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Millions of people world wide suffer from arthritis. With regard to arthritis in the foot, the big toe joint is the most commonly affected joint. Arthritis is defined as the degeneration of cartilage between two bones. Cartilage is the soft spongy material between bones that allows the bones to glide pass each other during movement. Unfortunately there currently is no cure for arthritis at the moment, only treatments.

What makes the big toe joint susceptible to arthritis depends on how a person walks. The most common condition that leads to big toe arthritis is called Hallux Limitus, which is a fancy latin word for “loss of motion at the big toe joint”. People that tend to be susceptible to hallux limitus tend to over pronate (ie “flat feet”). This over pronation causes destablization of the inside of foot, causing the arch to collapse. Without an arch, the ground pushes up near the ball of the foot, causing the metatarsal to pop-up. Over time the 1st metatarsal bone pictured here………

…….become fixated in this elevated position. This elevated position becomes deleterious to the motion of the big toe joint, causing eventual pain and loss of motion. The eventual result is narrowing of the big toe joint, loss of cartilage, and bone spurring.

Overtime various treatments have been used for big toe arthritis depending on its severity. Initially most patients are started on a short course of anti-inflammatories such as Meloxicam. If pain persists a steriod injection maybe needed, as well as shoe gear modification which can include innersole or outersole modifications. In more severe or persistent cases, surgery may be required which can include simple cleaning the joint of debris or more serious total joint replacements.

More often or not, anytime i throw up an foot x-ray, the 1st thing a patient asks me is “what are those round white spots?” These are called the sesamoid bones and are important in normal gait allowing the big toe joint the range of motion necessary for pain free ambulation.

Sometimes, however, these tiny bones can be come traumatized leading to inflammation and pain. Sesamoiditits is typically an overuse injury that results in repetitive trauma to the sesamoid bones. Pain is typically located under the ball of the foot. The tibial sesamoid is the most commonly affected bone in this condition.

Initial treatment usually involves shoe gear modification in the form of a dancers pad. This type of injury is prevalent throughout the dancing community, especially ballet dances due to the considerable of time spent on the ball of the foot. A dancers pad, is a pad with a special cutout near the ball of the foot, that allows for the weight of the body to be transferred more laterally, thereby taking pressure of the inside of the foot.

Further treatment usually involves prescription NSAIDS, application of ice, and possible need for a steriod injection. In really difficult cases orthotic devices may be prescribed with a dancers pad cut out built into the device itself

All surgery requires a period of recovery to all the bones and skin to heal properly.
In order to ensure a good result, foot or ankle surgery may require a period of non-weight bearing with crutches on the surgically operated limb. Depending on the type of surgery, your weight bearing status may vary in degree and length. Regardless of your weight bearing status, it would benefit you greatly to stay off your feet as much as possible for the first 48 hours. This will help reduce swelling and post operative pain. Only get up to use the restroom or eat. If wearing a surgical shoe or boot it is important to wear at all times, including at night while sleeping the first few nights to avoid hurting your foot when you are asleep.

Keep your bandages completely dry and clean. If you plan on taking a shower, there are commercially available shower bags at local pharmacy that can be purchased to prevent the bandages from getting wet. Some bleeding through the bandages is normal and is no cause for alarm. If there is bleeding larger than a size of 1 silver dollar, then call your doctor immediately.

While post-operative pain is normal, there are ways to lessen it. When you get home, you are not going to be in much pain due to the long lasting effects of the local anesthesia. However, this will soon wear off in a few hours. Once you start to feel the slightest hint of pain, take a pain pill. The pain pills work best while pain is at a minimum, not when it is at its peak.

The next goal of pain relief is to reduce the swelling. Elevating your foot continuously will help tremendously. Your foot needs to be at a level higher than your heart. Usually 2-3 pillows will achieve this. Icing the area is the next best way to reduce swelling. Depending on the type of dressing you have there are several areas where ice can be applied. Behind the knee, inside of the ankle, and on top of the ankle are all areas where ice can be applied safely and effectively. Try to avoid putting ice directly on the bulky part of the bandages near the incision as this wet the bandage, which can lead to infection. Ice should be applied for 20minutes, then off for 40 min. for the first 2 days while your awake.

If the above doesn’t lessen the pain, the next thing you should do is loosen the bandages. Sometimes the ace bandage is on too tight causing too much outward pressure causing extreme pain. Loosening up the ace bandages is usually a sure fire way to alleviate the pain. Try to leave the gauze bandages underneath intact.

