Common Causes of Foot Pain
Risk Factors for Plantar Fasciitis Age: Plantar fasciitis is most common between the ages of 40 and 60. Certain types of exercise: Activities that place a lot of stress on your heel and attached tissue, such as long-distance running, ballet dancing, and aerobic dance, can contribute to an earlier onset of plantar fasciitis. Faulty foot mechanics: Being flat-footed, having a high arch, or even having an abnormal pattern of walking can affect the way weight is distributed when you’re standing and can put added stress on the plantar fascia. Obesity: Excess pounds put extra stress on your plantar fascia. Occupations that keep you on your feet: Factory workers, teachers, and others who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.
Plantar Fasciitis Plantar fasciitis is the most common cause of heel pain. The plantar fascia is the flat band of tissue that connects your heel bone to your toes. It supports the arch of your foot. If you strain your plantar fascia, it gets weak, swollen, and irritated. Then your heel or the bottom of your foot hurts when you stand or walk.
Plantar Fasciitis
Treatment for plantar fasciitis is largely non-invasive, and usually succeeds. Weight loss is a common goal for patients; often one of the simple causes of the condition is the weight of the individual, and this can be making the current symptoms; and any damage done, much worse. Changing the type of footwear is also commonly advised; using a good pair of well supporting shoes or adding shoe inserts or orthoses can help manipulate the conditions on the foot, and reduce symptoms. Stretching, a very important part of the treatment is aimed at lengthening the calf and plantar fascia, and can consist of many different stretching exercises. Ice, used to reduce inflammation, and analgesics, to reduce the pain, and the complete avoidance of the pain causing activities are also commonly advocated. Occasionally an injection of corticosteroid may be used; this is to combat symptoms, not to try and cure the condition, and will only be used if the symptoms are very severe. Finally, as a last resort, there is always the surgical option. This will completely release the plantar fascia from the heel bone, but is a largely irreversible procedure and is only recommended if the damage is degenerative or the symptoms are so severe that the patient would rather not try and treat it with non-invasive methods.
Plantar fasciitis is the most common cause of foot pain. Severe and prolonged cases of plantar fasciitis can actually develop into a chronic and degenerative condition of the foot. The plantar fasciitis symptoms are sharp pain anywhere along the arch or heel from the bottom of the foot, often the telltale sign is the pain is worse in the morning when you first step out of bed. This is an interesting and very confusing fact about plantar fasciitis, it hurts most when taking the first steps of the day, then subsides, then hurts more after sitting or lying down for a while. This is made evident by the inactive foot and ankle being in a sub-pronated position (jargon for not much weight on the foot with the foot and ankle rolled outward). This provides mechanical advantage to the plantar fascia as it is then forced into a lengthened position during weight bearing activities. High impact activities or excessive weight can also damage the plantar fascia, as can an acute injury.
Bunions
Guideline 5: Ensure that the content for this section is coherent with the summary of the entire essay, reflecting its key ideas and themes.
Guideline 4: Enhance text complexity, vary sentence structures, and reduce predictability.
Guideline 2: Focus on delivering information, explaining concepts, or detailing processes or systems. A study conducted by Nix et al. using people from the same family (proving that genetic factors are a cause) confirmed that a flat foot does not cause bunions, as commonly assumed, by comparing the foot with the bunion to the foot of the same person who did not have a bunion. They also found no difference between the feet of the person with the bunion and the general population in the degree of hallux valgus. However, x-rays revealed that the metatarsophalangeal joint of the bunion foot had a higher incidence of hypermobility and a reduced rate of degenerative joint changes in older people.
Guideline 1: Informative tone While the exact cause of bunions is unknown, a number of factors increase the likelihood of developing bunions. Bunions have long been known to run in families, and this would suggest that inheritance is a factor. They are more common in women and are often associated with inappropriate footwear. This is consistent with the fact that bunions are rare in populations that do not wear shoes. It has been suggested that bunions are caused by continually wearing badly fitting shoes over a long period of time; however, many people who wear high-heeled shoes or tight-fitting shoes never develop bunions. There is also a higher incidence of bunions in ballet dancers, which contradicts the assumption that bunions are caused by friction or pressure on the joint.
