News Category: 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.

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.

Orthopedic surgeons from Japan report a new way to surgically repair acute Achilles tendon ruptures that keep athletes out of a cast and back on the playing field faster. 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. The Achilles tendon is where the calf muscle attaches to the heel.

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. Photographs from the operation are provided to show how the repair is done. A schematic drawing also shows details of how to make the side-locking loop sutures. Step-by-step details of the operative technique were also given.

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.

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.

This new rigid suturing method gives a stronger suture and higher tensile strength to make recovery faster. Although many people can recover from this injury without surgery, for those who want or need a quick turnaround in function, this new surgical technique may be the answer. Severe ruptures with large defects in the tendon tissue may still require immobilization after surgery.

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.

Bunions can get pretty ugly — and not just because they look funny. But because with the big toe angled so oddly, the foot loses the normal function of that joint and changes how a person walks. They can also be very painful.

It’s possible that the use of a shoe insert called an orthotic to support the arch early on may prevent this unsightly deformity. At least that’s what a group of physical therapists at the University of Minnesota Medical School are proposing. If that’s true, it will be the first treatment discovered to affect bunions in any way other than surgery. And that would be good news for bunion sufferers!

What is a bunion anyway? That bony knob sticking out from the big toe is caused by a change in the alignment of the first metatarsal and the hallux. The first metatarsal is the bone inside the big toe. The hallux is the bone in your foot that connects to the first metatarsal. The joint where these two bones meet is called the first metatarsophalangeal joint or MTP joint.

As the hallux shifts away from the foot (a movement called abduction), the first metatarsal adducts (moves toward the other toes). The result is a disruption of the metatarsophalangeal (MTP) joint. Swelling around the joint develops and forms the deformity you see on the outside of the foot that’s called a bunion. Once the shift begins, it seems there’s no stopping it without surgery.

No one knows exactly why this shift gets started. There have been many theories and experts agree that it’s probably multifactorial. In other words, there are many things combined together to cause this foot deformity. Some of those things include environment (shoe wear), genetics (family history), and anatomy. This group of therapists takes a look at the anatomical component and suggests that a collapse of the arch of the foot may be at fault.

If you look at the alignment of the foot arch from the front of the foot, it’s easy to see how a change in the tilt of the arch can change pressure placed on the big toe. Collapse of the arch while standing up on the foot in a weight-bearing (load) position may set up a chain of events that ultimately leads to hallux valgus (the medical term for bunions).

That sounds simple enough but as the authors of this article point out, the anatomy and movement of the joints in the first (big) toe are quite complex. By analyzing the joint in three dimensions (3-D), it’s possible to see that the joint functions like a pin around which the bones rotate. This is called a joint axis.

The shape of the arch of the foot affects the axis of the first metatarsal (big toe). As the arch drops down, the first metatarsal axis becomes more vertical (aligned up and down). Shifting of the hallux and first metatarsal occur and that affects the joint axis, too. Pressure on and stretching of the ligaments and cartilage around the joint further weaken the support of the bony structures.

As the bones of the first ray (all the bones lined up to form a toe) shift, so do the bones in the second ray. The angle between the first and second toes widens further changing the pattern of weight and pressure under the foot and at the point of the bunion. The changes also affect how the tendons attached to the bones and the muscles associated with the tendons pull on the foot. Besides being ugly, painful, and changing the person’s gait (walking) pattern, it can become increasingly difficult to find shoes that fit!

With the right kind of support, the metatarsal axis can be oriented more toward the horizontal (straight across from side to side). In this way, the arch can help support the weight of the body without collapsing, shifting the arch, and altering the alignment of the foot. The words of the song Dem Bones (the toe bone’s connected to the foot bone, the foot bone’s connected to the ankle bone) are quite right. A shift in one arch affects joint axis, bones, ligaments, alignment, and so on.

The authors conclude that hallux valgus (bunions) may not be irreversible with conservative treatment as was once thought. If they are right and a simple orthotic (shoe insert) can make a difference, the world will be a different place — at least for those who are affected by this foot deformity.

The next step will be to find a way to predict who is at risk for bunions and try using orthotics to prevent the hallux valgus deformity from forming. Research to identify the optimal time for this type of early intervention will also be helpful. Delaying the need for corrective surgery and possibly eliminating the need for surgery would be the final future goal of these studies.

Sometimes evidence-based medicine reveals some surprising findings. Take for example, surgery for bunions, a condition referred to in medical terms as hallux valgus. The surgeon removes a pie-shaped piece of bone from one side of the big toe and wedges it on the other side of the joint to restore a more normal alignment of the toe. The idea is to restore function in weight-bearing for walking.

But new studies using plantar pressure analyses have shown that all is not as expected or hoped for. Although the X-rays show the toe is lined up nicely and the person appears to be walking well, in fact, the normal physiologic gait (walking) pattern is not restored. And over time, that could mean arthritis will develop.

Hallux valgus (bunion) is a condition that affects the joint at the base of the big toe. The bunion actually refers to the bump that grows on the side of the first metatarsophalangeal (MTP) joint. Hallux is the medical term for big toe, and valgus is an anatomic term that means the deformity goes in a direction away from the midline of the body. So, in hallux valgus, the big toe begins to point towards the outside of the foot. The bunion that develops is actually a response to the pressure from the shoe on the point of the angle. At first the bump is made up of irritated, swollen tissue that is constantly caught between the shoe and the bone beneath the skin. As time goes on, the constant pressure may cause the bone to thicken as well, creating an even larger lump to rub against the shoe.

Plantar pressure analysis is done using a platform with 1,760 sensors that map how much pressure is exerted on each square centimeter on the bottom surface of the foot. The measurements are taken as the patient walks across the sensor platform and recorded in different colors to represent various amounts of pressure. The data goes directly into a computer that calculates peak pressure, contact area, and contact time for each anatomical region of the foot.

In this study from the Gait Analysis Laboratory at the Foot and Ankle Center in Vienna, Austria, 30 patients were tested after surgery for hallux valgus. All had pain in the area of the first toe (metatarsophalangeal joint). There were no other musculoskeletal or orthopedic problems in the low back, hip, or leg to account for this pain.

All patients were tested using the plantar pressure analysis before and after surgery. Post-operative measurements were taken at four weeks, eight weeks, and six months following the procedure. Other measures taken included range-of-motion of the toe and function using the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire. The patients completed the AOFAS survey before surgery and again six months later.

The results of pre-operative testing did, indeed, show low scores on the function test, decreased range-of-motion of the first toe, and increased plantar pressures. There was also evidence of load shifting in the forefoot from before to after surgery. At first (before surgery), patients shift the load off the painful metatarsophalangeal joint. After surgery, the patient shifted more load away from the great toe region. The result is an even more pathologic gait pattern.

What can be done to help patients recover fully after surgery for hallux valgus? Physical therapists have demonstrated through this study that a multimodal rehabilitation program can help restore more normal weight-bearing and walking patterns. Right after surgery, the patients were placed in a special cold cast called an Aircast cryo-cuff. This device helps reduce inflammation and swelling. All patients wore a special shoe for the first four weeks after the operation. The shoe allowed the patients to put weight on the toe with less stress through the forefoot. By decreasing the load at the surgical site, bone healing can take place uninterrupted.

Physical therapy began four weeks after surgery with leg elevation, lymphatic drainage, gait training, manual therapy, and strengthening exercises. Manual therapy included release techniques for the muscles of the foot and lower leg as well as manipulations of the big toe, forefoot, and ankle. Specific training exercises to restore normal walking patterns were also part of the rehab program. Everyone had four sessions (once a week for four weeks) and did a home program of daily exercises as well.

Post-rehab testing showed marked improvement in function and motion along with a decrease in the maximum force placed on the first toe. Total motion did not change significantly but dorsiflexion of the big toe improved by five degrees. Dorsiflexion describes the movement of the big toe needed to push off from the ground to move forward.

Analysis of the plantar pressure patterns from before to after surgery showed improvement. This suggests improved function of the big toe in pushing off while walking. This particular finding helps support the benefit of physical therapy intervention after bunionectomy surgery. Although there wasn’t a control group in this study (i.e., patients who had the surgery but did not have rehab), other before and after studies using plantar pressure data have not shown this type of change.

Physical therapy has been shown effective following many types of orthopedic surgeries (e.g., joint replacements, ligament reconstruction, bone fractures). This is one of the few studies to show how function can improve with rehab after forefoot surgery. Changes in plantar pressure distribution while walking were used to document the benefit of a rehab program following surgery for hallux valgus. The authors point out that without a control group, future studies including a control group are needed to verify their findings.

