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Foot and Ankle Surgery

Every patient is entitled to have full and accurate information about surgery. A complete knowledge and understanding are the best means to dispel unwarranted fears and create an atmosphere that is essential to quality care. From identifying sources of foot pain to exploring treatment, there are times when all this information can seem overwhelming and even confusing. It is important to have confidence in your foot pain diagnosis, and our foot and ankle doctors know how to diagnose and discuss what matters to your care.

We expect to address questions when a podiatrist is considering a patient for surgery, and we have designed this page to help you, too, find the information you need to know about surgery of the foot and ankle.

Common Foot & Ankle Problems (Click on topic to see description & treatment)

Introduction
A recent study performed by the American Podiatry Medical Association revealed that four out of every five adults will experience some sort of foot problem. In many cases, conservative care can alleviate most of these problems. This might include various treatments, such as arch supports, physical therapy, medications, injections, or special shoes. If conservative attempts do not relieve a painful foot condition, an alternative treatment is surgery. In general, surgery is indicated in four instances:

1. pain,
2. problems wearing shoes or walking comfortably,
3. inability to perform or participate in desired activities, and/or
4. preventing an existing painful condition from getting worse or causing other problems.

As there are four indications for surgery, there are four basic goals that we hope to achieve:

1. relieve pain,
2. restore proper function,
3. prevent problems from recurring, and
4. improve appearance.

Foot surgery can provide relief from problems unresponsive to conservative care and disability in most cases.

Anyone from infancy through adulthood can experience a painful and disabling foot problem, although children under the age of twelve usually do not complain of pain. Similarly, athletes usually tend to leave their foot complaints alone for a longer period of time than non-athletes, and until the problem becomes more severe. This can complicate treatment for the athletic individual and will result in wear and tear on bones, joints, and soft tissues. It is the doctor’s responsibility to explain three important facts concerning the patient’s foot problems: What the problem is, why the problem is there, and the ways to treat it. Additionally, all of the positive and negative aspects of the foot surgery must be stated. Since most surgeries are elective, you must then make the decision of whether or not to have the surgery based largely on information provided by the doctor.

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The Surgical Evaluation
The key to successful surgery is not just the skill necessary in the performance of the procedure, but the ability to diagnose the problem accurately. Merely looking at a foot and saying, “Mrs. Jones, have a corn on your little toe,” is not enough. You must be told about the problem, how it occurred, and how to treat it, including possible complications. This is accomplished through a history, physical examination, x-rays, and laboratory tests.

The history concentrates on your chief complaint or problem. It is important to know how long the problem has existed, whether it is caused by injury or overuse, or if it had disappeared and then recurred. Do certain types of shoes or activities cause it to worsen? Is it worse during the day or night? Has it been treated previously? Part of the history should ask about previous operations, any known sensitivity to drugs or foods, and your current medications. This information, along with a complete review of the medical history, is essential to uncover conditions such as gout or diabetes. Frequently, I am asked by patients why it is necessary to know all about their medical history. They say it is “just my foot!” Well, the foot is attached to the rest of the body! Many general medical conditions manifest themselves first in the foot. Poor circulation, diabetes, and gout are three of the most common. Knowledge of conditions such as these are important to ensure proper healing.

The examination performed follows a sequence to gather information regarding the problem. The circulation is checked and compared by feeling the pulses in both feet and legs. Examination of the deep tendon reflexes and nerves is also required, followed by the biomechanical examination which is divided into two parts. The first measures the amount of motion of the joints of the hip, upper leg, knee, lower leg, ankle, and foot structure as well as any leg length difference or tight leg muscles. The second part is the gait analysis. This is where you walk back and forth and are observed for abnormal head tilt, uneven shoulder height, curvature of the spine, limp, or faulty foot structure. The information from the biomechanical examination reveals why you have a particular foot problem. Appropriate x-ray studies are done to determine foot problems such as fractures, dislocations, calcium content of the bone, and bone position. In most cases, weight-bearing x-rays should be taken if foot surgery is indicated. Standing x-rays differ from non-standing views because the weight placed on the foot structure more accurately shows how a bone is positioned. This provides a more accurate determination of foot position and better treatment. Appropriate laboratory tests may also be considered. This can be a simple blood test and urinalysis, or more sophisticated tests depending on the condition.

