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Foot & Ankle Problems

Achilles Tendon Problems

There are a few problems that can affect the Achilles and this tendon can be very hard to heal and can take a long time to rehabilitate.   The reason this tendon is a problem is because it has a very poor blood supply, especially a couple of inches above the insertion on the heel called the “watershed” area. This is where the tendon will often rupture like was the case with Kobe Bryant. People who are very active or obese are prone to injury to this tendon. Patients with very tight tendons known as equinus deformity are also at risk. Often times if present for a while there will be a bine spur associated with this that is coming off the heel bone and causing irritation to the adjacent tendon. Also, there can be a bursitis present as well. This can be seen on x-ray as well as ultrasound. Poor shoe gear can also add to this problem with poor shock absorption.

 

Treatment - this is geared at reducing the swelling and pain with PT, Icing, and proper shoe gear.

 

Orthotics can be dispensed when indicated. This is indicated during the gait analysis. Topical pain cream is also prescribed. A Dynasplint brace is also sometimes used in more severe cases.   This is a brace that is worn at night and it is covered by insurance. You should not wear any flat shoes at anytime, and don’t walk barefoot. Some shoes will irritate the back of the heel if a spur is present.

 

Shockwave therapy is also very helpful with this condition. This is the latest technology for the treatment of tendon/ligament problems and can be done in the office setting. Usually we will try 6 weeks of conservative therapy and see how you respond. If no improvement then we move onto more aggressive treatment as surgery is last resort.

 

Shockwave with PRP (Platelet Rich Plasma) or Amniotic Fluid (Stem cells) injected around the tendon. The radial shockwave will stimulate blood flow to the tendon and cause some analgesia and then allow the injectable (PRP or Stem cells) to find the diseased area and repair it. This is done without any incisions and usually takes 4-6 weeks to get the desires results.

 

Surgery (when indicated)

  1. Rupture – this is repaired usually by using a small incision and a special device is placed into the incision and special strong sutures are brought through the device through the skin and the tendon is brought together to heal. This is much different than most other methods. In some cases the procedure must be done open and also may require lengthening of the tendon if it is too short. This is a long recovery up to 8 months.
  2. Chronic swollen tendon with bone spur- the repair is aimed at removing the diseased Achilles tendon after reflecting it off of the heel bone (calcaneus) to then remove the spur and smooth out the heel.   In 90% of the cases we also lengthen the gastrocnemius tendon using endoscopic technique. This increases the success rate by taking the pulling forces off the heel. We then use bone anchors to reattach the tendon to the heel. Recovery is about 2 months before you can begin to walk normally. Usually there is a period of 2-4 weeks of non-weight bearing.
Achilles Tendonitis

Achilles Tendonitis occurs when the Calcaneal tendon (Achilles tendon) becomes inflamed. The Calcaneal tendon joins the calf muscle to the heel bone. By lifting the heel, the Calcaneal tendon aids in walking and running. Athletes are prone to this injury because excessive recurring activities -- like running -- can overuse the tendon. Other individuals who don’t participate in such activities may acquire damage by prolonged stress on the feet, like standing for hours on end. People who have pronation of the foot -- flattening of the arch -- also have an increased risk of developing Achilles Tendonitis. The first symptom of inflammation includes mild discomfort around the tendon. As the condition progresses, other symptoms include:

 

  • Aching
  • Tenderness when the sides are squeezed
  • Soreness
  • Intense Pain

 

Several treatments are available to alleviate pain and heal the tendon. To reduce inflammation and pain, applying ice packs and taking an NSAID, like ibuprofen, are good ways to begin treatment. Proper rest with the combination of physical therapy can rehabilitate the injured tendon. Physical therapies such as strengthening exercises, massage, and ultrasound therapy, which normally lasts two to four weeks, can help to keep the inflammation under control. When physical therapy is not taking place, use of a walking boot may be helpful to reduce stress on the tendon. If Achilles Tendonitis is not treated, the condition could worsen to Achilles Tendonosis, which is the degeneration of the tendon.

Ankle Sprains

Ligaments of the ankle connect foot bones to each other. When one of these ligaments sustains damage, the ankle becomes sprained. Sprained ankles are common among athletes. Any movement that puts the ankle in an abnormal placement may cause an ankle sprain. Examples of such movements include twists or falls. When participating in athletic activities it is important to wear proper footwear because poor quality or inappropriate shoes may lead to this type of injury. Indications you may have a sprain include pain or soreness of the ankle. Other indicators include:

 

  • Swelling or bruising
  • Difficulties walking
  • Joint stiffness

 

Treatment is crucial for a sprained ankle and prompt medical attention is required because the leg may become weaker, the injury might not heal properly, or severe bone complications, such as fracture, may occur. A common treatment for a sprained ankle is RICE: Rest, Ice, Compression, and Elevation. Rest gives the ankle ligaments an opportunity to heal while ice helps reduce the inflammation. Compression -- wrapping of the ankle with an elastic wrap --and elevation -- supporting the ankle about 3 feet off the floor -- work to decrease swelling. Recommended medications to help with pain are NSAIDs, such as ibuprofen, but some physicians may prescribe pain medications if the injury is severe. If treatments fail to properly rehabilitate the ankle sprain, surgery may be necessary.

