FAQ Category: Foot

It turns out that your family history plays a larger role in developing bunions (called hallux valgus by doctors) than does the type of shoe you wear or what type of job you do. In one recent study, which looked at women in Hong Kong, researchers found that most women who had bunions didn’t wear heels very often but did have other family members who also had bunions.

If you want to see if you can prevent bunions from forming, you may want to speak with your doctor to see if shoe inserts or some type of therapy may be helpful for you.

Macrodactyly is a condition where the toe (or toes) on a foot is growing more quickly than the other normally growing toes. A child can be born with it (static) or it can begin growing (progressive). If you have the progressive type, it could grow to be very obviously larger than the other toes, but when you stop growing, the toe should also stop growing, if nothing has been done to fix it surgically.

The first metatarsophalangeal (MTP; base of the big toe) joint implant was tried back in 1952. Surgeons continued to modify implant designs to get a functional unit. But as you can imagine, with the weight of the body behind every footstep, an artificial joint at the base of the big toe doesn’t hold up very long.

The natural anatomy of the big toe is complex enough to make duplication with an implanted joint difficult at best. For example, two tiny bones called sesamoids just under the joint support and cushion the toe in a way that an implant hasn’t been able to reproduce.

Until recently, arthrodesis (fusion) of the joint has been the favored treatment. Patients suffering pain and joint destruction from trauma, gout, arthritis, and other conditions (e.g., deformities, bunions) have had success with arthrodesis.

With an arthrodesis procedure, wires, pins, and plates are used to fix or hold the joint in a locked or fused position. Fusion does limit motion at that joint, which in turn, causes changes in the way a person walks. Loss of motion at this joint can limit activities such as rising up on toes or running.

Total toe arthroplasty (another term for big toe joint replacement) is being developed. There are a couple of different designs available. Results so far comparing joint replacement with arthrodesis don’t favor the arthroplasty.

Some patients do report decreased pain. But the overall satisfaction rate is only around 77 per cent after five years. That doesn’t begin to compare with the 90 per cent rating for arthrodesis and up to 98 per cent rating for hip or knee replacements.

For those patients willing to try this approach, the implant can always be removed and the toe fused if it doesn’t work out. But there is usually bone loss with this type of revision surgery, so it isn’t done routinely.

You might want to consult with an orthopedic surgeon about the advantages and disadvantages of fusion versus joint replacement. Find out what your options are before making any decisions. Give yourself some time to think it through and weigh the pros and cons given your particular situation.

Standard of care for a painful big toe is conservative care first. Medications (e.g., pain relievers, antiinflammatories), physical therapy, and orthotics (special shoe inserts) are the main stays of nonoperative care. Even after a failed surgery, conservative care is advised.

Once you have reached the maximum benefit from conservative care, then additional surgery is often the next step. Arthrodesis (joint fusion) or osteotomy are the most common choices offered.

Fusion is accomplished with pins, screws, wires, and/or metal plates. The advantage is a stable joint that stops hurting. The disadvantage is an immobile joint that doesn’t move. You will be unable to push off with the big toe when you take a step. The foot and ankle will make the necessary changes but it will affect the biomechanics of the entire chain from foot up the leg. Still, the results are fairly positive with 90 per cent of patients expressing satisfaction with the results.

Osteotomy is a procedure to realign the toe. The surgeon removes a wedge-shaped piece of bone from the toe and straightens the remaining bones in a midline position. This might have been the surgery you already had.

Joint replacement for the big toe (metatarsophalangeal joint) is still fairly “new”. The idea has been around for 50 years but finding an implant that works well is still a challenge. Surgeons along with the help of companies that make the implants are working to find a design that will last with few if any problems.

Results of the current total toe arthroplasty (another term for big toe joint replacement) in use compared with arthrodesis don’t favor the arthroplasty just yet as a long-term solution for joint degeneration of the big toe. Some patients do report decreased pain. But the overall satisfaction rate is only around 77 per cent after five years. That doesn’t begin to compare with the 90 per cent rating for arthrodesis. Nor does it measure up to 98 per cent rating for other joint replacements like for the hip or knee.

