This is a congenital deformity where the 5th toe is turned in and riding high. This can sometimes cause footwear problems. A plastic surgery soft tissue procedure can correct this deformity.
Achilles tendonitis and ruptures occur in middle-aged due to chronic strain and minor trauma.
Achilles tendon is distal continuation of the calf muscle which is made up of two heads of gastrocnemius that arises from back of the femoral condyles above the knee and the soleus that arises from back of the tibia. Function of gastrocnemius to give push-off in terminal stance phase of gait and is useful motor in sprinting and jumping. Soleus is an antigravity muscle that allows slow controlled progression of the shank (tibia) on the ankle during forward progression whilst walking.
Sudden acute strain whilst playing tennis, squash, football can cause strain on the tendon and rupture in the middle aged people. Sometimes the strain is at the musculotendinous junction.
Achilles Tendon Rupture: In severe cases, the force may even rupture the tendon. The typical example is the middle aged tennis player who places too much stress on the tendon and experiences a rupture of the tendon.
Few centimetres above its attachment tendon is thickened and tender in Achilles tendoniitis. Pain is present with walking, especially when pushing off on the toes.
Rupture is an acute event associated with a snap and one feels as if he has been kicked in the calf. One loses the power to push-off and in acute situtation one hobbles and is unable to put much weight through the leg.
Conservative treatment for retrocalcaneal bursitis and Achilles tendonitis usually consists of a combination of rest, anti-inflammatory medication, and physical therapy (below). A cortisone injection for this condition is hazardous, due to increased risk of rupture of the tendon following the injection. An aircast boot or a cast immobilisation for 4 to 6 weeks can be helpful.
Conservative treatment for rupture of the tendon involves immobilisation in an above knee cast with plantarflexion for 8 weeks and then in neutral position for a further 4 weeks. Some kind of preventive measure for DVT is necessary. However rerupture risk with this regime is higher than operative treatment.
For tendon ruptures open repair is needed. This involves an incision along the tendon and apposition of the tendon with sutures. Post-operative cast immobilisation is for 12 weeks. In severe cases of Achilles tendinitis, surgery may involve removing any inflammatory and degenerative tissue around the tendon and heel bone.
In early phase of tendonitis, ice, rest, orthotic treatment, and stretching can be helpful. In late stages of healing one can use modalities such as contrast bath, friction massage, ultrasound, range of motion exercises, stretching, early strengthening, treadmill walking and orthotics.
Post – operative period following Achilles Tendon Repair
When you wake after your operation, you will have a complete plaster on up to the knee. This will include the foot, and you will notice that the foot is pointing slightly down. You may be kept in hospital for one night after the operation, and should the plaster feel tight or uncomfortable during this time, you must let the nurses know so this can be split to give the leg some breathing space.
This does NOT compromise the operation.
After the surgery, the surgeon and the nursing staff will be able to explain to you what has been done, and you will often be discharged home the same night or early the next morning. It is not always necessary to see the surgeon following the surgery but if you request this it can of course be arranged.
Two weeks following the operation, you will be seen in the outpatient clinic, where your plaster will be removed and the wounds checked. Should these be healthy at this point, you will go into a walking boot with several wedges in the heel. Your exact post-operative course will be determined by the nature of the surgery.
If a primary repair was performed, after two weeks you will go into a walking boot with three wedges. You will be able to take one wedge out every five days following your surgery, until the foot is flat inside the boot. This will take approximately fifteen days or two weeks. You will then walk for two further weeks in the boot, building the strength up in the rest of your leg, before it is safe to come out of the boot. At this point, you will be able to get the leg wet when taking it out of the boot, but must have the boot on for walking. This will take you up to the six week post-operation point, when you will the surgeon again and a programme of physiotherapy will be arranged to build the strength up in the muscles and to allow you to walk out of the boot.