In 1998, researchers received the Nobel Prize in medicine for their discovery of a molecule called nitric oxide. This molecule is made up of one nitrogen (N) and one oxygen (O) atom. It is present in all mammals, including humans. It is NOT the same as nitrous oxide (N2O), the laughing gas used by dentists.

Nitric oxide does many, many things in the body. For example, it acts like teflon in the blood vessels. It keeps the blood moving smoothly and prevents plaque build-up that causes atherosclerosis. It helps with long-term memory, sexual function, nerve transmission, and boosts the immune system function. Scientists have since discovered that it also plays a role in wound healing for fractures and tendon damage.

Now in a startling turn around, researchers from England have discovered nitric oxide may have a negative part to play in the development of tendinopathy. Their focus was on the Achilles tendon of the foot. The Achilles is at the end of the gastrocnemius (calf) muscle and inserts or attaches into the calcaneus (heel) bone of the foot. Tendinopathy refers to a degenerative process in the tissues without inflammation.

As it turns out, nitric oxide causes apoptosis or cell death. This is a programmed or predetermined cell death. That’s all part of the natural body function that gets rid of old cells to make way for new, healthier cells.

When apoptosis occurs, the dying cell doesn’t dump any of its contents, which is what would happen if there was damage to tendon cells from trauma as a result of injury or overuse. It’s those released enzymes in injured cells that signal inflammation and a repair sequence.In the case of apoptosis, the old cell orchestrates its own death without release of its contents.

Now how does all this fit with Achilles tendon problems? Well, with trauma and especially overuse injuries, the body releases more nitric oxide than usual. While a certain amount of nitric oxide is good, like anything else, too much of a good thing (i.e., nitric oxide) can go south. Overproduction of nitric oxide becomes toxic to the tendon tissue and sets up excessive apoptosis.

The result? Achilles tendinopathy. The incidence of these injuries in more and more adults is suggested to be the result of more people engaging in sports and recreational activities. But biomechanical factors and training errors also contribute to the problem.

And to add to the data collected, it appears that nitric oxide-induced apoptosis leading to achilles tendinopathy affects more than just the aging or overzealous athlete — it seems that folks with diabetes, hypertension, or obesity are also at risk for tendinopathy.

Just exactly what is the effect of nitric oxide on the tendon tissue? To find out, scientists studied samples of tissue taken from 14 patients with Achilles tendinopathy. They compared these samples with tissue collected from normal, healthy Achilles tendons in the same patients.

The samples were sent to the lab where they were examined and analyzed. Three separate types of cells were measured. These included caspase-3 cells, TUNEL cells, and inducible nitric oxide synthase (iNOS) — all three cell types are released at the time of cell death (apoptosis).

They found a significant increase in all three cell types in the tendon with tendinopathy. These results suggest that a larger number of cells in the diseased tendon were undergoing apoptosis. The natural conclusion is that apoptosis is a part of the reason why Achilles tendinopathy occurs.

Since many studies have proven there are no inflammatory cells present in chronically painful tendons, there must be some other mechanism to explain what’s going on. That’s where this idea that nitric oxide-induced apoptosis may be the pathway by which tendinopathies develop.

If scientists can solve the mystery of what’s happening at the cellular level, then it might be possible to find faster and more effective ways to treat tendon problems. Other studies have shown excessive apoptosis in tendons just before they ruptured, so maybe there will even be a way to prevent tendon injuries with this new knowledge.

There still remain many unanswered questions and conflicting information about nitric oxide, how it works, and what effects it has on tissues. For now, the results of this study add a bit more information. Too much nitric oxide from high-strain mechanical loading on a tendon may be harmful to the tendon healing process.

The authors conclude that the release of excess nitric oxide might be the reason tendinopathy occurs when there’s no obvious inflammation. Hopefully, future studies will continue to unravel and solve the complete mystery so we can get on with the business of finding ways to prevent (or treat) tendon problems.

Missed or delayed diagnoses of peritalar injuries can leave a patient limping for the rest of his or her life. To help orthopedic surgeons quickly and accurately diagnose these injuries, orthopedic specialists have written this article reviewing these rare and often subtle foot and ankle injuries.

Peritalar refers to the talus and the soft tissues and bones around that bone. The talus is one of the large bones in the back part of the foot that helps form the ankle joint. It sits just above the calcaneus, or heelbone. The two bones make up the back part of the foot (sometimes referred to as the hindfoot). The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. The subtalar joint allows the foot to rock from side to side.

Diagnosis can be difficult because the hindfoot and ankle is a very complex structure. Flat, two-dimensional X-rays don’t always show what’s really going on. It isn’t until the injury doesn’t heal and the patient continues to report pain and difficulty walking that additional imaging studies are done to find the real problem. By that time, it could be too late to save the natural biomechanics of the subtalar joint. Surgery may be needed to fuse the joint together to reduce pain and stabilize the joint. But fusion means a loss of motion and possibly, function.

Specific injuries covered in this article include bone fractures, joint dislocations, and ligament tears/ruptures affecting any of the periarticular joints. The talus articulates (moves against) the calcaneus, tibia (shin bone), and navicular bones. The calcaneus articulates against the talus and the cuboid.

So, injury to any of the following joints can result in peritalar instability: the tibiotalar joint, subtalar, calcaneocuboid, and talonavicular. That covers a lot of territory in the foot/ankle structure. And it makes up quite a bit of foot and ankle motion as we walk. The calcaneus hits the ground first, then the leg rocks over the foot until we push off with the toes to swing the leg through and start the cycle over again. Any disruption of the bones, joints, and ligaments can impair motion and function creating significant disability.

Pictures drawn of the foot/ankle anatomy along with X-rays and CT scans help illustrate what happens when any of these areas are injured. Descriptions are given for each injury and the most common mechanisms for those injuries. This information can help physicians recognize the history and clinical presentation of peritalar disruptions, thus making the diagnosis sooner than later. Things to watch out for include:

Most athletes really depend on their feet and ankles to propel them during sports activities. Running and jumping can become huge problems when the athlete experiences heel pain of any kind. The two most common heel problems affect the plantar heel (underneath) and the posterior heel (back of heel). In this review article, the diagnosis and treatment of four specific problems are addressed. These include 1) insertional Achilles tendon disorders, 2) plantar fasciitis, 3) plantar fascia rupture, and 4) calcaneal stress fractures.

Heel problems are not confined to these four groups. Other soft tissue disorders, bone disorders, and nerve problems can result in plantar or posterior heel pain. It’s even possible to experience heel pain as a result of lumbar spine disorders, metabolic disorders (e.g., Paget disease, sickle cell disease), tumors, and degenerative joint disease (arthritis). But the authors restricted the content of this article to the four most common problems encountered in a sports medicine practice.

Insertional Achilles tendon disorders develop as a result of overtraining, poor footwear, postural problems, and bumping up the training schedule too fast. Heel pain develops near where the Achilles tendon inserts into the calcaneus (heel bone). This can occur as a result of bursitis (inflamed bursa), tendinitis (inflamed tendon), tendinosis (tendon degeneration without inflammation), or pump bumps. It can be unilateral (one side) or bilateral (both sides). Pump bump is an area of bone enlargment like a bone spur over the posterolateral calcaneus (heel bone). Posterolateral refers to the location: back and slightly to the side of the calcaneus. The bump rubs on the back of shoes and causes pain, tenderness, and skin thickening or callous formation on the outside.

Plantar fasciitis is a fairly common problem in middle-aged women, possibly related to menopause. But when it occurs in a young athlete, other causes must be considered. First, what is the training level? Is the athlete running hills everyday for long hours? Has the affected athlete recently bumped up his or her training schedule? Is the Achilles tendon tight with limited ankle motion? Plantar fascia problems can be limited to plantar fasciitis but the fascia can also rupture or tear. Fracture of the calcaneus can also occur when the plantar fascia gets torn or disrupted.

How can the orthopedic surgeon tell what’s causing the heel pain? Location of symptoms is the first place to start. The examiner will also ask the patient what makes it better or worse, and what structures hurt when pressed or palpated. The presence of any visible changes (e.g., skin thickening, bony bump, swelling around the Achilles) will be noted. X-rays can help show areas of calcification (bone build-up from a pump bump) or bone breakdown around the area of a bone bump from chronic inflammation (bursitis).

Plantar fascia ruptures occur with a painful pop and sudden inability to stand on that foot, run, or push off with the toes. Swelling, bruising, and pain along the bottom of the foot are obvious signs and symptoms. Sometimes plantar fascia rupture leads to the fourth of our conditions: calcaneal stress fracture. Tiny cracks in the heel bone develop either as a result of plantar fascial rupture or in athletes who have increased their training and sports activity. At first, X-rays may not show anything, but after the body starts the bone healing process, there is evidence of the fracture. Usually this isn’t seen until six weeks after the original symptoms developed. Physicians tend to rely on the calcaneal squeeze test to diagnose stress fractures.

