Foot and Ankle Issues

A Hammer Toe deformity refers to an abnormal position of the toe, where one or more small toes buckle or bend-under, out of their normal position. A contracture of the toe occurs at the middle toe joint causing the toe to bend out of its normal straight position.

As the toe curls or bends-under certain soft tissue structures such as the tendons to the digits and the joint capsules may tighten and shorten over time. The shortening of the tendon will result in the toe contracture to worsen. The small toes consist of 3 bones and they articulate with 3 different joints. The toe becomes contracted at the middle joint of the toe leading to a very prominent bone on the top of the toe.

There are many causes of Hammer Toes. Some of them are congenital (a condition present at birth), hereditary, muscle imbalance around a toe, shoe gear and certain forms of arthritis may cause hammer toes to develop.

Skin irritation (inflammed skin areas) or even corns (an accumulation of hard dead skin cells) may form on top of these prominent, contracted joints where shoes are likely to rub. In severe cases, a painful, swollen bursitis may develop on the top of the toe due to the constant irritation. This usually will lead to pain and inability to wear most types of shoes comfortably.

Flat plate x-rays are taken to evaluate the severity of the deformity as well as any bony abnormality that may be present. We can determine the joint that is affected. X-rays will allow us to view the bones of the toe to see if a bone spur may be present and causing the problem. If surgical management is an option, x-rays are essential in the pre-operative workup. Fluoroscopy is another form of x-ray. It is a live x-ray and allows us to manipulate the joint while viewing the bones. Joint Fluoroscopy is performed to see the joint function and to evaluate the articular surface of the joint.

The latest technology for viewing soft tissue injuries such as ligaments or tendons is using Ultrasonography. Ultrasonography allows us to view soft tissue structures such as the joint capsule, the tendons to the digits, as well as bone with the use of sound waves. We can determine if there is any bone, ligament or tendon damage. Ultrasonography will allow us to view a bursitis as well as the extent of the bursitis.

There is a computerized gait exam that can be performed in the office. Our office is equipped with a special computerized sensor system that can identify any areas of increased pressure within the foot. The gait analysis system is very helpful in evaluating the foot function while you walk during the gait cycle. This is valuable information that is gathered which can help us in devising an Orthotic device that is custom made to your foot type.

There are many conservative treatment options for hammer toes such as:

1. Proper Foot Care. Daily debridement and shaving down of the painful corns and lesions will help alleviate many symptoms from the hammer toe deformity.
2. Padding and Strapping. Dispersion pads that can be placed on the top of the toes will help in preventing the toes from rubbing in the shoes. If the irritation to the top of the shoes is removed then the symptoms will start to resolve.
3. Shoe Gear. Altering shoe styles will help in preventing irritation of the hammer toes. A wide shoe and a shoe with a high toe box region is very helpful. If the toes don’t rub on the top of the shoes then the painful corns will not develop.
4. Injections. If a very irritated, painful bursitis develops on the top of the toe, then an injection of cortisone will help resolve the bursitis.
5. Orthotics. If the hammer toes are caused by a muscle imbalance, then a Custom Molded Orthotic device could help prevent the deformities from progressively getting worse.

If all conservative methods fail then surgical management of the hammer toe may be necessary. Surgery entails a minor in office surgical procedure. The procedure can be performed under local anesthesia where we only numb the affected toe. In order to straighten the toe, a portion of bone must be removed from the toe. You can return home the same day as the procedure and you can walk on the foot the same day as the surgery. Return to normal shoe gear may occur approximately 2-3 weeks.

A complete evaluation of the Hammer Toe deformity including x-rays of the foot are required in deciding which type of procedure has to be done in order to correct the Hammer Toe and prevent recurrence of the deformity.
Heel Pain in Children (Sever’s Disease)
Pain in the heel is a very common complaint that we see in our office. There are many entities that can cause heel pain ranging Plantar Fascitiis, Bursitis, Stress Fractures, Bone Cysts, Bone Tumors, Tendonitis and Growth Plate disturbances in the younger population.

