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Achilles Tendon

According to the Greek myth, Achilles was vulnerable only at his heel. It’s a trait that he must have passed down to all other humans when he gave his name to the Achilles tendon, which connects the calf muscles to the heel bone.

The Achilles tendon is the largest tendon in the human body and can withstand forces of 1,000 pounds or more. But it is also the most frequently ruptured tendon, and both professional and weekend athletes can suffer from Achilles tendinitis, a common overuse injury and inflammation of the tendon.

Any number of events may trigger an attack of Achilles tendinitis, including:

• rapidly increasing your running mileage or speed
• adding hill running or stair climbing to your training routine
• starting up too quickly after a layoff
• trauma caused by sudden and/or hard contraction of the calf muscles when putting out extra effort such as in a final sprint
• overuse resulting from the natural lack of flexibility in the calf muscles

Symptoms of Achilles tendinitis fall into a common pattern.

• Mild pain after exercise or running that gradually worsens
• A noticeable sense of sluggishness in your leg
• Episodes of diffuse or localized pain, sometimes severe, along the tendon during or a few hours after running
• Morning tenderness about an inch and a half above the point where the Achilles tendon is attached to the heel bone
• Stiffness that generally diminishes as the tendon warms up with use
• Some swelling

Because several conditions such as a partial tendon tear and heel bursitis have similar symptoms, you need to see your orthopaedic surgeon for a proper diagnosis.

Treatment depends on the degree of injury to the tendon, but usually involves

• Rest, which may mean a total withdrawal from running or exercise for a week, or simply switching to another exercise, such as swimming, that does not stress the Achilles tendon
• Nonsteroidal anti-inflammatory medication
• Orthoses, which are devices to help support the muscle and relieve stress on the tendon such as a heel pad or shoe insert
• A bandage specifically designed to restrict motion of the tendon
• Stretching, massage, ultrasound and appropriate exercises to strengthen the weak muscle group in front of the leg and the upward foot flexors

Surgery is often an option of last resort. If friction between the tendon and its covering sheath makes the sheath thick and fibrous, surgery to remove the fibrous tissue and repair any tears may be the best treatment option. Recovery is slow, may require a temporary cast and includes a rehabilitation program to avoid weakness.

You may not be able to prevent Achilles tendinitis, but here are six steps to reduce your risk of incurring an attack:

• Choose your running shoes carefully. They should provide sufficient cushion for the heel strike. Using a prescribed orthotic to change the position of a poorly aligned heel bone may also help. Perhaps the best precaution is to know your limits and to follow a sensible program when you exercise.
• Walk and stretch to warm up gradually before running. It’s better to spend few minutes warming up than to spend months on the sidelines with a ruptured Achilles tendon.
• Focus on stretching and strengthening the muscles in the calf.
• Increase your running distance and your speed gradually, in increments no greater than 10% a week.
• Avoid unaccustomed strenuous sprinting, hill running and the like.
• Cool down properly after exercise.

Adult (Acquired) Flatfoot

There’s an easy way to tell if you have flat feet. Simply wet your feet, then stand on a flat, dry surface that will leave an imprint of your foot. A normal footprint has a wide band connecting the ball of the foot to the heel, with an indentation on the inner side of the foot. A foot with a high arch has a large indentation and a very narrow connecting band. Flat feet leave a nearly complete imprint, with almost no inward curve where the arch should be.

Most people have "flexible flatfoot" as children; an arch is visible when the child rises up on the toes, but not when the child is standing. As you age, the tendons that attach to the bones of the foot grow stronger and tighten, forming the arch. But if injury or illness damages the tendons, the arch can "fall," creating a flatfoot.

In many adults, a low arch or a flatfoot is painless and causes no problems. However, a painful flatfoot can be a sign of a congenital abnormality or an injury to the muscles and tendons of the foot. Flat feet can even contribute to low back pain. If the condition progresses, you may experience problems with walking, climbing stairs and wearing shoes. See your doctor if:

• Your feet tire easily or become painful with prolonged standing.
• It’s difficult to move your heel or midfoot around, or to stand on your toes.
• Your foot aches, particularly in the heel or arch area, with swelling along the inner side.
• Pain in your feet reduces your ability to participate in sports.
• You’ve been diagnosed with rheumatoid arthritis; about half of all people with rheumatoid arthritis will develop a progressive flatfoot deformity.

Diagnosing Flatfoot

Although you can do the "wet test" at home, a thorough examination by a doctor will be needed to identify why the flatfoot developed. Possible causes include a congenital abnormality, a bone fracture or dislocation, a torn or stretched tendon, arthritis or neurologic weakness. For example, an inability to rise up on your toes while standing on the affected foot may indicate damage to the posterior tibial tendon (PTT), which supports the heel and forms the arch. If "too many toes" show on the outside of your foot when the doctor views you from the rear, your shinbone (tibia) may be sliding off the anklebone (talus), another indicator of damage to the PTT.

Be sure to wear your regular shoes to the examination. An irregular wear pattern on the bottom of the shoe is another indicator of acquired adult flatfoot. Your physician may request X-rays to see how the bones of your feet are aligned. Muscle and tendon strength are tested by asking you to move the foot while the doctor holds it.

Treatment Options A painless flatfoot that does not hinder your ability to walk or wear shoes requires no special treatment or orthotic device. Other treatment options depend on the cause and progression of the flatfoot. Conservative treatment options include:

• Making shoe modifications
• Using orthotic devices such as arch supports and custom-made orthoses
• Taking nonsteroidal anti-inflammatory drugs such as ibuprofen to relieve pain
• Using a short-leg walking cast or wearing a brace
• Injecting a corticosteroid into the joint to relieve pain
• Rest and ice
• Physical therapy

In some cases, surgery may be needed to correct the problem. Surgical procedures can help reduce pain and improve bone alignment. Types of surgery your orthopaedist may discuss with you include:

• Arthrodesis, or welding (fusing) one or more of the bones in the foot/ankle together
• Osteotomy, or cutting and reshaping a bone to correct alignment
• Excision, or removing a bone or bone spur
• Synovectomy, or cleaning the sheath covering a tendon
• Tendon transfer, or using a piece of one tendon to lengthen or replace another

Arthritis of the Foot and Ankle

There are more than 100 different types of arthritis. But when most people talk about arthritis, they are usually referring to the most common form, osteoarthritis ("osteo" means bone). Osteoarthritis develops as we age and is often called "wear-and-tear" arthritis. Over the years, the thin covering (cartilage) on the ends of bones becomes worn and frayed. This results in inflammation, swelling, and pain in the joint.

An injury to a joint, even if treated properly, can cause osteoarthritis to develop in the future. This is often referred to as traumatic arthritis. It may develop months or years after a severe sprain, torn ligament or broken bone.

Anatomy

There are 28 bones and over 30 joints in the foot. Tough bands of tissue, called ligaments, hold the bones and joints in place. If arthritis develops in one or more of these joints, your balance and walk may be affected. The foot joints most commonly affected by arthritis include:

• the ankle (tibiotalar joint), where the shinbone (tibia) rests on the uppermost bone of the foot (the talus)
• the three joints of the hindfoot: the subtalar or talocalcaneal joint, where the bottom of the talus connects to the heel bone (calcaneus); the talonavicular joint, where the talus connects to the inner midfoot bone (naviculus) and the calcaneocuboid joint, where the heel bone connects to the outer midfoot bone (cuboid)
• the midfoot (metatarsocunieform joint), where one of the forefoot bones (metatarsals) connects to the smaller midfoot bones (cunieforms)
• the great toe (first metatarsophalangeal joint), where the first metatarsal connects to the toe bone (phalange); this is also where bunions usually develop

Signs and symptoms

Signs and symptoms of arthritis of the foot vary, depending on which joint is affected. Common symptoms include pain or tenderness, stiffness or reduced motion, and swelling. Walking may be difficult.

Diagnosing arthritis of the foot and ankle

Your doctor will begin by getting your medical history and giving you a physical exam. Among the questions you may be asked are:

• When did the pain start? Is it worse at night? Does it get worse when you walk or run? Is it continuous, or does it come and go?
• Have you ever had an injury to your foot or ankle? What kind of injury? When did it occur? How was it treated?
• Is the pain in both feet or just one? Where is the pain centered?
• What kinds of shoes do you normally wear? Are you taking any medications?

Your doctor may do a gait analysis. This shows how the bones in your leg and foot line up as you walk, measures your stride, and tests the strength of your ankles and feet. You may also need some diagnostic tests. X-rays can show changes in the spacing between bones or in the shape of the bones themselves. A bone scan, computed tomography (CT) scan, or magnetic resonance image (MRI) may also be used in the evaluation.

Treating your arthritis

Depending on the type, location and severity of your arthritis, there are many types of treatment available. Nonsurgical treatment options include:

• Taking pain relievers and anti-inflammatory medication to reduce swelling
• Putting a pad, arch support or other type of insert in your shoe
• Wearing a custom-made shoe, such as a stiff-soled shoe with a rocker bottom
• Using an ankle-foot orthosis (AFO)
• Wearing a brace or using a cane
• Participating in a program of physical therapy and exercises
• Controlling your weight or taking nutritional supplements
• Getting a dose of steroid medication injected into the joint

If your arthritis doesn’t respond to such conservative treatments, surgical options are available. The type of surgery that’s best for you will depend on the type of arthritis you have, the impact of the disease on your joints, and the location of the arthritis. Sometimes more than one type of surgery will be needed. The primary surgeries performed for arthritis of the foot and ankle are:

• Arthroscopic debridement. Arthroscopic surgery may be helpful in the early stages of arthritis. A pencil-sized instrument (arthroscope) with a small lens, a miniature camera and a lighting system is inserted into a joint. This projects three-dimensional images of the joint on a television monitor, enabling the surgeon to look directly inside the joint and identify the trouble. Tiny probes, forceps, knives and shavers can then be used to clean the joint area by removing foreign tissue and bony outgrowths (spurs).

• Arthrodesis, or fusion. This surgery eliminates the joint completely by welding the bones together. Pins, plates and screws or rods through the bone are used to hold the bones together until they heal. A bone graft is sometimes needed. Your doctor may be able to use a piece of your own bone, taken from one of the lower leg bones or the hip, for the graft. This surgery is normally quite successful. A very small percentage of patients have problems with wound healing. These complications can be addressed by bracing or additional surgery.

• Arthroplasty, or joint replacement. In rare cases, your doctor may recommend replacing the ankle joint with artificial implants. However, total ankle joint replacement is not as advanced or successful as total hip or knee joint replacement. The implant may loosen or fail, resulting in the need for additional surgery.