Arthritis

Osteoarthritis and rheumatoid arthritis (RA) are two types of arthritis that occur in the feet and ankles, with osteoarthritis being the most common. Osteoarthritis occurs when the cartilage between the bones begins to degenerate. The most common symptom of osteoarthritis is pain. Other symptoms include:

 

  • Joint stiffness
  • Swelling near joint
  • Difficulties walking

 

Many non-surgical treatments are available to relieve pain and help regain function. NSAIDs, like ibuprofen, walking casts, and steroid injections are helpful in reducing inflammation. Custom shoe inserts can aid in pain reduction and correct abnormal arches. Special exercises may be encouraged by a doctor to help regain strength and stability.

 

RA is a type of arthritis that has unknown origins. Environmental triggers or genetics are two suggestions for the cause of RA. During RA, cells of the immune system get confused and begin attacking healthy joints, causing a myriad of foot issues. Symptoms of RA include:

 

  • Rheumatoid nodules (lumps)
  • Pain and swelling
  • Difficulties walking

 

Custom shoe inserts and shoes can relieve pain and assist with walking. The use of steroid injections is a common practice for delivering an anti-inflammatory. Surgery to help with foot conditions that occur because of RA is a last resort.

Athlete’s Foot

Tenea pedis, most frequently known as Athlete’s Foot, occurs when fungi grow on the feet and cause a skin infection. It is a common condition among athletes and children who attend summer camp, but can affect anyone. Certain facilities are prime growing conditions for fungi like locker rooms, swimming pools, and showers, which can increase the risk of infection. Sweaty feet that spend all day in shoes are more likely to contract the condition than dry feet. You may have Athlete’s Foot if you exhibit the following symptoms:

 

  • Itchy, dry, or scaly feet
  • Cracked skin
  • Inflammation
  • Blisters

 

Not only is this condition annoying due to excessive itching but if not treated a bacterial infection could set in and possibly spread to the toenails. Keeping feet dry will decrease chances of fungi growth, so changing socks frequently is a good idea if engaging in activities that cause you to sweat. Avoid walking barefoot in public showers at the gym, around the pool, or anywhere else the conditions are warm and damp. Most of the time, over the counter (OTC) anti-fungal powders, sprays, or creams will treat Athlete’s Foot. If the condition is extreme and persistent, a doctor will prescribe stronger medication.

Blisters

Those who walk or run long distances are not strangers to foot blisters. When the foot intensely and repeatedly rubs up against the inside of the shoe, a blister can form. A blister is a puffy, bubble of skin filled with fluid that protects the skin and promotes healing of the injured area. Wearing poorly fitting shoes -- or new shoes that haven’t been broken in – can set the wearer up for blisters. The main symptom is the appearance of a bubble-like, raised portion of skin. Other symptoms that may accompany the bubbled skin include:

 

  • Pain
  • Redness
  • Itching

 

When running or walking wear comfortable, well-fitted shoes and clean socks. If you get a blister, wear shoes as infrequently as possible. Protect the blister with a loose bandage until the body absorbs the fluid in the blister and the blister thoroughly heals. If you get a blister, do not pop it unless it is large and likely to be irritated further. To pop a blister, wash hands and sterilize a needle by pouring alcohol over it. Poke a small hole in the blister and squeeze the liquid out. Seek out medical attention if the blister pus is white or yellow. This means it is infected. After popping, apply an anti-biotic ointment to the site with a bandage loosely covering the area.

Bunions

A bunion is a genetic deformity of the 1st ray, which is made up of the 1st metatarsal and the phalanx/great toe. It is not a bone deposit or calcium deposit. It can get worse in a foot that is pronated or flat. Shoes can accelerated the deformity or make it worse. Most of the pain occurs because the nerve to the great toe is usually right over the bump from the bunion and this can cause significant and radiating pain. Even children can get bunions especially if the parents or grandparents have them. This must be treated earlier and more aggressive than adult bunions.

 

Conservative treatment - this is based on reducing the pressure around the bump and trying to help the alignment of the foot. NSAIDs and topical medications can be used to reduce inflammation and pain associated with the bunion. Change in shoe gear is also important. Orthotics can be used to relive pressure and help the mechanics of the foot but they do not cure bunions.

 

Surgical - Most people have heard horror stories about bunion surgery but we have performed thousands of bunion procedures and have mastered the art of correction and in most cased there is minimal or NO pain after surgery!

 

Each doctor, has their own preferred technique for correction. The procedures are based on the severity of the bunion and how it looks on x-ray. There are several important factors that determine procedure. Sometimes other procedures unrelated to the bunion are needed to correct the foot as a whole unit and to make sure the bunion will not return. Bunion surgery is 95% successful in our hands. The recurrence rate is less than 5%.

 

Dr. Bregman usually does one of the three procedures listed below in order of how common.