The most common cause of heel pain in children and adolescents is Sever’s Syndrome. This syndrome is an irritation of the growth plate of the heel bone. The average age of presentation for boys and girls with Sever’s Disease is approximately 11 years. The children experience pain with a variety of athletic activities and more than half are unable to participate in sport because of the pain.

A complete evaluation of the patients heel and a complete set of x-rays of the foot are necessary to confirm the diagnosis of Sever’s Disease. X-rays of the heel usually show an open growth plate which is located in the back of the heel bone. X-ray evaluation is necessary also to rule out a possible stress fracture, bone tumor or bone cyst.

The mainstay of treatment of Sever’s Disease is rest. The restriction of athletic activities for 2 – 4 weeks is often necessary. Sometimes a walking cast and/ or crutches with complete non-weightbearing is necessary. Oral anti-inflammatory medication may be necessary in order to resolve the inflammation that is around the growth plate.

High heeled shoes can predispose the foot and the body to many different imbalances as opposed to a flat shoe. Any elevated heel under a shoe automatically initiates an altered series of foot and body biomechanics.

Standing barefoot, the falling line of body weight normally forms a perpendicular angle with floor. The body weight is distributed 50-50 between the heel and the forefoot. The moment any heel elevation, even the most minimal, is applied to the shoe, the normal 90 degree perpendicular of body weight is altered. The higher the heel the greater the body column change. The heel on a man’s shoe is about one inch in height. On women’s shoe it varies from one to five inches and up to six inches in more extreme footwear.

The muscles, ligaments and various body joints associated with the body column and foot system must make compensatory changes with the elevated heel. If these compensatory changes were not made by the body then the elevated heel would cause our body to fall forward like the Leaning Tower of Pisa. Considering that the simple act of walking involves half the bodies 650 muscles and 208 bones, the number of automatic adjustments is enormous. The toll on the body can be quite extreme leading to leg, back and foot aches.

On a medium to higher heel the increased bowing of arch on the bottom of the foot can lead to a contraction or shortening of the plantar fascia. The plantar fascia is the ligament that helps support the arch of the foot. Overtime the fascia can become vulnerable to strain or tearing when lower heels are worn or with aggressive walking or running.

High heeled shoes are usually accompanied by pointed-toe shoe styles. The narrow toe boxes lead to very little room for the toes. Along with the very little toe space and the overactivity of muscles on the bottom of the foot, in order to keep the body stable while in a higher heel, hammer toe deformities can develop quite frequently.

The frequent use of high heels can lead to shortening or contracture of the large Achilles tendon which is attached to the calf muscle in the back of the leg. In the case of women who become habitual wearers of higher heels, they usually develop the classic aching of the calf muscles and Achilles tendonitis, especially when there are shifts to lower heel shoes. The bursa that is located in the back of the heel is also affected by the change and function of the Achilles tendon leading to a bursitis in the back of the heel bone.

Pain in the ball of the foot region leading to a bursitis of the joints in the ball of the foot result from the added pressure due to the elevated heel. Instead of 50% of the body weight in the heel and 50% in the ball of the foot, with an elevation in the heel 90% of the body weight is now concentrated in the ball of the foot and 10% in the heel.

As we can see high heeled shoes may look very fashionable but prolonged and extensive use of these kind of shoes can lead to many disabling deformities ranging from low back pain to the foot pain.

A Neuroma occurs most commonly between the third and fourth toes Neuromas are caused by a pinching of the nerve between the metatarsals and results in inflammation of the nerve. As this irritation continues, the nerve gets larger, causing sharp pain, cramping, and burning. The symptoms may move into the webspace or towards the tips of the affected toes. Neuromas are caused by high heeled shoes, trauma, inflammatory conditions such as arthritis and repetitive stress incurred in occupational and recreational activities. Shoes that are too tight will aggravate the condition. The condition is often related to an imbalance in the foot structure which may necessitate surgical removal of the neuroma.