Sometimes at the time of surgery, it is difficult to repair the Achilles tendon ends primarily, and a reconstruction is required. This may involve division of the muscle fascia higher up (this is the gristly bit within the muscle) to allow the ends to come together, or augmentation of the repair with a tendon taken from the toe. Either way, this requires a longer rehabilitation than a primary repair. It is usual to stay in plaster for up to four weeks following this surgery, and for six weeks in the boot. Again you will have three wedges in the boot, but one of these would be removed every one week to ten days as per your surgeon’s instructions, and then the remainder of the time would be spent in the boot walking with the foot flat. Again during the time, once the wound is healthy and healed, you will be able to take the boot off for bathing and indeed at night for sleeping. Once you come out of the boot, again physiotherapy will be instigated.
It is important to remember that both of these operations require a prolonged recovery period with the physiotherapy once the plaster is off, and strength is not returned to normal for at least six months.
It is also worth knowing in the early stages that should you feel any pain around the wound, we would like to check this early in case there is any infection, and should the leg become suddenly more swollen and not go down overnight, we would be concerned about blood clots, and again early contact should be made with the surgeon’s secretary to arrange to be seen as soon as possible. Although the risk of blood clots is low with foot and ankle surgery, it is slightly higher with Achilles tendon repair.
Should you have any concerns in the post-operative period or simply wish to clarify your instructions, please do not hesitate to contact the surgeon’s secretary at any time.
The foot is an incredibly complex part of the body. The following sections will touch on the various tissues that make the whole foot.
The two bones tibia and fibula come together with talus to form a secure mortise joint.
The mortise and tenon construct is well known to carpenters and craftsmen who use this joint in the construction of everything from furniture to large buildings because it is so stable.
The talus and calcaneus are the two hindfoot bones that are connected at the subtalar joint. The ankle joint allows the foot to bend up and down. The subtalar joint allows the foot to rock from side to side.
The next group of bones are tarsal bones that work together. These bones are very interesting in the way they fit together. When the foot is twisted inwards by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted outwards, they become unlocked and allow the foot to conform to whatever surfaces the foot is contacting.
The 5 long bones of the foot called the metatarsals which are joined to the tarsal bones. There is a fairly rigid connection between the two groups without much movement at the joints.
Finally, the phalanges are the group of bones that make up the toes. The joints between the metatarsals and the phalanges are called the metatarsophalangeal joints. These joints form the third rocker of the foot and allow for the push off for a normal walking pattern.
The big toe or hallux is the most important toe for walking, and the first metatarsophalangeal joint is a common area for problems.
Important Soft Tissue
The important soft tissues of the foot and ankle include ligaments, tendons, nerves, and blood vessels.
The main blood supply to the foot is by posterior tibial artery that runs behind the medial malleolus and to some extent by the anterior tibial artery. The main nerve supply is through the posterior tibial nerve and anterior tibial nerve that runs alongside the arteries. Of course there are other nerves and arteries that supply rest of the foot.
The calf muscle becomes the Achilles tendon and is attached distally to the os calcis. The posterior tibial tendon is attached to the inner part of the foot and the peroneal tendons are attached to the outer part of the foot. These tendons hold the foot straight whilst the Achilles tendon provides the push-off. The tibialis anterior tendon dorsiflexes the foot. The ligaments statically control the joints whilst the tendons provide the power for propulsion.
History and Physical Examination
The important symptoms of foot pathology are pain. The doctor may ask:
- to localize the pain
- was there any injury
- character and duration of the pain
- and problems with footwear
- This is followed by a physical examination of your feet, legs, how you walk, and the SHOES you wear.
X-rays are important in detecting bone and joint problems such as fractures and deformities.
These are good at detecting soft tissue problems such as ligaments, joint surface, tendons etc. This in conjunction with clinical examination help in the overall management.
These scans show slice of bones and to some extent soft tissues, and are also helpful in picking up subtle fractures. They also help to define bone tumours and diseases affecting the bones.
Blood test and other laboratory tests are done in some infective conditions and in diabetes. Common Foot and Ankle Syndromes.
