FOOT & ANKLE

Arthritis of of the Big Toe (Hallux Rigidus)

What is Hallux Rigidus?

Hallux rigidus is arthritis of the main joint of the big toe in the ball of the foot. It is a wearing out of the joint surfaces. It is called “hallux rigidus” because its main feature is stiffness (“rigidus”) of the big toe (“hallux”).

Sometimes only the upper part of the joint is affected and the rest of the joint is undamaged. In other people the whole joint is worn out.

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What causes it?

In most people there is no definite cause – it just develops. Probably the main reason why this joint is particularly subject to wearing out is that it is under tremendous stress in walking. With each step, a force equal to twice your body weight passes through this very small joint.

In a few people it may be caused by an injury or another medical problem such as gout or an infection in the joint.

What problems can this cause?

The commonest problem is pain in the big toe joint. In some people the pain is present whenever they walk or even at rest, but in others it only occurs when they turn the big toe up as far as it will go.

Stiffness is also a common problem. The ability to turn the big toe upwards is lost, although it can usually be turned downwards. Sometimes it gets so stiff it points downwards and cannot be laid flat on the floor.

A bony bump (“osteophyte” or “dorsal bunion”) may develop on top of the joint. This is your body’s natural response to the worn joint. The bump may rub on the shoes. In some people this is their only problem.

Because of the painful big toe some people tend to walk on the side of the foot. This may produce pain in the ball of the foot or down its outside border. Sometimes the joint wears down more on the outer side, towards the lesser toes, than on the inner side. This may make the toe tilt towards the second toe, and the toes may rub together.

Why have I got this condition in my twenties?

It is well known that hallux rigidus may begin early in life, even in the teens. The reason is unknown.

Fortunately, in many cases, your toe will not get progressively worse, and (apart from your other toe) you are not much more likely to get arthritis in other joints, such as your hips and knees, than anyone else.

Is there anything I can do to stop it getting worse?

  • Keep yourself generally fit and active
  • Wear shoes that comfortably fit your feet.
  • Don’t get overweight. 
  • All the usual advice for good health in fact! There is nothing else that reliably helps.

What can I do about this?

You can take simple pain-killers for the pain if it is bad and interfering with your life. Try paracetamol first as side-effects are rare at the correct dosage. If this does not work your doctor may prescribe stronger pain-killers or anti-inflammatory medicines if these are considered to be safe for you.

Because the joint is usually most painful when the toe is bent upwards during walking, it sometimes helps to stiffen the sole of your shoe so that it does not bend while walking. If you do this, you may need a small “rocker bar” on the sole of your shoe so that you can rock over this while walking instead of bending your toe up. This can be organised for you by an orthotist or chiropodist. One disadvantage of this treatment is that the stiff insole may push your osteophyte up against the shoe.

If the toe remains very painful, sometimes injecting some steroid mixed with local anaesthetic into the joint can help. This reduces the inflammation inside the joint. The injection can usually be given in the outpatient clinic, although sometimes you may have to come into hospital as a day patient. The toe may be painful for a few days after the injection and any improvement has usually occurred by a week. The effect can last from a few days or weeks to several months. Occasionally the improvement can be permanent.

What does the operation involve?

If none of the above treatments help, an operation may be useful. You would need to discuss this with an orthopaedic foot and ankle surgeon by referral from your GP. Here are some main operative options for hallux rigidus:

1. CHEILECTOMY

If only the upper part of the joint is involved, the upper part of the joint can be trimmed out and the joint washed out (cheilectomy). Most people who have a cheilectomy get less pain and a useful improvement. In about 75% this improvement is permanent. The others develop worsening of the arthritis over the following years and some will eventually need another operation.

