Mr Derek Robinson 01225 851185

Mr Tristan Barton 01225 838865

info@bfaclinic.co.uk

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Adult Onset Flat Foot

Most people's feet have a space on the inner side where the bottom of the foot is off the ground (the "arch" of the foot). The height of this arch varies a lot from one person to another. People who have a low arch, or no arch at all are said to have flat feet.

Many people have a low arch and have had it since childhood. If you have had a normally arched foot that becomes flat in middle age it is termed adult onset flat foot.

Symptoms

The onset of symptoms is usually gradual but it can follow an injury and be rapid. There are various stages to the disease process.

Stage 1

Initially pain and possibly swelling will be present on the inner side of the ankle just below the ankle bone (medial malleolus). During this phase the foot may keep its normal shape and the arch may not drop. It is due to inflammation around the tendon

Stage 2

The arch will fall and the heel will start to move outwards. Because of this pain will often start to be felt on the outer side of the ankle as the tissues on the outer side of the ankle become trapped between the heel and the outer ankle bone (fibula). Eventually the tendon may rupture and then the pain on the inner side of the ankle may improve. In stage 2, the joint of the foot remain supple and mobile.

Stage 3

If the condition progresses, the joints at the back of the foot develop arthritis due to the abnormal position that they are in and the joints become stiff. If this occurs, it is not possible for your doctor to correct the position of the foot in the clinic. Pain will occur due to the trapping of the tissues on the outer side of the ankle but also due to the arthritis in the joints.

Stage 4

Eventually the ankle joint may become deformed and arthritic and this is stage 4 disease. Because of the progression of the disease without appropriate treatment, it is essential to be assessed by an expert foot and ankle surgeon as soon as possible.

Cause

There are several causes of adult onset flat foot but the commonest is Tibialis Posterior Tendon Dysfunction. Tibialis Posterior is a large muscle that runs from the calf into the foot behind the inner aspect of the ankle (medial malleolus). Its function is to turn the foot inwards, support the arch and help to initiate tip-toe standing. Another cause is arthritis, which can cause the joints in the middle of the foot to become deformed and so the arch flattened.

Establishing a Diagnosis

This is based on the symptoms and examination findings. Following the examination it is usual to X-Rays to identify any arthritis that may be present, and then to perform an ultrasound or MRI scan of the foot to assess the state of the tendon.

Treatment Options

Stage 1

Treatment consists of anti-inflammatory medication, insoles (orthotics) and physiotherapy. It is sometimes necessary to ask a radiologist to perform a ultrasound guided steroid injection around the tendon. If symptoms fail to settle with these measures surgery may be necessary. Surgery at this stage involves opening the sheath in which the tendon runs and removing all the inflamed tissue and repairing any damage to the tendon (Tibialis Posterior Tendon Decompression).

Procedure Information

Stage 2

It is still usually possible to control the symptoms with insoles to realign the heel but it is sometimes necessary to perform surgery.  Surgery involves replacing the function of the damaged tibialis posterior with another tendon that runs in the same area. It is also necessary to move the heel over into a more normal position and this involves dividing the heel bone and moving it inwards then fixing it with a screw (Tibialis Posterior Tendon Reconstruction).

 

Procedure Information

Stage 3

It may be possible to control the symptoms with appropriate footwear and orthotics but if symptoms are significant and not controlled an operation will be necessary. The operation involves fusing 3 joints underneath the ankle so that they are in a corrected position and are pain free (a triple fusion).

Procedure Information

Achilles Tendon Pain

The Achilles tendon (or heel cord) is the largest tendon in the human body. It connects the calf muscles (gastrocnemius and soleus) to the heel. This allows you to powerfully raise the heel off the floor during walking and running.

Pain may originate either from the main body of the Achilles (non-insertional) or where it inserts into the heel bone (insertional). Pain in either site may be due to inflammation surrounding the tendon or degeneration of the tendon itself.

With age, the tendon becomes less flexible and weaker. Injuries therefore tend to occur in middle-aged people who keep active.

Symptoms

Pain is felt from the site of the problem. Initially this may just be at the start of exercise but later it can be constant. If there is pain at the insertion this can be associated with a prominence that rubs on your shoes. There is usually swelling of the tendon itself.

Cause

Several factors predispose an individual to Achilles tendon problems. Most Achilles tendon problems occur in middle-aged athletes and are basically overuse injuries. In a few cases, other medical conditions contribute to the weakening of the tendon. A high-arched or low-arched foot may increase the stresses on the Achilles tendon.

As we get older the tendon becomes less flexible and less able to absorb the repeated stresses of running. Eventually small "degenerative" tears develop in the fibres of the tendon. The body tries to repair these tears. Sometimes the repair process is successful. However, the blood supply of the lower part of the tendon is not very strong and the combination of this and the continued stresses of running mean that the tendon may not completely heal. Instead, the tendon and its lining become painful and swollen, and the tendon may feel weak. Sometimes the tendon becomes weakened by the degenerative process to the extent that it tears completely.