In the office x-rays would be taken to rule out any bony deformity that may be causing the pain or that may be aggravating the neuroma. In our office we have an Ultrasonography unit that enables us to view soft tissue structures. A thorough neurological examination is necessary to see if there is an abnormality in the nerves that are affected. The neurological exam can be performed in the office at the time of your visit. We can confirm the diagnosis through the soft tissue scan, the results of the nerve test and as well as the clinical picture. Once the diagnosis of the neuroma is confirmed then a treatment plan can be started immediately.

Conservative treatment for neuromas includes injection therapy, padding and strapping, and physical therapy. If padding and strapping proves to be successful, orthotics are strongly indicated. If conservative methods fail to relieve the pain, then surgical intervention may be indicated. The procedure is an out-patient procedure, and you can walk on the foot immediately after the surgery. The procedure can be done in an office-based setting with use of local anesthesia. The stitches are usually removed after a period of ten days to two weeks. Following the surgery, physical therapy, which is done in the office, is performed on the surgical site to aid in the healing process.

Osteoporosis is a silent condition characterized by reduced bone mass and abnormal internal bone architecture. Osteoporosis, the most common human bone disease, occurs when bone resorption exceeds bone formation, resulting in reduced bone strength, poor bone quality, and an increased risk of bone fracture. As part of the natural aging process, bones begin to deteriorate faster than new bone can be formed, eventually progressing to a point where a fracture can easily occur, causing pain, disability and even death. The most common fractures are the hip, spine, wrist and foot. Women are four times more likely to develop the disease than men. However, men suffer 1/3 of all hip fractures that occur and 1/3 of these men will not survive more than a year.
There are many Risk Factors for Osteoporosis including:

• AGE: The risk of Osteoporosis increases as a person gets older. The Bones become weaker and less dense as we age.
• GENDER: Women are at a greater risk of developing Osteoporosis because bone loss occurs more rapidly due to changes during menopause.
• RACE: Caucasian and Asian women are more likely to develop Osteoporosis.
• BONE STRUCTURE & BODY WEIGHT: Small-boned and thin women are at greater risk.
• MENOPAUSE/MENSTRUAL HISTORY: Normal or early menopause, brought about naturally or because of surgery increases the risk of developing Osteoporosis. Women who stop menstruating before menopause because of conditions such as anorexia or bulimia, may also lose bone tissue and develop Osteoporosis.
• LIFESTYLE: Smoking, excessive intake of alcohol, consuming inadequate amounts of calcium, or getting little or no weight-bearing exercise increases the chance of developing Osteoporosis.
• MEDICATIONS & DISEASE: Osteoporosis is associated with certain medications such as corticosteroids. A number of medical conditions including some endocrine disorders, rheumatoid arthritis and immobilization are also associated with Osteoporosis.
• FAMILY HISTORY: Susceptibility to a fracture may be hereditary. Women whose mothers have a history of vertebral fractures are at increased risk of fracturing.

The availability of a growing number of effective therapeutic options for the prevention and treatment of Osteoporosis have heightened interest in diagnostic testing and spurred the development of new testing methodologies. To confirm a diagnosis of Osteoporosis or determine one’s risk for developing the disease, most doctors require a comprehensive medical assessment, including a life style survey and medical history. Based on the number of risk factors, a doctor may recommend that the patient have a Bone Density test. Bone Densitometry is the accepted standard for quantifying bone mass at various skeletal sites. The heel bone is the preferred site to monitor bone density. It is 95% trabecular bone and is metabolically very active and reflects the effect of age, menopause and exercise. Bone Mineral Density screening can now be performed quite cost-effectively with peripheral scans of the heel bone in which we provide in our office for patients.
In August of 1997 President Clinton signed into law the Medicare Bone Mass Measurement Coverage Standardization Act, Which was effective July 1, 1998. The law requires Medicare coverage for Bone Mineral Density studies of estrogen-deficient women. The emphasis was on the PREVENTION of osteoporotic fractures.
If you feel if you are 65 and older, a post-menopausal women or have one or more risk factors then you should have a Bone Mineral Density Scan performed. Based on the Bone Mineral Density Scan results a prevention or treatment plan can be started. Don’t wait before it is too late.

