Foot treatments & procedures

Bunions

Bunions are swellings on the side of the big toe joint, a condition which occurs when the big toe leans too much toward the second toe. As the swelling is prominent, this area is prone to rubbing from shoes, causing inflammation and pain.

Some people have large bunions without experiencing any serious pain or discomfort. However the deviating big toe can cause pressure on the second toe, resulting in the second toe becoming a hammer toe. In some cases, the first two toes will cross over, making walking difficult.

Tight footwear is likely to cause the big toe to deform. This is almost certainly the reason why the condition is much more common in females than males. High heeled, pointed toe shoes are not the primary cause of the problem, but such footwear can accelerate the condition.

It is necessary to take an x-ray in order to determine the extent of the bunion and any associated arthritis. Around half of bunion cases can be successfully treated without surgery, the remainder are minimally invasive – involving new techniques. Gone are the days of 'extremely painful' bunion surgery.

Stiff big toe

A form of osteoarthritis which occurs when cartilage in the joint wears out. With every step, a force equal to about twice your body weight passes through the big toe. The big toe is under constant pressure - even whilst we stand still.

Symptoms include:

  1. Pain and stiffness whilst moving the toe joint

  2. Difficulty with activities such as running

  3. Swelling and inflammation

  4. Increased symptoms during cold or damp weather

Symptoms of advanced cases include:

  1. Constant pain and discomfort - even whilst resting

  2. Bony bumps on the top of the toe which rubs against footwear

  3. Walking on the outer side of the foot to avoid pain.

This in turn can produce pain in the ball or outside of the foot. The big toe can ultimately become 'frozen' - where all independent movement is lost.

It is recommended that you seek medical attention if the big toe feels stiff or it is painful when you walk, bend or stand. Once the condition becomes more advanced and bone spurs develop, it is more complicated to treat.

After an examination to determine the range of movement, x-rays are taken to evaluate the extent of the condition and to note any abnormalities, which may have developed.

If the condition is caught early, non-surgical treatment is more likely to be effective.

The toe joint is usually most painful when it is bent upwards whilst walking. It can help to stiffen the sole of the shoe so it does not bend. A small 'rocker bar' can be fitted so you can walk without bending the toe. Shoes with plenty of room for the big toe should be worn. High heels and shoes with pointed toes should not.

Anti-inflammatory drugs such as ibuprofen, and may be prescribed to help reduce pain and inflammation. Injections can also help in terms of reducing pain and inflammation.

Surgery may be considered if other approaches fail to eliminate or reduce pain. There are several different types of non-invasive surgery that can be undertaken to correct the condition.

Hammer toe

A key symptom is pain in the ball of the foot, after which the toe rapidly deforms.

 

This is due to rupture of a structure called the plantar plate. When the toe deforms, pain is much less noticeable, but this is usually a temporary event.

 

Pain in the ball of the foot often reappears and when the toe begins to rub against footwear and this can be very painful indeed.

Mallet toe

A mallet toe is caused by a tightening of flexor tendon and is the easiest condition affecting lesser toes to be treated.

Other toe conditions

There are a number of rarer conditions where lesser toes can be excessively short, long, big or bent.

Treatment of all of these problems can be non-operative or surgical but it is important to make a correct diagnosis and to understand the underlying mechanism that has lead to the deformity. For example operating on a hammer toe that has occurred as a result of a bunion will not work unless the bunion is treated at the same time.

Once an examination has been completed, the condition can be effectively treated.

Surgery is performed under local or general anaesthetic and for minor problems, a temporary wire in the toe will be required for up to six weeks.

Even minor toe deformities generally get worse with time and action now can prevent more serious problems in future.

Forefoot pain

Pain is often on the sole of the foot and described as 'sharp' or 'shooting pain', similar to having a stone in the shoe. Some people describe localised pain to one or two toes whilst others describe more generalised pain or burning pain.

Sometimes there is associated swelling in the foot although not always. Hard skin may build up in the painful area. This is called a callosity. People usually experience more pain when placing weight on the affected foot but this can also occur when at rest or in bed at night. Other symptoms include numbness in the toes.

Common causes include:

  1. Obesity

  2. Overuse caused by sporting activity

  3. Bunions

  4. Arthritis of the big toe

  5. Arthritis of other areas of the foot

  6. Gout

  7. Fracture of a metatarsal

  8. Stress reaction in a metatarsal (which can precede a fracture)

  9. Problems with the nerves

  10. Deformed toes rubbing in the shoe

Identifying the underlying diagnosis and cause is essential to being able to advise the correct treatment. Sometimes more than one condition will be present.

Using modern keyhole surgery, many of the problems encountered with older techniques are totally avoidable. The period of immobilisation after surgery for is about 2 months and it takes approximately 6 months to resume normal use.

Midfoot arthritis

Patients with midfoot arthritis often experience pain and swelling particularly when walking or taking part in sport. A change in the shape of the foot can then occur later.

The pain is described by sufferers as 'sharp' or 'burning'. The condition makes it difficult to find suitable and comfortable footwear.

