Flattening of the arch of the foot is due to an abnormal function of a joint complex called the Subtalar Joint. This joint complex is located just below the ankle joint. When this joint allows the foot to flatten excessively, the foot becomes over pronated. Pronation is a normal movement of the foot, but when it occurs too much of the time, it causes several different problems to occur in the foot, one of them being Tarsal Tunnel Syndrome.

Diagnoses

Diagnosis of Tarsal Tunnel Syndrome is made by physical exam and the patient’s history of their complaint. A history of gradual and progressive burning on the bottom of the foot should alert the doctor to the possible diagnoses. Physical exam will often reveal a flat foot or over-pronation of the foot that is observed when the patient walks. Observation of the area just below the ankle bone on the inside of the ankle may reveal a slight swelling. Tapping with the tips of the fingers or a neurological hammer in this area may reveal a tingling sensation in the bottom of the foot. X-rays may be of little value, because they will not show the nerve or reveal any evidence of soft tissue masses. X-rays may be useful in determining the extent of pronation of the foot but only if the x-ray is taken with the patient bearing full weight on the foot. An MRI may reveal the existence of a soft tissue mass, but will not demonstrate any damage to the nerve. Nerve conduction studies will reveal if there is damage to the Posterior Tibial Nerve, but will be negative in the early stages of the condition.

Other conditions that may cause similar symptoms are diabetic neuropathy, , or nerve compression at a level higher than the ankle. Poor circulation can also cause burning of the feet. If you experience these symptoms, you should consult your doctor at the earliest possible time.

Treatment

Treatment of Tarsal Tunnel Syndrome is directed at correcting the abnormal pronation of the foot. This is accomplished with functional foot orthotics. These devices are custom-made inserts for the shoes that correct abnormal function of the foot. Treatment with oral anti-inflammatory medications, vitamin B supplements, or steroids may provide some benefit, but are rarely curative. Calf muscle stretching can be useful, because it eases the tension and strain about the ankle joint. If the Tarsal Tunnel Syndrome is caused by a soft tissue mass, then surgical removal of the mass may be necessary. Surgical correction of Tarsal Tunnel Syndrome in the absence of a soft tissue mass has a very low success rate. This surgery, called nerve decompression, is intended to release the pressure on the nerve by freeing the soft tissue structures about the nerve as it passes through the tarsal tunnel. (See surgical Exploration for Tarsal Tunnel Syndrome) This surgery does not correct the over-pronation of the foot, however, and functional foot orthotics should be worn following the surgery.

When there has been significant damage to the nerve, permanent nerve damage may be present. In this case, a complete cure is very unlikely, and treatment is directed at easing the symptoms. Certain medications available, by prescription from your doctor, may be beneficial for the burning pain that may be experienced at night. Magnetic insole therapy and Galvanic Nerve Stimulation are alternative forms of treatment that may provide relief. A referral to a pain medicine specialist may also be necessary.

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The Tailors bunion is a bony prominence at the base of the fifth toe (little toe). Anatomically the toes are connected to long bones in the mid-foot called metatarsal bones. The tailors bunion is a prominence or enlargement of the head of the fifth metatarsal.

The cause of the tailors bunion is abnormal movements of joints in the rear portion of the foot that results in flattening, widening or splaying for the foot. Contributing factors to the abnormal movements of these joints in the foot are excessive tightness of the calf muscle that restricts adequate motion in the ankle and a difference in the length of the legs. Certain shoe styles also may contribute to symptoms of tailors bunions but do not cause them to develop. If the shape of the shoe is curved inward at the forefoot area it will cause excessive pressure on the outside portion of the foot and irritate an existing tailors bunion. The limitation of ankle movement caused by tight calf muscles contributes to the foot flattening, widening and splaying. If one leg is longer than the other leg the foot is also forced to widen or splay. As the deformity progresses and worsens shoe pressure may cause a secondary bursa and/or irritation of a skin nerve in the area. This may occur with any shape of style of shoe.

Tailors bunions may present as an isolated foot problem. However, they frequently present with other foot abnormalities such as hammertoes and bunions.

