What Are The Treatment Methods For Bunions?


Overview
Bunion Pain
A bunion, (medical term: hallux abductovalgus) is a condition resulting in boney prominence at the inside of the foot at the big toe joint. A bunion occurs when the big toe begins to deviate toward the second toe. The biggest misconception is that bunions occur from an overgrowth of bone. While that may be true in very few people, the bunion really represents a dislocation of the big toe joint as it bulges against the skin.

Causes
Bunions occur with greater regularity in women than men, and they may sometimes run in families. You may also have an increased likelihood of bunions if you are born with certain bone abnormalities in your feet. Factors that may increase your chances of developing a bunion include long-term use of narrow-toed and/or high-heeled footwear. Arthritis. Toe trauma. Laxity of your connective tissues (ligament laxity). Limb length inequalities. Genetics. Certain foot problems (e.g. flatfoot, over-pronation, etc.).
SymptomsSince the pain from a bunion is always aggravated by shoe wear, the symptoms will often depend on the type and size of shoes worn. The perception of pain or discomfort that people experience is quite varied. There are some individuals who have small bunions that are very uncomfortable. This limits their ability to wear shoes comfortably. On the other hand, some individuals may have quite significant deformities that are annoying but do not limit their activities in anyway.

Diagnosis
A doctor can very often diagnose a bunion by looking at it. A foot x-ray can show an abnormal angle between the big toe and the foot. In some cases, arthritis may also be seen.

Non Surgical Treatment
This is probably the most important step. Wearing the right footwear can help reduce stress on a minor deformity and reduce the likelihood of it progressing. Recommendations are that the forefoot easily fits within the width of the shoe and there is adequate cushioning and arch support. Soft materials such as smooth leather, suede or fabric will also help to reduce irritation to the area. The podiatrist plays an invaluable role in managing patients with bunions. This is because they can offer a number of options to the patient that can help relieve pain and reduce the severity of the deformity. They can also reduce pressure on skin lesions that develop as a result of the biomechanical changes. Podiatrists can prescribe customised orthotic devices that help reduce the stress on a bunion and control biomechanical factors which cause them. These may be used in conjunction with bunion splints or cushions to further offload the area. Evidence has shown a significant reduction in pain with the use of customized orthotic devices.
Bunions Hard Skin

Surgical Treatment
Depending on the severity of the deformity, this osteotomy can be done either at the end of the metatarsal (a distal osteotomy) or if the deformity is more severe, the osteotomy is performed at the base of the first metatarsal (a proximal osteotomy). One of the more common distal metatarsal osteotomies that is performed is called the chevron osteotomy. Typically a small screw is inserted into the bone to hold the metatarsal head in place and speed up bone healing. Following a chevron osteotomy, walking is permitted in a surgical shoe the next day after surgery and the shoe is worn for approximately three to four weeks before a more comfortable walking/running type shoe is worn.

What Is Overpronation

Overview


Over-pronation, or flat feet, is a common biomechanical problem that occurs in the walking process when a person?s arch collapses upon weight bearing. This motion can cause extreme stress or inflammation on the plantar fascia, possibly causing severe discomfort and leading to other foot problems.Pronation


Causes


Over-pronation occurs when the foot collapses too far inward stressing the plantar fascia (the area underneath the arch of the foot.) Normally, one pronates every time he or she walks, but excessive pronation is called over-pronation. When this occurs it can cause pain in the feet, knees, hips, low back and even the shoulder. Decreasing over-pronation, which is very prominent in runners, will help add endurance, speed and efficiency to your run and ultimately place less stress on your body.


Symptoms


Common conditions seen with overpronation include heel pain or plantar fasciitis, achilles tendonopathy, hallus valgus and or bunions, patellofemoral pain syndrome, Iliotibial band pain syndrome, low back pain, shin splints, stress fractures in the foot or lower leg.