- Ankle Sprain/Instability
- Ostechondritis Dissecans
- Posterior Tibial Tendinitis/Rupture
- Plantar Fasciitis
- Tarsal Tunnel Syndrome
- Bunion/Hallux Valgus
- Hallux Rigidus
- Morton’s Neuroma
- Ingrown Toenail
- Achilles Tendon Problems
Keyhole surgery for ankle problems is well established. Sport injuries, ligament problems, osteochondral dissecans, periarticular fractures (fractures involving the joint surface), ankle fusion and impingement problems can be treated with this technique.
A small telescope is inserted through small incision (less than 1cm). Through another small incision instruments such as shaver, bone burr is inserted to deal with the problems.
Even subtalar joints, 1st MTP joint and certain tendon sheaths (tenoscopy) can be approached with this technique.
Loose bodies, scar tissue, bone spurs, and joint surface problems can be dealt with this technique.
Arthroscopic ankle fusion
Ankle arthritis causes stiffness and pain. Keyhole ankle fusion avoids big incisions and shorter rehabilitation. This is a relatively new technique. Usually two screws are percutaneously inserted. Therefore the patient has only four small (less than 1cm) scars with this technique. Of course patients with severe deformity may not be suitable for this technique.
Ankle arthritis can be treated with replacing the Ankle joint by doing a Total ankle Replacement. This allows for mobility and relieves pain. Below is a type of ankle joint which is uncemented mobile bearing joint.
Ankle replacement is suitable for arthritis provided there is not significant deformity viz. tilt of the talus in the ankle mortise. Literature has shown that higher degrees of such deformities cause failure of the joint.
An ankle sprain is a common injury and happens when there is a sudden twist to the ankle.
The ligaments are soft tissue with some elasticity. There are three ligaments on the outer side of the ankle and on the inner side there is the deltoid ligament made of 5 parts. The lateral ligaments are usually injured in the ankle sprains. The first two viz. anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) are commonly injured. The ATFL prevents excessive anterior slide of talus and the and CFL prevents excessive roll of talus in the ankle mortise.
Initially the ankle is swollen, bruised and it is very painful to weightbear.
The diagnosis is made clinically although the x-rays are taken to rule out fractures. Often an external support such as a brace or a tubigrip is required, with some elevation, ice and intermittent rest. Usually the ligaments heal in 6 weeks and physiotherapy is useful.
In a small number of cases, the ligaments will not heal to be as strong as normal. This results in repetitive giving way of the ankle. Physiotherapy can be helpful in improving the stability and proprioception. If the symptoms fail to improve then the ligaments might have not completely healed or would have been stretched out.
If conservative treatment fails then surgery is recommended to reconstruct the ligaments. The operation is done through a scar on the outer part of the ankle and sometimes it is accompanied by keyhole (arthroscopy) procedure. After the operation a nonweightbearing cast is applied for 6 weeks and thereafter physiotherapy is needed.
Early Healing Phase:
Range of Motion Exercise: These are done to encourage physiological motion of the joint.
Strength Progression: Next, you will begin a strengthening progression for the muscles around the ankle. Emphasis should be placed on the muscles that pull the foot up and out (evertors), up (dorsiflexors), and raise the heel (plantarflexors). Isometrics exercises can be used in the early stage of rehabilitation. These are strengthening exercises with the ankle at different angles, helping you stay away from painful position of the ankle. (Figure 12: picture of patient with physical therapist)
Early resistive exercises: Some types of equipment like therapeutic band, pulleys or isokinetic devices are helpful in reducing the effects of gravity, allowing you to begin strengthening without causing pain.
Balanced resistive exercises: Healthy ligaments send information to the central nervous system about the position of a joint. Once a ligament has been injured, these receptors are unable to receive and send the needed information to the brain. This increases the possibility of injury in the future. Balance exercises such as standing and walking on uneven or very soft surfaces, single leg balance, mini trampoline balance, and progressive agility’s.