Unlike most other foot problems, which are known to affect the elderly, bunions do frequently occur in adolescents, where they are often referred to as “adolescent bunions”. It is not surprising to learn that people who suffer from bunions are mostly women. Common discomforts associated with bunions are the formation of calluses on the bunion, the development of ingrown toenails on the big toe, and stiffness and restricted motion of the big toe.
Morton’s Neuroma
The exact cause of Morton’s neuroma is unknown. However, there are a number of factors that are known to contribute to this condition. These include wearing high heels, pointed or tight shoes. These types of shoes force the toes into the abnormal position which can result in the instability of the metatarsal joints. High impact activities such as running and racquet sports can subject the feet to repetitive trauma and injury and can lead to the development of Morton’s neuroma. High impact activities increase the risk of trauma to the nerve in the foot. Another cause of Morton’s neuroma is foot deformities such as flat feet, bunions, and hammer toes. These deformities can cause instability around the joints and cause the ligaments to become stretched.
Morton’s neuroma is a condition that affects the nerve of the foot, most commonly occurs between the third and fourth toes, although it can affect any toe. This painful condition gets worse over time and the constant irritation to the nerve causes the affected individual to walk differently, this puts additional strain on other parts of the foot. Initially, an individual with Morton’s neuroma feels as if there is a pebble in his/her shoe or the sock is bunched up, many walk barefoot to alleviate the symptoms. As the condition develops, the pain increases and the symptoms become more prolonged, it can get to a point where the affected individual cannot walk even short distances.
Achilles Tendinitis
The pain associated with Achilles tendonitis can be a mild ache in the back of the leg, just above the heel after activity. It can progressively worsen to the point where it interferes with your sporting activities and eventually walking. High speed or sprinting used in running and even pushing off quickly from a standing start will increase the injury. Tenderness of the tendon area or a visible thickening of the tendon are the only ways to diagnose Achilles tendonitis. It is a common injury, and gathering more specific information often leads to confusion with other ailments.
The Achilles tendon connects your calf muscles to your heel bone and is used when you walk, run, climb stairs, jump, and stand on your tiptoes. All of these movements put a lot of stress on the Achilles tendon. It is a common injury in athletes that are involved in a lot of stop-start activity.
There are many other ailments of the lower leg that can cause pain around the Achilles region. These include Reiter’s syndrome, Ankylosing spondylitis, Ulnar, or any condition that includes enthesopathy or will cause synovitis of the long tendon sheaths. A rupture of the Achilles tendon could cause similar pain to that of Achilles tendonitis.
Achilles tendonitis is a condition that causes pain, swelling, and inflammation of the Achilles tendon. This is the largest and strongest tendon in the body and is found at the back of the lower leg, just above the heel. The pain caused by Achilles tendonitis can develop gradually without there being a specific incident. Chronic pain caused by Achilles tendonitis can lead to degeneration of the tendon (tendinosis) and a buildup of scar tissue.
Gout
Gout is a type of arthritis caused by the accumulation of uric acid crystals in tissues. It is often terribly painful and, if left untreated, can cause joint damage. I have seen several gout patients throughout the last year, and usually, they show up with a long history of frequent attacks of painful arthritis, especially in the feet or first toe. Often, the attacks occur at night, and they will be so severe that the patient will awaken with sudden sharp pain and swelling in the affected joint. The most common site of an attack is the big toe, although other joints can be affected. Gout arthritis in a long-standing joint can lead to the development of tophi. These are chalky collections of uric acid crystals that cause joint deformity and surrounding skin damage, for example, ulcerations. An acute gout attack is one of the most painful forms of arthritis, and it usually requires treatment with anti-inflammatory medicine such as NSAIDs or corticosteroids. Long-term management medications are usually required to lower uric acid levels and prevent future attacks. Treatment for tophaceous gout may also involve medications to lower uric acid and removal of tophi, usually done by a rheumatologist.
