Advanced Ankle & Foot
Keeping You on Your Feet
Computed tomography (CT) examination (also known as a CAT scan) is used in podiatry to help diagnose and treat foot or ankle problems. A CT is a kind of X-ray device that takes cross sectional images of a part of the body, giving the physician a three-dimensional image. CT scans are often superior to conventional X-rays because they can more accurately pinpoint a suspected problem. Common foot problems a CT exam can help diagnose include: arthritis, deformities, flat feet, foreign bodies, fractures, infection, and tumors.
Pregnant women, especially those in their first trimester, are advised against having a CT exam or any X-ray examination because the radiation may harm the unborn child.
Magnetic resonance imaging (MRI) is sophisticated diagnostic equipment used to diagnose an array of health problems or conditions, including:
- Injuries of the tendons, ligaments, or cartilage.
MRIs use no radiation like conventional X-rays or CT scans. They employ large magnet and radio waves to produce three-dimensional images. MRIs are very good at portraying soft tissues and bones in your feet and ankles.
People with the following conditions may not be good candidates for a MRI:
- Conditions that requires a heart pacemaker.
- Artificial heart valves.
- Electronic inner ear implants.
- Electronic stimulators.
- Implanted pumps.
- Metal fragments in eyes.
- Surgical clips in the head (particularly aneurysm clips).
Individuals with dental fillings or bridges, a replacement hip or knee, or tubal ligation clips are generally safe to have a MRI.
In most cases, a full exam of the foot and ankle via MRI lasts between 60 and 90 minutes.
Ultrasound is a very effective tool for diagnosing a wide variety of foot and ankle problems, particularly soft tissue problems. Ultrasound uses sound waves on the body in a way much like radar uses sound waves. The waves hit a targeted area and are bounced back to a recording device, which produces an image. Ultrasound is a completely safe, noninvasive, and painless diagnostic procedure.
Common problems for which ultrasound may be prescribed include:
- Heel spurs or plantar fasciitis.
- Injuries of the ligaments, tendons, or cartilage.
- Morton's neuroma.
- Presence of foreign bodies.
- Soft tissue masses.
- Tarsal tunnel syndrome.
- Tendonitis or tears in a tendon.
X-rays help determine whether a bone has been fractured or damaged by conditions such as an infection, arthritis, or other disease.
Other reasons for conventional X-rays on your feet are to:
- Evaluate changes in the bones from infections, arthritis, or other bone disease.
- Assess whether a child's bones are growing normally.
- Locate foreign objects (such as pieces of glass or metal) in a wound.
- Determine whether bones are properly set after treating a fracture.
Pregnant women, especially those in their first trimester, are advised against having X-rays because the radiation may harm the unborn child.
Surgery on the foot, ankle, or lower leg is usually performed by podiatric surgeons and orthopedic surgeons specializing in the foot and ankle.
Foot and ankle surgeries address a wide variety of foot problems, including:
- Sprains and fractures.
- Arthritis and joint disease.
- Benign and malignant tumors.
- Birth deformities.
- Calluses and warts.
- Corns and hammertoes.
- Heel or toe spurs.
- Neuromas (nerve tumors).
- Ankle instability repair.
- Ankle otsteochondral lesions.
Many foot and ankle surgeries today can be performed in the doctor's office or a surgical center on an outpatient basis. They frequently can be performed using local anesthesia, in some cases combined with sedation. Most foot surgeries require a period of immobilization after the procedures with protective devices, such as a bandages, splints, surgical shoes, casts, or open sandals. Limited weight bearing, elevating and icing the foot, and keeping the area dry are commonly required for the first two weeks following surgery until sutures are removed. Most surgeons will encourage post-operative exercise of the foot and legs to speed recovery. In addition, many patients need additional therapy or treatments after surgery in order to aid in the healing and recovery process. These may include physiotherapy, orthotic devices, and special footwear. After sufficient healing time, which varies from procedure to procedure, most patients can resume wearing their usual footwear.
Surgery to repair a torn (ruptured) Achilles tendon is conducted on an outpatient basis using a local anesthetic. It involves making an incision or cut in the back of the leg above the heel to access the torn tendon. The tendon is then sewn back together. Surgery may be delayed for about one week after the rupture to let the swelling go down.