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Anatomy
It is important to have knowledge of what structures or parts of the foot are involved in surgery and what they do. Some simple terms will clarify:

• Bones are the supporting structures of the foot. Each foot has 26 different bones.
• Ligaments are the structures that connect the bones together. They are like steel cables and are very strong. Each foot has over 100 ligaments.
• Joints are where two bones meet. Each joint is lined with cartilage. The cartilage is the main structure that allows the joint to work properly.
• Muscles contract and move the foot. They can extend, flex, or move the foot from side to side.
• Tendons connect the muscles to the bones and are like tough fibrous bands.

It is rare that only one particular structure is involved in foot surgery. Usually a combination of structures need to be corrected.

All the structures of the anatomy heal basically in two ways regardless of the type of procedure performed. Bone usually takes six to eight weeks to heal. Soft tissues such as muscles, tendons, and ligaments, take three to four weeks. Proper treatment and care after the surgery is imperative for good healing.

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Surgical Settings
Although some surgical procedures are more involved than others, there are no minor surgeries. Surgery is performed in an office, hospital, or surgical center, which is comparable to a mini-hospital where you do not stay overnight. The place where the surgery is done is picked according to your needs and the procedure to be performed. Most foot surgery is done as an outpatient; that is, the surgery is performed and you go home the same day. Prior to any surgical procedure, the doctor and staff will inform you whether or not to stop eating or drinking as well as to have a relative or friend provide transportation to and from the operation. Regardless of how well you may feel after the surgery, it is not advisable to drive. A relative or friend should take you home.

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Anesthesia
Surgery generally requires the administration of some sort of numbing agent or anesthesia. The three basic types are local, spinal, and general. Local anesthesia, used in most minor procedures, numbs only the part of the foot undergoing surgery. It is normally simple and safe. There can be some discomfort with the injection, but it quickly disappears. The numb feeling, depending on the type of anesthesia used, can last from one to several hours.

Spinal or general anesthesia is used only in a hospital or surgical center. Depending on your condition, the anesthesiologist determines the best type of anesthesia to use. Spinal anesthesia numbs both legs. You are still awake but comfortable during surgery. General anesthesia puts you to sleep during the procedure. Following completion of the operation, time is spent in the recovery room. You then go directly home or stay in the hospital for a day or two.

If, prior to surgery, you develop a cold, flu, or elevated temperature, the surgery is best postponed. Remember, most foot surgery is elective and it is best that all conditions be optimum for good results.

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Postoperative Care
The success of the operation is largely dependent on the care after the surgery. A properly done procedure can be affected by poor aftercare which could lead to postoperative problems. A written instruction sheet is provided on exactly how to take care of the foot following surgery.

• The foot should be elevated on several pillows. It must be higher than the waist.
• Ice should be applied for the first 48 to 72 hours. Usually it should be kept on 30 to 45 minutes every hour that you are awake. An ice cap is handy. Several plastic bags bound together with ice in them can be a viable substitute.
• The bandages should not get wet unless instructed otherwise. You should not take a shower with a plastic bag over the bandage. A leak can develop and if the stitches or bandages get wet, an infection can occur. If only one foot was operated on, a bath can be taken by holding the bandaged foot out of the tub. Otherwise, it is necessary to take a sponge bath.
• A special wooden postoperative shoe is usually used after surgery to protect the foot. This should be worn when walking but can be removed when resting. Certain procedures require that no weight be placed on the operated foot. Crutches or a walker can be used to help you get around as needed.
• Medications should be taken only as directed. Pain medication is most effective when it is taken as needed, and not in anticipation of pain. In most foot surgery, a long-acting local anesthetic helps reduce most of the pain. Also, anti-inflammitories may be used to help control postoperative discomfort. Too much postoperative medication is not advisable.
• You should not remove or loosen the bandages unless told to do so by the doctor or his staff. Correct position of the toes and foot structure is critical to successful alignment and good results. If you remove the bandage too early or re-wrap it incorrectly, the surgical procedure can be adversely affected. Sometimes, the foot will turn black and blue. This is normal, along with swelling. It will fade away like any other bruise and should not be a reason to remove the bandages.
• Casts may be used following surgery to help maintain position of the bones and protect the foot and leg. Casts are made of either plaster-of- Paris or fiberglass materials. They usually are kept in place for four to eight weeks. Some are non-weight bearing, others are not. All casts should be kept dry unless instructed otherwise.
• The doctor should always be consulted if anything appears to be wrong before your next appointment. If there is too much pain, nausea, bleeding through the bandage, or any other reason that causes concern, the doctor should be called day or night. There is no one more concerned for your health and well-being than the doctor.

