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Foot and Ankle Surgery

Diabetic Foot Care Guidelines
foot careDiabetes can be dangerous to your feet; even a small cut could have serious consequences which may cause nerve damage that takes away the feeling in your feet. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection. Because of these problems, you might not notice a pebble in your shoe — so you could develop a blister, then a sore, then a stubborn infection that might cause amputation of your foot or leg.

To avoid serious foot problems that could result in losing a toe, foot or leg, be sure to follow these guidelines:

  • Inspect your feet daily. Check for cuts, blisters, redness, swelling or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.
  • Wash your feet in lukewarm (not hot!) water. Keep your feet clean by washing them daily. But only use lukewarm water — the temperature you’d use on a newborn baby. Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or patting — and make sure to carefully dry between the toes.
  • Moisturize your feet — but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But DON’T moisturize between the toes — this could encourage a fungal infection.
  • Cut nails carefully — and straight across. Also, file the edges. Don’t cut them too short, since this could lead to ingrown toe nails. Never trim corns or calluses. No “bathroom surgery” — let your doctor do the job.
  • Wear clean, dry socks. Change them daily. Avoid the wrong type of socks. Avoid tight elastic bands (they reduce circulation). Don’t wear thick or bulky socks (they can fit poorly and irritate the skin).
  • Wear socks to bed. If your feet get cold at night, wear socks. NEVER use a heating pad or hot water bottle.
  • Shake out your shoes and inspect the inside before wearing. Remember, you may not feel a pebble — so always shake out your shoes before putting them on.
  • Keep your feet warm and dry. Don’t get your feet wet in snow or rain. Wear warm socks and shoes in winter.
  • Never walk barefoot. Not even at home! You could step on something and get a scratch or cut.
  • Take care of your diabetes. Keep your blood sugar levels under control.
  • Don’t smoke. Smoking restricts blood flow in your feet.
  • Get periodic foot exams. See your podiatric foot and ankle surgeon on a regular basis for an examination to help you prevent the foot complications of diabetes.

Bunions (Hallux Abducto Valgus)
Bunions (Hallux Abducto Valgus)Even though bunions are a common foot deformity, there are misconceptions about them. Many people may unnecessarily suffer the pain of bunions for years before seeking treatment.

What is a Bunion?
A bunion (also referred to as hallux valgus or hallux abducto valgus) is often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. The big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment – producing the bunion’s “bump.”

Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which becomes increasingly prominent. Symptoms usually appear at later stages, although some people never have symptoms.

Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion.

Although wearing shoes that crowd the toes won’t actually cause bunions, it sometimes makes the deformity get progressively worse. Symptoms may therefore appear sooner.

Symptoms, which occur at the site of the bunion, may include:

  • Pain or soreness
  • Inflammation and redness
  • A burning sensation
  • Possible numbness

Symptoms occur most often when wearing shoes that crowd the toes, such as shoes with a tight toe box or high heels. This may explain why women are more likely to have symptoms than men. In addition, spending long periods of time on your feet can aggravate the symptoms of bunions.

Non-Surgical TreatmentBunions are readily apparent – the prominence is visible at the base of the big toe or side of the foot. However, to fully evaluate the condition, the foot and ankle surgeon may take x-rays to determine the degree of the deformity and assess the changes that have occurred.

Because bunions are progressive, they don’t go away, and will usually get worse over time. But not all cases are alike – some bunions progress more rapidly than others. Once your surgeon has evaluated your bunion, a treatment plan can be developed that is suited to your needs.

Non-Surgical Treatment
Sometimes observation of the bunion is all that’s needed. To reduce the chance of damage to the joint, periodic evaluation and X-rays by your surgeon are advised.