More intensive exercises are done when painful symptoms have settled. Closed-chain exercises are done by fixing the sore-side foot on the ground. This allows the muscles around the ankle to be exercised while easing stress on the ligaments. Examples include partial squat, weight shifting, step ups/downs, single-leg balance, and lunge. These are actually the exercises can be used to heighten “motor” control in the ankle muscles. Progressive resistive exercises (PREs) are a group of exercises for the leg and ankle muscles in which the amount of weight being used is carefully increased. Moving a specific amount of weight but controlling the speed at which it is moved does this. Higher level exercises, like agilities, progressive running and cutting, polymerics, and heavy resistive training can be done to prepare the ankle for specific job or sport demands.
Bunion (hallux valgus) affects the big toe joint (1st MTP joint). The proximal phalanx of the big toe moves outwards making the metatarsal head prominent on the inner side of the forefoot. This broadens the forefoot. Shoes therefore rub on this bony prominence creating thickening and inflammation of the bursa. Also increase in the deviation of the 1st metatarsal inwards (metatarsus primus varus) can lead to hallux valgus deformity.
As time goes on, the constant pressure may cause the bone to thicken as well, creating an even largerlump to rub against the shoe.
Bunion is painful and a cosmetic problem. With severe deformities the big toe pushes the second toe upwards creating secondary deformity. These can cause difficulty in wearing fashionable shoes for women.
X-rays are done to quantify the deformity and plan treatment.
Wider shoes reduce the pressure on the bunion. Treatment of hallux valgus nearly always starts with adapting the shoes to fit the feet. In the early stages of hallux valgus, converting from a pointed-toe shoe to a shoe with a wider toe box can arrest the progression of the deformity. Bunion pads may reduce pressure and rubbing from the shoe. Although toe spacers are used to splint the big toe and reverse the deforming forces, they are not effective.
Almost always surgery is required for symptomatic bunions. There are well over 150 surgical procedures described to treat hallux valgus. The objective of correction of the deformity is to remove the bunion, to realign the bones that make up the big toe, and to balance the forces so the deformity does not return.
The angle made between the first metatarsal and the second metatarsal is used to make this decision. The normal angle is around 9-10 degrees. If the angle is 15 degrees or more, the metatarsal will probably need to be cut and realigned.
In some cases, the far end of the bone is cut and moved laterally (distal osteotomy).
This effectively reduces the angle between the first and second metatarsal bones. The bone is held in the desired position with a metal pin or small screw. In other situations, the first metatarsal is cut at the near end of the bone (proximal osteotomy). Nowadays Scarf Akin osteotomy is the preferred treatment. This involves longitudinal cutting and realigning of first metatarsal, cutting the proximal phalanx of the big toe and releasing the tight structure on the lateral side of the first MTP joint. This includes the tight joint capsule and the tendon of the adductor hallucis muscle. This muscle tends to pull the big toe inward. The toe is realigned and the joint capsule on the medial side of the big toe is tightened to keep the toe straight. Once the surgery is complete, it will take about 6 weeks before the bones and soft tissues are healed.
It is sometimes referred to as a “tailor’s bunion” due to the fact that tailors once sat cross legged all day with the outside of their feet rubbing on the ground. This produced a pressure area and callus at the base of the fifth toe.
A bunionette is similar to a bunion but on the outside edge or lateral side of the foot. Today a bunionette is most likely caused by an abnormal prominence over the fifth metatarsal head rubbing on shoes that are too narrow. Some folks have a widening of the foot as they grow older until the foot spreads or “splays.” The symptoms of a bunionette include pain and difficulty buying shoes that will accommodate the deformity.
X-rays may help to determine the extent of the Treatment is very similar to that of a bunion deformity. Anti-inflammatory medications can be helpful in the early stages. Shoes that have a wider toe box and a lower heel often resolve the problem after a few weeks. Small pads or the generous use of lamb’s wool to pad the deformity can decrease the irritation. If all else fails, your surgeon may recommend surgery.