  1. Scarf bunionectomy- this is a cut made with a special saw through the entire first metatarsal in the shape of a Z turned on it’s side. Once the cut is made the bone is shifted to correct the deformity and fixated with 2 or 3 screws. The remaining bump is removed. The recovery for this is 48 hrs off with ice and elevation, then a walking boot for 1-4 weeks and then into sneakers at 4-6 weeks. Return to full activity in 3 months or so. PT, cold laser, Dynasplint(medical device worn after surgery), topical pain cream, NSAIDs and pain meds when needed.
  2. Lapidus fusion– this is where the proximal joint is fused to provide a stable correction. This is near the middle of the foot on the inside. The first metatarsal-cuneiform joint is fused by removing the cartilage with special instruments and then fixated with a combination of plates, screws, and sometimes staples. There is also work done at the sight of the bump itself, which is removed and the capsule surrounding the joint is cut in a special way to remove the redundant tissues and tightened to help maintain correction. This requires 1-4 weeks of non-weight bearing using a knee roller or crutches then into a cam walker boot. PT, Laser, Dynasplint, topical cream. Takes about 3-4 months before can wear regular shoes depends on swelling.
  3. Silver bunionectomy-  A small incision is made at the bump and the bump is removed with a special saw or burr and the capsule is also cut and tightened to help with correction. Topical cream, laser, ice and possible PT. Back in shoes in 3-4 weeks.

Akin Ostetomy - This is when the hallux or big toe has an osteotomy or cut made where a small wedge is taken out of the bone to bring the toe to a straight position. This can be done by minimal incision technique (MIS) or traditional with staple fixation.

 

Sesamoids - these are the two small peanut shaped bones under the big toe joint/metatarsal head that are there to help generate power to the toe. They are almost always dislocated laterally (on x-ray) and sometimes the fibular or lateral sesamoid needs to be removed. This is a decision made at the time of the surgery.

 

* Please note that there are cases where other procedures may need to be done especially on the second toe when fixing a bunion. All procedures recommended may change during the actual surgery if the surgeon feels it is in your best interest.

Calluses

Calluses are hard, thickened areas of skin that are often not painful and require no treatment. Pressure or friction due to rubbing from socks and shoes or bunions may cause of calluses. It is easy to tell if you have a callus by the appearance of hard, thickened skin on your foot. Other symptoms of calluses may include:

 

  • Pain
  • Yellowish or gray appearance of skin

 

To prevent calluses, wear well-fitted shoes. If calluses become painful you might want to invest in thicker sole inserts for shoes. This will cushion the foot while walking and alleviate pressure on the sole of the foot. Home treatment includes soaking the foot in warm water to soften the callus and gently using a pumice stone to slough off dead skin. Take great care if you opt to use this method. Rubbing too rough with the pumice stone may cause the callus to bleed and an infection can develop. Under no circumstances should you try to cut the callus off by yourself. Improper techniques can result in cuts and bacterial infection. If the callus pain is persistent, visit the doctor for proper callus removal. If painful calluses remain untreated other conditions like bursitis, blisters, bone infections, or bacterial infection of the joint can occur.

Claw Toe

Tight fitting shoes that squeeze your feet are the most common cause for toes curling and digging into the sole of the shoe. Alcoholism, diabetes, trauma, and excessive inflammation also are culprits that may trigger the condition of claw toe. Both alcoholism and diabetes can cause nerve damage that weakens the muscles of the foot, causing claw toe. Performing special tests may be necessary to rule out neurological conditions that can cause weakening of the foot muscles. Symptoms of claw toe include:

 

  • Toes that bend upward
  • Toes that bend downward
  • Toes that curl under the foot
  • Calluses or corns

 

When symptoms of claw toe first appear the toes are still flexible and the use of tape or a splint may correct the position of the toes. Doctors recommend patients stay away from shoes that will cramp feet and opt for shoes with plenty of room in the toe-box. What has proven to be helpful are special toe exercises, like picking up small items with the toes, which can improve the condition or prevent it from worsening. Toes become rigid during the later stages of claw toe and special shoe pads and shoes with “in depth” toe boxes should be worn. Only as a very last resort should you consider surgery.

Corns

Corns are common foot conditions that occur from repeated pressure on the foot, such as rubbing of the skin against a shoe, wearing no socks with shoes, or foot deformities. Women are more likely to develop corns due to wearing high heels. Corns come in three different forms: hard corns, soft corns, and seed corns. Located on the top or outside of the little toe, hard corns look like a compressed patch of hard skin with a dense core. Soft corns are found between the toes while seed corns develop on the heel or ball of the foot. All corns can be painful. Other symptoms include:

 

  • Redness
  • Tenderness
  • Hard patch of skin (hard corns)
  • Thin skin with smooth center (soft corns)
  • Circle of dead skin (seed corns)

 

If corns are no longer exposed to friction they can heal by themselves. Moleskin pads may relieve the pressure if it is impossible to reduce friction. Over the counter (OTC) corn pads with medication are available but be wary; the salicylic acid on the corn pad may cause a chemical skin burn and an infection. Seek medical attention if your corn gets cut, discharges pus or fluid, or if you have diabetes because of the increased risk of infection. If an infection does occur, a physician can make a small incision to drain the corn and prescribe an oral antibiotic.

