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Foot & Ankle

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.

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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

Having flat feet is a serious matter. If you are experiencing foot pain and think it may be related to flat feet, talk to your orthopaedist.

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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.

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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.

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Bowed Legs

Description

Bowing of the legs in a toddler is not uncommon and may sometimes cause the child to trip. Most often, this is simply a variation of the normal appearance. When this is the case, it is known as physiologic genu varum. From the age of 15 to 18 months until the age of 3 years, a slow but progressive improvement usually takes place until complete correction of the problem has occurred. Generally, there is no need for any external bracing or special shoe wear.

However, there are other reasons for a child to have bowed legs. Blount's disease is a condition that can occur in toddlers (as well as in adolescents). It results from abnormal growth in the upper part of the shin bone (tibia). In a child under the age of 2 years, it may be impossible to distinguish infantile Blount's disease from physiologic genu varum. By the age of 3 years, however, progressive bowing develops, and an obvious problem can often be seen on X-ray. Unlike physiologic genu varum, Blount's disease does require treatment for improvement to occur.

  • If caught early in the disease course, treatment with a brace may be all that is needed.
  • If there is continued progression of the bowing despite the use of a brace, surgery may be needed to prevent further worsening and permanent damage to the growth area of the shin bone.

Unlike infantile Blount's disease, adolescent Blount's disease occurs in overweight adolescents. Brace treatment is not effective in this condition. Surgery is required to correct the problem.

Bowed legs in the toddler may also be caused by metabolic conditions such as rickets--a deficiency of vitamin D in the diet. This rarely occurs in developed countries because many foods, including milk products, are fortified with vitamin D. Rickets can also be caused by a genetic abnormality that does not allow vitamin D to be absorbed or metabolized correctly. The effects of this condition can often be controlled with medication. This form of Rickets may be inherited from the parents or it may occur spontaneously in children. Braces do not appear to be helpful for this condition. Surgery to realign the legs is often needed as the child gets older.

In most cases, your doctor can tell what is causing the bowing in your toddler's legs by asking questions and examining your child. Sometimes X-rays and blood tests are needed to make the diagnosis. In most cases of bowed legs, simple observation will lead to a diagnosis of physiologic genu varum, and the problem will resolve on its own. If treatment is required, however, the condition is usually correctable.

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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." In 2003, nearly 1.2 million people visited emergency rooms 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.

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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.

What Is A Bunion?

A bunion is one problem that can develop due to hallux valgus, a foot deformity. The term "hallux valgus" is Latin and means a turning outward (valgus) of the big toe (hallux). The bone which joins the big toe, the first metatarsal, becomes prominent on the inner border of the foot. This bump is the bunion and is made up of bone and soft tissue.

What Causes Bunions?

By far the most common cause of bunions is the prolonged wearing of poorly fitting shoes, usually shoes with a narrow, pointed toe box that squeezes the toes into an unnatural position. Bunions also may be caused by arthritis or polio. Heredity often plays a role in bunion formation. But these causes account for only a small percentage of bunions.

A study by the American Orthopaedic Foot and Ankle Society found that 88 percent of women in the U.S. wear shoes that are too small and 55 percent have bunions. Not surprisingly, bunions are nine times more common in women than men.

Can Bunions Be Prevented?

Bunions often become painful if they are allowed to progress. But not all bunions progress. Many bunion problems can be managed without surgery. In general, bunions that are not painful do not need surgical correction. For this reason, orthopaedic surgeons do not recommend "preventive" surgery for bunions that do not hurt; with proper preventive care, they may never become a problem.

Bunion pain can be successfully managed in the vast majority of cases by switching to shoes that fit properly and don't compress the toes. Your orthopaedic surgeon can give you more information about proper shoe fit and the types of shoes that would be best for you.

Follow these general points of shoe fit:

  • Do not select shoes by the size marked inside the shoe. Sizes vary among shoe brands and styles. Judge the shoe by how it fits on your foot.
  • Select a shoe that conforms as nearly as possible to the shape of your foot.
  • Have your feet measured regularly. The size of your feet change as you grow older.
  • Have both feet measured. Most people have one foot larger than the other. Fit to the largest foot.
  • Fit at the end of the day when your feet are the largest.
  • Stand during the fitting process and check that there is adequate space (3/8" to 1/2") for your longest toe at the end of each shoe.
  • Make sure the ball of your foot fits well into the widest part (ball pocket) of the shoe.
  • Do not purchase shoes that feel too tight, expecting them to "stretch" to fit.
  • Your heel should fit comfortably in the shoe with a minimum amount of slippage.
  • Walk in the shoe to make sure it fits and feels right. (Fashionable shoes can be comfortable.)

Some shoes can be modified by stretching the areas that put pressure on your toes. Splints to reposition the big toe and orthotics (special shoe inserts shaped to your feet) also may relieve pain. For bunions caused by arthritis, medications can be prescribed to reduce pain and swelling.

Is Bunion Surgery For You?

If nonsurgical treatment fails, you may want to consider surgery. Many studies have found that 85 to 90 percent of patients who undergo bunion surgery are satisfied with the results.

Reasons that you may benefit from bunion surgery commonly include:

  • Severe foot pain that limits your everyday activities, including walking and wearing reasonable shoes. You may find it hard to walk more than a few blocks (even in athletic shoes) without significant pain.
  • Chronic big toe inflammation and swelling that doesn't improve with rest or medications.
  • Toe deformity-a drifting in of your big toe toward the small toes.
  • Toe stiffness-inability to bend and straighten your toe.
  • Failure to obtain pain relief from nonsteroidal anti-inflammatory drugs. Their effectiveness in controlling toe pain varies greatly from person to person.
  • Failure to substantially improve with other treatments such as a change in shoes and anti-inflammatory medication.

As you explore bunion surgery, be aware that so-called "simple" or "minimal" surgical procedures are often inadequate "quick fixes" that can do more harm than good. And beware of unrealistic claims that surgery can give you a "perfect" foot. The goal of surgery is to relieve as much pain, and correct as much deformity as is realistically possible. It is not meant to be cosmetic.