Outcomes and rehabilitation

Initially, foot and ankle surgery can be quite painful, so you will be given pain relievers both in the hospital and after you are released. After surgery, you will have to restrict activities for a time. You may have to wear a cast and use crutches, a walker, or a wheelchair, depending on the type of surgery you had. Keeping your foot elevated above the level of your heart will be very important for the first week or so.

You will not be able to put any weight on your foot for at least four to six weeks, and full recovery takes four to nine months. You may also need to participate in a physical therapy program for several months to regain strength in the foot and restore range of motion. Usually, you can return to ordinary daily activities in three to four months, although you may have to wear special shoes or braces. In the vast majority of cases, surgery brings pain relief and makes it easier for you to do daily activities.

Athletic Shoes

Proper-fitting sports shoes can enhance performance and prevent injuries. Follow these specially-designed fitting facts when purchasing a new pair of athletic shoes.

• Try on athletic shoes after a workout or run and at the end of the day. Your feet will be at their largest.

• Wear the same type of sock that you will wear for that sport.

• When the shoe is on your foot, you should be able to freely wiggle all of your toes.

• The shoes should be comfortable as soon as you try them on. There is no break-in period.

• Walk or run a few steps in your shoes. They should be comfortable.

• Always relace the shoes you are trying on. You should begin at the farthest eyelets and apply even pressure as you a crisscross lacing pattern to the top of the shoe.

• There should be a firm grip of the shoe to your heel. Your heel should not slip as you walk or run.

• If you participate in a sport three or more times a week, you need a sports specific shoe.

It can be hard to choose from the many different types of athletic shoes available. There are differences in design and variations in material and weight. These differences have been developed to protect the areas of the feet that encounter the most stress in a particular athletic activity.

• Athletic shoes are grouped into seven categories: Running, training, and walking. Includes shoes for hiking, jogging, and exercise walking. Look for a good walking shoe to have a comfortable soft upper, good shock absorption, smooth tread, and a rocker sole design that encourages the natural roll of the foot during the walking motion. The features of a good jogging shoe include cushioning, flexibility, control and stability in the heel counter area, lightness, and good traction.

• Court sports. Includes shoes for tennis, basketball, and volleyball. Most court sports require the body to move forward, backward, and side-to-side. As a result, most athletic shoes used for court sports are subjected to heavy abuse. The key to finding a good court shoe is its sole. Ask a coach or shoes salesman to help you select the best type of sole for the sport you plan on participating in.

• Field sports. Includes shoes for soccer, football, and baseball. These shoes are cleated, studded, or spiked. The spike and stud formations vary from sport to sport, but generally are replaceable or detachable cleats, spikes, or studs affixed into nylon soles.

• Winter sports. Includes footwear for figure skating, ice hockey, alpine skiing, and cross-country skiing. The key to a good winter sports shoe is its ability to provide ample ankle support.

• Track and field sport shoes. Because of the specific needs of individual runners, athletic shoe companies produce many models for various foot types, gait patterns, and training styles. It is always best to ask your coach about the type of shoe that should be selected for the event you are participating in.

• Specialty sports. Includes shoes for golf, aerobic dancing, and bicycling.

• Outdoor sports. Includes shoes used for recreational activities such as hunting, fishing, and boating.

According to the National Sports Goods Association, $13 billion was spent on athletic shoes and sports footwear in 2000.

Broken Ankle

During the past 30 years, doctors have noted an increase in the number and severity of broken ankles, due in part to an active, older population of "baby boomers." Almost one million people visited emergency rooms in 1998 because of ankle problems. The ankle actually involves two joints, one on top of the other. A broken ankle can involve one or more bones, as well as injuring the surrounding connecting tissues (ligaments).

Anatomy of the Ankle

The top ankle joint is composed of three bones:

• the shinbone (tibia)
• the other bone of the lower leg (fibula)
• the anklebone (talus)

The leg bones form a scooped pocket around the top of the anklebone. This lets the foot bend up and down.

Right below the ankle joint is another joint (subtalar), where the anklebone connects to the heel bone (calcaneus). This joint enables the foot to rock from side to side. Three sets of fibrous tissues connect the bones and provide stability to both joints. The knobby bumps you can feel on either side of your ankle are the very ends of the lower leg bones. The bump on the outside of the ankle (lateral malleolus) is part of the fibula; the smaller bump on the inside of the ankle (medial malleolus) is part of the shinbone.

When a Break Occurs

Any one of the three bones that make up the ankle joint could break as the result of a fall, an automobile accident or some other trauma to the ankle.

Because a severe sprain can often mask the symptoms of a broken ankle, every injury to the ankle should be examined by a physician. Symptoms of a broken ankle include:

• Immediate and severe pain.
• Swelling.
• Bruising.
• Tender to the touch.
• Inability to put any weight on the injured foot.
• Deformity, particularly if there is a dislocation as well as a fracture.

A broken ankle may also involve damage to the ligaments. Your physician will order X-rays to find the exact location of the break. Sometimes, a CT (computed tomography) scan or a bone scan will also be needed.

Treatment and Rehabilitation

If the fracture is stable (without damage to the ligament or the mortise joint), it can be treated with a leg cast or brace. Initially, a long leg cast may be applied, which can later be replaced by a short walking cast. It takes at least six weeks for a broken ankle to heal, and it may be several months before you can return to sports at your previous competitive level. Your physician will probably schedule additional X-rays while the bones heal, to make sure that changes or pressures on the ankle don’t cause the bones to shift. If the ligaments are also torn, or if the fracture created a loose fragment of bone that could irritate the joint, surgery may be required to "fix" the bones together so they will heal properly. The surgeon may use a plate, metal or absorbable screws, staples or tension bands to hold the bones in place. Usually, there are few complications, although there is a higher risk among diabetic patients and those who smoke. Afterwards, the surgeon will prescribe a program of rehabilitation and strengthening. Range of motion exercises are important, but keeping weight off the ankle is just as important. A child who breaks an ankle should be checked regularly for up to two years to make sure that growth proceeds properly, without deformity or uneven leg-length.

Bunions

If the joint that connects your big toe to your foot has a swollen, sore bump, you may have a bunion. More than half the women in America have bunions, a common deformity often blamed on wearing tight, narrow shoes, and high heels. Bunions may occur in families, but many are from wearing tight shoes. Nine out of ten bunions happen to women. Nine out of ten women wear shoes that are too small. Too-tight shoes can also cause other disabling foot problems like corns, calluses and hammertoes.

With a bunion, the base of your big toe (metatarsophalangeal joint) gets larger and sticks out. The skin over it may be red and tender. Wearing any type of shoe may be painful. This joint flexes with every step you take. The bigger your bunion gets, the more it hurts to walk. Bursitis may set in. Your big toe may angle toward your second toe, or even move all the way under it. The skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe. An advanced bunion may make your foot look grotesque. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic and you may develop arthritis.

Relief from bunions

Most bunions are treatable without surgery. Prevention is always best. To minimize your chances of developing a bunion, never force your foot into a shoe that doesn’t fit. Choose shoes that conform to the shape of your feet. Go for shoes with wide insteps, broad toes and soft soles. Avoid shoes that are short, tight or sharply pointed, and those with heels higher than 2 1/4 inches. If you already have a bunion, wear shoes that are roomy enough to not put pressure on it. This should relieve most of your pain. You may want to have your shoes stretched out professionally. You may also try protective pads to cushion the painful area.

If your bunion has progressed to the point where you have difficulty walking, or experience pain despite accomodative shoes, you may need surgery. Bunion surgery realigns bone, ligaments, tendons and nerves so your big toe can be brought back to its correct position. Orthopaedic surgeons have several techniques to ease your pain. Many bunion surgeries are done on a same-day basis (no hospital stay) using an ankle-block anesthesia. A long recovery is common and may include persistent swelling and stiffness.

Adolescent Bunion

Your young teenager (especially girls aged 10-15) may develop an adolescent bunion at the base of his or her big toe. Unlike adults with bunions, a young person can normally move the affected joint. Your teenager may have pain and trouble wearing shoes. Try having your child’s shoes stretched and/or getting wider shoes. Surgery to remove an adolescent bunion is not recommended unless your child is in extreme pain and the problem does not get better with changes in shoe wear. If your adolescent has bunion surgery, particularly before they are fully grown, there is a strong chance his or her problem will return.

Bunionette

If you have a painful swollen lump on the outside of your foot near the base of your little toe, it may be a bunionette (tailor’s bunion). You may also have a hard corn and painful bursitis in the same spot. A bunionette is very much like a bunion. Wearing shoes that are too tight may cause it. Get shoes that fit comfortably with a soft upper and a roomy toe box. In cases of persistent pain or severe deformity, surgical correction is possible.

Bunion Surgery

Most bunions can be treated without surgery. But when nonsurgical treatments are not enough, surgery can relieve your pain, correct any related foot deformity, and help you resume your normal activities. An orthopaedic surgeon can help you decide if surgery is the best option for you. Whether you’ve just begun exploring treatment for bunions or have already decided with your orthopaedic surgeon to have surgery, this booklet will help you understand more about this valuable procedure.

Chronic Lateral Ankle Pain

Recurring or persistent (chronic) pain on the outer (lateral) side of the ankle often develops after an injury such as a sprained ankle. However, several other conditions may also cause chronic ankle pain.

Signs and symptoms

• Pain, usually on the outer side of the ankle—The pain may be so intense that you have difficulty walking or participating in sports. In some cases, the pain is a constant, dull ache.
• Difficulty walking on uneven ground or in high heels
• A feeling of giving way (instability)
• Swelling
• Stiffness
• Tenderness
• Repeated ankle sprains

Possible causes for chronic lateral ankle pain

The most common cause for a persistently painful ankle is incomplete healing after an ankle sprain. When you sprain your ankle, the connecting tissue (ligament) between the bones is stretched or torn. Without thorough and complete rehabilitation, the ligament or surrounding muscles may remain weak, resulting in recurrent instability. As a result, you may experience additional ankle injuries. Other causes of chronic ankle pain include:

• An injury to the nerves that pass through the ankle—The nerves may be stretched, torn, injured by a direct blow, or pinched under pressure (entrapment).
• A torn or inflamed tendon
• Arthritis of the ankle joint
• A break (fracture) in one of the bones that make up the ankle joint
• An inflammation of the joint lining (synovium)
• The development of scar tissue in the ankle after a sprain—The scar tissue takes up space in the joint, thus putting pressure on the ligaments.

Evaluation and diagnosis

The first step in identifying the cause of chronic ankle pain is taking a history of the condition. Your doctor may ask you several questions, including:

• Have you previously injured the ankle? If so, when?
• What kind of treatment did you receive for the injury?
• How long have you had the pain?
• Are there times when the pain worsens or disappears?

