FAQ Category: Foot

Getting your leg fully examined by a qualified medical provider is a good start. They are recommended to use the Thompson test or calf-squeeze-test, which been found to be the most effective way to diagnose a full Achilles tendon tear.

A review study found supportive evidence on electing for the conservative non-surgical choice followed by rehabilitation focused on getting the person back to prior function gradually. Better outcomes, less infections, less medical cost all weighed in on the side of avoiding the knife. 

The initial treatment protocol includes immobilization in a walking boot and, according to Weisskirchner Barfod et al, this period lasts eight weeks. During this time you may be instructed to stay off the injured leg fully, and comply with a weight bearing restriction, however this study has shown that full weight bearing during this period causes no setbacks and can improve quality of life. (Be sure to ask your physician and follow their protocol.) During this eight week immobilization phase there will be use of multiple heel wedges, and they will be slowly removed over the course of this time. There may also be instructions for gentle range of motion exercises. After the initial eight weeks the patient will be released from use of the walking good and will begin progressive strengthening. This may include referral to a physical therapist to lead this phase, which can last several months depending on individual progress.

The biggest challenges or complications occurring after an Achilles tendon rupture include possibility of re-rupture, decreased quality of life during initial immobilization phase especially if this includes limited weight bearing, time off work, difficulty regaining full strength, and difficulty with full return to previous level of sport participation.

Morton Neuroma refers to the interdigital nerve entrapment in the third webspace (occasionally the second webspace) of the foot.

Typically non-surgical treatment will be employed first. This may include anti-inflammatory medication, activity modification, night splinting, physical therapy and eliminating use of restrictive clothing or footwear. If this management fails to provide relief surgical measures may be considered.

Functional non-operative management is a relatively new bracing concept that involves early weight-bearing and range of motion. These two rehabilitation factors have shown to prevent detrimental alterations in muscle characteristics and increase maturation of collagen fibers during the tendon healing process. There is some difficulty with beginning early range of motion, in that the brace or orthosis must be removable which is more costly and requires patient compliance. Simply adding weight bearing to the early rehabilitation protocol, however is much easier, and involves changing casts to one that has a weight bearing device, such as a Bohler iron, added. There are several variations to functional braces that range from the non-removable early weight bearing casts with a Bohler Iron to the more technically advanced removable orthoses that can be adapted for early weight bearing.

Depending on your flat foot flexibility, you may not need orthotics at all and often custom orthotics can increase the pain in a rigid flat foot deformity. You might try no orthotics at all with some good calf stretches to see if this lessens your instep pain.

A physical therapist will at your overall alignment (joint structure), how you move, and will tease out any muscle imbalances that might be contributing to your ongoing plantar fasciitis.  They also can perform adjustments if need be, fabricate orthotics, and use manual therapy as well as some modalities to help you get rid of the plantar fasciitis and hopefully keep it away for good.  Especially since you were in a walking boot for a while, follow up with some ankle strengthening is indicated.

Typically plantar fasciitis is described as a sharp, stabbing pain with the first steps in the morning that then diminishes as the day progresses. The pain originates more towards the edge of the heel than towards the arch. The symptoms you are describing sound more like Baxter Nerve entrapment. A good thorough assessment by a physical therapist or a physician should tease out the actual diagnosis.

No, however most research shows that surgical repair results in significantly lower rerupture rates at three and a half percent compared to non-surgical repair, which has a rerupture rate around twelve and a half percent. More recently research has indicated that a functional non-operative protocol results in rerupture rates similar to those who have undergone surgical repair, with one study reporting seven percent and another reporting eight percent rerupture rate following non-surgical early weight bearing protocols. Functional non-operative management is a relatively new bracing concept that involves early weight-bearing and range of motion. These two rehabilitation factors have shown to prevent detrimental alterations in muscle characteristics and increase maturation of collagen fibers during the tendon healing process. At this time the protocols for early weight bearing and early range of motion for non-surgical Achilles tendon repair and very inconsistent and are not research supported. It is clear that more research is warranted to help surgeons and patients justify their choice of surgical vs. nonsurgical repair and decide to participate in rehabilitation that incorporates early weight bearing and early range of motion. At this time, research does show that non-surgical repair with early weight bearing is a viable option that does not seem to increase risk of rerupture rate or other complications.

A bent toe is typically due to ligamentous instability surrounding the toe joint.  Depending on the progression of the deformity (whether or not it is rigid or still flexible) there are several options.  Conservative treatment would be shoe alterations and physical therapy for foot strengthening and addressing your walking form.  Surgical treatment is typically reserved for more fixed deformities but can help with further progression of the toe deformity and involves suturing torn structures around the joint.

High heels are identified as a major cause for toes crossing or becoming stuck in a bent position, called hammer toe. Shoes with a narrow toe box or shoes that place an excessive amount of force across the base of your toes can cause hyperextension of the toe joints (bending past their normal range) and a stretching and tearing of the ligaments surrounding the toe joint. Genetics does play a small role, but is not as big of a factor as shoe choice. Wearing a flatter shoe with a wide toe box can help prevent problems with your feet in the future.