Most plantar fascia problems are worse in the morning. In fact, standing up after getting out of bed can be the worst of the painful symptoms. With insertional tendon problems, going up stairs or climbing hills makes the pain worse. Touching the area over the tendon is tender when the problem is caused by tendinitis. The inflamed bursa is not tender to touch but applying a 2-finger squeeze test on either side of the Achilles tendon while the ankle moves up and down and side to side reproduces bursitis pain.

Treatment always depends on the underlying cause of heel pain. That’s why a careful diagnostic sorting process is important and an understanding of what each condition is and how it presents clinically. Imaging tests start with X-rays. MRIs may be ordered when there is suspicion of plantar fascia rupture or calcaneal fracture.

Treatment can be categorized based on the four main types of heel problems. For example, insertional tendon disorders are most often treated conservatively with antiinflammatory medications, ice massage, rest, and activity modification. For the running athlete, this means backing off on daily/weekly mileage and avoiding hills or hard surfaces such as asphalt or concrete.

A physical therapist can advise patients on how to gently stretch the Achilles tendon and gastrocnemius (calf) muscle. Shoes may be changed to a backless or soft counter, possibly with a heel lift or heel cup inside. The counter is the part of the shoe that goes around the back of the heel. Other types of treatment (e.g., radiofrequency, shockwave therapy) are under investigation but there have been no studies published supporting these yet.

When all these measures fail to give the athlete relief from painful symptoms associated with insertional Achilles tendon disorders, then surgery may be considered. The exact procedure performed will depend on the cause of the problem. Chronically inflamed bursae, bone spurs (calcium build up on the heel), or degenerated tendons fibers may be removed. This type of surgery is referred to as decompression as pressure from the offending structure is alleviated by removing it.

Plantar fasciitis may resolve with nonoperative care much like what is used for insertional Achilles tendon problems — activity modification (stop running!) is aided by proper footwear, pain relievers and antiinflammatory medications, stretching the soft tissues, and strengthening the calf muscles. Some early studies show that high-energy shock wave therapy is helpful for chronic plantar fasciitis. How and when to use this modality for the best results remain to be determined.

And like treatment for insertional Achilles tendon problems, treating chronic plantar fasciitis may require surgery. If there’s been no change in symptoms after at least six months of nonoperative management, then surgery may be the next best option. Decompressive surgery is done to remove pressure from around the plantar nerve. Corticosteroid injections are not recommended for this problem. They can lead to plantar fascia rupture and/or calcaneal fractures because of the local weakening of soft tissues and bone created by the steroid.

For the athlete with a suspected or confirmed plantar fascia rupture or calcaneal fracture, nonweight-bearing immobilization is required. After a week to 10 days, the athlete may be given permission by the orthopedic surgeon to start putting some weight on that side. In the case of plantar fascia rupture, the cast is eventually replaced by a rigid-sole shoe. The entire progression from cast to shoe is about a month but permission to return to the field usually isn’t given for another two or three months. Fractures are treated with nonimpact weightbearing until the pain goes away. Then the athlete is allowed to slowly return to weight-bearing activities, especially load bearing activities. This progression takes about eight weeks.

The authors conclude that a proper diagnosis and treatment specific to the problem is the best way to avoid complications and progression of heel pain in the athlete. Conservative care is usually all that’s needed to avoid moving from the acute phase to chronic symptoms in these patients. Surgery is avoided when at all possible, but when it’s needed, decompression is usually the best way to address many problems involving bone bumps, compression on nerves, and tendon degeneration.

Only one per cent of all bone fractures affect the calcaneus (heel bone). But if that’s your foot, you’ll want to know the results of this study as to what happens years after surgery. Since this injury doesn’t happen very often, studying it has been a problem. Small studies have been done but there’s always the question of how reliable are the results? If enough small studies are done, it’s possible to combine the results into a meta-analysis to compare treatment results.

So far, the results of small studies and one meta-analysis done of those small studies points to better outcomes with surgery. How did those studies define better results? Less pain, better function, fewer cases of disability, greater patient satisfaction, and an earlier return to work. Now, in this study from Duke University Medical Center in North Carolina the long-term results of 157 patients with calcaneal fractures are reported. About half (73) of those patients had surgery. The other half was treated conservatively.

Everyone included in the study was at least 18 years old and had an intraarticular calcaneal fracture. Intra-articular refers to the fact that the fracture extended into and/or affected the joint surface. The fracture was displaced meaning the fracture separated the bones apart. That’s why surgery was necessary.

After surgery, everyone was followed for at least five years, some as long as 18 years. The outcomes were measured using three well-known and valid questionnaires to assess pain, function, and severity of disability. Test scores were collected and analyzed from the American Orthopaedic Foot and Ankle Society ankle-hindfoot test, the Foot Function Index, and the calcaneal scoring system. Activity limitations, pain, walking distance, and the use of walking aids are the types of data collected on these tests.

The authors chose these particular tests because the results can be compared from one study to the next. They hope that future studies will be able to compare results against their outcomes to give a clearer picture of what’s happening with postoperative calcaneal fractures. In some of the other studies that have been done, researchers used their own scoring system. That makes it more difficult to compare the results to other studies.

In this study, they also keep track of the patient’s age when the injury occurred, sex, Worker’s Compensation status, and some specific details about the fracture. Worker’s Compensation status is a way to track whether or not the injury occurred at work. Previous studies have suggested that patients on Worker’s Comp had worse results and were more likely to leave their jobs as a result of the injury. That wasn’t the case in this study. Worker’s Comp status did not seem to have an influence over the long-term results.

All of the tests were administered over the phone, so the investigators were also able to ask if patients had further treatment (especially surgery) for the foot. About 18 per cent of the 73 operative cases ended up having more surgery beyond the initial surgery to repair the fracture. The reasons for the second operation varied from infection to removal of hardware to ankle fusion for persistent pain. Eighteen per cent might seem high, but other studies report complications as high as 52 per cent. The authors considered their 18 per cent as being fairly low. They attributed this to better understanding of the procedure and improved surgical technique.

In general, the patients in this study had better results than has been reported for patients in other studies. A larger percentage was able to return to work (82 per cent compared to 52 per cent in other studies). Far fewer ended up with an ankle fusion — three per cent in this study compared with 17 to 22 per cent in other studies. In looking at other studies where patients weren’t always treated surgically, the number of patients who went on to have ankle fusion was much higher than for patients who had surgical treatment. That might be an indicator that surgery should be done in more cases that are initially treated conservatively.

The most striking finding of this study was the fact that how the injury occurred (called the mechanism of injury) seemed to make a difference in the final results. Those patients who suffered a broken and displaced calcaneal fracture from a car accident had the worst results. Those who had the same fracture from a fall seemed to do better in the long run.

The authors offer two possible theories for this finding but they are clear to say further study is needed to know for sure. The first possibility is that motor vehicle accidents cause more soft tissue damage along with the fracture. The three questionnaires administered in this study didn’t ask any questions about that. The second explanation may be that car accidents are higher-energy accidents compared with falls. The calcaneal fractures might have more bone fragments to heal or there could have been fractures of other bones in the ankle besides the calcaneus.

They may not have been able to explain the differences, but the purpose of the study wasn’t to investigate results based on the mechanism of injury. Their goal was to follow patients long-term and see what the overall outcomes were in terms of pain, function, and disability. They accomplished that initial task and suggest that further studies are needed to evaluate these other factors.

Imagine treating a patient with a musculoskeletal problem who can’t wear a brace, can’t have the joint taped, doesn’t go to the doctor until a small problem becomes a big one, and often doesn’t have health insurance. Those are the challenges orthopedic surgeons face when treating professional dancers.

In this article, physicians from the University of Southern California (USC) Dance Medicine Center help medical specialists understand the unique plight of dancers. They offer some suggestions to help bridge the gap between dancer and doctor. For example, education of all patients, but especially dancers is a key ingredient to a successful outcome of treatment.

Since dancers can’t perform on stage in a bulky knee brace or with the ankle taped inside the toe-shoe, early attention to even minor injuries is a must. Dancers must be taught early on how to prevent injuries but also how to manage them rather than ignore them.

