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 Non-Steroidal 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.

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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.

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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 non-operative 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.

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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

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BUNIONS (HALLUX VALGUS) AND HAMMERTOES

The initial treatment for any forefoot deformity, such as bun ion and hammertoes is non-operative. 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.

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CAVUS DEFORMITY

As with people with flat foot deformity, those who have painless feet and have no limitations with walking or ADL’s 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.

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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 dint heal. Your orthopaedic surgeon will be your best resource for the optimal management of these conditions.

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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.

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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.

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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.

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