Diagnosis:

The diagnosis of a tailors bunion is made by your doctor follow a history of your complaint, a physical exam and x-rays.

If a bursa is present the physical exam will reveal a soft moveable swelling over the area. This swelling will cause the tailors bunion to appear larger than the actual bony prominence. Should the nerve be inflamed and contributing to the pain the physical exam will demonstrate a “tingling” when the area is lightly tapped with the tip of a finger.

Treatment:

Treatment suggestions are based upon the results of the doctor’s findings. These suggestions take into consideration the overall health status of the patient, the level of pain and discomfort, any limitations of activity or the ability to wear normal shoes comfortably. They also take into consideration the normal daily activities of the patient, the type of work one performs, the required or desired shoes one wants to wear and the desired or expected results the patient seeks.

Treatment suggestions may include any of the following or a combination of them.

A recommendation in the style of shoes worn. This does not imply bigger shoes or the avoidance of high heels or dresses shoes.
Padding of the area to reduce shoe pressure. Gel pads are often very useful.
Topical gels or creams to sooth the inflamed area such as Biofreeze.
Over the counter insoles
Custom inserts for the shoes called orthotics that control abnormal movements in the joints of the feet.
Calf stretching exercises
Cortisone injections and/or oral anti-inflammatory medications to treat the inflammation of a bursa or inflamed nerve
Surgical correction to remove the bony prominence or realign the fifth metatarsal bone
In acutely painful situations the doctor may suggest an open toed shoe, protective shoe or cast boot temporarily
Tailors bunions are a common foot abnormality that can result in pain and the limitation of activity. It is easily diagnosed and treated successfully.

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The sesamoids serve 2 very important functions based on their location: 1) they serve to protect the large tendon to the great toe, the Flexor Hallucis Longus, which functions to pull the toe down against the ground during gait. The tendon courses between these two bones; 2) they also serve as a fulcrum for the short flexor tendon, Flexor Hallucis Brevis, which attaches to the base of the great toe. This tendon stabilizes the toe against the ground at the push-off phase of gait and allows for effective forward propulsion of the body.

Because of their location and the amount of force transmitted through these bones, they are susceptible to a variety of injuries. Additionally, certain foot structures and activities will increase the susceptibility of these bones. Fractures and inflammation (sesamoiditis) are quite common. Fractures of a sesamoid bone can involve either the tibial or fibular sesamoid. This is an actual break within the bone. Because the flexor hallucis brevis tendon is attached to the sesamoids, there is often displacement of the fracture, leading to a high rate of delayed or even nonunion.

Sesamoiditis is an inflammatory condition of the periosteum or bone lining of the sesamoid bone. Typically, patients will relate a history of excessive activity as a precursor to pain in this location. Other risk factors include: running, jumping from a height, ballet dancing, wearing of high heels or shoes with little cushioning and high-arched foot type. With early and appropriate treatment, these often improve.

Diagnosis

Initial diagnosis is made by a careful history and physical examination. Pain localized to the bottom of the great toe joint is the typically presentation of these types of injury. The pain can be easily localized to either the tibial or fibular sesamoid by directly pressing on either bone. Movement of the joint may also duplicate the patient’s pain. Occasionally, swelling and redness may also be seen depending on the mechanism of injury. X-rays are often obtained to differentiate sesamoiditis from a sesamoid fracture. Three different views of the sesamoids are commonly taken. Also, when sesamoid fractures are suspected, it is helpful to x-ray the uninvolved side as well. Typically, the sesamoid bones are 2 well-defined bones on x-ray. This is the case for approximately 85% of the population. However, in 15% of patients each sesamoid bone may consist of 2 or more fragments (referred to as multipartite – several pieces). This will often make the distinction between normal and fracture difficult. In this case, a bone scan or MRI can be helpful. It is important to differentiate between sesamoiditis versus fracture since the treatment is dramatically different.