Diagnosing Foot Pain
In Singapore, a doctor will make a diagnosis of foot pain based on the location and characteristics of your pain, as well as your medical history. The doctor will ask you questions about the pain: Did you injure your foot? When did your pain begin? Does any specific activity cause the pain to increase or decrease? Do other members of your family have similar foot pain? Have you had any previous injury to your foot? These and other questions will give the doctor a better understanding of your pain and how it is affecting you. Gathering a good history is important in making an accurate diagnosis, no matter what the problem might be. The doctor will next examine your foot to gather more information that will help make a diagnosis. This will include looking for swelling, redness, bruising, and deformity of the foot. The doctor will look at the way you walk and the movement of your foot joints to locate the source of your pain. For example, if you have pain on the bottom of your heel, you may have a “stone bruise” or a heel spur, and the doctor will look for tenderness and swelling in that area. If the pain is on the top of the foot, it may be metatarsalgia, capsulitis, or a neuroma, and the doctor will want to feel for a mass or tender area in the joints. A good examination often gives the doctor a good idea about the diagnosis.
Physical Examination
The physical examination of the foot necessitates the examination of the knee, hip, and lower back as they can cause referred pain to the foot. Patients with alignment problems may experience pain in the foot. Increased stress at certain points on the foot can cause pain, so there may be a need for the clinician to examine the wear patterns on the patient’s shoe. The primary requirements for the examination are a good understanding of the structure and function of the foot and a logical approach. An examination of the gait may be necessary. Abnormalities can often be seen simply by asking the patient to walk on their heels, tiptoes, and one leg. Observations in the resting position may also provide clues. A normal arch (particularly if there has been a recent accompaniment of pain) may appear raised due to ‘clawing’ of the toes. This can be observed in conditions such as cerebral palsy or lumbar radiculopathy. Muscular wasting of the small muscles of the foot can occur in various conditions and is often noticeable. Flat feet are usually apparent, and there may be callus formation at typical sites. High-arched feet tend to be slimmer, and there may be callus under the first metatarsal and the heel. The presence of swelling can have many causes, and its location and degree are often indicative of a particular pathology. Erythema or skin color changes may indicate infection, inflammation, or an ischemic state. Palpation of bony areas may reveal focal tenderness, and this needs to be compared to the other foot. The site of the pain is a good indication of the source of the problem; for example, pain under the 2nd metatarsal may indicate a stress fracture or Morton’s neuroma. Climate (and job) and the types of shoes worn can also give clues to the presence of skin conditions.
Imaging Tests
Ultrasound is an effective, lower-cost, and non-invasive modality for the assessment of soft tissue lesions in the foot. It can provide real-time dynamic assessment of the lesion and can often be performed by the clinician at the time of the clinical consultation. Both MRI and ultrasound can be useful for the guided biopsy of a soft tissue lesion. It is important to make a distinction between primary soft tissue and metastatic bone lesions, and in such cases, the soft tissue lesion is the site of interest for the histological diagnosis.
MRI is often cited as the gold standard imaging technique for soft tissue lesions due to its superb soft tissue contrast resolution and multiplanar imaging capabilities, making it ideal for the complex anatomy of the foot and ankle. However, the high cost and limited availability can make it an unsuitable initial examination for certain lesions. MRI is advisable in the investigation of locally aggressive or intermediate-grade malignancies and the assessment of non-calcified cartilaginous lesions but is often not necessary in low-grade malignancies which have a typical clinical and radiological presentation. An MRI is usually performed to further assess equivocal findings from other imaging modalities and to aid treatment planning.
X-rays remain the first-line imaging technique in the assessment of bone lesions. They are useful due to the ease with which the foot can be x-rayed and the ready availability of this widely accepted technique. Simple guidelines can be applied regarding the radiographic appearance of bony lesions, such as the well-circumscribed osteolytic areas of an enchondroma or the geographical bone pattern of a cyst. X-rays can also provide a preliminary assessment of a soft tissue lesion by evaluating its effect on local bone. X-ray is a radiographic diagnosis of soft tissue lesions in the foot but has become largely a semiological examination for further imaging studies.