As you probably know by now, synovial sarcoma is a malignant soft-tissue tumor that occurs most often in the extremities (arms and legs). A regular X-ray will not show soft tissue malignancies. It was unusual that the more advanced imaging (MRI) did not at least show some change in intensity to indicate a mass of this type.

MRI with contrast is not typically the next step in diagnosis when there has been no indication of a problem. It is a more expensive test and exposes the patient to a type of dye that is injected into the bloodstream just before (or sometimes during) the procedure. Certain abnormalities, such as tumors, will absorb the dye and show up very clearly on the MRI with contrast.

There have been reported cases where repeated MRIs did NOT reveal a malignant soft-tissue tumor later diagnosed as synovial sarcoma. As a result, an accurate diagnosis and appropriate treatment were delayed by a full year for the patients in question. This has led to a recent recommendation for physicians to consider synovial sarcoma when a patient presents with what looks like turf toe but has unusual patient history and lack of response to treatment.

Synovial sarcomas are rare but occur most often in young, healthy adults. They are often overlooked and/or mistaken for other problems. There have been 26 other cases reported of synovial sarcoma of the forefoot, so it is rare but may occur more often than anyone previously realized.

The name synovial sarcoma is a bit misleading since microscopic studies of the cells from these tumors show clear differences from true synovial cells. And the name would lead you to believe the tumors occur inside a synovial joint, when in fact, that is not the case. The tumors are close to joints and the cells resemble synovial tissue but that’s as far as the similarities go.

However, the term “sarcoma” does mean soft tissue malignancy and synovial sarcomas are malignant. Malignancy means they can spread to other tissues in the body causing disfigurement and even death.

In the case of synovial sarcoma, small tumors (less than five centimeters), in young people (less than 25 years old), and detected early can have a very good outcome with appropriate treatment (surgery to remove the mass). Wide margins (cutting around the tumor with normal tissue bordering the entire mass) must be obtained.

A delayed diagnosis with inappropriate treatment (e.g., in the case of misdiagnosis) has a less positive prognosis with an increased potential for cancer recurrence. Death occurs in as many as 40 per cent of the patients diagnosed with this condition after it has reached a larger size (five centimeters or more).

There have only been 25 or 26 reported cases of synovial sarcoma in the forefoot (including the big toe) so we do not have a large data group to rely on for these statistics. This malignancy occurs most often in young adults who are healthy and perhaps better able to respond well to treatment.

When a joint is injured as a result of a joint sprain or fracture, there can be damage done to the layer of cartilage just above the joint surface. These are called osteochondral or chondral lesions and they occur in up to half of all ankle injuries. It sounds like this may be what you have.

There are several different surgical transplantation techniques to repair the cartilage (including stem cell transplantation) that have been developed and improved over the last 10 years. Treatment is designed to restore the cartilage and provide relief from painful symptoms.

The use of stem cells (taken from the patient’s own bone marrow) and then injected into the osteochondral lesion is under investigation. Early studies (with animals) are underway now but no conclusions have been reached yet regarding results. The stem cells are not used alone but along with another technique known as microfracture (tiny holes are drilled through the subchondral plate). Microfracture allows stem cells from inside the bone marrow to enter the defect and form fibrocartilaginous repair tissue.

Currently, microfracture is available as a repair technique for osteochondral defects, holes, or lesions. Stem cell transplantation is still in the experimental/research stage. There is one other biologic treatment to repair cartilage that you might be interested in knowing about. It is with the use of hyaluronic acid. Hyaluronic acid is a substance normally contained within the joint (synovial) fluid. It helps keep the joint surfaces moving smoothly.

Hyaluronic acid injections into the joint have been done after microfracture and compared with patients who had microfracture without the hyaluronic acid injections. Outcomes with a limited number of patients show that results are much improved in the microfracture plus hyaluronic acid injection group over the microfracture-only group.

As you might expect, there is a need to compare all of these approaches to see which one works best for different groups of patients. Outcomes of well-designed studies with carefully selected patients will go a long way in guiding future treatment plans for osteochondral lesions of the talus. Your orthopedic surgeon is the best one to advise you on which approach would be best for your particular injury.

When a joint is injured as a result of a joint sprain or fracture, there can be damage done to the layer of cartilage just above the joint surface. These are called osteochondral or chondral lesions and they occur in up to half of all ankle injuries. Surgical transplantation techniques to fill in the defect (hole or lesion) and repair/restore the cartilage have been developed and improved over the last 10 years.

There are several different way to do this — a few may seem like filling a tooth. For example, autologous osteochondral transplantation is a filling of the defect with a tubular unit of donor hyaline cartilage and bone. Autologus means the plug of donor tissue is taken from the patient (usually the knee). Osteochondral allograft transplantation is another method for filling large defects but uses tissue harvested from a separate donor rather than from the patient (that’s what allograft means).