Establishing a Diagnosis

The diagnosis is made on the basis of the history and examination findings. The Achilles tendon will be examined to identify areas of tenderness and swelling. It is also important to assess the flexibility of the joints, the shape of the foot and how you walk as these factors can play a role in the development of the problem. If the problem is at the insertion then an x-ray will be taken as this will demonstrate the shape of the bones and also show any calcium that is often laid down within the tendon itself. An MRI scan will usually also be arranged as this will be able to identify the exact site of the main problem, whether it is the tendon itself or the surrounding tissue, and also the severity of the condition.

 

Treatment Options

Achilles tendon pain can be treated like any other athletic injury or overuse problem in the first instance. You may need to reduce your mileage or the frequency of your sports for a while. When you do run or play, warm up longer and do plenty of Achilles stretches. A change to a softer running surface and well padded running shoes may help. A raise in your shoe will reduce the stresses on the tendon. When the pain and swelling is bad, it will usually be helped by applying an ice pack. For the pain, try simple pain-killers such as paracetamol.

Physiotherapy is often a crucial part of treatment and is aimed at reducing the inflammation in and around the tendon. Once the inflammation is improving, the physiotherapist will start exercises to strengthen and stretch the Achilles tendon.

If you have a foot shape that increases the stresses on your Achilles tendon, an insole in your shoe may help.

Most people will improve a lot after physiotherapy. Some doctors are keen to treat the pain with a steroid injection. This is very rarely indicated and must only be done in extreme circumstances. If it is done it must only be done by an expert under ultrasound guidance. A wrongly placed steroid injection can weaken the tendon such that it may rupture.

A few continue to have trouble and in this case an operation will be considered. Surgery involves removing all the inflamed tissue and any degenerative tissue within the tendon itself, then repairing the tendon. If the degeneration is extensive then it may be necessary to reinforce the Achilles with another tendon that runs close by. If the problem is at the insertion of the tendon then it may also be necessary to remove some bone from the heel.

Procedure Information

Achilles Tendon Rupture

The Achilles tendon (or heel cord) is the largest tendon in the human body. It connects the calf muscles (gastrocnemius and soleus) to the heel. This allows you to powerfully raise the heel off the floor during walking and running.

Symptoms

Patients often describe the sensation of feeling as if someone has hit them on the back of the heel only to turn round and find no-one there. After rupture it is usually difficult to walk.

Cause

The tendon usually ruptures without any warning. It is most common in men between the ages of 40-50, who play sports intermittently, such as badminton and squash. There was probably some degeneration in the tendon before the rupture which may or may not have been causing symptoms.

Establishing a Diagnosis

It is usually possible to detect a complete rupture of the Achilles tendon on the history and examination. A gap may be felt in the tendon, usually 4-5cm above the heel bone. This is the normal site of injury and is called an intra-substance tear. The tear can occur higher up about 10cm above the insertion into the heel at the site where the muscles join the tendon, this is known as a musculo-tendinous tear. A special test will be performed which involves squeezing the calf. Normally if the Achilles tendon is intact this causes the foot to point downwards but if it is ruptured it causes no movement. To confirm the diagnosis and the exact site of the rupture it may be necessary to perform an Ultra-sound or MRI scan.

Treatment Options

If you believe that you have suffered a complete rupture, you should seek urgent medical advice as the sooner that treatment is started the better the chance of a complete recovery. There are 2 treatment options available which are non-operative and operative. Non-operative treatment involves the use initially of a below-knee plaster with the foot held fully bent downwards. This usually stays in place for 2 weeks then is changed for a brace(this is a boot from the knee down to the toes with Velcro straps) which should be worn day and night. The brace will be regularly altered to allow the foot to come up to a more neutral position. The brace will be on for a further 6 weeks. After the 8 weeks you will be referred for physiotherapy to regain movement and calf strength but will probably need to wear the brace during the day for a further 4 weeks. Non-operative treatment avoids the risks of surgery but the risk of the tendon re-rupturing, which normally occurs within 3 months of discarding the brace, is 8%. Operative treatment involves a 6cm incision along the inner side of the tendon. The torn ends are then strongly stitched together with the correct tension. After the operation a below knee half cast is applied for 2 weeks. At 2 weeks a brace will be applied that will allow you to move the foot and fully weight-bear for a further 6 weeks. After this you will need physiotherapy. Surgery carries the general risks of any operation but the risk of re-rupture is greatly reduced to 2-4%. The best form of treatment is controversial with good results being obtained by both methods. Surgery should be considered in the younger and more active patients. Non-operative treatment is generally recommended for less active, older individuals or those with a musculo-tendinous tear (not in the tendon itself). Your surgeon will discuss the options to decide the best form of treatment for you.

If the tendon is treated promptly then most people are able to return to their previous sporting activities. After operative repair and early active rehabilitation with supervised physiotherapy most patients may be expected to return to jogging at 3 months and running / jumping sports by 6 months.

Procedure Information

Ankle Arthritis

The ankle joint is a hinge between the tibia (shin bone) and the foot and allows up and down movement. The heel bone moves from side to side by movement of the joint underneath the ankle. The ankle has to bear 5 to 7 times the weight of your body during day to day activities, such as standing and walking.

Symptoms

Arthritis leads to loss of cartilage and roughening of the joint surface. This causes stiffness, pain and swelling.

During the early stages, there may be discomfort during exercise which settles with rest. As the arthritis advances, normal walking or weight-bearing becomes painful and eventually it may become constant. Despite this, it is rare to have pain in bed at night.

