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Injuries, Symptoms & Treatments
Ankle & Foot
You are a foot away from a finely turned ankle !
Your ankle and foot are an intricate network of bones, ligaments, tendons and muscles. Strong enough to bear your body weight, they can be prone to injury and pain.
Ankle/Foot pain can affect any part of your ankle or foot, from your toes to your Achilles tendon at the back of your heel. Although mild pain often responds well to home treatments, it can take time to resolve. Dr. Bellapianta should evaluate severe foot pain, especially if it follows an injury.
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Diseases/Conditions of the ankle and foot
Common Ankle & Foot Injuries/Disorders
Achilles Tendonitis
Achilles Tendonitis is an overuse injury of the Achilles (uh-KILL-eez) tendon, the band of tissue that connects calf muscles at the back of the lower leg to your heel bone. It most commonly occurs in runners who have suddenly increased the intensity or duration of their runs. It's also common in middle-aged people who play sports, such as tennis or basketball, only on the weekends. Most cases of Achilles tendinitis can be treated with relatively simple, at-home care under your doctor's supervision. Self-care strategies are usually necessary to prevent recurring episodes. More-serious cases of Achilles tendinitis can lead to tendon tears (ruptures) that may require surgical repair.
Achilles Tendon Rupture
Achilles Tendon Ruopture is an injury that affects the back of your lower leg. It most commonly occurs in people playing recreational sports. The Achilles tendon is a strong fibrous cord that connects the muscles in the back of your calf to your heel bone. If you overstretch your Achilles tendon, it can tear (rupture) completely or just partially. If your Achilles tendon ruptures, you might feel a pop or snap, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly. Surgery is often the best option to repair an Achilles tendon rupture. For many people, however, nonsurgical treatment works just as well.
Broken Ankle/Foot
A broken ankle or broken foot is a common injury. You may experience a broken ankle or broken foot during a car crash or from a simple misstep or fall. The seriousness of a broken ankle or broken foot varies. Fractures can range from tiny cracks in your bones to breaks that pierce your skin. Treatment for a broken ankle or broken foot depends on the exact site and severity of the fracture. A severely broken ankle or broken foot may require surgery to implant plates, rods or screws into the broken bone to maintain proper position during healing.
Bunion
Bunion is a bony bump that forms on the joint at the base of your big toe. A bunion forms when your big toe pushes against your next toe, forcing the joint of your big toe to get bigger and stick out. The skin over the bunion might be red and sore. Wearing tight, narrow shoes might cause bunions or might make them worse. Bunions can also develop as a result of an inherited structural defect, stress on your foot or a medical condition, such as arthritis. Smaller bunions (bunionettes) also can develop on the joint of your little toes.
Bursitis
Bursitis is a painful condition that affects the small, fluid-filled sacs — called bursae (bur-SEE) — that cushion the bones, tendons and muscles near your joints. Bursitis occurs when bursae become inflamed. The most common locations for bursitis are in the shoulder, elbow and hip. But you can also have bursitis by your knee, heel and the base of your big toe. Bursitis often occurs near joints that perform frequent repetitive motion. Treatment typically involves resting the affected joint and protecting it from further trauma. In most cases, bursitis pain goes away within a few weeks with proper treatment, but recurrent flare-ups of bursitis are common.
Flatfeet
Flatfeet you have flatfeet when the arches on the inside of your feet are flattened, allowing the entire soles of your feet to touch the floor when you stand up. A common and usually painless condition, flatfeet can occur when the arches don't develop during childhood. In other cases, flatfeet develop after an injury or from the simple wear-and-tear stresses of age. Flatfeet can sometimes contribute to problems in your ankles and knees because the condition can alter the alignment of your legs. If you aren't having pain, no treatment is usually necessary for flatfeet.
Gout
Gout is characterized by sudden, severe attacks of pain, redness and tenderness in joints, often the joint at the base of the big toe. Gout — a complex form of arthritis — can affect anyone. Men are more likely to get gout, but women become increasingly susceptible to gout after menopause. An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable.
Hammer Toe and Mallet Toe
Hammer Toe and Mallet Toe are foot deformities that occur due to an imbalance in the muscles, tendons or ligaments that normally hold the toe straight. The type of shoes you wear, foot structure, trauma and certain disease processes can contribute to the development of these deformities. A hammertoe has an abnormal bend in the middle joint of a toe. Mallet toe affects the joint nearest the toenail. Hammertoe and mallet toe usually occur in your second, third and fourth toes. Relieving the pain and pressure of hammertoe and mallet toe may involve changing your footwear and wearing shoe inserts. If you have a more severe case of hammertoe or mallet toe, you might need surgery to get relief.
Osteoarthritis
Osteoarthritis is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage on the ends of your bones wears down over time. Although osteoarthritis can damage any joint in your body, the disorder most commonly affects joints in your hands, knees, hips and spine. Osteoarthritis symptoms can usually be effectively managed, although the underlying process cannot be reversed. Staying active, maintaining a healthy weight and other treatments may slow progression of the disease and help improve pain and joint function.
Plantar Faciitis
Plantaf Faciitis is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, that runs across the bottom of your foot and connects your heel bone to your toes. Plantar fasciitis commonly causes stabbing pain that usually occurs with your very first steps in the morning. Once your foot limbers up, the pain of plantar fasciitis normally decreases, but it may return after long periods of standing or after getting up from a seated position. Plantar fasciitis is particularly common in runners. In addition, people who are overweight and those who wear shoes with inadequate support are at risk of plantar fasciitis.
Rheumatoid Arthritis
Rheumatoid Arthritis is one of the most common causes of heel pain. It involves pain and inflammation of a thick band of tissue, called the plantar fascia, that runs across the bottom of your foot and connects your heel bone to your toes. Plantar fasciitis commonly causes stabbing pain that usually occurs with your very first steps in the morning. Once your foot limbers up, the pain of plantar fasciitis normally decreases, but it may return after long periods of standing or after getting up from a seated position. Plantar fasciitis is particularly common in runners. In addition, people who are overweight and those who wear shoes with inadequate support are at risk of plantar fasciitis.