After surgery, a cast or walking boot is usually worn for six to 12 weeks. At first, the cast or boot is positioned to keep the foot pointed downward as the tendon heals. The cast or boot is then adjusted gradually to put the foot in a neutral position (not pointing up or down).
Specific gentle exercises (restricted motion) after surgery can shorten the time needed in rehabilitation.
Ankle surgery may be required to correct a serious deformity of the ankle and its bone structure. Injury (such as a fracture), birth defects, or changes throughout the course of life are the usual culprits. Diseases, such as diabetes, rheumatoid arthritis, and neuromuscular conditions, may cause severe foot and ankle deformities that, over time, cause pain and difficulty in walking.
Ankle surgeries emphasize the realignment of the structure either around or after removal of the deformity. Various kinds of internal and external fixation devices—some temporary, others permanent—are often required to maintain the appropriate alignment during, and beyond, the healing process.
Ankle surgeries vary in complexity, length, and severity, yet many of them today are conducted on a same-day, outpatient basis. Patients need to arrange for another person to take them home afterwards and stay with them for the first 24 hours following the surgery. Post-operative instructions, provided by your surgeon, will give you the information needed to care for your recovering ankle following surgery.
Patients who undergo surgery to correct arthritis in the foot are often diabetics with a type of arthritis known as Charcot Foot. The average age of patients developing a Charcot foot is 40 years. About one-third of patients develop a Charcot foot in both feet and/or ankles. This form of arthritis can develop suddenly and without pain. Quite suddenly, the bones in the foot and/or ankle can spontaneously fracture and fragment, often causing a severe deformity.
The arch of the foot often collapses, and pressure areas develop on the bottom of the foot, leading to open sores or ulcers.
While many of these deformities can be treated with nonsurgical care, surgery may be required. Such instances may include:
- Chronic deformity with increased plantar pressures and risk of ulcers.
- Chronic deformity with significant instability that cannot be corrected by braces.
- Significant deformity that may include ulcers that don't heal or respond to therapy.
Surgical procedures used to treat arthritis include:
- Hindfoot and ankle realignment. This kind of procedure is usually prescribed when there is significant instability resulting in a patient being unable to walk. Various types of internal fixation are placed within the foot during this kind of procedures.
- Midfoot realignment. This kind of procedure is usually prescribed when there is significant instability of the middle portion of the foot. During a midfoot realignment, various types of internal fixation are placed within the foot.
- Ostectomy. In this procedure, a portion of bone is removed from the bottom of the foot. It is usually performed for a wound on the bottom of the foot that is secondary to pressure from a bony prominence.
Arthroscopic surgery on the foot and ankle may be used as a diagnostic or treatment procedure, or both. A small instrument, called an arthroscope, penetrates the skin through small incisions.Tiny cameras can be inserted through the arthroscope, allowing the surgeon to accurately see the area and/or damage. Other small instruments can also be inserted through the arthroscope to make surgical corrections.
Because arthroscopy is less-invasive and traumatic than traditional surgery, it reduces the risk of infection and swelling, and allows for significantly speedier healing and recovery. Most arthroscopic surgeries of the foot and ankle are performed on a same-day, outpatient basis using a local anesthetic.
Bunions are progressive bone deformities of the foot that often cause recurring or chronic inflammation, irritation, and pain that require surgical correction. Surgical removal of a bunion is called a bunionectomy. However, there are multiple types of bunionectomies, each designed to resolve different structural changes caused by the deformity.
Bunion surgeries fall into two major categories:
- Head procedures that treat the big toe joint. In a head procedure bunionectomy, the bone is cut just behind the joint, moved into its proper position, and fixed in place with a screw or pin. Head procedures are often used for patients who cannot be immobilized for long periods of time.
- Base procedures concentrate on the bone near or behind the big toe joint. Different types of base procedures are conducted depending on the nature of the deformity. These range from cutting a wedge out of the bone and splitting it so that it can be moved into its proper position; making a semi-circular cut and rotating the bone into its correct position; or fusing the joint. Ligaments inside and outside the toe may also be treated during a base procedure.
There are three important factors that impact the success of bunion surgery:
- Choose a surgeon with extensive experience with bunionectomies. Because a deep understanding of the biomechanics of each patient's foot as well as the intricacies of each surgical option is needed, surgeons with more experience at doing bunionectomies are better able to help each patient achieve the best outcome.