Because there are so many potential causes for chronic ankle pain, your doctor may do a number of tests to pinpoint the diagnosis, beginning with a physical examination. Your doctor will feel for tender areas and look for signs of swelling. He or she will have you move your foot and ankle to assess range of motion and flexibility. Your doctor may also test the sensation of the nerves, and may administer a shot of local anesthetic to help pinpoint the source of the symptoms.

Your doctor may order several x-ray views of your ankle joint. You may also need to get x-rays of the other ankle so the doctor can compare the injured and noninjured ankles. In some cases, additional tests such as a bone scan, computed tomography (CT) scan, or magnetic resonance image (MRI) may be needed.

Treatment

Treatment will depend on the final diagnosis and should be personalized to your individual needs. Both conservative (nonoperative) and surgical treatment methods may be used. Conservative treatments include:

• Anti-inflammatory medications such as aspirin or ibuprofen to reduce swelling
• Physical therapy, including tilt-board exercises, directed at strengthening the muscles, restoring range of motion, and increasing your perception of joint position
• An ankle brace or other support
• An injection of a steroid medication
• In the case of a fracture, immobilization to allow the bone to heal

If your condition requires it, or if conservative treatment doesn’t bring relief, your doctor may recommend surgery. Many surgical procedures can be done on an outpatient basis. Some procedures use arthroscopic techniques; other require open surgery. Rehabilitation may take 6 to 10 weeks to ensure proper healing. Surgical treatment options include:

• Removing (excising) loose fragments
• Cleaning (debriding) the joint or joint surface
• Repairing or reconstructing the ligaments or transferring tendons

Prevention

Almost half of all people who sprain their ankle once will experience additional ankle sprains and chronic pain. You can help prevent chronic pain from developing by following these simple steps:

1. Follow your doctor’s instructions carefully and complete the prescribed physical rehabilitation program.
2. Do not return to activity until cleared by your physician.
3. When you do return to sports, use an ankle brace rather than taping the ankle. Bracing is more effective than taping in preventing ankle sprains.
4. If you wear hi-top shoes, be sure to lace them properly and completely.

Claw Toe

People often blame the common foot deformity claw toe on wearing shoes that squeeze your toes, such as shoes that are too short or high heels. However, claw toe also is often the result of nerve damage caused by diseases like diabetes or alcoholism, which can weaken the muscles in your foot. Having claw toe means your toes "claw," digging down into the soles of your shoes and creating painful calluses. Claw toe gets worse without treatment and may become a permanent deformity over time.

Symptoms

• Your toes are bent upward (extension) from the joints at the ball of the foot.
• Your toes are bent downward (flexion) at the middle joints toward the sole of your shoe.
• Sometimes your toes also bend downward at the top joints, curling under the foot.
• Corns may develop over the top of the toe or under the ball of the foot.

Evaluation

If you have symptoms of a claw toe, see your doctor for evaluation. You may need certain tests to rule out neurological disorders that can weaken your foot muscles, creating imbalances that bend your toes. Trauma and inflammation can also cause claw toe deformity.

Treatment

Claw toe deformities are usually flexible at first, but they harden into place over time. If you have claw toe in early stages, your doctor may recommend a splint or tape to hold your toes in correct position. Additional advice:

• Wear shoes with soft, roomy toe boxes and avoid tight shoes and high-heels.
• Use your hands to stretch your toes and toe joints toward their normal positions.
• Exercise your toes by using them to pick up marbles or crumple a towel laid flat on the floor.

If you have claw toe in later stages and your toes are fixed in position:

• A special pad can redistribute your weight and relieve pressure on the ball of your foot.
• Try special "in depth" shoes that have an extra 3/8" depth in the toe box.
• Ask a shoe repair shop to stretch a small pocket in the toe box to accommodate the deformity.

If these treatments do not help, you may need surgery to correct the problem.

Clubfoot

You know immediately if your newborn has clubfoot. One of the most common nonmajor birth defects, clubfoot affects your child’s foot and ankle, twisting the heel and toes inward. It may look like the top of the foot is on the bottom. The clubfoot, calf and leg are smaller and shorter than normal. Clubfoot is not painful, is correctable and your baby is probably otherwise normal. Approximately one in every 1,000 newborns has clubfoot. Of those, one in three have both feet clubbed. No one knows why it happens, but babies have been born with clubfoot for many hundreds of years. Two out of three clubfoot babies are boys. Clubfoot is twice as likely if you, your spouse or your other children also have it. Less severe infant foot problems are common and are often incorrectly called clubfoot.

Stretching and casting

Treatment begins right away. The goal is to make your newborn’s clubfoot (or feet) functional, painless and stable by the time he or she is ready to walk. Doctors start by gently stretching your child’s clubfoot toward the correct position. They put on a cast to hold it in place. One week later, they take off the cast and stretch your baby’s foot a little more, always working it toward the correct position. They apply a new cast, and one week later you come back and do it again. This process (serial casting) slowly moves the bones in the clubfoot into proper alignment. Doctors use X-rays to check the progress. Casting generally repeats for 6-12 weeks, and may take up to four months. (Note: Anytime your baby wears a cast, watch for changes in skin color or temperature that may indicate problems with circulation.)

About half the time, your child’s clubfoot straightens with casting. If it does, he or she will be fitted with special shoes or braces to keep the foot straight once corrected. These holding devices are usually needed until your child has been walking for up to a year or more. Muscles often try to return to the clubfoot position. This is common when your child is 2-3 years old, but may continue up to age 7.

Surgery if needed

Sometimes stretching, casting and bracing is not enough to correct your baby’s clubfoot. He or she may need surgery to adjust the tendons, ligaments and joints in the foot/ankle. This is usually done when your child is 6-12 months old. Surgery corrects all of your baby’s clubfoot deformities at the same time. It’s possible that your baby will not need another operation as the child grows. After surgery, another cast holds the clubfoot together while it heals. It’s still possible for the muscles in your child’s foot to try to return to the clubfoot position and special shoes or braces will likely be used for up to a year or more after surgery.

If your child’s clubfoot is not treated, he or she will have a severe functioning disability. With treatment, your child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however. You should expect it to stay 1 to 1 1/2 sizes smaller and somewhat less mobile than the normal foot. The calf muscles in your child’s clubfoot leg will also stay smaller.

Common Foot Problems

 

Bunions

If you have a bunion, you know it can be a painful enlargement at the joint of the big toe. The skin over the joint becomes swollen and is often quite tender. Bunions can be inherited as a family trait, can develop with no recognizable cause or can be caused by shoes that fit poorly.

An important part of treatment is wearing shoes that conform to the shape of the foot and do not cause pressure areas. This often alleviates the pain. In severe cases, bunions can be disabling. Several types of surgery are available that may relieve pain and improve the appearance of the foot. Surgery is usually done to relieve pain and is not meant for cosmetic purposes.

Heel pain

Heel pain is extremely common. It often begins without injury and is felt under the heel, usually while standing or walking. It is usually worst when arising out of bed.

Inflammation of the connective tissue on the sole of the foot (plantar fascia) where it attaches to the heel bone is the most common cause of pain. It is often associated with a bony protrusion (heel spur) seen on X-ray studies.

Most cases will improve spontaneously. Heel and stretching, medication to reduce swelling of the soft tissues in your foot and shoe inserts are quite helpful. If pain continues, steroid injections or walking casts are used. Only in the most troubling and prolonged cases is surgery recommended.

Morton's Neuroma

Morton's neuroma is caused by a nerve being pinched. This pinching usually results in pain between the third and fourth toes. Tight shoes can squeeze foot bones together. The nerve responds by forming a neuroma, a build up of extra tissue in the nerve. The neuroma results in pain, that may radiate into the toes.

Treatment usually involves wearing wider shoes and taking oral medications to decrease the swelling around the nerve. A pad on the sole of the foot to spread the bones is often helpful. Your doctor may also inject cortisone around the nerve. If your difficulty continues, surgery to remove the neuroma may be suggested.

Corns and Calluses

Corns and calluses are caused by pressure on the skin of your foot. They may occur when bones of the foot press against the shoe or when two foot bones press together.

Common sites for corns and calluses are on the big toe and the fifth toe. Calluses underneath the ends of the foot bones (metatarsals) are common. Soft corns can occur between the toes.

Treatment involves relieving the pressure on the skin, usually by modifying the shoe. Pads to relieve the bony pressure are helpful, but they must be positioned carefully. On occasion, surgery is necessary to remove a bony prominence that causes the corn or callus.

Hammertoes

Hammertoes are one of several types of toe deformities. Hammertoes have a permanent sideways bend in your middle toe joint. The resulting deformity can be aggravated by tight shoes and usually results in pain over the prominent bony areas on the top of the toe and at the end of the toe. A hard corn may develop over this prominence.

Treatment usually involves a shoe to better accommodate your deformed toe. Shoe inserts or pads also may help. If, after trying these treatments, you are still having marked difficulty, surgical treatment to straighten the toe or remove the prominent area of bone may be necessary.

Plantar Warts

Plantar warts occur on the sole of the foot and look like calluses. They result from an infection by a specific virus. They are like warts elsewhere, but they grow inward. The wart cannot grow outward because of weight placed on it when you stand. You may experience severe pain when walking, and can have just one or many plantar warts. Plantar warts are extremely difficult to treat, but success has been achieved with repeated applications of salicylic acid (available over the counter) to soften the overlying callus and expose the virus. Other treatments include injection of the warts with medication, freezing the warts with liquid nitrogen and, very rarely, surgery.

Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.

This brochure has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints.

Corns

Every day, the average person spends several hours on their feet and takes several thousand steps. Walking puts pressure on your feet that’s equivalent to 2-3 times your body weight. No wonder your feet hurt!

Actually, most foot problems can be blamed not on walking but on your walking shoes. Corns, for example, are calluses that form on the toes because the bones push up against the shoe and put pressure on the skin. The surface layer of the skin thickens and builds up, irritating the tissues underneath. Hard corns are usually located on the top of the toe or on the side of the small toe. Soft corns resemble open sores and develop between the toes as they rub against each other.

Causes of corns

• Shoes that don’t fit properly. If shoes are too tight, they squeeze the foot, increasing pressure. If they are too loose, the foot may slide and rub against the shoe, creating friction.
• Toe deformities, such as hammer toe or claw toe.
• High heeled shoes because they increase the pressure on the forefoot.
• Rubbing against a seam or stitch inside the shoe.
• Socks that don’t fit properly.

Diagnosis and treatment

Corns can usually be easily seen. They may have a tender spot in the middle, surrounded by yellowish dead skin. Treating foot problems like corns is a team effort. You will need to work with your physician to ensure that problems don’t recur.

