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Medical & Surgical Treatment of Foot & Ankle

Your best choices for your family's foot care needs

Why are my feet flat?

Adult-acquired flat foot is a condition that results in a fallen arch and the foot pointed outward.  This condition is most common in women over the age of 40.  A variety of foot problems can lead to adult acquired flatfoot deformity but the most common cause is a gradual stretching out of a tendon near the ankle bone, known as the posterior tibial tendon.  This tendon is the main stabilizer of the foot arch.  While the cause of the stretching is not fully understood, many doctors believe that wearing high heels and standing or walking for long periods may add to the problem.  Other risk factors include obesity, hypertension, and diabetes.


People with flatfoot experience different symptoms depending on the cause.  Pain and swelling may be felt on the inside of the foot and ankle.  This pain points to involvement of the posterior tibial tendon.  The pain may increase with activity and high intensity activities such as running can be very difficult.  As condition worsens, the arch can collapse causing the heel bone to move, and placing pressure on the outside of the ankle.  This can cause outside ankle pain and arthritis of the ankle joint.


The posterior tibial tendon is one of the most important tendons of the leg.  It starts at a muscle in the calf and travels down the inside of the ankle and attaches to bones on the inside of the foot.  The main function of this tendon is to support the arch.  If the tendon becomes inflamed or torn, the arch will slowly collapse.  Inflammatory arthritis can attached the ligaments as well as the cartilage in joints.  Arthritis can cause pain as well as changes to the shape of the foot.  Injury to the ligament sin the foot can cause joints to fall out of alignment and cause flat foot.  The last major cause of adult-acquired flat foot is diabetes.  People with diabetes or with a nerve loss can have arch collapse.  This is typically more severe and due to a loss of pain sensation as the arch collapses.


Adult-acquired flat foot is a very common problem affecting the foot and ankle.  The good news is orthotics and braces can help most people.  For people that have tried orthotics and braces without any relief, surgery can be a effective way to reduce pain and deformity.  Your podiatrist is specially trained in treating flat foot and will create a custom treatment plan.

Finding the Right Shoe Insert for Diabetics

For some diabetics, extra thought and care need to be given to protect the foot’s skin.  It can be damaged from pressure and shearing forces while inside a shoe.  With many types of shoe inserts available it is hard to determine which type protects the skin and prevents shearing damage.  Orthotics, store-bought arch supports, diabetic shoe inserts, and gel or foam shoe padding all fit inside shoe and are all designed to help the foot.  But there are big differences in the inserts, not only in design and materials but also in function and purpose.  These differences become very important when supporting a diabetic foot.


Buying an insert does not require a podiatrist, and many different options are available.  A shoe pad is a thin layer of foam or gel meant to replace the sock liner or a shoe with something that gives more cushion.  They offer little to no support, and simply make the shoe feel more cushioned.  These give a diabetic no real benefit besides comfort.  Store-bought arch supports come in a wide variety and price, ranging from flimsy arch pads purchased at a pharmacy to expensive hard plastic inserts sold at arch support chains.  All of these are sized based on a shoe size and do not adjust for the shape and function of an individual’s own feet.  These supports are excellent for people who need limited arch support or extra cushioning and provide a better level of support than shoe pad inserts.  However, they still provide little benefit to diabetics as their support will not reduce foot pressure enough to protect against skin wounds and pressure points.


The next two types of inserts can be found at a podiatrist’s office.  Prescription orthotics will actually alter foot structure.  They are made from a hard plastic that conforms to the shape of the foot.  They are commonly used in many individuals with and without diabetes to support excessive foot flattening, reduce arch pain, and treat excessive foot tendonitis.  Orthotics manage the structural cause of foot wounds and are the preferred way of protecting the foot.  Diabetic inserts are used to reduce pressure and shearing damage to diabetic feet.  They are commonly used for diabetics with prominent bones, calluses, or a history of foot wounds.  Both of these inserts require a podiatrist’s evaluation and fitting.

Peripheral Neuropathy Treatments

Peripheral neuropathy is the term used to describe damage to nerves of the peripheral nervous system.  It often causes numbness and pain in hands and feet.  Symptoms of peripheral neuropathy include a gradual onset of numbness and tingling, burning pain, sharp electric like pain, or extreme sensitivity to touch.  A wide range of factors from trauma to diabetes and alcoholism can cause these symptoms.  The one thing that is common of the causes is that many times peripheral neuropathy can be avoided.  The risk factors associated with peripheral neuropathy are diabetes (especially if sugar levels are poorly controlled), alcohol abuse, vitamin deficiencies, exposure to toxins, and repeated physical stress.


