FAQ Category: Foot

Many people are born with oddly shaped bones, extra bones, or fused bones and never know about it. In fact, studies show up to one-third of the general population have what is called an accessory (extra) bone. Sometimes these extra bones are in the joint and sometimes they occur embedded in a tendon or muscle.

Most of the time, unless the bone is prominent, no one knows about them. But dancers and other athletes are often the first to notice problems. The strain and stress on the feet from repetitive movements, wearing special (toe) shoes (dancers), and the positions assumed (up on toes, feet turned out) can cause tenderness and pain in the foot and/or ankle.

Usually the condition is suggested by the history and the tenderness over the area of the navicular. The only way to know for sure if you have this type of anomaly is an X-ray. Generally no other tests are required.

Just having an accessory navicular bone is not necessarily a bad thing. Not all people with these accessory bones have symptoms. Symptoms arise when the accessory navicular is overly large or when an injury disrupts the fibrous tissue between the navicular and the accessory navicular. A very large accessory navicular can cause a bump on the instep that rubs on your shoe causing pain. If you are not experiencing this type of pain and there is no bump on the instep of your foot, there’s no need to worry or get X-rays.

When we see someone shuffling along without picking up their feet, it’s easy to just attribute it to “old age” or being “out of condition.” But if you’ve noticed this and wondered about it, it’s likely you may have also wondered what’s wrong with the folks in wheelchairs or on a scooter who look perfectly able bodied?

In fact, the body may be fine but it’s the feet that are the problem. And without healthy, pain free feet and ankles, it’s plenty hard to get around easily. Health care professionals such as podiatrists, physical therapists, and orthopedic surgeons are very aware of just how common foot and ankle pain has become in the adult population. And it’s not just the very old but also the middle-aged groups.

According to a recent review of foot and ankle pain, there is an overall prevalence of foot/ankle/toe pain in 20 per cent of the adult population. That’s one in five people. And it turns out that foot pain is a bigger problem than ankle pain. The forefoot and toes seem to create the greatest pain and dysfunction. By age 50, over 50 per cent of the people polled reported disabling foot pain. Disabling pain refers to significant enough discomfort as to interfere with daily activities.

Women were more likely to report pain. That’s not surprising since fashionable footwear often includes narrow shoes and high heels, which have a distinct affect on the feet. But there’s more to it than just fashion footwear.

As we get older, our feet tend to spread out and get wider. But shoe manufacturers have not altered shoes to accommodate for this change. And many people continue to wear the same size they have always worn putting up with the discomfort of a too-small or too-tight shoe rather than admit they need a larger size. It is also possible that there is a link between foot pain and other musculoskeletal problems (e.g., knee, hip, or low back pain).

There is a need for further study in the future to get some agreement on what’s going on with foot and ankle pain in middle-to-older age groups and why it’s happening. Then we can address the need for more health care services directed at the feet and identify what those services should be to best serve our seniors. And maybe even identify ways to prevent these kinds of problems so you won’t develop the problem either!

You have uncovered a very well-kept secret among our older adults. Studies show that as we get older, our feet tend to spread out and get wider. But shoe manufacturers have not altered shoes to accommodate for this change. And many people continue to wear the same size they have always worn putting up with the discomfort of a too-small or too-tight shoe rather than admit they need a larger size.

Depending on the type of shoe your father prefers, the shoes may be too narrow just based on style. But he’s not alone. A recent review of studies published on foot pain showed that more than 50 per cent of adults aged 50 or older complain of foot pain. Women tend to have more problems in this area than men because of years in “fashion footwear” (high heels, narrow toe).

What can be done to help your father? Perhaps encouraging him to see his primary care physician or even a specialist such as a podiatrist would help. Sometimes when the “white coat” is speaking, older adults listen (at least more than they appear to be listening to their children).

Going shopping together might be helpful. We’ve noticed more and more shoe stores where the attendant actually measures the foot for an accurate shoe size. This is something that was done back in the 1950s and 60s but seemed to go out of practice until recently. Of course, they also had X-ray machines in shoe stores back then, too. X-rays gave a really accurate foot size but once the dangers of exposure to radiation were verified, this practice ended for good.

You might even want to pre-scout out shoe stores where the service is good and measurements are taken. Direct your father there first. Even if he doesn’t end up with shoes at that store, he may have a new mind set toward a larger size. Given how disabling foot pain can be, just experiencing the comfort of a larger shoe may be enough to sell your father on a properly fitting shoe. In the end, you will be doing him a good service. Good luck!

A quick review of anatomy might help us answer this question. The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group.

When they contract, they pull on the Achilles tendon. This action causes your foot to point down and helps you rise up on your toes. This powerful muscle group helps when you sprint, jump, or climb. Several different problems can occur that affect the Achilles tendon, some rather minor and some quite severe. In severe cases, the force of a violent strain can rupture the tendon.