- Be realistic in your expectation about what a bunionectomy can accomplish. No physician can guarantee that a bunion won't recur or that a patient will be absolutely pain free. Additionally, because of the complexity of the foot structures impacted by a bunion, patients may never be able to wear normal or slender shoes. Bunion surgery can reduce or eliminate the bone deformity, improve foot alignment and function, and prevent damage to other toes, but it does have its limitations. Be sure you understand all the possibilities before opting for this surgery.
- Bunion surgery is not a magic bullet. Surgery alone may not be all that is needed to achieve your best outcome. After surgery, many patients experience long healing and recovery times and often have to spend time in physical therapy. Additionally, you may need a corrective orthoticdevice on an ongoing basis.
What To Expect
Most bunions surgeries today are performed on an outpatient basis at a surgical center or hospital. Set aside the entire day for the surgery, although you may only be at the facility for a half day.
Prior to the surgery, patients will need to make some preparatory arrangements. These include:
- Seeing your Primary Care Physician (PCP) to make sure any other health conditions are stabilized prior to surgery and to document your complete medical history, which can then be given to the foot surgeon.
- Arranging your schedule to make sure you don't need to take any long trips for at least two to three weeks following the surgery.
- Lining up another person to drive you home and stay with you for the first 24 hours after the surgery.
- Stopping the use of any anti-inflammatory medications, such as aspirin, ibuprofen, or acetaminophen, for five to seven days before the surgery.
The night before the surgery, you will not be able to eat or drink anything after midnight. You should also wash your foot the night before and morning of the procedure to help reduce surrounding bacteria and prevent infection.
Bunion surgery is usually performed with a local anesthetic and is administered by an anesthesiologist. This may be combined with sedation medication to put you into "twilight" so that you are fully relaxed. After the surgery, patients are often given a long-acting anesthetic and pain medication, which is why someone else must drive the patient home.
The type of procedure you have will determine the degree to which you can put weight on the foot immediately after the surgery. Some patients, particularly those having base procedures, may have to use crutches; others may be sent home wearing a surgical shoe. The foot will be covered in a dressing, which you will need to keep dry for up to two weeks or until the sutures are removed.
During the first week after surgery, you will need to keep the foot elevated as much as possible. Ice packs also should be applied for the first three to four days to reduce swelling. Limited ambulation or walking is required over the first two weeks to promote healing. Most patients also are instructed on some basic exercises that need to be performed daily.
Sutures are generally removed about two weeks after the surgery in the doctor’s office. Once the sutures are removed, you can bathe and shower normally, but will still need to wear a dressing over the wound to keep it clean and prevent infection.
By the third or fourth week post surgery, swelling generally subsides enough for the patient to begin wearing a wide athletic shoe. It is important to continue daily exercises. If recommended, physical therapy may be initiated at this time. Once the wound has completely closed, you can use lotions to soften the skin in the surgical area.
By week five after the surgery, you will be able to walk short distances and do mild fitness activities. Continue following your surgeons instructions for increasing exercise and activities until you are back to normal.
Ganglion masses, or cysts, are normally removed through surgery. Most cyst removal surgeries are performed on an outpatient basis. Contact our office to have this procedure performed.
During the procedure, the cyst is dissected from the surrounding soft tissues and removed. The recovery period depends on the location of the ganglion and the amount of dissection required during surgery. In many cases, patients receive a splint or below-the-knee cast. The surgeon may require the patient to use crutches for several days to up to three weeks. This level of protection may be necessary if the ganglion is near the ankle joint.
Possible complications from cyst removal surgery include infection, excessive swelling, and nerve damage.
Adult-acquired flatfoot or posterior tibial tendon dysfunction usually leads to a gradual loss of the arch. The posterior tibial muscle is a deep muscle in the back of the calf and has a long tendon that extends from above the ankle and attaches into several sites around the arch of the foot. The muscle acts like a stirrup on the inside of the foot to help support the arch. The posterior tibial muscle stabilizes the arch and creates a rigid platform for walking and running. If the posterior tibial tendon becomes damaged or tears, the arch loses its stability and as a result, collapses, causing a flatfoot.