A natural response of the body to osteoarthritis is to lay down extra bone. In ankle osteoarthritis this is usually laid down at the front and so particularly limits the upward movement of the foot. Because of this, pain is often felt when the foot is forced upwards such as when going down stairs.

Inflammation can cause swelling of the ankle joint which you will see across the front of the ankle. Because of the cartilage damage you may feel the ankle grating or creaking. The cartilage may be worn away more on one side of the joint and this will lead to a deformity of the ankle. You may notice the heel turning more inwards or outwards.

Excess body weight can overload a joint and worsen the symptoms of arthritis. Every extra kilogram of body weight is multiplied by 5 to 7 times when it is carried by the ankle.

Cause

Ankle arthritis can be caused by degeneration (osteoarthritis) or inflammation (rheumatoid arthritis). In both cases the cartilage, which lines the joint becomes damaged. This causes bone to rub on bone, which is painful.

Osteoarthritis is usually secondary to damage to the joint, often as a result of a previous fracture, repeated sprains of the ankle, malalignment of the joint or infection.

Establishing a Diagnosis

This is based on the symptoms, examination findings and x-ray appearance. Examination will look for swelling and tenderness of the ankle. There may be ankle deformity, a limited ability to pull the foot upwards and pain on crouching. It may be possible to feel the ankle grating.

X-rays of the ankle will be taken whilst you are standing. This is necessary as the extent of cartilage damage is often not appreciated if the x-ray is taken while you are lying on a couch. It will be possible to see any ankle deformity and also extra bone that has been laid down at the front of the ankle.

Blood tests are sometimes used to investigate for inflammation.

Treatment Options

As with all forms of arthritis, simple measured should be tried first. These include resting when the pain necessitates, slowing down and altering sporting activities. Supportive boots and a walking stick are also useful. The most important and effective non-operative treatment is weight loss.

Pain killers such as Paracetamol can be effective. Non-steroidal anti-inflammatories such as Brufen, Ibuprofen and Diclofenac can reduce inflammation. Patients need to check with their General Practitioner or pharmacist that they are suitable for them, as they can have side effects, especially if you have asthma or stomach ulcers.

Dietary supplementation with Chondroitin and Glucosamine, which can be bought in health food shops, may be effective in some patients with early disease. No harm will be done by trying these for a few weeks to assess their benefit. If you feel no improvement then they can be stopped but if you feel that they are helping then you will probably wish to continue taking them. They will not however replace the lost cartilage.

Physiotherapy and hydrotherapy occasionally help with pain and stiffness.

Patients with inflammatory arthritis are usually looked after by a rheumatologist and so may require specialist medication. If there is inflammation in the ankle it is possible to inject steroid into the joint to try and reduce this.

Operations

There are several operations for ankle arthritis. The most appropriate for you is best decided by a specialist foot and ankle surgeon who has the expertise and ability to perform all the different procedures. The factors to be considered include the severity and type of the arthritis, your age and activity level, and whether other nearby joints are also stiff and arthritic.

There are 3 main procedures.

  1. Arthroscopic cheilectomy
  2. Ankle fusion.
  3. Ankle replacement.

Arthroscopic Cheilectomy

This is suitable for early arthritis and is undertaken through a keyhole technique. The ankle is washed out with fluid and the loose bits of 'gristle' and bone are removed. If there is extra bone at the front of the ankle this is removed at the same time.

This does not reverse the damage done to the cartilage but it can be beneficial in relieving pain for an unspecified period of time and improving stiffness.

Procedure Information

Ankle Fusion

This has been the treatment of choice for severe ankle arthritis for many years. The pain of ankle arthritis is due to the movement of the joint. If this movement is prevented then the pain should go. It involves completely removing the damaged cartilage from ankle joint and then fusing the bones together by holding them with screws.

Many patients are concerned that if they can’t move their ankle they will walk very badly. Surprisingly this is not the case. The rest of the foot has movement that to a degree can take over the movement that is lost from the ankle. To watch someone walk with a fused ankle it is often difficult to tell that they have had an operation, running however is often difficult. As almost all patients with severe ankle arthritis walk with a significant limp and can’t run before surgery their walking is often improved. It is the operation of choice for patients with severe arthritis who are young and active and also for older patients with significant deformity.

There is a theoretical risk of degeneration in the mid and hindfoot joints as they compensate for the lack of ankle movements but this may take >20 years to develop and be asymptomatic. We cannot tell who will develop symptomatic arthritis of the surrounding joints before the operation.

Ankle fusion itself has historically been done as a major open procedure but with the development in arthroscopic techniques and improvement in equipment it is now usual to fuse the ankle arthroscopically which has several advantages. The incisions are very small, the risk of infection is less, the bones heal more reliably and possibly faster, the pain is very much reduced and so is hospital stay.

Procedure Information

Ankle Replacement

Ankle replacement has been undertaken for many years. The initial designs were not very successful however newer designs are available. Since their initial development we have a much greater understanding of the ankle joint and much better materials. The new ankles have vastly improved outcomes and in appropriately selected patients it is the procedure of choice.

The aim of surgery is to relieve pain and allow retention of ankle movement.