Surgery involves removing the prominence along the metatarsal bone and tightening the soft- tissue structures to straighten the 5th toe. Sometimes a reverse Scarf osteotomy viz. oblique cut in the bone and fixation with a screw is necessary to reduce the bony prominence and correct the deformity.
In cultures where people don’t wear shoes these deformities are almost nonexistent.
Claw toes are flexion deformity of the PIP joints and hyperextension of the MTP joints. Hammertoes are flexion deformity of the PIP joints. Mallet toes are flexion deformity of DIP joints.
These deformities are often due to the 2nd and sometimes the third toe being longer which gets swished in the shoes.
Due to the shape of these toes and their constant rubbing in the shoes, secondary callosities develop on the PIP joint, at the ball of the toes and at the tip of the toes. Sometimes clawing of the toes is secondary to peripheral neuropathy.
Conservative treatment involves proper footwear, and application of pads on pressure points. However these cannot correct the deformities and surgery is often needed.
Surgery involves fusion of the PIP joints and soft tissue releases and tendon lengthening. Weil’s osteotomy is used for long metatarsals and involves shortening of the metatarsal head and fixation with special twist-off screws. This reduces the pressure on the balls of the toes and also reduces the length of the toes and makes footwear comfortable. Often 2nd to 5th metatarsal Weil’s osteotomy is done to improve the cascade and prevent transfer metatarsalgia.
Hallux rigidus is a osteoarthritis of the large joint at the base of the great toe (1st MTP joint).
Like any other joint in the body, the joint is covered with articular cartilage, a very slick, shiny covering on the end of the bone. If this material is injured, it begins a slow process of “wearing out” or degeneration. This can result in a wearing away of the articular surface, until raw bone rubs against raw bone.
Bone spurs form around the joint as part of the degenerative process.
Pain and a stiffness in the MTP joint cause painful gait and footwear problems.
Diagnosis is usually apparent on examination but x-rays are usually required to determine the extent of the degeneration.
Treatment begins with anti-inflammatory medication to control the inflammation of the degenerative arthritis. Special shoes that reduce the amount of bend in the toe during walking will also help the symptoms initially. A rocker-type sole allows the shoe to take some of the bending force, and may be combined with a metal brace in the sole to limit the flexibility of the sole of the shoe and reduce the motion needed in the MTP joint.
Injection of cortisone into the joint may temporarily relieve symptoms.
Surgery may be suggested if all else fails. These are:
If less than 50% of the MTP joint is worn out, an operative procedure canned cheilectomy is used to remove only the spur and worn out bone. However the success rate of this procedure is unpredictable.
Fusing the joint relieves pain but makes it rigid. The worn out joint is excised and the raw bones are brought together and fixed with a screw, staple or a plate. Over several months bone grows across the joint. The toe is fused in an upward angle to facilitate normal walking pattern in the shoes.
Although replacing the joint is an attractive option of relieving pain and allowing mobility, it has the drawback of not lasting a lifetime and therefore revision fusion is often necessary. There are ceramic joints and metal on plastic (HMWPE) joints available.
This is the pain in the forefoot. It can have various causes, but the commonest are long lesser toe metatarsals with formation of callosities on the ball of the toes. It can also happen due to Morton’s neuroma.
This is the swelling and inflammation of the digital nerves that get entrpped and compressed between the metatarsals, which can cause shooting pain and burning in the toes. This is usuall seen in the 2nd and third web space. If conservative tretatment fails then the treatment for long metatarsals is Weil’s osteotomy as described above. The treatment for Morton’s neuroma is described above.
A Morton’s neuroma is a condition that causes pain in the forefoot and toes due to swelling or inflammation of the small nerves that are in the second and third web space.
The nerves to the toes runs between the metatarsals and divides to give sensory innervation to the toes.
Many people with this condition report feeling a painful “catching” sensation while walking and many report sharp burning, shooting pains that radiate out to the two toes along the course of the involved nerve.