Surgery is often performed to give the patient a more functional and stable foot. Several procedures may be required to correct a flatfoot deformity, depending on the severity of the problem. These may include:
- Tenosynovectomy a procedure to clean away (debridement) and remove any of the inflamed tissue around the tendon.
- Osteotomy removal of a portion of the heel bone (calcaneus) to move the foot structure back into alignment.
- Tendon Transfer in which replacement fibers from another tendon are inserted to help repair damage.
- Lateral Column Lengthening. A procedure that implants a small piece of bone, usually removed from the hip, outside of the heel bone to create the proper bone alignment and rebuild the arch.
- Arthrodesis. Fusing of one or more bones together to eliminate any joint movement, which stabilizes the foot and prevents any further deterioration or damage.
Hammertoe is a deformity of the second, third, or fourth toes. In this condition, the toe is bent at the middle joint, causing it to resemble a hammer. Left untreated, hammertoes can become inflexible and painful, requiring surgery.
Hammertoe surgery can be done on an outpatient basis in the doctor's office or a surgery center using a local anesthetic, sometimes combined with sedation. The surgery takes about 15 minutes to perform. Up to four small incisions are made and the tendons are rebalanced around the toe so that it no longer curls. Patients usually can walk immediately after the surgery wearing a special surgical shoe. Minimal or no pain medication is needed following the surgery.
Icing and elevation of the foot is recommended during the first week following the procedure to prevent excessive swelling and promote healing. It is also important that the dressing be kept clean and dry to prevent infection. Two weeks after the surgery, the sutures are removed and a wide athletic shoe can replace the post-operative surgical shoe. Patients can then gradually increase their walking and other physical activities.
Many conditions can affect the rear part of the foot and ankle. Two common conditions can cause pain to the bottom of the heel and lead to surgical intervention: plantar fasciitis (an inflammation of a fibrous band of tissue in the bottom of the foot that extends from the heel bone to the toes) and heel spurs (often the result of stress on the muscles and fascia of the foot).
There are many causes of heel pain and most cases can be effectively treated without surgery. Chronic heel pain, however, often can be corrected only through surgery.
A surgical procedure, called an osteotomy, is performed to relieve the pressure on the bone from heel calluses. The procedure involves cutting the metatarsal bone in a "V" shape, lifting the bone and aligning it with the other bones. This alleviates the pressure and prevents formation of a heel callus.
Painful calluses on the ball of the foot are caused by an abnormal alignment of the metatarsal bones. There are five metatarsal bones in each foot, each consisting of the long bones behind each toe. The metatarsal bone behind the big toe is called the first metatarsal, and so on.
The most common metatarsal surgery is performed on the first metatarsal for the correction of bunions.
Surgery on the second through fifth metatarsal bones is performed infrequently, and is usually done to treat painful calluses on the bottom of the foot or non-healing ulcers on the ball of the foot. Patients with rheumatoid arthritis may also need metatarsal surgery.
During surgery, the metatarsal bone is cut just behind the toe. Generally, the bone is cut all the way through, and then manually raised and held in its corrected position with a metal pin or screw. Following the surgery, the patient's foot may be placed in a cast.
In some instances, a surgeon will also cut out the painful callous on the bottom of the foot, but most prefer to do the procedure in an outpatient setting.
Nerve Surgery (Neuroma)
A neuroma is an abnormality of a nerve that has been damaged either by trauma or as a result of an abnormality of the foot. Neuromas occur most often in the ball of the foot, causing a pinched and inflamed nerve. In cases of chronic nerve pain from neuromas, surgery may be recommended.
During neuroma procedures, an incision is made on the top of the foot in the location of the neuroma, usually between the second and third toes or between the third and fourth toes. After the nerve is located, the surgeon cuts and removes it.
Neuroma surgery is generally performed on a same-day outpatient basis in the doctor's office or a surgery center using a local anesthetic. The incision will be covered with a dressing after the surgery, which must be kept dry until the sutures are removed, usually within 10 to 14 days after the surgery. Most patients are sent home with a surgical shoe, although crutches may be recommended in cases where the incision must be made on the bottom of the foot. Elevation and icing are important in the first few days following surgery to reduce swelling. Patients are generally restricted to limited walking until the sutures are removed. Generally, patients can return to normal shoe wear in about three weeks. The overall recovery time is usually four to six weeks.