Types of Bunion Surgery

Orthopaedic surgeons use many different surgical procedures to treat bunions. The common goal of these procedures is to realign the joint, relieve pain, and correct deformity. These procedures include:

  • Repair of the Tendons and Ligaments Around the Big Toe These tissues may be too tight on one side and too loose on the other, creating an imbalance that causes the big toe to drift toward the others. Often combined with an osteotomy, this procedure shortens the loose tissues and lengthens the tight ones.
  • Arthrodesis Removal of the damaged joint surfaces, followed by the insertion of screws, wires, or plates to hold the surfaces together until it heals. Used for patients with severe bunions, severe arthritis, and when other procedures have failed.
  • Exostectomy Removal of the bump on the toe joint; used only for an enlargement of the bone with no drifting of the big toe. This procedure is seldom used because it rarely corrects the cause of the bunion.
  • Resection Arthroplasty Removal of the damaged portion of the joint, used mainly for patients who are older, have had previous bunion surgery, or have severe arthritis. This creates a flexible "scar" joint.
  • Osteotomy The surgical cutting and realignment of the joint. Your orthopaedic surgeon will choose the procedure best suited to your condition.

The Orthopaedic Evaluation

If you are interested in exploring bunion surgery, your family physician can refer you to an orthopaedic surgeon for an evaluation.

The orthopaedic evaluation consists of three components:

  • A medical history, in which your orthopaedic surgeon gathers information about your general health and asks you about the extent of your pain and ability to find shoes that don't hurt. He or she also will ask you about other medical conditions that could affect your surgical outcome. Diabetes and rheumatoid arthritis, for example, can increase the risk of infection and interfere with proper healing. Circulatory problems can increase postoperative pain and impede healing as well.
  • A physical examination to assess the extent of the misalignment and soft tissue damage and to check for the presence of other foot deformities, such as hammertoes and corns.
  • X-rays to determine the extent of damage and deformity in your toe joint.

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether surgery would be the best method to relieve your pain and deformity. Nonsurgical options, including switching to different shoes, also will be discussed.

Your orthopaedic surgeon also will explain the potential risks and complications of bunion surgery at this time.

Realistic Expectations About Bunion Surgery

An important factor in deciding whether to have bunion surgery is understanding what the procedure can and can not do. The vast majority of patients who undergo bunion surgery experience a dramatic reduction of foot pain after surgery, along with a significant improvement in the alignment of their big toe.

Bunion surgery will not allow you to wear a smaller shoe size or narrow-pointed shoes. In fact, you will have some shoe restrictions for the rest of your life. Always follow the recommendations for shoe fit presented in this booklet.

Remember that the main cause of the bunion deformity is a tight fitting shoe. If you return to that type of shoe wear, your bunion will reappear.

Preparing for Surgery

If you decide to have bunion surgery, you may be asked to have a complete physical with your family physician before surgery to assess your health. If you have heart or lung conditions or other chronic illnesses, you will need a preoperative medical clearance from your family physician.

Before surgery, tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should and should not stop taking before surgery.

Tests, including blood samples, a cardiogram, a chest X-ray, a urine sample, and special foot X-rays, may be ordered by your orthopaedic surgeon to help him or her plan your procedure.

Your Surgery

Almost all bunion surgery is done on an outpatient basis. You will most likely be asked to arrive at the hospital or surgical center one or two hours prior to surgery.

After admission, you will be evaluated by a member of the anesthesia team. Most bunion surgery is performed under ankle block anesthesia, in which your foot is numb, but you are awake. General or spinal anesthesia is used occasionally. The anesthesiologist will stay with you throughout the procedure to administer other medications, if necessary, and to make sure you are comfortable.

The surgery takes about one hour. Afterwards, you will be moved to the recovery room. You will be ready to go home in one or two hours.

Possible Complications After Surgery

Fewer than 10 percent of patients experience complications from bunion surgery. Possible complications can include infection, recurrence of the bunion, nerve damage, and continued pain.

If complications occur, they are treatable but may affect the extent of your full recovery. Your orthopaedic surgeon will explain various options in treating these complications.

Your Recovery at Home

The success of your surgery will depend in large part on how well you follow your orthopaedic surgeon’s instructions at home during the first few weeks after surgery. You will see your surgeon regularly for the next several months to make sure your foot heals properly.

Dressing Care You will be discharged from the hospital with bandages holding your toe in its corrected position. You also will wear a special postoperative surgical shoe or cast to protect your foot. Your sutures will be removed about two weeks after surgery, but your foot will require continued support from dressings or a brace for six to eight weeks. To ensure proper healing, it is very important not to disturb your dressings and to keep them dry. Interference with proper healing could cause a recurrence of the bunion. Be sure to place a plastic bag over your foot while showering.

Bearing Weight Your orthopaedic surgeon may advise you to use a walker, cane, or crutches for the first few days after surgery. You can gradually put more weight on your foot as your wound heals. However, walk only short distances during the first few weeks following surgery. You will probably be able to drive again within about a week.

Swelling and Shoe Wear Keep your foot elevated as much as possible for the first few days after surgery, and apply ice as recommended by your orthopaedic surgeon to relieve swelling and pain. You will have some swelling in your foot for about six months. After your dressings have been removed, wear only athletic shoes or soft leather oxford type shoes for the first several months until the surgery has completely healed. Do not wear fashion shoes, including high heels, until after six months. Follow the tips on shoe fit presented earlier in this booklet when selecting your shoes. This will help prevent the recurrence of your bunion.

Exercises to Strengthen Your Foot Some exercises or physical therapy may be recommended to restore your foot's strength and range of motion after your surgery. Your surgeon may recommend exercises using a surgical band to strengthen your ankle or marbles to restore motion in your toes. Always start these exercises slowly and follow your surgeon's or physical therapist's instructions regarding repetitions.

Medication Your orthopaedic surgeon may prescribe antibiotics to prevent infection for several days after your surgery. Pain medication to relieve surgical discomfort also will be prescribed for several days.

Avoiding Problems After Surgery

Though uncommon, complications can occur following bunion surgery. Contact your orthopaedic surgeon if:

  • Your dressing loosens, comes off or gets wet.
  • Your dressing is moistened with blood or drainage.
  • You develop side effects from postoperative medications.
  • Also, call your orthopaedic surgeon immediately if you notice any of the following warning signs of infection:
  • Fever.
  • Chills.
  • Persistent warmth or redness around the dressing.
  • Increased or persistent pain.
  • Significant swelling in the calf above the treated foot.

Your orthopaedic surgeon 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.

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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.

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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.

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Clubfoot

Description

Parents know immediately if their newborn has a clubfoot. Some will even know before the child is born, if an ultrasound was done during the pregnancy. A clubfoot occurs in approximately one in every 1000 births, with boys slightly outnumbering girls. One or both feet may be affected.