Stress Fractures
Stress fractures are tiny cracks in a bone. Stress fractures are caused by the repetitive application of force, often by overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also arise from normal use of a bone that's been weakened by a condition such as osteoporosis.Stress fractures are most common in the weight-bearing bones of the lower leg and foot. Track and field athletes are particularly susceptible to stress fractures, but anyone can experience a stress fracture. If you're starting a new exercise program, for example, you may be at risk if you do too much too soon.
Sprained Ankle
An ankle sprain occurs when the strong ligaments that support the ankle stretch beyond their limits and tear. Ankle sprains are common injuries that occur among people of all ages. They range from mild to severe, depending upon how much damage there is to the ligaments.
Most sprains are minor injuries that heal with home treatments like rest and applying ice. However, if your ankle is very swollen and painful to walk on — or if you are having trouble putting weight on your ankle at all, be sure to see your doctor.
Without proper treatment and rehabilitation, a more severe sprain can weaken your ankle—making it more likely that you will injure it again. Repeated ankle sprains can lead to long-term problems, including chronic ankle pain, arthritis, and ongoing instability.
Description
Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint.
Most sprained ankles occur in the lateral ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibers that make up the ligament to complete tears through the tissue.
If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. Over time, this instability can result in damage to the bones and cartilage of the ankle joint.
Cause
Your foot can twist unexpectedly during many different activities, such as:
Symptoms
A sprained ankle is painful. Other symptoms may include:
Stress Fractures of the Foot and Ankle
A stress fracture is a small crack in a bone, or severe bruising within a bone. Most stress fractures are caused by overuse and repetitive activity, and are common in runners and athletes who participate in running sports, such as soccer and basketball.
Stress fractures usually occur when people change their activities — such as by trying a new exercise, suddenly increasing the intensity of their workouts, or changing the workout surface (jogging on a treadmill vs. jogging outdoors). In addition, if osteoporosis or other disease has weakened the bones, just doing everyday activities may result in a stress fracture.
The weight-bearing bones of the foot and lower leg are especially vulnerable to stress fractures because of the repetitive forces they must absorb during activities like walking, running, and jumping.
Refraining from high impact activities for an adequate period of time is key to recovering from a stress fracture in the foot or ankle. Returning to activity too quickly can not only delay the healing process but also increase the risk for a complete fracture. Should a complete fracture occur, it will take far longer to recover and return to activities.
Description
Stress fractures occur most often in the second and third metatarsals in the foot, which are thinner (and often longer) than the adjacent first metatarsal. This is the area of greatest impact on your foot as you push off when you walk or run.
Stress fractures are also common in the calcaneus (heel); fibula (the outer bone of the lower leg and ankle); talus (a small bone in the ankle joint); and the navicular (a bone on the top of the midfoot).
Many stress fractures are overuse injuries. They occur over time when repetitive forces result in microscopic damage to the bone. The repetitive force that causes a stress fracture is not great enough to cause an acute fracture — such as a broken ankle caused by a fall. Overuse stress fractures occur when an athletic movement is repeated so often, weight-bearing bones and supporting muscles do not have enough time to heal between exercise sessions.
Bone is in a constant state of turnover—a process called remodeling. New bone develops and replaces older bone. If an athlete's activity is too great, the breakdown of older bone occurs rapidly — it outpaces the body's ability to repair and replace it. As a result, the bone weakens and becomes vulnerable to stress fractures.
Cause
The most common cause of stress fractures is a sudden increase in physical activity. This increase can be in the frequency of activity—such as exercising more days per week. It can also be in the duration or intensity of activity—such as running longer distances.
Even for the nonathlete, a sudden increase in activity can cause a stress fracture. For example, if you walk infrequently on a day-to-day basis but end up walking excessively (or on uneven surfaces) while on a vacation, you might experience a stress fracture. A new style of shoes can lessen your foot's ability to absorb repetitive forces and result in a stress fracture.
Bone Insufficiency
Conditions that decrease bone strength and density, such as osteoporosis, and certain long-term medications can make you more likely to experience a stress fracture-even when you are performing normal everyday activities. For example, stress fractures are more common in the winter months, when Vitamin D is lower in the body.
Studies show that female athletes are more prone to stress fractures than male athletes. This may be due, in part, to decreased bone density from a condition that doctors call the "female athlete triad." When a girl or young woman goes to extremes in dieting or exercise, three interrelated illnesses may develop: eating disorders, menstrual dysfunction, and premature osteoporosis. As a female athlete's bone mass decreases, her chances for getting a stress fracture increase.
Poor Conditioning
Doing too much too soon is a common cause of stress fracture. This is often the case with individuals who are just beginning an exercise program-but it occurs in experienced athletes, as well. For example, runners who train less over the winter months may be anxious to pick up right where they left off at the end of the previous season. Instead of starting off slowly, they resume running at their previous mileage. This situation in which athletes not only increase activity levels, but push through any discomfort and do not give their bodies the opportunity to recover, can lead to stress fractures.
Improper Technique
Anything that alters the mechanics of how your foot absorbs impact as it strikes the ground may increase your risk for a stress fracture. For example, if you have a blister, bunion, or tendonitis, it can affect how you put weight on your foot when you walk or run, and may require an area of bone to handle more weight and pressure than usual.
Change in Surface
A change in training or playing surface, such as a tennis player going from a grass court to a hard court, or a runner moving from a treadmill to an outdoor track, can increase the risk for stress fracture.
Improper Equipment
Wearing worn or flimsy shoes that have lost their shock-absorbing ability may contribute to stress fractures.
Symptoms
The most common symptom of a stress fracture in the foot or ankle is pain. The pain usually develops gradually and worsens during weight-bearing activity. Other symptoms may include:
Achilles Tendinitis
Achilles tendinitis is a common condition that occurs when the large tendon that runs down the back of your lower leg becomes irritated and inflamed.
The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, climb stairs, jump, and stand on your tip toes. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.
Achilles tendinitis pain can occur within the tendon itself or at the point where it attaches to the heel bone, called the Achilles tendon insertion.
Description
Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation.
There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed.
Noninsertional Achilles tendinitis
Noninsertional Achilles Tendinitis
In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken.