There are many kinds of toe problems requiring surgery. These include removal of:
- Bunions, an enlargement of the bone and tissue around the joint of the big toe.
- Hammertoes, which are frequently caused by an imbalance in the tendon or joints of the toes.
- Neuromas, an irritation of a nerve between the third and fourth toes.
- Bone spurs, an overgrowth of bone under the toenail plate, causing nail deformity and pain.
Athlete's Foot Treatment
If untreated, skin blisters and cracks caused by Athlete's Foot can cause serious bacterial infections. The treatment of Athlete's Foot depends on the type and extent of the fungal infection, so it is important to consult our practice before choosing a therapy.
Athlete's Foot can usually be treated with antifungal creams. Re-infection is common, so it is important to continue the therapy as prescribed, even if the fungus appears to have gone away. Lasting cases of Athlete's Foot may require foot soaks before applying antifungal creams. Severe infections that appear suddenly (acute) usually respond well to treatment. Toenail infections that develop with Athlete's Foot tend to be more difficult to cure than fungal skin infections.
Cryotherapy is a standard treatment for warts that uses a very cold substance (usually liquid nitrogen) to freeze and deaden the tissue. Cryotherapy can be done in a doctor's office and takes less than a minute.
During the procedure, the doctor applies the liquid nitrogen to the wart using a probe or a cotton swab. Liquid nitrogen can also be sprayed directly on the wart. The freezing liquid can cause discomfort or pain, which is why a numbing drug (local anesthetic) is sometimes used.
Most cryotherapy treatment requires return visits to ensure that the wart is completely removed.
Studies show that cryotherapy is successful about two-thirds of the time, and when combined with salicylic acid treatment, up to 78% of the time.
Extracorporeal Shock Wave
Extracorporeal Shock Wave Therapy (ESWT) is used to treat chronic heel pain (plantar fasciitis). "Extracorporeal" means "outside of the body." During this noninvasive procedure, sonic waves are directed at the area of pain using a device similar to that currently used in nonsurgical treatment of kidney stones.
Extracorporeal Shock Wave Therapy is prescribed for patients who have experienced plantar fasciitis for an extended period of time -- six months or more -- and have not benefited from other conservative treatments. The brief procedure lasts about 30 minutes and is performed under local anesthesia and/or "twilight" anesthesia. Strong sound waves are directed at and penetrate the heel area to stimulate a healing response by the body. ESWT is performed on an outpatient basis. Although there are no bandages, someone will need to drive the patient home.
People who are not candidates for ESWT include pregnant women and individuals with neurological foot disease, vascular foot disease, pacemakers, or people taking medications that interfere with blood clotting (such as Coumadin).
This therapy is a safe and effective alternative treatment for heel pain and only requires a short recovery time. Clinical studies show a 70 percent success rate for treatment of plantar fasciitis using Extracorporeal Shock Wave Therapy.
Iontophoresis is a procedure used to treat excessive sweating in the hands or feet. The procedure involves one or a series of short, 10- to 20-minute sessions in the doctor's office during which a light electrical current is passed through water into the feet. The current is gradually increased until the patient experiences a slight tingling sensation. It is believed, although not clinically proven, that this process plugs up the sweat glands.
Physical therapy can often help decrease the pain and swelling in a painful area of the foot or ankle. Heel spurs, bursitis, plantar fasciitis, bunions, corns and calluses, as well as many post-operative surgical conditions, respond well to physical therapy.
Common kinds of physical therapy may include hot packs, massage, paraffin baths, electrical stimulation, ultrasound, and diathermy (deep heating of tissues through use of electric current) to relieve pain and swelling, increase range of motion, prevent joint stiffening, rebuild muscle strength, and support the proper alignment of foot structures.
Neurolysis is a therapeutic procedure used to treat neuromas. During this nonsurgical procedure, the affected nerve is chemically destroyed via seven weekly injections of ethanol mixed with a local anesthetic. Because nerve tissue has an affinity for ethanol, it absorbs the substance, which, after repeated exposure, becomes toxic and destroys the pain-causing nerve. Neurolysis has a success rate of more than 60 percent. However, this treatment modality is not widely accepted by insurance companies.