Symptoms

The appearance is unmistakable: the foot is turned to the side and it may even appear that the top of the foot is where the bottom should be. The involved foot, calf and leg are smaller and shorter than the normal side. It is not a painful condition. But if it is not treated, clubfoot will lead to significant discomfort and disability by the teenage years.

Risk Factors / Prevention

Doctors still aren't certain why it happens, though it can occur in some families with previous clubfeet. In fact, your baby's chance of having a 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.

Treatment Options

Stretching and casting. Treatment should begin right away to have the best chance for a successful outcome without the need for surgery. Over the past 5 to 10 years, more and more success has been achieved in correcting clubfeet without the need for surgery. A particular method of stretching and casting, known as the Ponseti method, has been responsible for this. With this method, the doctor changes the cast every week for several weeks, always stretching the foot toward the correct position. The heel cord is then released followed by one more cast for three weeks. Once the foot has been corrected, the infant must wear a brace at night for two years to maintain the correction. This has been extremely effective but requires the parents to actively participate in the daily care by applying the braces. Without the parents' participation, the clubfoot will almost certainly recur. That's because the muscles around the foot can pull it back into the abnormal position.

The goal of this, and any treatment program, is to make your newborn's clubfoot (or feet) functional, painless and stable by the time he or she is ready to walk. (Note: Anytime your baby wears a cast, watch for changes in skin color or temperature that may indicate problems with circulation.)

Treatment Options: Surgical

Surgery if needed. On occasion, stretching, casting and bracing are not enough to correct your baby's clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to12 months of age, surgery corrects all of your baby's clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still 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. Surgery will likely result in a stiffer foot than nonsurgical treatment, particularly as the years pass by.

Without any treatment, your child's clubfoot will result in severe functional 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.

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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.

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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.

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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.

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Flexible Flatfoot in Children

Description

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 they 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.

To make the diagnosis, the doctor will physically examine your child to rule out other types of flatfeet that may require treatment. These could include 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.

Symptoms

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 weight-bearing. 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.

Treatment Options

Treatment for flexible flatfoot is required only if your child is experiencing symptoms from the condition. 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 relieve your child's foot pain and fatigue in many cases. They can also 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.

Treatment Options: Surgical

Occasionally, surgical treatment can help an adolescent with persistent pain. A small number of flexible flatfeet become rigid instead of correcting with growth. These cases may need further medical evaluation.

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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.

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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 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.

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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.

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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.

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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.

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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.

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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.

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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.

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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. 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.

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. Ingrown toenails are a common, painful condition--particularly among teenagers. Any of your toenails can become ingrown, but the problem more often affects the big toe. An ingrown nail occurs when the skin on one or both sides of a nail grows over the edges of the nail, or when the nail itself grows into the skin. Redness, pain and swelling at the corner of the nail may result and infection may soon follow. Sometimes a small amount of pus can be seen draining from the area.

Ingrown nails may develop for many reasons. Some cases are congenital--the nail is just too large for the toe. Trauma, such as stubbing the toe or having the toe stepped on, may also cause an ingrown nail. However, the most common cause is tight shoe wear or improper grooming and trimming of the nail.

Treatment Options

Ingrown toenails should be treated as soon as they are recognized. If they are recognized early (before infection sets in), home care may prevent the need for further treatment:

  • Soak the foot in warm water 3-4 times daily.
  • Keep the foot dry during the rest of the day.
  • Wear comfortable shoes with adequate room for the toes. Consider wearing sandals until the condition clears up.
  • You may take ibuprofen or acetaminophen for pain relief.
  • If there is no improvement in 2-3 days, or if the condition worsens, call your doctor.
  • 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.

Treatment Options: Surgical

If excessive inflammation, swelling, pain and discharge are present, the toenail is probably infected and should be treated by a physician . You may need to take oral antibiotics and the nail may need to be partially or completely removed. The doctor can surgically remove a portion of the nail, a portion of the underlying nail bed, some of the adjacent soft tissues and even a part of the growth center. Surgery is effective in eliminating the nail edge from growing inward and cutting into the fleshy folds as the toenail grows forward. Permanent removal of the nail may be advised for children with chronic, recurrent infected ingrown toenails.

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 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 regrow.

Risk Factors/Prevention

Unless the problem is congenital, the best way to prevent ingrown toenails is to protect the feet from trauma and to wear shoes and hosiery (socks) with adequate room for the toes. Nails should be cut straight across with a clean, sharp nail trimmer without tapering or rounding the corners. Trim the nails no shorter than the edge of the toe. Keep the feet clean and dry at all times.

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Intoeing

Description

Intoeing means that the feet turn inward instead of pointing straight ahead when walking or running. This is commonly found in children at different ages and for different reasons. It almost always corrects without treatment as children grow older. The three most commonly seen conditions include metatarsus adductus (curved foot), tibia torsion (twisted shin-bone) and increased femoral anteversion (twisted thigh bone).

Metatarsus adductus is a common finding in which your child's feet bend inward from the middle part out to the toes. Some cases may be mild and flexible, but others may be more apparent or rigid. In severe cases, it may be said to resemble a part of a clubfoot deformity.

Tibial torsion is a twisting of your child's lower leg (tibia). Before birth the legs were in a confined position and shaped to fit the womb. Internal tibial torsion means that after birth they didn't rotate outward. The feet turn inward because the leg bone above them points them that way. As the tibia grows taller, it is expected to grow out of the twisting.

Femoral torsion is in-turning of your child's thigh (femur bone). It is often most apparent when he or she is about 5 or 6 years old. The upper end of the thighbone has an extra amount of twist that allows the hip joint to turn inward more than it turns outward. This causes the knees to point inward when walking and the feet to toe in. Children with this condition often sit on the floor in the "W" position with their knees bent and their feet flared out behind them.

Risk Factors/Prevention

All of these conditions may tend to run in families, or they can just occur on their own. Infrequently they may be associated with other orthopaedic problems. Prevention is not usually possible because they occur from developmental or genetic reasons that can't be controlled.

Symptoms

Severe intoeing may appear to cause young children to stumble or trip, particularly if they are wearing long or floppy shoes. Intoeing usually does not cause pain or interfere with the way your child learns to walk. Intoeing has not been linked to wear-and-tear arthritis in adulthood. Sometimes children who are faster sprinters tend to intoe a bit. It may be so noticeable that well meaning family or even strangers may comment about it.

Treatment Options

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. In the great majority of children under age 8, intoeing will correct without casts, braces, surgery or any special treatment.