For patients willing to try this approach, the implant can always be removed and the toe fused if it doesn’t work out. But there is usually bone loss with this type of revision surgery, so it isn’t done routinely.

Be sure and go over the pros and cons with your surgeon to make certain you understand all the advantages and disadvantages of both procedures. Your decision should take into consideration your age, activity level, weight, and any other health problems that can affect healing and recovery.

Orthobiologics refers to growth factors and proteins used to help bone and soft tissues heal. It’s a fairly new area of study and development. These biologic agents are applied during surgery with the goal of boosting the body’s natural healing process.

Right now, there are three major orthobiologic products available for use during surgery. These include: 1) platelet-rich plasma (PRP), 2) bone morphogenetic proteins (BMPs), and 3) platelet-derived growth factor (PDGF).

With platelet-rich plasma, the patient donates his or her own blood for this procedure. The blood is separated in order to collect the platelets. Platelets travel around the body in the blood at all times. They are always ready to be available. When a cut or bleeding injury occurs, the platelets act like superglue and quickly form blood clots to stop the bleeding.

Platelets are full of various growth factors. Growth factors are important in wound healing because they are like the Maitre d’ (the man in charge at a restaurant). They signal to the waiters (other cells needed for inflammation, healing, and tissue recovery) when and where to go (the site in need of attention). Each stage of soft-tissue and bone healing requires different kinds of cells to complete the process.

Surgeons have found more and more uses for platelet-rich plasma. It started with mouth and jaw surgery and now extends to include bone healing in spine fusions, fracture repair, surgery to lengthen an uneven leg or arm, and tendon healing.

It makes sense that this same product could be used with ankle fusions. And especially when the patient is at high-risk for infection, delayed wound healing, or other complications after surgery. Studies show that platelet-rich plasma also works well for ankle fractures that aren’t healing well, for ankle joint replacements, surgery to correct foot deformities, and repair of Achilles tendon ruptures.

The platelet product can be painted on bone, sprayed on the surface of ankle implants used in joint replacements, or injected into healing tendons. The results are all the same: faster fusion or healing time. In the case of tendon repair, joint range of motion, function, and return to full activities improve much faster as well.

The next orthobiologic product reviewed is bone morphogenetic proteins (BMPs). These proteins specifically target bone growth. BMPs persuade the bone to create new bone cells in order to heal fracture sites or fill in bone defects.

The third group of orthobiologics includes platelet-derived growth factor (PDGF). You may be wondering how is this different from the first group we talked about: platelet-rich plasma? Platelet-derived growth factor is actually one of the specific platelet growth factors that make up part of the platelet-rich plasma.

It just happens that researchers have been able to take this one specific platelet growth factor and study it more closely for use in bone fractures. The clinical application of platelet-derived growth factor has been mostly with rats. But the findings so far suggest that it could be used to enhance bone healing in patients with poor bone healing of the foot and ankle.

Not every surgeon uses these products and not every patient is a candidate for their use. But it’s always good to be up on the latest treatment techniques for a problem you have. Don’t hesitate to ask your orthopedic surgeon what he or she thinks of these products and whether you might be able to take advantage of them yourself.

Studies show that surgically lengthening the gastrocnemius (calf) muscle in patients with diabetes helps heal foot ulcers. That discovery pointed out the association between abnormal foot positioning, altered biomechanics, and foot pain all linked to a tight calf muscle.

Armed with that information, surgeons started taking a closer look at different patients with chronic, persistent foot pain. They tried lengthening the gastrocnemius muscle and found good outcomes with it. As a result, more studies have been done to look at the effect of gastrocnemius lengthening on the ankle joint, foot arch, position of the hindfoot, and joint range of motion.

They recognized that an inflexible gastrocnemius muscle can pull so hard on the bones that it deforms the normal or natural shape of the foot and ankle. In someone with diabetes, the increased pressure on one area of the collapsed foot or foot with altered alignment can cause skin breakdown and eventually, skin ulcers.