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General Care After The Surgery
After surgery, you should refrain from using the operated foot. Rest, ice, compression, and elevation are customary for the first three or four days. Stitches are removed after seven to fourteen days, although self-dissolving stitches may be used in some cases. A wooden postoperative shoe is generally worn for two to three weeks, then a soft shoe; such as a slipper or tennis shoe is used for several more weeks. There is a gradual return to regular shoes and activities. Physical therapy and exercises may be utilized. This helps reduce inflammation and speed the healing process. One of the biggest mistakes that patients make after surgery is soaking their foot after the stitches are removed in hot salt water. This may make the foot feel better for a few moments but causes the tissues to swell and delays healing.

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Informed Consent
You must sign a consent form prior to the proposed surgery. This form lists important information about the surgery that the doctor must explain and that you must understand. It typically lists your name, age, the date and time of consent, and gives authorization to the doctor to perform the surgery. The nature and purpose of the operation, possible alternative methods of treatment, risks involved, and complications are explained and acknowledged. Most importantly it states that there is no 100% guarantee. There is the possibility of recurrence, infection, decreased motion, or excessive scar tissue build up following surgery. Although complications are unusual, you must have a reasonable level of expectation as to what can be achieved.

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COMMON SURGICAL PROCEDURES

Nail Problems
The three types of nail problems are incurvated nails, infected ingrown nails, and fungus nails.

Incurvated nails have hooks on one or both sides and press down into the skin. The pressure from the nail causes the skin to protect itself through thickening and it forms a callous under the hooked nail. The callous, in turn, causes even more pressure and pain.

Infected ingrown nails result when an incurvated nail gets a sharp point on its edge and then grows into the skin. Once the skin is broken, bacteria invades the area and it gets infected. Antibiotics and soaks can help alleviate the infection. However, it is best to treat the cause of the problem-the ingrown nail. If it is infected and very irritated, a mound of abnormal fleshy skin can grow in the nail groove. This kind of ingrown nail is very painful. Removal of the offending nail side gives immediate relief.

Fungus nails, also called mycotic nails, result from fungus invading the nail and causing it to grow abnormally thick. The thickening causes pressure on the skin.

Surgical treatment of any one of the three common nail problems involves numbing the toe with a local anesthetic and removal of one or both sides of the nail or the entire nail plate. The root is then treated surgically or chemically to prevent it from re-growing. If the nail side or whole nail is allowed to re-grow, another problem nail would grow in its place. Patients sometimes worry about the skin under the nail after it is removed. When it heals, it is just like the skin on the top of the foot only a little thicker. Shoes can be worn comfortably, and there is no disability. There are no stitches and the dressing is removed the day after surgery. It is permissible to take a shower or bath the very next day,and a closed shoe is able to be worn.

Nail surgery has a high rate of success. There are few problems associated with it and little if any disability. It is possible for a new nail to grow again or the skin to migrate over the new nail border, but this is very rare.

Some nails are very humped up in the middle and pinch the underlying skin. This may be due to a bone spur or calcium deposit pressing from underneath. An x-ray will confirm if this is a causative factor. If it is, a small incision is made at the tip of the toe and the spur filed smooth. There is no increased disability with this procedure when done in conjunction with the painful nail.