Tendinitis of the middle portion of the tendon more commonly affects younger, active people.
Insertional Achilles tendinitis
Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.
In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.
Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active. More often than not, however, it comes from years of overuse (long distance runners, sprinters).
Cause
Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including:
Symptoms
Common symptoms of Achilles tendinitis include:
If you have experienced a sudden "pop" in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.
Bunions
A bunion is a painful bony bump that develops on the inside of the foot at the big toe joint. Bunions are often referred to as hallux valgus.
Bunions develop slowly. Pressure on the big toe joint causes the big toe to lean toward the second toe. Over time, the normal structure of the bone changes, resulting in the bunion bump. This deformity will gradually increase and may make it painful to wear shoes or walk.
Anyone can get a bunion, but they are more common in women. Many women wear tight, narrow shoes that squeeze the toes together—which makes it more likely for a bunion to develop, worsen and cause painful symptoms.
In most cases, bunion pain is relieved by wearing wider shoes with adequate toe room and using other simple treatments to reduce pressure on the big toe.
Anatomy
The big toe is made up of two joints. The largest of the two is the metatarsophalangeal joint (MTP), where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx).
Bunions develop at the MTP joint.
Description
A bunion forms when the bones that make up the MTP joint move out of alignment: the long metatarsal bone shifts toward the inside of the foot, and the phalanx bones of the big toe angle toward the second toe. The MTP joint gets larger and protrudes from the inside of the forefoot.
The enlarged joint is often inflamed. The word "bunion" comes from the Greek word for turnip, and the bump on the inside of the foot typically looks red and swollen like a turnip.
Bunion Progression
Bunions start out small — but they usually get worse over time (especially if the individual continues to wear tight, narrow shoes). Because the MTP joint flexes with every step, the bigger the bunion gets, the more painful and difficult walking can become.
An advanced bunion can greatly alter the appearance of the foot. In severe bunions, the big toe may angle all the way under or over the second toe. Pressure from the big toe may force the second toe out of alignment, causing it to come in contact with the third toe. Calluses may develop where the toes rub against each other, causing additional discomfort and difficulty walking.
Foot Problems Related to Bunions
In some cases, an enlarged MTP joint may lead to bursitis, a painful condition in which the fluid-filled sac (bursa) that cushions the bone near the joint becomes inflamed. It may also lead to chronic pain and arthritis if the smooth articular cartilage that covers the joint becomes damaged from the joint not gliding smoothly.
Adolescent Bunion
In addition to the common bunion, there are other types of bunions. As the name implies, bunions that occur in young people are called adolescent bunions. These bunions are most common in girls between the ages of 10 and 15.
While a bunion on an adult often restricts motion in the MTP joint, a young person with a bunion can normally move the big toe up and down. An adolescent bunion may still be painful, however, and make it difficult to wear shoes.
As opposed to adult bunions — which usually are associated with long-term wear of narrow, tight shoes — adolescent bunions are often genetic and run in families.
Bunionette
A bunionette, or "tailor's bunion," occurs on the outside of the foot near the base of the little toe. Although it is in a different spot on the foot, a bunionette is very much like a bunion. You may develop painful bursitis and a hard corn or callus over the bump.
Cause
Bunions may be caused by:
Symptoms
In addition to the visible bump on the inside of the foot, symptoms of a bunion may include:
Claw Toe
People often blame the common foot deformity claw toe on wearing shoes that squeeze your toes, such as shoes that are too short or high heels. However, claw toe also is often the result of nerve damage caused by diseases like diabetes or alcoholism, which can weaken the muscles in your foot. Having claw toe means your toes "claw," digging down into the soles of your shoes and creating painful calluses. Claw toe gets worse without treatment and may become a permanent deformity over time.
Symptoms
Your toes are bent upward (extension) from the joints at the ball of the foot.
Your toes are bent downward (flexion) at the middle joints toward the sole of your shoe.
Sometimes your toes also bend downward at the top joints, curling under the foot.
Corns may develop over the top of the toe or under the ball of the foot.
Evaluation
If you have symptoms of a claw toe, see your doctor for evaluation. You may need certain tests to rule out neurological disorders that can weaken your foot muscles, creating imbalances that bend your toes. Trauma and inflammation can also cause claw toe deformity.
Treatment
Claw toe deformities are usually flexible at first, but they harden into place over time. If you have claw toe in early stages, your doctor may recommend a splint or tape to hold your toes in correct position. Additional advice:
Clubfoot
Clubfoot is a deformity in which an infant's foot is turned inward, often so severely that the bottom of the foot faces sideways or even upward. Approximately one infant in every 1,000 live births will have clubfoot, making it one of the more common congenital (present at birth) foot deformities.
Clubfoot is not painful during infancy. However, if your child's clubfoot is not treated, the foot will remain deformed, and he or she will not be able to walk normally. With proper treatment, however, the majority of children are able to enjoy a wide range of physical activities with little trace of the deformity.
Most cases of clubfoot are successfully treated with nonsurgical methods that may include a combination of stretching, casting, and bracing. Treatment usually begins shortly after birth.
Description
In clubfoot, the tendons that connect the leg muscles to the foot bones are short and tight, causing the foot to twist inward.
Although clubfoot is diagnosed at birth, many cases are first detected during a prenatal ultrasound. In about half of the children with clubfoot, both feet are affected. Boys are twice more likely than girls to have the deformity.
Appearance
Clubfoot can range from mild to severe, but typically has the same general appearance. The foot is turned inward and there is often a deep crease on the bottom of the foot.
In limbs affected by clubfoot, the foot and leg are slightly shorter than normal, and the calf is thinner due to underdeveloped muscles. These differences are more obvious in children with clubfoot on only one side.
Classification
Clubfoot is often broadly classified into two major groups:
Regardless of the type or severity, clubfoot will not improve without treatment. A child with an untreated clubfoot will walk on the outer edge of the foot instead of the sole, develop painful calluses, be unable to wear shoes, and have lifelong painful feet that often severely limit activity.
Parents of infants born with clubfeet and no other significant medical problems should be reassured that with proper treatment their child will have feet that permit a normal, active life.