Diagnosis


When sitting, an over-pronating foot appears quite normal, i.e. showing a normal arch with room under the underside of the foot. The moment you get up and put weight on your feet the situation changes: the arches lower and the ankle slightly turns inwards. When you walk or run more weight is placed on the feet compared to standing and over-pronation will become more evident. When walking barefoot on tiles or timber floors over-pronation is more visible, compared to walking on carpet or grass.Foot Pronation


Non Surgical Treatment


Over-pronation and the problems that go with it are treated with shoe inserts called arch supports or orthotics. You can buy orthotics at a pharmacy or athletic shoe store or they can be custom made. Make sure the arch supports are firm. If you can easily bend them in half, they may be too flexible.


Prevention


Pronation forces us to bear most of our weight on the inner border of our feet. Custom-made orthotics gently redistributes the weight so that the entire foot bears its normal share of weight with each step we take. The foot will not twist out at the ankle, but will strike the ground normally when the orthotics is used. This action of the custom-made orthotics will help to prevent shin splints, ankle sprains, knee and hip pain, lower back pain, nerve entrapments, tendonitis, muscle aches, bunions, generalized fatigue, hammer toes, and calluses.

The Way To Diagnose Calcaneal Apophysitis?

Overview


Sever?s disease, or calcaneal apophysitis, is a common cause of heel pain in patients whose bones are still growing; however, it is not really a disease. The pain is caused by stress at the point where the Achilles tendon meets tissue called the plantar fascia on the growth plate (apophysis) of the heel bone (calcaneus).


Sever's affects boys more often than girls. Boys are most often affected at age 12, and girls at age 9, though Sever's is typically seen in children and adolescents between the ages of 7 and 15.


Causes


Sever's Disease is a repetitive strain injury caused by the following. High impact injury activities and sport like netball, football, soccer, hockey, basketball, running, jumping and tennis. Tight calf muscles. Poor mechanics, structure and function of the foot. Excessive pronation. Rapid growth spurt. The above causes tension, inflammation and pain where the Achilles tendon inserts onto the calcaneus (Back/bottom surface of the heel bone). It is important that this problem is treated and monitored until the growth plate ossifies in the heel. This could occur between the ages of 14 and 16 years of age. In extreme cases the growth plate can become separated from the calcaneus.


Symptoms


The most common symptoms of Sever?s involves pain or tenderness in one or both heels. This pain usually occurs at the back of the heel, but can also extend to the sides and bottom of the heel. A child with Sever?s may also have these common problems, Heel pain with limping, especially after running. Difficulty walking, Discomfort or stiffness in the feet upon awaking. Swelling and redness in the heel, Symptoms are usually worse during or after activity and get better with rest.


Diagnosis


Sever's disease is based on the symptoms reported. To confirm the diagnosis, the clinician will examine the heels and ask about the child's activity level and participation in sports. They may also squeeze the back part of the heel from both sides at the same time to see if doing so causes pain and also ask the child to stand on tiptoes to see if that position causes pain. There may be tightness in the calf muscle, which contributes to tension on the heel. Symptoms are usually worse during or after activity and get better with rest. X-rays generally are not that helpful in diagnosing Sever's disease, but they may be ordered to rule out other problems, such as fractures. Sever's disease cannot be seen on an X-ray.


Non Surgical Treatment


The disease itself is self limiting and will resolve regardless of treatment once the growth plate has fully closed. Depending on the age of the youth at onset this could be a problem for many years. Treatment has always been aimed at managing the pain as well as the inflammation. This is done with the rest, ice, non steroidal anti-inflammatories like ibuprofen, stretching, taping, heel cups, heel lifts and orthotics. In severe cases, cast or walking boot immobilization is used. Each of these have differing levels of efficacy but in my experience orthotics are the golden treatment or the silver bullet. I am not talking about your run of the mill over the counter Dr. Scholls shoe insert. These definitely have their place in the world but not here. Custom molded orthotics made from a mold taken of the youths foot will provide the necessary control and support to stop the pain cycle. We can safely report over 85% of patients who are able to get back to sports and other activities as long as they wear the orthotics in supportive shoes as directed.