The diagnosis is usually made based on history and physical examination alone. In some confusing cases, an injection of xylocaine and cortisone into the area can help decide of the diagnosis of a Morton’s neuroma is correct. The injection should result in a reduction of symptoms temporarily.
Treatment of Morton’s neuroma usually begins with shoe adaptations. New research shows locally injecting the nerve with alcohol may resolve the symptoms without surgery. If conservative treatment fails, then surgery is recommended.
Surgery involves removing the neuroma, and since the neuroma is part of the nerve, the nerve is removed, as well. This results in permanent numbness in the area supplied by the nerve.
Osteochondritis dissecans can cause pain and stiffness of the ankle joint. These lesions are thought to be caused by injury to the bone underneath the joint surface or by loss of blood supply to a part of the bone.
There may be intermittent swelling, pain in the joint. X-rays of the ankle usually reveal a defect on the talar dome. A CAT scan or MRI scan may be necessary to determine the full extent of the area involved.
If these are discovered soon after a twisting injury to the ankle, then immobilization in a cast for 6 weeks may be suggested to see if the bone heals.
If the problem is not associated with an acute injury, surgery may be required to try and reduce the symptoms. Surgery usually involves placing small drill holes in the defect. The drill holes stimulate new blood vessels to fill the area and help to form scar tissue to fill the defect. Most often surgery is through the arthroscope.
Peroneal tendon synovitis can develop due to overuse. However sometimes acute injury such as plantarflexion inversion can cause a longitudinal split in the peroneus brevis tendon. A period of rest and physiotherapy is helpful.
Peroneal tendon subluxation or dislocation can happen with forced dorsiflexion which tears the retinaculum and allows the tendon to move superficial to the lateral malleolus. This condition is difficult to treat conservatively and often requires surgery which involves deepening the fibular groove and reconstruction of the peroneal retinaculum.
The deformity can be plantaris, equinocavus and calcaneocavus. The primary cause could be plantarflexion of first ray due to weakness of tibialis anterior in plantaris cavus foot. In equinocavus foot there is tight heel cord but also tibialis posterior contracture. In calcaneocavus foot the heel cord is weak and therefore the os calcis is dorsiflexed.
Following are some common causes of pes cavus:
- Hereditary sensory motor neuropathy (HSMN)
- Cerebral palsy
- Friederich’s ataxia
- Post traumatic
- Spinal dysraphism
- Muscular dystrophy
The Coleman block test assesses whether the cavovarus foot is mobile. This helps in planning treatment. Patients with this condition get pain in the ball of the big toe and also on the heel. They also can get recurrent sprain. A thorough neurological examination is a must.
The treatment varies according to the severity of the deformity. This could involve midfoot and hindfoot osteotomy with tibialis posterior transfer and plantarfasciotomy. Also lateral shift os calcis osteotomy can be combined with dorsiflexion basal 1st metatarsal osteotomy. Severe deformities can be treated with Ilizarov or Taylor Spatial Frame.
This condition causes pain on the bottom of the heel when putting weight on the foot. The plantar fascia is a structure that runs from the front of the heel bone (calcaneus) to the ball of the foot. This dense strip of tissue helps to support the longitudinal arch of the foot like a tie beam.
When the foot is on the ground a tremendous amount of force is concentrated on the plantar fascia. This can lead to stress on the plantar fascia where it attaches to the calcaneus.
The chronic inflammation of the fascia itself may be the source of pain in many cases. If the forces along the plantar fascia are great and the fat pad on the heel is thin, the actual heel bone can break. If it occurs on a microscopic level, this is called a stress fracture.
In many cases, the actual source of the painful heel will never be clearly defined without doubt.
The heel is usually most painful when first few steps are taken in the morning. It can also be painful to stand and walk. Other patients will complain of pain when standing after a brief rest of sitting.
There are several conditions that can cause heel pain and plantar fasciitis must be distinguished from these conditions. An x-ray is usually not needed. Laboratory investigation occasionally may be necessary in some cases to rule out a systemic illness causing the heel pain, such as rheumatoid arthritis, Reiter’s syndrome, or ankylosing spondylitis.