Cause
Researchers are still uncertain about the cause of clubfoot. The most widely accepted theory is that clubfoot is caused by a combination of genetic and environmental factors. What is known, however, is that there is an increased risk in families with a history of clubfeet.
Hammer Toe
A hammer toe is a deformity of the second, third or fourth toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.
Anatomy
The forefoot is made up of five toes. Each toe has three joints—except for the first (big) toe, which usually has only two joints.
In hammer toe, the affected toe is bent at the middle joint, which is called the proximal interphalangeal (PIP) joint.
Cause
Hammer toe is the result of a muscle imbalance that puts pressure on the toe tendons and joints. Muscles work in pairs to straighten and bend the toes. If the toe is bent in one position long enough, the muscles and joints tighten and cannot stretch out.
Wearing shoes that do not fit properly is a common cause of this imbalance. Shoes that narrow toward the toe push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. Shoes with a higher heel force the foot down and push the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles can no longer straighten the toe.
Symptoms
A hammer toe is painful, especially when the patient is moving it or wearing shoes. Other symptoms may include:
Plantar Fasciitis and Bone Spurs
Plantar fasciitis (fashee-EYE-tiss) is the most common cause of pain on the bottom of the heel. Approximately 2 million patients are treated for this condition every year.
Plantar fasciitis occurs when the strong band of tissue that supports the arch of your foot becomes irritated and inflamed.
Anatomy
The plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot, and supports the arch of your foot.
Cause
The plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis.
Risk Factors
In most cases, plantar fasciitis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:
Although many people with plantar fasciitis have heel spurs, spurs are not the cause of plantar fasciitis pain. One out of 10 people has heel spurs, but only 1 out of 20 people (5%) with heel spurs has foot pain. Because the spur is not the cause of plantar fasciitis, the pain can be treated without removing the spur.
Heel spurs do not cause plantar fasciitis pain.
Symptoms
The most common symptoms of plantar fasciitis include:
Rheumatoid Arthritis of the Foot and Ankle
Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body. It most often starts in the small joints of the hands and feet, and usually affects the same joints on both sides of the body.
More than 90% of people with rheumatoid arthritis (RA) develop symptoms in the foot and ankle over the course of the disease.
Description
Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.
How It Happens
The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes an overactivity of this lining. It swells and becomes inflamed, destroying the joint, as well as the ligaments and other tissues that support it. Weakened ligaments can cause joint deformities — such as claw toe or hammer toe. Softening of the bone (osteopenia) can result in stress fractures and collapse of bone.
Rheumatoid arthritis is not an isolated disease of the bones and joints. It affects tissues throughout the body, causing damage to the blood vessels, nerves, and tendons. Deformities of the hands and feet are the more obvious signs of RA. In about 20% of patients, foot and ankle symptoms are the first signs of the disease.
Statistics
Rheumatoid arthritis affects approximately 1% of the population. Women are affected more often than men, with a ratio of up to 3 to 1. Symptoms most commonly develop between the ages of 40 and 60.
Cause
The exact cause of RA is not known. There may be a genetic reason — some people may be more likely to develop the disease because of family heredity. However, doctors suspect that it takes a chemical or environmental "trigger" to activate the disease in people who inherit RA.
Symptoms
The most common symptoms are pain, swelling, and stiffness. Unlike osteoarthritis, which typically affects one specific joint, symptoms of RA usually appear in both feet, affecting the same joints on each foot.
Anatomy of the foot and ankle.
Ankle
Difficulty with inclines (ramps) and stairs are the early signs of ankle involvement. As the disease progresses, simple walking and standing can become painful.
Hindfoot (Heel Region of the Foot)
The main function of the hindfoot is to perform the side-to-side motion of the foot. Difficulty walking on uneven ground, grass, or gravel are the initial signs. Pain is common just beneath the fibula (the smaller lower leg bone) on the outside of the foot.
As the disease progresses, the alignment of the foot may shift as the bones move out of their normal positions. This can result in a flatfoot deformity. Pain and discomfort may be felt along the posterior tibial tendon (main tendon that supports the arch) on the inside of the ankle, or on the outside of the ankle beneath the fibula.
Midfoot (Top of the Foot)
With RA, the ligaments that support the midfoot become weakened and the arch collapses. With loss of the arch, the foot commonly collapses and the front of the foot points outward. RA also damages the cartilage, causing arthritic pain that is present with or without shoes. Over time, the shape of the foot can change because the structures that support it degenerate. This can create a large bony prominence (bump) on the arch. All of these changes in the shape of the foot can make it very difficult to wear shoes.
Forefoot (Toes and Ball of the Foot)
The changes that occur to the front of the foot are unique to patients with RA. These problems include bunions, claw toes, and pain under the ball of the foot (metatarsalgia). Although, each individual deformity is common, it is the combination of deformities that compounds the problem.
There can also be very painful bumps on the ball of the foot, creating calluses. The bumps develop when bones in the middle of the foot (midfoot) are pushed down from joint dislocations in the toes. The dislocations of the lesser toes (toes two through five) cause them to become very prominent on the top of the foot. This creates clawtoes and makes it very difficult to wear shoes. In severe situations, ulcers can form from the abnormal pressure.
Ankle Sprains
An ankle sprain is a common, painful injury that occurs when one or more of the ankle ligaments is stretched beyond the normal range of motion. Sprains can occur as a result of sudden twisting, turning or rolling movements.
Stress Fractures
Stress fractures are one or more tiny cracks in a bone. These fractures are common in the legs and feet. That's because your legs and feet have to support your weight and absorb the forces of walking, running and jumping.
Plantar Fasciitis
Plantar fasciitis is an irritation of the plantar fascia. This thick band of connective tissue travels across the bottom of the foot between the toes and the heel.
Bunion
This deformity affects the joint at the base of the big toe. It is a bony bump beneath the skin on the inner side of the foot. A bunion starts small, but over time it can grow to become very large. Bunions are more common in women.
Common Treatments of General Orthopedics
Ankle Fractures (Broken Ankle)
Treatment: Lateral Malleolus Fracture
A lateral malleolus fracture is a fracture of the fibula.
There are different levels at which that the fibula can be fractured. The level of the fracture may direct the treatment.
