Unraveling the Mysteries of the Bunion

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 this 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.

If you or your family members have a tendency toward bunions, what can you do to avoid this problem? Clearly, you can’t do much about the family tendency. Bunions tend to be most common on the mother’s side and among Caucasians more than African Americans.

Let’s take a look at some of the other factors that contribute to bunions. First, there is the problem of shoe wear mentioned earlier. For some people, high-heeled, narrow shoes are a problem. Likewise wearing shoes that are too small contributes to the problem. This is especially true when these types of shoe are combined with being overweight. Putting a lot of weight through the big toe during standing and excessive walking activities can really push the envelope so-to-speak.

What if you are born with naturally loose ligaments or a flat foot? Are you guaranteed to develop a bunion? Not necessarily. And the reason why not isn’t clear yet either. Likewise, 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.

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. And still we don’t know how to prevent or even adequately treat this condition.

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.

Part Two of a Study on Platelet-Rich Plasma for the Achilles Tendon

You may have heard the expression, What you see is what you get. Well, in medical research that isn’t always the case. Time can be an important factor. For example, treatment results using platelet-rich plasma for tennis elbow were better than results with steroid injections when measured a year after the injections. Three months after the treatments, there was no difference between the two groups.

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

Before we look at those results, let’s define a few terms. Tendinopathy refers to damage, degeneration, or pathology of a tendon. It could be from an acute injury or tendinitis. Or it could be a case of chronic tendon pain or tenderness. With both acute and chronic tendinopathy, loss of normal motion and function are observed. But as scientists have shown in chronic tendon problems, there’s no active inflammation.

So instead of calling the condition tendinitis, the term tendinosis is used. With tendinosis, the collagen fibers around the tendon are disorganized with an irregular placement of cell structure. There may be increased blood flow to the area but there are no inflammatory cells or processes present.

The next term platelet-rich plasma (PRP) may be new to you but its use is increasing as a treatment for a number of different musculoskeletal conditions. 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.

How can we measure the results of platelet-rich plasma (PRP) for problems like Achilles tendinopathy? Well, there are always the standard tests of joint motion, recording the presence and intensity of pain, and assessing function. And the authors of this study did use those measures. But they 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 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.

Where do we go from here? The authors make note of the fact that combining platelet-rich plasma (PRP) injection with an eccentric exercise program does not add value to the results. It may be necessary to compare PRP injections alone with exercise alone to see the true effects of each individual treatment.

Treatment for Plantar Fasciitis: What Works Best?

The search for pain relief from plantar fasciitis continues. In this study, a podiatrist reports on the results of comparing four different treatments for plantar fasciitis. One hundred patients received either ultrasound, orthotics (shoe inserts), injections, or arch supports.

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.

Treatment is usually with conservative (nonoperative) care. The physician might prescribe antiinflammatories for an acute case or analgesics (pain relievers) for chronic problems. Other possible medical treatments include cortisone (steroid) injection, shock wave therapy, or BOTOX injections.

A physical therapist might use ultrasound (a deep heat treatment), stretches, splinting at night, taping, and orthotics. If all efforts at pain relief are unsuccessful with conservative care, then surgery may be considered.

As you can see, there are many different ways to treat plantar fasciitis. Often patients are treated with multiple treatments at once. If it works, no one really knows why, which treatment combinations are best, or even which one treatment is most effective. That’s what makes this particular study so important.

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.

The results of this study also raise some interesting questions. For example, why do arch supports help some people while others do better with deep heat treatments? Or for that matter, why do some people need custom designed orthotics while others respond to a simple over-the-counter support? Why are multiple treatments needed and what should those be?

These are questions that have yet to be answered. In the meantime, when we look at possible causes of plantar fasciitis, there is one common factor among all the patients in this study and that is body weight. Being overweight seems to be a consistent pattern. And having plantar fasciitis makes it difficult to exercise in order to lose weight.

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.

Three Questions (and Answers) About Navicular Fractures of the Foot

In this study, orthopedic surgeons from The OrthoCarolina Foot and Ankle Institute in North Carolina asked three questions about navicular stress fractures. Let’s orient ourselves to the navicular bone, to stress fractures, and then we can tell you the three questions (and answers to the questions).

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). This distinction will be important in the results of this study.

The three questions posed by the authors of this study were:

  • Does surgically repairing a navicular stress fracture help the fracture heal?
  • Does a bony union (healed fracture) mean better clinical outcomes (motion, function)?
  • Is the bone lucency (thinning) often seen on CT scans after surgery linked with results or outcomes in any way?

    Who was in the study? Ten adults with navicular fractures whose medical records included X-rays, CT scans, and/or MRIs before and after surgery. Patients ranged in age from 18 to 54 and included football players, basketball players, baseball players, one cross-country runner, and three nonathletes.

    Fracture types ranged from incomplete, nondisplaced to complete, displaced, and complete, displaced. Bone grafts and screws were used in cases of displaced fractures. The surgical procedures were done by one of four orthopedic surgeons in advanced (fellowship level) training.

    Cross section cuts of the CT scans made it possible to rate the fractures as either healed (defined as more than 50 per cent of the fracture site closed) or not healed (referred to as a nonunion).

    Results showed that 80 per cent (eight of the 10) fractures healed fully. The two nonunions were in older adults (ages 47 and 54) but age might not have been as much of a risk factor as the fact that the bone graft used was an allograft (from a bone bank) rather than autograft (using the patient’s own bone).

    Function tested higher in those patients who did have a full fracture healing (union). The lucency seen in six of the healed fractures did not seem to affect function or recovery. Comparing the results of these patients (treated surgically) with results from other studies in which patients were treated nonoperatively, there did not appear to be a faster recovery or faster return-to-sports for the operative group.

    The authors acknowledge the small number of patients in their study creates some limitations in drawing strong conclusions or making firm suggestions. They couldn’t say that surgery to hold together navicular stress fractures got the athletes back on the field any faster than without surgery.

    But they did show that complete, displaced fractures are more likely to remain as nonunion fractures. The advantage of the surgical procedure is to prevent nondisplaced fractures from separating and becoming complete, displaced fracture that are less likely to heal. The earlier navicular stress fractures are treated (with or without surgery), the better the results.

    The authors think there is a chance that earlier treatment with surgical fixation has a chance of speeding up return-to-sports participation. But they say that further study is needed to prove this statistically.

  • Disability From Complications of Surgery for Achilles Tendon Rupture

    The diagnosis: acute Achilles tendon rupture. The treatment: minimally invasive surgery (MIS). The result: complications! The final outcome: that’s what this report is all about. Surgeons in The Netherlands followed 211 patients who had surgery to repair a ruptured Achilles tendon. The particular interest was in final outcomes for patients who developed complications following the procedure.

    What type of complications are we talking about here? Nerve injury was the most common complication affecting about 20 per cent of the patients. Rerupture and other problems such as a skin infection, pain at the suture site, scar adhesion, and pneumonia made up the list of complications reported by the rest of the group. Only one of the 211 patients had a serious wound infection.

    To assess the affect of these complications on the long-term results, the authors used a test called The Achilles Tendon Total Rupture Score (ATRS). The ATRS is based on points given for 10 items.