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Warts and Cysts
Warts are caused by a virus. Sometimes, even after they are removed, they will recur. There are many different treatments for warts; burning, freezing, laser, chemicals, and surgery. They can occur anywhere and everywhere. Warts are the most misdiagnosed soft tissue problem seen. They can be confused with other small soft tissue growths, like cysts from foreign materials that penetrate into the pores of the skin, or callouses with small cores in them caused by pressure from the bone structure of the foot. If properly identified and surgical treatment is desired, the area under the wart is numbed, then removed with an instrument that looks like a small ice cream scoop. Healing takes seven to ten days in most cases. Warts on the bottom of the foot are deeper than those on the toes or the top of the foot because of the pressure from the body weight on the wart as it grows. Small cysts are treated the same as warts. The tissue removed is always sent to a pathology lab to determine exactly what it is.

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Toe Problems
Problems with the toes are very common and can be disabling. They are the result of a muscular imbalance in the foot and leg that causes the toes to buckle up, override, or underlap. Most are inherited, but some are caused by tight fitting shoes and socks, which over a long period of time, can affect the skin and underlying bone.

Overlapping and underlapping toes are very common and are caused by either heredity or muscle imbalance. Frequently seen in infants and young children, taping of one toe to the other can in many instances cause it to straighten out. If it is resistant to taping, surgery can correct them.

Toes may be rigid or non-rigid. If a toe is curled and can be straightened, it is a non-rigid type and usually no bone operation is needed. The tendons on the top and bottom of the toe can be lengthened or balanced to realign the toe in its proper position. Rigid toes present a much different problem. They usually occur if the non-rigid toe is left untreated. After a period of time, the toe joints stiffen and cannot be straightened. This rigid type needs to have a portion of the bone remodeled, removed, or repositioned to straighten the toe. Small implants or joint spacers may also be used to realign the toe. The implant helps maintain the toe length and provide stability.

The two types of rigid toes are called hammertoes and mallet toes. The only difference between the two is the level where the joint is contracted. There are two joints in the small toes. The hammertoe is at the level nearest the ball of the foot, whereas the mallet toe is closer to the end of the toe. Some toes are a combination hammer and mallet type. Often hard corns can grow on the top of the toe.

Soft corns are also caused by malaligned joints or bony spurs between the toes. Excessive perspiration causes the skin between the toes to soften the hardened skin. This soft type corn is best treated by making a small incision in the skin, then smoothing down the high spot on the bone. The corn goes away because the pressure from the bone underneath has been eliminated.

Frequently, a corn or callous develops on the inside aspect of the big toe. This is commonly called a pinch callous. It results from an inrolling of the foot structure. Instead of pushing off of the bottom of the big toe, the pressure is placed on the inside. This causes the bone to enlarge and develop a spur. Like the soft corn, the bony spur can be filed smooth and the corn goes away. If the toe is very crooked a small pie-shaped wedge of bone is removed from the toe to straighten it.

Some toes develop a corn on the bottom of the toe instead of on the top. This is caused by a small pea-shaped extra bone that develops inside of the tendon that bends the toe down. It can be very painful, especially because of its location and the weight put on it when walking. Treatment is best accomplished by removing the small bone, thus alleviating the pressure and pain.

Postoperative care following any toe surgery can range from a few days of discomfort with the ability to wear shoes almost immediately, to several weeks disability and needing to wear a postoperative shoe to avoid undue pressure on the toes as they heal.

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Callouses
Like corns, callouses are caused by excessive pressure from underlying bones in the ball of the foot. If the bones are balanced, there will be even pressure on the ball of the foot and the skin will be smooth. If there is an imbalance in the muscles, bony enlargement, or malalignment, the unequal pressure will cause the skin to respond to the pressure and grow a protection for itself. This callous thickens and causes even more pressure and pain. Some callouses are spread out while others are small and have a core or nucleus inside them. This latter type is very painful. Trimming, padding, or the use of supports may only give temporary relief.

There are three common areas for a callous to form on the bottom of the foot. The most common is under the second bone or metatarsal. When the foot strikes the ground, the first metatarsal bone may be pressed excessively upward because of the rolling in movement of the foot. This allows for a transfer of pressure to the second bone in excess of what is normal and a callous grows. If the first bone is rigid or stiff, and does not move upwards, a large callous will develop under the first metatarsal bone. The third most common area, the fifth metatarsal or tailor’s bunion, also results from an inrolling of the foot. Excessive pressure builds up on the out- 8 side bone as it hits into the shoe. This causes the bone to grow in size and results in a painful callous.