Most soft tissue tumors and tumor-like lesions require an ultrasound examination. They are ideally suited for some of them. Contrary to the common belief that MRI and ultrasound are equivalent tests, it should be understood that certain foot lesions are best diagnosed using a specific imaging modality. It is the role of the radiologist to have a good understanding of the foot anatomy, to be aware of the patient’s clinical presentation, and to select the most appropriate imaging technique. This brief discussion will illustrate the most valuable imaging technique for many common soft tissue lesions in the foot.
Blood Tests
Blood tests are often employed to detect conditions which may be causing foot pain. There are many systemic diseases which can cause foot pain. By taking a sample of blood and checking the levels of certain factors, a doctor can determine if there is a systemic cause to the foot pain. Some examples of systemic diseases that cause foot pain and can be diagnosed with blood tests include diabetes and gout. High levels of serum glucose are associated with diabetes mellitus, and the long-term effects of this include damage to the peripheral nervous system. This can cause altered sensation, pain, and weakness in the feet. The presence of gout can be determined by raised uric acid levels in the blood. If the gout is present and causing symptoms, monitoring uric acid levels over time can determine the effectiveness of treatment. This can be useful in gout-related foot pain to see if there is an improvement. Blood tests will vary depending on what the doctor is trying to diagnose. Sometimes, the test can be used to rule out potential causes of foot pain, especially if the history and physical examination is inconclusive. Other times it can be used to confirm a suspected diagnosis. For example, if one has a suspected rheumatological condition, there are numerous blood tests which can be performed to identify the specific condition. In summary, blood tests have a wide-ranging application when it comes to foot pain. They are useful in determining many different causes of foot pain, and only a minimal amount of blood is required to perform them. Often, blood tests can be conclusive for a diagnosis or rule out a diagnosis, which can save time and money further down the track.
Non-Surgical Treatment Options
Orthotic Devices Orthotics are prescription shoe inserts which can correct mechanical foot conditions. This will indirectly improve the foot position and functions throughout weightbearing activities. A podiatrist can prescribe orthotic devices, and provide specific advice and education for each foot condition. A well-known general alteration can be for a flat foot, where a medial arch supporting orthotic is prescribed. The effectiveness of orthotic therapy is largely dependent on the type of device and the expertise and knowledge of the practitioner. It may take a few trial changes and reviews of the orthotics in different footwear before an optimal result is achieved. The main aim is to provide an orthotic that can allow pain free and normal function of the foot and lower limbs throughout weightbearing activities in any chosen sport or work.
Physical Therapy The most effective and definitive method to correct a chronic overuse injury is to perform therapeutic exercise to strengthen the injured area. A descriptively tailored flexibility and strengthening program for the affected foot has to be specifically conceived by a podiatrist or sports physician. Cross training activities like swimming or cycling can maintain general fitness levels. If pain disappears, a gradual and individualized return to a chosen sport can commence. A common analogy is that a return to sport too early with recurrence of pain is like taking two steps forward and one step back. It is wise to partake in a jogging or competition session as a test for the rehabilitated foot. If pain recurs, cross training activities are continued until an improvement is noticed. This reduces disappointment by avoiding withdrawal from the chosen program and lets patient and therapist know that the foot is not strong enough for that level of impact activity. Requirements for footwear and foot orthotics should be discussed with a podiatrist. Some patients with recurring pain or those who are pain free and wish to avoid injury, may opt to continue a foot specific strength and flexibility program for ongoing maintenance.
Medications Over the counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen are effective in reducing inflammation and pain from chronic overuse injuries. In more severe cases, prescription NSAIDs, or oral steroids may be necessary. In very severe cases of chronic overuse injury, it is possible that a physician may recommend a cortisone injection.