Cracks and Fissures

Tarly stages of heel cracking involve the splitting of the skin to produce unsightly cracks. If heel cracks remain untreated, the cracks can progress into fissures. Cracks only affect the upper layer of the skin called the epidermis, while fissures begin to crack deeper into the skin, just below the epidermis into the dermis. Dry skin is the reason most people assume they have cracking heels, but increased weight, diabetes, neuropathy, poor circulation, and poor nutrition can also cause poor foot health. Symptoms of heel cracks and fissures vary from mild to severe. The most apparent symptom is cracks in the epidermis of the heels. Other symptoms include:

 

  • Dry, itchy heels
  • Hard skin on the heels
  • Pain
  • Difficulties standing or walking
  • Difficulties standing or walking
  • Bleeding or discharge

 

With proper treatment, heel cracking will not evolve into fissures. Moisturizing the feet two times a day will heal the cracks in most cases. Exercise will improve poor circulation to the feet that can help heal or prevent cracks from reappearing again. If cracks or deep fissures are persistent, a diet lacking proper nutrients may be the culprit. Add foods to your diet that are rich in Vitamin E, Calcium, Omega 3 fatty acids and iron. Do not take over the counter vitamins without consulting with your doctor.

Diabetic Foot Care

Aoot care during diabetes is crucial because it can cause nerve damage that inhibits the sense of touch in the foot. Diabetics must keep a watchful eye on the condition of their feet because, with the lack of sensation in their feet, they may not recognize the severity of a foot issue until it escalates into a bad infection. Unfortunately, amputation may result because of poor diabetic foot care.

 

There are many steps diabetics can take to promote good foot health. Diabetic shoes, which can be purchased through a doctor and some pharmacies, are shoes specially fitted to the foot and contain a wide toe-box. Most of these shoes also come with custom fitted insoles. Never go barefoot, even when at home; shoes and slippers protect the foot from foreign objects you may not feel when stepped on and which can cause damage to the foot. Keep an eye out for ingrown toenails and cut toenails straight across. Getting a professional pedicure may be helpful if you have trouble keeping your feet in good condition. Moisturize daily but not in between the toes where fungi could grow and cause Athlete’s Foot. Be gentle with your feet, dry thoroughly when washing, and inspect your feet daily.

Flat Feet

Flat feet is a general term for feet that have little or no arch. If there is a strong family history of flat feet or other foot problems then it is likely that you will have more problems. A flat foot can cause problems with the tendons of the foot and ankle because they have to pull and work harder to try and maintain the arch. Flat feet can also cause knee and back pain. Think of your feet like the tires on a car. If the alignment is off then the car will start to shake and things will start falling apart.

 

The goal of caring for flat feet is to relieve any pain that is being caused by them and then try to realign the feet by either orthotic management or sometimes surgery. In them or wait and see what happened even if not causing pain.  If you do wait then the problems can be much worse.

 

Conservative treatment of flat feet is usually aimed at supporting the deformity by trying out an orthotic device of some kind. These can be as simple as an over the counter device or a custom device, this will depend on the severity of the deformity.

 

Surgical treatment:

In kids even though it may seem scary to mom and dad sometimes this is the best option. In most cases a small device can be implanted into the foot into the joint just below the ankle and this can correct the problem permanently. This is the HyProCure device. Often times the heel cord or Achilles is tight and also needs to be lengthened by endoscopic technique. In some cases in severe flat feet bone cutting or fusions may be required. In the case of the HyProCure the patient can be back to full activity in 2 months or so. The doctor will review your x-rays and discuss all of the options with you.

Foot Odor

Many adults and children suffer from foot odor. Sweat is often the main cause for foot odor but can occur from bacterial or fungal infections. Symptoms include:

 

  • Feet that smell bad
  • Sweaty feet
  • Infections (bacterial or fungal)

 

To treat foot odor check for bacterial or fungal infections. Bacterial infections occur when bacteria begin to eat away at the top layer of the skin, producing the bad smell. For this type of infection, a visit to the doctor and a prescription of antibiotics should clear the infection. Fungal infections, like Athlete’s Foot, can cause a myriad of issues that make the feet produce an odor, but can be fixed with over the counter foot sprays or creams. If none of these are the case, try the following tips. Practice good hygiene by washing feet daily and drying thoroughly. Wear clean socks and do not wear shoes without socks. If your feet sweat a lot, try a different type of sock that lets the foot breathe or change socks frequently. If the smell persists, try washing your shoes. Bad smelling shoes may have built up dirt and sweat that will cause your feet to smell bad.

Fractures

Fractures to the foot, heel, and ankle are a partial or full break in the bone that may occur due to an ankle sprain, falling, or other activity that may cause trauma to the foot. The first symptom you will notice upon fracturing a bone is pain at the breakage site. Other symptoms may include:

 

  • Swelling
  • Blistering
  • Bruising
  • Inability to walk
  • Protrusion of the bone

 

To prevent the condition from getting worse, it is important to visit with a physician as soon as possible if you think you may have a fracture. RICE is the most common treatment for foot, ankle, and heel fractures: Rest, Ice, Compression, and Elevation. Resting the injured area will give it the ability to heal without excess stress being put on it, while ice will help with the inflammation. Wrap an elastic covering around the area for compression and keep the injured body part elevated. Both compression and elevation work together to reduce swelling. To deal with pain, NSAIDs like ibuprofen will provide relief but your doctor can prescribe something stronger if you feel it is necessary. Sometimes an immobilization device, such as a cast or walking boot, may be necessary. Severe fractures may require surgery.

