Foot & Ankle Conditions

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Ankle Sprain

An ankle sprain is a common injury and usually occurs when the ankle is twisted, causing injury to the soft tissue of the ankle.

Anatomy

A ligament is made up of multiple strands of tissue similar to a nylon rope. A sprain results in tearing of the ligaments. The tear can be a complete tear of all the strands of the ligament or a partial tear. The lateral ligaments (those on the outside of the ankle) are by far the most commonly injured ligaments in a typical inversion injury of the ankle.

Symptoms

Initially, the ankle is swollen, painful, and can become bruised due to ruptured blood vessels from the tearing of the soft tissues. Most of the initial swelling is actually bleeding into the surrounding tissues which increases over the next 24 hours.

Diagnosis

The diagnosis of an ankle sprain is usually made by physical examination of the ankle with x-rays to make sure that none of the bones of the ankle are fractured. If your doctor suspects that there is a complete rupture of the ligaments, he or she may order stress x-rays, as well. These x-rays are taken while someone twists or “stresses” the ligaments. Also an MRI of the injured ankle will give the surgeon the ability to evaluate the ankle ligaments as well as the surrounding tendons.

Medical Treatment

Treatment begins by using the PRICE principle: Protection, Rest, Ice, Compression, and Elevation. Crutches can prevent weight bearing on the ankle, and casts are used in severe cases. Healing of the ligaments usually takes about 6 weeks, but the swelling may be present for several months. Depending upon the severity of the ligament damage, physical therapy, surgery and rehabilitation may be suggested.

Osteochondritis Dissecans

Osteochondritis dissecans causes pain and stiffness of the ankle joint. It can occur in all age groups. Most cases of osteochondritis dissecans usually follow a twisting of the ankle.

Anatomy

Osteochondritis dissecans occurs at the top of the talus. Most of these lesions are thought to be caused by injury to the bone underneath the joint surface by a twisting injury. Some are actual chip type fractures, while others may result from injury to the bone’s blood supply causing an area of the bone to actually die.

Symptoms

Osteochondritis dissecans can cause swelling and a generalized ache in the ankle. There may also be a “catching” sensation with the ankle in certain positions.

Diagnosis

The history and physical examination may suggest the diagnosis of osteochondritis dissecans. 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.

Medical Treatment

Treatment for osteochondritis dissecans depends on when the problem is discovered. If the problem is discovered immediately 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 your symptoms, which involves removing the loose fragment of cartilage and bone from the ankle joint and 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.

Posterial Tibial Tendonitis

Because we use our feet continually, tendinitis in the foot is a common problem. One of the most frequently affected tendons is the posterior tibial tendon.

Anatomy

The posterior tibial tendon runs behind the inside bump on the ankle, across the instep, and into the bottom of the foot. The tendon is important in supporting the arch of the foot and helps turn the foot inward during walking. Initially, irritation of the outer covering of the tendon causes inflammation around the tendon as it runs through the tunnel behind the inside bump of the ankle. As we age, the tendon is subject to degeneration within the tendon. The normal arrangement of the fibers of the tendon becomes jumbled and the tendon loses strength. This condition is called tendinosis.

Symptoms

The symptoms of tendinitis of the posterior tibial tendon include pain in the instep area of the foot and swelling along the course of the tendon. In some cases the tendon may actually rupture due the weakening of the tendon by the inflammatory process.

Diagnosis

Rupture of the tendon leads to a fairly pronounced flatfoot deformity that is easily recognizable.

Medical Treatment

Treatment of posterior tibial tendinitis begins with a good supportive arch support, decreased activity, and anti-inflammatory medications such as ibuprofen or aspirin. If the condition has been present for a long time, a brace known as an AFO (Ankle Foot Orthosis) can be very helpful. If the tissue thickening is severe or it has ruptured, surgery may be required to repair or reconstruct the tendon. This is also the case when neglected tendinitis/rupture has caused a fixed flatfoot deformity or deformity from arthritis.

Achilles Tendonitis

Problems that affect the Achilles tendon are common among active middle-aged people. The problems cause pain at the back of the calf and can result in a rupture of the Achilles tendon in severe cases.

Anatomy

The Achilles tendon is a strong, fibrous band that connects the calf muscles to the heel. When the muscles contract, they pull on the Achilles tendon causing your foot to point down and helping you raise up on your toes, sprint, jump, or climb. Several different problems can affect the Achilles tendon — some rather minor and some quite severe.

Tendocalcaneal Bursitis: A bursa is a fluid-filled sac designed to limit friction between rubbing parts. Tendocalcaneal bursitis is an inflammation in the bursa behind the heel bone, limiting the Achilles tendon movement.