Call the Office IMMEDIATELY if:
• Your bandages become saturated (soaked) with blood
• If the above measures fail to alleviate the pain
• If you develop a fever with a temperature of 100 degrees or more
• If you bump or injure your surgery site
• If you are having an adverse reaction to medication such as a rash, itching, shortness of breath, severe nausea, vomiting and diarrhea
• If you are having calf pain
• If the bandages become wet

The term “growing pains” is thrown around a lot. The term came about to describe nondescript pain in the lower extremities, throughout a child’s development. With regards to podiatry, the most common area for “growing pains” is the bottom of the heel. This pain is most commonly seen between ages 10-14.

All bones need to grow before we reach adulthood. The area where your bones get longer and bigger is known as the growth plate. Once you finished growing the growth plate becomes fused and disappears. The area behind the growth plate in the heel is known as the apophysis.

Inflammation of this part of the heel, is termed “calcaneal apophysitis or sever’s disease.” It is generally an overuse type injury that causes pain near the back of the heel during and after physical activity. Pain is usually relieved with rest.

We see this type of injury most commonly in athletes that wear cleats during sports, since there is lest support in that type of shoegear. It’s also pretty common in the winter when the ground hardens, and the repetitive pounding of the heel causes this type of pain.

While this condition is self-limiting, there are numerous ways to help speed up the healing process and get back on the field. Usually we suggest a combination of ice therapy, stretching, heel lifts, and orthotics to help alleviate the pain associated with this condition.

Athletes Foot, also known as “Tinea Pedis”, is a skin infection causes by fungus. There are generally 2 types of presentations seen in podiatry. The first is a flakey, white, dry, sometimes itchy disorder of the foot, caused by the organism T. Rubrum. This is the most common type of athletes foot, and generally responds well to over the counter antifungal medications such as Lotrimin and Tinactin.

The second type is a more aggressive condition, that causes small fluid filled blisters, severe itching, redness and sometimes swelling. This is caused by the organism T. Mentagrophytes. This type usually requires a stronger prescription strength antifungal and in the most severe cases a short course of oral antifungals may be necessary

Left uncheck, athletes foot can lead to a secondary bacterial infection, called cellulitis. So its important to follow up with your foot doctor, if your condition worsens.

Prevention of athletes foot, usually starts at home. Its important to make sure you dry your feet really well after showering before you put your socks on. Since fungus likes a dark, damp environment, its important to eliminate those factors that can contribute to athletes foot. White socks breath cause your feet to sweat less than dark socks, so switching may be necessary. If your feet sweat throughout the day, changing into a fresh pair of socks, can also help. Various foot powders on the market can also help absorb moisture. Lastly spray the insides of your shoes with Lysol will help eliminate the fungal spores hanging out in the bottom of your shoes.

Sprained ankles are the most common musculoskeletal injury sustained by active individuals. Two types of sprains can occur: inversion and eversion. The most common ankle sprain is the inversion sprain (comprising 95% of ankle sprains), where the foot rolls inward spraining the ligaments on the outer part of the ankle. Upon exam, it is not unusual to have pain in front of the lateral maleolus (outside ankle bone) where the anterior talofibular ligament (ATF) sits. This if the first ligament injured when an ankle is rolled. In more moderate to severe ankle sprains the other 2 ligaments of the lateral ankle are injured; the calcaneal fibular ligament (CFL) and posteror talofibular ligament (PTF).

Ankle sprains also tend to swell quickly and a substantial amount. The target of initial treatment should be focused on swelling reduction, leading to the restoration of range of motion and function. The cornerstone treatment remains the pneumatic “R.I.C.E”.

REST – Immobilization, with ankle brace, aircast, or cast boot, depending on severity of injury
ICE – Ice pack to the side of the ankle for 20 minutes on, then 20 minutes off, for 24-48 hrs.
COMPRESSION - manual compression via ace wrap to reduce swelling
ELEVATION – elevation with 2 pillows when at rest, to prevent swelling the lower extremity

Wow! I can’t believe i haven’t talked about heel pain yet…so lets get into it.