Nonsurgical Treatment
You may not require surgery if your ankle is stable, meaning the broken bone is not out of place or just barely out of place. A stress x-ray may be done to see if the ankle is stable. The type of treatment required may also be based on where the bone is broken.
Several different methods are used for protecting the fracture while it heals. ranging from a high-top tennis shoe to a short leg cast. Some physicians let patients put weight on their leg right away, while others have them wait for 6 weeks.
You will see your physician regularly to repeat your ankle x-rays to make sure the fragments of your fracture have not moved out of place during the healing process.
Surgical Treatment
If the fracture is out of place or your ankle is unstable, your fracture may be treated with surgery. During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together with special screws and metal plates attached to the outer surface of the bone. In some cases, a screw or rod inside the bone may be used to keep the bone fragments together while they heal.
Treatment: Medial Malleolus Fracture
A medial malleolus fracture is a break in the tibia, at the inside of the lower leg. Fractures can occur at different levels of the medial malleolus.
Medial malleolar fractures often occur with a fracture of the fibula (lateral malleolus), a fracture of the back of the tibia (posterior malleolus), or with an injury to the ankle ligaments.
Nonsurgical Treatment
If the fracture is not out of place or is a very low fracture with very small pieces, it can be treated without surgery.
A stress x-ray may be done to see if the fracture and ankle are stable.
The fracture may be treated with a short leg cast or a removable brace. Usually, you need to avoid putting weight on your leg for approximately 6 weeks.
You will need to see your physician regularly for repeat x-rays to make sure the fracture does not change in position.
Surgical Treatment
If the fracture is out of place or the ankle is unstable, surgery may be recommended.
In some cases, surgery may be considered even if the fracture is not out of place. This is done to reduce the risk of the fracture not healing (called a nonunion), and to allow you to start moving the ankle earlier.
A medial malleolus fracture can include impaction or indenting of the ankle joint. Impaction occurs when a force is so great it drives the end of one bone into another one. Repairing an impacted fracture may require bone grafting. This graft acts as a scaffolding for new bone to grow on, and may lower any later risk of developing arthritis.
Depending on the fracture, the bone fragments may be fixed using screws, a plate and screws, or different wiring techniques.
Treatment: Posterior Malleolus Fracture
A posterior malleolus fracture is a fracture of the back of the tibia at the level of the ankle joint.
In most cases of posterior malleolus fracture, the lateral malleolus (fibula) is also broken. This is because it shares ligament attachments with the posterior malleolus. There can also be a fracture of the medial malleolus.
Depending on how large the broken piece is, the back of the ankle may be unstable. Some studies have shown that if the piece is bigger than 25% of the ankle joint, the ankle becomes unstable and should be treated with surgery.
It is important for a posterior malleolus fracture to be diagnosed and treated properly because of the risk for developing arthritis. The back of the tibia where the bone breaks is covered with cartilage. Cartilage is the smooth surface that lines a joint. If the broken piece of bone is larger than about 25% of your ankle, and is out of place more than a couple of millimeters, the cartilage surface will not heal properly and the surface of the joint will not be smooth. This uneven surface typically leads to increased and uneven pressure on the joint surface, which leads to cartilage damage and the development of arthritis.
Nonsurgical Treatment
If the fracture is not out place and the ankle is stable, it can be treated without surgery.
Treatment may be with a short leg cast or a removable brace. Patients are typically advised not to put any weight on the ankle for 6 weeks.
Surgical Treatment
If the fracture is out of place or if the ankle is unstable, surgery may be offered.
Different surgical options are available for treating posterior malleolar fractures. One option is to have screws placed from the front of the ankle to the back, or vice versa. Another option is to have a plate and screws placed along the back of the shin bone.
Treatment: Bimalleolar Fractures or Bimalleolar Equivalent Fractures
"Bi" means two. "Bimalleolar" means that two of the three parts or malleoli of the ankle are broken. (Malleoli is plural for malleolus.)
In most cases of bimalleolar fracture, the lateral malleolus and the medial malleolus are broken and the ankle is not stable.
A "bimalleolar equivalent" fracture means that in addition to one of the malleoli being fractured, the ligaments on the inside (medial) side of the ankle are injured. Usually, this means that the fibula is broken along with injury to the medial ligaments, making the ankle unstable.
A stress test x-ray may be done to see whether the medial ligaments are injured.
Bimalleolar fractures or bimalleolar equivalent fractures are unstable fractures and can be associated with a dislocation.
Nonsurgical Treatment
These injuries are considered unstable and surgery is usually recommended.
Nonsurgical treatment might be considered if you have significant health problems, where the risk of surgery may be too great, or if you usually do not walk.
Immediate treatment typically includes a splint to immobilize the ankle until the swelling goes down. A short leg cast is then applied. Casts may be changed frequently as the swelling subsides in the ankle.
You will need to see your physician regularly to repeat your x-rays to make sure your ankle remains stable.
In most cases, Weightbearing is not be allowed for 6 weeks. After 6 weeks, the ankle may be protected by a removable brace as it continues to heal.
Surgical Treatment
Surgical treatment is often recommended because these fractures make the ankle unstable.
Lateral and medial malleolus fractures are treated with the same surgical techniques as written above for each fracture listed.
Treatment: Trimalleolar Fractures
"Tri" means three. Trimalleolar fractures means that all three malleoli of the ankle are broken. These are unstable injuries and they can be associated with a dislocation.
Nonsurgical Treatment
These injuries are considered unstable and surgery is usually recommended.
As with bimalleolar ankle fractures, nonsurgical treatment might be considered if you have significant health problems, where the risk of surgery may be too great, or if you usually do not walk.
Nonsurgical treatment is similar to bimalleolar fractures, as described above.
Surgical Treatment
Each fracture can be treated with the same surgical techniques as written above for each individual fracture.
Treatment: Syndesmotic Injury
The syndesmosis joint is located between the tibia and fibula, and is held together by ligaments. A syndesmotic injury may be just to the ligament -- this is also known as high ankle sprain. Depending on how unstable the ankle is, these injuries can be treated without surgery. However, these sprains take longer to heal than the normal ankle sprain.