Traditionally, this type of injury required a long period of time for healing, recovery, and rehab. But changes have been made in the way this problem is managed early on. Bracing like your sister used allows early weight-bearing and seems to allow for faster return to normal function without endangering the healing tendon.

The goal is to find the position that protects the healing Achilles while still allowing function in order to avoid atrophy (wasting) of the gastroc-soleus muscle group. The benefit is to restore motion and strength faster and therefore allow the patient to return to daily (and sports) activities sooner with less disability.

But there are some important things to know about this. The tendon must be kept in a shortened position while it heals. That means keeping your ankle in a slightly plantarflexed (toe pointed down) position. A special wedge under the heel is used to accomplish this. Healing in a position of too much dorsiflexion (foot neutral or with toes pulled up toward the face) could have long-term, disabling effects.

Don’t skimp on your medical care with this injury. You may be able to save some money by re-using that brace but it is important that you have an orthopedic surgeon evaluate what you really need for optimal healing. Take the brace with you to your appointment. It’s possible the brace can be modified for your specific needs. Achilles tendon ruptures are complex injuries and require careful management for optimal healing.

Research continues in the area of treatment for Achilles tendon ruptures. The last 10 years has brought a change from placing patients in a nonweight-bearing cast to using an ankle-foot orthosis (AFO) instead. An AFO is a brace usually made from plastic or light metal (carbon fiber). It allows for early weight-bearing.

The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon. This action causes your foot to point down and helps you rise up on your toes. This powerful muscle group helps when you sprint, jump, or climb. Several different problems can occur that affect the Achilles tendon, some rather minor and some quite severe.

In severe cases, the force of a violent strain can rupture the tendon. The classic example is a middle-aged tennis player or weekend warrior who places too much stress on the tendon and experiences a tearing of the tendon. In some instances, the rupture may be preceded by a period of tendonitis, which renders the tendon weaker than normal.

Traditionally, this type of injury required a long period of time for healing, recovery, and rehab. Management with early weight-bearing is helping change that. The question now is what’s the best AFO design for this problem? We don’t know yet but studies are ongoing looking for some answers. Here’s what a recent study from England has revealed.

Using 15 normal, healthy adults, the researchers compared three different AFOs with four different heel-wedge combinations. That gives a total of 12 different possible combinations. The heel wedge is used to place the ankle in a position of plantar flexion (toe pointed) in order to take stretch and pressure off the Achilles tendon while it is healing.

The goal is to find the position that protects the healing Achilles while still allowing function in order to avoid atrophy (wasting) of the gastroc-soleus muscle group. The benefit is to restore motion and strength faster and therefore allow the patient to return to daily (and sports) activities sooner with less disability.

They found that with smaller wedges, more dorsiflexion (toe pulled up toward face) was allowed and more pressure was placed on the forefoot/less pressure on the heel. The more rigid AFO used in the study (a rigid rocker-bottom design) resulted in less pressure on the heel and more pressure on the forefoot.

In fact, the greatest heel pressures were measured when subjects wore the rigid rocker-bottom AFO. When this AFO was combined with the thickest wedge, there was more motion restriction than any other AFO/wedge combination.

This makes sense because the amount of load placed on the Achilles tendon, heel, and forefoot depends on motion at the ankle. When more dorsiflexion is allowed, force is transferred from the heel to the forefoot. Less dorsiflexion means less transfer of force from the heel to the forefoot so there is less pressure on the forefoot and more on the heel.

How does this all translate to someone who has a ruptured Achilles tendon? Reducing ground-reaction forces and the degree of loading by using an ankle-foot orthosis with wedging is an important rehab strategy. Weight-bearing is allowed but in a protected mode. The foot and ankle are held in a plantarflexed position so the Achilles tendon can heal properly. If the ankle is dorsiflexed, the Achilles tendon is lengthened. Healing of the tendon in a lengthened position results in severe problems later.

All the details of type of brace and amount of ankle plantarflexion/dorsiflexion are not fully answered yet. But you should be able to work with an orthopedic surgeon, orthotist, and physical therapist to find the optimal rehab management program that will protect the healing tendon while accomodating your individual needs. Whatever your circumstances, you don’t want to compromise healing of this important tendon as it can have lifelong consequences.

It sounds like you have both bunions and bunionettes. Bunionettes are not as common as bunions. In a recent study on this topic, surgeons found only 30 cases in 21 patients (so some people had bunionettes on both feet) over a 10 year period of time.

With a bunion of the big toe, a large bump seems to grow out of the side of the great toe. But in fact what is happening is that the two bones that meet to form the big toe joint angle away from each other. A bump we call a bunion forms at the end of the metatarsal (long bone of the toes).

