Ankle

Ankle Pain & Instability

Ankle pain is usually associated with arthritis, impingement, or instability. Chronic ankle arthritis, like knee arthritis, usually develops slowly over time and is usually caused by an injury or deformity. Local swelling, stiffness, aching pain, and symptoms worsening with activity are hallmarks of ankle arthritis. Sometimes rheumatic conditions can lead to more acute pain and swelling. Ankle impingement presents in similar fashion, but is less predictable and more specific in its location. Instability is linked to anterolateral pain and feelings of looseness or “giving out.” Frequently other conditions such as FHL or peroneal tendonitis can cause ankle pain. This pain is usually more of a sharp burning pain and usually courses along the tendon.

Forefoot Pain & Deformity

Forefoot pain can be caused by many problems, however, most are related to deformities of the toes and metatarsal bones. Bunions (hallux valgus) cause pain at the great toe prominence, but also cause pain under the second and third toes (metatarsalgia). Congenitally long metatarsals and tight Achilles tendons contribute to this problem. Hammertoes cause pain and make it difficult to find appropriate footwear, and are also associated with bunions. Corns and callouses are usually markers of the above problems but can exacerbate pain and discomfort. Great toe arthritis (hallux rigidus) is also very common, causing stiffness and achiness of the big toe. Diabetes, neuropathy, and nerve entrapments can cause either burning foot pain or loss of sensation.

Hindfoot Pain & Deformity

Hindfoot symptoms occur just under the ankle and are often confused with ankle pain. Problems such as posterior tibial tendon insufficiency cause flat feet and pain. Pain can occur on the inside or outside of the hindfoot. This also causes feelings of weakness and instability around the ankle (hindfoot). Other people have cavo-varus feet (high-arch) which cause associated problems such as peroneal tendonitis, ankle instability, and stress fractures. Arthritis can also affect the hindfoot, leading to stiffness, dull pain, and later deformity.

Heel Pain

Heel pain is probably one of the most common symptoms and complaints of otherwise healthy middle-aged adults. If the pain is under the heel then plantar fasciitis is likely. If it occurs above the heel then Achilles tendonitis is more probable. Common symptoms of plantar fasciitis include; first-step morning heel pain, cramping of the plantar arch, and calf tightness. Achilles tendonitis usually presents with swelling at the Achilles insertion or in the tendon itself and pain related to increased activity. Other heel symptoms can be caused by nerve compression or foot deformities.

Ankle Arthritis

Ankle arthritis usually presents with aching pain and stiffness. Usually a degenerative ankle joint is caused by repetitive or significant trauma. Deformities above or below the ankle can also cause arthritis. Longstanding instability has been shown to generate ankle arthritis as well. The pathology of ankle arthritis involves the loss of normal cartilage, the creation of abnormal exostoses (spurs), and frequently angular deformity. Spurs usually cause early symptoms and deformity is seen with long-standing arthritis. Achy pain is usually improved with anti-inflammatories like ibuprofen or bracing. Surgeries like ankle fusions and replacements are discussed in the “treatment” section of this website.

Ankle Impingement

In the early stages of ankle degeneration symptoms are sometimes localized to specific areas. In other cases small abnormalities such as spurs, ligaments, scar tissue, or synovial tissue can get caught or impinge in the ankle mechanism. This can cause significant pain. This impingement syndrome can occur without warning but usually follows injuries. Ankle sprains and fractures are the most common causes. Occasionally loose bodies and cartilage defects can cause impingement as well. Anterior and posterior impingement syndromes have been described, and are treated commonly by our foot and ankle team.

Ankle Instability

Ankle instability is usually caused by multiple sprains and can be encouraged by specific scenarios. The improperly or insufficiently treated ankle sprain has a much higher rate of leading to instability. Additionally certain foot-shapes such as cavo-varus foot posture can predispose to instability. Patients feel uneasy about their ankle, don’t trust its strength, and have frequent sprains. Anterolateral pain is also consistent with this problem. Diagnosis is made with history, physical exam, anterior draw tests, and radiology such as X-ray and MRI.

Achilles Tendonitis

Achilles tendonitis is classified as insertional (at the heel attachment) or midsubstance (in the tendon itself). This problem seems to be more common in athletes but occurs in most age groups and activity levels. The problem usually occurs insidiously and without an obvious cause. Patients complain of localized pain and swelling that persists permanently. Some swelling and pain can fluctuate and is probably related to pure inflammation; however, most of the symptoms are caused by degeneration of the tendon and its surrounding structures. Diagnosis is made by history and physical exam, occasionally MRI or ultrasound. Treatment options include nonsurgical and surgical procedures.