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2. PROXIMAL PHALANX OSTEOTOMY

Either as a separate operation or at the same time as a cheilectomy, the bone in the base of your great toe (proximal phalanx) may be reshaped to make the most of the movement you have left (proximal phalanx osteotomy)

If the whole joint is involved, there are two main options, depending on the age and activity of the patient:

3. FUSION of the big toe joint

In young fit people, especially those doing heavy jobs, a fusion of the joint would be recommended. This removes the painful joint and stiffens it completely. 95% of people will get rid of their pain. However, the toe is stiffer than before and the choice of shoes is more limited. A few people will go on to get arthritis of the small joint in the middle of the toe after a fusion, but this is not usually troublesome.

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4. REPLACEMENT of the big toe joint

In certain circumstances, it may be appropriate to consider a replacement joint. There are a number of joint replacements available, although they are only appropriate in certain patients. As with all joint replacements, there are risks with the procedure. In particular there is a risk that the new joint may loosen or wear out, in which case a more complex procedure may be necessary. Your surgeon will of course, discuss this with you.

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Complications of surgery

As with any operation, there are always potential complications associated with this sort of surgery. The risk of complications is very low but can include:

  • Infection
  • Damage to nerves or blood vessels or tendons
  • Risk of blood clots in the leg or lungs
  • Bone does not heal at all (non-union) or takes longer to heal than expected (delayed union)
  • Persistent pain in the great toe or other lesser toes
  • Risk of an anaesthetic

What usually happens after the operation?

This operation is usually done as a Day Case operation and you will normally be able to go home the same day. You will have a bulky dressing around your foot after the operation, which looks like this.

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You will be fitted with special shoes (Darco™ shoe) that will allow you to walk on the heel of the foot which has had the operation, with crutches for support.

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You will be sent home with painkillers to help with any pain you may have. You will be seen 2 weeks after your operation in clinic to look at the operation site and to make sure that there are no problems or concerns. At 6 weeks, you will be seen again in clinic and have an X-Ray done to check that the position of the bone and healing of the bone has taken place.

How long will it take for me to fully recover?

Most patients after their operation take between 6 weeks to 6 months to recover fully. Driving can usually start after 6-8 weeks. If all has gone well, you will usually be discharged from clinic somewhere between 3 and 6 months or so.

Ankle Arthritis

What is ankle arthritis?

Most ankle arthritis is as a result of what is known as “wear and tear” (or osteoarthritis). Other forms of ankle arthritis exist which can affect the ankle such as inflammatory arthritis (e.g rheumatoid arthritis).

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When you look at Xrays of the ankle with arthritis, the joint space is narrowed, there are outgrowths of bone (osteophytes) around the joint and the bone beneath the joint surfaces is thickened and dense. These are common features of all arthritic joints and are not specific to ankle arthritis.

The inside of a normal ankle joint is lined completely by smooth cartilage which looks very like the covering of the joint one sees with a chicken drum stick for example. The arthritic ankle loses this smooth cartilage lining which normally allows the joint to glide smoothly and in a pain free manner.

What causes ankle arthritis?

Ankle arthritis is commonly the result of either a direct injury into the joint such as an ankle fracture or the result of longstanding ankle ligament damage. Occasionally it may occur secondary to chronic and recurrent inflammation such as with rheumatoid arthritis, or gout.

Clinical features

It is possible that in the early stages or even in the “late” stages of ankle arthritis that one may experience only minor pain, swelling or stiffness

Most commonly pain is the presenting symptom and in ankle arthritis this is usually localised to the ankle joint and felt deep within the joint. The intensity and duration of pain from an arthritic ankle varies significantly from person to person and at different times. Generally, early symptoms in ankle arthritis are pain and perhaps swelling, after prolonged weight bearing or high impact type activities. If the ankle arthritis progresses then pain can become a more frequent occurrence and provoked by progressively less and less activity. Eventually pain can become present most of the time, even when non-weight bearing or at night in bed.

Treatment

Non-operative options

Conservative (non-operative) management can be useful in the early stages of ankle arthritis. Physiotherapy can help by strengthening some of the muscles around the joint but generally ankle arthritis is a difficult condition to treat successfully with physiotherapy. The problem with treating the arthritic ankle with physiotherapy is that the joint is often stiff and painful and the muscles around the joint relatively wasted.  All of these factors make improving the situation with physiotherapy alone difficult.  Injections of steroid and local anaesthetic into the joint can help for shorter periods of time but tend to need to be repeated.