Treatment

The treatment of sesamoid injuries is dependent on making a definitive diagnosis. Because sesamoiditis is an inflammatory condition, treatment directed at reducing inflammation is often helpful. This may include: rest, ice, anti-inflammatory medications and physical therapy. More resistant cases of sesamoiditis may be helped by an occasional cortisone injection. These should only be performed after the physician is fairly certain a fracture does not exist.

Long-term therapy must be geared to identifying the cause of the sesamoiditis so as to avoid these situations or to accommodate foot deformities or modify shoes. This may include the use of orthotic devices. This may also include the limited use of high heel shoes.

Sesamoid fractures require a more aggressive course of treatment because of the high risk of nonunion. Cast immobilization for 6-8 weeks is the initial treatment of choice. The patient should then be advanced gradually to full weightbearing with a removable brace. Even in spite of appropriate treatment, many sesamoid fractures go on to delayed or non-unions. When conservative care has failed to render the patient pain free, consideration to removal of the offending sesamoid should be given. Once again, long-term therapy should be geared at identifying the cause of the fracture and treating or modifying those activities leading to the fracture in the first place.

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Anatomy

The posterior tibial tendon starts in the deep portion of the calf and runs behind the prominent bone on the inside of the ankle. The tendon continues along towards the foot and inserts into multiple locations on the inside and the bottom of the arch. With each step a tremendous amount of tension and stress is placed is on the posterior tibial tendon as it helps to maintain and recreate the arch of the foot. With each step there is a natural depression and recreation of the arch that allows for shock absorption. The amount of shock absorption or depression of the arch is variable from person to person depending on the architecture of their foot (flatfeet versus a very high arch). It would seem that only a flatfooted person would get posterior tibial tendonitis but this is not always the case. It can happen to people with any foot type, weight or activity level.

Symptoms

Symptoms of posterior tibial tendonitis include pain and swelling along the inside of the ankle and arch along the course of the tendon. Pain is present with exercise, extended periods of walking or standing. This discomfort will usually increase as the disease progresses and is localized along the course of the tendon around the inside of the ankle or along the inside of the arch. This pain initially is absent when at rest but may progress to the point where pain is present even when not active. Pain and swelling are signs of injury to the tendon. The sheath or sleeve that surrounds the tendon will produce excessive amounts of lubricating fluid in an attempt to allow the tendon to glide easier during the healing process. This excessive fluid production results in the swelling the patient sees and feels on the inside of the ankle and arch. In advanced cases the injury to the tendon that started as tendonitis may progress to a full or partial tear of the tendon.

Diagnosis

The diagnosis can often be made from your doctor by the history and physical exam. In many instances a MRI or ultrasound will be performed to determine the extent of damage to the posterior tibial tendon. A simple assessment of tendon strength can be performed by standing on the “tip of the toes” on each foot. The affected foot may feel weak and painful in cases of tendonitis. In advanced cases the patient may not be able to lift the heel from the ground as much or not at all in comparison to the unaffected foot.

Treatment

Treatment can depend on how long the symptoms have been present and if the amount of strength that is lost (if any) in the tendon. Non-steroidal anti-inflammatory medication, physical therapy, rest and orthotics are often first courses of treatment. Injections of cortisone type medications are performed on rare occasions and often accompanied by cast immobilization. These are all designed to decrease the inflammation in and around the tendon and to decrease the stresses placed on the tendon. In more severe cases a cast from the knee down may be utilized from four to six weeks to allow the tendon to completely rest without placing the day-to-day demands of walking on it. If these measures fail to produce acceptable results surgical intervention may be necessary to clean around the tendon and repair any defects in the tendon. Surgical repair is more commonly needed when there is a progressive weakness in the tendon. As mentioned earlier this loss of strength is called posterior tibial tendon dysfunction and is covered in detail in that section.