Achilles Tendinitis: A violent strain can cause injury to the calf muscles or the Achilles tendon. This can happen during a strong contraction of the muscle, as when running or sprinting.

Achilles Tendon Rupture: In severe cases, the force may rupture the tendon. The classic example is the middle-aged tennis player or “weekend warrior” who places too much stress on the tendon and experiences a rupture of the tendon.

Symptoms

Tendocalcaneal bursitis begins with pain, irritation, and swelling at the back of the heel. Achilles tendinitis usually occurs farther up the leg, just above the heel bone itself. Pain is present with walking or touching the area. Finally, Achilles tendon rupture is usually an unmistakable event. Sometimes a snap can be heard, and the victim of a rupture usually describes a sensation like “someone kicked me in the calf.” Following rupture there can be swelling in the calf and usually the patient cannot rise up on the toes.

Diagnosis

Diagnosis is almost always made based on clinical history and physical examination. In cases where there is an Achilles tendon rupture in question, an MRI scan may be necessary to confirm the diagnosis.

Medical Treatment

Medical treatment for tendocalcaneal bursitis and Achilles tendinitis usually consists of a combination of rest, anti-inflammatory medication, and physical therapy. Many orthopedists and podiatric surgeons feel that Achilles tendon ruptures in younger active patients should be repaired surgically due to the increased strength of the healed tendon following surgery versus non-operative cast treatment.

Plantar Fascitis

Plantar fasciitis is a condition that is sometimes called a “heel spur.” There are probably many underlying causes of heel pain and some physicians feel that it is probably more accurate to simply make a diagnosis of “heel pain” rather than try and define an absolute cause in every instance.

Anatomy

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 by acting similar to the string on a bow. When the foot is on the ground a tremendous amount of force is concentrated on the plantar fascia, leading to stress where it attaches to the calcaneus. Small tears of the tendon can result, and although the body often heals itself, repeated injury and repair causes a bone spur to form in the hopes of firmly attaching the fascia to the bone.

Symptoms

This condition causes pain on the bottom or center of the heel when putting weight on the foot. This is usually most pronounced in the morning when the foot is first placed on the floor. Other patients will complain of pain when standing after a brief rest of sitting.

Diagnosis

The diagnosis of plantar fasciitis is generally made after the history and physical examination. There are several conditions that can cause heel pain and plantar fasciitis must be distinguished from these conditions. An x-ray can rule out a stress fracture of the calcaneus and show whether a bone spur is present that is large enough to actually cause problems. Laboratory investigation 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.

Medical Treatment

Supporting the area with orthotics such as a well-fitted arch support or inserting a heel cup can reduce the pressure on the sore area and add padding to a heel that has lost some of the fat pad through degeneration. Anti-inflammatory medications are sometimes used to reduce pain. An injection of cortisone onto the area of the fascia is effective but should be used sparingly because this medication may contribute to the process of degeneration of the fat pad or rupture of the plantar fascia, actually making the problem worse.

A gentle stretch held for at least one minute several times per day is extremely helpful. As a last resort, surgical procedures can be used to remove the bone spur, release the plantar fascia, or release pressure on the small nerves in the area.

Morton's Neuroma

A Morton’s neuroma is a condition that causes pain in the foot due to swelling or tumor of the small nerves of the foot.

Anatomy

The nerves of the foot run into the forefoot and out to the toes between the long bones of the feet. Once they reach the end, they split and continue out to the end of the toes. Each nerve splits to supply sensation to half of two different toes. A Morton’s neuroma occurs just before the nerve splits into the two branches. The cause of the neuroma is not entirely understood but likely results from chronic injury to the nerve in this area.

Symptoms

The neuroma usually causes pain in the ball of the foot with weight bearing. Many people with this condition report feeling a painful “catching” sensation while walking and many report sharp pains that radiate out to the two toes along the course of the involved nerve.

Diagnosis

The diagnosis is usually made based on history and physical examination alone. X-rays are only useful to make sure the pain is not coming from some other cause such as a stress fracture.

Medical Treatment

Treatment of Morton’s neuroma usually begins with shoe adaptations. Sometimes simply moving to a wider shoe will reduce or eliminate the symptoms. New research shows locally injecting the nerve over a series of several weeks with a sclerosing agent may resolve the symptoms without surgery. However, if this fails to resolve the pain, surgery may be suggested to remove a portion of the nerve.

Hammertoes

Claw toes and Hammertoes are fairly common conditions among people in cultures that wear shoes. In most cases, these problems can be traced to improperly fitting shoes.