During your office visit:

• To restore the normal contour of the skin and relieve pain, your doctor may trim the corn by shaving the dead layers of skin off with a scalpel. This procedure should be done by a professional, and not by yourself, particularly if you have poor circulation, poor eyesight, or a lack of feeling in your feet.
• If the doctor discovers an underlying problem, such as a toe deformity, he or she can correct it. Most surgeries can be done on an outpatient basis.

At home:

• You can soak your feet regularly and use a pumice stone or callus file to soften and reduce the size of corns and calluses.
• Wearing a donut-shaped foam pad over the corn will also help relieve the pressure. Use non-medicated corn pads; medicated pads may increase irritation and result in infection.
• Use a bit of lamb’s wool (not cotton) between your toes to help cushion soft corns.
• Wear shoes that fit properly and have a roomy toe area.

Diabetic Foot

If a doctor has ever said you had an elevated blood sugar level – even just once when you were pregnant – you are at risk for diabetes. About 15.7 million people (5.9 percent of the United States population) have the disease. Nervous system impairment (neuropathy) is a major complication that may cause you to lose feeling in your feet or hands. This means you won’t know right away if you hurt yourself. The problem affects about 60 to 70 percent of people with diabetes.

Foot problems are a big risk. Like all diabetic people, you should monitor your feet. If you don’t, the consequences can be severe, including amputation, or worse.

Minor injuries become major emergencies before you know it. With a diabetic foot, a wound as small as a blister from wearing a shoe that’s too tight can cause a lot of damage. Diabetes decreases your blood flow, so your injuries are slow to heal. When your wound is not healing, it’s at risk for infection. As a diabetic, your infections spread quickly.

If you have diabetes, you should inspect your feet every day. Look for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, scratches, cuts and nail problems. Get someone to help you, or use a mirror. Feel each foot for swelling. Examine between your toes. Check six major locations on the bottom of each foot: The tip of the big toe, base of the little toes, base of the middle toes, heel, outside edge of the foot and across the ball of the foot. Check for sensation in each foot.

If you find any injury -- no matter how slight -- don’t try to treat it yourself. Go to a doctor right away.

Here’s some basic advice for taking care of your feet:

• Wash your feet every day with mild soap and warm water. Test the water temperature with your hand first. Don’t soak your feet. When drying them, pat each foot with a towel and be careful between your toes.

• Use quality lotion to keep the skin of your feet soft and moist – but don’t put any lotion between your toes.

• Trim your toe nails straight across. Avoid cutting the corners. Use a nail file or emery board. If you find an ingrown toenail, see your doctor.

• Don’t use antiseptic solutions, drugstore medications, heating pads or sharp instruments on your feet. Don’t put your feet on radiators or in front of the fireplace.

• Always keep your feet warm. Wear loose socks to bed. Don’t get your feet wet in snow or rain. Wear warm socks and shoes in winter.

• Don’t smoke or sit cross-legged. Both decrease blood supply to your feet.

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. Buy shoes that are comfortable without a "breaking in" period. Check how your shoe fits in width, length, back, bottom of heel and sole. Avoid pointed-toe styles and high heels. Try to get shoes made with leather upper material and deep toe boxes. 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.

• Choose socks and stockings carefully. Wear clean, dry socks every day. Avoid socks with holes or wrinkles. Thin cotton socks are more absorbent for summer wear. Square-toes socks will not squeeze your toes. Avoid stockings with elastic tops.

Foot deformities

When your feet lose their feeling, they are at risk for becoming deformed. One way this happens is through ulcers. Open sores may become infected. Another way is the bone condition Charcot (pronounced "sharko") foot. This is one of the most serious foot problems you can face. It warps the shape of your foot when your bones fracture and disintegrate, and yet you continue to walk on it because it doesn't hurt.

A doctor may treat your diabetic foot ulcers and early phases of Charcot fractures with a total contact cast. The shape of your foot molds the cast. It lets your ulcer heal by distributing weight and relieving pressure. If you have Charcot foot, the cast controls your foot’s movement and supports its contours if you don’t put any weight on it. To use a total contact cast, you need good blood flow in your foot. Your doctor monitors it carefully. The cast is changed every week or two until your foot heals.

A custom-walking boot is an another way to treat your Charcot foot. It supports the foot until all the swelling goes down, which can take as long as a year. You should keep from putting your weight on the Charcot foot. Surgery is considered if your deformity is too severe for a brace or shoe.

Flexible Flatfoot in Children

Do your child’s feet look flat when he or she is standing? Does an arch appear in the foot when your child sits or stands on tiptoes? Children are born with flexible flatfoot, a condition in which the arch of the foot shrinks or disappears when you stand on it. Parents and other family members often worry needlessly that an abnormally low or absent arch in a child’s foot will lead to permanent deformities or disabilities. Most children eventually outgrow flexible flatfoot without any problems. The condition usually:

• Is painless.
• Does not interfere with walking or sports participation.
• Corrects itself over time without surgery or other treatment.

A flexible flatfoot has normal muscle function and good joint mobility and is considered normal. The shape of bones and lax ligaments in the foot prevent a strong arch between the toes and heel (longitudinal arch) on weightbearing. As the child grows and walks on it, the foot’s soft tissues tighten, shaping its arch gradually. Flexible flatfoot often continues until your child is at least age 5 or older. If flexible flatfoot continues into adolescence, your child may experience aching pain along the bottom of the foot. See your doctor if your child’s flatfeet cause pain.

Doctor’s exam

Your doctor will physically examine your child to rule out other types of flatfeet that may require treatment such as flexible flatfoot with a tight heel cord, or rigid flatfoot, a more serious condition. Make sure your child wears his or her regular shoes so the doctor can see the pattern of wear. Tell the doctor if anyone else in the family is flatfooted or if your child has a known neurological or muscular disease. The doctor may ask your child to sit, stand, raise the toes while standing and stand on tiptoe. He or she will probably examine your child’s heelcord (Achilles tendon) for tightness and may check the bottom of the foot for calluses.

Treatment

If your child has activity-related pain or tiredness in the foot/ankle or leg, the doctor may recommend stretching exercises to lengthen the heelcord. If discomfort continues, your doctor may recommend shoe inserts. Soft-, firm- and hard-molded arch supports may in many cases relieve your child’s foot pain and fatigue, plus extend the life of his or her shoes, which may otherwise wear unevenly. Sometimes a doctor may prescribe physical therapy or casting if your child has flexible flatfoot with tight heel cords. Occasionally, surgical treatment can help an adolescent with persistent pain. A small number of flexible flatfeet become rigid instead of correcting with growth and may need further medical evaluation.

Foot Activity and Exercise Guide

Regular exercise and a gradual return to everyday activities are important for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that you exercise approximately 20 to 30 minutes, two or three times a day once you are out of your postoperative dressings. This guide can help you better understand your exercise/activity program, supervised by your physical therapist or orthopaedic surgeon.

Early Postoperative Exercises

Walking - Proper walking in a postoperative shoe is important. At first, you may walk with a walker or crutches. Your surgeon or therapist will tell you how much weight to put on your foot. Stand comfortably and erect with your weight balanced on your walker or crutches. Advance your walker or crutches a short distance; then put your operated foot forward so that the heel of your foot touches the floor first. As you move forward, most of your weight should remain on your heel. You will later be instructed when you can put your entire foot on the floor and when you will no longer need crutches or a walker.

Ankle Pumps - Move your foot up and down rhythmically by contracting the
calf and shin muscles. Perform this exercise periodically for two to three minutes,
two or three times an hour in the recovery room.

Advanced Exercises

Towel Curls - Place a small towel on the floor and curl it toward you,
using only your toes. You can increase the resistance by putting a weight
on the end of the towel. Relax and repeat this exercise 5 times.

Toe Raises, Toe Curls - Hold each position for 5 seconds and
repeat 10 times.

Big Toe Pulls - Place a thick rubber band around both big toes and pull the
big toes away from each other. Hold for 5 seconds and repeat 10 times.

Toe Pulls - Put a thick rubber band around all of your toes and spread them.
Hold this position for 5 seconds and repeat 10 times.

Toe Squeezes - Place small corks between your toes and squeeze for 5 seconds.
Repeat 10 times.

Marble Pick Up - Place 20 marbles on the floor. Pick up one marble at a time
and put it in a small bowl. Repeat with all 20 marbles.

Activity

Soon after your surgery, you can gradually begin to walk short distances and perform everyday activities. This early activity aids your recovery and helps you regain mobility.

Walking - Once you are able to wear athletic shoes comfortably, you may begin walking for exercise. Your physical therapist and orthopaedic surgeon will advise you.

Running - Once you can walk pain-free and most of your big toe motion returns, you may begin running. Your physical therapist and orthopaedic surgeon will advise you.

Other Sports - Once you can run pain-free, most patients may return to competitive sports. This includes team sports, aerobics, and step-climbing.

Pain or Swelling After Exercise or Activity - You may experience mild foot pain or swelling after exercise or activity. Elevate your foot and apply ice wrapped in a towel. Exercise and activity should consistently improve your strength and mobility. If you have any questions, contact your orthopaedic surgeon or physical therapist.

Foot Pain

Foot pain in the "ball of your foot," that area between your arch and the toes, is generally called metatarsalgia (met'-a-tar-sal'-gee-a). The pain usually centers on one or more of the five bones (metatarsals) in this mid-portion of the foot.

Causes of foot pain

Sometimes, the foot pain is caused by a callus that forms on the bottom of your foot. A callus is a build-up of skin that forms in response to excessive pressure over the bone. Normally, a callus is not painful, but the build-up of skin can increase the pressure and eventually make walking difficult.

Shoes that don’t fit properly because they are too tight or too loose can cause foot pain. Tight shoes squeeze the foot and increase pressure; loose shoes let the foot slide and rub, creating friction.

Pain on the underside of the foot may indicate a torn ligament or inflammation of the joint. Your podiatrist or orthopedic surgeon can do some simple tests to assess joint stability.

Treating foot pain

Most of the time, practical measures can help ease foot pain.

• Your doctor may recommend that you use a shoe insert (orthosis) as a kind of shock absorber, or that you wear a different kind of shoe.
• Sometimes, simply buying shoes that fit properly can solve the problem. Shoes should have a wide toe box that doesn’t cramp your foot. Heels should never be higher than 2-1/4" high.
• Soaking your feet to soften calluses, then removing some of the dead skin with a pumice stone or callus file will also ease pressure.
• Occasionally, surgery may be necessary to remove a bony prominence or correct a deformity.

Footwear and Falls

Whether it’s from a medical condition or the shoes you wear, foot problems make walking difficult and make you more susceptible to falling.