Metatarsus Adductus improves by itself most of the time. It is usually appropriate to watch for improvement over the first 4 to 6 months of life. Applying casts or special shoes may be used to treat a foot with severe deformity or one that is very rigid. This has a high rate of success in babies aged 6 to 9 months. Surgical correction is seldom required.

Tibial Torsion improves almost always without treatment, and usually before school age. Splints, special shoes and exercise programs don't help. Surgery to re-set the bone may be done in a child who is at least 8 to 10 years old and has a severe twist that causes significant walking problems.

Increased Femoral Anteversion is expected to spontaneously correct in almost all children as they grow older. Studies have found that special shoes, braces and exercises don't help. Surgery is usually not considered unless there is a severe deformity in a child older than 9 or 10 years who has a lot of tripping and an unsightly gait.

A child whose intoeing is associated with pain, swelling or a limp should be evaluated by an orthopaedist.

Research on the Horizon/What's New?

More advanced imaging techniques, such as CT scans have made it possible to more accurately measure the amount of abnormal twisting in the tibia and the femur for an older child with persistent and severe intoeing.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Shinbone Fractures

A broken or fractured shinbone (tibia) is the most common long-bone injury. Several types of fractures can occur, ranging from the hairline stress fractures common in runners to severe open fractures (where the skin is broken) resulting from motor vehicle crashes.

Toddler's fracture

A toddler (one to three years of age) can fracture the shinbone when he or she trips over a toy or falls down a stair while learning to walk. These fractures usually do not break the skin, and the bone stays fairly well-aligned. There will be acute pain and possibly some swelling. The toddler may refuse to get up and walk again. The area of the fracture may be very tender.

It may be difficult to see this type of fracture on an X-ray, and your physician may request a bone scan to verify the diagnosis. These fractures heal quickly and can be treated with only a short leg weightbearing cast.

Growth plate fractures

Growth plate fractures are more common in older children and adolescents. These injuries occur near the ends of the bones at the ankle or knee. Bones do not grow from the center out, but from these growth plate areas. A fracture can disrupt the bone's development, leading to unequal limb length.

Growth plate fractures need to be identified early and watched carefully until the child reaches skeletal maturity to ensure that there is no shortening of the limb. The orthopaedic surgeon may need to use internal fixation devices, such as screws or nails, to stabilize the bone.

Stress fractures

Stress fractures are overuse injuries that occur when fatigued muscles can no longer absorb shock and transfer the load to the bone. More than 50 percent of all stress fractures occur in the lower leg. Stress fractures can develop gradually, with swelling and pain during activity.

The most important treatment for stress fractures is rest. It takes six to eight weeks for most stress fractures to heal. During that time, the individual should not participate in the activity that caused the fracture, but can participate in other pain-free activities.

Closed fractures

In a closed fracture, the skin is not broken. Closed fractures may be classified in several different ways, depending on the force of the injury, the stability of the bone, and the type and location of the break. The mechanism of the injury, such as a direct blow to the bone or an indirect twisting injury, can also cause soft-tissue damage.

Many stable closed fractures can be aligned without surgery, immobilized in a cast, and later supported by a fracture brace until healing is complete. However, if there is severe soft-tissue injury or if the fracture is grossly unstable, the orthopaedic surgeon may not be able to manipulate the bone into alignment and surgical treatment may be necessary. Surgical treatment may also be needed if the bone is fragmented into three or more pieces.

Open fractures

Because the shinbone is so close to the skin surface, a high-energy direct force may push the bone through the skin, resulting in an open fracture. All open fractures have an increased risk of infection and require surgical exploration and treatment. Open fractures are also often associated with trauma elsewhere in the body.

The use of small-diameter, interlocking nails to stabilize the fracture can result in less deformity, improved limb function, and shorter healing times. External fixators, such as a frame constructed around the leg, may also be used for the more severe, contaminated fractures, although these generally have higher rates of infection, poor alignment, or nonunion. In severe cases, amputation may be necessary.

Complications

Tibial fractures typically take a long time to heal. So that the bone can heal properly, you may need to use crutches and avoid placing any weight on the leg for several weeks. Periodic X-rays may be needed to ensure that the bone remains aligned and is healing properly. Closed fractures may take 5 to 6 months to heal; severe open fractures may take 9 months or more.

The type of complication encountered depends on the type of fracture and the treatment provided. Knee or ankle pain, unequal leg length, malalignment that leads to arthritis, nonunion, infection, rotational deformity, compartment syndrome, and vascular injuries are among the possible complications. Orthopaedic surgeons are continuing to research ways to reduce complications and to identify fractures at risk for delayed healing or nonunion.

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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.
  • If one of your feet is considerably larger than the other, an insole can be added to the shoe on the smaller foot.
  • Fashionable shoes can be comfortable, too.

Children's Shoes

Children don't need shoes until they begin walking, usually at around 12 to 15 months of age. Until then, socks or booties are enough to protect a crawling infant's feet and keep them warm. When your child does begin standing and walking, however, shoes provide an excellent form of protection from injury. After your child begins wearing shoes, there is nothing wrong with letting him or her go barefoot indoors.

A good time to buy your child's first pair of shoes is when he or she starts standing and walking. Shoe stores that specialize in children's shoes are likely to offer the widest range of sizes and styles, and will usually take more time to make sure a pair of shoes fits properly.

Never try to force your child's feet to fit a pair of shoes.

A soft, pliable shoe with plenty of room, such as a sneaker, is the ideal shoe for children of all ages. The toe box should provide enough space for growth, and should be wide enough to allow the toes to wiggle. (A finger's breadth of extra length will usually allow for about three to six months' worth of growth, though this can vary depending on your child's age and rate of growth.)

If your child frequently removes his or her shoes, those shoes may be uncomfortable. Check your child's feet periodically for signs of too-tight shoes, such as redness, callouses or blisters. And have your child's feet measured periodically at the shoe store to determine whether his or her feet have grown enough to warrant a larger pair of shoes.

Remember that the primary purpose of shoes is to prevent injury. Shoes seldom correct children's foot deformities or change a foot's growth pattern. Casting, bracing or surgery are often needed if a serious deformity is present. If you notice a problem, have your child examined by an orthopaedic surgeon.

Because high-top shoes tie above the ankle, they are recommended for younger children who may have trouble keeping their shoes on. Contrary to common belief, however, high-top shoes offer no advantages in terms of foot or ankle support over their low-cut counterparts.