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Description of the Surgery

The surgical procedure involves a long, often curvilinear, incision on the bottom of the foot. The incision extends from the heel to the ball of the foot. The surgeon will dissect through the fatty tissue layer on the bottom of the foot to expose the thick fibrous plantar fascia. The plantar fascia, which includes the multiple benign fibromas, extends from the bottom of the heel, through the arch, all the way to the ball of the foot. The fascia removal requires careful separation from deeper soft tissues structures, and small nerves. Once the fascia has been removed, the bottom of the foot is stitched closed. Often a drain is placed into the surgery site to help prevent blood and other fluids from collecting here. The surgical wound is bandaged and the patient must remain non-weight bearing on the foot (with crutches) for a minimum of three weeks. Normal post-operative care including rest, ice, elevation, and maintaining a clean surgical site would be followed. The drain is usually removed 3 to 5 days after the surgery. The stitches are removed between 2 and 3 weeks after the surgery.

Post Operative Advice

Once the incision site is well healed, the patient may begin gentle calf muscle stretching exercises, and weight bearing with a soft soled shoe. Functional foot orthotics are generally recommended to help support the arch of the foot which has been weakened by removal of the plantar fascia. Although the patient will often resume walking about 1 month after the surgery, normal activities, including sports, will usually resume about three months after the surgery. There may be some residual tenderness in the area of the incision.

Possible Complications

Some possible complications of the surgery include infection, swelling, and numbness on the bottom of the foot. The possibility of uncomfortable scarring on the bottom of the foot may also develop if the patient walks on the foot, damaging the incision, before the incision is properly healed. As previously mentioned, recurrence of the plantar fibroma is also possible, although this becomes less likely with removal of the entire plantar fascia. Other less common risks associated with this surgery should be personally reviewed with your own surgeon, as individual factors may play a role.

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Diagnosis

Taking a through history of the course of the condition and physical exam makes the diagnosis of plantar fasciitis.

Treatment

Treatment of plantar fasciitis is similar to that for heel pain. Cortisone injections, used in the treatment of heel pain, are not commonly used for the treatment of plantar fasciitis. The main emphasis of treatment is to reduce the forces that are causing the plantar fascia to stretch excessively. This includes calf muscle stretching, over the counter arch supports, and orthotics. Oral anti-inflammatory medications may be useful in controlling the pain.

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There are three peroneal muscles in the lower leg. These muscles attach to the tibia and fibula bones on the outside of the lower leg. The tendons of these muscles pass around the outside of the ankle and attach into the foot. These tendons are a part of the “stirrup muscles” that work to support the arch of the foot. They also function to move the foot in an outward direction. One of these tendons attach into the base of the fifth metatarsal. The fifth metatarsal is the long bone behind the fifth toe.

Pain on the outside of the foot can be the result of inflammation of the peroneal tendons. In children this can cause tenderness at the base of the fifth metatarsal, which is located in the middle of the outside of the foot. Peroneal tendonitis can also cause pain along the outside of the foot and outside of the ankle.

The causes of peroneal tendonitis are excessive calf muscle tightness, twisting of the foot or ankle and chronic abnormal foot function. In many instances the cause of the tendon inflammation is not evident.

Treatment:

In mild cases of peroneal tendonitis rest and an oral inflammatory medication is sufficient. In more acute cases cast immobilization may be necessary. Long-term treatment includes regular calf muscle stretching and an insert for the shoes called orthotics.

On occasion the peroneal tendon may sublux over the outside of the ankle. This condition is called subluxing peroneal tendon. This condition often requires surgical correction.

If you have any further questions make an appointment with a podiatrist in your area.

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A puncture wound or laceration that injures a nerve can cause a neuroma. These are called traumatic Neuromas. Neuromas can also result following a surgery that may result in the cutting of a nerve.

Diagnosis

The diagnosis of Neuromas is made by a physical exam and a thorough history of the patient’s complaint. Conditions that mimic the pain associated with Neuromas are stress fracture of the metatarsals, inflammation of the tendons in the bottom of the toes, arthritis of the joint between the metatarsal bone and the toe, or nerve compression or nerve damage further up on the foot, ankle, knee, hip, or back. X-rays are generally taken to rule out a possible stress fracture or arthritis. Because nerve tissue is not seen on an x-ray, the x-ray will not show the neuroma. A skilled foot specialist will be able to actually feel the neuroma on his exam of the foot. Special studies such as MRI, CT Scan, and nerve conduction studies have little value in the diagnosis of a neuroma. Additionally, these studies can be very expensive and generally the results do not alter the doctor’s treatment plan. If the doctor on his exam cannot feel the neuroma, and if the patient’s symptoms are not what is commonly seen, then nerve compression at another level should be suspected. In this instance, one area to be examined is the ankle.

