Foot & Ankle

At some point, almost everyone will have a problem with their feet. Most can be avoided by wearing correctly sized shoes and by regularly inspecting the feet.

Bunions
When the joint at the big toe grows, it becomes painful and may swell. Often, it is tender. Bunions can be a result of shoes that fit poorly, inherited as a family trait, or develop for no obvious cause.

The first step and most critical step is to wear shoes that do not cause pressure on the bunion. This alone may relieve the pain. In severe cases, bunions can be disabling, and surgery may be necessary to reduce the discomfort.

Heel pain
This pain is most commonly caused by an inflammation of the connective tissue on the sole of the foot where it attaches to the heel bone. Often a bony protrusion (heel spur) is seen on X-rays, however the heel spur does not cause the pain. Heel pain is quite common, and may begin without any injury.

Pain under the heel often feels worse when getting out of bed.

Most cases improve spontaneously. It may be helpful to stretch the Achilles tendon, take medication to reduce swelling and/or use shoe inserts. Steroid injections or walking casts may be used if the pain does not improve. Rarely is surgery needed.

Morton’s neuroma
When the nerve between the third and fourth metatarsal bones is pinched, radiating pain may be experienced into the third and fourth toes. The primary cause of this problem is tight shoes that squeeze foot bones together, triggering the nerve to form a neuroma. This buildup of extra tissue in the nerve can cause marked discomfort.

Initial treatment should consist of wearing wider shoes and taking nonsteroidal anti-inflammatory medication which can decrease the swelling around the nerve. Using a pad on the sole of the foot can help spread the bones and decrease pressure on the nerve. Cortisone may be injected around the nerve. Surgery to remove the neuroma is a last resort.

Corns and calluses
Pressure on the foot’s skin may result from bones of the foot pressing against the shoe or two bones in the foot pressing together. This can result in the formation of a corn or callus. These are usually found on the big toe and the fifth toe. Soft corns can occur between the toes.

First, relieve pressure by modifying the shoe in the area of pressure. If a callus forms between the toes, lambs wool placed between the toes can be effective in decreasing the pressure. On occasion, the bony prominence causing the corn or callus may have to be surgically removed.

Hammertoes
One of several types of toe deformities, a hammertoe has a bend in the middle toe joint. The resulting deformity can cause pain on the top or at the end of the toe. Tight shoes will aggravate the pain.

Shoes that accommodate the deformed toe decrease the pressure and help relieve the pain. Shoe inserts or pads also may help. If these treatments do not relieve the discomfort, surgical treatment may be necessary.

Plantar warts
These are warts that look like calluses and appear on the sole of the foot. They can be very painful. A viral infection creates these warts that always grows inward. The wart cannot grow outward because of weight placed on it when standing. More than one may occur.

Severe pain may be experienced when walking. Plantar warts are hard to treat. Repeated applications of salicylic acid (available over the counter) helps to soften the overlying callus and expose the virus. Other treatments include injecting the warts with medication, freezing the warts with liquid nitrogen and, very rarely, surgery.

Sprained ankle
This is a common injury. Upwards of 25,000 people sprain their ankle each day.

Cause:
The ankle’s ligaments hold the ankle bones in the proper position. As an elastic structure, ligaments stretch within their limits, and then return to their normal positions. When a ligament is stretched beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers.

People who have sprained their ankle in the past may have recurrent sprains if the ligaments do not have time to completely heal.

Chronic problems (pain and/or instability) may develop if range of motion, strength and balance sense (proprioception) are not reestablished before returning to vigorous sport or activity.

Treatment:
Most ankle sprains will heal within four to six weeks. You may need to use crutches if walking causes pain. Usually swelling and pain will last two to three days. However, with severe sprains, the pain and swelling may last for 4-6 weeks.

After a sprain, immediately follow the RICE formula: rest, ice, compression and elevation. Rest the ankle by minimizing walking. Ice immediately for 20-30 minutes three or four times a day to keep the swelling down. Compress the ankle using dressings, bandages or Ace-wraps to immobilize and support the injured ankle. Elevate the ankle above the heart level for 48 hours.

For more severe sprains, the physician may recommend a device to immobilize or splint the ankle, a short leg cast or a cast-brace.

All ankle sprains recover through three stages: 1) rest, protect the ankle and reduce swelling during week one; 2) restore range of motion, strength and flexibility over one to two weeks; and 3) gradually return to activities while avoiding activities that require turning or twisting the ankle. Do maintenance exercises.

The goal is to increase strength and range of motion as balance improves over time.

Diabetic foot
People with diabetes should regularly monitor their feet, as the consequences of foot injuries can be severe, including amputation.

Minor injuries can quickly become major emergencies. Diabetes decreases blood flow, so injuries are slow to heal. With a diabetic foot, a wound as small as a blister can cause a lot of damage. A wound that is not healing is at risk for infection. Infections in a diabetic can spread quickly.

