Painful swelling of the nerves between the knuckle bones (metatarsals) of the feet are a common cause of burning forefoot pain (metatarsalgia) and can be caused by swelling of the interdigital nerves (Morton’s neuroma).
Insoles, shoe wear modification and steroid injections can be helpful. Surgery involves a cut on the top of the foot and removal of the neuroma. This is done as a day case procedure and recovery is usual after two to four weeks.
Lesser Toe Problems
Deformity of the lesser toes can be present from birth or develop over time. A variety of deformities (mallet, hammer or claw toes) can cause shoe wear impingement, callous and pain. Non-operative treatment including shoe wear alteration and orthosis should precede surgical treatment.
Surgery for lesser toe problems depends on the deformity and the affected joint. Procedures range from simple tendon releases (tenotomy) to joint fusions (arthrodesis). Fusions often require the use of a wire extending from the tip of the toe for up to six weeks.
Bunions are commonly considered to be the painful swellings on the side of the foot and are usually accompanied with deformity of the big toe away from the mid-line of the body (hallux valgus). Hallux valgus can often run in the family. Occasionally, prominence and deformity of the fifth toe can also occur (bunionette or Tailor’s bunion). Orthotics, physiotherapy, splints and shoe wear modification are always exhausted prior to surgery.
Surgery for bunions is indicated having attempted unsuccessfully non-operative remedies and persisting symptoms which are intrusive and limiting. Surgery is performed as a day case procedure and involves cutting the bones of the first ray (osteotomy) and fixing them with metal work to hold the realigned bone until they heal. This procedure improves the alignment and therefore shoeability of the foot. Although mobile on the foot post-operatively, recovery usually takes 6-12 weeks.
Big toe arthritis
(Metatarsal phalangeal joint arthritis/hallux rigidus)
The big toe joint (metatarsophalangeal joint/ MTPJ) is frequently affected by arthritis which causes pain, stiffness and sometimes bulkiness of the joint which causes shoe wear impingement. Physiotherapy, medication and shoe wear modification are the mainstay of non-operative treatment. Sometimes steroid injections into the joint give temporary relief.
Surgery for MTPJ arthritis depends on the complaint and involves numerous factors including lifestyle and how advanced the condition is. Debulking the joint (cheilectomy) is sometimes effective, whereas fusion (arthrodesis) is the gold standard treatment for intrusive pain. Recently, a new technique of implanting a man- made spacer into the joint (interposition arthroplasty) has gained in popularity, especially in patients who find the concept of fusion difficult. All procedures are performed as day cases. Fusion surgery requires the bone surfaces to heal to one another and therefore requires protected weightbearing postoperatively for up to six weeks.
Pain involving the multiple joints of the small bones of the foot can gradually become intrusive, often limiting activities such as walking and golf. Arthritis can be the result of previous injury and sometimes result in painful lumps which can rub on shoes. As with any complaint, physiotherapy, shoe wear modification and orthotics can combine to make the pain acceptable. Steroid Injections are often used to determine which joint is painful and as a temporary pain relieving manoeuvre.
Surgery for midfoot arthritis involves fusion (arthrodesis) of the affected joints to one another, using plates and screws, to limit the motion of the arthritic joint and improve the pain. Protected weight bearing after the procedure using crutches allows the bones to heal and is often six weeks.
Tendons are structures which attach muscle to bone and can be loaded millions of cycles per year. Biological failure of these tendons can cause pain, swelling and weakness. If untreated, deformity of the foot and ankle can occur leading to additional problems with shoe wear and mobility. Tendinopathy of the Achilles at the heel is common and can involve either the mid-portion or the insertion. Peroneal tendinopathy involves the paired tendons behind the fibula on the outside of the ankle and can be the result of a “sprained” ankle. Posterior tibial tendinopathy involves the tendon that passes on the inside of the ankle and its failure is the common cause of an adult flat foot deformity. Non-operative treatment following diagnosis almost always consists of physiotherapy and insoles (orthotics). Surgery for tendinopathy requires extensive post- operative recovery periods.
Operative procedures for foot and ankle tendinopathies range from open debridement (removing abnormal tissue), excision and repair of tears or tendon transfers and bone procedures in combination, to realign the foot and transfer the function of a healthy tendon, to do the job of the painful, tendinopathic tendon. Following surgery, protected weight bearing on crutches, plater cast, and restricted mobility is usual for four to six weeks. Orthotics may be required post-operatively.
As with many foot and ankle conditions, physiotherapy and insoles can greatly improve the symptoms of flat foot deformity and are often used prior to surgery. An acquired flat foot deformity in adults is often the result of failure of the tendon which runs behind the inside of your ankle (posterior tibial tendon). Depending on the stage of dysfunction of this tendon (inflammation, degeneration or tear), various surgical procedures are indicated to replace the painful, non-functioning tendon (tendon transfer) and improve the alignment of the heel (heel shift procedure). Following surgery, patients are instructed to non-weight bear for up to four weeks. Walking is then gradually resumed in a post-surgical boot for four to six weeks. An insole is often useful for up to a year as functional recovery following this surgery can take six months.
Flat feet can be a condition you are born with or can develop, often in middle age. A careful history, examination and special tests are usually required to provide an accurate diagnosis and plan appropriate treatment.
Rheumatoid foot complaints
Rheumatoid arthritis is an autoimmune disease which causes swelling, pain and deformity in many joints, especially the feet. Severe, stiff deformity of all toes, pain and callous on the ball of the foot are common. Managing the condition includes appropriate anti-inflammatory medication, sometimes prescribed by a specialist (Rheumatologist) and shoe wear modification including insoles.
Surgery involves realigning the big toe joint by a fusion procedure combined with multiple lesser toe procedures to improve the shape of the foot and its ability to bear weight. Protected weight bearing following surgery is required and wires extending from the tips of the lesser toes are used to maintain their improved alignment for four to six weeks. Timing of surgery and limiting the use of anti-inflammatory medication requires careful planning to avoid post-surgical complication and prevent worsening of symptoms.