More than 11 million seniors—one out of every three people age 65 or older—have foot problems. This is twice the rate of the total adult population with foot problems—43 million Americans or one out of every six adults.

The majority of those affected are women. Studies show that 90 percent of females wear shoes that are too small for their feet.

Everyone should select shoes for comfort, not the latest fashion. Foot comfort is essential to maintaining your stability, mobility and safety.

The American Academy of Orthopaedic Surgeons has developed foot and shoe wear guidelines to help seniors prevent falls:

• Wear properly fitting, sturdy shoes that provide support. Be sure your shoes have a nonskid sole.

• Avoid high heels and shoes with smooth, slick soles. If you have a comfortable shoe that has a slippery sole, ask a shoe repair shop to add textured strips to the sole.

• Have your feet measured every time you purchase shoes. Your shoe size may change.

• Do not wear shoes that have extra-thick soles.

• Shoes with laces are safer than slip-ons, but keep the laces tied. Loose or long laces can cause you to fall. People unable to tie laces can select footwear with Velcro® fasteners.

• Replace slippers that have stretched out of shape and are too loose.

• If you have trouble putting on your shoes, use a long-handled shoehorn.

• Never walk in your stocking feet.

• Wear slippers with non-slip soles.

• Keep toenails trimmed.

• Women who cannot find athletic shoes that are wide enough for proper fit should shop in the men’s shoe department: shoe manufacturers make men’s shoes wider than women’s shoes.

Footwear Guide

More than 43.1 million Americans--one in every six persons--have trouble with their feet, mostly from improperly-fitting shoes. A huge public health risk, foot problems cost the U.S. $3.5 billion a year.

We’re all susceptible to foot and ankle injuries, but we can reduce our risk for them by wearing properly-fitting shoes that conform to the natural shape of our feet. In selecting shoes, keep this basic principle of good fit in mind: Your feet should never be forced to conform to the shape of a pair of shoes.

Although style is often a key consideration in choosing a pair of shoes, the most important quality to look for in shoes-from a practical standpoint-is durable construction that will protect your feet and keep them comfortable. Shoes that do not fit can cause bunions, corns, calluses, hammertoes and other disabling foot disorders.

Recommendations for Footwear

The American Academy of Orthopaedic Surgeons has developed tips to help people reduce their risk of foot problems. Use this guide when you shop for shoes:

• Have both feet measured every time you purchase shoes. Your foot size increases as you get older.

• Women should not wear a shoe with a heel higher than 2 1/4 inches.

• Try on new shoes at the end of the day. Your feet normally swell and become larger after standing or sitting during the day.

• Shoes should be fitted carefully to your heel as well as your toes.

• Try on both shoes.

• There should be 1/2-inch space from the end of your longest toe to the end of the shoe.

• Fit new shoes to your largest foot. Most people have one foot larger than the other.

• Walk around in the shoes to make sure they fit well and feel comfortable.

• Sizes vary among shoe brands and styles. Judge a shoe by how it fits on your foot not by the marked size.

• When the shoe is on your foot, you should be able to freely wiggle all of your toes.

• If the shoes feel too tight. don't buy them. There is no such thing as a "break-in period."

• Most high heeled-shoes have a pointed. narrow toe box that crowds the toes and forces them into an unnatural triangular shape. As heel height increases, the pressure under the ball of the foot may double, placing greater pressure on the forefoot as it is forced into the pointed toe box.

Fracture of the Talus

The talus (TAY-lus) is a small bone that sits between the heel bone (calcaneus) and the two bones of the lower leg (tibia and fibula). It has an odd humped shape, somewhat like a turtle. The bones of the lower leg "ride" on top and around the sides to form the ankle joint. Where the talus meets the bones of the foot, it forms the subtalar joint, which is important for walking on uneven ground. The talus is an important connector between the foot and the leg and body, helping to transfer weight and pressure forces across the ankle joint.

Most injuries to the talus result from motor vehicle accidents, although falls from heights also can injure the talus. These injuries are often associated with injuries to the lower back. An increasing number of talar fractures result from snowboarding, which uses a soft boot that is not rigid enough to prevent ankle injuries.

Signs and symptoms

Most talar fractures are marked by

• acute pain
• an inability to bear weight
• considerable swelling and tenderness

A fracture that breaks through the skin has an increased risk of infection. Talar fractures that result from snowboarding injuries may be mistaken for ankle sprains because of the tenderness on the outer side of the ankle and severe bruising.

Diagnosis

Your doctor will examine your foot and ankle and ask you to describe how the injury occurred. He or she will order X-rays of your foot and ankle. In some cases, the X-ray will not show the fractures, so a computed tomography (CT) scan may be needed. These diagnostic tests will help pinpoint the location of the fracture. They also will show whether the bones are still aligned (nondisplaced fracture) or have shifted out of place (displaced fracture). Any loose bits of bone that may need to be removed also can be identified.

Your doctor will check the functioning of the nerves to the foot to ensure that there is no damage. He or she also will make sure that an adequate supply of blood is flowing to the toes and that pressure is not building in the muscles of the foot (compartment syndrome).

Treatment

A talar fracture that is left untreated or that doesn’t heal properly will create problems for you later. Your foot function will be impaired, you will develop arthritis and chronic pain, and the bone may collapse.

Immediate first aid treatment for a talar fracture is to apply a well-padded splint around the back of the foot and leg from the toe to the upper calf. Elevate the foot above the level of the heart and apply ice for 20 minutes every hour or two until you can see a doctor. Don’t put any weight on the foot.

In rare cases, a talar fracture can be treated without surgery if X-rays show that the bones have not moved out of alignment. You will have to wear a cast for at least six to eight weeks and will not be able to put any weight on the foot during that time. Afterwards, your doctor will give you some exercises to help restore the range of motion and strength to your foot and ankle. Most fractures of the talus require surgery to minimize later complications. The orthopaedic surgeon will realign the bones and use metal screws to hold the pieces in place. If there are small fragments of bone, they may be removed and bone grafts used to restore the structural integrity of the joint.

After the surgery, your foot will be put in a cast for six to eight weeks and you will not be able to put any weight on the foot for at least three months. As the bones begin to heal, your orthopaedist may order X-rays or a magnetic resonance image (MRI) to see whether blood supply to the bone is returning. If the blood supply is disrupted, the bone tissue could die, a condition called avascular necrosis or osteonecrosis. This could cause the bone to collapse. Even if the bones heal properly, you may still experience arthritis in later years. Most of the talus is covered with articular cartilage, which enables bones to move smoothly against each other. If the cartilage is damaged, the bones will rub against each other, resulting in pain and stiffness. Treatments for arthritis include activity modifications, ankle-foot orthoses, joint fusion, bone grafting and ankle replacement.

Fractures of the Heel

It’s not easy to break your heel bone (calcaneus). Because it takes a lot of force, such as that sustained in a motor vehicle accident or a fall from a height, you may also incur other injuries as well, particularly to the back.

Signs and symptoms

• Pain
• An inability to bear weight

The pain may be centered on the outer side of the ankle, just below the lower leg bone (fibula). Or, it may be focused in the heel pad, particularly when you try to put weight on the foot. Your foot may become swollen and stiff. See your doctor right away, because if the bone heals improperly, severe problems may result later.

Diagnosing a heel fracture

Your doctor will try to pinpoint the area of pain and tenderness. You will probably need to get several x-rays of the heel and ankle area. A computed tomography (CT) scan may also be helpful. If you are also experiencing back pain, your doctor will recommend x-rays of the lower back as well to see if there is a fracture there.

The nerves that bring sensation and movement to the foot pass close to the heel bone. Your doctor will check their functioning to ensure that there is no damage. He or she will also make sure that an adequate supply blood is flowing to the toes and that pressure is not building in the muscles of the foot (compartment syndrome).

Treating heel fractures

If the pieces of broken bone have not been pushed out of place by the force of the injury, you may not need surgery:

• Your foot will need to be elevated above the level of your heart and wrapped in a bulky, compressive dressing to keep the bones from shifting.
• Ice packs, applied for 20 minutes every hour or two, can help reduce swelling and pain.
• Your doctor may apply a splint until the swelling goes down, which can take one to three weeks. Then the doctor may give you a removable splint and prescribe some exercises to maintain flexibility and movement.

You won’t be able to put any weight on your foot until the bone is completely healed, which takes at least six to eight weeks, and perhaps longer.

Surgical treatment

If the bones have shifted out of place (a displaced fracture), you will most likely need surgery. A metal plate and small screws are used to hold the bones in place. A bone graft may be used to aid in the healing of the fractures. The incision will be bandaged and a splint applied until it is healed. Then, you’ll get a removable splint so that you can begin exercising the joint. You won’t be able to put any weight on your foot for approximately 10 weeks after surgery. When you begin walking, you may need to use a cane and wear a special boot. It may take up to a year for the injury to heal completely. Depending on the type of job you have, you may not be able to return to the same type of work. Because of the amount of force needed to break the heel bone initially, even if your fracture heals properly, your foot may never be the same as it was before the injury. You may continue to experience stiffness and you may need to wear a heel pad, lift, or cup as well as special shoes with extra depth in the toe compartment.

Hammer Toe

A hammer toe is a deformity of the second, third or fourth toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.

People with hammer toe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.

Causes of hammer toe

Hammer toe results from shoes that don’t fit properly or a muscle imbalance, usually in combination with one or more other factors. Muscles work in pairs to straighten and bend the toes. If the toe is bent and held in one position long enough, the muscles tighten and cannot stretch out.

Shoes that narrow toward the toe may make your forefoot look smaller. But they also push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. A higher heel forces the foot down and squishes the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles become unable to straighten the toe, even when there is no confining shoe.

Treatment for hammer toe

Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. (Note: For many people, the second toe is longer than the big toe.) Avoid wearing tight, narrow, high-heeled shoes. You may also be able to find a shoe with a deep toe box that accommodates the hammer toe. Or, a shoe repair shop may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.

Your doctor may also prescribe some toe exercises that you can do at home to stretch and strengthen the muscles. For example, you can gently stretch the toes manually. You can use your toes to pick things up off the floor. While you watch television or read, you can put a towel flat under your feet and use your toes to crumple it.

Finally, your doctor may recommend that you use commercially available straps, cushions or nonmedicated corn pads to relieve symptoms. If you have diabetes, poor circulation or a lack of feeling in your feet, talk to your doctor before attempting any self-treatment.

Hammer toe can be corrected by surgery if conservative measures fail. Usually, surgery is done on an outpatient basis with a local anesthetic. The actual procedure will depend on the type and extent of the deformity. After the surgery, there may be some stiffness, swelling and redness and the toe may be slightly longer or shorter than before. You will be able to walk, but should not plan any long hikes while the toe heals, and should keep your foot elevated as much as possible.