The nervous system can be divided into two broad categories.  The central nervous system consists of the brain and spinal cord.  All other nerves in the body can be considered part of the peripheral nervous system.  These nerves include sensory nerves that receive feelings such as heat, pain, or touch, motor nerves that control the muscles, and autonomic nerves that control blood pressure, heart rate and digestion.  Peripheral neuropathy most commonly starts with the longest nerves (the ones that extend to the toes).  It is important to seek medical care right away if any unusual tingling, weakness, or pain is noticed in the hands or feet.  Early diagnosis and treatment offers the best chance for controlling your symptoms and prevent further damage to the nerves.


Before visiting your podiatrist for peripheral neuropathy or any other issue, it is important to get prepared.  An excellent idea is to write down questions to ask your doctor.  This allows you to ask the most important and pressing questions first.  It is also important to make a list of all medications, vitamins, and supplements.  This allows your doctor to evaluate quickly your current treatments.  The final list to make before visiting concerns any symptoms you are experiencing.  This should include problems that may seem unrelated to the reason why you are seeing the doctor

Is there a rock in my shoe?

A common cause of pain between the toes while walking is a neuroma.  Neuromas are caused by a small growth of nerve tissue and are otherwise known as a pinched nerve or nerve tumor.  The nerve most commonly affected nerve is found between the third and fourth toes.  A neuroma is a growth of nerve tissue causing a burning sensation, tingling and numbness, or swelling between the toes and in the ball of the foot.  Those suffering from the condition often find relief by stopping their walk, taking off their shoe, and rubbing the affected area.  Another common feeling during walking is that of a stone beneath the foot.


The exact cause of a neuroma is unclear but foot structure such as high-arched or flat foot can lead to the formation of a neuroma.  This is because nerves run close to the bones of the foot and at times can touch.  When the nerve rubs against the bone, it becomes irritated and inflamed.  This causes the nerve to become painful while continuing to rub and grow.  Trauma can also cause damage to the verve resulting in inflammation or swelling.


Treatment options vary with the severity of each neuroma.  Wearing shoes with plenty of room for the toes to move, low heels, and laces or buckles that allow for width adjustment are great for preventing and managing a neuroma.  Resting the foot and massaging the affected area can temporarily alleviate pain.  Icing the area can help dull the pain and improve comfort.  For undeveloped neuromas a pair of thick-soled shoes with a wide toe area is adequate treatment, and will allow the condition to diminish on its own.  For more severe conditions, surgery may be needed.  The wide range of neuroma treatment possibilities point to the importance to see a podiatrist at the first sign of pain or discomfort.  Untreated neuromas tend to get worse and it is important to prevent the nerve from enlarging.  The primary goal of podiatric treatment is to relieve pressure on the nerve.  This can be done through padding, medication, or orthotics.  Depending on the extent of damage, a podiatrist is trained to provide adequate therapy to prevent surgery.

New Ways to Fix Hammertoes

For the past few decades, surgeons have used the same method to hold the toe in place after hammertoe surgery.  Traditionally, they use a wire stabilize the toe for 4-6 weeks after surgery.  This wire, known as a k-wire, runs down the middle of the bones in the toe, through the skin, and out the end of the toe.  It is fast, technically sound, and inexpensive.  Unfortunately, using the wire adds to the patient’s worry of a pin sticking out of the end of their toe, small possibility of infection, and the anxiety and discomfort of removing the pin.


Modern technology has allowed for newer forms of screws and staples to replace the k-wire.  There are three different types of implants now available.  The first type is heat moldable metal implant known as Hammerlock and Smart Toe.  These implants are stored in cold temperature.  Once they are inserted into the warm bone, the medal expands to grip and lock the bone.  This prevents the implant and bone from moving.  The next type of implant is known as a peg-and-hole style.  These implants have two parts, with one being inserted into both sides of the bones needing to be fused together.  Then, the two pieces are snapped together to create one stable implant.  StayFuse and Pro-Toe are peg-and-hole implants.  The last type of implant is the Arrow-LOK implant.  This implant has a 3- dimensional arrow tip at both ends of a metal wire that allow it to grip and unite two bones.


These new methods have created options for surgeons and patients to choose from when decided on surgery.  K-wires are still the gold standard, but newer implants offer patients the option of internal stabilization.  It is important for patients to know their options and speak with their surgeon before any operation.  Drs Hirt, Holdren, and Castelein are trained in multiple methods to fix hammertoes and develop tailored plans for each patient.

Fast Facts on Diabetic Neuropathy

Diabetes can damage your nerves over time and lead to their deterioration and eventual death.  Burning and tingling sensations are warning signs that your nerves are having a difficult time carrying messages from your brain to parts of the body.  These sensations will eventually stop, but this occurs once the nerves stop functioning.  The nerve damage is called diabetic neuropathy.  Luckily, this process can be delay or even prevented by taking control of your diabetes.  Here are some important facts.


  1. 1. Nerve damage is common among diabetics.