Sometimes we see a callous on more than one area on the bottom of the foot. This results from an imbalance of more than one bone. In this instance, all of the involved bones are realigned to resolve the problem. A bone causes a callous to form. If the callous is removed without treating the bone, the callous will recur. Callouses with a hard core are often misdiagnosed as a wart. Warts are caused by a virus, callouses are caused by bone. They are not treated alike. An improper diagnosis can result in unnecessary treatment and recurrence.

The object of metatarsal bone surgery is to relieve the pressure from the bone pressing under the skin. The longer the bone, the lower it is. Conversely, the shorter it is, the higher it will be. Therefore, to eliminate the callous, the bone is shortened. Lifting the bone removes the pressure under the skin, and the callous disappears. In some cases, the bone is shortened and the callous is also removed on the bottom of the foot. Both of these procedures are done only when the callous is very deep, long standing, and has scar tissue in it.

The bone is shortened by making a small “V” cut in it. Usually there is no need for pins, wires, or casts. Another procedure involves making a cut further back in the bone and then a wire is used to hold the bone in place until it heals.

Metatarsal surgery requires six to eight weeks for the bone to heal. However, with the aid of a wooden shoe, you can walk after the first several days. The stitches are removed in seven to ten days, and a regular shoe is worn in two to three weeks. The callous usually takes three to four weeks to disappear.

Following the operation the callous rarely re-grows or moves underneath a different metatarsal bone. If it does, however, it is because of the pressure being transferred from the operated bone to the adjacent one. While this transfer callous is rare, it may require further surgery.

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Foot Problems caused by Diabetes & Diabetes Foot Treatments

Diabetes is a significant risk to foot health. As the disease progresses, loss of sensation and reduced blood supply can occur, leading to open ulcers, foot deformities, infection, and even loss of the limb. These are called diabetic foot problems. Areas of high pressure (bone spurs or enlargements) cause a callous to form in non-diabetics. However, in diabetics, they can cause ulcers. Surgical removal of the ulcer and underlying bony deformity can correct the problem. It is important to have these areas inspected and treated. Diabetic patients are sometimes scared into thinking they should never have surgery, but if their blood supply is good and their sugar level controllable, healing potential is excellent. Prevention is the key to diabetic foot problems.

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Neuromas
There are three basic kinds of nerves and how they function. There are sensory nerves which allow us to feel,motor nerves which make things move, and combinations of these. Neuromas lie between and beneath the heads of the metatarsal bones. Because of the abnormal pressure from faulty foot structure or injury, these nerves can become irritated, inflamed, and enlarged. This causes a burning, stinging, or numbness-like sensation on the bottom of the foot which also affects the toes. If the nerve is very enlarged, a lump can be felt on the bottom of the foot. You often get relief by removing your shoe and massaging your foot. Most often a neuroma or nerve growth is located between the third and fourth bones in the ball of the foot and extending to the third and fourth toes. There is a nerve that passes down the back of the leg, divides in the ankle area, and has branches that lie on the inside and outside of the foot. There is only one spot where these branches come together, and that is between the third and fourth metatarsal bones. Because this nerve is larger than the other nerves in this area, it is subject to increased injury. Normally the thickness of a piece of kite string, it can enlarge to the diameter of a number two pencil.

If conservative care such as injections or orthotics is unable to alleviate the pain, that portion of the nerve which is enlarged is removed. Patients often are concerned about the removal of a nerve. The nerve segment removed in a neuroma surgery is a sensory nerve. It does not affect how the foot functions or the toes work. Following surgery, there is a decreased feeling between the third and fourth toes. However, this will not affect wearing shoes, walking, or running. You would need to rub your finger between the toes to know that there was decreased feeling in this area.

Neuroma surgery is straight forward and effective. There is no bone work done; therefore, there is a speedy return to normal activities. It is possible for nerve to re-grow, however, this is extremely unusual.

