgery, here are some pointers that can help you recover quickly and without complications, and help get you back on your feet again.
Pain:  To help relive pain and reduce swelling in the first 24 to 48 hours after surgery, apply an ice pack to the affected area and elevate your foot above heart level, as recommended.  Pain is usually most severe the second and third days after surgery, and after you first begin to walk again.
Bathing:  You will need to keep your foot dry.  Getting the stitches wet can lead to infection, so be sure to keep your foot outside the shower or bath.
Weight-Bearing:  Bearing weight and walking can stimulate circulation and promote healing.  But overtaxing a healthy foot can detract from the results of your surgery.
Shoes:  Our team may give you a wide surgical shoe to wear on the affected foot.  A surgical shoe stabilizes and protects the foot as it heals.
Returning to Work: How soon you can return to work depends on the type of surgery you had and the activities you job requires.  You can generally return earlier to a desk job than to physical labor.   Consider beforehand how much time you can take off from work until you are back on your feet.

Thursday, March 28, 2013

Treatment of Foot Problems Pt.2

Anatomy of the Foot

Before you have your foot surgery, it helps to understand how your foot works in supporting you and carrying you from place to place.  Knowing how skin and bone heal following surgery can help you to better understand the importance of post-operative foot care during your recovery.
Ligaments are flexible bands of fiber joining bone to bone.  The foot has over 100 ligaments.  Joints form where two bones meet.  The 33 complex joints in each foot permit flexibility.  Bones form the basic supporting structure of your foot.  There are 26 bones in each foot.  Tendons are tough, fibrous cords that connect muscle to bones.  Muscles help move the feet and toes.  When a muscle contracts, it pulls on a tendon, which in turn moves the bone.

The Healing Process

All foot surgeries involve the skin, and in some cases, the bone inside must be cut as well.  When you understand the healing process, you can help make your foot surgery a success.
Skin heals in phases.   First, it grows together so the stitches can be removed.  The scar may look slightly inflamed; some redness and swelling are normal.  After about six months, the scar blends with the surrounding skin.
Bone also heals in phases.   A bone-like "cement" forms, bridging the affected bone and allowing it to bear weight.  Later, the extra bone is dissolved, and in about six months, the bone is back to normal strength.


A bunion is an enlargement of bone in the joint at the base of the big toe.  Bunions are most often inherited.   Tight shoes do not cause bunions, but they can aggravate them.  There are several types of bunions and surgical treatments for each.  Your surgery may be similar to some of the common examples listed.
Positional Bunion
A positional bunion develops when a bony growth on the side of the metatarsal bone enlarges the joint, forcing the joint capsule to stretch over it.  As this growth enlarges, it pushes the big toe toward the others making the tendons on the inside tighten.  This, in turn, forces the big toe further out of alignment.  The bunion presses against the shoe, irritating the skin, and causing further pain.
Structural Bunion
Structural bunions occur when the angle between the first and second metatarsal bones increases to a point where it is greater than normal.  The increase angle of the metatarsals makes the big toe bow toward the other toes.  Sometimes bony growths may form.  Irritation and swelling may often follow.  The tendency toward developing this painful condition is usually inherited.  A structural bunion becomes severe when the angle between the metatarsal bones of the first and second toes grows greater than the angle of a mild structural bunion.  Again, a tendency toward developing this condition is usually inherited.  The big toe bows toward the others, sometimes causing the second and third toes to buckle.  Irritation, swelling and pain may increase when tight shoes are worn.
Degenerative Disease
While not a true bunion, this condition is often associated with bunions.  Bunions, left untreated, can increase wear and tear in the joint of the big toe, break down the cartilage, and pave the way for degenerative diseases such as arthritis.  Pain and stiffness are symptoms of both.

Monday, March 25, 2013



Reasons for Foot Surgery

The more you know about what to expect, the more smoothly your treatment, either conservative or surgical, is likely to be.  While each problem is unique, there are three basic goals: to relieve pain, to restore function, or to improve the appearance of your feet.

Relieve Pain
Feet that hurt interfere with your work, family, and your social life.  Pain often signals an underlying problem.   Fortunately, in many cases, foot treatment can correct the problem and relieve the pain.

Restore Function
If your feet are not doing their job, it is hard for you to do yours.  When simply walking becomes a problem, your lifestyle is affected.  But accepting a life of hobbling or sitting on the sidelines can make you old before your time.  Foot surgery can be performed at almost any age - and in most cases, surgery can restore the normal use of your feet.

Improve Appearance
Although foot surgery is not usually performed for cosmetic reasons alone, it can often improve the appearance of your feet.