Rest and Ice Rest is the key element to the recovery of most overuse injuries. Simply reducing the level of activity that caused the pain, or changing to an activity that puts less stress on the foot, will cure many overuse injuries. In more severe injuries, or in cases where the pain is not reduced after changing activities, further measures may be needed. In these cases it is beneficial to use ice to reduce the inflammation. The most convenient way to apply ice is to purchase a plastic bag of ice at a convenience store and apply it to the injured area, although crushed ice in a bag or ice put into a paper cup can also be used. It is not recommended to put bare toes into direct contact with ice, as this can damage the skin. Ice massage is often the best way to apply ice to the injured area. To perform an ice massage, freeze water in a small paper or foam cup. Tear away the top section of the cup so that an inch or so of ice is showing. Perform the massage by applying the ice in small circular motions to the injured area. A flexible footed person should use caution when applying ice, as excessive icing can cause the foot to supinate. Use caution and ice for short periods. If your foot pain persists, please seek medical advice to avoid further foot complications.
If possible, non-surgical treatment for your foot pain reason and treatment should be considered before surgery. Non-surgical treatment options for foot pain reason and treatment include: rest and ice, medications, physical therapy, and orthotic devices.
Rest and Ice
Phase I (1-7 days post injury): – Decrease inflammation: Ice is used to decrease the blood flow to the injured tissue. Decreased blood flow can help to decrease swelling and pain. Use crushed ice in a plastic bag and a damp cloth on the affected area for 15-20 minutes every 1-2 hours for the first 24-72 hours. Continue this for the first 48 hours after the injury. – Decrease swelling: Elevate the foot above the level of the heart as much as possible (use pillows when sleeping). Keep the foot elevated anytime that you are sitting. Lift the foot when driving. This allows gravity to help decrease the swelling in the foot. It is also helpful to wrap the injured area in a compression bandage to help decrease the swelling. Do not wrap too tightly. A sign that the bandage is too tight is if the toes become numb, cool to the touch, or if the pain increases below the bandage.
Rest and Ice Purpose: To decrease the inflammation of the foot.
Medications
Overall, medication is often an effective way to reduce pain and inflammation associated with foot conditions, making it easier to progress with other foot pain treatments and general activity. Always remember to consult a doctor before taking any medication.
It is also important to remember that every medication may have side effects, and you should usually start with the smallest dose that is still effective for your foot pain. If the foot pain is not relieved after one to two weeks of this treatment, you should consult your doctor to discuss alternative medications and treatments. You should not assume that the medication is not effective, as often the dose simply needs to be adjusted. If you experience any side effects after starting a new medication such as increased pain, rash, nausea, visual changes or headaches, you should stop taking the medication and consult your doctor.
Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, can help reduce both pain and inflammation. There are many other medications that can be used for foot pain, from corticosteroids to anesthetic injections. However, some of these medications are used to simply reduce the pain associated with foot conditions and do not correct the problem, so they are symptomatic treatments and not cures. Although these drugs can have some serious side effects, it is generally safe to try them for a short period to see if they help with your specific condition. It is important to consult your doctor before taking any medication.
Physical Therapy
It is beyond the scope of this article to go into details of every treatment method for every foot problem, but we can generalize certain physical therapy modalities and the types of foot problems they would be useful for. Modalities include massage and manipulation, which are useful in most foot problems. They help to increase blood flow to the affected area, increase range of motion of the joints on either side of an immobilized area, and maintain and even increase strength of muscles that are not directly affected by the foot problem. This type of treatment would help to avoid many secondary problems resulting from the initial foot issue, such as atrophy of muscles.
Physical therapy is useful for many different types of foot problems. This is particularly important as foot problems are often slow to heal, and patients may have difficulty remaining non-weight bearing on the affected foot for the required time. This would often lead to weakening of the soft tissues and delayed healing. Physical therapy can be useful in preparing an individual to return to full activity after an injury. It could also be a useful means to try to avoid an invasive form of treatment, whether it is surgery or injection therapy.