By releasing the gastrocnemius muscle and its tendon (the Achilles tendon, the foot and ankle can return to a more normal midline position. Release of pull on the bony structures makes it possible to restore normal arch shape, structure, and function. It has been suggested that arch collapse in its more advanced stages can’t be restored without the gastrocnemius release procedure.

There are a few downsides to the procedure. It can cause some calf weakness but this is only temporary. The gastrocnemius is a large muscle that can quickly recover with full return of strength.

Damage to the sural nerve is also possible. The sural nerve goes through the gastrocnemius muscle down to the foot. One other risk with this surgery is an unsightly scar because it is done with an open incision.

Be sure and ask your surgeon this same question. It’s always good to speak with someone who knows your specific case and needs.

Plantar fasciitis is a painful condition affecting the bottom of the foot. It is a common cause of heel pain and is sometimes called a heel spur. The plantar fascia 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.

Both the plantar fascia and the Achilles tendon attach to the calcaneus. The connections are separate in the adult foot. Although they function separately, there is an indirect relationship. Force generated in the Achilles’ tendon increases the strain on the plantar fascia. The Achilles tendon is part of the gastrocnemius (calf) muscle.

Studies show that lengthening the Achilles or gastrocnemius muscle can have a positive effect on a painful foot from plantar fasciitis. Taking the pull off the bone realigns the foot toward a more normal, midline position. When bones are in their proper place with the correct orientation, then the attached soft tissues can relax and function as they are supposed to.

It is always recommended before trying any surgery for this condition that you follow a conservative approach daily for six weeks up to six months. Many patients report the use of medications, exercise, splinting, orthotics and so on but they haven’t always applied these principles religiously everyday.

If you have, indeed, followed through and still haven’t gotten pain relief, then surgery like this one might just be indicated. Check with your surgeon and find out just what are your various options (including gastrocnemius muscle lengthening).

People with diabetes and other chronic health problems are often at increased risk for poor or delayed wound healing. With the changes in circulation associated with diabetes, bone fractures, pressure sores, even minor injuries just don’t heal quickly.

Tendon repairs that don’t heal or don’t hold up can be augmented by a product called platelet-rich plasma (PRP). It is painted on the tendon at the time of the surgery to repair the ruptured tissue. It works by sending signals to the cells that are needed to bring blood to the area along with the cells needed for an inflammatory process.

The use of platelet-rich plasma (PRP) for tendon healing is fairly new. It is not considered a routine procedure or one that is used with everyone. With diabetes as a risk factor, this approach might be a good one for you. Talk with your surgeon about your various treatment options, including the use of orthobiologics like platelet-rich plasma.

Stress fractures are breaks in the bone that are caused by overuse. They typically occur in athletes or dancers, who put a lot of pressure on their feet and legs, although a stress fracture could occur anywhere.

The thing about stress fractures is they are not always easy to see on x-rays. In the early stages, they may not be visible at all. It could take between six to 10 weeks for a stress fracture to be seen by x-ray. There are other ways to diagnose, including magnetic resonance imaging (MRI) and bone scans, but they are costly and, in the case of a bone scan, invasive. If the symptoms your son showed didn’t cause the first doctor to suspect a stress fracture and the x-ray didn’t show one, it isn’t surprising that the fracture was missed.

If you have sustained a stress fracture in your foot, a break in the bone caused by overuse, the most recommended and best way to manage it is by limiting the use of your foot as much as possible. Usually, this means stopping the activity that likely caused the fracture in the first place. If you continue the same activity, the injury will not heal and could become worse, causing other problems, including chronic pain.

Fusing the joint of the big toe is often done if the damage in the joint is causing a lot of pain and discomfort to the patient. The surgery involves adding pins, screws, wires, and/or plates to stabilize the joint.

When to get a patient up out of bed, after surgery, and bearing weight is always a bit controversial because doctors try to find the right combination of the type of surgery and when weight-bearing should start. Early ambulation after surgery has many advantages. Patients who stay in bed after surgery are at higher risk of some complications, such as blood clots and pneumonia. So it is usually in their best interest to move about as early as possible.