Surgeons need to educate themselves about what dancers really do all day. Watching Dancing With the Stars is a good visual orientation to the grueling, daily training that goes on. It also gives us all an idea of the final outcome during the performances. But learning the lingo (dance terms and vocabulary) is an important part of understanding injuries and offering both management and prevention techniques. To do that means rolling up the sleeves and spending some time at the barre. That’s the ballet barre, not tavern!

Screening clinics can also help identify dancers who are at risk for injury. Evaluating dancers while they are still healthy and before an injury occurs can go a long way in keeping the dancers on their toes and dancing. Screening clinics can also be helpful in identifying dancers who may already be suffering an injury. Early intervention may be able to keep it from getting worse.

Overuse and repetitive motions comprise the bulk of the problems leading to dance injuries. The foot and ankle seem to be the number one area of problems. Tendonitis, ankle impingement, shin splints, and stress fractures head up the list of conditions encountered in the dance world. This makes sense when you realize that a dancer routinely puts 300 pounds of stress on the foot — and that’s before doing any moves that require jumping or leaping.

Poor technique and technical errors can often be corrected with coaching and/or some specific exercises. Adding a physical therapist to the team who has been a dancer or who has a special interest in dancers is essential. Most dancers will do anything they can to avoid surgery. And they are no strangers to exercise, so when it comes to doing remedial or rehab exercises, they make willing and compliant patients.

For most professional dancers, dancing isn’t just a way of life, it’s also a job and a way to support themselves. It’s a profession and a career that they love but one that puts them at increased risk for foot and ankle injuries. That includes all types of dancers from hip-hop to ballet. Working together, medical specialists can help healthy dancers stay that way while getting injured dancers back on stage as quickly as possible.

In each issue of the Journal of the American Academy of Orthopaedic Surgeons, there is a special section called Perspectives on Modern Orthopaedics. In that section, new or controversial techniques are discussed. The authors review the literature and summarize current understanding about the topic at hand. And they offer their own opinions from personal experience.

In this issue, cartilage transplantation techniques for talar cartilage lesions are presented. The talus is a bone in the ankle just above the calcaneus (heel) and just below the tibia (lower leg bone). The bottom of the tibia and the top of the talus form a curved dome-shape that allows the foot and ankle to move up and down smoothly.

Cartilage tears or defects in this area are like cartilage lesions in other joints. There is no direct blood supply, so healing without surgery is unlikely. Methods of repairing the cartilage are under investigation. The first place to start is by trying techniques used for other areas of the body such as the hip or knee.

But researchers are proceeding cautiously because the cartilage protecting the talus isn’t exactly the same as articular cartilage in other joints. For one thing, talar cartilage is thinner and it seems to hold up better with age. A good stiff cartilage is what helps stabilize the joint. Loss of tensile stiffness is a common change in the mechanical properties of the hip and knee that isn’t seen so much with the ankle.

Surgeons know a lot more about cartilage, its properties, and its injuries now that there are MRIs and arthroscopic examinations available. These diagnostic techniques make it possible to see the exact size, shape, and location of cartilage lesions. All of these tools are used to plan the most appropriate treatment.

Nonoperative (conservative) care might work okay for sedentary (inactive) adults with a small lesion. But active individuals and especially athletes eager to get back into action will need surgery to repair or restore the cartilage. Repair debridement is the first line of treatment for small lesions (less than 1 cm2 in size). The surgeon carefully removes any loose pieces and smoothes any frayed edges.

If that doesn’t work, then the debridement may be repeated. If further treatment is needed, restoration rather than repair is advised. Restoration means that normal hyaline cartilage is harvested from a donor site and transplanted to the defect or hole in the cartilage. Sometimes the donor material comes from the patient. That’s called an autograft. When the harvested healthy cartilage comes from another person, it’s referred to as an allograft.

In either case, essentially what happens is the surgeon takes a plug of cartilage and the bone underneath it from a healthy site (usually the nonweight-bearing portion of the knee) and transplants it into the defect or hole in the damaged cartilage. This is called an osteochondral autograft transplantation (OAT).

The patient stays off that leg for several weeks after surgery to avoid disrupting the healing process. Reports so far of short- to mid-term results are very favorable with this technique. The studies are small but the majority of patients report good-to-excellent results. They say they would have the same procedure done again if they had it to do all over.

That was the first method used to try and restore the cartilage. Now, the technique has advanced forward. A new method called autologous chondrocyte implantation (ACI) is available. Healthy cartilage cells are taken from the patient and grown in a lab until 200 to 300 cells becomes 12 million cells. It takes about six to eight weeks to accomplish the multiplication process.

Then the new cartilage cells are transferred back into the defect (hole). The advantage of this approach is that the new cells can be saved in a cold place for more than a year. The disadvantage is that the procedure requires two separate operations.

In the second operation, the lesion is smoothed and prepped for the new cells. A special patch of bone is layer over the top to protect the healing area. The new cartilage cells are injected under the patch. Then the patch is sealed with a special fibrin cement or glue. Again, small studies are reporting good-to-excellent results that last beyond 48 months (four years).

In a few patients, the surgeons are able to do a repeat arthroscopy exam and sample some of the healed tissue to see what’s really going on. They have been able to see that the defect doesn’t always fill in with good hyaline cartilage. Sometimes it’s just a fibrous filler, so there’s some concern about that.

One final restorative technique under investigation is the matrix-induced autologous chondrocyte implantation (MACI). This is similar to the autologous chondrocyte implantation. But instead of growing the harvested cells in a culture and then injecting them into the defect, they are placed on a special membrane where they grow and multiply. The membrane is then used to fill and cover the defect. No extra bone patch or flap is needed. Cells can also be harvested right next to the damaged area, rather than finding another spot to gather them (e.g., from the knee).

The authors were quite enthusiastic about the MACI treatment approach for talar dome lesions. They pointed out five possible advantages of this procedure over the others:

Bunions. They are more than just ugly toes. The medical term is hallux valgus. Hallux refers to the big toe. Valgus describes the awkward angle that forms as the base of the metatarsal bone drifts away from the rest of the foot. Surgery for the deformity is more than just for cosmetic reasons. Hallux valgus can be very painful and disabling.

In this study, surgeons from Japan take a look at how often hallux valgus comes back after surgery based on one risk factor: the position of the sesamoid bones. The sesamoids are two tiny, pea-sized bones that sit just under the main joint of the big toe. They are embedded in the soft tissues and play an important role in how the foot and big toe work. If the sesamoid bones are not properly realigned after bunion surgery (called a bunionectomy), will the patient have a recurrence of the problem? That’s the question this study attempted to answer.

They compared two groups of women: one group with normal feet, the other group with diagnosed hallux valgus. The women with the bunions had surgery to restore normal alignment of the bones. The medical term for a bunionectomy procedure is proximal metatarsal osteotomy. More specifically, the surgeon cut through the involved soft tissues and joint capsule of the first toe. The bump that had started to form around the angled joint was removed. A wedge-or pie-shaped piece of bone was removed from the metatarsal bone. That step helps restore the straight alignment of the bones forming the joint at the base of the big toe.

The adductor hallucis tendon and the transverse metatarsal ligament were also cut. Any other steps necessary to restore normal alignment and function of the big toe were also completed. Each patient was evaluated on an individual basis as to what else was needed surgically. In some cases, bone spurs along the bottom of the bone called callosities were removed to give the patient some additional pain relief. Sometimes it was necessary to shorten the second and/or third metatarsals (toe bones).

But when it was all said and done, the surgeons took a second look to see what the results were with a special focus on the position of the sesamoid bones. They used X-rays to determine angles of the bones forming the first joint. The position of the sesamoid bones was also charted in relation to a line drawn down the center of the first metatarsal. They measured how far away the sesamoid bones were from this line. Then they watched the patients over time to look for recurrence of the deformity. Follow-up was between one and 10 years.

The sesamoid bones are supposed to be right under the big toe so that when you rise up on your toes, the bones form a separate point of support and stability for the joint. For such tiny bones, they have a powerful function. With is one sesamoid bone on each side of the base of the big toe, they act as a fulcrum point for the toe flexors. That gives these muscles extra leverage and power. The sesamoids also help absorb pressure under the foot during standing and walking. And they ease friction in the soft tissues under the toe joint when the big toe moves.

So you can see why the position of these little bones is important after a metatarsal osteotomy. Now let’s see how important their location is after surgery. Because the sesamoids are embedded in the soft tissues, they can’t always be moved exactly underneath the joint where they belong. The tendons and ligaments have a way of tethering (anchoring) the sesamoids. If the sesamoids remain too far away from the base of the big toe joint, it’s referred to as incomplete reduction of the sesamoids. The soft tissues start to pull again and after a while, the same deformity returns.