A physical therapy program is an important part of treatment for almost all orthopedic conditions. Physical therapists use different modalities and techniques to increase strength, flexibility, mobility, and function. The goal of therapy is to minimize pain and restore function. Sometimes, a physical therapy program is a stepping stone to other types of treatment, and sometimes it is the main treatment. The very nature of physical therapy as a process involving the use of physical methods to relieve pain and restore function makes it very suitable for the treatment of foot pain.
Orthotic Devices
Semi-rigid devices are designed to provide foot support while allowing for some foot movement. The materials and build of the orthotic device will determine the level of support and rate of motion the device allows. This type of device is chosen based on the individual’s weight, activities, and footwear.
Soft devices are often made from compression-molded materials. They are used to offload high-pressure areas of the foot or provide cushioning in certain areas. This type of device is often used to help with foot pain in the elderly, arthritic, or patients with a deformed foot.
Rigid devices (also known as functional orthotics) are designed to control function. They are often made from a firm material, such as plastic or carbon fiber, and are molded to the exact shape of the foot. They are used in shoes with a low heel and have a small heel platform. This design is to help the foot adopt a more anatomical position.
Orthotic devices are shoe inserts, heel cups, or shoe insoles prescribed by healthcare professionals to help relieve foot pain. They are intended to correct an abnormal or irregular walking pattern by altering slightly the angles at which the foot strikes a surface when walking or running. Orthotic devices come in many shapes, sizes, and materials and fall into three main categories: those designed to change foot function, those that are protective, and those that combine functional control and protection.
Surgical Treatment Options
Joint Fusion Fusion, also known as arthrodesis, is a surgical procedure in which the damaged joint is removed and plated or pinned to allow the two bones to grow together. The joint is rendered immobile and pain is eliminated in the joint as the arthritic surfaces no longer rub together. Fusion is generally the procedure of choice with patients suffering from a painful and debilitating arthritic condition in the hindfoot. If successful, fusion will provide the patient with a very stable, pain-free, and functional foot. However, the opposite of the functional deformed joint that is pain-free must be carefully considered by the patient. The foot and ankle unit specializes in hindfoot fusion procedures and is currently involved in trials that are comparing the outcomes of traditional open surgery with those of minimally invasive surgery using arthroscopy.
Arthroscopy The foot and ankle surgeons of Longmont Clinic are now using a new and advanced minimally invasive procedure for the treatment of arthritic conditions of the foot and ankle. Arthroscopic surgery allows the surgeon to directly see the bone and joint surfaces and to treat the abnormalities that cause pain. The procedure is performed with a fiberoptic camera and small surgical tools through 2-4 small incisions. The camera is connected to a television camera and the surgeon watches the picture on a TV screen. The main advantage of arthroscopic surgery is that it may allow treatment of the problem with less damage to the normal surrounding tissues. It’s highly debatable whether the results are any better than open arthrotomy procedures, and there are cases where a more traditional open joint procedure is necessary. This depends on factors such as the surgeon’s experience, the nature and extent of the problem, and the specific joint that is involved. If arthroscopy is a feasible option for the patient, the postoperative recovery is usually much quicker and the patient will spend less time in the hospital.
Arthroscopy
Arthroscopy is used for many conditions of the foot and ankle, which includes diagnosing unexplained pain, removing loose bodies, and treating joint pain caused by damaged articular cartilage. This is a procedure that is commonly used to treat a wide variety of conditions. The reason why it is so popular is that it is much less invasive than open surgery. It is usually performed under local anesthesia on an outpatient basis, but some patients require an overnight stay in the hospital. The surgeon makes small incisions (about the size of a buttonhole) to insert the arthroscope and other instruments into the joint. A TV monitor is used to visualize the area being worked on. The advantages are smaller scars, faster healing, and less damage to surrounding tissues. On occasion, it can be so much less invasive that the patient is permitted to be weight-bearing and to move the joint immediately after the surgery. This would depend on what the surgery involved and the opinion of the surgeon. Movement soon after the surgery may well be a key factor in a successful procedure.