The bunion that develops is actually a response to the pressure from the shoe on the point of this angle. At first the bump is made up of irritated, swollen tissue that is constantly caught between the shoe and the bone beneath the skin. As time goes on, the constant pressure may cause the bone to thicken as well, creating an even larger lump to rub against the shoe.

A bunionette is similar to a bunion, but it develops on the little toe side of the foot where the small toe connects to the foot. This area is called the metatarsophalangeal joint, or MTP joint. A bunionette here is sometimes referred to as a tailor’s bunion. It formed because tailors once sat cross-legged all day with the outside edge of their feet rubbing on the ground. This produced a pressure area and callus at the bottom of the fifth toe.

Today a bunionette is most likely caused by an abnormal bump over the end of the fifth metatarsal (the metatarsal head) rubbing on shoes that are too narrow. Some people’s feet widen as they grow older, until the foot splays. This can cause a bunion on the big toe side of the foot and a bunionette on the little toe side if they continue to wear shoes that are too narrow. The constant pressure produces a callus and a thickening of the tissues over the bump, leading to a painful knob on the outside of the foot.

Bunions and bunionettes are anatomically similar — just located on different sides of the foot. With a bunion of the big toe, a large bump seems to grow out of the side of the great toe. But in fact what is happening is that the two bones that meet to form the big toe joint angle away from each other. A bump we call a bunion forms at the end of the metatarsal (long bone of the toes).

The bunion that develops is actually a response to the pressure from the shoe on the point of this angle. At first the bump is made up of irritated, swollen tissue that is constantly caught between the shoe and the bone beneath the skin. As time goes on, the constant pressure may cause the bone to thicken as well, creating an even larger lump to rub against the shoe.

A bunionette is similar to a bunion, but it develops on the little toe side of the foot where the small toe connects to the foot. This area is called the metatarsophalangeal joint, or MTP joint. A bunionette here is sometimes referred to as a tailor’s bunion. It formed because tailors once sat cross-legged all day with the outside edge of their feet rubbing on the ground. This produced a pressure area and callus at the bottom of the fifth toe.

Today a bunionette is most likely caused by an abnormal bump over the end of the fifth metatarsal (the metatarsal head) rubbing on shoes that are too narrow. Some people’s feet widen as they grow older, until the foot splays. This can cause a bunion on the big toe side of the foot and a bunionette on the little toe side if they continue to wear shoes that are too narrow. The constant pressure produces a callus and a thickening of the tissues over the bump, leading to a painful knob on the outside of the foot.

You may not need to jump right into surgery. Treatment is first directed at getting shoes that are wide enought to fit properly around the forefoot. Pads over the area of the bunionette may help relieve some of the pressure and reduce pain. These pads are usually sold in drug and grocery stores. They are small and round with a hole in the middle, like a small doughnut.

If all conservative (nonoperative) care fails, then surgery may be recommended to reduce the deformity. The surgeon may shave the metatarsal head and reshape it but recurrence of the problem is reported with this approach. More often, the surgeon will opt to remove the prominence of bone underneath the bunion to relieve pressure. Surgery may also be done to realign the fifth metatarsal if the foot has splayed. The boney bump can be removed (cut out) with a small chisel or saw and the remaining bone edges smoothed. Once enough bone has been removed, the skin is closed with small stitches.

If the angle of the metatarsal is too great, the fifth metatarsal bone may be cut and realigned. This is called an osteotomy. Once the surgeon has performed the osteotomy, the bones are realigned and held in position with metal pins or wires. The hardware remains in place while the bones heal (usually four weeks).

The osteotomy procedure can be done percutaneously. The surgeon can insert the surgical instruments through a very small incision that doesn’t require opening the foot up with a large incision. The obvious advantages to this technique are shorter operating time and fewer complications.

Studies show that percutaneous osteotomy for Tailor’s bunionette is safe, reliable, and effective. The short operative time, minimal disruption of soft tissues around the bone, and quick return to weight-bearing status are three major advantages of this updated surgical technique. Patient satisfaction is high and complications are minimal (some residual pain and mild loss of corrective alignment).

Physical therapists are well-trained to handle musculoskeletal injuries and problems such as cuboid syndrome. They understand the anatomy, mechanics during standing and walking, and clinical presentation associated with this condition. And by the way, other names for cuboid syndrome are cuboid fault syndrome, dropped cuboid, subluxed cuboid, locked cuboid, peroneal cuboid syndrome, and lateral plantar neuritis.