Orthotic (splints or ankle support) management can be very useful for ankle arthritis. This involves both using a rigid plastic splint which runs from behind the calf down on to the foot (an AFO or ankle foot orthosis) combined with the use of a shoe or boot with a stiffened sole with a gentle curve from heel to toe, a rocker sole.

Operations

Ankle arthroscopy (keyhole surgery) and debridement

A debridement for ankle arthritis is useful in the earlier stages of the arthritic process. It is normally performed as a day case procedure and generally patients can weight bear straight away on the operated ankle. The success rate for the procedure is in the region of 75%-80%. This corresponds to the percentage chance of improvement but not complete symptom resolution. On occasion it can take a number of months before this benefit is achieved. It needs to be borne in mind that there is approximately a 5% chance of significant symptomatic worsening following debriding an arthritic ankle.

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Before proceeding with ankle arthroscopy for arthritis, it is important to realistically way up the pros and cons with your surgeon.  There is a chance that you would need more extensive surgery shortly after this initial procedure if you fall into the 5% group of patients with symptoms getting significantly worse.

Ankle fusion

Ankle fusion involves preparing both sides of the joint back to healthy and bleeding bone. This can be done through arthroscopic (“keyhole”) surgery or it can be performed openly, which means making a bigger incision to prepare the ankle joint for fusion. The arthritic joint lining is removed and the ankle joint is placed in a good position and held there until the bone has grown across the joint and the ankle is thus fused. The ankle is held in position whilst the fusion is occurring and this is most commonly done with large screws which are buried beneath the skin. Occasionally a large metal rod may need to be inserted through the heel to compress the ankle and subtalar joints (known as a double fusion). On average it takes at least three months for bone and ankle joint to fuse but sometimes, it can take significantly longer.

Diabetes, smoking and poor blood supply in the legs (peripheral vascular disease) can significantly reduce the chances of the joint fusing.

Ankle fusion for ankle osteoarthritis is a good option for younger and more active patients.  A return to heavy manual occupations and some sports is possible and is largely determined by the mobility of the compensatory joints which are left intact.

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Ankle replacement

Ankle replacement involves replacing the two worn out surfaces with replacement highly polished surfaces and adding a high molecular weight polyethylene (“plastic”) spacer between the two surfaces. Ankle replacement generally maintains the range of movement which a patient has pre-operatively. It is not suitable for heavy manual or sporting activities and probably has a ten-year survivorship in the region of 80 – 85%.

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Lesser Toe Deformities (Problems with small toes)

What are the small toes for?

The small toes are important in walking, especially when pushing off with the foot towards the next step. They share the pressure with the big toe and the ball of the foot.

Why do they become deformed?

Toes become deformed when the pressures on the toe are stronger than their joints can resist. This may because the joints are weak or the pressures strong, or both.

The joints may be weak because they have been damaged by injury or arthritis. The muscles that control them may become unbalanced, so that one set pulls harder than others and causes the toe to bend. In some people the tissues in the lower part of the joint at the base of the toe become weak, allowing the base of the toe to drift upwards and unbalancing it.

The main pressures that cause toes to become deformed, come from shoes which press on the tip of the toe, either because the shoe is tight or because it has a high heel, which tends to force the toes into the tip of the shoe.

Sometimes, these toe deformities occur because of a bunion (hallux valgus) that pushes against the 2nd toe and starts to cause the other toes to become deformed.

Examples of lesser toe problems

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What problems do deformed toes cause?

The main problem with deformed toes is that they tend to rub on shoes, either on the top, at the tip, or both. This rubbing may simply be uncomfortable, or the skin may be rubbed raw.

Sometimes the toe may press down and cause pain in the ball of the foot (“metatarsalgia”).