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Ganglions/Cysts
A ganglion is a fluid-filled sack-like growth that can occur anywhere on the foot or ankle. It is usually found along the course of a tendon. Tendons pass through a sheath or covering. There is a liquid-like oil between the tendon and its sheath which lubricates the tendon and aids in its sliding action. An injury or poorly fitted shoe, can cause the tendon sheath to tear and allow the fluid to leak out. The body then forms a sack-like structure surrounding the leaky fluid. This type of growth can also come from joints and other structures but is commonly near tendons. Ganglions can be quite large and feel hard. They can also affect the function of nearby vital structures such as arteries, tendons, veins, and nerves. In most instances, ganglions are removed surgically. An incision is made, the ganglion carefully removed, and the tear in the tendon sheath or hole near the joint repaired.

Post-operatively, there is little pain or disability. The surgical site is protected for several weeks to avoid a re-tearing of the tissues underneath and a possible re-growth.

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Bunions
Bunions are an enlargement of bone near the base of the big toe. They are most often hereditary. Frequently, they are associated with a painful bursitis, limitation of motion, angulation of the toe and chronic irritation and pain. Bunions can make it impossible to walk and wear shoes comfortably. The most important joint in the ball of the foot is the big toe joint. Undue pressure on this joint from a faulty foot structure or injury can be very disabling. Conservative care for bunion deformities includes: padding, strapping, arch supports, bunion shields, injections, physical therapy, or special shoes. This might help relieve some symptoms but does not correct the cause of the problem, namely, the foot structure and underlying bone and soft tissue imbalances.

There are many different surgical approaches to correct bunions. Careful evaluation is mandatory to determine the correct procedure. Besides a biomechanical examination, weight-bearing x-rays are necessary. The x-rays show the entire foot structure including the bottom surface of the bunion joint area. This is where there are two small bones, called sesamoids, under the big toe joint. Like miniature knee caps, their function is to give power to the muscles in the arch to pull the big toe down straight. If they are arthritic or out of position, they must be realigned as part of the bunion correction. If they are not, the joint will be stiff and not work properly.

There are four main types of bunion deformities: 1) positional or soft tissue 2) structural or bony 3) combinations of soft tissue and bone and 4) degenerative joint disease or arthritis. You must have the particular type of bunion deformity properly diagnosed first. After this has been done, a specific procedure can be designed to correct the problem.

Some bunion corrections remove the enlarged bone, while others involve repositioning the bone and using pins, wires, screws, or casts. While some bunion corrections can be walked on immediately, others require that no weight be placed on the foot for six to eight weeks.

The surgical treatment of a bunion is doing what needs to be done to correct the problem. For example, if the structures on one side of the joint are too tight and too loose on the other side, they are re-balanced and realigned. If there is an excess of bone, it is removed. If a bone is not positioned correctly, it is realigned.

Most bunions require a combination of soft tissue and bony corrections. Some bunions may have arthritic or degenerative changes in the joint. When this occurs, the joint stiffens and will not move up and down properly. The joint jams and then destroys the cartilage. Surgery to correct this aims at restoring and relieving the pain. The diseased bone and cartilage is removed and replaced with an artificial joint or the diseased joint is fused in a stable position.

Postoperative care for bunions, like other bone surgery, involves resting of the foot, elevation, and ice for the first few days. There is a gradual return to walking and wearing shoes on a regular basis. Range of motion exercises are essential immediately after surgery and throughout the healing process to ensure a good functional result.

Scar tissue forms randomly, that is, it fills in and around the operated area. Exercise forces the scar tissue to align and stretch itself out, allowing for better motion.

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Midfoot Bone Spur
A bump that commonly is found on the top of the foot is the midfoot spur. When the first metatarsal bone pushes against the ground there can be so much pressure that the bone is forced upwards. This causes a jamming of the bones at the top of the arch and new bone forms. Normally this would not cause a problem. However, this area is not well padded or protected with fat. Major tendons, blood vessels and nerves pass through this area, and the spur, in combination with pressure from the shoe, squeezes these vital structures causing pain. Also, the tendon controlling the big toe crosses this area and its covering can tear, thus making this a common area for a ganglion to form. Conservative treatment is difficult. Arch supports, used to control foot instability and provide cushioning, unfortunately lift the foot up and may jam the bone spur into the shoe. Surgery removes the pointy spur and resolves the problem. A shoe with an open top is worn for two or three weeks until the area is healed.