Men's Shoes

Most men's shoes conform to the shape of the feet and have a roomy toe box with sufficient horizontal and vertical space and a low heel (usually about half an inch high). Soles made of hard materials such as leather or soft materials such as crepe can both be worn, but softer soles tend to be more comfortable. If you stand for extended periods of time, shoes with soft, pliable soles will protect your feet and help keep them comfortable.

Work Shoes

Work shoes are also available with varying characteristics, depending on the wearer's occupation. Boots made of thick leather with steel toe boxes can be worn to protect the feet from injury. Boots with varying degrees of traction also are available.

Women's Shoes

Low-heeled shoes (one inch or lower) with a wide toe box are the ideal choice for women. An ample toe box that can accommodate the front part of the foot is as important as the heel in determining fit.

High-heeled, pointed-toe shoes can cause numerous orthopaedic problems, leading to discomfort or injury to the toes, ankles, knees, calves and back. Most high heeled-shoes have a pointed, narrow toe box that crowds the toes and forces them into an unnatural triangular shape. These shoes distribute the body's weight unevenly, placing excess stress on the ball of the foot and on the forefoot. This uneven distribution of weight, coupled with the narrow toe box characteristic of most high heels, can lead to discomfort, painful bunions, hammertoes. and other deformities.

The height of the heel makes a dramatic difference in the pressure that occurs on the bottom of the foot. 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.

Even low-heeled shoes can cause problems if they don't fit well. Years of wearing too-small shoes can lead to permanent deformities.

Athletic Shoes

The purpose of athletic shoes is to protect the feet from the specific stresses encountered in a given sport and to give the player more traction. A jogging shoe will be designed differently from an aerobics shoe, for example. The differences in design and variations in material, weight, lacing characteristics and other factors among athletic shoes are meant to protect the areas of the feet that encounter the most stress.

The key ingredient in a well-fitted athletic shoe is comfort. A good fit will reduce blisters and other skin irritations.

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.

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Smelly (Malodorous) Feet

Smelly feet can be not only embarrassing but uncomfortable as well. But once you understand the problem, you'll be able to take steps to reduce the odor.

What causes foot odor?

Feet smell for two reasons: you wear shoes and your feet sweat. The interaction between your perspiration and the bacteria that thrive in your shoes and socks generates the odor. So any attempt to reduce foot odor has to address both your sweating and your footwear. The feet and hands contain more sweat glands than any other part of the body (about 3,000 glands per square inch) and provide a ready supply of perspiration. You're probably familiar with the phenomenon of sweaty palms, but sweat on your hands doesn't produce the same strong odor as sweaty feet. That's because your hands are usually exposed to the air and the sweat has a chance to evaporate.

Feet, however, are trapped inside shoes, where temperatures can easily reach 102 F. The perspiration moisture combines with the dark warmth to create a fertile breeding ground for the bacteria that normally live on our skin. The bacteria produce isovaleric acid, the substance associated with foot odor. The more moisture there is, the more bacteria proliferate, and the greater the odor. Smelly feet can also be caused by an inherited condition called hyperhidrosis, or excessive sweating, which primarily affects males. Stress, some medications, fluid intake and hormonal changes also can increase the amount of perspiration your body produces.

Preventing foot odor

Fortunately, smelly feet generally can be controlled with a few preventive measures. The American Orthopaedic Foot and Ankle Society recommends that you:

  • Practice good foot hygiene to keep bacteria levels at a minimum.

    - Bathe your feet daily in lukewarm water, using a mild soap. Dry thoroughly.

    - Change your socks and shoes at least once a day.

    - Dust your feet frequently with a nonmedicated baby powder or foot powder. Applying antibacterial ointment also may help.

    - Check for fungal infections between your toes and on the bottoms of your feet. If you spot redness or dry, patchy skin, get treatment right away.

  • Wear thick, soft socks to help draw moisture away from the feet. Cotton and other absorbent materials are best.
  • Avoid wearing nylon socks or plastic shoes. Instead, wear shoes made of leather, canvas, mesh or other materials that let your feet breathe.
  • Don't wear the same pair of shoes two days in a row. If you frequently wear athletic shoes, alternate pairs so that the shoes can dry out. Give your shoes at least 24 hours to air out between wearings; if the odor doesn't go away, discard the shoes.
  • Always wear socks with closed shoes.

These preventive measures also can help prevent athlete's foot, which can flourish in the same environment as sweaty feet. However, athlete's foot won't respond to an antibacterial agent because it's caused by a fungus infection. Use an anti-fungal powder and good foot hygiene to treat athlete's foot.

Treating foot odor

Persistent foot odor can indicate a low-grade infection or a severe case of hereditary sweating. In these cases, your doctor may prescribe a special ointment. You apply it to the feet at bedtime and then wrap your feet with an impermeable covering such as kitchen plastic wrap.

Soaking your feet in strong black tea for 30 minutes a day for a week can help. The tannic acid in the tea kills the bacteria and closes the pores, keeping your feet dry longer. Use two tea bags per pint of water. Boil for 15 minutes, then add two quarts of cool water. Soak your feet in the cool solution. Alternately, you can soak your feet in a solution of one part vinegar and two parts water.

A form of electrolysis called iontophoresis also can reduce excessive sweating of the feet, but requires special equipment and training to administer. In the most severe cases of hyperhidrosis, a surgeon can cut the nerve that controls sweating. Recent advances in technology have made this surgery much safer, but you may notice compensatory sweating in other areas of the body afterwards.

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Sprained Ankle

Description

A sprained ankle is a very common injury. Approximately 25,000 people experience it each day. A sprained ankle can happen to athletes and non-athletes, children and adults. It can happen when you take part in sports and physical fitness activities. It can also happen when you simply step on an uneven surface, or step down at an angle.

The ligaments of the ankle hold the ankle bones and joint in position. They protect the ankle joint from abnormal movements-especially twisting, turning, and rolling of the foot.

A ligament is an elastic structure. Ligaments usually stretch within their limits, and then go back to their normal positions. When a ligament is forced to stretch beyond its normal range, a sprain occurs. A severe sprain causes actual tearing of the elastic fibers.

How it happens

Ankle sprains happen when the foot twists, rolls or turns beyond its normal motions. A great force is transmitted upon landing. You can sprain your ankle if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range in an abnormal position.

Mechanism of injury

If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, the ligaments can tear. You may lose your balance when your foot is placed unevenly on the ground. You may fall and be unable to stand on that foot. When excessive force is applied to the ankle's soft tissue structures, you may even hear a "pop." Pain and swelling result.

The amount of force determines the grade of the sprain. A mild sprain is a Grade 1. A moderate sprain is a Grade 2. A severe strain is a Grade 3.