About half of the people with diabetes develop some type of neuropathy.  This is because over time, high blood glucose levels will injure small blood vessels and nerves.  The excess glucose damages the walls of small blood vessels preventing them from supplying nourishment to nerves.


  1. 2. Certain things increase your risk for nerve damage.

Diabetes and high blood glucose levels increase your risk of developing neuropathy.  Smoking, high blood cholesterol and high blood pressure also increase your risk.  Alcohol use and being overweight are other risks to develop neuropathy.


  1. 3. Symptoms may be unnoticed.

Symptoms of neuropathy include pain, burning or tingling sensations, and loss of feeling.  These symptoms typically start in the tips of fingers or toes, as this is where the smallest nerves and blood vessels are found.


  1. 4. Neuropathy is diagnosed with an exam.

Along with your symptoms, a physical exam is used to diagnose neuropathy.  Your podiatrist may test your feet to see how well you sense touch, vibration, and temperature.  Nerve conduction studies can provide useful information as to the ability of your nerves to transmit signals.


  1. 5. Glucose control is the best prevention and treatment.

The most important method to improve blood glucose is to prevent further nerve damage.  Good glucose control protects your nerves.  In addition to daily blood glucose checks, follow a healthy eating and exercise plan.  Talk with your doctor if you are having trouble managing your blood glucose, as many medications exist to assist.


  1. 6. Daily foot care is essential.

Neuropathy often starts in the feet.  If you have lost feeling in your feet, you can develop an unknown injury.  Untreated problems can quickly lead to infection and amputation.  Check your feet every day for sore, hot, cold, numb, or dry spots.  Look for bumps, cuts, sores, and swelling as well.  If you notice any irregularities, make sure to tell your podiatrist.  A yearly thorough foot exam by a podiatrist is recommended to monitor your diabetes.  Tell your doctor right away, if you have symptoms of neuropathy as early treatment may prevent further damage.

Bunion Surgery Myths

A bunion, otherwise known as hallux abducto valgus involves misalignment of the bones at the big toe joint and sometimes the joint within the big toe.  This abnormal anatomy causes the boney prominence on the inside of the big toe.  Conservative treatments vary, but surgery is the best treatment and extremely common.  Some people avoid the surgery because they have heard stories and misconceptions.  The surgery does typically require realignment of the bones through bone cuts and screws.  The podiatrists at Coastal Podiatry Associates are well trained, having executed hundreds of bunion surgeries.  The following statements are myths, especially when using Coastal Podiatry.


Myth 1: Bunion Surgery is Extremely Painful

Bunion surgery is not different from other surgeries.  In general, foot surgery can lead to increased pain due to swelling as the foot is below the level of the heart and blood can easily rush to the area.  In addition, the foot has less soft tissue surrounding the bones, so moderate swelling can aggravate the nerves leading to pain.  Swelling can be reduced through elevation and icing the affected foot.


Myth 2: Bunion Surgery Means a Cast and Crutches

Modern surgical techniques allow patients to mobilize quicker.  Most bunion surgeries involve walking in a surgical shoe for six weeks.  There are extremes; mild surgeries can lead to an early return to shoes while more complex surgeries may require casting and crutches.


Myth 3: You Have to be Off Work

As a general statement, this is not true.  The amount of time away from work depends on the demands of the job and type of surgery.  A patient can return to a sedentary desk job within two weeks of the surgery.  However, jobs requiring excessive walking, standing, and physical activity may require a medical leave of absence.


Myth 4:  Healing after Bunion Surgery Results in Unsightly Scars

Surgical healing is part of the process with any surgery.  Newer techniques allow for smaller incisions and alternative surgical approaches may be used to hide surgical scars.  Bunion incisions are either on the top of the foot or along the side, based on the surgeon’s technique.  A surgeon may use a plastic surgery-type closure to minimize scaring.


Myth 5:  Bunions Come Back After Surgery

Recurrence can happen after any surgery.  The return of a bunion is no different, and it may be something that can happen over time.  Patients that have excessive motion in the foot or do not reduce their risk for developing a bunion may experience a recurrence.

Ankle Sprain 101

Ankle injuries can occur to anybody and may be tricky to treat.  Many times a sprain will initially get better but fail to completely heal or even start to become painful again.  People with conditions outside of the ankle that have not been diagnosed or treated properly are at an increased risk for recurrent ankle injuries.  Many of these conditions are difficult to assess on initial exam and often fail to be diagnosed immediately following injury.  Persistent inability to bear weight or bear weight without pain, persistent swelling, clicking or popping, feeling of instability, or pain that doesn’t decrease are all reasons to see a podiatrist for a physical exam and treatment.  Ankle sprains can commonly be classified into several different types.  These types include bone, cartilage, and soft tissue injuries and are all treated differently.