    The items were self-reported by answering questions about calf muscle strength, ability to run and jump or participate in sports and recreation, and performance of daily activities. Each item on the ATRS is worth 10 points. With 10 items, there is a maximum number of 100 points possible. The closer the patient was to scoring 100, the better the results. Lower scores were an indication of disability.

    To back track just a bit, you should know that there were a total of 340 patients who had this surgery for an acute Achilles tendon rupture. Not all of those individuals wanted to participate in the study. But from looking at the medical records, the authors could tell that there was a total of 16.5 per cent of patients who had complications from the minimally invasive procedure.

    Of the 211 patients in the study, 135 people had no complications. Seventy-six (76) of the 211 did have complications. That’s more than one third of the group (about 36 per cent actually).

    But the goal of the study wasn’t to see how many patients developed problems or complications. The goal was to see how the complications affected their overall function and assess their level of disability. And as it turns out, the long-term results were quite excellent.

    Most of the complications were temporary. Once the patients recovered from their early post-operative problems, their healing and recovery was uneventful. Rerupture was really the most difficult complication. It required another surgery and a delay in completing rehab.

    The authors conclude that preventing rerupture is the single most important way to avoid delays in recovery from surgery following an acute Achilles tendon rupture. Even the temporary nerve damage was minor compared to a second tendon tear.

    Reruptures increased the chances of preventing sports athletes from returning to play two-fold (i.e., doubled the risk). Some players changed the sport they were involved in, a decision that could be potentially very disappointing for some. Others bide their time and are able to return to full participation in the sport of their choice at their preinjury level.

    Effects of a Custom-Fit Orthosis for Plantar Fasciitis

    Physical therapists are front and center in the nonsurgical treatment of plantar fasciitis, a painful foot condition 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 custom made foot orthosis. That’s the focus of this study. An orthosis 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 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.

    What goes wrong that so many people suffer from this problem? 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.

    There probably isn’t one single reason why someone starts to develop heel and foot pain from plantar fasciitis. Foot and ankle alignment certainly seem to head up the list of “reasons why I have plantar fasciitis.” For example, a flat foot with no arch or a naturally high arch that is not properly supported is commonly present in patients with plantar fasciitis.

    Other risk factors that may contribute to the problem include being overweight, weak plantar flexor muscles, limited ankle dorsiflexion (movement of the foot toward the face), trauma, and deformity or alignment issues in other areas of the ankle and/or foot.

    Likewise, there doesn’t appear to be one individual way to treat this problem successfully with each patient. Treatment options range anywhere from stretching, taping, and manual therapy to electrical therapy, steroid injections, and surgery. The idea to use splinting or bracing (orthotics) is not new either.

    The authors of this study combined the temporary use of a custom foot orthosis with stretching to see how well these two treatment tools work. 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 authors suggest that the use of the orthotic as the only treatment worked for one of several reasons. First, just getting pressure off the plantar fascia and allowing it time to heal without repeated microtearing was important. Second, having the insert in contact with the foot may have helped 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 helped reduce the pull on the plantar fascia. Again, this could prevent trauma to the fascia allowing healing to take place.

    There are still many unanswered questions from a study like this. For example, was the stretching really needed? The idea behind stretching is that 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 as well.

    The authors point out these and other limitations of their own study. They suggest using a temporary foot orthosis 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.

    New Treatment Advice for Plantar Fasciitis

    If you suffer from heel pain as a result of plantar fasciitis, you are not alone. An estimated two million adults in the United States experience significant heel pain every year. And over time, at least one in 10 Americans will report this common foot pain problem.

    The problem may be more aptly named by calling it “plantar heel pain” because studies show there is no active inflammatory component. The tissue quit trying to self-repair long ago. Sharp pain without swelling, heat, or other signs of inflammation is the only symptom. But that pain can be very disabling affecting quality of life.

    The standard treatment for plantar fasciitis includes actively stretching the gastrocnemius and soleus (calf) muscles and passively stretching the plantar fascia (connective tissue along the bottom of the foot). Other conservative measures often used include medications and steroid injections. In severe cases that don’t respond to nonoperative treatment, surgery may be an option.

    In this study, physical therapists from Brazil compare the use of stretching alone with a program of manual therapy combined with stretching. In this instance, manual therapy refers to the release of trigger points in the calf. This technique is done by the therapist’s hands directly over the calf muscles and applying pressure and then light stroking to the soft tissue structures.

    Trigger points are irritable areas in the muscle. The area becomes tight and stiff keeping the muscle from moving (and stretching) normally. It’s that stiffness that these researchers thought might respond better to manual therapy along with stretching.

    Stretching alone doesn’t always stop the pain or alleviate the problem. In theory, until the trigger point has been released, the heel pain will continue (or come back as soon as the stretching stops).

    The groups were randomly assigned to the two treatment groups. Group one performed stretching exercises prescribed by the physical therapist. Group two were actively treated with manual therapy by the therapist and then did the same stretching program as group one.

    Everyone came to the physical therapy clinic four times each week for a month. At the beginning and end of treatment (i.e., four weeks later), patient levels of pain, function, and pressure pain thresholds (PPTs) were measured.

    As the name suggests, pressure pain threshold is the amount of pressure applied to the heel needed to create a painful response. A special device called a mechanical pressure algometer was used to take this measurement.

    Results showed greater improvement in all measures for the manual therapy plus stretching group. Patients in both groups got better but the manual therapy group had statistically significant improvements over the stretching only group.

    The conclusion is that stretching is good but stretching with a little hands-on work is yields much better results. The exact mechanism by which this works isn’t known. It could be that trigger point therapy as described here decreases pressure pain sensitivity. Perhaps it turns off a reflex that is triggering muscle tightness so that the stretching becomes more effective.

    The next step for the researchers is to follow patients long-term to see if the effects last beyond the short-term period (four weeks) of this study. Additional study is recommended to see if there are better ways of doing the manual therapy that might be more effective.

    This could include comparing Swedish massage, friction massage, myofascial release, acupressure, and other similar techniques with the manual therapy described in this study. Since we don’t know if other types of touch (just placing the hands over the tissue) might also work well, this might be another technique included in the comparisons.

    Step-By-Step Evaluation of Midfoot Fractures

    In this review article, orthopedic surgeons remind us how midfoot injuries called Lisfranc injuries come about, why they are called by that funny name, how the physician makes the diagnosis, and what type of treatment is called for.

    Most people have a general idea of what is meant by the midfoot — that area between the base of the toes and the ankle/heel complex. The proper anatomical term is the tarsometatarsal (TMT) joint. Metatarsals are the long bones of the forefoot. These are the bones of each toe between the ankle (tarsal bones) and the bones we usually refer to as the toes.

    Lisfranc injuries describe any injury that occurs at the tarsometatarsal joints. This could be at the base of any of the five metatarsals (toes) or the place where the metatarsals glide against the tarsals (ankle bones). There is also an actual Lisfranc ligament at the base of the second toe. Damage to this ligament can also be called a Lisfranc injury.

    Where does the term Lisfranc come from? The French surgeon (Dr. Jacques Lisfranc) who served in Napoleon’s army back in the 1800s. He treated a soldier with this type of injury, named it after himself, and the rest is history.

    The bones, ligaments, and connective tissue that form the entire Lisfranc area are important in keeping a strong, stable midfoot with a supportive arch. Injuries to this area can cause collapse of the arch, deformity, pain, and loss of foot function. That’s why an early and accurate diagnosis is important followed by proper treatment.