In many other cases, however, some type of treatment is needed. Early treatments are aimed at easing the pain of bunions, but they won’t reverse the deformity itself. These include the following:

  • Changes in shoewear - Wearing the right kind of shoes is very important. Choose shoes that have a wide toe box and forgo those with pointed toes or high heels which may aggravate the condition.
  • Padding - Pads placed over the area of the bunion can help minimize pain. These can be obtained from your surgeon or purchased at a drug store.
  • Activity modifications - Avoid activity that causes bunion pain, including standing for long periods of time.
  • Medications - Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
  • Icing - Applying an ice pack several times a day helps reduce inflammation and pain.
  • Injection therapy -  Although rarely used in bunion treatment, injections of corticosteroids may be useful in treating the inflamed bursa (fluid-filled sac located around a joint) sometimes seen with bunions.
  • Orthotic devices - In some cases, custom orthotic devices may be provided by the foot and ankle surgeon.

When Is Surgery Needed?
If non-surgical treatments fail to relieve bunion pain and when the pain of a bunion interferes with daily activities, it’s time to discuss surgical options with a foot and ankle surgeon. Together you can decide if surgery is best for you.

A variety of surgical procedures is available to treat bunions. The procedures are designed to remove the “bump” of bone, correct the changes in the bony structure of the foot, and correct soft tissue changes that may also have occurred. The goal of surgery is the reduction of pain.

In selecting the procedure or combination of procedures for your particular case, the foot and ankle surgeon will take into consideration the extent of your deformity based on the X-ray findings, your age, your activity level and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.

Flat Feet
Most people have a gap under the arch of their foot when they are in a standing position. The arch, the inner part of the foot, is slightly raised off the ground. People with flat feet or fallen arches either have no arch, or it is very low.

The feet of people with flat feet may roll over to the inner side when they are standing or walking, and the feet may point outwards as a result.

A significant number of people with fallen arches (flat feet) experience no pain and have no problems. Some, however, may experience pain in their feet, especially when the connecting ligaments and muscles are strained. The leg joints may also be affected, resulting in pain. If the ankles turn inwards because of flat feet, the most likely affected areas will be the feet, ankles and knees.

Some people have flat feet because of a developmental fault during childhood, while others may find that the problem develops as they age, or after a pregnancy. There are some simple devices which may prevent the complications of flat feet.

According to Medilexicon's medical dictionary, pes planus (flat feet) is "a condition in which the longitudinal arch is broken down, the entire sole touching the ground."

What are the signs and symptoms of flat feet or fallen arches?
A symptom is something the patient feels and reports, while a sign is something other people, including the doctor may detect. An example of a symptom may be pain in the ankle, while a sign may be a swelling.

Symptoms may vary and generally depend on the severity of the condition. Some have an uneven distribution of bodyweight and find that the heel of their shoes wears out more rapidly and more on one side than the other. The most common signs or symptoms of flat feet are:

  • Pain in...
    ...the ankle (inner side), there may also be swelling
    ...the foot in general
    ...the arch of the foot
    ...the calf
    ...the knee
    ...the hip
    ...the back
    ...the general lower leg area
  • People with flat feet may also experience stiffness in one or both feet.
  • One or both feet may be flat on the ground (either no arch, or very slight arch).
  • Shoes may wear unevenly.

What are the causes of flat feet?

  • Family history - Experts say fallen arches can run in families.
  • Weak arch - The arch of the foot may be there when no weight is placed on it, for example, when the person is sitting. But as soon as they stand up the foot flattens (falls) onto the ground.
  • Injury
  • Arthritis
  • Tibialis posterior (ruptured tendon)
  • Pregnancy
  • Nervous system or muscle diseases - such as cerebral palsy, muscular dystrophy or spina bifida
  • Tarsal Coalition - The bones of the foot fuse together in an unusual way, resulting in stiff and flat feet. Most commonly diagnosed during childhood.
  • Diabetes
  • Age and wear and tear - Years of using your feet to walk, run and jump eventually may take its toll. One of the eventual consequences could be fallen arches. The posterior tibial tendon may become weakened after long-term wear and tear. The postario tibial tendon is the main support structure of the arch of our feet. The tendon can become inflamed (tendinitis) after overuse - sometimes it can even tear. Once the tendon is damaged, the arch shape of the foot may flatten.

