Foot and Ankle Surgery
Common reasons for referral to The Tagoe Clinic
Pain in the foot and ankle
Pain can be general and difficult to place, or it may be at a particular site or during a certain movement. Possible reasons may include: arthritic change, a response to injury or trauma, nerve entrapment, a systemic cause e.g rheumatoid arthritis or diabetes, soft tissue inflammation or an unstable foot and/or ankle perhaps due to an underlying biomechanical problem. Management: The effective management of your symptoms requires an accurate diagnosis, the treatment options can then be explained to you and a treatment plan agreed.
Hallux Valgus (Bunion)
A bunion (hallux valgus) is the movement of the 1st metatarsal away from the 2nd with the big toe drifting towards the second toe. Most patients complain of pain, a prominent joint and the inability to wear shoes comfortable. Bunions are considered to be a progressive condition. The cause of bunion’s is unknown but possible factors include a family history, foot function and footwear.
This is a clinical diagnosis made by examining the foot. While the diagnosis can be made clinically the severity of the condition is assisted by an X-ray. There is no direct correlation between the size of the deformity and the degree of symptoms experienced.
Is a stiff and painful big toe joint as a result of wear and tear (osteoarthritis). Symptoms vary from sharp shooting, cramp, burning or gnawing pain that are often brought on by walking or kneeling with the big toe bent. Typically, symptoms may fluctuate, having good and bad periods.
The Xray shows complete obliteration of the big toe joint in a case of severe arthritis.
Here the toes are bent causing it to rub against adjacent toes or be irritated by your footwear. Symptoms include soreness between the toes, over the joint or on the tip of the toe. Hard skin or corns may form and there can be associated toenail damage. Symptoms tend to be relived by wider/deeper or open toe shoes, or temporarily by chiropody treatment. Surgery would straighten the toes and therefore alleviate the problem.
A term covering pain affecting the balls of your feet:
- Synovitis (Inflammation of the lesser metatarsal heads)
- Skin conditions eg Verrucae
- Midfoot pain
- Midfoot arthritis
- Tendon injuries
Most patients with plantar digital neuritis/neuroma (a painfully enlarged nerve) complain of a sharp shooting pain affecting the ball of the foot radiating into the toes. Some patients also experience numbness. The symptoms are often brought on by wearing tight fitting shoes and normally occur after prolonged walking or driving. The pain can often be relieved by taking the shoe off and resting. The cause of neuromas is not clear although local irritation has been suggested.
A severe example of an exostosis.
The left Achilles tendon is enlarged & painful (non insertional Achilles tendinopathy)
This is inflammation of the plantar fascia, a soft tissue structure on the sole of your foot that runs from the heel to the toes and helps support your arch. Patients often complain of:
- Pain and tenderness beneath the heel that radiates into the arch of the foot
- Stiffness and discomfort on rising in the morning or after long periods of sitting
This condition affects 10% of the population and normally resolves within 10 months irrespective of treatment. It is classified as a chronic condition when symptoms persist past 6 months. Within this chronic classification there are a minority of patients (estimated at 10%), who develop persistent and often disabling symptoms which continues for more than a year.
Posterior heel pain
Inflammation of the back of the heel. This can be due to a exostosis (bony outgrowth) on the back of the heel that projects into the achilles tendon causing soft tissue pain or inflammation of Achilles tendon.
The achilles on the left side is enlarged & painful (non insertional achilles tendonitis)
The cause of pain around the ankle joint can be divided anatomically into bone, joint, ligament and tendon injuries. The symptoms can also be focused on the inside, outside, front and back of the ankle. Symptoms from the back of the ankle commonly relate to problems with the achilles tendon. In certain instances an accessory bone at the back of the ankle can impinge on the surrounding tendons and cause local pain and inflammation.
Pain from the ankle joint normally feels like a deep pain that is worse with activity and relieved by rest. The movement of the ankle joint can be restrcited and painful as the articular cartilage that lines the surface of the joint is lost. Bone then articulates with bone with pain and swelling. Sometimes the damaged area is small and can be treated arthroscopically or there is a loose body that can be removed. When large areas are affected then a joint fusion or replacement might be appropriate.
Ankle arthroscopy: a small camera is inserted into the joint allowing direct visualisation of the joint surfaces and surrounding soft tissues. In cases where there are loose bodies or ingrowth of soft tissue this can be removed using specialist equipment, leaving no more than 2 small holes in the skin.