Bone injuries include fractures, stress fractures, and contusions.  Several common fracture patterns occur with ankle sprains.  If pain or swelling persist at a particular area of the foot or ankle, it is essential to see a physician.  They may take x-rays or order an MRI to further evaluate the area and start treatment.


Cartilage injuries such as scuffs to the joint surface within the ankle may result in increased swelling or pain after activity.  Commonly the pain and swelling improves with rest but then returns once normal activity is resumed.


Soft tissue injuries come in many forms.  If a frayed ligament associated with the sprain heals in the joint, a catching sensation can cause pain or instability.  Premature return to activity may allow poor healing of ligaments and cause weakness or instability.  Muscles and tendons that stabilize the ankle may be damaged in a sprain.  This results in pain, weakness, and/or unsteadiness. Nerve damage can occur in a sprain leading to weakness, numbness, or pain to the ankle or foot.


Seeking a podiatrist treatment plan is important to improving the long-term outcome of a sprain.  Communication with the physician about the pain and how treatment is progressing is essential, especially if symptoms are not becoming better.  Treatment plans depend on the extent of the sprain and tissues involved and may consist of immobilization, casting, physical therapy, or surgery.

Rheumatoid Arthritis In the Foot and Ankle

Rheumatoid arthritis (RA) is a systemic disease that attacks multiple joints throughout the body with the first symptoms typically appearing in the toes and feet.  These initial symptoms include pain, swelling, and stiffness in the joints, sole, or ball of the foot.  The joints may also feel warm and the pain may be so severe that a person’s walking pattern changes.  The new demands placed on the foot can lead to corns, bunion, claw toes, or hammertoes.  Since RA affects the entire body, people frequently have feelings of fever, fatigue, and loss of appetite.  Women are affected three times more often than men are especially under 40 years of age.


The frequent appearance of symptoms to initiate in the foot may mean a podiatrist is the doctor diagnosing RA.  To determine a patient has RA, our doctors will ask about the patient’s medical history, occupation, recreational activities, and family history.  They commonly conduct x-ray studies to determine the amount of damage to the bones and joints.  Blood tests are used to determine if the patient is anemic or has an antibody called rheumatoid factor.  While antibodies are normally produced by and protect the body, in RA a few antibodies turn against the body by attacking the lining of joints.  The attacks lead to joint inflammation causing pain and swelling.  Eventually the lining in the joint breaks down and damage to the bones can occur.  The damage may be so severe that joint deformities form.


Many people with RA can control the pain and disease with medication and exercise.   Medications such as aspirin or ibuprofen are used to control the pain and there are many prescription drugs able to help slow the spread of the disease.  There are also steroid injections available to relieve the joint swelling and inflammation.  In addition to drugs, a podiatrist may prescribe special shoes to help the foot function properly.  Unfortunately, RA is a progressive disease that currently lacks a cure.  Through medication, exercises, and surgery the effects of RA can be reduced and its progress slowed.

A Painful Big Toe

The most common site of arthritis in the foot is at the base of the big toe.  This joint is called the first metatarsophalangeal joint or 1st MTPJ.  This joint is especially important because it must bend every time a step is taken.  As the joint ages, walking can become painful or difficult.  The 1st MTPJ is made up of two bone ends, each protected and covered by smooth cartilage.  Wear and tear from injury or normal use can cause damage to this cartilage.  As the protective cartilage wears away, the bones start rubbing together.  This may lead to a bone spur (bone overgrowth).  Spurs will reduce the joints normal function and range of movement.  The result is a stiff big toe known as hallux rigidus.


Hallux rigidus normally develops in adults between the ages of 30 and 60 years.  Typical symptoms include pain in the joint with activity, swelling around the joint, a bump on the top of the toe, or stiffness in the big toe and inability to bend it up or down.  It is not know why this appears in some people and not in others.  It may be due to injury or a foot structure that increases stress on the joint.  Hallux rigidus is easier to treat when diagnosed early.  If you have difficulty bending your toe up and down, or notice you are walking on the inside of your foot see your podiatrist right away.  Waiting until a bony bump on the top of the toe develops or the toe cannot bend can cause greater treatment difficulties.


After a foot examination and maybe x-rays, the doctors at Fenton Foot Care and Brighton Family Foot Care can determine the correct treatment.  Pain relievers and anti-inflammatory medications are commonly used to ease the pain.  Using ice packs and topical medications also help reduce inflammation and control the pain.  If hallux rigidus is caught early, wearing shoes with a large toe box, rocker bottom design, or orthotics may be all that is needed.  Many times surgery is necessary to correct this condition.  There are three main types of surgery used.   Spur removal, joint replacement, or joint fusion.   Drs Hirt, Holdren, and Castelein are able to determine which surgery is best biased on joint function and patient demands.  Stop in today!