Foot and ankle disorders
Foot ankle disorder treatment may include the following procedures:
A bunion is a bony prominence on the inner aspect of the base of the big toe. Bunions are extremely common in the United Kingdom. The cause of bunions remains uncertain although they seem to be more common in families where bunions are prevalent and there is some evidence to suggest that wearing narrow shoes may also be a cause. A large number of patients with bunions do not require surgical treatment. It is only when they become painful and when conservative treatment is unsuccessful that surgery should be considered.
Bunions normally coexist with hallux valgus; a condition characterised by the big toe drifting off towards the second toe. Provided that there is no arthritis in the big toe joint, surgical treatment for bunions involves removing the bony prominence and also correcting the associated hallux valgus deformity by cutting and realigning the bone; an operation known as an osteotomy.
There are three different type of osteotomies ; the chevron, the scarf and the basal osteotomies to treat the spectrum of bunion deformities which all have good results in the scientific literature. The type of osteotomy recommended is dependent on how severe the deformity is.
Lesser toe deformities
These are common deformities that often present with the affected toe being painful and rubbing on shoes or the neighbouring toe. Surgical correction is indicated if conservative measures fail. The correction recommended depends on the nature of the deformity which may be of two types; flexable or fixed.
For a flexable deformity, when the toe can be easily corrected, a soft tissue procedure is recommended. The soft tissue procedure performed depends on the position of the toe but would involve either a tenotomy (tendon release), a tendon lengthening, a capsulotomy (soft tissue joint release), or tendon transfer (reattaching one tendon to another).
For a fixed deformity, when the toe cannot be corrected, a bony correction is required. This involves removal of the stiff joint affected and stabilisation with a wire which is removed after 4-6 weeks.
Heel pain (Plantar Fascitis)
Plantar fasciitis is a common cause of heel pain which typically presents at the base of the heel and is worse in the morning. It is normally self limiting but may take 18 months to resolve.
Conservative treatment involves pain killers, heel pads and physio. Night splints, steroid injections and ultrasoundtherapy may also be helpful. Surgical treatment involves the release of the plantar fascia, although this is rarely necessary.
Arthritis of the foot and ankle
There are many different types of arthritis that may affect joints; osteoarthritis and rheumatoid arthritis are the two commonest seen in the foot and ankle. Osteoarthritis refers to a degenerative loss of cartilage that normally lines the joint. It is seen as patients get older or may be a result of a previous injury that has disrupted the joint.
Rheumatoid arthritis is an inflammatory condition that causes destruction of bone and cartilage. Both conditions commonly present with pain, swelling and reduced mobility. If the pain is severe and does not respond to conservative measures, then surgery is considered. The options of surgical intervention for arthritis of the foot and ankle include:
Steriod/local anasathic injection
This may be helpful in rheumatoid disease or osteoarthritis of the big toe joint but it is unlikely to provide long lasting pain relief.
Performed for the big toe where the upper part of the arthritic joint is removed.
Arthoroscopy with debridement
Useful for osteochondral defects and tears in the cartilage in the ankle joint which may be curetted or shaved.
It involves the refashioning and subsequent stiffening of the joint with high levels of patient satisfaction when correctly performed.
Treatment for all fractures of the foot and ankle including calcaneal, pilon and lisfranc injuries.
Treatment of sports injuries of the foot and ankle
Treatment for all sports injuries of the foot and ankle including chronic ankle sprains, chondral/osteochondral defects of the ankle, midfoot sprains, stress fractures, sesamoid injuries, freibergs disease and nerve entrapment syndromes.
Surgical treatment includes the use of arthroscopy for some of these injuries.
Treatment of tendon disorders of the foot and ankle
The achilles, peroneal and tibialis posterior tendons are most commonly affected.
This structure is very important in walking and by providing the power to ‘toe off’. The tendon may become inflamed(tendinitis), tear(complete or partial) or become degenerative. Conservative treatment for Achilles tendon problems includes immobilisation in a plaster(for acute ruptures not for surgery), physiotherapy (tendinitis), orthotics and ultrasoundtherapy. Surgical treatment is indicated as a primary treatment in most active patients for conditions such as acute Achilles tendon rupture where there is a lower re-rupture rate for surgery or in conditions when conservative treatment has failed. Achilles Tendon Reconstruction is indicated for complete/partial tears and for severe tendon degeneration. It may be primary (direct suture of the tendon ends) or secondary (using tendon lengthening/transfer techniques) for delayed rupture when the tendon ends retract. Achilles tendon decompression is considered for tendinitis resistant to conservative measures.
These tendons lift the foot up and out during walking. Following a twisting injury, these tendons may tear causing pain and swelling behind the fibula(outer bone of the ankle) or may dislocate to lie in front of the fibula. Surgical treatment involves repair and restoration of the normal shape of the tendon for tears and repair of the supporting tendon sheath and deepening of the normal bony grove for dislocations.
Tibialis posterior tendon
An important structure in walking that pushes the foot down and also maintains the inner foot arch. Tendon dysfunction causes pain behind the inner aspect of the ankle and a flat foot. Most forms may be successfully treated conservatively with medial arch support insoles and physiotherapy. Surgery is indicated for severe forms which have not improved with conservative treatment. Surgery involves reconstruction with a tendon transfer or in advanced cases, partly fusing(stiffening) the foot.
This is a common cause of forefoot pain and tingling, typically affecting the 2nd and 3rd toes. It is due to a swelling on the nerve in the sole of the foot. Conservative treatment involves the use of an insole which offloads this area. An ultrasound guided steroid injection is often helpful. Surgical excision of the neuroma is reserved for cases resistant to conservative treatment.
Information provided by Mr R Russell - Consultant Orthopaedic Surgeon, Springfield Hospital.