Surgical Treatment


The surgeon may select one or more of the following options to treat calcaneal apophysitis. Reduce activity. The child needs to reduce or stop any activity that causes pain. Support the heel. Temporary shoe inserts or custom orthotic devices may provide support for the heel. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Physical therapy. Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed issue. Immobilization. In some severe cases of pediatric heel pain, a cast may be used to promote healing while keeping the foot and ankle totally immobile. Often heel pain in children returns after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of calcaneal apophysitis, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with your foot and ankle surgeon.

Posterior Tibial Tendon Pain Symptoms


Overview
PTTD is most commonly seen in adults and referred to as "adult acquired flatfoot". Symptoms include pain and swelling along the inside arch and ankle, loss of the arch height and an outward sway of the foot. If not treated early, the condition progresses to increased flattening of the arch, increased inward roll of the ankle and deterioration of the posterior tibial tendon. Often, with end stage complications, severe arthritis may develop. How does all this happen? In the majority of cases, it is overuse of the posterior tibial tendon that causes PTTD. And it is your inherited foot type that may cause a higher possibility that you will develop this condition.
Flat Feet

Causes
Women are affected by Adult Acquired Flatfoot four times more frequently than men. Adult Flatfoot generally occurs in middle to older age people. Most people who acquire the condition already have flat feet. One arch begins to flatten more, then pain and swelling develop on the inside of the ankle. This condition generally affects only one foot. It is unclear why women are affected more often than men. But factors that may increase your risk of Adult Flatfoot include diabetes, hypertension, and obesity.

Symptoms
As different types of flatfoot have different causes, the associated symptoms can be different for different people. Some generalized symptoms are listed. Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running and jumping, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time and may experience pain at the inside of the ankle and in the arch of the foot. Feeling like one is ?dragging their foot.? When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain in the bones and tendons in the outside of the ankle joint. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoe wear very difficult. Sometimes, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes. Diabetic patients may not experience pain if they have damage to their nerves. They may only notice swelling or a large bump on the bottom of the foot. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoe wear is not used.

Diagnosis
Although you can do the "wet test" at home, a thorough examination by a doctor will be needed to identify why the flatfoot developed. Possible causes include a congenital abnormality, a bone fracture or dislocation, a torn or stretched tendon, arthritis or neurologic weakness. For example, an inability to rise up on your toes while standing on the affected foot may indicate damage to the posterior tibial tendon (PTT), which supports the heel and forms the arch. If "too many toes" show on the outside of your foot when the doctor views you from the rear, your shinbone (tibia) may be sliding off the anklebone (talus), another indicator of damage to the PTT. Be sure to wear your regular shoes to the examination. An irregular wear pattern on the bottom of the shoe is another indicator of acquired adult flatfoot. Your physician may request X-rays to see how the bones of your feet are aligned. Muscle and tendon strength are tested by asking you to move the foot while the doctor holds it.

Non surgical Treatment
Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities.
Acquired Flat Foot

Surgical Treatment
Types of surgery your orthopaedist may discuss with you include arthrodesis, or welding (fusing) one or more of the bones in the foot/ankle together. Osteotomy, or cutting and reshaping a bone to correct alignment. Excision, or removing a bone or bone spur. Synovectomy, or cleaning the sheath covering a tendon. Tendon transfer, or using a piece of one tendon to lengthen or replace another. Having flat feet is a serious matter. If you are experiencing foot pain and think it may be related to flat feet, talk to your orthopaedist.

Understand Heel Painfulness

Overview


Heel Discomfort


Heel Pain is a very challenging problem as it can be local and/or referred. It has been more prevalent recently due to the hard grounds on which people have to run. Commonly people will present with heel pain, thrusting an x-ray at you, and being adamant that the problem is a heel spur. This is defined as a small bone that grows from the heel, directing forwards towards the toes. This may be as small as 1 mm to anything as large as 8 - 10 mm. Most of the time, this is an incidental finding, as there many heels that are pain free that have heel spurs evident on x-rays. The spur is thought to be a result of traction of the plantar fascia on the heel. In some cases, the spur may contribute to the symptoms, but is not the main cause. This should be explained very carefully to the patient, as the focus on the spur may limit the recovery, as the patient may believe that the only way to eliminate the pain is to remove the spur.