Thursday, March 21, 2013

Bunions Pt. 2

                                           Information on Bunions 


There are a few basic pointers to remember when buying shoes. Do not buy shoes by simply buying the size that you think you should fit into. The shoe must be tried on and worn in the store for several minutes until you make sure that it is not compressing your foot. The shoe itself should look as close as possible to the normal shape of a foot. You should realize that the size and shape of your feet will change as you get older. With age your arch generally flattens out slightly and your foot will become slightly longer. As well the left foot will not always be the same size as the right foot. Shoes should be fitted at the end of the day when your feet are at their largest due to gravity and natural occurrence. You should stand during the fitting process and make sure that you measure width as well as for length of the shoe. Do not expect your shoes to stretch to fit you.

Indications for Surgery

Pain is the commonest indication for bunion surgery. You may also notice redness and inflammation and usually this means that the bunion has progressed to a point that it will not respond to simple modification in shoe wear. Eventually that major joint of the big toe will become stiff and this makes it difficult for activities such as climbing stairs and sports.

Types of Bunion Surgery

There are many different procedures described to correct bunions. You should be aware that usually just shaving the bunion off, although it is attractive and minimally invasive, is usually not enough. Initially the foot will look much better but with time the bunion will recur.
Arthrodesis refers to surgery performed on the great toe joint where the joint is fused. This is usually reserved for people with very severe deformities when other surgical options are impossible.
Bunionectomy refers to the simple removal of the bunion itself. This is seldom used because it doesn’t correct the underlying bone problems.
Osteomety is the commonest surgical procedure. The bone is cut and the bones realigned and pinned in place until they heal so that the underlying bone deformity is corrected and the bunion will not recur.
The resection arstplasty refers to the removal of the toe joint and this creates a flexible scar that functions as the joint instead. In the past there has been some interest in implanting artificial joints but this has fallen out of favor due to the fact that they usually do not hold up with the normal every day stress that people put their feet through.

Surgical Results

All patients should understand pre-operatively what they can expect from the surgery. The majority of patients who have bunion surgery are very pleased with their results and have a significant improvement in both their cosmetic appearance as well as the pain. Surgery does not however make it possible to fit into smaller shoes for the purpose of cosmetic reasons. If this is done the bunion generally will recur. You have to wear good shoe wear after surgery.
You should also be aware of the risks and complications and alternatives such as infections, nerve injury and recurrence of the bunion and failure of the hardware. Other medical risks such as blood clots in the legs and risks related to the anesthetic must also be considered. Unfortunately no surgery can be formed that is actually risk free no matter what kind of surgery is performed. Generally speaking bunion surgery is safe and effective. Surgery is performed on an outpatient basis unless there is underlying medical problems. The patient will enter and leave the hospital on the same day and the patient will have a choice of different anesthetics such as spinal, general anesthetic and various nerve blocks. The anesthesiologist will discuss this with the patient in detail.

Post Operative Care

Crutches will need to be worn for the first few days. After that a special boot is placed on the bandage and the patient can weight bear but will have to wear that special post-op shoe for approximately 4-6 weeks to ensure proper healing. This dressing has to be kept clean and dry but usually the patient can get around for day to day activities quite well after just 2-3 days. But they will have to modify their activities during the 4-6 week healing period.

Monday, March 18, 2013

Information on Bunions


What is it?

A bunion is a very common foot deformity that develops over the first metatarsal phalageal joint of the big toe of the foot. The joint that joins the big toe to the foot is called the first MTP joint. When it becomes prominent and the big toe starts to become crooked this is known as a bunion. The term referring to deformity of the big toe as it becomes crooked is called Hallux Valgus. It is the bump itself that is known as the bunion. When it gets red and swollen over the bunion because it gets sore this is usually due to an inflamed soft tissue over the underlying bone.


The commonest cause of bunions is prolonged wearing of poorly designed shoes such as the narrow high heels that women wear. This is one of the reasons why bunions are much more common in women than in men. There is also a hereditary component to bunions in that many times we will see a grandmother, mother and daughter all with various stages of bunions. 38% of women in the United States wear shoes that are too small and 55% of women have some degree of bunion formation. Bunions are 9 times more common in women than they are in men.


Left untreated bunions will gradually become worse especially if women continue to wear the narrow pointed shoes. Not all bunions progress because if the patient starts wearing good shoewear and they are caught early enough they may not get any worse. In general however, they will certainly not get any better no matter how they are treated. We generally reserve surgical treatment for bunions that are painful. If they are not painful they should simply be observed and shoewear modified. Occasionally the patient will want the bunion corrected for cosmetic reasons.

Thursday, March 14, 2013

Treatment for "Sprained Ankle"


Ankle Arthroscopy
In the more mild forms of sprains the best treatment is known as R.I.C.E.  This is an acronym which stands for Rest, Ice, Compression, and Elevation.  The rest is quite self-explanatory and consists of non-weight bearing with crutches.  The ice should be applied as ice packs, and these should be applied for the first 72 hours as much as can be conveniently performed in order to keep the swelling down.  Compression consists of a tensor bandage which will help to limit the swelling, although occasionally a cast is required.  Elevation must be performed to help keep the swelling down.  This period of compression and elevation can often take up to 2-3 weeks if the sprain is bad enough.  As the pain subsides an exercise program with physiotherapy can be started to increase the strength of the ankle and foot muscles.  The advice of physiotherapists or similar knowledgeable individuals should be sought for proper teaching of these exercises.
Although somewhat controversial it is rare to operate on even severely sprained ankle injuries.  In the U.S.A., immobilization involving bracing and non-weight bearing with crutches is usually employed.
Depending upon the situation, the surgical repair for instability, whether acute or chronic, is a viable alternative and can be very gratifying.