There is a more complex, two-stage autologous chondrocyte implantation technique available. It involves removing good, healthy chondrocytes (cartilage cells), taking them to the lab and making more chondrocytes, and then reimplanting the cells into the lesion (defect or hole in the cartilage). Again, this is somewhat like filling a hole in a tooth.

Each method of repair has its own advantages and disadvantages. The operative treatment for this problem is carefully selected for each patient in order to provide the best possible results. The surgeon who is treating you will explain which approach is recommended for you and why. You can certainly ask this question at your next appointment to better understand the treatment planned for you.

Interdigital neuroma (sometimes called a Morton’s neuroma) is the medical term for a painful growth in the forefoot. The pain is most commonly felt between the third and fourth toes but can also occur in the area between the second and third toes.

The most common cause of pain is thought to be irritation on the nerve. The chronic nerve irritation is believed to cause the nerve to scar and thicken, creating the neuroma. Many foot surgeons feel that the problem may arise because the metatarsal bones squeeze in on the nerve, and the ligament that joins the two bones irritates, or entraps, the nerve. Entrapment of the nerve that is in the space between the toes is thought to lead to the chronic irritation and pain you are experiencing.

The pain occurs most often in the ball of the foot when weight is placed on the foot. Many people with this condition report feeling a painful catching sensation while walking, and many report sharp pains that radiate out to the two toes where the nerve ends. There may be swelling between the toes or a sensation similar to having a rock in the shoe. This can feel like electric shocks, similar to hitting the funny bone of the elbow. Although it’s not life-threatening, this condition can be very disabling.

Treatment usually begins with changes in shoe wear. Sometimes simply moving to a wider shoe will reduce or eliminate the symptoms. A firm, crepe-soled shoe may help. The firm sole decreases the amount of stretch in the forefoot as the affected person takes a step. This lessens the degree of irritation on the nerve.

A special metatarsal pad can also be placed within the shoe under the ball of the foot. It sounds like this is what you are trying out now. The pad is designed to spread the metatarsals apart and take pressure off the neuroma. These simple changes to your footwear may allow you to resume normal walking immediately. But with the continued pain you are reporting, you may want to try cutting back more on activities for several weeks to allow the inflammation and pain to subside.

Other treatments directed to the painful area can help control pain and swelling. Examples include ultrasound, moist heat, and soft-tissue massage administered by a physical therapist. Physical therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections. For those who can handle an injection, a combination of lidocaine and cortisone into the area may help temporarily relieve symptoms.

The question of whether size matters when treating Morton’s neuroma) by steroid injection has been raised by a group of researchers from Scotland. Usually, this type of treatment involves an injection of lidocaine and cortisone into the area. There is some evidence that this approach may help temporarily relieve symptoms. But this is usually short-lived (days to weeks) and is mainly useful to help the doctor make a diagnosis.

The study performed at The Royal Infirmary of Edinburgh in Scotland was done to test out whether a corticosteroid injection is more effective than an anesthetic injection. In the process, they used ultrasound imaging to guide the needles and were thus able to measure the size of the neuromas and study the influence of size on the results.

Half of the 131 patients (85 per cent women, 15 per cent men) were given a single injection of methylprednisone (a corticosteroid antiinflammatory) combined with an anesthetic (numbing agent) directly into the neuroma. The other half received the same treatment but with just the anesthetic (lignocaine).

Results based on pain, function, and patient opinion of their own general health were measured one- and three-months later. Patient-surveys were used to gather information on pain, work and activity levels, walking, sense of well-being, emotional pain, rating of general health, and quality of life.

They found a significant difference (greater improvement in the corticosteroid group) one month and three months after treatment. It turns out that size did NOT make a difference. Patients with small to large neuromas received the same amount of relief and improvement with the corticosteroid injections. For the most part, results favored the use of corticosteroid injection. Complete pain relief was not reported in either group. Longer follow-up will be conducted to see if the benefits continue into the long-term as well.

Results of treatment to repair or restore defects like this (called osteochondral lesions) can be measured by comparing MRI images before and after treatment. MRIs are able to show the location and depth of the defect as well as the presence and percentage of regenerated tissue and condition of the cartilage and bone. MRIs also show how well the new cells are integrated into the surrounding cartilage, joint surface, and edge of the lesion.

MRIs can show the percentage of defect filling and how much of the new tissue is actual cartilage versus fibrocartilage. Patients who develop more tissue like hyaline cartilage and less like fibrocartilage have a better chance of good recovery. In a recent study from Italy using stem-cells as a reparative agent, patients who had 80 per cent hyaline cartilage with only 20 per cent fibrocartilage had the best results.

Clinical outcomes are often considered the best measure of results. Using pain, motion, weight-bearing status, ankle alignment, physical activity, and level of sports participation treats the patient not the picture. Follow-up arthroscopic exams (referred to as second-look procedures are more invasive than MRIs and don’t provide complete structural information about the entire repaired area. It might be worth asking your surgeon about the possibility of using imaging over the second-look arthroscopy. There may be reasons why he or she suggested arthroscopy to take into consideration.