A common cause of pain around the medial aspect of ankle are injured tendons specifically tibialis posterior tendon. Ths can cause a collapse of the foot (see flat feet). Less commonly the medial ankle ligaments can be inflammed or torn nomally following an ankle sprain. These injuries often respond to physiotherapy and intially with relative rest, somtimes using a brace or an Aircast.
The most common ankle sprains occur when you go over on the ankle and injury the ligaments on the outside. The anterior talo fibula ligament is structurally weak and therefore prone to tearing. In addition the peroneal muscles which provide dynamic stability to the ankle can be subject to damage with tears or inflammation of the tendons as they pass aroufnd the ankle.
The picture shows the main lateral ligaments and the 2 peroneal muscles and respective tendons passing around the outside of the ankle.
This can be a concern for children and their parents, as well as adults. Usually, the concern is a lower than normal arch on the inside of the foot. This can be a normal finding and is very commonly observed in children requiring no more than reassurance. In a small number of cases, the foot can assume a position in which the joints, tendons and muscles are under an abnormal degree of stress, causing pain in the foot which can radiate into the leg.
Management: The flat foot is often managed by supportive footwear with or without orthoses inside the shoe. Exercises may also help. Surgery is reserved for those with very severe mal alignment perhaps due to congenital deformity or a torn tendon who do not respond to conservative care. In these cases the alignment and stability of the foot is restored with a combination of bone and soft tissue techniques.
Pathological flat foot with excessive rolling in – Post surgery the heel is sitting vertically.
Pes Cavus (High Arched Feet)
A high arched foot can present a range of problems from retraction of toes to prominent metatarsal heads which are painful to walk on. In severe cases the patients cancerns are more fundlemental with ankle instability and dificulty in walking. The underlying cause for the majority of patients is a neurological condition which might be static or progressive. The other causes include trauma and for others the aetiology remains unknown.
Before treatment is started the cause needs to be identified. Conservative options are aimed at keeping the symptoms under control using palliative care, insoles, braces and footwear advice. When this is ineffective or the patient is looking for a permanent solution then surgery is an option. This ranges from straightening the toes through to tendon transfers in mild conditions. For severe and progressive conditions major surgery is required.
Pre and post surgery to reduce the height of the arch and provide an even distribution of weight across the foot.
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All forms of diabetes may lead to damage to the circulation and to the nerves. This is particularly common in the extremities of the body. The foot is a vulnerable area because it is enclosed in a shoe and it can be difficult to see and check regularly. If some sensation is lost in the foot because of nerve damage, pain may not alert the person that damage has occurred. Problems such as broken areas of skin around the foot can easily arise, but these can be difficult to heal. Prevention is therefore very important and following the appropriate advice is vital.
Management: This will involve regular check-ups to ensure good foot health. Prompt treatment for any foot problems is also important. Prevention of possible long-term problems may also be appropriate, with the use of modified footwear, orthoses and surgery to correct deformity. In cases where severe infection or lack of circulation are prevelant then salvage surgery might be required to re-estabilish the circulation or restrict the spread of infection by amputation.
Joint problems are very common in the foot because of the impact incurred during walking and other activities. Wear and tear occurs in the foot as the skeleton ages, but may also be the result of sudden or repeated trauma e.g a heavy object dropped on the foot or a repeated stress e.g going on points. Age-related wear and tear in the ankle is rare, although may be secondary to injury.
The foot and ankle are sites which may be affected by some systemic conditions, such as rheumatoid arthritis or gout. A swollen painful joint(s) which has appeared without a history of injury should always be investigated further. This is likely to require blood tests, as well as examination and imaging of the joint(s). A positive family history can also be relevant.
Many sports place considerable stresses on the foot and ankle and these are common sites of injury. Trauma may cause soft tissue inflammation (tears in tendons, muscles and ligaments), stress fractures as well as joint problems.
Some people have a foot or ankle ‘type’ that may predispose them to a greater incidence or severity of injuries. An unstable foot and/or ankle, a tight muscle group, or a functional characteristic during standing or walking will lead to increased stress and can lead to an an overuse or an acute injury.
Management: Dependent on the cause. Common techniques used in sports injuries include strapping, external supports, physiotherapy, orthoses, advice e.g training, footwear, anti-inflammatory therapies (ice and medication) and in certain cases surgery.
There are many ways to injure the foot and ankle. These range from ankle strains/sprains and fractures to stepping on a foreign body e.g a needle or nail, a hair, or a splinter. Sports injuries are also often acute i.e require immediate attention e.g Achilles tendon rupture