In many cases, a syndesmotic injury includes both a ligament sprain and one or more fractures. These are unstable injuries and they do very poorly without surgical treatment.
Your physician may do a stress test x-ray to see whether the syndesmosis is injured.
Recovery
Because there is such a wide range of injuries, there is also a wide range of how people heal after their injury. It takes at least 6 weeks for the broken bones to heal. It may take longer for the involved ligaments and tendons to heal.
As mentioned above, your doctor will most likely monitor the bone healing with repeated x-rays. This is typically done more often during the first 6 weeks if surgery is not chosen.
Pain Management
Pain after an injury or surgery is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover faster.
Medications are often prescribed for short-term pain relief after surgery or an injury. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your treatment.
Rehabilitation
Rehabilitation is very important regardless of how an ankle fracture is treated.
When your physician allows you to start moving your ankle, physical therapy and home exercise programs are very important. Doing your exercises regularly is key.
Eventually, you will also start doing strengthening exercises. It may take several months for the muscles around your ankle to get strong enough for you to walk without a limp and to return to your regular activities.
Again, exercises only make a difference if you actually do them.
Weightbearing
Your specific fracture determines when you can start putting weight on your ankle. Your physician will allow you to start putting weight on your ankle when he or she feels your injury is stable enough to do so.
It is very important to not put weight on your ankle until your physician says you can. If you put weight on the injured ankle too early, the fracture fragments may move or your surgery may fail and you may have to start over.
Supports
It is very common to have several different kinds of things to wear on the injured ankle, depending on the injury.
Initially, most ankle fractures are placed in a splint to protect your ankle and allow for the swelling to go down. After that, you may be put into a cast or removable brace.
Even after the fracture has healed, your physician may recommend wearing an ankle brace for several months while you are doing sporting activities.
Complications
People who smoke, have diabetes, or are elderly are at a higher risk for complications after surgery, including problems with wound healing. This is because it may take longer for their bones to heal.
Nonsurgical Treatment
Without surgery, there is a risk that the fracture will move out of place before it heals. This is why it is important to follow up with your physician as scheduled.
If the fracture fragments do move out of place and the bones heal in that position, it is called a "malunion." Treatment for this is determined by how far out of place the bones are and how the stability of the ankle joint is affected.
If a malunion does occur or if your ankle becomes unstable after it heals, this can eventually lead to arthritis in your ankle.
Surgical Treatment
General surgical risks include:
Arthritis
Pain from the plates and screws that are used to fix fracture. Some patients choose to have them removed several months after their fracture heals
Outcomes
Although most people return to normal daily activities, except for sports, within 3 to 4 months, studies have shown that people can still be recovering up to 2 years after their ankle fractures. It may take several months for you to stop limping while you walk, and before you can return to sports at your previous competitive level. Most people return to driving within 9 to 12 weeks from the time they were injured.
Ankle Sprains
Almost all ankle sprains can be treated without surgery. Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately.
A three-phase program guides treatment for all ankle sprains—from mild to severe:
This three-phase treatment program may take just 2 weeks to complete for minor sprains, or up to 6 to 12 weeks for more severe injuries.
Home Treatments
For milder sprains, your doctor may recommend simple home treatment.
The RICE protocol. Follow the RICE protocol as soon as possible after your injury:
Medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help control pain and swelling. Because they improve function by both reducing swelling and controlling pain, they are a better option for mild sprains than narcotic pain medicines.
Nonsurgical Treatment
Some sprains will require treatment in addition to the RICE protocol and medications.
Crutches. In most cases, swelling and pain will last from 2 to 3 days. Walking may be difficult during this time and your doctor may recommend that you use crutches as needed.
Immobilization. During the early phase of healing, it is important to support your ankle and protect it from sudden movements. For a Grade 2 sprain, a removable plastic device such as a cast-boot or air stirrup-type brace can provide support. Grade 3 sprains may require a short leg cast or cast-brace for 2 to 3 weeks.
Your doctor may encourage you to put some weight on your ankle while it is protected. This can help with healing.
Physical therapy. Rehabilitation exercises are used to prevent stiffness, increase ankle strength, and prevent chronic ankle problems.
Early motion. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
Strengthening exercises. Once you can bear weight without increased pain or swelling, exercises to strengthen the muscles and tendons in the front and back of your leg and foot will be added to your treatment plan. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
Proprioception (balance) training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
Endurance and agility exercises. Once you are pain-free, other exercises may be added, such as agility drills. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.
Surgical Treatment
Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability after months of rehabilitation and nonsurgical treatment.
Surgical options may include:
Arthroscopy. During arthroscopy, your doctor uses a small camera, called an arthroscope, to look inside your ankle joint. Miniature instruments are used to remove any loose fragments of bone or cartilage, or parts of the ligament that may be caught in the joint.
Reconstruction. Your doctor may be able to repair the torn ligament with stitches or sutures. In some cases, he or she will reconstruct the damaged ligament by replacing it with a tissue graft obtained from other ligaments and/or tendons found in the foot and around the ankle.
Immobilization. There is typically a period of immobilization following surgery for an ankle sprain. Your doctor may apply a cast or protective boot to protect the repaired or reconstructed ligament. Be sure to follow your doctor's instructions about how long to wear the protective device; if you remove it too soon, a simple misstep can re-tear the fixed ligament.
Rehabilitation. Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.
Outcomes
Outcomes for ankle sprains are generally quite good. With proper treatment, most patients are able to resume their day-to-day activities after a period of time.
Most importantly, successful outcomes are dependent upon patient commitment to rehabilitation exercises. Incomplete rehabilitation is the most common cause of chronic ankle instability after a sprain. If a patient stops doing the strengthening exercises, the injured ligament(s) will weaken and put the patient at risk for continued ankle sprains.
Chronic Ankle Sprains
Once you have sprained your ankle, you may continue to sprain it if the ligaments do not have time to completely heal. It can be hard for patients to tell if a sprain has healed because even an ankle with a chronic tear can be highly functional because overlying tendons help with stability and motion.
If pain continues for more than 4 to 6 weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces and participating in sports that require cutting actions or rolling and twisting of the foot.