Grade 1 sprain: Slight stretching and some damage to the fibers (fibrils) of the ligament.

Grade 2 sprain: Partial tearing of the ligament. If the ankle joint is examined and moved in certain ways, abnormal looseness (laxity) of the ankle joint occurs.

Grade 3 sprain: Complete tear of the ligament. If the examiner pulls or pushes on the ankle joint in certain movements, gross instability occurs.

Diagnosis

See your doctor to diagnose a sprained ankle. He or she may order X-rays to make sure you don't have a broken bone in the ankle or foot. A broken bone can have similar symptoms of pain and swelling.

The injured ligament may feel tender. If there is no broken bone, the doctor may be able to tell you the grade of your ankle sprain based upon the amount of swelling, pain and bruising.

The physical exam may be painful. The doctor may need to move your ankle in various ways to see which ligament has been hurt or torn.

If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. If this occurs, it is possible that the injury may also cause damage to the ankle joint surface itself.

The doctor may order an MRI (magnetic resonance imaging) scan if he or she suspects a very severe injury to the ligaments, injury to the joint surface, a small bone chip or other problem. The MRI can make sure the diagnosis is correct. The MRI may be ordered after the period of swelling and bruising resolves.

Symptoms

The amount of pain depends on the amount of stretching and tearing of the ligament. Instability occurs when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.

Treatment Options

Walking may be difficult because of the swelling and pain. You may need to use crutches if walking causes pain. Usually swelling and pain will last two days to three days. Depending upon the grade of injury, the doctor may tell you to use removable plastic devices such as castboots or air splints.

Most ankle sprains need only a period of protection to heal. The healing process takes about four weeks to six weeks. The doctor may tell you to incorporate motion early in the healing process to prevent stiffness. Motion may also aid in being able to sense position, location, orientation and movement of the ankle (proprioception). Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately. Even if an ankle has a chronic tear, it can still be highly functional because overlying tendons help with stability and motion.

For a Grade 1 sprain, use R.I.C.E (rest, ice, compression and elevation):

  • Rest your ankle by not walking on it.
  • Ice should be immediately applied. It keeps the swelling down. It can be used for 20 minutes to 30 minutes, three or four times daily. Combine ice with wrapping to decrease swelling, pain and dysfunction.
  • Compression dressings, bandages or ace-wraps immobilize and support the injured ankle.
  • Elevate your ankle above your heart level for 48 hours.

For a Grade 2 sprain, the RICE guidelines can also be used. Allow more time for healing to occur. The doctor may also use a device to immobilize or splint the ankle.

A Grade 3 sprain can be associated with permanent instability. Surgery is rarely needed. A short leg cast or a cast-brace may be used for two weeks to three weeks.

Rehabilitation is used to help to decrease pain and swelling and to prevent chronic ankle problems. Ultrasound and electrical stimulation may also be used as needed to help with pain and swelling. At first, rehabilitation exercises may involve active range of motion or controlled movements of the ankle joint without resistance. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Lower extremity exercises and endurance activities are added as tolerated. Proprioception training is very important, as poor propriception is a major cause of repeat sprain and an unstable ankle joint. Once you are pain-free, other exercises may be added, such as agility drills. The goal is to increase strength and range of motion as balance improves over time.

All ankle sprains recover through three phases:

  • Phase 1 includes resting, protecting the ankle and reducing the swelling (one week).
  • Phase 2 includes restoring range of motion, strength and flexibility (one week to two weeks).
  • Phase 3 includes gradually returning to activities that do not require turning or twisting the ankle and doing maintenance exercises. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities) such as tennis, basketball or football (weeks to months).

Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to control pain and inflammation.

Long-term outcome: If an ankle sprain is not recognized, and is not treated with the necessary attention and care, chronic problems of pain and instability may result.

Risk Factors/Prevention

The best way to prevent ankle sprains is to maintain good strength, muscle balance and flexibility.

Warm-up before doing exercises and vigorous activities

Pay attention to walking, running or working surfaces

Wear good shoes

Pay attention to your body's warning signs to slow down when you feel pain or fatigue

Is it acute or chronic?

If you have sprained your ankle in the past, you may continue to sprain it if the ligaments did not have time to completely heal. If the sprain happens frequently and pain continues for more than four weeks to six weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces, cutting actions and sports that require rolling or twisting of the foot, such as trail running, basketball, tennis, football and soccer.

Possible complications of ankle sprains and treatment include abnormal proprioception. There may be imbalance and muscle weakness that causes a re-injury. If this happens over and over again, a chronic situation may persist with instability, a sense of the ankle giving way (gross laxity) and chronic pain. This can also happen if you return to work, sports or other activities without letting the ankle heal and become rehabilitated.

Treatment Options: Surgical

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for persistent instability after months of rehabilitation and non-surgical treatment.

Surgical options include:

  • Arthroscopy: A surgeon looks inside the joint to see if there are any loose fragments of bone or cartilage, or part of the ligament caught in the joint.
  • Reconstruction: A surgeon repairs the torn ligament with stitches or suture, or uses other ligaments and/or tendons found in the foot and around the ankle to repair the damaged ligaments.

Rehabilitation

Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.

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Stiff Big Toe (Hallux Rigidus)

The most common site of arthritis in the foot is at the base of the big toe. This joint is called the metatarsophalangeal, or MTP joint. It's important because it has to bend every time you take a step. If the joint starts to stiffen, walking can become painful and difficult.

In the MTP joint, as in any joint, the ends of the bones are covered by a smooth articular cartilage. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe, or hallux rigidus.

Hallux rigidus usually develops in adults between the ages of 30 and 60 years. No one knows why it appears in some people and not others. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint.

Signs and symptoms

Pain in the joint when you are active, especially as you push-off on the toes when you walk

Swelling around the joint

A bump, like a bunion or callus, that develops on the top of the foot

Stiffness in the great toe and an inability to bend it up or down

Diagnosing the problem

If you find it difficult to bend your toe up and down or find that you are walking on the outside of your foot because of pain in the toe, see your doctor right away. Hallux rigidus is easier to treat when the condition is caught early. If you wait until you see a bony bump on the top of your foot, the bone spurs will have already developed and the condition will be more difficult to treat.

Your physician will examine your foot and look for evidence of bone spurs. He or she may move the toe around to see how much motion is possible without pain. X-rays will show the location and size of any bone spurs, as well as the degree of degeneration in the joint space and cartilage.