Patients who are most suitable for replacement tend to be less active therefore usually over 60 years of age or have rheumatoid arthritis. Patients with rheumatoid arthritis are also particularly suitable as they may also have other stiff arthritic joints in the foot. Because of this it is important to retain some movement in the ankle.

Ankle replacement is less appropriate if the ankle is very stiff as it does not necessarily increase the movement. Young, active individuals may wear out the ankle and are better served with a fusion. If there is severe ankle deformity this may put extra strain on the replacement causing it to fail early.

Long-term results for ankle replacements are not yet as good as those for hip or knee replacements. We would however expect that >90% of ankle replacements would be successful for at least 5 years and often much longer.

This is a challenging surgical procedure and should only be undertaken by surgeons with experience and expertise.

Procedure Information

Osteochondral Lesions of the Talus (OLTs)

The ankle joint is composed of three bones. On the top are the Tibia and Fibula and they form a joint with the talus beneath. An osteo-chondral lesion is a defect in the upper surface of the talus that involves bone(osteo-) and cartilage (chondral). There are differing degrees of severity varying from very small undisplaced lesions to those that create large loose bodies and develop cysts in the talus.

Symptoms

The typical history is that of a sprained ankle that never gets better. It may cause aching in the ankle or symptoms of clicking, locking and swelling. Sometimes you can feel something moving in the ankle.

Cause

The most common cause of an osteo-chondral lesion of the talus is twisting the ankle. As the ankle twists a small area of bone and cartilage can be knocked of the surface of the talus. It is not necessary for the ankle itself to fracture to create this lesion. This is a very common cause of on-going symptoms after a sprained ankle. It has been estimated that 6% of ankle sprains are complicated by an osteo-chondral lesion. Occasionally the lesion can just develop and the cause for this is not completely understood.

Establishing a Diagnosis

This is initially based on the history, symptoms and examination findings. Examination will look for swelling and specific areas of tenderness of the ankle. X-rays of the ankle will be taken but it is often difficult to see osteo-chondral lesions unless they are large and displaced. Because of this it is usually necessary to perform an MRI scan that will clearly demonstrate the abnormality.

Treatment Options

If you sprain your ankle and an X-ray demonstrates an osteo-chondral lesion then this should be treated with plaster immobilization if it is undisplaced. If there is a displaced fragment then you should be assessed by an orthopaedic surgeon as the abnormality will need to be addressed. The size of the fragment will determine whether it can be re-attached or whether it should be removed. Assessment will be required with a small camera in the ankle.

Usually however the lesion is not obvious on initial x-rays and the problem only comes to light when the ankle fails to settle after a sprain. It is therefore often months or years before you will attend your doctor complaining about your ankle after what may have been a very minor sprain. At this stage the lesion may be more apparent on x-rays but it will be clearly seen on an MRI scan which is the best form of investigation. Treatment for an ankle that has an osteo-chondral lesion and ongoing symptoms involves an ankle arthroscopy (key-hole surgery). The operation involves assessing the joint and removing the damaged tissue. If this leaves an area of exposed bone then this will be freshened to expose healthy underlying bone that will then produce a form a cartilage to cover the area.

Surgery is performed under general anaesthetic usually as a day case procedure. The procedure takes around 60 minutes. The aim of surgery is to assess the damage to the joint, remove any torn cartilage and then freshen the underlying bone. This then encourages the growth of a different form of cartilage to cover the defect. It is hoped that this will then resolve the symptoms. The success of the operation depends on several factors but mainly the severity of the lesion. If a lesion has been left untreated for a long period of time it appears that the lesion grows and a cyst forms beneath the area originally damaged. The bigger the cyst becomes the less likely it is that surgery will resolve your symptoms.

Procedure Information

Peroneal Tendon problems

There are 2 peroneal tendons that lie on the outside part of the lower leg behind the fibula. They then pass into the foot and are responsible for pulling the foot downwards and outwards and also contribute to stabilising the ankle joint. The tendons are held behind the fibula by a thick layer of tissue called the peroneal retinaculum.

Symptoms

The tendons can become inflamed, causing pain and swelling behind the fibula at the ankle. It can also cause weakness of the ankle which may predispose the ankle to giving-way easily on uneven ground.

The tendons are held in place by a structure called the peroneal retinaculum. This structure can be torn causing instability of the tendons, and they may be felt to ‘flick’ over the edge of the fibula. This will cause the tendons to become inflamed and painful, and you may also be able to feel the tendons moving and snapping on the outside of the ankle.

Cause

The reticulum comes away from the bone most commonly following a twisting injury to the ankle. It is one of the causes of ongoing pain around the ankle after what may appear to have been a simple ankle sprain. The tendons may become inflamed as a result of physical activity, and this inflammation of the tendons may eventually lead to rupture.

Establishing a Diagnosis

Most peroneal tendon injuries may be diagnosed by careful history and examination. Examination may reveal specific tenderness over the tendons and it may be possible to make the tendons snap over the bone. X-rays are taken to assess the ankle for other causes of pain. An ultrasound or MRI scan can be organised to demonstrate the abnormality, highlight any tears in the tendons and also show if there are problems elsewhere in the ankle that need to be addressed.

Treatment Options

The initial treatment for inflammation of the tendons is conservative. Anti-inflammatory medication, activity modification, footwear changes and physiotherapy may help. Acute injuries and inflammation of the tendon sheath frequently respond to non-operative therapy. Tendon tears and dislocating tendons, however, often require surgery to repair the tendons and reconstruct the retinaculum.

