Foot and Ankle Surgery
Foreword
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. There are times when all
this information can seem overwhelming
and even confusing. This booklet
supplies the necessary information
you need to know about surgery
of the foot and ankle.
Table of Contents Page (click
on topic below)
Introduction
The Surgical Evaluation
Anatomy
Surgical Settings
Anesthesia
Postoperative Care
General Care After
The Surgery
Informed Consent
Nail Problems
Warts and Cysts
Toe Problems
Callouses
Diabetes and Foot
Surgery
Neuromas
Ganglions/Cysts
Bunions
Heel Spurs
Midfoot Bone Spurs
Accessory Bones
Tendon Injuries
Nerve Entrapments
High-Arched Feet
Low-Arched Or
Flat Feet
Ankle Problems
Inflammation and
Scar Tissue
Cartilage Wear
and Tear
Bone Spurs
Ligament Tears
Ankle Fractures
Ankle Fusion
Total Ankle Replacement
(TAR)
The Surgical Team
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Diabetes and
Foot Surgery
 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. 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.
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.
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.
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.
Heel Spurs
The heel is designed to absorb
tremendous stress. Attached
to the heel are strong bands
of ligaments and muscles that
help support the arch. If there
is too much pressure on the
heel bone at the attachment
of these structures, a spur
can form. Another new theory
of heel spur formation suggests
that the spur results from small
fractures or cracks that occur
in the bone. The spur, which
is actually a shelf of bone
across the entire length of
the heel,should not be confused
with arthritis. It is caused
by excessive pressure on the
heel bone, whereas arthritic
spurs usually affect multiple
areas and are associated around
joints.
 Conservative
care for a heel spur includes
one or more injections of steroids
to help reduce inflammation
or arch supports to help decrease
the pressure on the ligaments
and muscles. Surgery on the
heel spur relaxes the bands
of ligaments where they attach
as well as smoothing down the
bone. After surgery, walking
with crutches is usually necessary
for a few days. Regular shoes
are used after two to three
weeks. Soft, shock-absorbing
orthotics are used to reduce
the risk of re-growth.
Two other kinds of spurs can develop
on the back of the heel. One,
originally called a pump bump
because it was thought to be
from shoe pressure from pump-style
shoes, is located where the
Achilles tendon attaches to
the back of the heel. The other
spur is located further down
the heel. Just like the spur
that forms on the bottom of
the heel, these spurs can cause
pain and problems wearing shoes.
Conservative care includes using
heel cushions to lift the heel
away from the back of the shoe.
Steroid injections, commonly
used for the heel spur on the
bottom of the foot, are rarely
used in this area because it
may weaken the Achilles tendon.
Surgery removes the spur. Inflammation
of the tendon may develop following
surgery, but this gradually
resolves.
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.
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.
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.
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.
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.
Low-Arched
Or Flat Feet
 Low-arched
or flat feet are very common.
It has been estimated that 70%
of the general population has
a tendency towards excessive
inrolling problems of the foot.
Some of the more common causes
of flat feet are heredity, muscle
imbalance, and faulty foot structure.
Low-arched feet, unlike high-arched
feet, are usually flexible and
absorb shock well. They are
often associated with foot deformities
such as bunions, hammertoes,
callouses, heel spurs, tendon
injuries, and leg and back pain.
Conservative care using shoe
modifications, padding, arch
supports, and physical therapy
is sometimes effective. There
are two basic types of flat
feet: rigid and non-rigid. The
difference between the two types
is determined by standing and
sitting positions. While standing,
see if the foot flattens or
lowers in the arch area. Then,
pick up the foot and see if
the arch height increases. If
it does it is a non-rigid type.
Conversely, the rigid type arch
remains the same with or without
weight on it.
Rigid flat feet occur less frequently
and are often associated with
abnormal bridges of bone in
the hind foot that prevent the
joints from working properly.
Without adequate movement, the
muscles that move the foot and
leg go into spasm and cause
pain. Surgery unlocks the bones
and normal motion returns. It
takes six to eight weeks to
recover from this surgery which
helps to build a foot with an
arch.
 The
non-rigid foot is the most commonly
seen flat foot condition. Young
children often go untreated
and can suffer from major foot
problems when they are older.
Conservative care such as arch
cookies, special shoes, orthotics,
and exercises are used to support
and strengthen the muscles of
the leg and foot. If these are
unsuccessful, surgery can help.
We must remember that young
children usually do not complain
of painful flat feet. They do,
however, demonstrate that they
do not like to wear shoes, tend
to run their heels over, and
generally are clumsy. Some complain
of night cramps. Most often,
there is a strong hereditary
tendency in children with flat
feet. Sometimes examining the
child’s parents helps predict
what foot conditions may appear
later in life if left untreated.
An important difference in the
flat foot of a child verses
that of an adult is that much
of the foot structure in a child
is still cartilage and will
continue to grow as they get
older. Unlike the child’s
foot, an adult foot has all
of the bones already formed.
The foot bones are usually fully
grown at the age of twelve for
girls and fourteen for boys.
Therefore, the earlier the surgery,
the better the results because
of the growth that occurs after
the foot has been properly positioned.
 An
excellent procedure to correct
a flat foot is the Smith Sta-Peg
operation. A small piece of
angled plastic is inserted between
two bones in the foot structure
which prevents the arch from
collapsing. Both feet can be
done at the same time, walking
is allowed the day after surgery,
and there is no need for casts.
If the excessive flattening of
the foot is reduced, the bones
will develop normally. This
surgery prevents problems such
as bunions, calluses, and hammertoes
from occurring later in life.
 In
older children and adults surgery
also involves supporting the
structures of the inside of
the foot. A wedge of bone is
removed from the middle of the
arch area that sags and a new,
normal arch is created. A common
cause of flat feet in an adult
is a partially or completely
ruptured posterior tibial tendon.
As previously described under
Tendon Injuries, this often
causes flattening of the arch
and tilting of the heel bone.
The ruptured tendon is supported
with another tendon and the
heel bone can be repositioned.
These procedures help support
the arch by restoring normal
function to the torn tendon
and heel.
In older children and adults,
the tendon that supports the
arch (posterior tibial tendon)
is often partially or completely
torn. This causes continued |