Bunions (Hallux Valgus) and Hammertoes

A bunion is an angular deformity that occurs between the metatarsal and the phalanx of the great toe. Inflammation of the medial eminence contributes to the deformity, however, the majority of the medial “bump” is caused by this angle change. Pain typically occurs over this bump, but can also occur at the adjacent toes and under the ball of the foot. The angular deformity of the bunion changes foot mechanics and contributes to other diagnoses such as metatarsalgia and hammertoes. As the weight bearing surface of the great toe changes , forces are abnormally redistributed to the ball of the foot and the adjacent toes. This “transfer metatarsalgia” causes painful calluses and hammertoes. Once hammer toes form pain and problems with shoeing become amplified. Hallux rigidus (great toe arthritis) also causes a prominence at the great toe joint but without the angulation. These problems are usually treated differently, but shoe modifications and orthotics may help both.

Cavus Deformity

The opposite of a pes plano-valgus (flatfoot) deformity is a cavo-varus (high arch) deformity. High-arched feet are not pathologic per se, however, they predispose to a number of foot and ankle conditions. Ankle instability, ankle impingement, stress fractures, and peroneal tendonitis are all more common when cavo-varus deformities are present.

Diabetic Foot

Diabetes is a complex disease that affects every body system. Diabetes causes vascular insufficiency and neuropathy both of which are particularly destructive to the feet. Sensory neuropathy increases the chance of unrecognized injury and relative ischemia prevents normal healing. The effects of diabetes are cumulative and related to sugar control. Diabetics suffer from; plantar ulcers, infections, ischemic gangrene, foot deformities, nail disorders, and charcot arthropathy. Almost any of the above problems can lead to limb-threatening problems, especially if left untreated. Prevention is paramount. Our specialists are adept at treating all aspects of diabetic foot and ankle disorders.

Flatfoot Deformity

The most common cause of and adult acquired flatfoot deformity is posterior tibial tendon insufficiency. This tendon is an important stabilizer of foot structure and function. Tendonitis of this tendon causes its dysfunction and subsequent pain and deformity. Patients often complain of medial hindfoot pain, swelling, and loss of stability or strength during standing and walking. This problem usually occurs around age 50-60. The pathology of this disease is poorly understood and usually occurs without warning, however, some congenital problems such as accessory navicular bones and tarsal coalitions can precipitate posterior tibial tendonitis and flatfeet.

Midfoot Arthritis

The midfoot is a common location for degenerative arthritis. Sometimes an old injury can be linked to the problem, but frequently no cause can be identified. Swelling on the dorsal surface of the midfoot (top of the foot) associated with aching pain is the hallmark. Arch collapse is possible in severe cases. Pain is usually exacerbated by activity and may be relieved with anti-inflammatories, rest, or arch-support orthotics.

Plantar Fasciitis

Heel pain is very common and plantar fasciitis is the most common diagnosis. This occurs in middle-aged people and usually occurs without injury. Predisposing factors include; Achilles tightness, hindfoot malposition, obesity, and diabetes. Symptoms include morning heel pain and burning medial heel pain that increases with standing. Treatment is usually nonsurgical but unfortunately minimally successful. Plantar fasciitis usually lasts less than three months but severe cases can persist for years and occasionally require surgery.

Ankle Arthritis

Depending on the cause of the arthritis, treatment may be disease specific. The goal of treatment is to alleviate pain. This can be accomplished through the use of medicines, mechanical devices and/or surgical intervention.

Medical management may include use of oral medications such as nonsteroidal anti-inflammatory drugs ( NSAIDs), corticosteroids (prednisone) and medications that may target Rheumatoid Arthritis. Injection of a steroid medication into the affected joint may also provide relief of pain.

Mechanical devices such as an orthotic or a brace may help limit painful motion. Use of a cane may also help offload the arthritic ankle.

Surgical treatment is necessary when conservative measures have failed to provide consistent pain relief and the individual is debilitated. Surgery may involve a combination of arthroscopy, osteotomies (cutting of bone for realignment) fusion or total ankle replacement.

Fusion is performed with the goal of eliminating painful motion of the ankle. This may require the use of screws and/or plates. Total ankle arthroplasty (TAA) is an alternative to fusion. This is where the arthritic joint is replaced with a metal and plastic bearing surface. There are select indications for ankle replacement and your doctor can advise you on this.