Procedure Information

Plantar Fasciitis

There are a number of strong ligaments underneath the foot which help to support the arch. The strongest of these ligaments is the plantar fascia. It is attached at the back of the foot to the heel bone and passes forward to the toes. In some people the plantar fascia becomes painful and inflamed. This condition is called plantar fasciitis.

Symptoms

Typically, severe pain is felt at the start of the day with the first few steps. The pain then eases but as the day progresses the pain builds up and the foot begins aching. The pain is also increased after periods of sitting when the foot is again put to the floor.

Cause

A problem may occur when part of the plantar fascia is repeatedly placed under stress. This creates inflammation usually at the point where the fascia is attached to the heel bone.

The causes include constant stress, so plantar fasciitis is therefore commoner in people who spend all day on their feet, or are overweight. Stiffness of the ankle or tightness of the Achilles tendon increases the stresses on the heel. People who have high-arched or flat feet are less able to absorb the stress of walking and are at risk of plantar fasciitis.

The inflammation at the heel bone may produce spike-like projections of new bone called heel-spurs. The heel spurs do not however cause the heel pain and they are not the initial cause of the problem.

Establishing a Diagnosis

This is based on the symptoms and examination findings. Examination may reveal specific tenderness at the site where the plantar fascia inserts into the heel bone. You will also be examined for any evidence of predisposing factors. X-rays are usually taken to help exclude other causes of heel pain and the diagnosis can be confirmed with an ultrasound or MRI scan. Blood tests may also be performed to look for an underlying cause.

Treatment Options

95% of patients with plantar fasciitis get better but in the more severe cases this can take up to 2 years. There are many ways that you can help the symptoms.

  • Reduce the time you spend on your feet.
  • Lose weight to reduce the stress.
  • Wear shoes with a soft, cushioned heel (such as training shoes).
  • Heel pads can be bought in most chemists. These pads can be put in standard shoes to reduce the impact of walking.
  • Take anti-inflammatory medication (such as ibuprofen) which is available from the chemist (always take advice before using anti-inflammatories as they can have side effects)

If you have troublesome ongoing symptoms that are not responding you should seek medical advice from your GP. Further treatments options include

  • Physiotherapy. This remain the mainstay of treatment. Techniques can be used to help calm down the inflammation and also ensure full mobility of the Achilles tendon and the plantar fascia itself.
  • Night Splints. These are plastic splints that keep the foot stretched and the ankle at right-angles when you are asleep. This maintains the tension in the plantar fascia and may help to alleviate some early-morning symptoms during the first few steps of the day.
  • Steroid injection into the attachment of the plantar fascia to damp down the inflammation. This can be repeated if it is beneficial.
  • Shockwave treatment. This new treatment has been shown to a very successful method of treating plantar fasciitis. This involves the sessions of treatment over 1-2 week intervals.
  • Surgery. This is rarely required for plantar fasciitis. It would only be considered if all forms of conservative treatment fail and if the pain is still incapacitating after at least 12 months. Surgery would be likely to involve releasing the calf muscle which can become tight in patients with plantar fasciitis.

Sprained Ankle

The most commonly occurring sports injury is the ankle sprain. It is so common that it accounts for about 20% of all sports injuries. During walking or running the ankle and foot move inwards more than the stabilizing structures normally allow.

Ligaments are structures that connect bones together. A sprain is an injury to a ligament. There are differing severities of sprain that vary from mild to a complete rupture. On the outside of the ankle the principle ligament is the anterior talo-fibular ligament (ATFL) that lies at the front and connects the talus to the fibula. It is this structure that is most frequently injured during an ankle sprain.

Symptoms

As you twist your ankle you may hear a pop or crack and feel a tearing sensation. There is usually a rapid onset of swelling around the site of the damaged ligaments which is often on the outer side of the ankle and later on bruising will appear. You will probably be able to walk if you have only damaged ligaments but if severe it may not be possible. When you twist your ankle there are a lot of structures that can be damaged. There are several bones which can be fractured and also some tendons which can be torn.

If you have a severe ankle injury it is best to get professional advice immediately. Things that suggest a severe injury include, your ankle is so painful that you cannot walk on it, the ankle looks deformed, the skin over the ankle is broken, the injury was caused by a severe force such as a fall from a height or a blow from a heavy object, or the pain and swelling seem to get worse rather than better over the first 3-4 days.

Establishing a Diagnosis

This is based on the history of the injury and examination findings. Because it is possible to injure bones, ligaments and tendons when you twist your ankle you will be examined to identify the specific site of tenderness as this will help to identify the structures that are injured. It may be obvious that you have only sustained a sprain but if there is any doubt about the possibility of a fracture then an x-ray will be obtained.

Treatment Options

Most ankle sprains are fairly minor injuries, which will get better with simple self-care treatment. The word RICE reminds us of the basic treatment of a sprained joint:

  • Rest - take the weight off the injured joint as much as possible for a day or two
  • Ice - an ice pack (a small bag of frozen peas is ideal) can be applied for 10-15 minutes, 3-4 times a day to reduce swelling
  • Compression - a support bandage or strapping will help to reduce the swelling
  • Elevation - resting with the ankle above the height of the body will allow swelling to drain away into the bloodstream

Although a couple of days rest is useful, it is best to start taking some weight on the injured ankle reasonably soon after injury, usually within 2-3 days. Also start to exercise and stretch the injured ankle as soon as possible after the injury. Normally a sprained ankle will recover within 6-8 weeks, although it may tend to swell for a few months longer.

