Foot Conditions

Bunions involve a deformity of the big toe. The deformity usually occurs at the first metatarsophalangeal joint, but can also be influenced by the joints further above the actual deformity. Bunions usually have a genetic component associated with them and are more likely in patients with ligamentous laxity. Patients may often have other deformities such as flat feet. Bunions usually present with difficulty with shoe wear and rubbing across the prominence of the great toe, but can also lead to arthritic changes later in life. Weightbearing feet x-rays help to confirm the diagnosis as well as its severity and potential causes.

Treatment

Treatment for bunions can include non-operative interventions such as shoe wear modification, the use of a toe spacer, or a bunion brace. While these treatments do not correct the underlying deformity, they may help manage the condition. For those patients who fail non-operative interventions and have a symptomatic bunion, operative intervention can be considered. This will usually involve osteotomies (breaking and resetting the bone) and ligament balancing surgery. These operations may occur in conjunction with treatment of deformities in the lesser toes. For those patients with severe bunions or arthritic changes, a fusion of the joint may be recommended. Theepan does not recommend surgery on bunions for purely cosmetic reasons. Risks of bunion surgery include infections, recurrence of the deformity, lack of healing of the osteotomy sites, as well as damage to neurovascular structures.

First metatarsophalangeal arthritis (hallux rigidus) is a condition characterised by arthritis of the big toe /first metatarsophalangeal joint. This typically results in pain during walking, but can also cause night time and rest pain. The pain usually begins with the extremes of motion in this joint, but as the disease progresses, it may occur throughout any range within this joint. 

Causes for first metatarsophalangeal joint arthritis include genetic predisposition, malalignment of the joint, and post-traumatic arthritis. Certain inflammatory arthritis conditions such as rheumatoid arthritis and gout can indicate a predisposition to destruction and arthritis of the joint. 

Treatment

Non-operative interventions form the first line of therapy in first metatarsophalangeal joint arthritis. These include shoe wear modifications and potentially the use of a Morton's extension orthotic. The use of anti-inflammatory medications and potential steroid injections may also help to manage the condition, although it does not treat the underlying arthritis.

A number of surgical interventions may be available to patients with first metatarsophalangeal joint arthritis. For patients who have early arthritic changes with predominance of pain on the extension of the joint, surgical excision of spurs may be offered. Patients who have severe arthritis with pain throughout the range of arc of motion typically benefit from first metatarsophalangeal fusion surgery. This involves preparing the joint surfaces and holding them together with screws +/- plate to eliminate painful movement within the joint. Patients are typically still able to walk and run post this surgery and most individuals return to their usual activities of daily living. However, patients are advised against the use of high heeled shoes following first metatarsophalangeal fusion.

The risks of surgery include deep vein thrombosis, infection, damage to neurovascular structures, as well as non-healing of the fusion site.

Midfoot arthritis refers to the degeneration of the cartilage within the joints of the midfoot. There are numerous joints within the midfoot, and each one of these is susceptible to arthritic changes. This can result from normal aging processes as well as post-traumatic injuries or inflammatory arthropathies such as rheumatoid arthritis. Arthritis typically presents with pain on weight bearing, but can also cause pain at rest or during the night. Scans used to help diagnose midfoot arthritis include x-rays, CT scans, MRI and CT spect/bone scan.

Treatment for midfoot arthritis begins with non-operative interventions. In the early stages, arthritis may be managed with good supportive footwear, and Theepan may refer you to a podiatrist for this. A trial of orthotics may also be beneficial. Furthermore, patients may elect to trial a corticosteroid injection into the affected joints, usually under radiological guidance, to help alleviate some symptoms. Unfortunately, arthritis cannot be reversed.

When non-operative interventions have failed, surgery may be considered. This is usually in the form of a fusion of the affected joints. A fusion involves preparation of the joints and bringing them together with plates and screws to prevent painful motion within the affected area. Typically, following midfoot fusion, patients can resume most of the activities they were previously doing. Midfoot fusions may be done in conjunction with foot or ankle realignment surgery. Theepan will discuss the implications of fusion surgery with you during your consultation. The usual risks of this surgery include deep vein thrombosis, infection, damage to the neurovascular structure surrounding the area, failure of the bones to fuse, as well as adjacent joint disease.

Lisfranc injuries refers to a serious injury of the midfoot. These can include both bony injuries as well as ligamentous injuries, all of which help to stabilise the midfoot region. Typically, Lisfranc injuries occur with the foot in a flexed position but can have various other mechanisms of injury. They can be related to both low and high velocity injuries. Lisfranc injuries are important to diagnose as they have a high chance of progressing to arthritis when missed. Usually, patients will present with significant swelling and bruising within the foot. Most Lisfranc injuries can be identified on plain x-rays and CT scans but, in some circumstances, an MRI scan will need to be performed. 

Treatment for Lisfranc injuries depends upon the stability of the injury as well as any dislocation or malalignment of the joints. Theepan will be able to go through your scans with you and determine the best course of action. Patients who are deemed suitable for non-operative treatments are typically non-weight-bearing for six weeks, during which time they will start physical therapy. It is likely they will use arch support orthoses throughout the rest of their life. Patients with unstable Lisfranc injuries deemed suitable for surgical intervention, will typically involve the use of either plates and screws (which usually will need to be removed) to stabilise the affected joints or an internal brace device which usually does not need to be removed. Recovery from Lisfranc surgery can take between four and six months. Patients with severe Lisfranc injuries may be best suited to primary fusion surgery, particularly in those with significant joint destruction and those of an older age demographic. The risks of Lisfranc surgery include deep vein thrombosis, infection, damage to the neurovascular structures in the area, as well as development of post-traumatic arthritis.