Heel Pain

Every mile you walk puts 60 tons of stress on each foot. Your feet can handle a heavy load, but too much stress pushes them over their limits. When you pound your feet on hard surfaces playing sports or wear shoes that irritate sensitive tissues, you may develop heel pain, the most common problem affecting the foot and ankle. A sore heel will usually get better on its own without surgery if you give it enough rest. However, many people try to ignore the early signs of heel pain and keep on doing the activities that caused it. When you continue to use a sore heel, it will only get worse and could become a chronic condition leading to more problems. Surgery is rarely necessary.

Evaluation and treatment

Heel pain can have many causes. If your heel hurts, see your doctor right away to determine why and get treatment. Tell him or her exactly where you have pain and how long you’ve had it. Your doctor will examine your heel, looking and feeling for signs of tenderness and swelling. You may be asked to walk, stand on one foot or do other physical tests that help your doctor pinpoint the cause of your sore heel. Conditions that cause heel pain generally fall into two main categories: pain beneath the heel and pain behind the heel.

Pain beneath the heel

If it hurts under your heel, you may have one or more conditions that inflame the tissues on the bottom of your foot:

• Stone bruise: When you step on a hard object such as a rock or stone, you can bruise the fat pad on the underside of your heel. It may or may not look discolored. The pain goes away gradually with rest.

• Plantar fasciitis (subcalcaneal pain): Doing too much running or jumping can inflame the tissue band (fascia) connecting the heel bone to the base of the toes. The pain is centered under your heel and may be mild at first but flares up when you take your first steps after resting overnight. You may need to do special exercises, take medication to reduce swelling and wear a heel pad in your shoe.

• Heel spur: When plantar fasciitis continues for a long time, a heel spur (calcium deposit) may form where the fascia tissue band connects to your heel bone. Your doctor may take an X-ray to see the bony protrusion, which can vary in size. Treatment is usually the same as for plantar fasciitis: rest until the pain subsides, do special stretching exercises and wear heel pad shoe inserts.

Pain behind the heel

If you have pain behind your heel, you may have inflamed the area where the Achilles tendon inserts into the heel bone (retrocalcaneal bursitis). People often get this by running too much or wearing shoes that rub or cut into the back of the heel. Pain behind the heel may build slowly over time, causing the skin to thicken, get red and swell. You might develop a bump on the back of your heel that feels tender and warm to the touch. The pain flares up when you first start an activity after resting. It often hurts too much to wear normal shoes. You may need an X-ray to see if you also have a bone spur.

Treatment includes resting from the activities that caused the problem, doing certain stretching exercises, using pain medication and wearing open back shoes.

• Your doctor may want you to use a 3/8" or 1/2" heel insert.
• Stretch your Achilles tendon by leaning forward against a wall with your foot flat on the floor and heel elevated with the insert.
• Use nonsteroidal anti-inflammatory medications for pain and swelling.
• Consider placing ice on the back of the heel to reduce inflammation.

If the Shoe Fits, Wear It

Improperly-fitting shoes, which can cause bunions, corns, calluses, hammertoes, and other disabling foot problems, are a huge public health risk in the U.S.

One in six persons or 43.1 million people in the U.S. have foot problems. Thirty-six percent regard their foot problems as serious enough to warrant medical attention.

The cost of foot surgery to correct foot problems from tight-fitting shoes is $2 billion a year. If time off from work for the surgery and recovery is included, the cost is $3.5 billion.

A study conducted by the American Orthopaedic Foot and Ankle Society found that:

• Nine out of 10 women are wearing shoes that are too small for their feet.

• Eight out of 10 women say their shoes are painful.

• More than 7 out of 10 women have developed a bunion, hammertoe, or other painful foot deformity.

• Women are nine times more likely to develop a foot problem because of improper fitting shoes than a man.

• Nine out of 10 women's foot deformities can be attributed to tight shoes.

Ingrown Toenail

If you trim your toenails too short, particularly on the sides of your big toes, you may set the stage for an ingrown toenail, a common disorder. Like many people, when you trim your toenails, you may taper the corners so that the nail curves with the shape of your toe. But this technique may encourage your toenail to grow into the skin of your toe. The sides of the nail curl down and dig into your skin. An ingrown toenail may also happen if you wear shoes that are too tight or too short. Any of your toenails can get ingrown, but it’s most likely with your big toes.

When you first have an ingrown toenail, it may be hard, swollen and tender. Later, it may get red and infected, and feel very sore. You may see pus drain from it. Finally, your skin may start to grow over the ingrown toenail.

Treatment

To treat an infected ingrown toenail, soak your foot in warm, soapy water several times each day. You may need to gently lift the edge of the ingrown toenail from its embedded position and insert some cotton or waxed dental floss between the nail and your skin. Change this packing every day. If your infection is severe, your doctor may prescribe a course of antibiotics. Learn how to trim your toenails properly. Wear clean socks and open-toed shoes, such as sandals.

If you are in a lot of pain and/or the infection keeps coming back, your doctor may remove part of your ingrown toenail (partial nail plate avulsion). Your toe is injected with an anesthetic and your doctor uses scissors to cut away the ingrown part of the toenail, taking care not to disturb the nail bed. An exposed nail bed may be very painful. Removing your whole ingrown toenail (complete nail plate avulsion) increases the likelihood your toenail will come back deformed. It may take 3-4 months for your nail to re-grow.

Ingrown toenails often recur. If you have a chronic problem with an ingrown toenail, your doctor may recommend another surgical procedure in which the toenail’s formative part is permanently removed.

Prevention

You can lower your risk of developing an ingrown toenail by trimming your toenails straight across with no rounded corners. The length of your toenail should extend out past your skin. The top of each nail should form a straight line across, level with the top of your toe. Some additional guidelines for preventing ingrown toenails include:

• Don’t pick at your toenails or tear them off.
• Make sure your shoes and socks are not too tight.
• Keep your feet clean at all times.

Intoeing

Intoeing means that the feet curve inward instead of pointing straight ahead when walking or running. If your young child has intoeing, he or she will probably outgrow the condition naturally. You don’t need special shoes, stretching exercises or other treatments. By age 2, most children walk with their feet pointing in the direction they are heading.

Parents or other family members often worry about a child’s intoeing. They may believe the child or infant with intoeing will have permanent deformities as an adult. They may ask a doctor to "fix" the shape of their child’s feet or legs. But intoeing in children under age 8 usually corrects itself on its own without casts, braces or surgery. Infants and toddlers with intoeing don’t need shoes except for keeping their feet warm and protected from injury when outside. They can go barefoot without causing problems to the feet.

Severe intoeing may cause your child to stumble or trip. Other facts you should know include:

• Intoeing usually does not cause your child pain.
• Intoeing usually does not interfere with the way your child learns to walk.
• Intoeing has not been linked to degenerative arthritis in adulthood.

Intoeing conditions

Tibial torsion is in-turning of your child’s lower leg (tibia). In the womb, the legs were in a confined position. Tibial torsion means they didn’t rotate into the turned out position after birth. The condition improves without treatment, usually before age 4. Splints, special shoes and exercise programs don’t help. Consider surgery only if your child is at least 8-10 years old, and the problem has persisted, causing significant walking problems.

Femoral torsion is the in-turning of your child’s upper leg (femur). It’s most apparent when he or she is about 5-6 years old. Doctors don’t know why femoral torsion happens. It gets better without treatment. Modified shoes, braces and exercises don’t help. Consider surgery only if your child is older than 9 and has a very severe condition that causes a lot of tripping and an unsightly gait.

Bow legs and knock knees usually straighten out as your child grows. A wide range of knee alignment is normal in young children. Special shoes and wedges don’t help either condition.

Flatfeet is normal in infants and young children. The arch develops in your child’s foot until at least age 5. You don’t need special wedges, inserts or heels.

Metatarsus adductus is a common birth defect in which your child’s feet bend inward from the middle to the toes. In severe cases, it may resemble clubfoot deformity. The condition improves by itself most of the time. That’s why most newborns with it are not treated until they’re at least several months old. Treatment, when necessary, usually involves applying casts or special corrective shoes and has a high rate of success in babies aged 6-9 months.

Lisfranc (Midfoot) Fracture

Have you ever dropped a heavy box on the top of your foot? Or accidentally stepped in a small hole and fallen, twisting your foot? These two common accidents can result in a Lisfranc fracture-dislocation of the midfoot. This fracture gets its name from the French doctor who first described the injury.

Lisfranc injuries occur at the midfoot, where a cluster of small bones forms an arch on top of the foot between the ankle and the toes. From this cluster, five long bones (metatarsals) extend to the toes. The second metatarsal also extends down into the row of small bones and acts as a stabilizing force. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.

Signs and symptoms

Lisfranc fracture-dislocations are often mistaken for sprains. The top of the foot may be swollen and painful. There may be some bruising. If the injury is severe, you may not be able to put any weight on the foot. Lisfranc injuries are often difficult to see on X-rays. Unrecognized Lisfranc injuries can have serious complications such as joint degeneration and compartment syndrome, a build-up of pressure within muscles that can damage nerve cells and blood vessels. If the standard treatment for a sprain (rest, ice and elevation) doesn’t reduce the pain and swelling within a day or two, ask your doctor for a referral to an orthopaedic specialist.

Diagnosis

The orthopaedist will examine your foot for signs of injury. He may hold your heel steady and move your foot around in a circle. This motion produces minimal pain with a sprain, but severe pain with a Lisfranc injury. If your initial X-ray did not show an injury, the orthopaedist may request several other views, including comparison views of the uninjured foot and stress or weightbearing X-rays. In some cases, a computed tomography (CT) scan or magnetic resonance image (MRI) may be necessary to confirm the diagnosis.

Treatment

Treatment for a Lisfranc injury depends on the severity of the injury. If the bones have not been forced out of position, you will probably have to wear a cast and refrain from putting weight on the foot for about six weeks. When the cast is removed, you may have to wear a rigid arch support. Your orthopaedist will also recommend foot exercises to build strength and help restore full range of motion.

Often, operative treatment is needed to stabilize the bones and hold them in place until healing is complete. Pins, wires or screws may be used. Afterwards, you will have to wear a cast and limit weightbearing on the foot for six to eight weeks. A walking brace may be prescribed when the fixation devices are removed. You may also have to wear an arch support and a rigid soled shoe until all symptoms have disappeared. In some cases, if arthritis develops in these joints, the bones may have to be fused together.

It is important to follow your doctor’s orders and refrain from activities until you are given the go-ahead. If you return to activities too quickly, you may easily suffer another injury, resulting in damage to the blood vessels, the development of painful arthritis and an even longer healing time.