How often does this happen? Some studies report that recurrence happens anywhere between four and 11 per cent of the time when everything lines up well after the first surgery. This is the first study to examine the recurrence rate when the sesamoids are not completely realigned (reduced) under the base of the big toe joint. About 25 per cent of the patients did not get an optimal reduction of the sesamoid bones as measured at the end of the first month postop.

This figure increased to 35 per cent later in the follow-up. They also found that the more the sesamoid bones were displaced from their normal, neutral position under the big toe joint, the more likely it was that the foot would develop a hallux valgus angle again. And once the bones started to shift, the deformity got worse over time. So some joints that looked pretty good one month after surgery didn’t maintain their good alignment 12 months later. And the reason for the displacement was the lack of proper alignment of the sesamoid bones at the time of the first operation.

What’s the take home message here? Incomplete reduction of the sesamoid bones sets some patients up for recurrence of their bunions. Yet, complete reduction of the sesamoid bones is possible with improved surgical technique. And it’s necessary in order to improve the final results.

Surgeons performing a proximal metatarsal osteotomy for hallux valgus must pay attention to the position of the sesamoid bones before completing the procedure. If these two little bones are not completely reduced (placed back in their normal, neutral position under the joint of the big toe), then the surgery must be modified until they are in the necessary alignment. The surgeon may have to release other soft tissue structures, including the capsule (fibrous soft tissue) surrounding the joint. X-rays must be taken to confirm proper alignment before closing up the surgical incision.

Despite the fact that every year, many people (athletes and nonathletes alike) injure their Achilles tendons, the best way to treat these injuries is still up in the air. Should you use ice? Are steroid injections helpful? Wear a cast? Have surgery? If surgery is needed, the questions start over. What kind of surgery? How invasive? Would a tendon transfer help?

The authors of this review article on tendon disorders of the foot and ankle provide suggestions from their experience in the management of these problems. They discuss treatment options for Achilles tendon overuse injuries, tendinosis, paratenonitis, insertional tendinitis, bursitis, and both acute and chronic Achilles tendon ruptures. For all cases requiring surgery, the authors describe and show (through photos) their preferred surgical techniques for the operative management of Achilles tendon disorders.

Treatment may depend on the cause of the problem. Inflammation from chronic overuse may respond to antiinflammatory drugs and physical therapy. Tendinosis (degeneration of the tendon without inflammation) from microtrauma or aging causes thickening of the tendon. This condition often responds well to rest and a slight heel lift or Achilles heel pad.

For athletes in training, training errors should be corrected. These might include a sudden increase in intensity (e.g., running more miles faster), change in terrain or surface, or wearing rundown shoes. A short time in a controlled ankle-motion (CAM) boot or molded ankle orthosis (MAFO) brace might be advised for older adults with tendinosis who are less active and for people with severe Achilles pain from this condition.

Surgery isn’t usually recommended for tendinosis. In fact, the studies are so few and far between, there’s not even agreement on who should have it or what works best. There have been a few small studies on the use of a tendon transfer to replace the diseased Achilles tendon. Before surgery is even considered, the authors suggest at least three to six months of conservative (nonoperative) measures, especially physical therapy. The therapist will help get the painful symptoms under control and then get the patient started on eccentric muscle strengthening, a technique that has been shown helpful in the past.

Paratenonitis, a common problem in middle- and long-distance runners is treated by correcting training errors, improving flexibility, and using nonsteroidal antiinflammatory drugs. Paratenonitis refers to inflammation of the paratenon, which is a thin membrane around the tendon. The paratenon helps the tendon glide up and down smoothly as the Achilles tendon contracts and relaxes to move the foot and ankle up and down.

Paratenonitis is another condition that should be treated with physical therapy and other nonoperative methods first before considering surgery. Eccentric stretching/strengthening, ice therapy, and correcting any limb alignment problems are first. Steroid injections aren’t used because they can weaken the tendon structure and lead to tendon rupture. When surgery is advised, it’s for chronic problems that just won’t clear up with conservative care. The surgeon removes any adhesions or thickened areas of the paratenon.

Bursitis, a painful inflammation of the retrocalcaneal bursa is caused by compression of the bursa located between the Achilles tendon and the calcaneus (heel bone). A bursa is a round or oval pad that reduces friction between two areas that rub together. This condition occurs most often in uphill runners.

The physician confirms the problem by squeezing the Achilles tendon just above the bursa. Reproducing the pain with this test is a positive response for retrocalcaneal bursitis. Follow-up tests with X-rays, ultrasound, or MRIs can confirm the diagnosis. Once again, conservative care is recommended as the most effective treatment. Nonsteroidal antiinflammatories, combined with physical therapy and activity modification have been shown to work in 90 per cent of all cases. For chronic cases, cast immobilization can be helpful. Surgery can be done to remove the burse and shave the bone when a bump called Haglund’s deformity is present and contributing to the problem.

And finally, tendon ruptures are handled according to the age of the patient, activity level, and patient/surgeon preference. There is no agreement yet as to the optimal treatment of acute tendon ruptures. The authors advise surgical management for tendon ruptures and they include a description of their surgical technique. Published studies so far show there are fewer reruptures after surgery, improved strength, and faster return to sports for affected athletes.

For patients with acute tendon ruptures who don’t want surgery, conservative care continues to be used successfully by many people. Treatment begins with a cast that places the foot and ankle in slight plantar flexion (toes pointed down). After four weeks, the patient is recast or put in an ankle immobilizer in the neutral position. Rehab and a gradual return to activities follows cast or splint removal.

In the case of chronic Achilles tendon rupture, MRIs may be needed to show the extent of damage. Although the patient may have weakness and a limp, pain and swelling aren’t always present and other tests used for acute tendon rupture are negative. MRIs give the additional information needed to make a treatment decision. Surgery is usually the only way to restore function in the young, athletic or older, active adult. The operation is a bit more tricky than with acute (fresh) ruptures.

By the time the patient has surgery, many weeks have passed by from the acute injury. That means the torn tendon has retracted (snapped back) away from the bone where it originally inserted. And the body has laid down scar tissue to try and heal itself. The surgeon will have to remove the scar tissue, pull the tendon back down and reconstruct the tendon-muscle unit. How this is done depends on how much distance must be made up between the tendon and insertion point on the bone.

The authors make note of the fact that although Achilles tendon injuries are fairly common, high-quality studies with conclusions about the best way to treat them are just lacking right now. Information on surgical techniques isn’t the only area where questions exist. There really isn’t much evidence to support one form of conservative care over another. Successful sports rehab treatment protocols is another area where future research is needed to help guide the management of Achilles tendon injuries, especially for competitive athletes.

Feet are prone to injury because of their role. Your feet bear your weight every day in whatever fashion you choose: walking, running, jumping, or dancing and what types of shoes you wear. Sometimes it’s the back of your foot that hurts or the top, or the toe area. One disorder, called hallux rigidis, affects the big toe. Hallux refers to your toe and rigidus refers to the stiffness. The disorder is progressive, which means it gets worse with time.

It used to be that standard treatments for hallux rigidus was surgery to remove the end part of the bone that was causing the problem, although other types of surgery have been tried, even replacements or arthroplasties. The problems with the surgeries that have been done are the lasting effects, such as deformity of the joint and pain. Another surgery, cheilectomy, has been fairly successful for hallux rigidus that hasn’t progressed too far. Cheilectomy is a procedure where the surgeon removes the boney bump on the top of the joint, which presses down and causes pain.

Researchers have been trying to find other ways to relieve the problem and have been looking at various types of replacements and fusing bones together. The important issue is to try to maintain flexibility in the big toe joint, unlike some of the surgeries. Flexibility of the toe is needed for proper walking.

There are a few types of replacements available to doctors in the United States right now. They have been trying them on various patients but with mixed results. In one study, by Drs. Townley and Taranow, 95 percent of 279 patients who received one particular implant were doing well. Another study, led by Dr. Pulavarti had similar findings (88 percent) from his smaller study of 32 patients. But in another study, led by Dr. Fuhrmann, which showed good results for most patients, there were also reports of loosening implants in 9 percent of patients and significant instability in 28 percent.

Patients who have had arthrodesis, or fusion, of the bones seemed to do quite well. In one study, by Drs. Gibson and Thomson, patients in the arthrodesis group had 100 percent union of the bone (meaning it didn’t open or break) compared with the replacement group, where six of 27 patients had to have surgery to repair broken or slipping hardware.

Another type of arthroplasty, called the interpositional arthroplasty has been in the works, trying to correct some of the flaws in previous models. Researchers like this approach because it can be done with younger patients and still allow for them to have function and motion of the toe. To do the surgery, the surgeon removes the boney bump at the top of the joint and removes a small part of the bone. Different materials may be used to maintain the joint space, rather than joining the bones together. So far, the results have been promising.