Joint Fusion
A below the joint fusion is actually often involved with treating rheumatoid disease than foot pain. This is because rheumatoid disease often affects the joints in a way in which they no longer have a smooth articular surface to articulate movement, the joint becomes destroyed and a painful flat foot deformity results. This is often associated with severe dysfunction of the rear and midfoot and also collapse of the arch. By stabilizing the joint between the two bones by means of fusion, the joint is placed in the correct position and pain is alleviated. The same principles apply for the treatment of severe arthritis, and so below joint fusion can actually be quite a successful way of pain relief in the rheumatoid patient.
Two types of fusion exist. In a fusion, the same two bones involved are fixed or made to grow together with the use of pins, screws, or plates. There is an above joint fusion where the joint is not the main link between the two bones. An example of this is a fusion of the big toe joint. A below the joint fusion is performed when the joint is the main link between two bones.
Tendon Repair
Debridement and repair: Peroneal tendon tears will benefit from debridement and repair of the damaged tendons. It is usually possible to debride the inflamed or torn portion of the peroneus brevis. Repairing the peroneus longus is a slightly more complicated procedure due to its location under the cuboid bone. The surgeon will create a tunnel in the cuboid to access the torn tendon, pull the remaining portion of the tendon through the tunnel, and suture it to the peroneus brevis to prevent future tears. Flexor hallucis longus tears are usually chronic and partial thickness. The tendon will be debrided, and the repair is based on the location of the tear. If it is a distal tear, the tenosynovitic tissue is usually so inflamed that it increases in volume and loses its ability to comfortably fit through the posterior tibial tendon sheath. This will be addressed with synovectomy of the posterior tibial tendon sheath and FHL tendon, with the repaired FHL tendon being placed in a tendon groove on the back of the tibia to allow it to better act on the big toe and regain its function. If it is a proximal tear, it usually tears through the master knot of the FHL, so the repair would involve suturing the two ends of the tendon together. MRIs and ultrasound usually provide a clear indication as to the follow of the FHL tendon and the location of the tear.
Surgical treatment is only considered if the patient’s symptoms fail to improve with non-surgical treatment. Surgical intervention is aimed at releasing the tight, inflamed tendon as it glides through the sheath, along with repairing the tears, and addressing the bony deformity if it is significant.
Bunionectomy
A bunion is an enlargement of bone at the joint of the great toe that occurs when the bone or tissue at the great toe joint moves out of place. The big toe may turn in toward the second toe (angulation), and the tissues surrounding the joint may be swollen and tender. A bunion is usually more than what it appears when you are looking at it. There are complex changes that occur in the alignment of the bones and the joint that if left untreated can result in a painful arthritis and/or a stiff and deformed joint. The big toe carries more of the body’s weight than the other toes, so if a bunion develops, it can cause pain not only in the joint, but also in the big toe itself. You may feel the pain when walking or when you are active. Bunion surgery (bunionectomy) is done to reduce pain and to correct the deformity of the great toe joint. A variety of surgical procedures are used to treat bunions. The procedures are designed to remove the bump of bone, correct the changes in the bony structure of the foot, as well as correct soft tissue changes that may also have occurred. The goal of these corrections is the reduction of pain and the restoration of normal alignment and function of the big toe joint.
Neuroma Removal
Neuroma removal is the surgical excision of a swollen nerve. It is the best treatment option when the neuroma is clearly the cause of foot pain. Surgical techniques include excision of the affected nerve often with a portion of the nerve it innervates. The space created is often filled with muscle or vein wrapping the nerve to prevent its return. When neuroma is suspected as the pain generator, the diagnosis must be confirmed by injection of local anesthetic around the nerve and should be followed by corticosteroid injection to decrease inflammation of the perineural tissue and provide relief of symptoms. If symptomatic relief is only temporary after the corticosteroid injection, then formal excision of the neuroma is indicated. This operation is highly successful with low recurrence for interdigital and other areas of foot pain. Postoperative care is crucial for a successful outcome. A postoperative shoe or other device to offload the surgical site must be worn until the patient is able to return to normal shoe wear. High impact activities and narrow tight shoes should be avoided. Full return to activity and shoe wear without pain usually occurs in two to three months.