Gout

Gout is a painful condition that affects the joints and tissues, most often the big toe. Crystallized uric acid will begin to build up in the joints and cause pain and inflammation. Individuals at high risk for developing gout are those with diabetes, high blood pressure, high levels of stress, or those who have undergone chemotherapy. Additionally, it is not uncommon for alcoholics to develop gout. A diet rich in red meat or shellfish may also produce high levels of uric acid that can contribute to the onset of gout. Symptoms include:

 

  • Pain in the joints
  • Redness
  • Swelling
  • Joint warmth

 

See your physician and follow the treatment regimen set forth by your doctor. When properly following this regimen, there should be fewer or no additional attacks of gout. Medications or injections can also be used to treat joint pain and reduce the inflammation. It is imperative to change your diet if it is high in red meat, shellfish, red wine, or beer as these types of foods and drinks produce excess uric acid. Extensive walking may cause pain so keep it to a minimum. Elevate the foot to relieve swelling. If attacks continue to occur despite these efforts, inform your doctor who will see if the gout is being caused by underlying issues. If not taken care of swiftly, arthritic damage may occur.

Hallux Limitus/Rigidus

This is arthritis of the big toe joint (metatarsal phalangeal joint) which is graded by it’s severity:

Stage 1 = Mild arthritis with inflammation, swelling and some pain which is usually not constant.

Stage 2 = Moderate arthritis with a limitation in the range of motion of the big toe joint and aggravated with activity and high heels. X-rays will show spurring and some loss of joint space. Sesamoids can be affected.

Stage 3 = Severe arthritis with almost complete loss of joint space on x-ray and constant pain. Sesamoids are almost always involved.

Stage 4 = No joint space

 

Treatment Options:

Stage 1 - NSAIDS, Rx Topical Medication, Laser, ICE and Orthotics management

Stage 2 - Same as Stage 1 but if fails may consider injection of Amniotic fluid (insurance usually won’t cover this) Surgery in the form of a cheilectomy, which is a removal of the arthritis/spurs by removing it with surgical equipment. Not always definitive. Also may consider an osteotomy of the metatarsal or phalanx depending upon the structure of the foot.

Stage 3 - Can try amniotic fluid injection but this will not cure it, may last for 6 months to a year. Can inject over and over if you like this treatment. Surgical-osteotomy of bone to shorten or lower with or without implant. Implant into one side of the joint or both. This is surgeon preference based on patient activity level and x-rays. Fusion is an option as well but this will cause permanent loss of motion to the joint but will relieve all pain in 95% of patients.

Stage 4 - Fusion or Implant

 

Post Operative courses for above surgical options:
Cheilectomy - 48 hours stay off foot and elevate and ice. PT. Dynasplint (medical device to wear at home covered by insurance) Then wear boot for 2-3 weeks, then back in sneakers till 6 weeks or so then regular shoes to tolerance. We recommend post op cold laser treatment to speed recovery. Topical pain meds.

Osteotomy with or without implant - Stay off for 48 hours completely, elevate and ice. Wear cam walker boot for 4-6 weeks. PT and Dynasplint. Topical pain medication, cold laser therapy. Back in regular shoes around 8-10 weeks. Return to full activity around 3-4 months depending on activity level. Can swim or do stationary bike after 4-6 weeks.

Implant - 48 hours ice and elevate, start walking in cam walker boot for 1-2 weeks then wear sneaker at 3-4 weeks will depend on swelling. Return to full activity in 6-8 weeks. Laser, topical cream and PT and Dynasplint post op.

Hammertoe

Hammertoes or Claw toes are deformities of the toes where they start to curl up and then put pressure on the metatarsal heads below them, which can cause pain. They will often develop painful lesions called corns on the top of the toes from irritation on shoes. The reason most hammertoes occur is from an imbalance between the tendons on the top of the foot and the ones on the bottom. Often times the foot will be hyper-pronated or very high arched. These conditions create the imbalance.

 

Conservative care - this is aimed at keeping pressure off of the toes by wearing bigger shoes with a wider toe box. Straps or metatarsal pads can also be helpful but they will not cure the deformities.

 

Surgical treatment - the standard technique for hammertoe repair is to perform either an arthroplasty (remove the head of the bone) or arthrodesis/fusion where the joint is straightened out and usually a pin or other type of hardware is used to maintain the position of the toe. During the procedure the tendons that are out of balanced are rebalanced by cutting or lengthening some tendons or in some cases transferred. In more severe deformities it is necessary to shorten the associated metatarsal by using a special saw to shorten the bone and this is fixated with one or two screws. Sometimes a transfer of a tendon is needed too. The recovery requires about 6-8 weeks minimum before regular closed shoes can be worn.

MIS (Minimal Incision Surgery) - this technique has been around for many years but has been updated and can provide dramatic results. Dr. Bregman is one of the only foot doctors doing this technique in the state of Nevada. A special drill is used with a small drill bit. Small 2mm incisions are made on the foot and the hammertoes can be repaired through these small incisions. The recovery is faster, with less swelling and results can be dramatic. There is usually no pain after this procedure.  The toes just require splinting for about 4-6 weeks.