    The surgeon relies on what the patient says about how the injury came about. There can be a variety of ways Lisfranc’s injuries can occur. Any time enough force is applied to the top of the foot in a downward direction, ligament tears, fractures, and dislocations can occur.

    Car accidents, falls from up high down to the ground, having a horse stand on your foot (or other crush injuries) — these are the kinds of events that occur that contribute to a Lisfranc injury. Likewise, stepping off a curb or step without realizing it or unexpectedly catching the heel on the curb or step can result in a Lisfranc injury. Athletes are also at risk for midfoot injuries of this type.

    If the surgeon doesn’t see the patient right away, there is usually a report of foot bruising, swelling, and pain. Obvious soft-tissue trauma (either seen or reported), especially accompanied by mid-foot deformity or loss of an arch is diagnostic. The surgeon will likely order imaging studies.

    First, X-rays are taken. The radiologist looks for any obvious (or subtle) fractures, bone displacement, joint narrowing, and displacement of the toes or other obvious signs of a problem.

    X-rays help show whether an injury is stable or unstable. That’s an important distinction when trying to decide what kind of treatment (conservative care versus surgery). A tiny fleck of bone at the base of the second metatarsal may be a sign of an avulsion injury. Avulsion means the soft-tissue ligament or tendon attached at that area has pulled away from its insertion to the bone taking a small piece of bone with it.

    If a ligamentous tear is suspected, CT scans are ordered. MRIs may be used when there is edema (swelling) and the surgeon suspects a more subtle injury. There are hands-on clinical (stress) tests that can also be performed. The surgeon may use these to confirm a Lisfranc injury. If negative, then the injury is treated as a sprain.

    For true Lisfranc fractures and/or Lisfranc soft tissue injuries, treatment is aimed at restoring alignment and stability. The authors provide a list of five steps that can be taken to determine when surgery is needed. We’ve mentioned all five: physical examination, X-rays, MRIs, CT scans, and stress tests.

    Some surgical cases are obvious: the foot is deformed, the patient can’t walk on it, and it isn’t painful — it’s numb. Instability is the big key in deciding the best treatment because stable fractures and injuries can still be treated nonsurgically with a cast or walking boot.

    When the damage is healed and immobilization is no longer needed, the patient is guided in finding the right (supportive) shoe. A special shoe insert called an orthotic is made and worn whenever weight-bearing. Total recovery time of a stable Lisfranc injury treated conservatively is about four months.

    Even small malalignment problems of the midfoot should be treated surgically. This is not a very forgiving joint. Tiny shifts in alignment can lead to more injuries later and eventual disability from arthritis.

    The surgeon uses an open incision to put the bones back in place and hold them there with pins, wires, metal plates, and/or screws. The procedure is called an open reduction and internal fixation (ORIF). Some surgeons do use a percutaneous (through the skin without an open incision) approach. A special real-time X-ray called fluoroscopy is used to accomplish this.

    Post-operative care involves wearing a non-weight-bearing cast for three weeks. The cast is removed and a special boot is worn for another three to five weeks. Small amounts of weight are allowed on the foot at first. The patient is advised to gradually increase the amount of weight-bearing for the next few weeks. By the end of eight weeks, the patient should be able to put full weight on that leg.

    At that point, the patient will be sent to a physical therapist for gait and balance training. When the screws are removed (usually around four months post-op), then the therapist helps the patient regain full motion, strength, proprioception (joint awareness), and kinesthia (movement awareness and accuracy).

    These are important components of rehab to help prevent future injuries or re-injuries of the same area. This is especially important for the athlete who must make sudden changes in direction on the field or push-off on toes or jump and land on the midfoot.

    The authors point out that patients (especially athletes) should be made aware of the fact that severe Lisfranc injuries don’t always recover fully even with the best of treatment. They can achieve a stable foot but stiffness and pain may persist.

    More research is needed to find future treatments that don’t damage the joint, don’t result in arthritic changes later on, and do provide fixation that lasts. Right now, a plate along the bottom-side of the joint is being tested as a possible alternative treatment technique. This approach is called dorsal plating. Another new method of fixation under investigation is an EndoButton designed to mimic the function of the Lisfranc ligament.

    Studies will be needed to compare these new surgical fixation techniques against the methods currently being used. Although Lisfranc injuries are not common, they also aren’t rare. With more people participating in sports activities, surgeons need to recognize Lisfranc injuries quickly and be prepared to treat them as effectively as possible.

    Report on Turf Toe in Athletes

    If you pay attention to any sports news, then you know how sports radio and TV hosts talk endlessly about athletes’ injuries. With more and more focus on sports, even the tiniest scratch or dent is headline news. One of the more unusual injuries reported in football players is called Turf Toe.

    Turf toe describes damage to the base of the big toe. The medical term for this problem is hyperextension injury to the hallux metatarsophalangeal (MTP) joint. Hyperextension means the toe is bent way back on itself. You’ve probably seen this occur on TV and not even been aware of it.

    Picture this: a football player has the ball. He gets tackled and as he goes down, his foot is in a position with the toes in contact with the ground but the foot with the heel up toward the sky.

    The player doing the tackling goes down with his knee on the ball holder’s upended heel. The force of the tackler’s knee pushing down on the ball holder’s heel is enough to injure the soft tissues and even the joint of the big toe still in contact with the ground.

    It’s called turf toe because most of these injuries occur on artificial turf. The injury can be mild (grade I) to severe (grade III). Treatment and length of time on the bench depend on the severity of the injury.

    With a grade I injury, the ligaments around the base of the big toe are stretched and strained but nothing is torn or broken. The player may experience some pain, perhaps a little bruising, and some swelling. He may not even miss a game or practice because of it.

    Grade II injuries are a little more problematic. Some of the soft tissue structures are torn. Swelling and pain limit motion. A walking boot and crutches may be needed. The player will be off the field for up to two weeks. When he does return, the athletic trainer will likely tape the toe to protect it for another two weeks.

    In the most severe injuries (grade III), there is significant swelling, bruising, and pain. That’s because the ligaments, joint capsule, and cartilage under the toe have been completely torn or ruptured. As a result, the hallux metatarsophalangeal (big toe) joint is weak and unstable.

    At all levels of severity, treatment begins with managing the symptoms using the tried and true formula of R.I.C.E. — rest, ice, compression, and elevation. Anti-inflammatory medications help keep the swelling down.

    Accurate diagnosis with physical exam and imaging studies (X-rays, MRIs) help determine whether the athlete will continue with conservative (nonoperative) care or go on to have surgery. With low-grade injuries, a splint, cast, or boot is used to immobilize the foot and protect the soft tissues while healing takes place.

    Some cases can be treated with long-term (six to eight weeks or longer) immobilization in a boot or cast. But surgery is often required for grade III turf toe injuries. The surgeon makes every effort to restore the toe to its normal anatomy. Most of the time, the soft tissues can be repaired and stitched back in place.

    The player with this level of injury will be off the field for three to four months. The timing of his return-to-play may depend on the position he plays on the team. At a minimum, before being released to full participation (especially running or explosive movements), athletes with turf toe must have 50 to 60-degrees of passive toe flexion without pain. Passive motion means the examiner moves the patient’s toe rather than the player actively bending the toe himself.