Prevention: In many cases arthritis may not be preventable. However, weight control and nutritional supplements may help minimize symptoms. Low impact exercise may also be of value.

Ankle Impingement

This condition may represent an early sign of ankle arthritis or as a result of an ankle sprain. Initial treatment would include activity modification, analgesics (NSAIDs, acetaminophen) and/or shoe modifications.

Pain is often felt in front of the ankle. Squatting or walking up inclines may painful. The use of a heel lift (~1/4 inch) might limit upward motion of the ankle. A lightweight ankle brace may help with activities on uneven ground.

An injection with a corticosteroid into the ankle joint may also be helpful.

When conservative treatment is unsuccessful and symptoms interfere with activities of daily living (ADL’s) surgery is an option. Open or arthroscopic techniques may be performed to alleviate the cause of the impingement along the front of the ankle. The goal of surgery is to remove soft tissue and/or bony structures that contribute to the pain.

Ankle Instability

Instability is typically a result of an incompletely rehabilitated ankle sprain. In some cases, patients with a cavus (high arched foot) may be more predisposed to ankle instability. Certain congenital conditions (such as tarsal coalition) may also contribute to a feeling of giving way.

The goal of treatment is to reduce the episodes of instability and alleviate pain. Use of bracing and/or taping techniques may help. Strengthening exercises are also important in preventing repetitive episodes of instability.

When nonoperative techniques are unsuccessful and symptoms remain persistently disabling, surgery becomes an option. Surgical repair is directed at stabilizing loose ligaments and correcting any associated conditions that contribute to the instability pattern. These may be performed through arthroscopic and/or open techniques.

Achilles Tendonitis

Treatment is determined by the severity and duration of symptoms.

A period of rest would be the initial approach to control symptoms.

• Low impact exercise may minimize symptoms.
• Anti-inflammatory medications or analgesics can provide symptomatic relief.
• Appliances placed in the shoe (such as a heel lift) or soft, off the shelf insert may relieve tension on the Achilles tendon. In severe cases, immobilization in a cast or a walking boot can provide relief.
• Physical therapy, focusing on Achilles tendon stretching and strengthening may assist in the recovery of symptoms caused by Achilles tendinitis.
• Surgical repair is an option when conservative treatment is exhausted and symptoms interfere with daily activities. Surgical treatment requires removal of unhealthy tendon and at times, excision of spurs. This would require a period of immobilization followed by physical

Bunions (Hallux Valgus) and Hammertoes

The initial treatment for any forefoot deformity, such as bun ion and hammertoes is nonoperative. Specifically, shoe changes that accommodate the shape and width of the foot will alleviate symptoms in a majority of cases. It’s important to pick shoes that conform to your foot. Don’t pick a shoe on size alone as sizes vary among shoe brands and styles. It’s important to try the shoe on.

Appliances such as toe spacers may help re-position the great toe into more comfortable alignment. Shoes that are made with soft materials and are ~1/2 inch longer than your longest toe can provide symptomatic relief from a painful bunion or hammertoe. Stretching a shoe will also provide additional room for your toes.

Strengthening exercises for the toes as well as stretching exercises may provide relief in certain cases. Pads or straps may provide relief from a painful hammertoe.

In cases where pain persists and symptoms are debilitating, surgery becomes an option. This typically involves realignment procedures that require intricate balancing of the abnormal soft tissue and bony deformities that contribute to the development of bunions and hammertoes.

Given the complexity of the condition and the various surgical options available, your orthopaedic surgeon can advise you on the appropriate procedures. We do not recommend preventive surgery for bunions and/or hammertoes that are not symptomatic.

Cavus Deformity

As with people with flat foot deformity, those who have painless feet and have no limitations with walking or ADLs require no specific treatment.

For people with pain, initial treatment would consist of the use of the following:

• NSAIDs, rest, ice
• Shoe modifications
• Orthotics/bracing
• Injections with corticosteroid

Initial use of an orthotic would accommodate the positioning of the foot and provide shock absorption.

When pain and associated symptoms persist despite conservative treatment, surgery becomes an option. The goal of surgery is to alleviate pain and perform re-alignment surgery on the foot. This may be accomplished through a combination of soft tissue and bony procedures. As with a flatfoot deformity, this condition is quite complex and surgical repair is highly individualized. Your orthopaedic surgeon can best described what repair is necessary and what to expect after surgery.

Diabetic Foot

Foot problems are a significant risk for patients with diabetes. Prevention and daily surveillance are critical to avoid injuries and complications to your foot.