Heel Spurs, Heel Pain, and Plantar Fasciitis are all terms that are thrown around that generally indicate the same pathology. Heel pain is caused by inflammation of the plantar fascia at its insertion to the plantar aspect of the calcaneus, hence the term “Plantar Fasciitis”

Plantar fasciitis is probably the most common cause of heel pain in adults. The plantar fascia is a thick band of fibrous connective tissue that attaches to the heel bone, runs across the bottom of the foot and then fans out to connect at the base of each toe. It provides support for the arch of the foot, helps to lift the arch during normal walking, and also acts as a shock absorber during walking and running.

During normal walking the plantar fascia lengthens and then shortens as the foot lands. If the plantar fascia is insufficiently elastic, repetitive lengthening and shortening can result in damage to the fibers, causing small tears. The pulling and shortening of this band also causes a piece of bone to pull out of the calcaneus, which becomes to be known as a heel spur.

This is most common in overuse injuries such as prolonged weight-bearing activities, or extended periods of standing. The resultant inflammation and swelling produces the pain of plantar fasciitis. Damage is most common in areas where the stress on the connective tissue is greatest and where the fascia is thinnest, as it curves around the back of the heel. The pain of plantar fasciitis is usually at its worst in the early morning hours. The first change that takes place while we sleep is that we don’t move as much, so the tissue on the bottom of our foot does not stretch. Hence, it loses some elasticity during the night and is painfully stiff in the morning.

Treatment may include placement of a heel pad or insole (to relieve pressure from the painful area), ice, rest, NSAIDS (non-steroidal anti-inflammatory drugs), special foot strappings, and changes to your shoe type. In some cases cortisone injections, or a referral to physical therapy for treatment may be needed. In difficult case’s Platelet Rich Plasma (PRP), Radiofrequency Ablation, or Endoscopic Plantar Fascia Release may need to be performed.

Exercises may be the most important treatment modality, as they are not only effective for the relief of active plantar fasciitis, but also help to minimize recurrence of this painful condition.

In previous post’s we talked about what a bunion is and how mild and moderate bunions are treated, most notably the Silver, McBride and Austin Bunionectomies were discussed. Today i will discuss the common procedure for more severe bunion deformities.

Treatment for severe bunion deformities becomes more complicated, requiring a period on non-weightbearing on the surgically corrected foot (unlike that of the mild and moderate bunion procedures).

A severe bunion deformity is diagnosed when the intermetatarsal angle is greater than 15 degrees. The intermetatarsal angle shown below in red.

as this angle increases in severe bunion deformities, the need to close down this angle to a more acceptable 0-8 degrees become important. An Austin bunionectomy cannot be used to correct such large angle, since the procedure is located so far away from the apex of the deformity. Therefore the best way to achieve correction of the deformity is to perform procedures closer to the apex, thereby utilizing the longer lever arm. These procedures are collectively known as “base bunion procedures”.

Base bunion procedures usually come in two flavors. The 1st is the closing base wedge osteotomy. In this procedure a wedge of bone is taken out of the bottom of the metatarsal and is then closed down, this allows the 1st metatarsal to swing inward, thereby closing down the intermetatarsal angle (as shown below).

The other commonly used procedure is the Lapidus. The Lapidus procedure is similar to the closing base wedge, with the only difference being the placement of the wedge being taken out. In the Lapidus the wedge is taken out even closer to the apex of the joint at the metatarsal-cuneiform joint.

both procedures require a period of non-weight bearing ambulation of about 6-8 weeks, and the use of bone screws and/or plates.

also known as “DVT” or “Blood clots” is a serious disorder that can happen to just about anybody. As the name goes, this disorder is caused by a blood clot in the deep veins of the lower extremities. Left untreated/undiagnosed, this serious condition can lead to a death via a pulmonary embolism. Basically what happens, is the blood clot gets dislodge from the the lower limbs, and lodges in the main artery of the lungs, causing a lung infarct (death of that portion of the lung).

Blood clots are the 3rd major cause of death after surgery and therefore are taken seriously by the medical community. Signs and symptoms include soreness, swelling, hot, red lower extremity. The gold standard test is a venous doppler exam that can be perform in most ER’s.

Besides surgery, there are several risk factors that predispose people to blood clots, which include: birth control pills, genetics, atrial fibrillation, prolonged bedrest, tobacco smoke, obesity, cancer, and old age.

Treatment usually requires anticoagulation therapy that may include Aspirin, Lovenox, Coumadin, and heparin, as well as placement of a filter in the large vein to the lungs to prevent blood clots from traveling that far.