    Whenever the injured player returns to his preinjury level of participation, toe protection is provided. This could be as simple as taping the toe. A stiff-soled shoe to prevent over extending the toe is a must. Special shoe inserts called orthotics are also available. There is even a special design for post-turf toe injuries called the turf toe plate.

    In summary, sports athletes playing on artificial turf are at increased risk for turf toe injury. With more attention and focus on sports than ever before, it’s only a matter of time before this becomes a well-known problem.

    But sports fans can relax because orthopedic surgeons have the problem well in hand. Early diagnosis and treatment will ensure that affected athletes will be back in action as quickly as possible.

    Which Is Better: Stretching or Shock-Wave Therapy for Plantar Fasciopathy?

    Many people suffer from foot pain attributed to plantar fasciitis. But when the pain becomes chronic and lasts months to years, the problem isn’t one of inflammation but rather a failure to heal. The condition is referred to as plantar fasciopathy. What can be done to help?

    The plantar fascia is a thick band of connective tissue along the bottom of the foot. It goes from the calcaneus (heel bone) to the metatarsal bones (toes). It supports the arch of the foot and helps carry the load of body weight during standing and walking activities.

    Usually treatment of musculoskeletal conditions depends on the cause of the problem. But with plantar fasciopathy, the cause remains unknown. Or rather, we should say, the cause is poorly understood. For some people (like runners), overuse, training errors, and poor footwear may be contributing factors. Older adults who are overweight or who have problems with foot alignment may be at increased risk for plantar fasciopathy.

    Chronic pain from plantar fasciopathy likely starts out as plantar fasciitis, a true inflammatory process. If caught early, such cases can be cured with conservative care such as stretching exercises. But a failed healing response can lead to continued, unresolved pain.

    In this study, researchers from Germany compare two treatment methods for acute pain associated with the plantar fascia. Adults between the ages of 27 and 70 were included. Everyone had plantar fascia pain for less than six weeks. No one had received any treatment of any kind for the problem.

    They were divided randomly into two groups. One group received a stretching program for the plantar fascia. The stretches were done three times daily for eight weeks. The second group received low-energy radial shock-wave therapy to the bottom of the foot. The shock wave therapy was given once a week for three weeks.

    The patients were followed for three years. Results were reported comparing pain levels and foot function. They found that in the short-run (first four months), the stretching group had significantly better results. But by the end of 15 months, there was no difference between the two groups.

    The authors concluded that their belief that any treatment for plantar fasciitis when delivered early in the process would have the same curative effect. But that didn’t turn out to be the case as the patients who did the stretching exercises had much better results than those who received the shock-wave therapy.

    The results might seem logical if shock-wave therapy was a placebo or bogus treatment. But it is not. Shock-wave therapy has been shown effective in other conditions because it gets rid of substance P (P stands for Pain) in the sensory nerve fibers and in the spinal cord (pathway to the brain). Shock-wave therapy also stimulates and speeds up the healing response — at least that’s what other studies have shown when using this tool.

    So why does stretching work and shock-wave therapy doesn’t? The answer to that may take more study. For now, it is suggested that perhaps more time is needed for the healing response to kick in.

    Maybe two or even four months isn’t enough time to see the desired results. Maybe three sessions over a three-week period of time is just the beginning of what’s really needed. The authors even suggested it’s possible that stretching isn’t necessary. If everyone was pain free by the end of 15 months, maybe the condition will resolve on its own in the end no matter what treatment is applied.

    The dilemma of finding an effective early treatment for plantar fasciopathy continues. The results of this study add some information by comparing two specific treatment approaches (stretching and shock-wave therapy). More study is needed to solve this puzzle.

    Achilles Tendon Rupture: Surgery or No Surgery?

    If we told you the rate of re-rupture after surgery for acute Achilles tendon injuries is four per cent (compared with 12 per cent for patients treated nonsurgically), would you have the surgery? At first glance, the numbers seem to speak for themselves. But listen to what surgeons and physical therapists have to say about these results.

    The large Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. Along with other tendons, it supports, stabilizes, and helps move the ankle. It is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the calcaneus (heelbone) and allows us to point our toes or raise up on our toes.

    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.

    The surgeons and physical therapists who wrote this report have been studying acute Achilles tendon ruptures for a while. This study is actually the result of a previous study where they compared surgical to nonsurgical treatment but the groups did not have identical follow-up treatment.

    It was impossible to tell if the differences in outcomes was due to the treatment approach (surgical versus conservative or nonoperative) or a result of the period of immobilization for the nonsurgical group compared to functional bracing and movement prescribed for the surgical group.

    In this study, patients in both groups were treated with exactly the same rehab protocol. The idea was to eliminate differences in the rehab approach so that any differences between early treatment (surgical versus nonsurgical) could be seen more accurately.

    Everyone was given the initial treatment within 72 hours of the acute injury. They were randomly placed in either the surgical group or the nonsurgical group. The nonsurgical group was treated by placing a cast on the lower leg (below the knee). The foot was held in a equinus position (toes down and turned in slightly). This position takes the pressure off of the healing tendon.

    The surgical group had a tendon repair procedure and then were placed in the same type of equinus immobilization cast. After two weeks in the cast, patients in both groups graduated from the cast to an adjustable brace.

    The brace was worn by everyone for six weeks. The position of the foot and ankle was changed within the brace every two weeks bringing the toes up and less pointed down. That’s what makes it an adjustable brace.

    By the end of the six weeks period of time, the foot had been moved from the equinus position (toes down) past neutral (zero degrees of movement) and to a +10 degree position of ankle dorsiflexion (foot pulled up toward the face). At that point, the patients could wear a special shoe with a heel-lift and start putting some weight on the foot.

    By week eight, everyone in both groups entered a 24+ week-long rehab program. The program was supervised by a physical therapist and progressed through a wide range of activities and exercises. The therapists performed the follow-up evaluation of results. They measured joint motion, symptoms, muscle strength and endurance, activity level, and function.

    We started out by telling you the final results based on rate of re-rupture. Twelve per cent for the nonsurgical group versus four per cent for the surgical group. But it turns out those figures are not all that statistically significant when all other factors are considered. For example, there are complications from surgery (infections, scarring, contractures, appearance, difficulties walking) that patients in the nonsurgical group don’t face.

    And the final results one year later were equal between the two groups. Patients in both groups achieved rapid improvements in the first six months after treatment. The surgical group had better results at the end of the sixth month. In both groups, the injured leg still wasn’t as strong as the uninjured side even after a year’s time.

    The early lag in the nonsurgical group may be an indication that there is a longer recovery period required when healing takes place on its own without surgery to help it along. Gradual changes were still recorded for both groups between six and 12 months. But again, by the end of 12 months, there were no major differences between the two groups.

    The authors could not say one way of treatment was better than the other. The results were too much the same between groups. Surgery is more expensive and carries the risk of greater complications.

    No matter how the acute Achilles tendon injury is treated, it’s clear from the results of this study that early mobilization is beneficial. The positive healing effect of early mechanical loading of the tendon has been shown in other studies as well. Use of a functional (adjustable) brace is recommended over rigid casting.