Morton's Neuroma

If you sometimes feel that you are "walking on a marble," and you have persistent pain in the ball of your foot, you may have a condition called Morton’s neuroma.

Definition

A neuroma is a benign tumor of a nerve. Morton’s neuroma is not actually a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes. It occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. Morton’s neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma or excessive pressure. The incidence of Morton’s neuroma is 8 to 10 times greater in women than in men.

Signs and Symptoms

• Normally, there are no outward signs, such as a lump, because this is not really a tumor.
• Burning pain in the ball of the foot that may radiate into the toes. The pain generally intensifies with activity or wearing shoes. Night pain is rare.
• There may also be numbness in the toes, or an unpleasant feeling in the toes.

Runners may feel pain as they push off from the starting block. High-heeled shoes, which put the foot in a similar position to the push-off, can also aggravate the condition. Tight, narrow shoes also aggravate this condition by compressing the toe bones and pinching the nerve.

Diagnosis and Treatment

During the examination, your physician will feel for a palpable mass or a "click" between the bones. He or she will put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot.

Initial therapies are nonsurgical and relatively simple. They can involve one or more of the following treatments:

• Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.
• Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.
• Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.

Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton’s Neuroma. If conservative treatment does not relieve your symptoms, your orthopaedic surgeon may discuss surgical treatment options with you. Surgery can resect a small portion of the nerve or release the tissue around the nerve, and generally involves a short recovery period.

Orthotic Devices

A foot pad or heel insert purchased at your local pharmacy or sporting goods store is an orthotic device. So is a custom-molded, individually designed shoe insert or ankle brace. Orthotic devices like these are frequently used to treat various conditions of the foot and ankle. They are often very effective in relieving common complaints.

Orthotic devices may be recommended for several reasons, including:

• aligning and supporting the foot or ankle
• preventing, correcting or accommodating foot deformities
• improving the overall function of the foot or ankle

For example, a wedge inserted into the inner (medial) side of the sole of a shoe can be used to help support a flatfoot, thus reducing the risk of tendinitis. An ankle-foot brace can help relieve the pain of rheumatoid arthritis in the heel or ankle. A heel flare can be used to increase support and help prevent ankle sprains. Heel cushions can help absorb impact and relieve stress on the heel and ankle when you walk or run. The type of orthosis recommended by your doctor will depend on your symptoms, the underlying cause for those symptoms, and the shape of your feet. In some cases, your doctor may prescribe an insert or pad; in other cases, modifications to your shoes may be necessary.

Although custom orthoses are considerably more expensive than off-the-shelf devices, they last much longer and provide more support or correction. In some cases, however, an over-the-counter device can be just as effective, particularly when combined with a stretching and exercise program. In the past, plaster molds of the foot were used to construct the custom-made orthosis. Now, computerized foot analysis is often used to develop orthoses that more accurately reflect the dynamics of your gait.

Plantar Fasciitis

When your first few steps out of bed in the morning cause severe pain in the heel of your foot, you may have plantar fasciitis (fashee-EYE-tiss). It’s an overuse injury affecting the sole or flexor surface (plantar) of the foot. A diagnosis of plantar fasciitis means you have inflamed the tough, fibrous band of tissue (fascia) connecting your heel bone to the base of your toes.

You’re more likely to get the condition if you’re a woman, if you’re overweight, or if you have a job that requires a lot of walking or standing on hard surfaces. You’re also at risk if you walk or run for exercise, especially if you have tight calf muscles that limit how far you can flex your ankles. People with very flat feet or very high arches are also more prone to plantar fasciitis.

The condition starts gradually with mild pain at the heel bone often referred to as a stone bruise. You’re more likely to feel it after (not during) exercise. The pain classically occurs again after arising from a midday lunch break.

If you don’t treat plantar fasciitis, it may become a chronic condition. You may not be able to keep up your level of activity and you may also develop symptoms of foot, knee, hip and back problems because of the way plantar fasciitis changes the way you walk.

Treatments

Rest is the first treatment for plantar fasciitis. Try to keep weight off your foot until the inflammation goes away. You can also apply ice to the sore area for 20 minutes three or four times a day to relieve your symptoms. Often a doctor will prescribe nonsteroidal anti-inflammatory medication such as ibuprofen. A program of home exercises to stretch your Achilles tendon and plantar fascia are the mainstay of treating the condition and lessening the chance of recurrence.

In one exercise, you lean forward against a wall with one knee straight and heel on the ground. Your other knee is bent. Your heel cord and foot arch stretch as you lean. Hold for 10 seconds, relax and straighten up. Repeat 20 times for each sore heel.

In the second exercise, you lean forward onto a countertop, spreading your feet apart with one foot in front of the other. Flex your knees and squat down, keeping your heels on the ground as long as possible. Your heel cords and foot arches will stretch as the heels come up in the stretch. Hold for 10 seconds, relax and straighten up. Repeat 20 times.

About 90 percent of people with plantar fasciitis improve significantly after two months of initial treatment. You may be advised to use shoes with shock-absorbing soles or fitted with a standard orthotic device like a rubber heel pad. Your foot may be taped into a specific position.

If your plantar fasciitis continues after a few months of conservative treatment, your doctor may inject your heel with steroidal anti-inflammatory medications (corticosteroid). If you still have symptoms, you may need to wear a walking cast for 2-3 weeks or positional splint when you sleep. In a few cases, you might need surgery to release your ligament.

Plantar Warts

Plantar warts are a common skin infection on the bottom (plantar) side of your foot. About 10 percent of teenagers have warts. Using a public shower or walking around the locker room in your bare feet after a workout increases your risk for developing plantar warts.

Cause and symptoms

Contrary to the old folk tale, you can’t get warts from touching a toad. Warts are caused by a virus that enters the body through a break in the skin. The virus grows in warm, moist environments, such as those created in a locker room or in your shoes when your feet perspire and the moisture is trapped. Plantar warts often spread to other areas of the foot, increase in size, and have "babies," resulting in a cluster that resembles a mosaic.

Plantar warts can erupt anywhere on the sole of the foot. They may be difficult to distinguish from calluses. However, you may be able to see tiny black dots on the surface layer of a plantar wart. These are the ends of capillary blood vessels. Calluses have no blood vessels, usually resemble yellow candle wax and are located only over weightbearing areas.

Plantar warts can be very painful and tender. Standing and walking push the warts flat. They grow up into the skin, making it feel like there’s a stone in your shoe.

Treatment

Although plantar warts may eventually disappear by themselves, you should seek treatment if they are painful. Your physician will carefully trim the wart and apply a chemically treated dressing. The physician will also give you instructions for self-care. Salicylic acid patches, applied on a daily basis, and good foot hygiene, including regular use of a pumice stone, are often all that is needed. However, it may take several weeks for the wart to disappear completely.

If the wart is resistant to treatment, your physician may recommend an office procedure to remove it. After a local anesthetic is applied, the physician may use liquid nitrogen to freeze the wart and dissolve it. To avoid scarring or damaging other tissues, this method removes only the top portion of the wart. The treatment must be repeated regularly until the entire wart is dissolved. Alternatively, the physician can cut out (excise) the wart.

Prevention

To reduce your risk for getting plantar warts, be sure to wear shower thongs or sandals when you use a public locker room or shower. Use foot powders and change your socks frequently to keep the feet dry.

Posterior Tibial Tendon Dysfunction

Tendons connect muscles to bones and stretch across joints, enabling you to bend that joint. One of the most important tendons in the lower leg is the posterior tibial tendon. This tendon starts in the calf, stretches down behind the inside of he ankle and attaches to bones in the middle of the foot.

The posterior tibial tendon helps hold your arch up and provides support as you step off on your toes when walking. If this tendon becomes inflamed, over-stretched or torn, you may experience pain on the inner ankle and gradually lose the inner arch on the bottom of your foot, leading to flatfoot.

Signs and symptoms of posterior tibial tendon dysfunction

• Pain and swelling on the inside of the ankle

• Loss of the arch and the development of a flatfoot

• Gradually developing pin on the outer side of the ankle or foot

• Weakness and an inability to stand on the toes

• Tenderness over the midfoot, especially when under stress during activity

Risk factors

Posterior tibial tendon dysfunction often occurs in women over 50 years of age and may be due to an inherent abnormality of the tendon. But there are several other risk factors, including:

• Obesity

• Diabetes

• Hypertension

• Previous surgery or trauma, such as an ankle fracture on the inner side of the foot

• Local steroid injections

• Inflammatory diseases such as Reiter’s syndrome, rheumatoid arthritis, spondylosing arthropathy and psoriasis

Athletes who are involved in sports such as basketball, tennis, soccer or hockey may tear the posterior tibial tendon. The tendon may also become inflamed if excessive force is placed on the foot, such as when running on a banked track or road.

Diagnosis

The diagnosis is based on both a history and a physical examination. Your physician may ask you to stand on your bare feet facing away from him/her to view how your foot functions. As the condition progresses, the front of the affected foot will start to slide to the outside. From behind, it will look as though you have "too many toes" showing. You may also be asked to stand on your toes or to do a single heel rise: stand with your hands on the wall, lift the unaffected foot off the ground, and raise up on the toes of the other foot. Normally, the heel will rotate inward; the absence of this sign indicates posterior tibial tendon dysfunction. Your doctor may request X-rays, an ultrasound or a magnetic resonance image (MRI) of the foot.

Treatment

Without treatment, the flatfoot that develops from posterior tibial tendon dysfunction eventually becomes rigid. Arthritis develops in the hindfoot. Pain increases and spreads to the outer side of the ankle. The way you walk may be affected and wearing shoes may be difficult.

The treatment your doctor recommends will depend on how far the condition has progressed. In the early stages, posterior tibial tendon dysfunction can be treated with rest, nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen, and immobilization of the foot for 6 to 8 weeks with a rigid below-knee cast or boot to prevent overuse. After the cast is removed, shoe inserts such as a heel wedge or arch support may be helpful. If the condition is advanced, your doctor may recommend that you use a custom-made ankle-foot orthosis or support.

If conservative treatments don’t work, your doctor may recommend surgery. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at the same time. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include:

• Tenosynovectomy. In this procedure, the surgeon will clean away (debride) and remove (excise) any inflamed tissue surrounding the tendon.

• Osteotomy: This procedure changes the alignment of the heel bone (calcaneus). The surgeon may sometimes have to remove a portion of the bone.

• Tendon transfer: This procedure uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon.

• Lateral column lengthening: In this procedure, the surgeon removes a small wedge-shaped piece of bone from the hip and places it into the outside of the calcaneus. This helps realign the bones and recreates the arch.

• Arthrodesis: This procedure welds (fuses) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.