Heel Pain

There are several varieties of foot conditions that may instigate heel pain. Excessive standing or walking are normal sources for foot and heel pain. To treat mild to moderate heel discomfort, rest and ice will reduce the inflammation and aching. Replacing old shoes or improperly fitting shoes with new ones, and the use of shoe inserts, can also improve heel pain dramatically. If discomfort continues to persist, try an over the counter NSAID like ibuprofen.

 

If the heel pain is severe enough to interfere with your daily activities and includes symptoms other than discomfort, it is possible that there is an underlying condition contributing to the pain. Such conditions may include Achilles Tendonitis, Plantar Fasciitis, or heel spurs. You should see a doctor immediately if your symptoms include:

 

  • Swelling near the heel with severe pain
  • Inability to bend the foot downward
  • Heel pain, numbness, or tingling, along with a fever
  • An injury followed by severe heel pain

 

While you can speculate which condition you may have, it is best to get it looked at by a doctor who can give you a clear-cut diagnosis with treatment instructions. Self-treatment without a diagnosis could result in further injury.

Heel Spurs

Heel spurs are common conditions among athletes who run and jump frequently. The strain and the stretching of foot muscles and ligaments trigger the deposit of calcium on the underside of the heel bone. These calcium deposits turn into protrusions that can be as long as half an inch. Individuals who are on their feet a lot, have arch issues, or are obese are at an increased risk of developing a heel spur. Poor fitting shoes also play a role in the onset of this condition. Heel spurs have no symptoms besides pain, and sometimes there is no pain. Heel spurs affect the soft-tissue associated with it and may cause a sharp pain that turns into a dull ache throughout the day. If you have heel spurs and are overweight, shedding the excess pounds will help to treat the condition. To deal with the pain, NSAIDs like ibuprofen are frequently used or your doctor may give you a cortisone injection. Custom orthotics that cushion the heel, or foot stretching exercises, may also provide some pain relief. If none of this helps, or the condition worsens, surgery is an option which will either remove the spur or release the plantar fascia.

Ingrown Toenails

Ingrown nails occur when the toenail begins to curve and grow into the skin, which can be a result of many different factors. Some of these cannot be prevent, such as genetics making some individuals naturally more prone to ingrown toenails. Controllable factors that may lead to the growth of ingrown toenails are tight shoes and cutting the toenails too short. The main reason individuals seek treatment for an ingrown toenail is the pain. Other symptoms that may coincide with pain include:

 

  • Swelling
  • Redness
  • Infection

 

Even if there is no pain, it is important to pay attention to toenail health because an ingrown toenail could lead to an infection. Those with diabetes, nerve damage, or poor circulation should never attempt to treat their ingrown toenails at home. For others, pain is mild to moderate, soak the foot in warm water -- perhaps with Epsom salts -- and begin to massage the side of the nail. Do not try to fix the nail by continuing to cut it. If pain persists or does not get better, visit a doctor who will determine a proper course of treatment. If infection is causing the pain, your doctor will prescribe an oral antibiotic. In some cases minor surgery may be necessary to remove the toenail.

Metatarsalgia

This is a symptom of a problem with one of the metatarsal phalangeal joints of the foot usually the 2nd, but can be others or more. The joint will have more pressure on it for a variety of reasons but most commonly from an elongated metatarsal with or without a hammer toe. In many cases a bunion can be present which may or may not be painful but often needs to be addressed as well. This condition must be differentiated from a nerve entrapment or both can be present.

 

Conservative treatment- this is focused on reducing the inflammation and pain with ice, Rx topical cream, laser and sometimes injections.   Strappings can also provide temporary relief and can be done in the office at time of visit. Orthotics also can be effective at removing the load to the affected joint. Sometimes oral steroids can be given for 5 days or so.  Shockwave treatment is also another option. In rare cases a walker boot can be given. Avoid any high heels at all. You must apply ice 4x/day for 15 minutes at a time or it will not help. NO exercise till your pain is gone by at least 90%. Can swim anytime though.

 

Surgical options- this will depend on what deformities are present on the foot when reviewing x-rays. The goal is to remove the forces on the joint. Commonly a shortening osteotomy of the affected bone(s) is carried out and fixated with a screw. In some cases if a bunion is present this will have to be addressed as well because the first ray must be functional to take the load from walking or running. If a hammertoe is present this must also be addressed and this can be done via minimal incision technique (MIS) or standard technique. Also very often one of the main contributors of this problem is a tight heel cord or Achilles. If significant enough this will need to be lengthened by endoscopic technique.

 

Post Op recovery is typically 48 hours of elevation, ice and no weight bearing. Then into a cam boot for 4 weeks followed by graduated weight bearing in a stiff shoe or sneaker. Full activity in 3 months.