    Next step for this group: assess the effect of functional bracing along with early range-of-motion training. Look for better ways to rehab to speed up the process. On the flip side, consider whether a one-year follow-up is too short — maybe this type of injury takes much longer than that to achieve optimal results. And so, researchers continue to look for the best way to treat acute Achilles tendon ruptures that affect so many athletes of all ages.

    Foot Pain: Causes and Treatment

    In this review article, orthopedic surgeons specializing in foot care bring us up-to-date on a type of foot pain called metatarsalgia. Metatarsals refer to the long bones of the toe. The term -algia always indicates pain. So in metatarsalgia, the pain occurs at the base of the toes where the metatarsals join the phalanges (end of the toes). You might recognize this area as the “ball” of the foot.

    If you look up the treatment for metatarsalgia, you won’t find a “one-size-fits-all” recipe. Every patient who presents to the surgeon with this problem has a different reason why it developed. And in order to get the best results, treatment must be individualized for each person.

    What are some of the most common causes of metatarsalgia? The first is congenitalfoot problems (deformities). Congenital means they are present at birth. This can include pes cavus (excessively high arch), equinovarus (clubfoot), or abnormal differences in the length of the toes.

    Acquired problems such as neuromas, malignant tumors, infection, arthritis, or fractures (especially fractures that don’t heal properly) can contribute to metatarsalgia. Basically, anything that alters the way the foot hits the ground or changes the contact points for pressure and load through the foot can lead to metatarsalgia.

    There are still other potential causes such as trauma, failed foot surgery, or nerve entrapment. This is called iatrogenic metatarsalgia. In order to get to the bottom of the problem, the surgeon will conduct a careful exam, look at the wear pattern of the shoes, and probably order some X-rays or other imaging studies (e.g., MRIs).

    Often calluses on the bottom of the foot point right to the area of abnormal weight bearing and overload. The problem can be severe enough for the bones to form spurs or shift out of alignment. The end-result can be even more deformities such as hallux valgus (bunions).

    The examiner will check out the motion of each individual joint (ankle, forefoot, toes) and assess muscle strength and function. Pulses will be palpated (felt) to assess circulation to the foot and any skin changes (e.g., ulcers) or swelling will be noted.

    Most cases of metatarsalgia are treated conservatively (nonoperative care) first. Physical therapy may be a good idea. The therapist will help find the right shoe modifications, work on correcting postures that might be contributing to the problem, and address any muscle imbalances.

    Stretching and strengthening may be needed as well. The therapist’s evaluation will guide the specifics of which muscles need additional training in either direction (flexibility or endurance training).

    Other noninvasive approaches may include corticosteroid injections into the painful area. This treatment technique is used carefully as there are often more side effects than benefits. For patients who have painful calluses, the surgeon may decide to shave or trim off the excess tissue. Injections and callus shaving really only provide short-term relief of pain. Getting to the main cause of the problem is the best treatment approach.

    And that’s where surgery comes in. If conservative care is unsuccessful in changing the pressure distribution along the bottom of the foot, then it may be time to try something else. Just what that “something else” is depends on the underlying pathology.

    The surgeon may decide to perform a simple muscle release or tendon transfer. These techniques can help shift alignment more toward normal. But sometimes more involved bone surgery is required. The most common surgeries performed include fusion, osteotomy, and bone resection.

    Fusion is fairly self-explanatory. Bone graft placed around the joint is used to stop motion at a particular joint. This procedure helps stabilize a joint that is overloaded and has too much motion.

    An osteotomy refers to one of many ways to remove a pie- or wedge-shaped piece of bone. The effect of an osteotomy is to shift bone angles and change the distribution of weight through that bone. The type of osteotomy performed depends on where the wedge of bone is removed and if it is placed somewhere else to alter the bone alignment. Some of these procedures include a distal oblique metatarsal osteotomy, midshaft segmental metatarsal osteotomy, or basal metatarsal osteotomy.

    Bone resection is the removal of a specific area of the bone — for example, the end of the metatarsal bone called the metatarsal head. The metatarsal head is where the joint can get subluxated (partially dislocated) or fully dislocated.

    For surgeons interested in what the authors have to say, each surgical procedure is described along with reasons why each one might be used. Expected results are reviewed and statistics of outcomes from previous studies presented.

    They conclude by repeating the main point of this article: metatarsalgia may be a pain in the foot plain and simple, but the causes behind this condition are complex and varied. Understanding of normal foot anatomy and what went wrong is important when planning treatment for each and every affected patient.

    If all deformities are not corrected, the patient won’t have a good result. Conservative care should be tried first because it’s not invasive and it won’t ruin the patient’s chances for surgery later.

    Long-term Results of Foot Injuries From Airbags

    You probably won’t be surprised to know that front-end collisions resulting in airbag release cause significant physical injuries. The force of the bag inflating against the body protects the person from smashing into the dashboard or going out the front window.

    But as Newton’s third law of motion states, For every action, there is an equal and opposite reaction. This means that for every force there is a reaction force that is equal in size but in the opposite direction. The transfer of force during the car crash and air bag release can result in a traumatic injury to the otherwise unprotected body. And more than one-third of those injuries are to the foot and ankle.

    Such injuries can lead to arthritis of the foot. In particular, the midfoot or tarsometatarsal joint (TMT) joint is affected. This is where the bones and connecting joints between the heel and the base of the toes are located. Pain from midfoot arthritis can cause limping when walking and an inability to navigate uneven surfaces or move faster than a slow walk. Going up and down stairs can be next to impossible.

    There are other causes of midfoot arthritis such as gout, inflammatory conditions, and degeneration due to age or neurologic conditions affecting the foot. But torn ligaments, fractures, and dislocations from high-energy car accidents are the main cause of midfoot arthritis developing years later.

    Structural changes from the injury lead to abnormal alignment, collapse of the arch, and other foot deformities. The patient experiences instability as the foot is no longer able to provide a rigid lever over which the body moves during forward propulsion.

    What can be done for patients with this type of foot arthritis? The first goal is to reduce the painful symptoms and any destructive inflammation that might be present. Nonsteroidal antiinflammatory drugs (NSAIDs) are used at first to accomplish this.

    Next, an attempt is made to stabilize the midfoot. This may be done with special shoes, shoe modifications, or orthotics (inserts placed inside the shoe). The orthotics help off-load the midfoot and protect the already damaged joint. Special plastic braces that fit inside the shoe (called polypropylene ankle-foot clamshell orthosis) can reduce pressure on the bottom of the foot by 30 per cent.

    When nonsurgical measures such as these just described are not successful in reducing pain and stabilizing the joints, then surgery may be needed. The surgeon fuses the bones of the midfoot together. The procedure is called an arthrodesis. The specific bones that get fused depend on where the damage is located. Surgeons rely on imaging studies (X-rays, CT scans) taken before surgery to plan the type of procedure needed.

    Often, the base of the metatarsal bones (long bones in the forefoot) must be fused to the bones in the midfoot to achieve the rigid stabilization needed. Metal plates and screws are used to hold everything together.

    As with all fusion procedures, there is a chance that the fusion won’t be successful and movement will continue to occur in the midfoot. Research has not been done to show which method of fixation works best. Other possible complications include infection, pain from the hardware, stress fractures, and joint arthritis in the adjacent joints. The need for a second surgery due to complications arises in up to 10 per cent of all cases.