Plantar Fasciitis is an inflammation of the band of fibrous connective tissue (fascia) running along the bottom of the foot, from the heel to the ball of the foot. It is very common among athletes who run and jump quite often and can be very painful. This condition occurs when the plantar fascia flattens out and elongates, causing the soft tissue fibers of the fascia to tear or stretch at various points along its length.

The inflammation may be aggravated by shoes that lack appropriate support, especially in the arch area, and by the chronic irritation that sometimes accompanies an active lifestyle. Resting provides temporary relief. When you resume walking, particularly after a night’s sleep, you may experience a sudden elongation of the fascia band which stretches and pulls on the heel, resulting in pain.

The most common cause for Plantar Fasciitis is excessive pronation or more commonly known as Flat Feet. Pronation is the normal flexible motion of the foot that allows the foot to adapt to ground surfaces and absorb shock during the normal gait pattern. As we walk, the heel contacts the ground first; the weight shifts to the outside of the foot, then moves towards the big toe. As the foot progresses along the gait cycle, the arch rises and the foot becomes rigid and stable. This is necessary in order to lift the body and move it forward. When the foot excessively pronates (flattens), it creates an abnormal amount of stretching and pulling on the fascia. The foot has a much more difficult time lifting the body and moving it forward. Therefore, resulting in excessive stress on the plantar fascia and you can develop plantar fasciitis. In the office, we are equipped with a Gait Analysis system which allows us to observe the function of the foot during the gait cycle.

Supporting the plantar fascia and arch region is of the utmost importance in this condition. Orthotic devices are custom made shoe inserts that are intended to adjust an abnormal, or irregular walking pattern. They will aid in supporting the arch and the plantar fascia and help relieve the excessive stress on the ligament. With the information that the Gait Analysis system collects, a custom Orthotic device can be constructed for your feet.

The most common disorder that occurs on the bottom of the foot and presents like a soft lump in the arch region is known as a Plantar Fibroma. This is a disorder where a soft tissue mass forms or develops within the plantar fascia which is located on the bottom of the foot. The plantar fascia is located in the arch region and helps to support the arch while we are standing.

A Plantar Fibroma is most often a benign soft tissue mass. The most common compliant is pain upon standing on the foot. The mass can get irritated and inflamed from the pressure of the body weight when we are standing.

An MRI or a soft tissue scan using a Diagnostic Ultrasonography unit can be very useful in locating the Fibroma and determining the size of the Fibroma. X-rays can be taken to see if there is any bone involvement, but they usually are negative.

Plantar Fibromas are usually treated by surgical excision of the mass if the pain persists. Conservative treatment can consist of padding for dispersion of the bodyweight off the mass. Following surgical excision, a biopsy of the lesion is performed, in order to confirm the diagnosis of a plantar fibroma.

Immediate treatment of any mass on the foot which appears to be getting larger should be evaluated by a physician. At that time the appropriate testing modalities can be performed, and a treatment regimen can be started.

Shoes are an important part of your clothing, comfort and fashion. Selecting the appropriated shoe for a specific activity and having it fit properly are the key elements for comfort, function and safety.
When shopping for shoes and sneakers you should look for:

1. FIT: Shoes should fit snugly in the heel and provide ample room in the toe area. Shoes should not cause redness or irritation to any part of the foot.
2. SHAPE: Pointed toe shoes should accommodate for toe space. If there is not enough room in the toe box region of the shoe many different deformities can start to develop.
3. MATERIALS: For maximum comfort, look for breathable, lightweight materials that are strong yet supple. Best bets are leather and cotton canvas. Vinyl does not let the foot breathe.
4. TREAD: Shoe soles should be chosen for how they interact with the surface on which they will come in contact with.
5. CUSHION: Shoes constructed with more cushioning will absorb more impact and better protect your feet.
6. SHOE WEIGHT: Lighter shoes may seem more comfortable initially, but heavier shoes may provide more support.
7. SPECIAL NEEDS: Extra-depth shoes or custom-shoes may be necessary to accommodate for structural foot deformities. Custom shoes can be prescribed by any Podiatrist.