Morton’s Nerve Entrapment

This condition is a problem that is a direct compression of a common metatarsal nerve that is between the heads of the metatarsals. The compression is created by the deep transverse metatarsal ligament, which sits on top of the nerve. Every time you take a step the nerve hits this ligament and damages the nerve, creating swelling and pain. Pain is usually worse with walking and wearing shoes. It is important to rule out Tarsal Tunnel syndrome when this condition is identified. This is when the nerve on the inside of the ankle is actually causing the pain or at the very least contributing to it. The pain is in the ball of the foot. Sometimes this pain can be misdiagnosed and it is really a problem with one of the joints in the same area.

 

Conservative treatment- this is aimed at keeping the nerve from being compressed and attempting to reduce the inflammation associated with the rubbing of the nerve. Wearing proper shoes, and avoiding high heels is best. Icing can help, along with topical pain cream. Orthotics can also be helpful to spread the metatarsals out and relieve pressure on the area.

 

Surgical treatment- in this particular condition sometimes it is best for early intervention by performing a decompression of the nerve. This is where a small incision is made on the top of the foot and the deep transverse ligament is cut very carefully to relieve the pressure from the nerve. Cutting this ligament does not cause any other issues. There is no pain after surgery and the success rate is 90%. You may return to full activity in 6 weeks or sooner. With this technique you retain sensation unlike when it is cut. We can also use Amniotic fluid with the decompression which increases the success rate to 95%.

 

* Stump neuroma- in some cases people who have already had surgery where the nerve was damaged and is continuing to cause pain is called a stump neuroma. In cases like this the only treatment that can be done at this point is to either 1) Radiofrequency treatment where the nerve is super heated to stop the stump neuroma from being painful 2) Nerve replant, where the nerve(s) is found in the bottom of the foot and then buried in muscle to prevent any future pain. This procedure requires 2-3 weeks of non weight bearing.

Nail Fungus

Onchomycosi, fungal infections of the nail, affect men more than women and are commonplace in people with weakened immune systems. There are several types of fungal infections of the nail, but the most common two are distal subungual onychomycosis (DSO) and white superficial onychomycosis (WSO).

 

DSO makes up the majority of fungal infections of the toe, caused by the same fungi that cause Athlete’s Foot. Symptoms of a DSO infection include:

 

  • A white or yellow nail
  • Skin or nail debris build up underneath the nail
  • Crumbling or splitting of the nail
  • Nail separation from the skin
  • Discomfort

 

Overtime, debris will build up underneath the nail and can cause discomfort when walking or wearing shoes. DSO can be a long-lasting condition that is hard to treat therefore prevention is ideal. To prevent infection wash feet daily, dry thoroughly, and wear clean socks and shoes. Avoid areas where fungi grow like public showers and swimming pools.

 

WSO, on the other hand, is easily treated. WSO fungi affect the upper layer of the nail with the following symptoms:

 

  • White spots on the surface
  • Crumbly, chalky powder on nail surface
  • No nail thickness
  • Does not separate nail from the skin

 

The doctor can prescribe an oral anti-fungal medication to eradicate the infection. For persistent infections, like DSO, it may take months or longer to eliminate infection. Steps to prevent nail fungus may be easier than trying to fight the infection once you have it.

Neuropathy

When a person has peripheral neuropathy, essentially what they have is damage of the peripheral nervous system. There are two regions to the nervous system – Central and Peripheral. The central system includes the brain and spinal cord, while the peripheral system includes all the nerve roots and extremity nerves emanating from it. Examples of peripheral nerves include lumbar nerve roots, the median nerve, the shoulder’s brachial plexus, the sciatic nerve, etc. It’s a broad network, and all of these peripheral nerves transmit vital motor and sensory information throughout the body. They may tell your foot when to feel cold, or cause pain in your shoulder, or allow your biceps to flex. A peripheral neuropathy may interrupt some of these transmissions, or at a minimum distort them.

 

Symptoms from peripheral neuropathy are caused from this damage. Some individuals with peripheral neuropathy experience tingling, numbness, or pricking sensations, sensitivity to touch, or muscle weakness. More severe neuropathy symptoms may include burning pain, muscle wasting, paralysis, or gland dysfunction. People often mistake neuropathy for poor circulation.

 

What are the different types of peripheral neuropathy?
There are 3 types of peripheral neuropathy:

  1. Mononeuropathies = damage to only one nerve
  2. Polyneuropathy = multiple nerves affecting all limbs
  3. Mononeuritis multiplex = 2 or more nerves in separate areas of the body being affected in isolation.

Peripheral neuropathy is complicated in how it progresses, resolves, or plateaus. Diabetic neuropathy, which is a polyneuropathy, often affects one’s feet first, travels up both legs, and then subsequently affects the fingers and hands moving up the arms. It is ascending nerve damage. Not everyone experiences the same pain areas or severity. However there is great risk for ulceration of the foot and possible amputation.

 

An example of a mononeuropathy is carpal tunnel syndrome, where the median nerve is a victim of compression in a person’s wrist. It is where one nerve is affected, and it is well known that there are infinite levels of severity with a mononeuropathy. It may affect a person so severely that surgery becomes necessary, or it may simply be a nuisance from time to time.