    There is some evidence from studies that the surgeon’s ability to line the bones of the midfoot up as close to normal as possible before fusing them gives the best results. The senior surgeon who helped write this article provided her preferred technique for the surgical management of post-traumatic midfoot arthritis that does not respond to conservative care.

    Specific surgical techniques are described and discussed. Specific location and type of incision, use of tourniquet, and type of anesthesia and nerve block are presented. Fixation devices and their location are included along with advice on how to fuse patients whose bone quality is less than normal.

    Finally, the surgeon advises that patients should be warned that arthrodesis of the midfoot helps reduce but doesn’t always eliminate foot pain. The procedure provides stability to improve function but the patient should not expect to regain normal motion. Recovery includes rehab and final results aren’t known until at least 12 months after the surgery (longer if a second surgery is required).

    Family History Plays Large Role in Developing Bunions

    Hallux valgus, or bunions, is a chronic condition caused by the deformation of the joint just below the big toe, the metatarsophalangeal joint. It can be identified by the big toe moving towards the other toes, with a large bump forming to the side of the foot.

    Although there aren’t any firm statistics, reports of adults with bunions are estimated anywhere from 28.4 percent to 64.7 percent. Researchers Coughlin and Jones studied data of patients with bunions and they found that 83 percent of patients had a family history of bunions, and wearing constricting shoes and the type of occupation only made up 34 percent of causes. Another study reported that the body mass index and wearing high heels contributes to bunion formation in women between 20 years and 64 years. It was thought that dancers, who put a lot of stress on the toe joint, would have a higher rate of bunions, but this didn’t show in the research data.

    The authors of this article undertook a study to determine the prevalence of bunions in relation to wearing high heels among Chinese women. Researchers distributed questionnaires to women in Hong Kong between the ages of 18 and 65 years. A total of 1,080 women responded and 98 percent of the responses (1,056) were usable. They were asked to rate their feet according to photographs included in the questionnaire that demonstrated how a foot looks according to degree of bunion. The women were also asked questions about family history, if they had foot problems, how often they wear high heels, pain and symptoms and if they have any effect on their daily life, as well as any diagnosis and treatment they may have received.

    The women were from different socioeconomic backgrounds:

    – 29.7 percent, clerical workers
    – 4.4 percent, salespersons
    – 6.2 percent, flight attendants
    – 4.5 percent, service workers
    – 12 percent, teachers
    – 6.8 percent, discipline force
    – 6.4 percent, health care
    – 30.1 percent, housewives

    In all, 36.5 percent reported having some sort of bunions: 29.5 percent (312) said they were mild, 4.8 percent moderate (50), and 2.2 percent (24) severe. When breaking this down by age, the older women had a higher incidence of bunions:

    – 18 years to 40 years: 65.8 percent normal feet, 29.5 percent mild bunions, 3.7 percent moderate, 1.1 percent severe
    – 41 years to 65 years: 58.6 percent normal feet, 29.4 percent mild bunions, 7.4 percent moderate, 4.6 percent severe

    Two hundred twenty six women said they always wore high heels, while 453 reported wearing them sometimes, with the average length of time for wearing the heels being 9.4 years. Of just the women who had bunions, the average length was 10 years.

    Family history was noticeable. Of those who had bunions, 88 percent said they had family members who also had them. Interestingly, 73.2 percent of this group did not wear high heels regularly. Of women who did not have a family history of bunions and wore heels often, only 2.8 percent had bunions.

    Complaints that the women with bunions had included feeling that their legs felt tired, pain in the bunion area, changes in daily walking, balance issues, and effects on their daily work. However, only 93 percent of women with bunions contacted a doctor, as did 93 percent consult a physiotherapist. Eighty three percent used an orthotic device (insert for a shoe), 61 percent added a foot pad, and 43 percent bought wider boxed shoes.

    The authors found that their study’s prevalence was 36.5 percent for bunions, closer to the 33 percent in other studies. Although many say it is the wearing of high heels and constricting shoes that cause bunions, research isn’t backing this up. High heels aren’t harmless though. Steady use can put too much force on the feet, ankles, knees, and lower back, which are not meant to have that much force. As well, the position of the feet in the high heels puts tremendous pressure on the plantar (bottom) of the forefoot. The authors concluded that heels were not the main issue, but “a family history appeared to be a major concern for developing hallux valgus in Chinese females.”

    Review of Pedal Macrodactyly

    Macro means larger than what is considered normal; pedal macrodactyly is a condition where the toe on a foot is growing more quickly than the other normally growing toes. It is a rare congenital disease, which means that you are born with it, although it doesn’t seem to run in families. Because the toe is larger than the others, it has extra fibrous fatty tissue on the bottom (the plantar part of the toe, causing it to curl upwards, the dorsal or top. The authors of this article reviewed previous case reports to better understand the etiology or cause of the disease.

    Macrodactyly falls into one of two types: static or progressive, the most common type. Patients with static macrodactyly have larger toes (or toe) when they are born. It then continues to grow proportionally to the other toes. The other type, progressive, the toe grows faster than it should, given the growth pattern of the child. The condition seems to affect slightly more boys than girls, and it can occur on one foot only, on both feet, and it can be symmetrical or asymmetrical. Macrodacytly isn’t necessarily associated with any other type of deformity, although it can be found in people with some types of syndromes, such as Proteus syndrome, Banayan-Riley-Ruvalcabe, Maffuccin, Ollier’s disease, and Milroy’s disease.

    Although the cause of macrocactyly isn’t known, there are theories, which include one hypothesis of a defect in a cell that causes certain areas of the body to become supersensitive to growth. Another theory is that it may be caused by an interaction of genetic and environmental factors. There may be hemangiomas, which are benign (noncancerous) tumors made of a mass of blood vessels. These may also cause enlargement of the toes. Another cause could be damage in the nerves, causing rapid overgrowth of the area.

    When the affected toes of children are examined, it is seen that the subcutaneous fat, the fat just below the skin, looks like adult fat, not a child’s. As well, all the elements of the toe are larger (the tendons, nerves, blood vessels, fat, nails, skin and the bones in the toe. The exception is the bone in the foot that goes to the affected toe is not larger than normal. The skin on the affected toe is thicker than normal and the toe feels rubbery and soft.

    Treatment for the disorder depends on several issues, particularly, if the toe or toes are causing pain or disability. If surgery needs to be done, the surgeon could destroy the growth part of the bone, along with removing as much as the excess tissue as is possible. This part, however, called defatting, is done in a two-step process. The first step involves reducing the thickness on the convex side of the toe by 10 to 20 percent. The second step involves doing the same to the other side, and shortening the bone and removing excess skin. Amputation could be considered, but this is not common and is usually only used as a last resort. As well, amputations of the smaller toes do not seem to have as big an effect on the foot as with the larger toes, so this is also taken into consideration.

    In one case presented by the article’s authors, a three-year-old had an affected fourth toe. The parents wanted to make the foot more normal-looking and to allow for wearing appropriate shoes. The surgeon removed a large piece of full-thickness skin and subcutaneous tissue. A k-wire was inserted to stabilize the toe. The child wore a walking cast for six weeks and there were no reports of complications. Although the surgery was a success, there will likely be more in the future.

    In the second case, a 24-year-old patient wanted surgery to correct the look of her second toe and the practicality of no longer having to buy two different sized shoes, one in a larger size for the affected foot. She had no problems with mobility and was able to run and walk without pain or difficulty. Although the toe had been affected since she was a toddler, her parents did not seek treatment.