The treatment of heel pain/plantar fasciitis usually begins with adjustments to the shoes to try and reduce symptoms.
Soft heel cups, and insoles can be helpful to support the arch. Anti-inflammatory medications are sometimes used to decrease the inflammation in the fascia and reduce pain. An injection of cortisone onto the most tender area of the fascia is effective.
Surgery is rarely done as the results are not that good. However this is a self limiting condition that can last for several years.
One of the most frequently affected tendons is the posterior tibial tendon.
The posterior tibial tendon courses behind the medial malleolus, across the instep, and into the bottom of the foot. The tendon supports the instep of the foot.
This tendon is prone to rupture. Initially tendonitis and swelling around the tendon sets . In later stages this gets attenuated and finally undergoes attrition tear.
The symptoms of tendinitis of the posterior tibial tendon are pain in the instep area of the foot and sausage shaped swelling along the course of the tendon. Rupture of the tendon leads to a fairly pronounced flatfoot deformity.
Treatment of posterior tibial tendinitis begins with a good supportive arch support, decreased activity, and anti-inflammatory medications such as ibuprofen. Sometimes an ankle foot orthosis (AFO) helps. Surgery is used to excise the inflamed synovium off the tendon.
If the tendon has ruptured, surgery may be required to either repair the ruptured tendon or to reconstruct it with a tendon transfer. Usually, another tendon in the foot, such as the tendon that bends the four lesser toes, is used as a tendon graft to replace the function of the posterior tibial tendon.
In late diagnosed cases bony surgery such as cutting the heel bone and shifting it to make the foot more straight is required.
Finally, if the foot has severe deformity with arthritis, a fusion (or arthrodesis) of the foot may be required. A fusion is an operation where a joint between two bones is removed and the two bones on either side of the joint are allowed to grow together, or fuse. This type of operation is used to stop pain from joints that are worn out and can be used to realign the bones when the normal mechanisms for maintaining normal alignment are deficient, such as when the tendon and ligaments no longer work properly.
Following surgery, a cast and/or a brace is worn for 8 to 12 weeks.
Bursa is a fluid filled sac of tissue that is often found around the bony prominences over which tendons and soft tissues rub. This therefore helps the tendons to glide with least amount of friction. Retrocalcaneal bursa is found behind the heel under the Achilles tendon.
Retrotendoneal bursa is found on the back of the attachment of the tendon where the shoe rubs on the skin. This can cause swelling, pain and difficulty in footwear. Sometimes there is a bony prominence on the heel bone that predisposes to this condition (Haglund’s deformity).
Treatment of this can be modification of footwear. However surgery is often required which involves excision of the bursa and also the bony prominence on the heel bone.
The rheumatoid disease can affect the whole foot. However commonly it affects the forefoot. It causes inflammation of the joints of the toes which leads to subluxation and dislocation of the toes. It destroys the joint cartilages due to inflammation. This causes callosities in the ball of the toes and clawing. The big toe deviates sideways and a severe bunion can develop.
Treatment is forefoot arthroplasty which inolves excision of the metatarsal heads and fusion of the first MTP joint.
In the hindfoot rheumatoid arthritis can cause valgus deformity. Tibialis posterior tendon could rupture aggravating the deformity. This leads to midfoot and subtalar arthritis. Treatment often is tripe fusion.
Total ankle replacement is a good option for patients with ankle involvement provided they don’t havd much of varus or valgus deformity.
These operations are commonly performed for painful stiff joints as in osteoarthritis and rheumatoid arthritis. Pain arises when two apposing bones which have lost their joint cartilage rub against each other.
Joints commonly affected that need fusion are big toe MTP (metatarsophalangeal), PIP (proximal interphalangeal), DIP (distal interphalangeal). Midfoot and hindfoot arthritis can be treated with triple fusion. Ankle joint sometimes needs fusing if joint replacement is not possible.