Midfoot arthritis is largely caused by specific injury, often minor. It can lead to joint damage and osteoarthritis. The process can develop over years if the middle part of the foot is under stress because of, for example, an existing serious bunion.

Rheumatoid arthritis may also affect the midfoot. A careful clinical assessment needs to be supplemented with x-ray and MRI scans may be neccessary.

Pain relief and anti-inflammatories can help to reduce symptoms. Limiting activities that aggravate the condition is advised. Shoes should be stiff, rather than soft. Walking boots and MBT trainers are effective.

In some instances, where arthritic spurs have developed, these can be removed with a minor surgical procedure.

If the condition is advanced, fusion of the joints may be considered. By fusing together the joints using screw plates and / or staples, pain is significantly reduced.

Heel pain

Around one in ten people will suffer heel pain during their lives. There are two main types of heel pain, occurring in different places.

1. The 'grumbling' Achilles.
A ruptured Achilles is well known condition, but it is more common to suffer from a grumbling Achilles. The pain is felt at the back of the heel above where the Achilles tendon joins the bone. Symptoms are stiffness and swelling, especially in the morning.

2. Policeman's heel.
The fascia is a strong band of tissue stretching from your heel to your toe bones. It supports the arch of your foot and performs the role of a 'shock absorber' for the foot. Symptoms are pain at the bottom of the heel where it meets the ground with each step. This can see patients "limping" first thing in the morning. Pain can be acute, especially after standing for prolonged periods.

Causes of the conditions vary but include:

  • Long distance running

  • Obesity and a sedentary lifestyle which places the heel under excessive pressure

  • Tight calf muscles. This can cause the patient to 'walk on tip toes', putting the Achilles and the arch of the foot under significant pressure.

The first treatment is calf stretching exercises – as demonstrated by a qualified physiotherapist. Heel cushions are very helpful. Most patients with this condition find the pain is managed by the use of stretching exercises.

For those experiencing significant heel pain, other options include

  • Extracorporeal shockwave therapy

  • A course of injections

  • Surgical calf stretching

After a full examination of the foot and an ultrasound 'Doppler' scan, a same day assessment can be completed. If the calf is extremely tight, we recommend surgical calf stretching because injections or shockwave therapy will prove ineffective.

Surgical calf stretching is a simple procedure involving a very small incision behind the knee.

Flat feet

This occurs when the main arch on the insole of the foot drops, and this can be mild to severe in its extent. Often people are completely unaware of the condition.

Common causes of painful flat foot are:

Inflammation of the tendon which passes to the foot on the inside of the ankle. The symptoms are pain, swelling and progressivde flattening of the foot. Untreated this can result in major disability.

Arthritis of the joints. Joints affected are the ones in the middle of the foot and the one below the ankle. These occur a result of an inflammatory condition after an injury or due to 'wear and tear'. The symptoms are those of pain and progessive deformity over time.

Many patients with a structural deformity require surgery but often no treatment other than observation and special footwear modifications are required.

Physiotherapy can help manipulate tightened muscles but won't correct a deformity. Surgery is recommended for patients with a deformity.

Surgery involves tendon transfers, reshaping bones and fusing joints, thereby releasing contractures of the soft tissue.

After a limited period in plaster, physiotherapy can optimise the final recovery.  This procedure is mostly very successful, allowing the patient to resume normal activities and wear normal footwear.

Tendon problems

Tendons and ligaments perform differing roles. Tendons connect muscles to bones. When the muscle contracts, the tendon pulls on the bone and movement occurs at the joint. Ligaments stop a joint moving too far in the wrong direction.

Tendons can be thought of as ropes, and are not as dynamic as the muscle, they do have a degree of elasticity. Stress on the tendon results in thickening, splitting or even tearing. When this occurs the whole unit of muscle and tendon loses elasticity and cannot function properly.

Patients may notice pain, swelling, weakness or a reduced sense of balance.

Problems include:

Achilles tendinopathy

Pain and discomfort is noted just above the heel bone, often due to a compromised blood supply. Thickening and tenderness of the tendon causes pain and stiffness and is often worse first thing in the morning.

Insertional tendinopathy

This condition occurs when the back of the heel bone, where the tendon meets the bone, becomes painful and swollen. Normally with the right shoes and insoles and physiotherapy surgery is not required, however surgery may be needed for the most severe cases of inflammation.

Adult flat foot

Not all cases of flat foot are due to tendon problems. However a problem involving the posterior tibial tendon is the most common. This tendon runs around the inner ankle bone and attaches to the navicular bone in the instep. It functions like braces to hold up the arch of the foot and if the tendon fails to perform its role, adult flat foot often develops.

Peroneal Tendinopathy

This condition occurs when there is damage to the tendons which run around the outer ankle bone and turn upwards and outwards at the ankle. Pain, swelling and giving-way or ankle instability are the usual complaints from this type of tendon problem.

In certain instances surgery is required to correct these problems – please speak to your GP about a referral if you believe you may suffer from one of the above conditions.

 
 
 
 
 
 
 
 
 
 
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(Spire Fylde Coast Hospital)


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Website:
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