Our feet are incredibly well specialized structures. There are 26 different bones in each foot, held together by 33 joints and more than 100 muscles, tendons and ligaments (in each foot). They way they weave and align together determine the formation of our arches.

The aim of the arches is to give us spring and distribute our body weight across our feet and legs. The structures of the arches of our feet determine how we walk - they are rigid levels which allow us to move smoothly. However, the arches need to be sturdy as well as flexible to adapt to various surfaces and stresses.

During childhood it is normal to have flat feet. This is because our feet form during our childhood. In other words, having what appears to be flat feet during early childhood does not necessarily mean that it will persist throughout the individual's life.

People with very low arches or what appear to be no arches at all may experience no problems.

What are the risk factors for flat feet?
A risk factor is something that increases the likelihood of an illness or condition developing. For example, people who are obese are more likely to develop diabetes type 2 compared to slim people. Therefore, obesity is a risk factor for diabetes.

The following risk factors are linked to a higher probability of having flat feet:

  • Obesity
  • Diabetes
  • Getting older (aging)
  • Pregnancy
  • Rheumatoid arthritis
  • Foot or ankle injury
  • Posterior tibial tendon tear or dysfunction

How are flat feet or fallen arches diagnosed?
People who have flat feet without signs or symptoms that bother them do not generally have to see a doctor or podiatrist about them. However, if any of the following occur, you should see your GP or a podiatrist:

  • Obesity
  • The fallen arches (flat feet) have developed recently
  • You experience pain in your feet, ankles or lower limbs
  • Your unpleasant symptoms do not improve with supportive, well-fitted shoes
  • Either or both feet are becoming flatter
  • Your feet feel rigid (stiff)
  • Your feet feel heavy and unwieldy

Most qualified health care professionals can diagnose flat feet just by watching the patient stand, walk and examining his/her feet. A doctor will also look at the patient's medical history. The feet will be observed from the front and back. The patient may be asked to stand on tip-toe while the doctor examines the shape and functioning of each foot.

In some cases the physician may order an X-ray, CT (computed tomography) scan, or MRI (magnetic resonance imaging) scan.

What are the treatment options for fallen arches (flat fleet)?
Some patients with flat feet may automatically align their limbs in such a way that unpleasant symptoms never develop. In such cases treatment is not usually required.

  • Pain in the foot that is caused by flat feet may be alleviated if the patient wears supportive well-fitted shoes. Some patients say that symptoms improve with extra-wide fitting shoes.
  • Fitted insoles or orthotics (custom-designed arch supports) may relieve pressure from the arch and reduce pain if the patient's feet roll or over-pronate. The benefits of an orthotic only exist while it is being worn.
  • Patients with tendonitis of the posterior tibial tendon may benefit if a wedge is inserted along the inside edge of the orthotic - this takes some of the load off the tendon tissue.
  • Wearing an ankle brace may help patients with posterior tibial tendinitis, until the inflammation comes down.
  • Rest - doctors may advise some patients to rest and avoid activities which may make the foot (feet) feel worse, until the foot (feet) feels better.
  • A combination of an insole and some kind of painkiller may help patients with a ruptured tendon, as well as those with arthritis.
  • Patients with a ruptured tendon or arthritis who find insoles with painkillers ineffective may require surgical intervention.
  • Patients, usually children, whose bones did not or are not developing properly, resulting in flat feet from birth, may require surgical intervention to separate fused bones (rare).
  • Body weight management - if the patient is obese the doctor may advise him/her to lose weight. A significant number of obese patients with flat feet who successfully lose weight experience considerable improvement of symptoms.