    The affected toe was 15 mm longer and 15 mm thicker than the same toe on the opposite foot. Since the toe wasn’t causing any physical problems, the surgeon used a nail graft after removing some of the bone and also removed some of the subcutaneous tissue. This was chosen over an amputation because it would leave the patient with a normal looking toe, while an amputation wouldn’t.

    The authors concluded that the number of people affected by this condition is unknown, but it is found more often in males. The cause of macrodactyly is unknown and treatment varies according to which toe is affected, what the surgeon prefers to do and what – if any – problems are being caused by the enlargement.

    Despite Early Childhood Surgery, Some Issues Remain in Adults with Clubfoot

    Clubfoot, called congenital talipes equinovarus or CTEV in medical language, is a common birth defect, occurring in about one out of every 1,000 births. At first, the foot is treated by trying to manipulate it back into its proper place and shape, but how the manipulation is done depends on the doctor, the facility, and the extent of the defect.

    Many studies have been done comparing techniques for managing clubfeet and in most cases, adults who were born with a clubfoot did well with manipulation and casting as children. They have good function for the most part, but many do have limited range of motion and may have pain if they are participating in long activities. Undergoing surgery during adolescence seemed like a good idea, but studies have shown that adolescents who do have surgery on their clubfoot often report problems after the surgery, including pain, weakness, difficulty using the foot properly, and difficulty with their gait. Studies have also reported that adolescents who had the surgery had more difficulty with their ankle and foot motion than did children who had the surgery at a younger age. Adults who undergo clubfoot correction surgery also seem to be at a disadvantage. They reported stiffness in the ankle and foot, arthritis, ankle muscle weakness, pain, and deformity.

    The authors of this article reviewed and evaluated the long-term outcomes of the comprehensive surgical release. They collected data from 24 adults (17 males), aged from about 18 years old to 24 years old and a control group (with no clubfoot) of 48 people. Eleven patients had only one clubfoot (unilateral), while the remaining had two clubfeet (bilateral>). As children, none were successful with casting so they underwent surgery before they were 18 months old. Fourteen patients went on to have further repairs.

    Each patient was examined and range of motion was assessed of ankles and feet, using the International clubfoot Study Group (ICFSG) rating score. X-rays, with patients standing, were obtained, and the strength of the feet were established. The patients were also assessed for their gait, which provided information not only of the foot and ankle, but of the pelvis, hip, and knee, as well. Assessments were also done suing the American Orhtopaedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot and Midfoot scales, the Foot Function Index (FFI), and the SF-36, as well as a few others.

    In the clubfoot group, there were leg length differences of between 0.5 centimeters and 3.5 centimeters in the unilateral group and from 0.91 to 0.77 cm in the bilateral group. Among the unilateral group, the calf circumference on the affected side (the one with the clubfoot) was smaller than the unaffected leg. The range of motion of the affected legs were also lower for the clubfoot group, as was the strength.

    In the assessments, only five out of the 37 clubfeet were rated as excellent (according to the ICFSG), 17 were good, 15 were fair to poor, and seven were fair. The Turco score, which classified surgery outcomes, rated six feet as excellent, 24 as good, and seven as fair.

    The pain and movement issues lowered the AODFAS scores in both the Ankle/Hindfoot and the Midfoot scales. The Disease Specific Index, another assessment, found that 96 percent of the feet were painful. Results also showed that patient who were on their feet for long periods of time or needed to do stressful activities, such as running, jumping, or stair climbing, to name a few, experienced more problems with their affected foot or feet. In fact, all patients reported some level of pain at the end of the day or after strenuous exercise.

    The conclusion seems to be that adults who were treated as children for their clubfoot or feet still have issues with their feet later in adulthood. Although these problems don’t cause problems with basic daily living, they do provide limitations in how active the patients can be. The authors suggest that following these patients into their later years to see if any changes occur, particularly as they enter the stages where arthritic changes may occur.

    Is There a Link Between Tight Calf Muscles and Foot Pain?

    Serendipity is a fancy word for the idea that sometimes things happen unexpectedly. And the results of the event have a positive effect on us or benefit us in some special way. Sometimes surgeons discover things serendipitously.

    For example, 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 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.

    Specific diagnoses have now been treated with good results using the gastrocnemius lengthening procedure. Conditions such as plantar fasciitis (bottom of the foot pain and fascial tightness), metatarsalgia (toe joint pain), fallen arches, foot arthritis, and tendon problems have all responded well to gastrocnemius lengthening.

    In this article, surgeons from Michigan State University review the results of the studies done so far using this technique for foot and ankle problems. They also present their own treatment approach to gastrocnemius contracture (tight or fixed muscle).

    They recognize 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. Their method is to evaluate patients and place them in a management group based on symptoms, diagnosis, and biomechanical structures present at the time of the exam.

    For example, type 1 contracture refers to patients who have a weakened ligamentous support of the arches. The diagnosis is often plantar fasciitis, metatarsalgia, Achilles pain, or painful arches. Type 2 gastrocnemius contracture describes a patient with a collapsed forefoot and/or bunion.

    Type 3 contracture results in a collapse of the midfoot with midfoot arthritis. Type 4 is a collapse of the hindfoot affecting the spring ligament in the middle arch of the foot. And type 5 is a tilted ankle linked with deltoid ligament problems and ankle arthritis. Each type is featured in the article with either a photograph of the foot and ankle or corresponding X-ray.

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

    The authors point out that 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.

    Future studies will be done in the area of gastrocnemius lengthening. The focus will be two-fold: 1) accomplishing the operation endoscopically (long, thin needle with a tiny TV camera on the end) with a very small incision and 2) finding out what types of foot problems can best benefit by this procedure.

    Joint Replacement For the Big Toe

    Joint replacements are widely used for the hip, knee, and shoulder. Ankle, elbow, and finger joint replacements are available but are less common. Now on the cutting edge are toe replacements — specifically the first metatarsophalangeal joint (MTP) or base of the big toe.

    Companies that make joint implants are working with surgeons to find the right materials and design for the first ever successful metatarsophalangeal (MTP) joint replacement. Actually, the first MTP 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.

    Silicone joint replacements have been tried but studies show that patients don’t put weight on the toe. Even with reduced weight-bearing on the silicone implants, they don’t hold up. The implants themselves start to break down and the bone underneath the implant softens and flakes away. Bone spurs form around the area as the body’s response to the changes in toe and foot biomechanics.

    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 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.

    The author proposes that the implant science around total toe arthroplasty will continue to evolve and improve. When results are equal to or better than for arthrodesis and when the implant survives 10-years or more, then the metatarsophalangeal (MTP) implant will be used more often. Improving the implant’s ability to function under normal weight-bearing without loosening is an important goal.

    Using Ultrasound Can Help Diagnose Stress Fracture in Foot

    A stress fracture is a broken bone, an overuse injury. It can happen in just about any bone, but is most common in the feet or the tibia, the shin bone. Diagnosing stress fractures can be difficult because early fractures don’t always show up on regular x-rays. In fact, it can take up to 10 weeks from the initial injury and beginning of the symptoms to when the fracture is visible. The problem is the delay in diagnosis may lead to other problems, such as chronic pain.