Nonoperative treatment options

Pain relievers and anti-inflammatory medications such as ibuprofen may help reduce the swelling and ease the pain. Applying ice packs or taking contrast baths (described below) may also help reduce inflammation and control symptoms for a short period of time. But they aren't enough to stop the condition from progressing. Wearing a shoe with a large toe box will reduce the pressure on the toe, and you will probably have to give up wearing high heels. Your doctor may recommend that you get a stiff-soled shoe with a rocker or roller bottom design and possibly even a steel shank or metal brace in the sole. This type of shoe supports the foot when you walk and reduces the amount of bend in the big toe.

A contrast bath uses alternating cold and hot water to reduce inflammation. You'll need two buckets, one with water as cold as you can tolerate and the other with water as warm as you can tolerate. Immerse your foot in the cold water for 30 seconds, then immediately place it in the hot water for 30 seconds. Continue to alternate between cold and hot for five minutes, ending in the cold water. You can do contrast baths up to three times a day. However, be careful to avoid extreme temperatures in the water, especially if your feet aren't very sensitive to heat or cold.

Surgical options

Cheilectomy (kI-lek'-toe-me) This surgery is usually recommended when damage is mild or moderate. It involves removing the bone spurs as well as a portion of the foot bone, so the toe has more room to bend. The incision is made on the top of the foot. The toe and the operative site may remain swollen for several months after the operation, and you will have to wear a wooden-soled sandal for at least two weeks after the surgery. But most patients do experience long-term relief.

Arthrodesis (are-throw-dee’-sis) Fusing the bones together (arthrodesis) is often recommended when the damage to the cartilage is severe. The damaged cartilage is removed and pins, screws, or a plate are used to fix the joint in a permanent position. Gradually, the bones grow together. This type of surgery means that you will not be able to bend the toe at all. However, it is the most reliable way to reduce pain in these severe cases.

For the first six weeks after surgery, you will have to wear a cast and then use crutches for about another six weeks. You won't be able to wear high heels, and you may need to wear a shoe with a rocker-type sole.

Arthroplasty (are-throw-plas'-tee) Older patients who place few functional demands on the feet may be candidates for joint replacement surgery. The joint surfaces are removed and an artificial joint is implanted. This procedure may relieve pain and preserve joint motion.

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Stress Fractures of the Foot and Ankle

Stress fractures are a type of overuse injury. These tiny cracks in your bones develop when your muscles become overtired (fatigued) and can no longer absorb the shock of repeated impacts. When this happens, the muscles transfer the stress to the bones, creating a small crack or fracture.

Stress fractures also can occur with normal usage if osteoporosis or some other disease weakens your bones and leaves them vulnerable. These fractures are often called "insufficiency fractures" because there isn't enough bone to withstand the normal stress of daily use.

Most stress fractures occur in the weightbearing bones of the foot and lower leg. The most commonly affected site is the second or third of the long bones (metatarsals) between the toes and the midfoot. Stress fractures also can occur in the heel, the outer bone of the lower leg (fibula) and the navicular, a bone on the top of the midfoot.

Who's at risk?

Athletes who participate in high-impact sports such as track and field, basketball, gymnastics, ballet or tennis

Adolescents whose bones have not yet fully hardened

Women, particularly female athletes, who have abnormal or absent menstrual cycles that can result in decreasing bone mass

Military recruits who suddenly must shift from a sedentary civilian life to a more active training regime

Causes of stress fractures

Doing too much too soon is a common cause of stress fractures. Runner who have been confined indoors for most of the winter may want to pick up where they left off at the end of the previous season. Instead of starting slowly, they try to match their previous mileage. The result could be stress fractures in the foot and ankle.

Improper sports equipment, such as shoes that are too worn or stiff, also can contribute to stress fractures. A change of surface, such as going from a grass tennis court to one of clay or from an indoor to an outdoor running track, can increase the risk of stress fractures. Errors in training or technique are another cause of stress fractures. Some conditions, such as flatfoot or bunions, can change the mechanics of your foot and make stress fractures more likely to develop.

Insufficiency stress fractures result when the bone itself is weak. Conditions such as osteoporosis reduce the density and quality of bone matter, thus increasing the risk of fracture. Female athletes who experience irregular or absent menstrual periods may also have decreased bone density and an increased risk of stress fractures.

Signs and symptoms

Pain that develops gradually, increases with weight-bearing activity, and diminishes with rest

Swelling on the top of the foot or the outside ankle

Tenderness to touch at the site of the fracture

Possible bruising

Diagnosing a stress fracture

If you suspect a stress fracture in your foot or ankle, stop the activity and rest the foot. Ignoring the pain can have serious consequences, and the bone may break completely. Apply an ice pack and elevate the foot above the level of your heart. Try not to put weight on the foot until after you see a doctor.

Stress fractures are difficult to see on X-rays until they've actually started to heal. Your orthopaedist may recommend a bone scan, which is more sensitive than an X-ray and can detect stress fractures early.

Treating stress fractures

Treatment will depend on the location of the stress fracture. Most stress fractures will heal if you reduce your level of activity and wear protective footwear for two to four weeks. Your orthopaedist may recommend that you wear a stiff-soled shoe, a wooden-soled sandal, or a removable short leg fracture brace shoe. Athletes should switch to a sport that puts less stress on the foot and leg. Swimming and bicycle riding are good alternative activities.

Stress fractures in the fifth metatarsal bone (on the outer side of the foot) or in the navicular or talus bones take longer to heal, perhaps as long as six to eight weeks. Your orthopaedist may apply a cast to your foot or recommend that you use crutches until the bone heals. In some cases, you may need surgery so that the orthopaedist can insert a screw in the bone to ensure proper healing.

Preventing stress fractures

Because stress fractures that don't heal properly can develop into complete breaks of the bone and can become a chronic problem, it's better to prevent them in the first place. Here's what you can do:

  • Maintain a healthy diet. Eat calcium-rich foods to help build bone strength.
  • Use the proper equipment for your sport. Don't wear old or worn running shoes.
  • Alternate activities. For example, you can alternate jogging with swimming or cycling.
  • Slowly increase any new sports activity. Gradually increase time, speed and distance; a 10 percent increase per week is fine.
  • If pain or swelling returns, stop the activity. Rest for a few days. If pain continues, see an orthopaedist.