Abnormal proprioception—a common complication of ankle sprains—can also lead to repeat sprains. There may be imbalance and muscle weakness that causes a reinjury. If you sprain your ankle over and over again, a chronic situation may persist with instability, a sense of the ankle giving way, and chronic pain. This can also happen if you return to work, sports, or other activities before your ankle heals and is rehabilitated.
Prevention
The best way to prevent ankle sprains is to maintain good muscle strength, balance, and flexibility. The following precautions will help prevent sprains:
Plantar Fasciitis and Bone Spurs
Nonsurgical Treatment
More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods.
Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics).
Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day.
Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor.
Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.
Calf stretch
Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.
Plantar fascia stretch
This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.
Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain.
Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.
Soft heel pads can provide extra support.
Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.
Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, and medication to decrease inflammation around the plantar fascia.
Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.
ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.
Surgical Treatment
Surgery is considered only after 12 months of aggressive nonsurgical treatment.
Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite a year of calf stretches.
In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope, an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs.
Complication rates for gastrocnemius recession are low, but can include nerve damage.
Plantar fascia release. If you have a normal range of ankle motion and continued heel pain, your doctor may recommend a partial release procedure. During surgery, the plantar fascia ligament is partially cut to relieve tension in the tissue. If you have a large bone spur, it will be removed, as well. Although the surgery can be performed endoscopically, it is more difficult than with an open incision. In addition, endoscopy has a higher risk of nerve damage.
Complications. The most common complications of release surgery include incomplete relief of pain and nerve damage.
Recovery. Most patients have good results from surgery. However, because surgery can result in chronic pain and dissatisfaction, it is recommended only after all nonsurgical measures have been exhausted.
Bunion Surgery
In many areas, nonessential orthopaedic procedures that were postponed due to COVID-19 have resumed. For information: Questions and Answers for Patients Regarding Elective Surgery and COVID-19. For patients whose procedures have not yet been rescheduled: What to Do If Your Orthopaedic Surgery Is Postponed.
This article provides information on surgery for bunions. For more general information: Bunions.
Most people with bunions find pain relief with simple treatments to reduce pressure on the big toe, such as wearing wider shoes or using pads in their shoes. However, if these measures do not relieve your symptoms, your doctor may recommend bunion surgery.
There are different types of surgeries to correct a bunion. Bringing the big toe back to its correct position may involve realigning bone, ligaments, tendons, and nerves.
Are You a Candidate for Surgery?
In general, if your bunion is not painful, you do not need surgery. Although bunions often get bigger over time, doctors do not recommend surgery to prevent bunions from worsening. Many people can slow the progression of a bunion with proper shoes and other preventive care, and the bunion never causes pain or other problems.
It is also important to note that bunion surgery should not be done for cosmetic reasons. After surgery, it is possible for ongoing pain to develop in the affected toe — even though there was no bunion pain prior to surgery.
Good candidates for bunion surgery commonly have:
Deciding to Have Bunion Surgery
After bunion surgery, most patients have less foot pain and are better able to participate in everyday activities.
As you explore bunion surgery be aware that so-called "simple" or "minimal" surgical procedures are often inadequate "quick fixes" that can do more harm than good. Although many bunion procedures are done on a same-day basis with no hospital stay, a long recovery period is common. It often takes up to 6 months for full recovery, with follow-up visits to your doctor sometimes necessary for up to a year.
It is very important to have realistic expectations about bunion surgery. For example, bunion surgery may not allow you to wear a smaller shoe size or narrow, pointed shoes. In fact, you may need to restrict the types of shoes you wear for the rest of your life.
As you consider bunion surgery, do not hesitate to ask your doctor questions about the operation and your recovery. Some examples of helpful questions to ask include:
Be sure to write down your doctor's answers so you can remember them at a later time. It is important to understand both the potential benefits and limitations of bunion surgery.
Surgical Procedures
In general, the common goals of most bunion surgeries include:
Realigning the metatarsophalangeal (MTP) joint at the base of the big toe
Relieving pain
Correcting the deformity of the bones making up the toe and foot
Because bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, bunion surgery includes correcting the alignment of the bone and repairing the soft tissues around the big toe.
Your doctor will talk with you about the type of surgery that will best correct your bunion.
Repairing the Tendons and Ligaments Around the Big Toe
In some cases, the soft tissues around the big toe may be too tight on one side and too loose on the other. This creates an imbalance that causes the big toe to drift toward the other toes.
Surgery can shorten the loose tissues and lengthen the tight ones. This is rarely done without some type of alignment of the bone, called an osteotomy. In the majority of cases, soft tissue correction is just one portion of the entire bunion corrective procedure.
Osteotomy
In an osteotomy, your doctor makes small cuts in the bones to realign the joint. After cutting the bone, your doctor fixes this new break with pins, screws, or plates. The bones are now straighter, and the joint is balanced.
Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.
As discussed above, osteotomies are normally performed in combination with soft tissue procedures, as both are often necessary to maintain the big toe alignment.
Arthrodesis
In this procedure, your doctor removes the arthritic joint surfaces, then inserts screws, wires, or plates to hold the surfaces together until the bones heal. Arthrodesis is commonly used for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery.
Exostectomy
In this procedure, your doctor removes the bump from your toe joint. Exostectomy alone is seldom used to treat bunions because it does not realign the joint. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion.
Exostectomy is most often performed as one part of an entire corrective surgery that includes osteotomy, as well as soft-tissue procedures. If a doctor performs exostectomy without osteotomy, however, the bunion deformity often returns.
Resection Arthroplasty
In this procedure, your doctor removes the damaged portion of the joint. This increases the space between the bones and creates a flexible "scar" joint. Resection arthroplasty is used mainly for patients who are elderly, have had previous unsuccessful bunion surgery, or have severe arthritis not amenable to an arthrodesis (see above). Because this procedure can change the push off power of the big toe, it is not often recommended.
Preparing for Surgery
Medical Evaluation
Before your surgery, you may be asked to visit your family doctor for a complete physical examination. He or she will assess your health and identify any problems that could interfere with your surgery. If you have a heart or lung condition or a chronic illness you will need a preoperative medical clearance from your family doctor.