Causes


As stated above, if biomechanical complaints such as over pronation exist during running then this can lead to planter fascitis and heel pain. Over pronation occurs when there is excessive mobility in the sab-taler joint of the foot which causes hyper mobility of the foot. Conditions such as flat feet can also cause over pronation. This increased mobility adversely affects all the muscles in the foot and can even affect the lower leg, upper leg and cause back pain. The mechanical imbalance is highlighted during running due to the increased forces being applied to the body Runners often complain that the pain increases when they enter the toe off phase of the running cycle as this stretches the muscle away from the heel bone. Apart from over pronation, other causes of planter fascitis are a change of running shoes, dramatic increases in speed work, hill work and mileage.


Symptoms


Sever?s Disease. This is a condition that occurs in 10 - 15 year old children, predominantly boys and is associated with running and repetitive jumping. It is also associated with flimsy footwear that kids may wear. It occurs when the Achilles tendon continually pulls on the apophysis of the calcaneum and does not allow for it to fuse with the body of the calcaneum. Calcaneal enthesopathy. This occurs when there is repetitive trauma at the attachment of the Achilles tendon, resulting in a spur from the calcaneum up into the Achilles tendon. It is usually visualized on x-ray and may be tender if there is an associated bursitis or tendonitis. "Pump Bump". Also known as Haglund?s Deformity, this is a bony enlargement that exists on the back of the heel - usually related to a congenital abnormality or with chronic bursitis, causing a thickening. There may have already been trauma or pressure from footwear. Treatment is usually protection of the bump and correct footwear. Associated with a symmetrical swelling at the base of the Achilles tendon. It is usually related to repetitive trauma or inappropriate footwear. It is often red and hot in the early stages. Treatment is usually to correct the footwear, provide padding and treat the local symptoms e.g. ice, rest, physiotherapy and cortisone injection. Fat Pad Syndrome. Direct contact with the base of the heel may result in trauma to the fat pad. Related to obesity, training on hard surfaces, uneven grounds, poor shoes especially overlarge shoes which can cause shearing forces on the heel. These conditions are renowned for taking a long time to recover - usually many months.


Diagnosis


Your doctor will listen to your complaints about your heel and examine you to see what is causing the pain, and whether anything else has started it off. If the cause of your pain seems obvious, your doctor may be happy to start treatment straight away. However, some tests may be helpful in ruling out other problems. Blood tests may be done for arthritis. An Xray will show any arthritis in the ankle or subtalar joint, as well as any fracture or cyst in the calcaneum. (It will also show a spur if you have one, but as we know this is not the cause of the pain.) Occasionally a scan may be used to help spot arthritis or a stress fracture.


Non Surgical Treatment


If pain and other symptoms of inflammation-redness, swelling, heat-persist, you should limit normal daily activities and contact our office, or another doctor of podiatric medicine. Your foot would be examined, and an X-ray may be taken to rule out problems of the bone. Early treatment might involve oral or injectable anti-inflammatory medication, taping, padding, massage, stretching, exercise, shoe recommendations, physiotherapy, over-the-counter shoe inserts or, if the condition is chronic and there is a biomechanical basis to the complaint, orthoses (or orthotic devices) may be used to permanently take strain off the fascia. Only rarely is surgery required for heel pain. If necessary, however, it may involve the release of the plantar fascia, removal of a spur, removal of a bursa, or removal of a neuroma or other soft-tissue growth.


Surgical Treatment


When a diagnosis of plantar fasciitis is made early, most patients respond to conservative treatment and don?t require surgical intervention. Often, when there is a secondary diagnosis contributing to your pain, such as an entrapped nerve, and you are non-responsive to conservative care, surgery may be considered. Dr. Talarico will discuss all options and which approach would be the most beneficial for your condition.


Prevention


Heel Discomfort


Maintaining flexible and strong muscles in your calves, ankles, and feet can help prevent some types of heel pain. Always stretch and warm-up before exercising. Wear comfortable, properly fitting shoes with good arch support and cushioning. Make sure there is enough room for your toes.
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