Sometimes patients have symptoms that are ongoing and they complain that their ankle has never been right since they twisted it. If this is the case and you are making no improvement then it is best to be assessed by a foot and ankle surgeon. Ongoing symptoms are often due to damage to the ankle joint surface (osteochondral lesions – OLTs) or ruptured tendons that lead to chronic instability (see unstable ankle) such that you keep going over on it or may be due to another small fracture that has not been previously identified. Sprains that show no signs of improvement by 3 months require further assessment.

The Unstable Ankle

The most commonly occurring sports injury is the ankle sprain. It is so common that it accounts for about 20% of all sports injuries. During walking or running the ankle and foot move inwards more than the stabilizing structures normally allow.

Ligaments are structures that connect bones together. A sprain is an injury to a ligament. There are differing severities of sprain that vary from mild to a complete rupture. On the outside of the ankle the principle ligament is the anterior talo-fibular ligament (ATFL) that lies at the front and connects the talus to the fibula. It is this structure that is most frequently injured during an ankle sprain.

An unstable ankle occurs when an ankle sprain never completely heals. It usually follows a severe twisting injury to the ankle.

Symptoms

The symptoms include recurrent instability, swelling, bruising and difficulty walking. The ankle may give way easily, particularly on uneven ground or if you are walking on a slope such that the affected ankle is facing down the slope. There may be a continual ache from the outer aspect of the ankle. It is often stated that the ankle has never felt right after the original twisting injury.

Establishing a Diagnosis

The diagnosis is made by history, examination findings and specific further investigations. Examination may reveal specific tenderness over the site of the injured ligament(s). Your ankle will also be assessed for stability by specific tests that stress the ligaments. An x-ray will be performed to identify any other abnormality which may have arisen such as an osteo-chondral lesion(see osteo-chondral lesion (OLT) of the talus) or arthritis of the ankle. Sometimes the ligaments themselves do not rupture but they pull a small piece of bone off at its attachment. This is termed an avulsion and may be visible on the x-ray. An MRI scan is then usually organised as this can clearly demonstrate the extent of the ligament damage and also any other abnormalities that my need to be addressed.

Treatment Options

Patients with unstable ankles need a thorough assessment by a foot and ankle specialist to determine the exact cause of their symptoms. If the problem is due to ankle ligament damage then a course of physiotherapy should be tried. This will aim to strengthen the muscles that run around the outside of the ankle and also give you more control over the ankle. It may be necessary to wear a form of ankle brace to support the ankle and stop it giving way. Despite these measures if you have ongoing symptoms of instability then it is usually necessary to perform an operation to stabilize the injured ligaments. It is usually possible to just strengthen the ligaments that have been damaged by dividing them, re-attaching them to the fibula and then overlapping them. Sometimes the ligaments are so damaged this is not possible and it is necessary to use part of a tendon that passes around the ankle to replace the function of the disrupted ligament.

There are several operations that may be performed to reconstruct the lateral ligaments. The commonest one is called a Brostrum repair and it is often combined with an ankle arthroscopy so that the ankle joint itself can be cleaned and inspected for any other damage.

Procedure Information

Osteoarthritis / Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory condition that very commonly causes problems with the feet.

Bunion (Hallux Valgus) Deformity

A bunion is a deformity of the big toe in which instead of lying straight the big toe bends towards the smaller toes. A bony prominence appears on the inside of the foot at the base of the big toe. This prominence often rubs on shoes causing inflammation and pain.

Once a deformity has appeared it often progresses but the rate of progression is highly variable. As the deformity worsens, pressure is exerted on the smaller toes, especially the second, which then themselves become deformed and painful as they rub on the top of the shoe.

Because the big toe is deformed it can predispose to arthritis.

Symptoms

The main problem is usually the pressure of the shoe over the bony prominence, which causes discomfort or pain. Sometimes the skin over the lump becomes red, blistered or infected. The foot may become so broad that it is difficult to get wide enough shoes. The big toe sometimes tilts over so much that it rubs on the second toe, or pushes it up out of place so it presses on the shoe. Also, the big toe does not work as well with a bunion, and the other toes have to take more of the weight of the body as you walk. This can cause pain under the ball of the foot.

Cause

There is no single cause of bunions. They tend to run in families and you may be aware that your mother or grandmother had them. They are also commoner in women than in men. Bunions do occur in cultures in which shoes are not worn, but much less commonly. Shoes which squeeze the big toe, do not fit properly, or have an excessively high heel can probably help to cause the deformity especially in people who are at higher risk anyway. Inflammation of the joint due to conditions such as Rheumatoid Arthritis and Gout can also cause the deformity.

Establishing a Diagnosis

The diagnosis is obvious on examination of the feet. You will also be examined for small toe deformities and areas of pressure under the ball of the foot. It is also important to assess the whole shape of the foot as mal-alignment of other parts of the foot and ankle can be a cause of the deformity.