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The Foot And Ankle

More than 11 million visits were made to physicians' offices in 2003 because of foot, toe and ankle problems, including more than 2 million visits for ankle sprains and strains and more than 800,000 visits for ankle fractures (Source: National Center for Health Statistics; Centers for Disease Control and Prevention; 2003 National Ambulatory Medical Care Survey.) Consider this:

  • Walking puts up to 1.5 times your bodyweight on your foot.
  • Your feet log approx. 1,000 miles per year.
  • As shock absorbers, feet cushion up to one million pounds of pressure during one hour of strenuous exercise.

How do the foot and ankle work?

Here are some facts from the American Academy of Orthopaedic Surgeons: Each foot has 26 bones. The ankle bone (talus) and the ends of the two lower leg bones (tibia and fibula) form the ankle joint, which is stabilized and supported by three groups of ligaments. Muscles and tendons move the foot and ankle.

What are the most prevalent foot and ankle injuries?

Ankle sprains. Sprained ankles are one of the most common injuries in sports. Because the inner ankle is more stable than the outer ankle, the foot is likely to turn inward (ankle inversion) from a fall, tackle, or jump. This stretches or tears ligaments; the result is an ankle sprain. The lateral ligament on the outer ankle is most prone to injury.

Achilles tendon injury. The strongest and largest tendon, the Achilles tendon connects muscles in the lower leg with the heel bone. Sports that tighten the calf muscles, such as basketball, running and high-jumping can overstress this tendon and cause a strain (Achilles tendinitis) or a rupture. A direct blow to the foot, ankle, or calf can also cause it.

Overuse injuries. Excessive training, such as running long distances without rest, places repeated stress on the foot and ankle. The result can be stress fractures and muscle/tendon strains.

Shin splints. Pain in front of the shin bone (tibia) usually is caused by a stress fracture, called shin splints. Overtraining, poorly fitting athletic shoes, and a change in running surface from soft to hard puts athletes at risk for this injury.

What activities make people most susceptible to foot and ankle injuries?

Athletes who jump risk ankle sprains because they can accidentally land on the side of their foot. Extensive running, exercise, or training also can overstress the ligaments, leading to injury. Contact and kicking sports expose the foot and ankle to potential trauma-direct blows, crushing, displacement, etc. Especially prevalent in football, hockey, and soccer-trauma can dislocate a joint, fracture a bone, stretch or tear ligaments, or strain muscles and tendons.

What other factors make people susceptible to foot and ankle injuries?

Improperly fitting shoes or improper footwear for a particular sport can damage your feet. Training errors, i.e., running up hills, or running on bumpy roads, predispose you to serious sprains and strains. If you start a new sport without proper conditioning, you are at risk.

How are foot and ankle injuries treated?

Most sprains and strains are initially treated with rest, ice, compression, and elevation. Moderate and severe sprains and strains are often immobilized with a cast or splint. Severe fractures often require surgical repair.

No one is immune from these injuries, but the American Academy of Orthopaedic Surgeons developed these tips to help reduce your injury risk:

  • Warm up before any sports activity, including practice
  • Participate in a conditioning program to build muscle strength
  • Do stretching exercises daily
  • Listen to your body: never run if you experience pain in the foot or ankle.
  • Wear protective equipment appropriate for that sport
  • Replace athletic shoes as soon as the tread or heel wears out
  • Wear properly fitting athletic, dress, and casual shoes

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Toe and Forefoot Fractures

Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken (fractured) bone in your forefoot (metatarsals) or in one of your toes (phalanges) is often painful but rarely disabling. Most of the time, these injuries heal without operative treatment.

Types of fractures

Stress fractures frequently occur in the bones of the forefoot that extend from your toes to the middle of your foot. Stress fractures are like tiny cracks in the bone surface. They can occur with sudden increases in training (such as running or walking for longer distances or times), improper training techniques or changes in training surfaces. Most other types of fractures extend through the bone. They may be stable (no shift in bone alignment) or displaced (bone ends no longer line up). These fractures usually result from trauma, such as dropping a heavy object on your foot, or from a twisting injury. If the fractured bone does not break through the skin, it is called a closed fracture.

Several types of fractures occur to the forefoot bone on the side of the little toe (fifth metatarsal). Ballet dancers may break this bone during a misstep or fall from a pointe position. A ankle-twisting injury may tear the tendon that attaches to this bone and pull a small piece of the bone away. A more serious injury in the same area is a Jones fracture, which occurs near the base of the bone and disrupting the blood supply to the bone. This injury may take longer to heal or require surgery.

Signs and symptoms

Pain, swelling, and sometimes bruising are the most common signs of a fracture in the foot. If you have a broken toe, you may be able to walk, but this usually aggravates the pain. If the pain, swelling, and discoloration continue for more than two or three days, or if pain interferes with walking, something could be seriously wrong; see a doctor as soon as possible. If you delay getting treatment, you could develop persistent foot pain and arthritis. You could also change the way you walk (your gait), which could lead to the formation of painful calluses on the bottom of your foot or other injuries.

Diagnosis

The doctor will examine your foot to pinpoint the central area of tenderness and compare the injured foot to the normal foot. You should tell the doctor when the pain started, what you were doing at the time, and if there was any injury to the foot. X-rays will show most fractures, although a bone scan may occasionally be needed to identify stress fractures. Usually, the doctor will be able to realign the bone without surgery, although in severe fractures, pins or screws may be required to hold the bones in place while they heal.

Treatment

See a doctor as soon as possible if you think that you have a broken bone in your foot or toe. Until your appointment, keep weight off the leg and apply ice to reduce swelling. Use an ice pack or wrap the ice in a towel so it does not come into direct contact with the skin. Apply the ice for no more than 20 minutes at a time. Take an analgesic such as aspirin or ibuprofen to help relieve the pain. Wear a wider shoe with a stiff sole.

Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for three to four weeks. Substitute another activity that puts less pressure on the foot, such as swimming. Gradually, you will be able to return to activity. Your doctor or coach may be able to help you pinpoint the training errors that caused the initial problem so you can avoid a recurrence.

The bone ends of a displaced fracture must be realigned and the bone kept immobile until healing takes place. If you have a broken toe, the doctor will "buddy-tape" the broken toe to an adjacent toe, with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed. Remove or replace the tape if swelling increases and the toes feel numb or look pale. If you are diabetic or have peripheral neuropathy (numbness of the toes), do not tape the toes together. You may need to wear a rigid flat-bottom orthopaedic shoe for two to three weeks.

If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace, or a rigid, flat-bottom shoe. It could take six to eight weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, the doctor may request another set of X-rays to ensure that the bones remain properly aligned. As symptoms subside, you can put some weight on the leg. Stop if the pain returns.

Surgery is rarely required to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success.

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