First Metatarsophalangeal joint arthrodesis is the fusing of bones at the base of the big toe. This is done if you’ve had surgery already for arthritis in the joint and the symptoms haven’t improved enough. The surgeons feel that because the pain is being caused by motion, by fusing the bones together and eliminating the ability for the joint to move, the pain will no longer be there.

The authors of this article conclude that if nonsurgical treatment doesn’t work for early hallux rigidus, then the next step should be cheilectomy, because of its reported success. However, there isn’t much in the literature to show what treatment is best for more severe hallux rigidus. The authors recommend that the surgeons try to save the joint as much as possible, particularly for younger or more active patients.

Foot pain is a very common complaint among people in the United States. Plantar fasciitis, a very painful condition of the heel, is the most common cause of heel pain. Around two million Americans experience plantar fasciitis every year. The cause is the inflammation – and pain – of a thick band of tissue that runs across the bottom of your foot, the plantar fascia. The plantar fascia, which isn’t very flexible, is what connects your heel bone to your toes. Because it isn’t flexible, it’s pulled on (tension) if every time you flex your toes, or the toes are pointed upwards. This happens when you walk, particularly with high heels, for example.

Constant stretching and pressure can result in inflammation of the plantar fascia, which results in plantar fasciitis. Risk factors for plantar fasciitis include hurting your heel or under the foot (trauma, stress), as well as repetitive use, like runners do, but even others who are on their feet a lot are at higher risk.

When going to the doctor, in order to diagnose plantar fasciitis, your history is important. You will also be examined and your doctor will likely watch how you walk. You’ll be asked about the type of pain, because plantar fasciitis pain is typically a sharp shooting pain that is relieved with activity and may become more like a dull ache by the end of the day. It hurts more first thing in the morning or if you’ve not been on your feet for a while.

While the doctor may suspect plantar fasciitis, he or she has to rule out a few other foot problems first. These include the foot’s equivalent of carpal tunnel syndrome, called tarsal tunnel syndrome, problems with the nerve being trapped near the plantar nerve, fractures, masses, or another problem called central heel pain syndrome. If necessary, your doctor may order some tests, such as x-rays while you’re standing (called weight-bearing x-rays), bone scans, or even magnetic resonance imaging (MRI) or ultrasound.

Treatment for plantar fasciitis is first usually nonsurgical. The most successful nonsurgical treatment so far has been stretching the Achilles tendon, the tendon that connects your heel to the leg. This can be done with special exercises or with splinting. Exercises can be done any time anywhere, so these are often the first choice treatment. Night splints are a popular choice for treatment too and, according to studies, help relieve up to 80 percent of the foot pain. But, many patients don’t like the inconvenience of wearing the splint or can’t afford to buy it.

Foot inserts into the shoe, called orthotics is another approach. This can be done alone or with the exercises. Researchers aren’t so sure of their effectiveness though. Research seems to show that although there are improvements with orthotics over the first few months, after a year, there doesn’t seem to be any advantage to them.

Medications may be tried to help relieve the inflammation and thus the pain. Anti-inflammatory medications can be given by mouth, used as a cream, or as an injection directly into the fascia. Research hasn’t really found any strong benefits to these treatments, but they could be useful with splinting.

From what sounds a bit like science fiction is another treatment called extracorporeal shock wave therapy. This therapy involves aiming shock waves to hit the fascia, although doctors aren’t quite sure how it works. The treatment does seem to be effective, but is recommended to be used after some of the other treatments have been tried first. One advantage to the shock wave therapy is there seem to be few complications, so this may be a treatment option for considering surgery, which is the next step.

If no other treatment has helped relieve the pain of the plantar fasciitis, surgery may be the only option left. The problem with surgery is two-fold. The first is the risk of surgery. As with any surgery, there are risks of infections, difficulty healing, and so on. The second is that most studies didn’t find that surgery helped very many of the patients.

The authors of this article conclude that the nonsurgical treatments are the traditional and mostly used treatments for plantar fasciitis. They point out that stretching can play a key role in therapy and seems to be quite successful for many patients.

You might not realize it, but a fracture of the long bone in the foot to the little toe can be a very serious injury. It’s called a fifth metatarsal fracture and it’s most often seen in athletes. What makes this such a problematic injury?

Disruption to any part of the anatomy such as the bones, ligaments, joint capsule, blood supply to the area, and nerves controlling sensation can lead to poor recovery. In fact, the risk of nonunion and even refracture after successful union is a reality for many patients.

To help us better understand fifth metatarsal fractures, surgeons from the Foot and Ankle Center of South Texas in San Antonio offer this review article on the problem. They provide information on the anatomy and classification of fifth metatarsal fractures. The three main parts of the fifth metatarsal bone include the base, diaphysis, and head.

The base is the part of the long foot bone (metatarsal) toe that sits next to the midfoot. The diaphysis is the middle portion or shaft of the long bone. Because the diaphysis is in the middle, one end attaches to the base. The other end (closest to the toes) connects with the third part called the head of the metatarsal. Each end of the diaphysis has a growth plate called the metaphysis, which allows the bone to grow longer at either end in a growing child or teenager. In the adult, the metaphysis and the diaphysis fuse together. A fracture of any of these components usually affects one of the other three.

The breaks are divided into base fractures, metaphyseal fractures, diaphyseal fractures, and head fractures. This classification scheme follows the bone anatomy of the three parts described. If the break involves the joint or joint capsule, it is considered an intraarticular fracture. If the bone is fractured more in the middle and away from any of the other bones or joints, then it is extraarticular.

Wherever the fracture occurs, the patient usually has pain, swelling, and can’t put weight on that foot. Treatment depends on the location and severity of the fracture. The more displaced or separated the broken parts are, the greater likelihood that surgery will be needed to repair the damage.

If the broken ends of the base fracture are less than two millimeters apart, then the patient can use a cast boot, walking cast, or even a hard-sole shoe to protect the bone while it heals. Patients should expect about a six weeks period of time before healing is complete. This can take longer if there has been any damage to the ligaments, blood vessels, or nerves.

More severe base fractures and fractures that don’t heal with conservative (nonoperative) care require surgery. An incision is made directly over the bone. The surgeon is careful to avoid the nerves in that area while aligning the bone and holding it together with screws. This procedure is called an open reduction and fixation.

Postoperative recovery can take quite awhile. The patient is treated in a series of steps. First is a weight bearing cast boot. The patient wears it for the first two to three weeks. Once pain has been controlled, then a motion-controlled athletic shoe is worn for another three to six weeks. A physical therapist sees the patient early on to begin rehab. The goal is to return the patient to sports participation as soon as possible.

With metaphyseal-diaphyseal fractures, an acute injury can become a chronic problem if the symptoms are mild at first. Even a mild ankle or foot malalignment can increase the likelihood of refracture. Sometimes a corrective shoe or shoe insert called a foot orthosis can realign the ankle and foot and prevent this from happening.

As with base fractures, metaphyseal-diaphyseal fractures can be compromised by disruption of the blood vessels or tears in the ligamentous attachments that hold the bones together. Loss of blood supply can result in slow healing or failure to heal. When MRIs are used, the fracture lines can be seen and the injury addressed quickly. The patient is placed in a non weight-bearing cast or goes right to surgery for internal fixation (plate and/or screws).

Sometimes, a bone graft is needed to help fuse the pieces of the broken bone together. There is a slight curve along the bottom of the fifth metatarsal that is preserved with wires and screws. To avoid a stress fracture of this bone, alignment of the foot and ankle is once again preserved as much as possible. The surgeon must leave enough bend in the bone without too much stiffness in order to have a successful fracture repair.

Head fractures are treated with conservative care (walking cast or cast boot) when the two ends of the fracture have not been displaced (moved apart). Too much displacement requires surgical repair. The authors describe the technique they use to expose the area and correct the problem. Head fractures are more likely to affect the joint so problems can occur after surgery with stiffness, hardware that sticks out or causes pain, and the formation of a painful neuroma (nerve tumor).

The authors comment that even with these treatment guidelines, there are still many unknowns about treating fifth metatarsal fractures. Future studies are needed to identify which patients need surgery and when (how soon). Results may vary with different types of fixation devices. Research to show which ones to use with each fracture type would be helpful. And finally, studies are needed to develop evidence-based guidelines on when it’s safe for the athlete to return to sports (and at what level of activity).

Managing blood sugar levels isn’t the only problem facing patients with diabetes. Over time, complications such as collapse of the arch in the foot can occur. This condition is called Charcot midfoot arthropathy. Charcot is the name of the physician who first discussed this problem.