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Accessory Bones
Accessory or extra bones can occur in up to twenty percent of normal foot structures. Like the pea-shaped bones described in hammertoes, they can cause pain. Of particular interest is an extra bone found on the inside of the foot near the center of the arch. Sometimes called a double ankle bone, this accessory bone is inside the tendon of the foot responsible for supporting the arch.

It can become painful in flat feet and makes wearing shoes very uncomfortable. Steroid injections are not advised because of possible weakening of the tendon. Arch supports are only marginally effective. Surgical removal of the accessory bone eliminates the rubbing and pain. Healing takes three to four weeks and normal function is restored.

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Tendon Injuries
Tendon injuries are common and often associated with abnormal foot function or trauma. Tendons can rupture completely across or lengthwise along their fibers. Think of a tendon as a pound of uncooked spaghetti. It is made up of thousands of individual strands. Some or all of the strands can tear. The two most common tendon injuries involve the Achilles tendon and the posterior tibial tendon.

The Achilles tendon functions to stabilize the outside of the foot to the floor. It provides the power for normal walking. If it is partially torn, stretched out, or completely torn, it is best to surgically repair the tendon to maintain proper function.

The posterior tibial tendon functions to lift the instep or arch of the foot. It often spontaneously ruptures either partially or completely. This occurs mostly in women in their 50’s and 60’s. The exact cause is unknown. Because this tendon supports the arch, if left untreated it can cause the foot to collapse or roll-in. It is best to repair this tendon and correct the collapsed foot structure to prevent severe arthritic changes. This is most commonly done by attaching the torn tendon to a new stronger tendon and by moving the heel bone back in position to re-create an arch.

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Nerve Entrapments
A burning sensation or lack of feeling can occur on the inside aspect of the heel and spread to the arch of the foot. This happens underneath a broad, flat ligament on the inner aspect of the ankle. Commonly associated with flat feet, the inrolling of the foot presses on the ligament and then the nerve, causing it to be entrapped.

A useful test to help diagnose the condition is the nerve conduction study. The nerve is tested by determining how well it can transmit its electrical signal. If the signal length is delayed, the nerve is considered abnormal. However, studies have shown that the test is only fifty percent reliable compared to a similar nerve entrapment condition seen in the wrist, where the test is over ninety percent accurate. Therefore, the nerve may still be abnormal, even with a negative test.

Conservative treatment aims at releasing the pressure and inflammation around the nerve. Arch supports and injections may help. In those cases non-responsive to conservative care, surgery is used to relieve the trapped nerve by loosening the ligament. When healing, scar tissue can cause pressure to reform on the nerve. Therefore, you should not put undue pressure on the operated foot until it is healed. Sometimes casts and crutches are used for support protection.

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High-Arched Feet
The arch of the foot, if too high, tends not to be able to absorb shock nor does it readily adapt to the ground. The excessively high-arched foot is infrequently seen. It may be associated with neuromuscular diseases. High-arched feet have certain basic characteristics associated with them, such as rigid hammertoes, painful callouses, heel spurs, ankle spurs, frequent sprained ankles, and tight heel cords. When the toes are severely contracted upward, the fat pad on the ball of the foot is pulled forward. This leaves the heads of the metatarsal bones without cushioning, causing injury to the skin and the growth of painful callouses. High-arched feet do not respond well to conservative treatment. Orthotics, custom designed arch supports, must be very shock absorbing and flexible. Frequently, severe high-arched feet make it impossible to wear shoes or walk comfortably. Surgery is directed at correcting the many toe, metatarsal, midfoot, heel, and tendon problems. The surgery must sometimes be staged; that is divided into several operations because of its complexity. It is common to fix only one foot at a time so you can at least walk around with the aid of crutches. High-arched foot surgery repositions and realigns the bones and tendons of the foot structure, thus allowing for proper function.

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Ankle Problems
Two common ankle problems are the sprained ankle, and the uninjured but painful ankle.

An ankle, when sprained, can injure the ligaments and other structures that surround the ankle joint. Statistically in eighty percent of those ankles which are severely sprained, the ligaments will heal themselves. In the other twenty percent of the cases they do not heal, and the ankle can turn or sprain itself again and again.