Cause:
People with diabetes should inspect their feet every day looking for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, scratches, cuts and nail problems. Feel each foot for swelling. Examine between toes. Check the bottom of each foot. Avoid tight shoes that may cause pressure and create damage to the skin.

If there are any injuries, go to a doctor right away.

Prevention:
Diabetic patients should take good care of their feet:
• Wash feet every day with mild soap and warm water. Be sure to dry between toes.
• Use quality lotion to keep the skin soft and moist. Don’t put any lotion between the toes.
• Trim toenails straight across. Use a nail file or emery board. If you find an ingrown toenail, see a doctor.
• Don't use antiseptic solutions, drugstore medications, heating pads or sharp instruments on your feet.
• Keep your feet warm. Wear loose socks to bed. Don't get your feet wet in snow or rain.
• Keep blood supply flowing to your feet. Don't sit cross-legged or smoke.

Here's some basic advice about shoes and socks: Never walk barefoot or in sandals or thongs. Choose and wear your shoes carefully. Buy new shoes late in the day when your feet are larger. Wear new shoes for only two hours or less at a time. Don't wear the same pair everyday. Inspect the inside of each shoe before putting it on. Don't lace your shoes too tightly or loosely. Wear clean, dry socks everyday. Avoid socks with holes or wrinkles. Thin cotton socks are more absorbent for summer wear. Square-toed socks will not squeeze your toes. Avoid stockings with elastic tops.

Treatment:
Ulcers can cause infection to develop in the foot. Another problem is the development of Charcot (pronounced "sharko") change in the foot and ankle. This is one of the most serious foot problems a diabetic can face. It deforms the foot because the bones fracture and disintegrate. Unfortunately, the person experiences no pain and continues to walk.

A total contact cast may be used to treat diabetic foot ulcers and early phases of Charcot fractures. These can be effective in the healing process by distributing weight and relieving pressure. The cast is changed is changed as the swelling goes down.

A custom-walking boot may be used after the total contact cast to support the foot until all the swelling goes down, which can take as long as a year. Surgery is considered if the deformity is too severe for a brace or shoe.

Posterior tibial tendon dysfunction
Tendons connect muscles to bones and stretch across joints. When the muscle fires, the joint moves. The posterior tibial tendon starts in the calf, stretches behind the inside of the ankle and attaches to bones in the middle of the foot. It helps hold the arch up and provides support when walking. When this tendon becomes inflamed, over-stretched or torn, pain on the inner ankle may be felt. Stretching or tearing of the tendon can lead to the development of a flatfoot.

Cause:
Posterior tibial tendon dysfunction often occurs in women over 50 years of age and may be due to an inherent abnormality of the tendon. Other risk factors include obesity, diabetes, hypertension, inflammatory diseases, local steroid injections or previous surgery or trauma.

Treatment:
Without treatment, the resulting flatfoot will eventually become painful. Treatment depends on how far the condition has progressed. In the early stages, it can be treated with rest, anti-inflammatory drugs such as aspirin or ibuprofen, and immobilization of the foot for six to eight weeks with a rigid below-knee cast or boot. Once the cast is removed, a heel wedge or arch support inserted in shoes may be helpful. For advanced conditions, a custom-made ankle-foot orthosis or support may be necessary.

If conservative treatments aren’t effective, surgery may be needed.

Stress fractures of the foot and ankle
Overuse can cause tiny cracks in bones. As a result muscles become fatigued and can no longer absorb the shock of repeated impacts. When the muscles transfer the stress to the bones, a small crack or fracture is created. Most stress fractures occur in the weight bearing bones of the foot and lower leg.

Cause:
Various activities can lead to stress fractures. People who participate in high-impact sports or who move from a sedentary lifestyle to a more active one may experience stress factures. Stress fractures can be seen in runners who increase their training too rapidly, change the running surface, or change their model of running shoe may develop stress fractures.

Prevention:
Stress fractures that don't heal properly can develop into complete breaks of the bone and can become a chronic problem.

Prevention is critical:
• Maintain a healthy diet, including calcium-rich foods to help build bone strength.
• Don't wear old or worn running shoes.
• Alternate exercise activities. This can be done with cross training. Participate in running, swimming and bike riding.
• Gradually increase time, speed and distance for any new sports activity. Try for a weekly increase of 10 percent.
• If pain or swelling returns, stop the activity. Rest for a few days. If pain continues, see a doctor.

Treatment:
Most stress fractures will heal by reducing the activity level and wearing protective shoes for two to four weeks. Your physician may recommend a stiff-soled shoe, a wooden-soled sandal, or a removable short leg fracture brace shoe. It’s important to put less stress on the foot and leg. Swimming and bicycle riding are good alternative activities.

Some stress fractures take up to eight weeks to heal. Your physician may apply a cast to your foot or recommend that you use crutches until the bone heals. In some cases, you may need surgery.