What are the possible complications of flat feet or fallen arches?
As fallen arches can affect the way a person's body is aligned when standing, walking or running, the risk of subsequent pain in the hips, knees or ankles is significantly greater.

People with other foot problems may find that flat feet either contribute to them or make symptoms worse. Examples include the following:

  • Achilles tendinitis
  • Arthritis in the ankle(s)
  • Arthritis in the foot (feet)
  • Bunions
  • Hammertoes
  • Plantar fasciitis (pain and inflammation in the ligaments in the soles of feet)
  • Posterior tibial tendinitis
  • Shin splints

Neuroma'sThere are many causes of foot pain, but if you are experiencing a sharp, stabbing pain that feels better when you stop walking and massage your foot, you may have what's known as Morton's neuroma. While it has a scary sounding name, this condition is benign and fortunately highly treatable.

In basic terms, a neuroma is an enlargement or thickening of a nerve in the foot in the area between the toes, usually the third interspace between the third and fourth toes, followed by the second interspace between the second and third toes. Morton's neuromas can rarely affect the fourth and first interspaces.

It is also sometimes referred to as an intermetatarsal neuroma, interdigital neuroma, Morton's metatarsalgia (pain in the metatarsal area), perineural fibrosis (scar tissue around a nerve) or entrapment neuropathy (abnormal nerve due to compression).

If you have a Morton's neuroma, there is a 15% chance you will develop it in both feet. Morton's neuromas occur most commonly in women who are between 30 to 50 years old, often due to poor-fitting shoes.

Causes of Morton's Neuroma: Injury or Poor Biomechanics
A Morton's neuroma is thought to be caused by an injury to the nerve, but scientists are still not sure about the exact cause of the injury. The injury may be caused by damage to the metatarsal heads, the deep transverse intermetatarsal ligament (holds the metatarsal heads together) or an intermetatarsal bursa (fluid-filled sac). All of these structures can cause compression and injury to the nerve, initially causing swelling and damage in the nerve. Over time, if the compression/injury continues, the nerve repairs itself with very fibrous tissue that leads to enlargement and thickening of the nerve.

Other causes of injury to the nerve may include simply having an incorrect walking style or an awkward foot structure, such as overpronation (foot rolls inward), hypermobility (too much motion), cavo varus (high arch foot) and excessive dorsiflexion (toes bend upward) of the toes.

These biomechanical (how the foot moves) factors may cause injury to the nerve with every step. If the nerve becomes irritated and enlarged, then it takes up more space and gets even more compressed and irritated. It becomes a vicious cycle.

Signs and Symptoms of Morton's Neuroma

  • Pain (sharp, stabbing, throbbing, shooting)
  • Numbness
  • Tingling or "pins and needles"
  • Burning
  • Cramping
  • A feeling that you are stepping on something or that something is in your shoe

Initially these symptoms may happen once in a while, but as the condition gets worse, the symptoms may happen all of the time. It usually feels better by taking off your shoe and massaging your foot.

How a Diagnosis Is Made
Your podiatrist (foot doctor) will ask many questions about your signs and symptoms and will perform a physical exam. Some of the exams may include a web space compression test. This is done by squeezing the metatarsals (the bones just below the toes) together with one hand and using the thumb and index finger of the other hand to compress the affected area to reproduce the pain/symptoms. A palpable click (Mulder's click) is usually present. This test may also cause pain to shoot into the toes and that is called a Tinel's sign. Gauthier's test involves squeezing the metatarsals together and moving them up and down for 30 seconds. This will usually cause pain or it will bring on your other symptoms. Sullivan's sign is positive when you stand and the affected toes spread apart.

A Morton's neuroma is usually diagnosed based on the history and physical exam findings, but sometimes other tests such as an X-ray, ultrasound or an MRI are needed.

Plantar Fasciitis
What is Plantar Fasciitis?

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Branford Podiatry Center

125 Montowese St.
Branford, CT 06405

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Phone: 203-481-8969

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