Prevention starts with blood glucose control. Elevated blood sugars will eventually destroy the nerves on your foot leading to a condition known as neuropathy. It's the neuropathy that puts your foot at risk injury and deformity. With the loss of feeling in your foot, you won't know when an injury or problem arises. Any injury that occurs MUST be addressed by a physician.

You should inspect your foot daily for breaks in the skin, blisters, bruises and areas of warmth and redness. If need be use a mirror to inspect your feet or ask for help from a loved one. Look in between your toes, the ball and sides of your feet and your heel.

In addition, keep your feet clean. You may wash with mild soap and water. Avoid soaking your feet and dry them carefully especially in between the toes. ALWAYS check water temp with your hand first. Avoid lotion between the toes.

Trim nails straight across and avoiding leaving sharp edges or corners. Ask for assistance if difficulty arises. Avoid use of antiseptic solutions, heating pads and sharp objects. Don't put your foot in front of a fireplace or space heater.

Never walk barefoot and avoid use of sandals and/or flip flops.

Shoe wear selection is a critical element in protecting your foot. When buying shoes, go later in the day when your foot is typically larger. Shoes should fit comfortably and not need to be broken in. Look for a shoe with a soft leather material and wide, deep toe box. Check your foot regularly before and after shoe use. Wear clean dry sock. Avoid socks with wrinkles. Avoid socks or stockings with elastic tops. Many commercially made diabetic socks are available.

Orthotic management plays an important role in protection of the diabetic foot and prevention of an ulcer. These are specialty items that are customized to your foot.

As a result of diabetic neuropathy, deformities in the foot can and often do, occur. This results in the change in the shape of your foot and puts you at risk for ulceration. Charcot arthropathy is the term that describes the deformities that occur in the diabetic foot as a result of neuropathy. Treatment for a Charcot foot is possible through the use of casting, bracing and customized insoles and shoes.

Despite optimal management of the diabetic foot and its deformities, surgery may be necessary to correct these deformities and address ulcers that didn't heal. Your orthopaedic surgeon will be your best resource for the optimal management of these conditions.

Flatfoot Deformity

Treatment is guided by the patient’s symptoms. If an individual’s flat foot is painless and does not interfere with daily activity, then generally, orthotics or “special shoes” are not required. Otherwise, depending on the severity of symptoms and the degree to which the foot is affected, management may consist of the following:

• Rest, NSAIDs, ice
• Cortisone injection to symptomatic joints
• Cast or boot immobilization
• Shoe modifications
• Custom orthotics or bracing
• Physical Therapy

Surgery is reserved for those individuals whose symptoms are persistent and disabling despite the outlined measures. The goal of surgery is to alleviate pain and correct the malalignment of the foot associated with flat foot deformity. This can be accomplished through soft tissue procedures (tendon transfer) along with bony procedures (osteotomies or fusion) that address the underlying causes. Given the complexity of this condition, treatment remains extremely individualized and your orthopaedic surgeon can best explain what surgical repair will require.

Midfoot Arthritis

Depending on the cause, severity and location of the arthritis, there are multiple options for treatment.

• Medications such as NSAIDs and/or acetaminophen can help reduce the pain.
• Modification of shoe wear and orthotics may be useful to limit the painful motion across these arthritic joints. Along with these devices, use of a cane may help offload the arthritic foot.
• Injections with a corticosteroid preparation may be a useful adjunct to alleviate the pain.
• In rare cases, when conservative treatment is unsuccessful, surgical intervention becomes an option. Surgery typically involves fusion of the affected joints.

Plantar Fasciitis

Rest remains the mainstay for the initial treatment of plantar fasciitis. This may be as simple as restricting ones activities or immobilization in a cast or a walking boot. The intensity of symptoms would dictate the method chosen.

• As with any of the conditions discussed, judicious use of NSAIDs and/or analgesics may provide symptomatic relief.
• Off the shelf inserts or heel cups or pads may provide cushioning and shock absorption from impact activities.
• Once pain improves, a stretching program focusing on the Achilles tendon and plantar fascia has been proven to be useful. Night splints have also been helpful in alleviating morning symptoms.

The majority of patients improve with the above options. However, in some cases, symptoms persist. In these instances a corticosteroid injection may help. You may need to wear a protective boot after injection.

In rare cases pain becomes debilitating and surgical intervention becomes an option. Your orthopaedic surgeon can best advise you on what surgical procedures exist and what to expect after surgery.