Ulceration, fracture, dislocation, and deformity associated with the Charcot foot can be serious problems to deal with. There isn’t an easy answer to treatment. In this study, surgeons from the Cincinnati Sports Medicine and Orthopaedic Center try an alternative surgical approach. They used several metal screws through the bones of the foot to line everything up and hold it in place.

Their technique was to use screws long enough to thread them through the fragmented areas. The screws were placed through normal, healthy bone on either side of the damaged area. This particular treatment method is used for patients with severe deformity and loss of independence in walking. Most have poor bone quality and loss of normal blood supply to the foot. Delayed tissue healing is typical because of the diabetes.

The goal of this surgery is to fuse the midfoot in order to give the patient a stable foot to walk on — one that doesn’t break down and form ulcers. They hoped that by spanning a wider area of bone, they could correct the severe foot deformity and keep that correction. The type of screws used allowed for tightening of the hardware across the fusion site. This technique makes it possible to create a compressive, holding force.

The study involved 22 patients with severe midfoot deformity from Charcot disease. Surgical reconstruction for the midfoot collapse was done as described. Patients were classified according to the Sammarco and Conti system. This system involves four basic patterns of foot deformity.

The classifications depend on the location and amount of destruction across the midfoot. Drawings and X-ray examples are provided to help the reader understand the different patterns of joint separation and deformity. Changes in bone angles and places of dislocation were viewed and described.

All of the patients had a terribly swollen and red foot with obvious deformity. The feet were unstable. Conservative care had not worked. Bracing was no longer an option. Some of the patients had ulcers on the bottom of the foot where the misaligned bones rubbed during weight-bearing and walking. The ulcers had to be treated first before surgery to correct the foot deformity could be done.

Successful treatment of the ulcers can be a challenge in itself. Many of the patients had multiple comorbidities (other health problems) as well. High blood pressure, low thyroid, heart disease, and a history of cancer or stroke were common. Each patient was under the care of a primary care physician or internist for these medical comorbidities.

The authors provide a detailed description of the patients’ position during the procedure, type of anesthesia used, and surgical technique performed. Fusion of the midfoot was only one part of the total reconstruction process. In addition to the placement of the screws, most of the patients required the release of tight or contracted soft tissues to restore ankle motion.

Fluoroscopy, a special kind of X-ray, was used in the operating room to make sure the bones were placed correctly and in the best alignment possible. There were many challenges facing the surgeons. For example, the tension on the bones and soft tissues had to be just right to avoid loss of blood supply to the area.

Sometimes the bones weren’t just dislocated, they were broken into tiny little pieces. In some cases, the damaged or dead bone had to be removed. Places of dense scar tissue had to be cut out. Some of the methods used to realign the bones in the earlier cases in this series didn’t work. The surgeons gradually perfected their technique over time. They found better ways to accomplish the fusion that didn’t result in bone or screw fracture.

Postoperative care was as important as the surgery. The patients worked with a physical therapist while in the hospital during the early days after the procedure. Serial (weekly) casting was done during the first stage of healing. Casting was used to help hold the foot alignment and prevent weight-bearing, sometimes for as long as seven months.

Patients progressed from a cast to a removable pneumatic walking boot. Full weight-bearing was allowed when X-rays showed a stable fusion (no movement in the fused joints) with hardware still in place. Eventually, a special shoe insert called an orthotic was designed for each patient. X-rays were retaken from time to time to measure foot angles and deformity while also making sure everything was still holding stable.

There were some individual complications such as nonunion, failure of the hardware (migration or movement, breakage), bone fracture, collapse of the foot arch, infection, and recurrence of foot ulcers. Many of the patients required more than one surgery to accomplish the final reconstruction. Healing took a long time (many months). But in the end, the results allowed the patients to regain independent walking.

The authors conclude that their surgical technique can be used to stabilize severe Charcot foot deformities. The rates of success (measured by deformity correction and maintenance and fusion rates) were equal to results from other studies using other techniques. The foot can be saved with this technique. It has the advantage of not being as invasive as other approaches and that’s important for this particular patient population because of the negative effects of diabetes on healing tissue.

Certain types of athletes, football players for example, have a higher than usual risk of developing foot and ankle injuries. Tarsometatarsal injuries, those the area where the bones meet at the base or flat part of the foot, are usually caused by a high-energy trauma, but not when they happen to athletes. When an athlete sustains a tarsometatarsal injury, usually their symptoms are very subtle and the injury may be difficult to see by x-ray. For this reason, it’s very important that doctors be aware of the possibility of this type of injury if an athlete complains of pain in the tarsometatarsal area.

The tarsometatarsal is really three joints together that are between the tarsals (small foot bones) and metatarsals (long foot bones). The combination of the bones and the joints is what helps form the arch of the foot and adds stability to the foot itself. This stability is made stronger by the ligaments, strong fibrous tissue, that holds them all the bones together. Although the bones are all very close together and work together, each has its own role to play in the foot and toe movements.

Because the joints are complex, the injuries that can happen are also complex. An high-impact cause, such as those by car accidents or crushing, cause different types of injuries than a low-impact injury, such as a twisted ankle or foot, which happens to an athlete out on the field. In fact, this type of injury is being seen more often now than before to athletes such as football players, because of the advancement in shoes that are meant to help the player.

Playing on artificial turf is very hard on the feet. It’s like playing on concrete covered by an indoor/outdoor carpet. If an athlete falls while running on this foundation and a team mate or opponent falls on his or her foot, the force lands in such a way that it can cause damage to the tarsometatarsal joints. These injuries are divided into two categories: plantar flexion (flexing inward) or abduction, bending outwards.

When the force is pushed down onto the length of the foot as it’s trapped usually causes a flexion injury. Another example would be when a player is running forward and has the base of his foot on the ground and the heel up as he is pushing off the ground. If he’s tackled, while his foot is in that position, forcing the foot down, this results in the flexion injury. On the other hand, abduction can occur to athletes like equestrians. If their foot is in a stirrup and the front of the foot is forced down, this results in the abduction.

Aside from the flexion and abduction categories, there are others that describe if the bones are moved or not, if there are other fractures in the bones around the joint, and so on. An important point to remember is that it’s not very often that an injury only happens to the joint itself. Often, the surrounding area has been injured as well.

Diagnosing a midfoot sprain can be challenging since the signs are often very subtle in athletes. A red flag would be if the athlete mentioned hearing a popping sound and complaints of pain when bearing weight on the foot. At this point, the signs may become more obvious. These include differences between the first and second toes, some swelling, and tenderness at a certain point over the midfoot area. If doctors are worried about the stability of the bones, by gently moving the foot up and down, they should be able to assess the amount of pain that is caused.

Some athletes will experience one or both provocative maneuvers, motions done deliberately by the doctor to see if they cause pain. These are done by pressing on the midfoot and squeezing on the sides of the foot in the middle. The second test seems to be a bit more reliable in assessing injury.

When x-rays are ordered, they should be done with the patient standing, bearing weight, on the injured foot. This will show if there are any bones that have moved and this may only be obvious when there is weight on the foot. If, however, the x-rays don’t show an injury, the doctor can still evaluate how stable the foot is. This is done by repeating x-rays, but this time with the patient putting as much weight as possible on the injured foot. According to the author of this article, up to 20 percent of tarsometatarsal joint injuries are missed in the first round of x-rays.

If, because of tenderness over the joint, the doctors still suspect a mid-foot injury, despite negative x-rays, they can perform stress x-rays. For this, the patient must have anesthetic and the examination is done by fluoroscopy, sort of a “moving x-ray.” This type of test allows the doctors to put more pressure on the foot and move it differently than if the patient is conscious, revealing injuries that might not otherwise be detected.

In some cases, computed tomography imaging (CT scans) can be useful in detecting injuries. This type of scanning provides a more detailed look of the bones and tissue around them. However, doctors must be cautious as the authors note that sometimes the CT scan finds “injuries” that aren’t really there. Also, because of how the CT scans are done, they can’t be done with the patients putting any weight on their foot, so finding if bones have been displaced is more difficult. Magnetic resonance imaging (MRI) is another sensitive test where the images are made with magnets rather than radiation. This type of test is usually done as a back up to confirm injuries rather than detect them. Finally, some doctors prefer to use a test called bone scintigraphy. This test uses a dye injected into the patients’ vein to see various aspects of the bone and soft tissues.