Rheumatoid Arthritis of the Foot and Ankle

Rheumatoid arthritis (RA) is a systemic disease that attacks multiple joints throughout the body. About 90% of the people with rheumatoid arthritis eventually develop symptoms related to the foot or ankle. Usually, symptoms appear in the toes and forefeet first, then in the hindfeet or the back of the feet, and finally in the ankles. Other inflammatory types of arthritis that affect the foot and ankle include gout, ankylosing spondylitis, psoriatic arthritis, and Reiter’s syndrome.

The exact cause of RA is unknown, but there are several theories. Some people may be more likely to develop RA because of their genes. However, it usually takes a chemical or environmental "trigger" to activate the disease. In RA, the body’s immune system turns against itself. Instead of protecting the joints, the body produces substances that attack and inflame the joints.

Signs and symptoms

The most common symptoms of RA in the foot are pain, swelling, and stiffness. Symptoms usually appear in several joints on both feet. You may feel pain in the joint or in the sole or ball of your foot. The joint may be warm and the way you walk may be affected. You may develop corns or bunions, and your toes can begin to curl and stiffen in positions called claw toe or hammer toe.

If your hindfoot (back of the foot) and ankle are affected, the bones may shift position in the joints. This can cause the long arch on the bottom of your foot to collapse (flatfoot), resulting in pain and difficulty walking.

Because RA affects your entire system, you may also feel feverish, tire easily, and lose your appetite. You may develop lumps around your joints, particularly by the elbow.

Diagnosis

Sometimes, arthritis symptoms in the foot are the first indication that you have RA. Your doctor will ask you about your medical history, your occupation, and your recreational activities, as well as any other persistent or previous conditions in your feet and legs. The appearance of symptoms in the same joint on both feet or in several joints is an indication that RA might be involved. Your doctor will also request X-rays to see how much damage there is to the joints. Blood tests will show whether you are anemic or have an antibody called the rheumatoid factor, which is often present with RA. If you’ve already been diagnosed with RA, you and your doctor should be aware that the disease will probably spread to your feet and ankles. Watch for early signs such as swelling and foot pain.

Treatment

Many people with RA can control their pain and the disease with medication and exercise. Some medications, such as aspirin or ibuprofen, help control pain. Others, including methotrexate, prednisone, sulfasalazine, and gold compounds, help slow the spread of the disease itself. In some cases, an injection of a steroid medication into the joint can help relieve swelling and inflammation.

Your doctor may also prescribe special shoes. If your toes have begun to stiffen or curl, you should wear a shoe with an extra deep toe box. You may also need to use a soft arch support with a rigid heel. In more severe cases, you may need to use a molded ankle-foot orthotic device, canes, or crutches.

Exercise is very important in the treatment of RA. Your doctor or physical therapist may recommend stretching as well as functional and range of motion exercises.

Surgical Options

Surgery can correct several of the conditions, such as bunions and hammer toes, associated with RA of the foot and ankle. In many cases, however, the most successful surgical option is fusion (arthrodesis). Fusion is often performed on the great toe, in the midfoot, in the heel, and in the ankle. In this procedure, the joint cartilage is removed; in some cases, some of the adjacent bone is also removed. The bones are held in place with screws, plates and screws or a rod through the bone. The surgeon may then implant a bone graft from the hip or leg. Eventually, the bones unite, creating one solid bone. There is loss of motion, but the foot and ankle remain functional and generally pain-free. Replacing the ankle joint with an artificial joint (arthroplasty) may be possible. However, this is a relatively new surgical technique. Whether it will be as successful in the long term as hip or knee replacement surgery is not yet known.

As in all surgeries, there is some risk. Infections, failure to heal, and loosening of the devices are the most common problems. Intravenous antibiotics and/or repeat surgery may be needed. Severe complications may require amputation, but this is rare.

Recovery and rehabilitation

Your doctor will prescribe pain medication for your use after the surgery. Before you leave the hospital, you will be taught how to use crutches. It takes a long time to recover from foot surgery. Here are some things to consider as part of your recovery:

• Ask friends or family for help in preparing meals and doing other activities of daily living.

• For the first week or so after surgery, keep your foot elevated above the level of your heart as much as possible.

• Be sure to do the prescribed physical therapy exercises. They will help you regain strength, motion, and the ability to walk.

• You won’t be able to put all your weight on your foot for several weeks, and you may need to wear a special shoe or a cast for several months.

• You will probably be able to resume ordinary daily activities 3 to 4 months after surgery.

RA is a progressive disease that currently has no cure. However, medications, exercises, and surgery can help lessen the effects of the disease and may slow its progress.

Sesamoiditis

Most bones in the human body are connected to each other at joints. But there are a few bones that are not connected to any other bone. Instead, they are connected only to tendons or are embedded in muscle. These are the sesamoids. The kneecap (patella) is the largest sesamoid. Two other very small sesamoids (about the size of a kernel of corn) are found in the underside of the forefoot near the great toe, one on the outer side of the foot and the other closer to the middle of the foot.

Sesamoids act like pulleys. They provide a smooth surface over which the tendons slide, thus increasing the ability of the tendons to transmit muscle forces. The sesamoids in the forefoot also assist with weightbearing and help elevate the bones of the great toe. Like other bones, sesamoids can break (fracture). Additionally, the tendons surrounding the sesamoids can become irritated or inflamed. This is called sesamoiditis and is a form of tendinitis. It is common among ballet dancers, runners and baseball catchers.

Signs and symptoms

• Pain is focused under the great toe on the ball of the foot. With sesamoiditis, pain may develop gradually; with a fracture, pain will be immediate.

• Swelling and bruising may or may not be present.

• You may experience difficulty and pain in bending and straightening the great toe.

Examination and diagnosis

During the examination, the physician will look for tenderness at the sesamoid bones. Your doctor may manipulate the bone slightly or ask you to bend and straighten the toe. He or she may also bend the great toe up toward the top of the foot to see if the pain intensifies.

Your physician will request X-rays of the forefoot to ensure a proper diagnosis. In many people, the sesamoid bone nearer the center of the foot (the medial sesamoid) has two parts (bipartite). Because the edges of a bipartite medial sesamoid are generally smooth, and the edges of a fractured sesamoid are generally jagged, an X-ray is useful in making an appropriate diagnosis. Your physician may also request X-rays of the other foot to compare the bone structure. If the X-rays appear normal, the physician may request a bone scan.

Treatment

Treatment is generally nonoperative. However, if conservative measures fail, your physician may recommend surgery to remove the sesamoid bone.

• Sesamoiditis

- Stop the activity causing the pain.

- Take aspirin or ibuprofen to relieve the pain.

- Rest and ice the sole of your feet. Do not apply ice directly to the skin, but use an ice pack or wrap the ice in a towel.

- Wear soft-soled, low-heeled shoes. Stiff-soled shoes like clogs may also be comfortable.

- Use a felt cushioning pad to relieve stress.

- Return to activity gradually, and continue to wear a cushioning pad of dense foam rubber under the sesamoids to support them. Avoid activities that put your weight on the balls of the feet.

- Tape the great toe so that it remains bent slightly downward (plantar flexion).

- Your doctor may recommend an injection of a steroid medication to reduce swelling.

- If symptoms persist, you may need to wear a removable short leg fracture brace for 4 to 6 weeks.

• Fracture of the sesamoid

- You will need to wear a stiff-soled shoe or a short, leg-fracture brace.

- Your physician may tape the joint to limit movement of the great toe.

- You may have to wear a J-shaped pad around the area of the sesamoid to relieve pressure as the fracture heals.

- Pain relievers such as aspirin or ibuprofen may be recommended.

- It may take several months for the discomfort to subside.

- Cushioning pads or other orthotic devices are often helpful as the fracture heals.

Shoes

The primary purpose of shoes is to protect your feet and prevent injury. But in order to do so, they must fit well. Poorly fitted shoes--shoes that are too narrow, too short or too large--can cause discomfort, injury and even permanent deformity.

Understanding the components of proper fit can help you make sensible shoe purchases for yourself and your family. This brochure describes the parts of a shoe and how they can affect fit. It also discusses special considerations related to children's, men's, women's, work and athletic shoes, and provides recommendations on footwear selection.

Although style is often a key consideration in choosing a pair of shoes, the most important quality to look for in shoes--from a practical standpoint--is durable construction that will protect your feet and keep them comfortable. In selecting shoes, keep this basic principle of good fit in mind: Your shoes should conform to the shape of your feet; your feet should never be forced to conform to the shape of a pair of shoes. Soreness, blisters, callouses, and, with time, permanent disfigurements can be caused by habitually crowding your feet into shoes that don't fit well.

Anatomy of a Shoe

A shoe is composed of different parts. Understanding the basics of shoe construction can help you choose intelligently from among the thousands of available styles.

The toe box is the tip of the shoe that provides space for the toes. The toe box may be rounded or pointed and will determine the amount of space provided for the toes.

The vamp is the upper middle part of the shoe where the laces are commonly placed. Sometimes Velcro is used instead of laces.

The sole consists of an insole and an outsole. The insole is inside the shoe; the outsole contacts the ground. The softer the sole, the greater the shoe's ability to absorb shock.

The heel is the bottom part of the rear of the shoe that provides elevation. The higher the heel, the greater the pressure on the front of the foot.

The last is the part of the shoe that curves in slightly near the arch of the foot to conform to the average foot shape. This curve enables you to tell the right shoe from the left. On occasion. an orthopaedic surgeon may prescribe a child's shoe that has a straight or reverse last.

The material from which the shoe is made can affect fit and comfort. Softer materials decrease the amount of pressure the shoe places on the foot. Stiff materials can cause blisters. A counter may be used to stiffen the material around the heel and give support to the foot.

Recommendations for Footwear

• Because your feet may vary in size, ask the salesperson to measure the length and width of each of your feet.

• Your feet expand when bearing weight, so stand while your feet are being measured.

• Because swelling during the course of the day can enlarge your feet, have your feet measured at the end of the day.

• The shoes you buy should be fitted to your longer and wider foot. Although the toe box should be spacious, too much space can cause the feet to slide around in the shoes, possibly causing blisters or abrasions.

• Shoes should be fitted carefully to your heel as well as your toes. Check to make sure your heel does not slip out of the back of the shoe.

• Walk around in the shoes to make sure they fit well and feel comfortable.

• Don't select a shoe by size alone. A size 10 in one brand or style may be smaller or larger than the same size in another brand or style. Buy the shoe that fits well.

• Select a shoe that conforms as closely as possible to the shape of your foot.

• Have your feet measured regularly. Their size may change as you grow older.

• If the shoes feel too tight. don't buy them. There is no such thing as a "break-in period." With time, a foot may push or stretch a shoe to fit. But this can cause foot pain and damage.