Manipulation is the first line-of-treatment for cuboid syndrome. A little anatomy will help you understand the problem and the treatment. The cuboid bone is one of many bones in the foot. It is situated close to the center of the foot and is surrounded by other bones. It is an oddly shaped bone with smooth places (the articular surfaces) where the other bones connect and are held together by ligaments and tendons.

The main area where the cuboid bone makes contact with the calcaneus (heel bone) is called the calcaneocuboid (CC) joint. This is an important joint for stability, load transfer, and movement of the foot and ankle. As some of the names for this condition suggest, a shift in the position of the cuboid bone can cause loss of motion with the bone “locked” in place. The surfaces of the connecting bones no longer line up. This effect with the accompanying symptoms is a cuboid syndrome. When this happens, we say the joint has lost its congruence.

The loss of congruence can be small enough that it doesn’t show up on an X-ray or other types of imaging studies. Pain develops along the lateral side of the foot. It feels like a ligament sprain. Loss of ankle and/or foot motion is common. Putting weight on the foot (especially the outside edge of the foot) becomes difficult. The ability to stand, walk normally, or hop on the painful foot is affected.

Lateral foot pain could be caused by a number of other problems. The list of possible sources of lateral foot pain includes gout, compression neuropathy of the sural nerve, ankle impingement, tendinopathy, or congenital fusion of the bones in that area (calcaneus, navicular, talus).

Cuboid syndrome is clearly a mechanical problem but one that could be caused by impaired muscle or tendon function, faulty anatomy such as flat feet, being overweight, or wearing the wrong kind of shoes. Other factors that may increase the risk of developing cuboid syndrome include poorly constructed orthotics (shoe inserts), training on hard or uneven surfaces, and overtraining without enough rest or time to recover. Your therapist will likely review your case for any of these risk factors and work with you to reduce your risk of re-injury.

During a cuboid manipulation, the therapist holds the foot to stabilize the bones around the cuboid and then applies a force to shift the bone back in place. Two techniques used to manipulate the cuboid are called the cuboid whip and the cuboid squeeze. Neither of these movements is painful. You may feel and/or hear a click or pop. Immediate pain relief is often reported after manipulation.

It may take more than one manipulation to completely resolve the problem. The longer the syndrome has been present, the more likely that a series of manipulations will be needed. Manipulation may be followed by local treatment such as icing, taping, ultrasound (heat), massage, or electrical stimulation. The therapist will also likely show you stretching stretching exercises for the leg muscles. Shoe inserts to support the cuboid bone may be provided.

In cases of acute (recent) ankle/foot sprain with swelling and bruising, a high-velocity thrust manipulation may not be appropriate. It may be better to apply this treatment method after the injured soft tissues have had time to heal and can withstand the force of a manipulative movement.

If the treatment for cuboid syndrome is applied and the symptoms go away, the diagnosis may be confirmed. If you do not respond to this proposed treatment, you may have some other problem. At that point, reevaluation is required. It may be that there is a sprain severe enough to require unloading with a cane or crutches or off-loading in a cast or splint. Your therapist will guide you through this decision-making process. Don’t hesitate to ask her this very question that you have posed here.

The cuboid bone is one of many bones in the foot. It is situated close to the center of the foot and is surrounded by other bones. It is an oddly shaped bone with smooth places (the articular surfaces) where the other bones connect. The bones connected to the cuboid are held together by ligaments, tendons, and a thick fibrous attachment called the labrum.

The first thing to know about cuboid syndrome is that it feels a lot like an ankle sprain with tenderness and pain along the lateral (outside) edge of the foot. Loss of ankle/foot motion and pain on standing or other weight-bearing activities are other common symptoms. Other names for this condition are cuboid fault syndrome, dropped cuboid, subluxed cuboid, locked cuboid, peroneal cuboid syndrome, and lateral plantar neuritis.

The main area where the cuboid bone makes contact with the calcaneus (heel bone) is called the calcaneocuboid (CC) joint. This is an important joint for stability, load transfer, and movement of the foot and ankle. As some of the names for this condition suggest, a shift in the position of the cuboid bone can cause loss of motion with the bone “locked” in place. The surfaces of the connecting bones no longer line up. This effect with the accompanying symptoms is a cuboid syndrome. When this happens, we say the joint has lost its congruence.

The loss of congruence can be small enough that it doesn’t show up on an X-ray or other types of imaging studies. Lateral foot pain could be caused by a number of other problems. The list of possible sources of lateral foot pain includes gout, compression neuropathy of the sural nerve, ankle impingement, tendinopathy, or congenital fusion of the bones in that area (calcaneus, navicular, talus).

Cuboid syndrome is clearly a mechanical problem but one that could be caused by impaired muscle or tendon function, faulty anatomy such as flat feet, being overweight, or wearing the wrong kind of shoes. Other factors that may increase the risk of developing cuboid syndrome include poorly constructed orthotics (shoe inserts), training on hard or uneven surfaces, and overtraining without enough rest or time to recover.