Tips for proper shoe fit include:

1. Purchase shoes at the end of the day, or after work or playing sports for best fit. Earlier in the day your feet are the smallest and you may purchase shoes which are too tight.
2. Measure both feet. No two feet are the same size. Purchase shoes for the larger foot.
3. Wiggle your toes in the shoes. If you can’t, the shoes are probably to small.
4. Walk around the store to ensure a comfortable fit before buying.
5. Try on shoes with the socks or hose with which you will wear them.
6. Don’t rely on the shoe “stretching” for fit. Shoes should feel good when you try them on.
7. Ensure the widest part of your foot fits comfortably, but securely, in the shoe.

People with diabetes may lose feeling in their feet, become more susceptible to injury, and have a harder time healing sores. To prevent serious damage, including ulcers and infections, take special precautions including;

1. Wear cushioned, athletic, walking or casual shoes.
2. Wear a good arch support to reduce pressure to the heel and ball of the foot.
3. Examine feet daily to ensure good foot health.
4. Care by a Podiatrist is very important. Medicare has extended its coverage to patients with Diabetes. Medicare covers for one pair per year for a special custom shoe and innersoles for patients that suffer from Diabetes. You can contact the office for further information regarding the custom shoes.

The symptoms such as the burning pain and numbness is of nerve origin. There are many different deformities that can lead to nerve pain such as Neuropathy, Neuroma formation and Nerve Entrapments. Tarsal Tunnel Syndrome is a common nerve entrapement syndrome in the foot. This is very similar and related to Carpal Tunnel Syndrome in the hand.

Tarsal Tunnel Syndrome is a nerve entrapment of the main nerve that enters the foot just behind the ankle bone and into the bottom of foot. The nerve gets trapped in the tunnel where the nerve enters the foot and can cause burning pain and sometimes numbness.

A careful and thorough history and physical examination is imperative in order to come up with a definitive diagnosis of Tarsal Tunnel Syndrome. X-rays and Nerve Studies need to be performed to confirm the diagnosis. If surgery is to be performed an MRI may be useful in order to evaluate the foot, prior to the surgery.

There are many treatment options from Conservative to Surgical management of Tarsal Tunnel Syndrome. Conservative treatment consists of anti-inflammatory medicine, injection therapy, physical therapy, paddings and strappings, Orthotic therapy and immobilization in very severe cases.

When and if conservative therapy fails then Surgical management is an option. The surgery consists of releasing the entrapped nerve and removing any soft tissue mass or bony abnormality that may be compressing on the nerve. Following the surgery the patient is placed in a soft cast for approximately 3-4 weeks and slowly returns to activity. Physical therapy is performed following the surgery to enhance healing and to return to full range of motion for the ankle joint.

If the pain has been present for a long time and progressively getting worse, immediate evaluation of the foot should be performed before the condition becomes worse. The longer the pain exists, it becomes increasingly more difficult to resolve.

The typical discoloration and thickening of the nails are most commonly caused by a Fungus. About 1 in 5 adults between the ages of 40 and 60, almost 30 million Americans, are affected by Nail Fungus. Toenail fungus can be caused by many different avenues such as:

• An untreated athlete’s foot infection which can spread to nails and infect the nail plates of the toes.
• Microtrauma to the nail plate such as ill-fitting shoes or stubbing of the toe.
• Cuticle damage during a manicure.
• A long-term condition that affects your immune system such as your circulation, Diabetes or HIV along with aging can make it harder to fight off a fungal invasion.
• Not changing out of sweaty socks right after exercise also can contribute to the problem. Fungi thrive in moist, dark environments such as this.