X-rays will be performed to demonstrate the degree of deformity and the presence of any arthritis.

Treatment Options

As symptoms are usually due to pressure on the bunion the first step is to find comfortable shoes that give the front of the foot enough room. Patients often find that the bunions do not cause significant symptoms in the summer as sandals can be worn. However when the weather becomes colder and enclosed shoes are worn, symptoms may develop. Some patients find benefit in wearing pressure relieving plasters or inserts between their toes. All of these things can help to relieve symptoms but they will not stop the progress of the bunion.

If simple measures fail to provide acceptable relief of symptoms then surgery can be considered. There are a lot of different operations for bunions, depending on the severity of the deformity, the shape of your foot and whether arthritis has developed in the big toe joint. The operation will remove the prominence on the inner side of the big toe and also straighten it. If there are symptomatic deformities of the smaller toes then these can all be addressed at the same time.

There is a myth that bunion surgery is very painful. This is probably because techniques commonly used until 5 years ago involved cutting the bone but not using any screws to stabilize it. This was indeed often painful but using modern surgical techniques, the bones are solidly fixed with small screws. This means that the operation is much less painful than it was just a few years ago and post-operative mobilisation is quicker. It is only in occasional cases that a plaster cast is required after a bunion operation. When this is combined with local anaesthetic techniques, most patients are up and walking within hours of the surgery without significant discomfort.

Procedure Information

Forefoot problems in Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory condition that very commonly causes problems with the feet. Whilst any of the joints in the foot and ankle may be affected it is often the toes that are most severely involved and cause the most problems.

The classical changes that affect patients with rheumatoid arthritis are that they will develop a bunion so the big toe will deviate towards the lesser toes. As well as this the lesser toes become deformed with hammering or clawing. The lesser toes will slowly become more deformed and because the ligaments holding the toes in place becomes weakened by the arthritis they will eventually dislocate upwards out of position. Because the toes themselves are out of joint it exposes the bones in the sole of the foot (metatarsal heads) to more pressure and they can often be felt just underneath the skin.

Symptoms

There are varying degrees of severity. Initially you may only notice pain, swelling and warmth of a single joint, usually one at the base of the toes. As the disease progresses the deformities will increase. Symptoms will be felt from the bunion and the dislocated toes as they will rub on shoes. Due to the prominent bones in the sole of the foot it often feels as if you are walking with a pebble in your shoe. This is often very painful. It will be difficult to buy shoes that are comfortable and it may be necessary to have specially made shoes.

Establishing a Diagnosis

If you have significant deformities you will almost undoubtedly have been under the care of a rheumatologist, probably for many years. The diagnosis of the foot problems will be obvious on examination but x-rays will be taken to confirm the severity of the forefoot involvement.

If you present with swelling and pain in a single joint or possibly several of the toes and rheumatoid arthritis has not been diagnosed you will need to be fully assessed. It is necessary to perform blood tests to obtain a definitive diagnosis and it may also be necessary to have further x-rays and ultrasound scans to give further information. If rheumatoid has not been formally diagnosed you will be referred to a rheumatologist who is best placed to undertake the tests and start treatment which will be in the form of medication to calm the inflammation.

Treatment Options

For patients with long-standing forefoot changes and significant deformities the first stage of treatment involves the use of insoles to alleviate pressure on the prominent areas and obtaining appropriate shoes that allow enough room for the toes without them rubbing. It may be necessary for these shoes to be specially made for your feet. If you have ongoing pain and difficulty then surgery may be required. The exact operation that is performed will depend on the severity of the deformities that you have. There are many techniques and they include cutting the bones to re-align them, fusing them in a better position or simply removing the prominent sections of bone. Surgery for foot problems in rheumatoid arthritis is usually very successful and most patients are delighted with the results.

Procedure Information

In-growing Toenail

This is when the edge of the toenail (usually the big toe) digs into the skin fold beside the nail. This is often very painful, and sometimes bacteria from the skin get into the inflamed skin and an infection begins. The side of the toe becomes red, hot, tender and swollen and pus may discharge from the edge of the nail.

Cause

The nail edge may dig in because of its shape, because it becomes ragged and sharp (due to picking or inappropriate cutting) or because of an injury.

Whilst it is not always possible to prevent in growing toenails, if you look after your toenails well and prevent them from getting ragged or developing painful spikes, you will reduce the chance of getting one. If you cut your nails straight across they will not have spikes on the end and the end will be clear of the edge of the nail fold where it usually digs in.

Treatment Options

If the nail is only mildly inflamed, trimming it straight across and easing the spike or nail edge out of the irritated area in the nail fold can help. Salt baths can help reduce the inflammation. Salt water can be made by boiling a pint of water and then adding a teaspoon of salt. The water should be allowed to cool before use.

If you have an in growing toenail that is not getting better with simple treatment and is interfering with your life it is worth contacting your GP or a chiropodist.

They will want to check that you have tried all the simple measures outlined above. If the nail is still not getting better, it is usually best to partially or completely remove the nail to allow the nail to heal. This is usually done under a local anaesthetic to numb the toe.

Many in growing toenails will heal after this treatment, but many others will not. If the in growing toenail recurs it is often best to remove the corner of the nail bed to stop the edge of the nail growing again. This may be done either with a chemical (phenol) or by cutting it out surgically.