Medications
Tell your doctor about any medications you are taking. He or she will tell you which medications you can continue taking and which you should stop taking before surgery.
Tests
You may require several preoperative tests, including blood counts, a cardiogram, and a chest x-ray. You may also need to provide a urine sample.
To help plan your procedure, your doctor may order special foot x-rays. These x-rays should be taken in a standing, weight bearing position to ensure your doctor can clearly see the deformity in the foot. These x-rays assist your doctor in making decisions about where along the bone to perform an osteotomy in order to provide enough corrective power to straighten the toe.
Your Surgery
In planning your surgery, your doctor will consider several things, including how severe your bunion is, your age, your general health and activity level, and any other medical issues that may affect your recovery.
Almost all bunion surgery is done on an outpatient basis. You will most likely be asked to arrive at the hospital or surgical center 1 or 2 hours before your surgery.
Anesthesia
After admission, you will be evaluated by a member of the anesthesia team. Most bunion surgery is performed with anesthesia that numbs the area for surgery but does not put you to sleep.
The anesthesiologist will stay with you throughout the procedure to administer other medications, if necessary, and to make sure you are comfortable.
Procedure
Depending upon your bunion and the procedures you need, your doctor will make an incision along the inside of your big toe joint or on top of the joint. In some cases, more than one incision is needed to correct the bunion deformity.
The surgical time varies depending on how much of your foot is malaligned. Surgery will take longer if your deformity is greater or if more than one osteotomy is required. Every bunion correction is a little bit different, and there is no reason to be concerned if your surgery takes more time.
Afterward, you will be moved to the recovery room. You will be ready to go home in an hour or two. Be sure to have someone with you to drive you home.
Complications
As with any surgical procedure, there are risks associated with bunion surgery. These occur infrequently and are usually treatable — although, in some cases, they may limit or extend your full recovery. Before your surgery, your doctor will discuss each of the risks with you and take specific measures to avoid complications.
The possible risks and complications of bunion surgery include:
Recovery at Home
The success of your surgery will depend in large part on how well you follow your doctor's instructions at home during the first few weeks after surgery. You will see your doctor regularly for several months — occasionally up to a year — to make sure your foot heals properly.
Dressing Care
You will be discharged from the hospital with bandages holding your toe in its corrected position.
Because keeping your toe in position is essential for successful healing, it is very important to follow your doctor's directions about dressing care. Do not disturb or change the dressing without talking to your doctor. Interfering with proper healing could cause a recurrence of the bunion.
Be sure to keep your wound and dressing dry. When you are showering or bathing, cover your foot with a plastic bag.
Your sutures will be removed about 2 weeks after surgery, but your foot will require continued support from dressings or a brace for 6 to 12 weeks.
Medications
Your doctor will prescribe pain medication to relieve surgical discomfort. The most effective medications for providing postsurgical pain relief are opioids. These medications are narcotics, however, and can be addictive. It is important to use opioids only as directed by your doctor.
As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
In addition to pain medicine, your doctor may prescribe antibiotics to help prevent infection in your wound for several days after surgery.
Swelling
Keep your foot elevated as much as possible for the first few days after surgery, and apply ice as recommended by your doctor to relieve swelling and pain. Never apply ice directly on your skin. It is common to have some swelling in your foot from 6 months to a year after bunion surgery.
Bearing Weight
Your doctor will give you strict instructions about whether and when you can put weight on your foot. Depending upon the type of procedure you have, if you put weight on your foot too early or without proper support, the bones can shift and the bunion correction will be lost.
Some bunion procedures allow you to walk on your foot right after the surgery. In these cases, patients must use a special surgical shoe to protect the bunion correction.
Many bunion surgeries require a period of no weightbearing to ensure bone healing. Your doctor will apply dressings, a brace, or a cast to maintain the correct bone position. Crutches are usually used to avoid putting any weight on the foot. A newer device called a knee walker is a good alternative to crutches. It has four wheels and functions like a scooter. Instead of standing, you place the knee of your affected foot on a padded cushion and push yourself along using your healthy foot.
In addition to no weightbearing, driving may be restricted until the bones have healed properly — particularly if the surgery was performed on your right foot.
No matter what type of bunion surgery you have, it is very important to follow your doctor's instructions about weightbearing. Do not put weight on your foot or stop using supportive devices until your doctor gives approval.
Physical Therapy and Exercise
Specific exercises will help restore your foot's strength and range of motion after surgery. Your doctor or physical therapist may recommend exercises using a surgical band to strengthen your ankle or using marbles to restore motion in your toes.
Always start these exercises slowly and follow instructions from your doctor or physical therapist regarding repetitions.
Shoe Wear
It will take several months for your bones to fully heal. When you have completed the initial rehabilitation period, your doctor will advise you on shoewear. Athletic shoes or soft leather oxford type shoes will best protect the bunion correction until the bones have completely healed.
To help prevent your bunion from recurring, do not wear fashion shoes until your doctor allows it. Be aware that your doctor may recommend that you never return to wearing high-heeled shoes.
Avoiding Complications
Though uncommon, complications can occur following bunion surgery. During your recovery at home, contact your doctor if:
Outcomes
The majority of patients who undergo bunion surgery experience a reduction of foot pain, along with improvement in the alignment of their big toe. The length of your recovery will depend upon the surgical procedures that were performed, and how well you follow your doctor's instructions.
Because a main cause of bunion deformity is a tight-fitting shoe, returning to that type of shoe can cause your bunion to return. Always follow your doctor's recommendations for proper shoe fit.
Achilles Tendon Lengthening
This procedure is designed to treat problems with the Achilles tendon, such as chronic tendonitis or a short or contracted Achilles tendon.
Bunionectomy
This outpatient procedure is performed to correct a bunion, a deformity of the toe joint. During the procedure, the surgeon may remove excess bone and then shift the toe into proper alignment.
Ankle Fracture Surgery
This surgery fixes an unstable break in your ankle. The break could be in the small bone of your lower leg, called the "fibula" or the larger bone, called the "tibia."
Plantar Fascia Release
This outpatient procedure is a surgical cutting of part of the plantar fascia, a thick band of connective tissue that supports the foot's arch.
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