Some nails infections are just surface problems and can be treated with creams or liquids. Most fungi creep in from the edges and spread downward. They infect the nail bed (the skin to which the nail is attached) and the matrix (the hidden root of the nail). Oral medication is the only way to reach these areas. They travel through the bloodstream to the matrix and prevent the fungus from spreading into the new nail growth. The newer Oral medications remain in the matrix and bed for months after you stop taking the drug. So, you may only need to take these pills for three months. Cure rates are as high as 70-80% and relapse rates are low.
If you are suffering from toenail fungus and interested in medication for this problem contact our office and a full physical examination can performed. At that time a treatment regimen can be instituted immediately. The complete risks and benefits of all the topical and oral medication can be reviewed at that time.

Warts have long been the subject of myth and folklore. Over the centuries there have been various remedies used to treat warts. Other such wife’s tales include, baking an onion, rubbing the wart with it, and then burying the onion in the ground under a full moon and making a drawing of the wart and sending it to someone whose name you know but have never met. You should take both the myths and the folk remedies “with a grain of salt,” since there is no scientific evidence to support them.

Before any treatment is rendered on these painful lumps a thorough physical examination of the lesions must be performed in order for an accurate diagnosis. These painful lesions on the bottom of the feet can be many things including, a callus, a corn, a soft tissue mass (such as a Lipoma, Fibroma etc.), a porokeratoma (a cyst of a sweat gland) and a ganglion ( a soft tissue cyst of a tendon sheath).

Warts are benign growths on the surface of the skin. Usually small and firm, these warts are caused by a virus called the human papilloma virus. Warts are contagious and can be spread from one person to another. It is more likely that these skin growths are spread from one part of the body to another part. You can get warts, by walking barefoot in damp places, such as showers, locker rooms and around swimming pools. Workers whose hands are continually exposed to moisture, for example, food handlers, plumbers, masons, and hairdressers appear to be at greater risk. Warts can spread by sharing washcloths, towels, brushes, combs, and other personal items. If not properly or completely removed, warts can recur.

There are many different treatment options for Warts which include.

1. Cryotherapy. The wart is frozen, using liquid nitrogen.
2. Electrodessication. The wart is burned, using an electric current.
3. Curettage. The wart is excised out surgically.
4. Laser Vaporization. The wart is destroyed by a laser beam that vaporizes it.
5. Pharmaceutical Topical Therapy. Topical treatments include acid treatments that burn the wart.
6. Pulsed Dye Laser. This is the newest form of Laser treatment that has proven to be very successful in treating warts.

Clinical studies have proven that Pulsed Dye Laser treatment for resistant warts is very successful as compared to acids, cryogenics, chemical agents, and surgical excision. In one study, over two-thirds of patients treated with the laser therapy had their warts successfully removed in as few as two treatments.

The Pulsed Dye Laser treatment works by selective absorption of laser energy by the blood supply that feeds the wart. The treated area then separates from the dermis and gradually sloughs off. Depending on the size and the type of the wart, some conditions will respond to the very first treatment. However, most will require additional treatment sessions spaced two weeks apart.

Treatment consists of placing a small hand piece against the surface of the skin and activating the laser. The laser is pulsed rather than a continuous action. As many patients describe it, each pulse feels, for a fraction of a second like a snapping of a rubber band against the skin. Some warts require more than one pulse. Anesthesia by local injection is never utilized. The laser leaves no open wound following treatment, resulting in little or no chance of an infection.

Due to no open wounds and minimal pain, patients can resume their active lifestyles immediately. There will be discoloration of the skin at the treatment site. Over the 24 hours following laser exposure, the gray discoloration will darken to black and will be present for about 2 weeks.

Plantar warts can be quite painful, unattractive, and bothersome. For all these reasons, prompt and effective treatment is advisable.