Procedure Information

Morton's Neuroma

A Morton's neuroma is a benign swelling of a nerve in the ball of the foot. It affects the nerves which supply sensation to the toes, most commonly the nerve between the third and fourth toes. Thomas Morton was an American doctor who described the condition in 1876.

Symptoms

Pain is felt in the ball of the foot, when walking and standing, that may radiate down into the toes. It is worse when wearing shoes, particularly with a high heel. Relief is felt on removing shoes at the end of the day. It may feel as if you are walking on a pebble and you may also feel a clicking sensation in the ball of the foot. The swollen nerve may make two adjacent toes spread apart.

Cause

The cause of nerve swelling is repeated compression. The nerve sits in a tight space between 2 bones (metatarsal heads) and underneath a ligament that connects the 2 bones. The nerve becomes trapped when standing and walking. The nerve becomes inflamed and scar tissue is laid down around the nerve. It therefore has even less room and is more liable to further compression.

It affects women 10 times more commonly than men and usually between the ages of 30-60. It most commonly occurs between the third and fourth toes, and less frequently between the second and third toes.

Establishing a Diagnosis

This is based on the symptoms and examination findings. Examination may reveal tenderness between two toes and specific tests may reproduce the pain. The diagnosis is usually confirmed by further imaging (ultrasound or MRI)

Treatment Options

Initial treatment is by shoe modification. High heels and tight fitting shoes should be avoided. An insole may be of benefit to relieve pressure on the affected area. A steroid injection can be used in the early stages of treatment. If symptoms fail to settle then the neuroma can be removed surgically.

Procedure Information

Osteoarthritis of Base of Great Toe

Hallux rigidus is arthritis of the main joint at the base of the great toe. It may affect one or both feet but it is not normally associated with generalized arthritis throughout the body. 

Symptoms

Pain is felt at the base of the great toe. This is made worse on walking and is more noticeable when going up-hill or when wearing a higher heeled shoe. The base of the great toe becomes stiff, particularly limiting the upward bend of the toe. The downward bend is less affected but is often painful. A swelling may develop on the top of the joint, and this represents the extra bone that has been laid down in response to the arthritis. There may be altered sensation on the top of the great toe.

Cause

In most people there is no particular cause but in others it may follow an injury or another joint disease such as gout or infection. If the great toe is deformed (bunion), then this predisposes the joint to arthritis. The response of the joint to arthritis is to lay down extra bone.

 

Establishing a Diagnosis

This is based on the symptoms and examination findings. The bony swelling may be palpable. There will be a reduction in the amount of upward movement of the great toe and this is usually painful. An x-ray will be taken to confirm the diagnosis and assess the severity of the condition

Treatment Options

Simple measures should be tried in the first instance. These include avoiding activities that exacerbate the pain, taking analgesics and wearing comfortable shoes that do not rub. Usually stiffer soled shoes are better as they limit the amount of movement of the great toe. High-heeled shoes may also make the pain worse.

If symptoms continue then treatment depends on the severity of the condition. Initially a steroid and local anaesthetic injection can be performed to reduce the pain in the joint.

If the arthritis is more advanced but only affects part of the joint, then an operation can be performed which will remove the extra bone which has been laid down and the joint can also be cleaned out. This is known as a cheilectomy. It should reduce the pain and increase the range of movement of the toe.

Procedure Information

If the whole joint is affected then the most common operation performed is a fusion. This involves removing the joint surfaces and then holding them together with screws until they knit together. Following this the toe is stiff but pain free.

Replacement of the joint is a newer technique. To date, long-term studies are not available and outcome is less predictable. Because of this, very careful consideration needs to be given before undergoing a replacement.

Procedure Information

Small Toe Deformities

The small toes are important in walking, especially when pushing off with the foot towards the next step. They share the pressure with the big toe and the ball of the foot.

There are many different types of toe deformity with different names such as hammer, mallet and claw toe.

Symptoms

The main problem with deformed toes is that they tend to rub on shoes, either on top or at the tip, or both. This rubbing may simply be uncomfortable, or the skin may be rubbed raw.

If the toe is bent upwards, particularly if it is stiff, it may cause pressure underneath the ball of the foot.

Cause

Toes become deformed when the pressures on the toe are stronger than their joints can resist. This may be because the joints are weak or the pressures strong, or both. The joints may be weak because they have been damaged by injury or arthritis. The muscles that control them may become unbalanced, so that one set pulls harder than another and causes the toe to bend.

Pressure on the toe from the shoe gradually causes the toe to buckle. The toe may curve over the next toe and rub on it. This is especially common in the 2nd toe, particularly if the big toe bends towards the second toe (bunion).

Treatment Options

As the symptoms are due to pressure on the top or tip of the toe or under the ball of the foot, the most important thing is to buy shoes that have enough room in the toe area for your toes to fit comfortably. Avoid high heels, which tend to force the toes down into the tip of the shoe. Small pads on the top or end or the toe may improve the discomfort.

If your toes are interfering with your daily activities and the problem is not helped by he simple measures outlined above, then an operation to straighten the toes may be necessary.

There are a number of different operations which can be used, depending on the shape of your toes and how stiff they are.

Procedure Information



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