Treatment for tarsometatarsal injuries usually are surgical if the injury is unstable, even if minimally. If they aren’t treated, the patient may eventually develop arthritis in the injured area. However, surgery isn’t always needed if the injury is stable. In a study performed by Curtis and colleagues, they found that of 17 athletes with tarsometatarsal injures, seven of nine patients who didn’t have surgery reported good results, two of three who had surgery did well, but the seventeenth athlete, who was treated with a cast, wasn’t able to return to his or her previous level of sports.

The authors of this article wrote that stable injuries, on weight bearing, may be treated by immobilizing the foot in a boot, with follow-up x-rays within two weeks and with weight-bearing as the patient can tolerate. They also recommend using a store-bought padded orthotic arch support inside the boot while the injury is healing or until there is no pain in the midfoot area. If treatment is done this way, it’s important that the athlete be careful when returning to his or her previous level of activity. This means although training and exercising will be permitted, activity that could result in the foot being twisted or injured shouldn’t be permitted and that a solid-soled shoe should be worn for at least six months while healing continues.

If surgery is chosen, there are several procedures available to the surgeon. The timing of the surgery is important: the sooner the better because this allows the athlete to begin rehabilitation more quickly. Delayed surgery due to delayed diagnosis or other circumstances could result in a less than ideal outcome and longer rehabilitation.

The hardware that’s inserted to stabilize the joints usually stays in for a minimum of four months to allow for proper stabilization and healing. However, sometimes the hardware is left in permanently if it doesn’t cause the patient any problems.

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. 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.

The natural history of this condition is that left alone (untreated), it will eventually go away on its own. Another term for this kind of response is to say that plantar fasciitis is usually self-limiting. That’s why many studies using a placebo (pretend treatment) get good results no matter how it’s treated.

But sometimes, the problem lasts a long time. When it doesn’t go away, doctors say it’s recalcitrant, which means it’s chronic. The painful symptoms limit movement and function, which can reduce quality of life. Finding a way to treat patients with chronic plantar fasciitis is important.

In this study, the use of radial extracorporeal shock wave therapy (rESWT) was compared with a placebo treatment in patients with recalcitrant plantar fasciitis. Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. Radial shock waves apply the energy at a specific point of tenderness and then the force of the vibration spreads out over a larger area. The pattern of vibrational energy released looks like the shape of a megaphone.

The study design of this research project was a double-blind, randomized, placebo-controlled trial. Double-blind means the patients didn’t know if they were receiving a real rESWT session or a placebo. The physicians evaluating and following up with the patients didn’t know which group the patients were in either. Only the orthopedic surgeon or podiatrist administering the treatment knew who was getting which treatment. Randomized means the group they were assigned to was chosen at random by a computer program. The control group received the placebo treatment.

Everyone in the study had a history of chronic plantar fasciitis for at least six months. All other conservative (nonoperative) care had not been successful in reducing the painful symptoms. Drug (pharmacologic) treatment and nonpharmacologic treatment were tried. Nonpharmacologic intervention included steroid injection(s), stretching, night splints, ultrasound, ice, massage, electrotherapy, and/or orthotics (shoe inserts). In order to be included in the study, the pain was rated as at least a five on a scale from zero (no pain) to ten (worst pain).

Each person enrolled in the study was given three treatments (either rESWT or placebo). The sessions were given two weeks apart. The patients were followed for 12 months after the last treatment. The first follow-up check-up was 2 weeks after the third treatment. If the pain was unchanged, they were allowed to seek other forms of treatment. In other words, they didn’t have to suffer a full 12 months just to complete the study if the treatment they received wasn’t working.

The same experiment was carried out in eight different treatment centers (in the USA and Europe) as part of an FDA approval study. This type of design is referred to as a parallel group design. Treatment effectiveness was measured based on patients’ reports of heel pain with the first steps of the day when plantar fasciitis is usually the most symptomatic.

Pain during daily activities and with pressure placed on the heel were also used as measures of change. A special device called a Dolormeter was used to apply local pressure to the bottom of the foot. The amount of pressure needed to reproduce the pain was measured and recorded for each patient. Patient satisfaction and function were tested using several patient surveys. This gave a separate way to measure effectiveness of the treatment other than just pain. These are referred to as secondary outcome measures.

The results showed much better outcomes with rESWT compared with placebo treatment. And the patients who received rESWT continued to improve up to the 12-month check-up. This shows that rESWT gives stable results that last. All results (primary and secondary outcome measures of reduced pain, improved function, increased patient satisfaction) favored rESWT. Patients receiving rESWT rated the treatment as very tolerable.

The authors conclude by saying rESWT is a safe and effective outpatient treatment that works quickly and offers patients an alternative to surgery. Athletes with plantar fasciitis can get back to their sports participation without delay. It is recommended for patients who have not benefited from other types of conservative care before considering surgery as the next treatment option.

Shoe wear can be an extremely important item of clothing in the older adult. Studies show that almost half of all falls are linked with the type of shoes worn at the time of the fall. Slippers and heels double the risk of falling in older people. Even younger adults are at risk of fractures from shoes with a high or narrow heel. And walking barefoot isn’t any better. The risk of falling also increases with bare feet (and especially wearing just socks).

In this study, investigators looked at specific shoe features and how they affect walking and balance. Young adults in their early-to-mid twenties were compared with older adults (over 65). Everyone was tested on a flat surface and again on an uneven surface wearing shoes with different heels, soles, tread, and collar.

A standard shoe was defined as an Oxford-style lace-up shoe with a low heel collar, square heel, and smooth sole. Five other shoe designs were included: high-collar shoe, elevated heel shoe, tread sole shoe, soft sole shoe, and hard sole shoe. An orthopedic boot maker made all the shoes and fit them to each participant.

Before starting the walking part of the study, each person was tested for sensation, balance control, and strength. Then they completed three walking trials wearing each of the different shoes on a level flat floor and on an uneven walkway. Special motion detector equipment recorded three-dimensional (3-D) movement data of the entire body.

Center-of-mass (COM) and ground reaction forces were calculated. Each person also rated their own sense of stability on a scale from one (most unstable) to five (most stable). Level of comfort was also rated using a similar scale (one to five for least comfortable to most comfortable).

The researchers pointed out that maintaining stability when walking requires control of the center of mass as the person’s base of support (BOS) changes. As a person’s balance is challenged, the center-of-mass expands and reaches the edges of the base-of-support. The difference between these two measures is referred to as COM-BOS margin.

They used this study to find out if shoe wear could improve center of mass, stability, and comfort. The hope was to find a shoe that would enhance balance and improve an older adult’s ability to respond when suddenly off balance.

The authors looked at four areas and compared them between the two groups. These four areas were: 1) age-related effects, 2) surface-related effects, 3) shoe condition effects, and 4) shoe comfort and stability.

First, they found many differences based on age. Older adults had poorer visual contrast sensitivity (seeing differences or changes in floor/surface color or design). They also had less sensitivity on the bottom of their feet and decreased knee strength compared to younger adults. Older adults were more likely to take shorter steps, walk slower, and spend more time with both feet on the ground at the same time.

The response to the uneven surface was the same between the two groups. Everyone took wider steps, walked more slowly, and expanded their center of balance to the edge of their base of support. Both groups were able to walk faster and take longer steps when wearing a tread shoe on an even surface. Soft-soled shoes also allowed a faster pace.

Shoes with an elevated heel or hard soles resulted in smaller step width. Subjects kept both feet on the ground for longer time than with the standard shoe. When wearing the soft soled shoes or shoes with a high collar, adults in both groups had a larger shift in their center-of-mass and base-of-support (from side to side). Some of the shoe types (hard sole, elevated heel, high collar) also reduced the margins between center-of-mass and base-of-support from front to back.

In the final category of outcome measures (shoe comfort and stability), everyone felt the elevated heel shoes were less comfortable and more unstable. The younger adults felt that the soft sole shoes were less stable than the standard shoes. Older adults with less sensitivity on the bottom surface of the feet did not notice the difference between soft, standard, and hard soles.

In summary, this was the first study to look at the effects of specific shoe features on walking stability in young and older adults. As might be expected, uneven surfaces did challenge balance control. COM-BOS margins were less when there was an unstable surface or shoe type such as the elevated heel shoes.

Soft sole shoes offer less mechanical support while tread sole shoes and the standard shoe allowed people to walk faster and take a longer stride length. Anyone with balance problems, or decreased sensation in the feet should beware of soft sole shoes. This type of footwear is considered a potential hazard.

For the older adult, an increased shoe heel height is a risk factor for loss of balance. It appears that the optimal shoe type is a low heeled, low collar, lace-up Oxford with or without tread. They may not be the height of fashion, but they will reduce the risk of falls and disabling fractures in anyone 65 or older.