Anatomy

The hammertoe deformity usually starts on the larger toes and creates a curved appearance, often a result of shoes that are too short. If the deformity isn’t corrected, over time the other toe joints will become hyperextended and also curl.

Symptoms

Starting out flexible and becoming rigid over time, toes that are squished day after day become fixed in the curled position and will not straighten out. Pressure builds up at the end of the toe and over the joints, causing painful calluses to develop.

Diagnosis

Diagnosis is obvious from the physical exam. In some cases, special tests may be required to make sure no other nerve problems are to blame for the condition.

Medical Treatment

Early in the process, simply switching to shoes that fit properly can stop the process and return the toes to a more normal condition. If the condition is more advanced and the toes will not completely straighten out on their own, a contracture may exist. Pressure points and calluses caused by the contractures can be treated by switching to shoes that have more room in the toes or by placing pads over the calluses to relieve the pressure. If all else fails, surgery may be suggested to correct the alignment of the toe. After surgery, you will usually be fitted with a postoperative shoe with a stiff, wooden sole that protects the toes by keeping the foot from bending. Pins placed in the toes during surgery to help them heal straight are usually removed after 2 or 3 weeks.

Bunion

A bunion (hallux valgus) is a condition that affects the joint at the base of the big toe, causing a bump to grow. Pointed-toe shoes that squeeze the foot such as high heels and cowboy boots can contribute to the development of bunions.

Anatomy

“Hallux” is the medical term for big toe and “valgus” is an anatomic term meaning the deformity goes in a direction away from the midline of the body. With a bunion, the big toe begins to point toward the outside of the foot. After time, the bone just above the big toe, the first metatarsal, develops too much of an angle in the other direction. The bunion that develops is a response to the pressure from the shoe on the point of this angle. At first the bump is made up of irritated, swollen tissue that is constantly caught between the shoe and the bone beneath the skin. After time, the constant pressure may cause the bone to thicken as well, creating an even larger lump to rub against the shoe.

Symptoms

A bunion can be painful and the deformity can become a cosmetic problem to many, often making it hard to find appropriate shoe wear. Increasing deformity begins to displace the second toe upward, creating additional rubbing on the shoe.

Diagnosis

Diagnosis begins with a careful history and physical examination by your doctor. X-rays will allow your doctor to measure several important angles made by the bones of the feet to help determine the appropriate treatment.

Medical Treatment

Treatment of a bunion nearly always starts with adapting the shoes to fit the feet; 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. These are also numerous devices, such as toe spacers, that attempt to splint the big toe and reverse the deforming forces.

If all conservative measures fail to control the symptoms, then surgery may be suggested. There are well over 100 surgical procedures described to treat hallux valgus. The basic considerations are removing the bunion, realigning the bones that make up the big toe, and balancing the forces so the deformity does not return.

Hallux Rigidis

Hallux rigidus is a degenerative-type arthritis condition that affects the large joint at the base of the great toe. Degenerative arthritis is a condition that results from wear and tear on the joint surface over time.

Anatomy

Like any other joint in the body, the joint at the base of the great toe 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.

Symptoms

The degeneration causes two problems: pain and a loss of motion in the joint. Without the ability of the joint to move enough to allow the foot to roll through while walking, the gait is painful and difficult.

Diagnosis

Diagnosis is usually apparent on examination but x-rays are usually required to determine the extent of the degeneration and the bone spur formation.

Medical Treatment

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. If all else fails, surgery may be suggested.

Bunionette

A bunionette is similar to a bunion but on the outside edge or lateral side of the foot. 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.

Anatomy

A bunionette is most likely caused by an abnormal prominence over the fifth metatarsal head rubbing on shoes that are too narrow. As they grow older, some people have a widening of the foot until it spreads or “splays”, causing a bunion on one side of the foot and a bunionette on the other if the patient continues to wear shoes that are too narrow. The constant pressure produces a callus and a thickening of the bursa over the area, leading to a painful knob on the outside of the foot.

Symptoms

The symptoms of a bunionette include pain and difficulty buying shoes that will accommodate the deformity. The swelling in the area causes a visible bump that some people find unsightly.

Diagnosis

The diagnosis of a bunionette is usually obvious on physical examination. X-rays may help to determine whether the joint has arthritis or if there is an abnormal growth from the metatarsal bone.

Medical Treatment

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 to remove the bump along the bone and tighten the soft-tissue structures to straighten the 5th toe. Although initially very successful, if you return to tight shoes the deformity frequently returns.