    In order to earlier diagnosis stress fractures, doctors must use more advanced procedures, such as magnetic resonance imaging (MRI) or bone scans, say the authors of this article. Ultrasound is a technique that has been used, but there have been varying reports of its usefulness for diagnosing stress fractures. The way ultrasound works it should, theoretically, make a good option for looking at bone and revealing any imperfections or breaks. The authors state that ultrasounds should be a good backup for diagnosis if x-rays don’t show any fractures, but symptoms still indicate that there may be a break. They describe three case studies of patients with stress fractures.

    In the first case, a 22-year-old male athlete complained of anterior (front) pain of the tibia in the right leg. He had originally thought the injury was a soft-tissue injury and he treated it with ice, nonsteroidal anti-inflammatory drugs (NSAIDs), changing his shoes, and decreasing his activity level. However, the pain continued to worsen.

    There was no obvious swelling or bruising of the area and the doctor suspected a stress fracture. An ultrasound of the tibia found an irregularity. The ultrasound was followed by a bone scan, which confirmed the stress fracture. The patient was advised to rest his leg significantly more than he had been and the injury healed without any problems.

    The second case was a 16-year-old female who came in with complaints of five weeks of mid-foot pain, near the third and fourth metatarsals (toes). Despite the pain, the patient continued with her regular activities, including playing netball and tennis, and rock climbing. Earlier x-rays had not shown any specific injury, but the pain was getting increasingly worse during activities, as well as after.

    An ultrasound was performed on the painful area of the foot, which showed a fracture and callus formation. Four weeks later, x-rays also showed the callus formation. The patient was instructed to modify her activity, change her shoes, use orthosis (foot supports), and the pain resolved, allowing her to return to her previous level of activity.

    A 21-year-old female is presented as the third case. A long-distance runner, she was experiencing increasing pain under her foot, at the base of the fifth metatarsal. She had not experienced any trauma or done anything different that could be the cause of the pain. On examination, a red area was clearly visible around the area that the patient said was painful, which could mean a soft tissue injury, rather than a fracture. Since the symptoms were not in line with a soft tissue injury, the physician ordered an ultrasound, which showed a clear break through the bone.

    To manage the stress fracture, the patient was told to stop all sporting activities and change her shoes. After six weeks, the fracture healed and the patient was able to resume running.

    The authors concluded that the ultrasound is an underutilized tool that can be valuable in helping diagnose injuries of the foot. Earlier studies looked at the use of therapeutic ultrasounds, rather than imaging, but they use different frequencies. The higher frequencies of the therapeutic ultrasound would cause pain if a fracture is present, but this pain does not occur if the ultrasound is set for imaging. Therefore, it would be useful for physicians to consider using the less costly and noninvasive ultrasound to investigate for stress fractures of the foot before suggesting MRIs and bone scans.

    Non-Invasive Shock Therapy as Effective as Screw Fixation in Treating Nonunion of Proximal Fifth Metatarsal Metaphysial-Diaphyseal Fractures

    The severity of a fractured (broken) metatarsal (toe) depends on how and where the bone was broken. The metaphyseal part of the bone is the wider part of the bone, next to the end of the long bone. The diaphyseal part is the shaft of the long bone. The fifth metatarsal is the bone that runs from the center of your foot to the little toe. There are three distinct types of fractures that can happen to the fifth metatarsal, but each of them has challenges in healing properly. Reports of nonunion rates range from 7 percent to 44 percent. Treatment ranges from nonsurgical, using casting and non-weight-bearing to surgery. Nonsurgical procedures do not offer consistent good outcomes and can result in nonunion of the bones and/or chronic pain. For this reason, most surgeons recommend surgery to insert wires, bone grafts, or screws, or a combination of these.

    The surgery outcomes are fairly successful, but there have also been reports of complications, particularly with the screws, the intramedullary screw fixation. Because of the movement of the bones, healing may not occur (nonunion), the screw may break through the bone, or there may be lasting chronic pain at the fracture site.

    As research continues looking for better treatments, one such treatment for this problem is shock wave therapy for fractures that have not healed. Although researchers don’t yet understand how the shock wave therapy works, they have found that the therapy helps the bone to heal and stimulate bone cell growth. The treatment is appealing because it is not invasive, as is surgery, and it is quite safe. On the other hand, the negatives include how available it is and how variable treatment could be. The authors of this article undertook a study to determine if shock wave therapy was a safe, effective technique for treating nonunions of the proximal part of the fifth metatarsal, the part closest to the foot.

    Researchers recruited 43 patients with fractured nonunion of the fifth metatarsal. Twenty-three patients (13 males) received high-energy shock wave therapy (2,000 to 4,000 shocks). The patients ranged in age from 17 to 78 years. Two patients smoked regularly and one had diabetes. The time since the original injury ranged from six to 39 months. The other 20 patients (eight men) were treated with surgery, insertion of screws. They ranged in age from 19 to 78 years, and as with the other group, two patients smoked and one had diabetes.

    Both procedures were done under general anesthesia. After the shock therapy treatment, the feet were examined for swelling, hematoma (gathering of blood in one area) and ecchymosis (bruising). A weight-bearing cast was then applied and the patients were discharged the following day. The cast was to remain on for four to six weeks. When the patients went for follow-up, the researchers assessed progress with x-rays.

    For patients in the surgery group, they were given a splint for their foot and were not allowed to do any weight bearing for two weeks following the surgery. After the two weeks, the patients were assessed, the skin staples or sutures were removed, and the patient was given a hard-soled shoe or walking boot. With these, the patients were allowed to begin toe-touch weight bearing (not bringing the heal down when stepping) and moving on to regular weight bearing, slowly over the course of four to six weeks.

    In comparing the healing between the two groups, the researchers found that 20 of the 23 patients in the shock group and 18 of the 20 patients in the surgery group had healed within three months of their procedure. One of the patients in the shock group that had not healed by three months, did heal by six months. One of the two remaining nonhealing shock patients went for another shock treatment six months of the first treatment and healed within a month. Only one complication was reported. One patient experienced petechiae, tiny red and purple spots on the skin, that came and went within 24 hours of treatment.

    For the nonhealing patients in the surgery group, they still had not healed by six months after the procedure. One patient underwent surgery again to remove the screw, due to constant pain,. He was then put into a cast and healed after two months. The other patient who hadn’t healed experienced a skin infection cellulitis that resolved on its own. The patient also underwent another surgery to remove the screw that was causing pain, but he did not heal after four weeks of using a hard-sole shoe. In all, nine patients in this group experienced 11 complications: the two mentioned plus the one with cellulitis. Seven patients had impingement (pressing) of the screw against the bone and had to have them removed. One other patient broke the same bone a year after the procedure, which was treated successfully with splinting in a walking boot.

    There were three athletes in the shock treatment group and all returned to playing soccer after about three months following treatment. Among the athletes in the surgery group, one college soccer player returned to recreational soccer after six months, a recreational soccer player returned to the same level of play, also after six months. A jogger and basketball player were able to resume their previous level of activity after about four months.

    The authors wrote that treating with non-weightbearing casts may be a solution but for those patients who are not very active. However, patients who are active need a more aggressive approach. The two treatments, shock therapy and screw fixation are effective for most patients, however screw fixation does have more complications associated with it than does shock therapy.