Conservative care such as taping or the use of arch supports can help some of these painful symptoms. If ankle surgery is needed, the most common operation is called the lateral ankle stabilization. In this procedure, either the torn ligament is repaired or a new ligament is created using a piece of tendon. The bone grows around the transferred tendon and becomes a ligament, a cable-like structure that connects the two bones together. After the operation, a non-weight bearing cast is used for four weeks. Then there are two additional weeks in a weight-bearing cast. After this, the cast is removed and physical therapy is used to strengthen the muscles. It takes six or more weeks to recover from a lateral ankle stabilization because of the time needed for the newly formed ligament to heal to the bone. The procedure is very successful in solving related ankle problems, since it approaches ninety-eight percent good results.

The other common ankle procedure is ankle arthroscopy. This technique is both diagnostic and therapeutic, that is, it can tell what the problem is and treat it all at the same time. It allows for direct visualization of the ankle problems and can prevent unnecessary surgery. Its broadest application is in the management of patients with long term ankle complaints non-responsive to conservative care.

A small incision, often not needing a stitch to close it, is made at the ankle joint level. A thin probe is placed into the ankle and is connected to a camera and video tape machine with monitor, and the ankle joint is then seen from the inside. The appropriate procedure is done to correct the problem and the patient goes home the same day. The bandages are removed in two to three days, and Band-Aids can be placed over the incisions. A regular shoe can be worn after three to four days.

Arthroscopy can be used in patients where there is a limitation of motion, arthritis, cartilage damage, scar tissue buildup, or unstable ligaments. If you have persistent joint complications not explained by history and physical examinations, arthroscopy allows for a relatively low-risk treatment with high diagnostic and therapeutic results.

A survey of patients who have undergone arthroscopy reported approximately ninety percent improvement in their ankle joint problems. None reported that their symptoms were made worse following the surgery. Thus arthroscopy has proven to be a superior surgical tool much like it has already been proven in knee surgery.

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Inflammation and Scar Tissue (called Synovitis)
Basic injuries can damage the soft tissue inside your ankle joint, causing discomfort and swelling for a few days. When these injuries heal, scar tissue can form inside your ankle, making it catch or lock when you bend it.

Treatment: Your doctor can remove the inflamed or scar tissue with small instruments and lasers that vaporize the abnormal tissue.

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Cartilage Wear and Tear
Like anything else, your body suffers from normal wear and tear. The cartilage in your ankle wears down too, as you continuously use it. Sometimes this aging process is sped up by diseases like arthritis or gout. When the joint loses its gliding ability, stiffness and discomfort occur.

Treatment: Your doctor can smooth out these bad areas, and remove broken pieces of bone and cartilage called loose bodies.

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Bone Spurs
Injury to the bones can cause them to form spurs. Bone spurs restrict the motion of the ankle joint and cause discomfort. They can also pinch the lining of the ankle joint, causing inflammation and scar tissue.

Treatment: Your doctor will first remove the inflamed scar tissue, then use a specialized instrument to remove and smooth down the spur.

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Ligament Tears
Ankle sprains can cause the ligaments to tear. If injured,ligaments may not heal properly, or heal in a stretched position. This will cause your ankle to be unstable and uncomfortable.

Treatment: Your doctor can actually see the ligaments from inside the joint and then reattach or reroute them to tighten the loose joint.

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Ankle Fractures
Ankle injuries or problems resulting in ankle fractures can be treated either conservatively with casting, or surgically with specially designed plates and screws to hold the bone together. Regardless of the method used, the primary goal in the treatment of ankle fractures is to restore the normal anatomy of the bones and surrounding tissues, i.e. ligaments and tendons. The injured structures must be realigned perfectly to insure proper pain-free function. If the ankle joint is not aligned, the joint can become arthritic and painful.

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Ankle Fusion
When the ankle is too badly damaged due to injury or disease, it may be necessary to actually fuse the bones together. This means eliminating the motion of the joint. No motion. No pain. Ankle joint fusion is sometimes the best alternative to relieve ankle pain and deformity.

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