As these risk factors suggest, athletes and especially ballet dancers are affected most often by cuboid syndrome. In fact studies show that four per cent of all athletes with foot pain have pain coming from the cuboid gone. And in several studies, 17 per cent of ballet dancers examined with lateral foot pain had cuboid syndrome. Anyone (athlete or nonathlete) who has sprained an ankle is also at risk for this problem.

If the treatment for cuboid syndrome is applied and the symptoms go away, the diagnosis may be confirmed.

Treatment is with manipulation of the bones. The examiner holds the foot to stabilize the bones around the cuboid and then applies a force to shift the bone back in place. The patient may feel and/or hear a click or pop. Immediate pain relief is often reported after manipulation.

It may take more than one manipulation to completely resolve the problem. The longer you have had this condition, the more likely that a series of manipulations will be needed. Manipulation may be followed by local treatment such as icing, taping, ultrasound (heat), massage, or electrical stimulation. Stretching of the leg muscles and/or shoe inserts to support the cuboid bone may be provided.

In cases of acute (recent) ankle/foot sprain, a high-velocity thrust manipulation may not be appropriate. It may be better to apply this treatment method after the injured soft tissues have had time to heal and can withstand the force of a manipulative movement.

Anyone with lateral foot pain who does not respond to treatment for a cuboid syndrome may have some other problem. At that point, reevaluation is required. It may be that there is a sprain severe enough to require unloading with a cane or crutches or off-loading in a cast or splint. If an X-ray has not been previously taken, this may be the time to take one.

As you have discovered, plantar fasciitis can be very difficult to treat successfully. Most of the time it seems to take a combination of different treatment approaches to get the desired pain relief. But the problem is: the successful combination isn’t the same for each person. So it becomes a process of trial and error.

For those who may not know or understand what plantar fasciitis is, here’s a quick review. Plantar fasciitis is a painful condition affecting the bottom of the foot. The plantar fascia (also known as the plantar aponeurosis) is a thick band of connective tissue. It runs from the front of the heel bone (calcaneus) to the ball of the foot.

This dense strip of tissue helps support the arch of the foot by acting something like the string on an archer’s bow. It is the source of the painful condition plantar fasciitis. Plantar fasciitis is the correct term to use when there is active inflammation.

Plantar fasciosis is more accurate when there is no inflammation but chronic degeneration instead. Acute plantar fasciitis is defined as inflammation of the origin of the plantar fascia and fascial structures around the area. Plantar fasciitis or fasciosis is usually just on one side. In about 30 per cent of all cases, both feet are affected.

To help you with your own process, there is a recent study done by a podiatrist with 35 years experience treating plantar fasciitis. One hundred patients received either ultrasound, orthotics (shoe inserts), injections, or arch supports.

By comparing patient results with one treatment approach at a time, it was possible to rate them against each other. In terms of before and after pain, the group that got the most consistent pain relief was in the ultrasound treatment group. Eighty-one per cent (81%) of the patients in this group had less pain. After that the next best treatment for pain relief was injection (72 per cent) orthotics (64 per cent), and over-the-counter arch supports (35 per cent).

The results were also measured by looking at how many patients in each group were completely pain free after treatment. When ranked this way, the best treatment methods were: orthotics (most number of patients who were pain free after treatment), then ultrasound, injection, and arch supports (least number of patients who had no pain).

These outcomes confirm why many patients end up receiving multiple different treatments for painful plantar fasciitis. It seems to take a number of different approaches to really get the desired results.

After 35 years of practice in podiatry and conducting various studies like this one, the author suggests the following treatment approach for most people with plantar fasciitis. First, ultrasound treatment along with arch supports. If foot or heel pain persists, then a single cortisone injection is given. When every treatment possibility and combination has been tried without success, then surgery is the final treatment approach.

This is a complex challenge for many people with plantar fasciitis. Plantar fasciitis is a painful condition affecting the bottom of the foot. The plantar fascia (also known as the plantar aponeurosis) is a thick band of connective tissue. It runs from the front of the heel bone (calcaneus) to the ball of the foot.

This dense strip of tissue helps support the arch of the foot by acting something like the string on an archer’s bow. It is the source of the painful condition plantar fasciitis. When we stand or walk, we put tremendous pressure on this small strip of connective tissue. It wasn’t meant to withstand hundreds of pounds of force and pressure day-after-day.

And weight loss that depends on exercise can clearly become a challenge. The goal, of course, is to find a way to exercise with minimal (and hopefully no) pain. There are two possible solutions to try. The first is pool exercise where your body weight is supported by the buoyancy of the water. You don’t have to be able to swim to participate in these classes. They are usually held in the shallow end of a pool.