Flat feet are a common condition that can affect people in various ways. Some patients may have flat feet their whole lives and remain asymptomatic. However, in some patients, flat feet can cause pain behind the ankle, within the arch, and later on the outside part of the ankle. In severe cases of flat feet, the condition may ultimately cause degenerative changes within the midfoot, as well as the ankle and surrounding joints. Flat feet can be congenital or develop later in life as a result of inflammation and weakening of the tibialis posterior tendon. In some instances, flat feet can also be linked to inflammatory arthritis such as rheumatoid arthritis.

Treatment

The treatment for flat feet starts with non-operative interventions. This can include the use of orthotics as well as ankle support braces. Furthermore, physical therapy can be utilised to help strengthen the tibialis posterior tendon, and stretching exercises can be given to address a tight Achilles tendon. When non-operative interventions have failed or the flat foot deformity has progressed significantly, various operative treatment strategies exist. If the joint surfaces do not show significant arthritis, a flat foot reconstruction may be entertained. This would usually include a combination of bone realignment surgery as well as tendon rebalancing. In those patients who have developed significant arthritis, fusion surgery with or without an ankle replacement may be considered.

Theepan will go through your images and clinical findings with you and tailor the best management plan for your circumstances. Flat foot surgery typically takes four to six months to fully recover from. The risks of flat foot surgery include deep vein thrombosis, infection, recurrence and progression of the deformity, as well as damage to the surrounding neurovascular structures.

Plantar fasciitis is a condition that affects the soft tissue which helps to form the arch of the foot. This band of tissue can cause pain when inflamed. It is believed that chronic overuse leads to small tears in the plantar fascia, resulting in recurrent inflammation. Plantar fasciitis may or may not be associated with a calcaneal heel spur.

Typically, plantar fasciitis is a clinical diagnosis, but this can be further confirmed on ultrasound or MRI scan, with the calcaneal spur being detected on a plain x-ray.

Treatment

The first line of treatment for plantar fasciitis is non-operative intervention. This includes activity modification, orthotics, and stretching of the plantar fascia. The use of anti-inflammatory medications and corticosteroid injections can also help alleviate the inflammation associated with the condition. Shockwave therapy may also be utilised in appropriate cases. Theepan also encourages lifestyle modification to enhance recovery, including weight loss and smoking cessation.

When plantar fasciitis does not respond to non-operative therapies, surgical intervention can be considered. This is usually in the form of a plantar fascia release through a small incision on the sole of the foot. This may be combined with a calcaneal spur resection and an Achilles or gastrocnemius release. Risks of the procedure include damage to the surrounding nerves, infection, and recurrent disease.

Metatarsal fractures are fractures that occur in the metatarsal bone/s of the foot and can result from both low velocity and high velocity mechanisms. Isolated metatarsal fractures are common. The foot is divided into three columns: the medial column, the middle column, and the lateral column. The medial column includes the first metatarsal, the middle column incorporates the second and third metatarsals, and the lateral column incorporates the fourth and fifth metatarsals. The outer lateral column is more mobile to allow for walking on uneven surfaces and is thus more predisposed to fractures.

The metatarsals in the foot are also prone to stress fractures from repetitive trauma. Some stress fractures can be related to metabolic conditions, and Theepan will determine if a referral to an endocrinologist is necessary.

Treatment

Isolated and undisplaced metatarsal fractures can often be treated non-operatively with supportive footwear, including a Darco shoe or a Cam boot. In some circumstances, supportive runners can also be used. Following a period of immobilisation and confirmation of fracture healing, targeted physiotherapy can help return patients to their usual levels of functioning.

In injuries where the fracture is displaced, there are multiple metatarsal fractures, or there is a high chance of non-healing, surgical interventions may be suggested. This usually involves fixation with plates and screws, as well as a potential bone graft to aid recovery. If there is an alignment issue predisposing the fracture to non-healing, this will usually be addressed at the same time as fixation of the metatarsal. The risks of these surgeries include infections, deep vein thrombosis, non-union, and damage to the neurovascular structures.

Morton's neuroma is a condition caused by inflammation and scarring of the interdigital nerve between the toes. The most common location is between the third and fourth toes, but neuromas can occur in between other toes as well. Patients usually present with nerve-type pain in between their toes and sometimes will complain of a feeling of walking on a marble or pain on the sole of their foot. Morton's neuroma is a benign condition but can be quite limiting in terms of physical function.

Treatment

Treatment for Morton's neuroma starts with non-operative therapy. This includes shoe wear modification to allow for a wider toe box, as well as the use of orthotics to offload the metatarsal head. The use of a corticosteroid injection can also help with the pain and inflammation associated with the condition. When non-operative therapies have failed, excision of a Morton's neuroma can be performed. A consequence of this surgery is that the patient will lose some, if not all, of their feeling in their affected toes. The risks of this surgery include infection, damage to the vascular structures or further nerve pain.