In the case of foot surgery, this can be tricky, but surgeons have found that after certain types of fusions, if patients are wearing specially fitted shoes, they often can begin weight bearing almost immediately after surgery. This helps the patient resume his or her normal activities while the foot is healing.

Fusions of joints, including the joint between the big toe and foot, are most often done because of degeneration of the joint, which causes substantial pain and mobility problems for the patient. There are different techniques that can be used for joint fusion, depending on the problem with the joint, the surgeon, and the available materials.

No two patients are alike, so even if they have the same procedure done, with the same materials, they will not necessarily have the same outcomes. What happened to your neighbor could be due to any number of issues and they may not necessarily happen to you.

To make your decision, bring your concerns to your surgeon and ask questions. The decisions should be based on what is best for you though, not what happened to someone else.

Shock therapy has been used for a while for treating some problems such as kidney stones, this is true. However, shock therapy is proving to be useful in other areas as well.

In the case of a broken toe, certain types are difficult to treat because of the way the foot is made and the heavy weight the feet and toes take when you bear weight. For this reason, it isn’t always easy to help a broken toe heal properly. Surgery is a frequent solution, but all surgeries have their risks and there is a 7% to 44% rate of complications for this particular type of surgery.

Researchers and doctors don’t understand how shock therapy can help heal a broken bone, but they do know that it can enhance bone growth and healing, without the complications associated with surgery. More research is going on to learn more and to see how else they can use the technology.

As with many situations, every case is a bit different from another. While you both may have broken the same toe, it’s possible that it wasn’t the same type of break either by the actual type of fracture or where on the bone the fracture was.

Surgery is done to stabilize the bone, usually using screws or wires to hold the bone into place. If the break is clean, without any other tissue damage, and the doctor feels it will heal without surgery, then this will be the best approach.

The tarsal bone is between the navicular and the calcaneus (the heel bone). The navicular bone is between the tarsal bone and the toes. It’s the one you can feel sticking up the most on top of the foot.

A stress fracture means there is a tiny crack in the bone where pressure from overuse has stressed the bone. There are two main types of navicular stress fractures: complete and incomplete.

As the labels suggest, a partial stress fracture doesn’t go all the way through the bone. A complete fracture does go all the way through the bone and can separate forming two pieces of bone where only one previously existed.

Bone takes six to eight weeks to heal in the average, healthy adult. Partial stress fractures may heal in a slightly faster fashion but it will still be about six weeks of recovery time before X-rays show normal bone again.

Patients who have diabetes, heart disease, or other chronic diseases may take a bit longer to heal. Anyone who smokes or uses tobacco products is also likely to find the timetable is stretched out more than average.

The treatment approach can make a difference in recovery, outcomes, and rate of fracture recurrence. Treatment is broken down into two main categories: conservative (nonoperative) and surgical.

Conservative care means the patient’s foot and lower leg are put in a cast until the fracture heals — usually six to eight weeks. Patients treated conservatively use crutches to get around without putting weight on the foot.

Based on X-ray findings, they are gradually allowed to slowly start putting weight on the foot. The radiographs help show the stage of healing. They wear a special weight-bearing boot that protects the healing bone while still allowing some pressure from the ground up.

Surgery is done to help return athletes to their sports activities more quickly. The procedure usually involves an open incision and pins or screws to hold the bone together while healing. Sometimes a bone graft is used to help things along. There’s been some question as to whether or not surgery is being done unnecessarily for these injuries.

Studies show that the fastest healing time with the best outcomes are shared by patients who were treated conservatively with a nonweight-bearing approach. Surgery doesn’t speed up healing, recovery, or provide a faster return to sports or daily activities.

The nonweight-bearing treatment for tarsal-navicular stress fractures is really the best overall approach. It’s possible this type of management could even be done without the cast but specific studies looking at the difference in results between nonweight-bearing with and without immobilization must be done before coming to any firm recommendations about this approach.

The navicular bone is the one you can feel sticking up the most on top of the foot. For people with a high arch, that bone is often prominent enough to rub against the shoe causing irritation. The tarsal bone is between the navicular and the calcaneus (the heel bone).