It may be possible to attempt other types of exercise such as sit-and-be-fit or a stationary bike. If the pain is just too severe to attempt any of these programs, then your focus and attention must remain on gaining some measure of pain control.

That may mean a combination of therapies such as arch supports, ultraound and stretching, antiinflammatory medications, or night splinting. Alternative approaches such as acupuncture, massage, Reiki, or BodyTalk might help as well.Some people gain relief from pain with a steroid (cortisone) injection. When nothing helps at all, then surgery to remove the offending piece of soft tissue may be suggested.

Hallux valgus, otherwise known as “bunions” is found more often in women than men and especially Caucasian (white) women. It tends to run in families but it can skip a generation or appear for the first time in any family.

What happens in this foot deformity is that the two bones that form the big toe lose their anatomic relationship with each other. Instead of lining up with each other, they start to angle outward. The result is the odd-shaped bump you see along the inside of the big toe. The muscles get unbalanced and the soft tissue (e.g., ligaments, joint capsule) get stretched out.

The question of shoe wear always seems to come up in relation to bunions. There are some studies that show a link between wearing high heels and narrow (or “pointy”) shoes and bunions. But there just as many people who wear this type of shoe who never develops a bunion so it can’t just be the shoe, right?

Studies show two types of factors that contribute to the development of bunions. The first are extrinsic factors. These are events outside of the feet that contribute to the problem. Shoe wear is one extrinsic factor. Excessive weight (obesity) and load (being on your feet a lot) is another.

Intrinsic (internal) factors that may contribute to the formation of bunions include heredity, tight Achilles tendon, and flat feet. Other anatomic features such as ligament laxity (looseness) or hypermobility (excess motion) of the big toe may be important.

In juveniles (teens) with hallux valgus, there’s no evidence that shoe wear makes a difference (better or worse). Juvenile hallux valgus has a different cause and effect.

For the best results, seek the advice of a qualified health care professional. See a board certified podiatrist or orthopedic surgeon for an evaluation and proper treatment.

In many ways, hallux valgus more commonly known as “bunions” remains a mystery. What causes it? Why does it seem to run in some families but not others? Is it caused by wearing pointy shoes? If it is caused by shoe wear, why doesn’t everyone who wears those shoes develop bunions? These and other questions are investigated in a recent review of the problem.

Here’s what we know so far. Studies have been done that show shoe wear is a factor. But it isn’t the only factor because some people who don’t wear shoes also develop hallux valgus or bunions. Anatomically speaking, we know there is a problem in the line up of the bones of the first toe.

It’s this bony misalignment that causes a disruption in the way the muscles of the toes and foot work. Without the necessary muscle balance, the bones remain at an angle to one another causing the distinctive pattern that suggests bunions. And once the bone angle and muscle balance have been disrupted, then the surrounding ligaments and joint capsule get stretched out (called laxity).

And there’s one more anatomic piece to this problem. Normally, there are two tiny round bones underneath the base of the big toe. These bones are called sesamoid bones. They may be small but their influence is huge. The sesamoids help create a pulley mechanism that allows for normal movement of the big toe as you walk. They help absorb ground forces with every step you take.

In hallux valgus (bunions), the altered bony alignment moves the bones of the first toe away from the sesamoids. There is a downward spiraling effect that ultimately leads to instability of the big toe and foot.

Many studies have been done on the problem of hallux valgus. There are reports on the role of each individual anatomical and biomechanical change that contributes to the problem. For example, if you are born with a short big toe or extra long second toe, there is an increased risk (but not guarantee) that bunions may develop over time.

There is a need for further studies to really answer the questions of what causes this problem and how does it come about. The ultimate goal is to prevent hallux valgus with a secondary goal of treating it effectively when it does develop. Understanding each piece of the puzzle is bringing us closer to answering your questions and guiding others with this same problem.

Platelet-rich plasma (PRP) is also known as blood injection therapy. PRP refers to a sample of serum (blood) plasma taken from the patient being treated. The plasma is then injected into the symptomatic (painful or tender) area.

Platelet-rich plasma has as much as four times more than the normal amount of platelets. Platelets contain growth factors that act to promote tendon repair. These growth factors send signals to the body that increase blood flow to the area and transport cellular debris and waste from cellular metabolism away from the tissue.

This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries. Most of the work done and studies reported have been on acute injuries, especially tennis elbow. But results from research into the use of platelet-rich plasma with chronic problems is slowly starting to trickle in.

There is a recent study from The Netherlands that may have some answers for you. In this study, orthopedic surgeons used platelet-rich plasma (PRP) to treat chronic Achilles tendinopathy. The study included a second (control) group of patients who received an injection of saline instead of PRP. Results were reported six months after the single injection and again now at the end of a full year.