 

Mononeuritis multiplex is a fairly complicated, painful condition involving at least 2 separate nerve areas. It is actually a group of disorders that is associated with disorders such as diabetes, rheumatoid arthritis, vasculitis, amyloidosis, Lyme disease, and potentially numerous other conditions. The incidence of mononeuritis multiplex in the US is actually unknown.

 

What causes peripheral neuropathy?

The most common cause of peripheral neuropathy in the USA is diabetes (by far). Sometimes the cause is completely unknown (idiopathic). Here are some other potential causes for neuropathy:

 

  • Autoimmune disorders rheumatoid arthritis or lupus
  • Chronic kidney disease
  • Infections such as HIV and liver infections
  • Low levels of vitamin B12 or other problems with your diet
  • Poor blood flow to the legs
  • Underactive thyroid gland
  • Drug use such as heavy alcohol consumption
  • Toxin exposure such as lead, mercury, and solvents may lead to peripheral neuropathy
  • Pharmaceutical drugs used to treat infections, cancer, seizures, or high blood pressure
  • MTHFR enzyme disorder
  • Idiopathic is often used but many times there is actually a nerve entrapment that is present and this can be treated
Peripheral Vascular Disease

Peripheral vascular disease (PVD) is a disease of the arteries that can affect the extremities of the body. Plaque from fatty materials, combined with calcium and other substances, will build up on the sides of the arteries making it difficult or impossible for blood to pass through. Diabetes, injuries, or infections are other factors that can contribute to the narrowing or weakening of the arteries. Not all individuals who have PVD are symptomatic. Those who do experience symptoms notice the following indicators:

 

  • Pain throughout the leg and sometimes the foot
  • Pain while walking
  • Achy pain in the feet or toes while at rest
  • Sores on feet that do not heal
  • Pale, bluish, or dark reddish foot color

 

To combat PVD, receive treatment for any underlying conditions you may have, such as diabetes. Begin a healthy lifestyle by eating nutritious foods, staying away from foods that have unhealthy cholesterol, exercising regularly, and maintaining a healthy weight. Smoking hardens the arteries so it is important to try and quit. Keep a close eye on blood pressure and cholesterol levels; you may need to take a prescription medication to keep these under control. These changes can correct PVD. In extreme cases, an angioplasty (balloon) surgery may be necessary.

Plantar Fasciitis

There are many possible sources for heel pain but the most common is plantar fasciitis. Heel pain from plantar fasciitis occurs when the tissue that stretches between the heels to the toes (the fascia) becomes inflamed. People with arch issues are more prone to plantar fasciitis pain. Individuals who wear non-supportive shoes or who work on hard surfaces frequently can have the following symptoms:

 

  • Pain on the arch of the foot
  • Pain on the heel
  • Pain that hurts more upon rising
  • Pain that increases over months

 

Treatment of plantar fasciitis is moderately easy and the condition can begin to correct itself when taking the proper steps. Always wear supportive shoes and do not go barefoot. Adding padding to your shoes can cushion the feet and soften the impact of walking. Rest your feet when possible and take an NSAID like ibuprofen to relieve the pain. Stretching exercises for the calf help to relieve the pain in the foot. If those techniques do not work, visit a podiatrist who can provide you with a night splint and customized orthotic devices. Physical therapy, in addition to the stretching exercises, can also be beneficial. Only in rare cases is surgery needed for plantar fasciitis.

Shin Splints

Shin splits are pains that occur on the front of the lower legs. While runners may be most familiar with this pain, other individuals may suffer from them as well. Repetitive activities, like running, are the most well known cause but flat feet, tight calves, improper training or shoes, or old shoes may cause shin splints. The repeated pulling of the muscle that attaches to the tibia causes shin splints. Symptoms of shin splints include pain of the muscle connected to the tibia (shinbone) and swelling. Shin splints may go away for some runners after they become acclimated to the activity, but for others, the pain can persist. It is important not to push too hard when shin splints are the issue because the result could be a stress fracture of the tibia. Rest and do not continue to do any activity that causes pain. Wait until the pain subsides before trying the activity again. Use ice and NSAIDS to reduce the inflammation. Proper stretching and shoes that fit properly may significantly help to prevent shin splints. If you suffer from flat feet, visit a podiatrist to receive information on how to treat that condition, maybe eliminating your shin splints in the process.

Warts

Plantar warts are warts that appear anywhere on the foot, but normally on the bottom. A wart is an area of tissue that appears thickened, raised, and is normally circular. They are normally not painful unless there is an application of pressure. Contact with the human papilloma virus (HPV) is the main reason warts develop. Anyone can have a wart, but warts occur more frequently in children and the elderly. Symptoms of warts include:

 

  • A circular area or clusters of thick, raised tissue
  • Pain when squeezed or stepped on
  • Tiny black dots (dried blood)

 

The majority of warts will go away with outside intervention but it may take a long time. Many individuals desire to have the wart gone as quickly as possible and opt to treat with products purchased from the store. Do not try to treat it on your own because you could damage your skin or otherwise injure yourself. Visit a physician who will give you proper removal instructions, prescribe medications, or will remove it for you. Different medications that treat warts are topical or oral treatments. Laser therapy, freezing (cryotherapy), acid treatments, and minor surgery are also viable options. If wart removal is successful, there is still the possibility it may return.