Fractures in this area can be difficult to see with plain X-rays. Many fractures in this area are located in the central one-third of the bone. The initial fracture might be partial but can become complete if the patient continues to put weight on it. That’s when imaging studies pick up on the injury.

Based on a recently published systematic review, we know a little bit more about the care and treatment of these injuries. In a systematic review, orthopedic experts take a look at all the published reports on single topic like tarsal navicular stress fractures.

Because this injury is uncommon, there aren’t large studies with 100s of people to learn from. So in order to find out how these injuries respond to treatment, it becomes necessary to look at the combined data from many smaller studies.

A systematic review makes it possible to look at type of navicular stress fractures, how they are treated, and the result of that treatment. There are two main types of navicular stress fractures: complete and incomplete. Treatment is also broken down into two main categories: conservative (nonoperative) and surgical.

They basically found that the approach you are now following works best: nonweight-bearing for six to eight weeks. Then a couple of weeks in a walking cast or special boot as you start to gradually put more and more weight on the foot. The protocol calls for another two weeks at least.

You may find it necessary to continue using the walking cast/boot for up to six full weeks. It’s based on your pain levels (you must be pain free to walk without this support) and X-ray results showing the stage of healing.

Most athletes with this type of fracture are back to full participation in their sport within six months’ time. The average nonathlete might find it takes a little longer than that. For some people, less activity and lower demands on the foot can mean faster recovery.

Achilles tendon rupture (complete tear of the calf muscle tendon that inserts into the back of the heel) can be treated conservatively without surgery. But the best results usually come with surgery to repair the damage. There’s less risk of reinjury with surgical reconstruction.

Surgery comes with a risk of wound-healing problems and damage to the sural nerve of the foot. Surgeons have tried various ways to increase the strength of the repair but so far, nothing has really made a difference in terms of added benefit with these approaches.

Studies have been done comparing outcomes with early weight-bearing and mobility versus delayed (six weeks post-op) weight-bearing. Some studies used an ankle-foot orthosis (AFO) (brace) to support the joint during the early recovery phase. Patients are told to put as much weight as they want or feel comfortable putting on the foot. This is called weight-bearing as tolerated.

The studies show that patients who wait four to six weeks before weight-bearing and those who weight-bear as tolerated right after surgery have the same results by the end of six months. Getting up on the foot early makes the patient feel better overall. In terms of any limitations caused by putting weight on the foot early, there were none.

The real concern about putting too much weight too soon on the operated side is that the healing tendon might re-rupture. But, in fact, this hasn’t really happened. Patients report that the improved mental health and quality of life early on after surgery make it worth getting up sooner than later.

Your surgeon may have a feeling about what would work best for you given all things considered. If not, then weight-bearing as tolerated may be an acceptable approach for you. A physical therapist will help you learn how to walk with crutches (or a walker if you need more support), so you’ll have some support and some guidance. Take it slow and easy at your own pace. You can always back off it doesn’t feel right to you. And don’t hesitate to check in with your surgeon if anything comes up that concerns you.

The first thing to find out is whether your surgeon has given you the go-ahead to try supporting your weight on the operative side. The surgeon takes into consideration several factors when making this decision. There’s your age, weight, and severity of the injury to consider. The surgeon also knows what type of surgery was done, how extensive the injury was, and the condition of the damaged tendon after repair.

If he or she thinks you have enough tensile strength to support the load of your weight, then it’s safe to proceed ahead. Before attempting single-leg toe-raises, you can try double-leg toe raises. By rising up on the toes of both feet together at the same time, you off-load the surgical site by at least 50 per cent. Use a support to hold on to (e.g., chair or fixed surface like a kitchen counter top) when starting these exercises.

Start with one to three toe rises the first day. If you don’t experience any problems or severe pain by the next day, repeat the experiment and increase the number of repetitions by two. A day later, add two more toe raises. Gradually reduce the amount of support you are giving yourself. By the time you can do 10 double-leg toe raises easily, you’ll be ready to try a single-leg toe raises.