They used the standard tests of joint motion, recording the presence and intensity of pain, and assessing function to report on outcomes of treatment. But they also went a step further in actually looking at the tendon fibers.

They used a recently validated technique called ultrasonographic tissue characterization (UTC). This is an imaging technique that allows for assessing the condition of individual tendons. It gives a three-dimensional view of the tendon structure. The ultrasonic view of the tendon also made it possible to measure the quality of blood vessels and blood supply to the area (referred to as neovascularization of the tendon).

In addition to asking patients about their level of satisfaction with the treatment, ultrasound measurements were taken before and after treatment. What did they find? There wasn’t a measurable difference between the two groups (one treated with platelet-rich plasma and the other with saline).

Both groups were equally satisfied with the results. Both groups had an equal amount of tendon healing and blood flow as shown by the ultrasound testing. The only measurable difference was in terms of return-to-sports. There were more patients in the platelet-rich plasma group (56.5 per cent) who went back to their previous sport compared with the saline (control) group (41.7 per cent).

These results were pretty much the same as the results reported six months after the injection. There are two possible reasons why the two groups had similar results. The first is the fact that both groups had an injection and it might not be the contents of the needle (plasma versus saline) as much as it is the effects of the needle entering the area. And secondly, patients in both groups performed an exercise program for three months. It is possible the exercise program had as much to do with the results as anything else.

The results of this study did not support the use of platelet-rich plasma for chronic Achilles tendon problems. More study is needed before this treatment will be approved for all tendon problems. For example, it may be necessary to compare PRP injections alone with exercise alone to see the true effects of each individual treatment. For now, the exercise program seems to have the best results and remains a standard part of treatment for this problem.

Platelet-rich plasma (PRP) is also known as blood injection therapy. PRP refers to a sample of serum (blood) plasma taken from the patient being treated. The plasma is then injected into the symptomatic (painful or tender) area.

How does it work? Platelet-rich plasma has as much as four times more than the normal amount of platelets. Platelets contain growth factors that act to promote tendon repair. These growth factors send signals to the body that increase blood flow to the area and transport cellular debris and waste from cellular metabolism away from the tissue. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

It has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems like tennis elbow, but gaining popularity quickly.

Researchers are still examining all the evidence around the use of this treatment technique. It seems to work best for areas of the upper extremity (hand, wrist, elbow). These are non load bearing tendons.

Tennis elbow seems to burn itself out after a while and for this reason is considered “self-limiting.” But Achilles tendon problems in the foot and ankle don’t seem to respond quite as well. The poorer results may be linked with increased load and shear forces. More studies are underway to understand the most effective use for platelet-rich plasma treatments. Good luck with your treatment!

The navicular bone of the foot is one of the small bones on the mid-foot. The bone is located at the instep, the arch at the middle of the foot. One of the larger tendons of the foot, called the posterior tibial tendon, attaches to the navicular before continuing under the foot and into the forefoot. This tendon is a tough band of tissue that helps hold up the arch of the foot.

Stress fractures are breaks in the bone that occur with repetitive motions, strains, or stresses. Navicular stress fractures are fairly uncommon. The person at greatest risk for this type of fracture is a high-level athlete engaged in activities that involve repeated push-off of the foot. Track and field runners head the list for this type of injury.

Any fracture can be further categorized as displaced (ends of the bone separate and possibly shift) or nondisplaced (no separation or shift after fracture). Studies show that complete, displaced fractures are more likely to remain as nonunion fractures.

Some surgeons advise surgery to prevent nondisplaced fractures from separating and becoming displaced fractures (less likely to heal). The fracture is held together with screws, wires, bone graft material, or some combination of those fixation devices. The earlier navicular stress fractures are treated (with or without surgery), the better the results.

Altered sensibility of the skin is usually a sign of nerve impairment. Even with minimally invasive surgery, it is very difficult to miss cutting one or more of the tiny sensory nerves that supply the foot. This is the most common complications of surgery to repair a ruptured Achilles tendon.

Other complications include rerupture, skin infection, pain at the suture site, scar adhesion, and pneumonia or deep vein thrombosis (blood clot). Most of these complications are temporary. Once the patients recovers from early post-operative problems, healing and recovery are usually uneventful.

Rerupture was really the most difficult complication. It often requires another surgery and a delay in completing rehab. Even temporary nerve damage is minor compared to a second tendon tear. If your symptoms do not go away with a little time, let your surgeon know you are having this symptom.

Complications after surgery of any kind are a fact of life. Some are minor, others are more drastic. Studies following patients with Achilles tendon ruptures report the following most common complications to watch out for: nerve injury, rerupture of the healing Achilles tendon, skin infection, pain at the suture site, scar adhesion, and pneumonia. Deep wound infection is also a possibility but rather rare.