  • Perform stretching exercises.
  • Use proper footwear.  Your shoe should have good lateral support, a relatively low heel (different from jogging shoes which have a built up heel and poor lateral stability) and rounded contours to avoid "going over."  Shoes with a higher boot top ("high cuts") may be indicated for those with chronic instability.  Lace-up ankle supports may be very helpful.
  • Avoid uneven surfaces which might include anything from your opponents foot to poor court flooring to uneven training ground.

Deciding on Surgery

If you get repeated ankle spraining easily, you may need to have your ligaments reconstructed.  This will re-stabilize your ankle and allow you to return to sport without constantly worrying about re-spraining your ankle.  It is a very satisfying procedure, but like all surgeries, does carry some elements of risk to it.  Discuss these risks/advantages with your doctor.

Monday, March 11, 2013

What is a "Sprained Ankle"

What is it?

A "sprained ankle" is one of the most common injuries a sports medicine physician encounters.  It is also one of the most poorly understood by lay persons and health care providers (including physicians), and is often under treated.  A severe ankle sprain, although treated properly, can still result in chronic instability of the ankle.  Fortunately, most are not severe and with quick and proper treatment these injuries heal well.


AnatomyThree essential ligaments cross the lateral (outside) surface of the ankle joint and are the most commonly injured with ankle sprains.
  • Anterior Talofibular Ligament (ATFL)
  • Posterior Talofibular ligament (PTFL)
  • Calcaneo Fibular Ligament (CFL)
Much more uncommonly, however, on the medial (inside) surface of the ankle joint, the deltoid ligament is injured.

Mechanisms of Injury

The injury is usually the result to the ankle turning in, commonly referred to as "going over the ankle."  In squash this can occur with sudden pivoting or cutting movements.  More often the ATFL and CFL are involved.

Classification of  Ankle Sprains
  • First Degree: Most common and often neglected.   The ligaments are stretched, not torn.  There may be minimal to mild swelling and no instability.  This patient usually treats him/herself and simply puts up with a sore ankle for a week or so.
  • Second Degree: Ankle ligaments are partially torn and bleeding into the surrounding soft tissue occurs resulting in ecchymosed (bruising and discoloration).  Swelling and pain may be very minimal initially and gradually worsen over the next few days peaking within a week.  This degree of tear requires varying degrees of immobilization and usually 3-6 weeks before the person van resume activities.
  • Third Degree: Most severe and ominous.   Represents complete disruption of at least the ATFL and CFL and sometimes the PTFL.   The ankle is unstable.  X-rays are normal.  Healing requires 8 to 10 weeks.

Thursday, March 7, 2013

The Lingering Effects of Whiplash

The Lingering Effects of Whiplash
Soft-tissue Injuries of the Cervical Spine 15-year Follow-up
Key Points from Dan Murphy
1)      At a mean of 15.5 years post whiplash trauma, 70% of whiplash-injured patients continued to complain of symptoms referable to the original accident.
2)      Long-term symptoms from whiplash injury include neck pain, arm paresthesia, back pain, headache, dizziness, and tinnitus.
3)      Women and older patients have a worse outcome from whiplash injuries.
4)      Radiating arm pain is more common in those with severe symptoms.
5)      Between 10 and 15 years after the accident, 18% of the patients had improved, whereas 28% had deteriorated.
6)      Soft-tissue injuries to the cervical spine may give persisting symptoms.
7)      Most whiplash-injured patients reach their final state by two years after being injured, but this study shows ongoing symptom fluctuation between years 10 to 15.
8)      At the 15-year follow-up, neck pain was present in 65% and low-back pain was present in 48%.
9)      80% of women and 50% of men continued to have symptoms at 15 years.
10)   Back pain and tinnitus increased between years 10 and 15.
11)   Symptoms remained static in 54%, improved in 18% and worsened in 28%.
12)   Degenerative changes are associated with a worse prognosis for recovery.
13)   60% of symptomatic patients had not seen a doctor in the previous five years because the doctors were unable to help them.
14)   18% had taken early retirement due to health problems, which they related to the whiplash injury.
15)   Whiplash symptoms do not improve after settlement of litigation.
16)   Most radiating pain is referral from the facets, and not radicular.
17)   Chronic whiplash symptoms will cause an abnormal psychological assessment after 3 months.
18)   In this study, 100% of patients with severe ongoing problems had cervical spine degeneration.