Now repeat the same sequence of performing one to three single-leg toe raises, first on the uninvolved leg and then on the involved side. Use your support at the start and gradually reduce your reliance on it. You’ll probably be able to do many more repetitions on the good side. Add a few more single-leg toe rises every day until you can do at least 10 without pain, without difficulty, and without support.

Athletes in training will probably want to continue this exercise until they can do 20 unsupported double- and single-toe raises. Again, make sure your surgeon approves this plan before proceeding.

Surgeons around the world continue to look for new and better ways to do things. New surgical tools and materials on the market have enhanced what can be done in orthopedic surgery and the way it’s done. The big push right now is to find ways to perform surgery with the least amount of disruption to the soft tissues around the injury site. Getting people back on their feet and on-the-job (or back on the playing field for competitive athletes) reduces the cost of health care and saves people money.

One of those ways has been recently reported for the treatment of acute Achilles tendon injuries. Orthopedic surgeons from Japan have tried a novel approach using a new suture technique. They used a strong suture thread and a new suture technique that allowed patients to get back into action in three months. The suture thread used was a high tensile strength, braided polyethylene-blend material. The technique they used was a side-locking loop that was easy to use and provided a secure repair of the torn tendon.

Tears or ruptures of this tendon usually occur from side-to-side (horizontal direction) rather than up and down (vertical). The authors used their new side-locking loop from the upper side of the tear and placed the knots for each suture between the locking loops, buried in the tendon.

The surgeons used this new technique in a case series of 20 patients who had sports-related or work-related Achilles tendon tears. Patients ranged in ages from 16 to 70 and were followed for at least two years to see how well they did with this new surgical approach.

The big difference using this technique was that no one was placed in a cast, splint, ankle brace, or other form of immobilization following the procedure. The patients were given active range-of-motion exercises to do the day after the surgery. They were allowed to put weight on the foot by the end of the first week and used crutches to get around.

After four weeks, they progressed to full weight-bearing without crutches. And they were instructed to begin rising up on toes (both feet at the same time) six weeks after surgery. Muscle strengthening exercises were also added to the program at that time. By the end of 12 weeks, everyone was back to work or involved in sports at full participation and without any post-operative problems. By this time, they could also complete 20 single-toe rises (raising up on the toes of one foot without the support of the other leg).

The surgeons used MRIs taken at regular intervals after surgery (four weeks, eight weeks, and 12 weeks) to follow the progress of the healing tendon tissue. Their hope was that with early mobilization, tendon healing would be faster. And, in fact, that’s exactly what they found. The benefits to patients who want to get back up on their feet quickly are obvious.

Since this study was a case series with a limited number of patients, more research is needed to confirm these findings and follow patients over time to see if there are any new issues or long-term problems. It will be necessary to compare patients treated this way with those who are immobilized before this technique can be recommended for use in acute Achilles tendon ruptures. The advantage of this new approach is clear: patients are able to recover faster, avoid the expense of an ankle brace, and experience an early return to normal activities, including sports.

That’s a good question because certainly there are many women who wear high-heeled, pointed-toed shoes without ever developing bunions. But there is some evidence that there’s a genetic component, which can predispose you to bunions. In other words, you are at risk for developing bunions just by the fact that you have a positive family history (two generations worth at least!).

Adding an environmental factor (shoe wear) to genetics increases your odds of developing bunions even more. Does it guarantee this will happen to you? No, but experts advise women like yourself to practice an ounce of prevention to avoid this unsightly and painful deformity. Research shows that once it gets started, there’s no stopping it short of surgery. And people have tried everything: toe spacers, tape, foot exercises, special shoes, and so on.

There is some evidence that a special shoe insert called an orthotic to support the arch might help prevent bunions in people at risk. But this only under investigation and hasn’t been proven yet. And although there are orthotics designed to fit inside a high-heeled shoe, there’s no evidence yet that this type of insert is enough. It may be that the foot has to be flat as well as supported by an arch support to effectively prevent bunions from developing.

The decision is yours, of course. You might try wearing supportive, flat shoes whenever you aren’t wearing fashion shoes. You can consult with an orthopedic surgeon or podiatrist to see if there are any signs of bunions developing yet. This information might help guide you in making your decision about shoe wear.