Most of the complications are temporary. Once patients recover from their early post-operative problems, their healing and recovery is uneventful. Rerupture is really the most difficult complication. It can mean another surgery and a delay in completing rehab.

Reruptures increase the chances of preventing sports athletes from returning to play two-fold — in other words, it doubles the risk that they will have to quit sports. Some players will end up changing the sport they are involved in, a decision that could be potentially very disappointing for some. Others bide their time and are able to recover fully.

Plantar fasciitis, a painful foot condition is a fairly common problem. And one that affects 10 per cent of all Americans at some time in their lives. With an estimated one million patient visits to physicians each year in the United States for this painful condition, finding effective treatment strategies has become an important research goal.

One of those treatments is the use of a special shoe insert that you mentioned called an orthotic. An orthotic is a molded piece of plastic that is made to fit each individual’s foot. It is worn inside the shoe with the express purpose of taking weight off the plantar fascia while standing and walking (i.e., during weight-bearing).

The authors of a recent study combined the temporary use of a custom foot orthosis with stretching to see how well these two treatment tools work for plantar fasciitis. Patients included in the study had heel pain that was the worst when getting up after resting or inactivity. This symptom called first-step pain is typical of plantar fasciitis.

No one in the study had been treated with any other approach before trying this plan of temporary orthosis and stretching. Everyone was examined closely and measures of motion for the low back, hip, knee, ankle, and foot were taken. Clinical tests for plantar fascia problems (e.g., palpation, Windlass test) were also conducted and results recorded.

A physical therapist made the special orthotic for each patient in the study. The insert was designed to put the foot in a toe-down (plantar flexed) position with the toes turned in slightly (inversion). The goal was to take pressure off the plantar fascia during weight-bearing activities.

The orthotic was worn everyday for two weeks whenever in a standing or weight-bearing position. At the end of two weeks, a twice-daily stretching program was started. The stretches were specific to the plantar fascia, calf muscles, and ankle joint.

Patients were re-evaluated and weaned off the orthotics as symptoms improved. The therapist reheated the plastic molded orthotic and reshaped it to lower the heel as the painful symptoms decreased. Once the patient was completely orthotic-free, then a supportive shoe was recommended.

Everyone was followed for a full 12 weeks. The results showed that this type of program with temporary use of a foot orthotic followed by soft tissue stretching was quite successful in reducing foot pain from plantar fasciitis.

By the end of the first two weeks, 80 per cent of the group had a significant improvement in pain. There was an equally big change in function of the lower leg during daily activities and sports participation. Improvements were maintained through to the end of the study.

The evidence from this study suggests that using a foot orthosis even temporarily is a good place to get started in the treatment of plantar fasciitis. It is noninvasive, provides early relief of symptoms, and improves leg function quickly.

Stretching may be an important step in treatment as it allows the soft tissues to return to their normal length. By remaining flexible, it may be possible to prevent recurrence of the problem. The long-term effects of this program remain unknown.

If you don’t get the results you were hoping for, there are other forms of treatment to pursue as well. Treatment options range anywhere from stretching (already mentioned), taping, and manual therapy to electrical therapy, steroid injections, and surgery.

The plantar fascia is a thick band of connective tissue that goes from the base of the heel to the base of each toe. It actually forms an arch the length of the foot and provides needed support during all weight-bearing activities.

Plantar fasciitis may not be an accurate term to describe the underlying problem because “-itis” suggests inflammation. Our understanding and thinking about plantar fasciitis has changed over the years as new studies examine the tissue more closely. Instead of active inflammation, scientists report this condition is actually more of a degenerative problem.

Off-the-shelf soft or semi-rigid shoe inserts, supportive shoes, and/or orthotics (molded plastic foot support) are all ways to support the arch and realign the ankle and foot. They have the potential to work because they take pressure off the fascia during weight-bearing activities.

There may be several reasons why supportive shoe inserts or orthoses help reduce the pain of plantar fasciitis. First, just getting pressure off the plantar fascia and allowing it time to heal without repeated microtearing may be helpful. Second, having the insert in contact with the foot may reduce pain by changing sensory input to the brain.

It is also possible that transferring the load and pressure during weight-bearing from the heel to the forefoot helps reduce the pull on the plantar fascia. Again, this could prevent trauma to the fascia allowing healing to take place.

It’s a simple and inexpensive way to treat early stages of heel pain. You’ll know within a few hours to a few days if it is going to help you. If your symptoms are not improved or the symptoms come back quickly, you may need to see a specialist for an evaluation and more appropriate treatment. Custom made inserts (made to fit your foot) may be the next step.