Just below the ankle bone on the inside of the ankle, a large nerve passes into the foot. At this level, the nerve can become inflamed. This condition is called Tarsal Tunnel Syndrome. Generally, there is not pain at this site of the inflamed nerve at the inside of the ankle. Pain may instead be experienced in the bottom of the foot or in the toes. This can be a difficult diagnosis to make in certain circumstances. Neuromas, however, occur more commonly than Tarsal Tunnel Syndrome.

Treatment

Treatment for the neuroma consists of cortisone injections, orthotics, chemical destruction of the nerve, or surgery. Cortisone injections are generally used as an initial form of treatment. Cortisone is useful when injected around the nerve, because is can shrink the swelling of the nerve. This relieves the pressure on the nerve. Cortisone may provide relief for many months, but is often not a cure for the condition. The abnormal movements of the metatarsal bones continue to aggravate the condition over a period of time.

To address the abnormal movement of the metatarsal bones, a functional foot orthotic can be used. These devices are custom-made inserts for the shoes that correct abnormal function of the foot. The combination treatment of cortisone injections and orthotics can be a very successful form of treatment. If, however, there is significant damage to the nerve, then failure to this treatment can occur. When there is permanent nerve damage, the patient is left with three choices: live with the pain, chemical destruction of the nerve, or surgical removal of the nerve (see neuroma surgery) or a nerve decompression.

It is important for you to understand that the information provided is of a basic educational nature only, and does not constitute medical advice nor should it replace a medical consultation or the advice of your doctor.

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Diagnosis

A typical presentation for someone with a metatarsal stress fracture would be pain and swelling in the ball of the foot, which is most severe in the push off phase of walking. Pressing on the bones in this area of the foot will reproduce the pain. X-rays taken during the first two to three weeks after the injury often will not show any fracture. A bone scan at this stage will be much more sensitive in diagnosing the early stress fracture. The decision to order a bone scan will be up to your doctor. Often times the diagnosis can be made based upon clinical findings, thus making the bone scan unnecessary. After several weeks, an x-ray will show the signs of new bone healing in the area of the stress fracture.

Treatment

Treatment for a metatarsal stress fracture usually consists of rest, elevation, and ice initially. Sometimes a compression bandage is applied to help reduce the swelling. Frequently a post-operative type of shoe or removable below the knee cast is used to prevent you from pushing off the ball of your foot, thus eliminating any additional stress while the bone is healing. Occasionally a short leg walking cast may be applied for a short period of time. Typical healing times range from 4 to 8 weeks. After the fracture is healed, special attention should be paid to using a well-padded insole or a functional orthotic in the shoes to reduce the stress in this area. For those who may have osteoporosis, bone densitometry testing should be done, and appropriate treatment initiated to prevent further weakening of the bones.

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Treatment

Treatment for ingrown toenails is relatively painless. The injection to numb the toe may hurt some, but a skilled doctor has techniques to minimize this discomfort. Once the toe is numb, the nail margin is removed and the nail root in this area is destroyed. Most commonly, the doctor will use an acid to kill the root of the nail, but other techniques are also available. It may take a few weeks for the nail margin to completely heal, but there are generally no restrictions in activity, bathing or wearing shoes. Once the numbness wears off, there may be some very mild discomfort but rarely does this require pain medicine. A resumption of sports activities and exercise is generally permitted the following day.

There are very few complications associated with this procedure. Reoccurrence of the ingrown toenail can occur a small percentage of the time. Continuation of the infection is possible which can be controlled easily with oral antibiotics. On occasion, the remaining nail may become loose from the nail bed and fall off. A new nail will grow out to replace it over several months. With removal of the nail margin, the nail will be narrower and this should be expected.

To prevent ingrown toenails it is recommended to wear properly fitting shoes and to trim the toenails straight across and not too short.

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