Bent toes may rub on one another or on the big toe, especially if the big toe is bent towards the second toe (hallux valgus or bunion).

My toes are curled and rub on my shoe. Is there anything simple I can do?

The most important thing is to buy shoes that have enough room in the toe area for your toes to fit comfortably. Avoid high heels, which tend to force the toes down into the tip of the shoe. Small pads on the top or end of the toe may improve the discomfort.

Can chiropody help with deformed toes?

A chiropodist can give advice about shoes and insoles, and can treat the hard or raw skin that develops over some deformed toes. Chiropodists in Britain and most parts of Europe do not operate to straighten toes.

Do I need an operation?

If your toes are interfering with your daily activities and the problem is not helped by the simple measures outlined above, it may be best to have an operation to straighten the toes.

Your GP can refer you to an orthopaedic foot and ankle surgeon who will listen to your problems, examine you and advise you on the best method for straightening your toes.

There are a number of different operations that can be done, depending on the shape of your toes and how stiff they are:

  • the joints may be freed up to allow them to come straight
  • one of the tendons which curl your toes may be brought up to the top of the toe to help keep it straight
  • a small piece of bone may be removed from the toe joint, or more than one, to allow it to come straight
  • occasionally, the tip of a toe may be removed to shorten the toe and stop it rubbing
  • rarely, some patients (usually the very elderly or frail) prefer to have the toe removed (amputation) rather than have the toe continue to cause them problems.

Any of these operations may be held straight with a metal pin inserted into the toe, which is later removed.

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Are the results of surgery good?

Yes. Over 80-90% of toe operations correct the problem for which they were done.

Most people are satisfied with their toe surgery and “terrible” results are rare. Toe surgery is not easy, however, and it is important to have it done by someone with proper training and experience.

Complications of surgery

As with any operation, there are always potential complications associated with this sort of surgery. The risk of complications is very low but can include:

  • Recurrence of the toe deformity
  • Infection
  • Damage to nerves or blood vessels or tendons
  • Risk of blood clots in the leg or lungs
  • Bone does not heal at all (non-union) or takes longer to heal than expected (delayed union)
  • Persistent pain or swelling in the toes
  • Risk of an anaesthetic

How long will it take for me to fully recover?

Most patients after their operation take between 6 weeks to 6 months to recover fully. Driving can usually start after 6-8 weeks. If all has gone well, you will usually be discharged from clinic somewhere between 3 and 6 months or so.

Achilles Tendon

What is the Achilles Tendon?

The Achilles tendon (or heel cord) is the thick strap that can be felt running down the back of the calf into the heel. The tendon is made up of many bundles or fibres of a strong material called collagen, which is the body’s main tissue building block. It is attached to, and worked by, the large muscles that make up the calf (gastrocnemius and soleus). When the Achilles tendon pulls on the heel it makes us go up on tiptoe, or pushes us forwards when walking or running. If this tendon is not working it is difficult to walk and the ankle feels weak.

How does it get injured?

Most Achilles tendon problems occur in middle-aged athletes and are basically overuse injuries. In a few cases, other medical conditions contribute to the weakening of the tendon. A high-arched or low-arched foot may increase the stresses on the Achilles tendon.

As we get older the tendon becomes less flexible and less able to absorb the repeated stresses of running. Eventually small “degenerative” tears develop in the fibres of the tendon. The body tries to repair these tears. Sometimes the repair process is successful. However, the blood supply of the lower part of the tendon is not very strong and the combination of this and the continued stresses of running mean that the tendon may not completely heal. Instead, the tendon and its lining become painful and swollen, and the tendon may feel weak. The combination of degenerative and repair processes in the tendon is called tendonosis (or sometimes tendonitis). Because the lining of the tendon is called its tenosynovium, inflammation of the lining is called tenosynovitis.

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Sometimes the tendon becomes weakened by the degenerative process to the extent that it tears completely.

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The foot on the left side is the injured foot with the ruptured Achilles tendon. The foot on the right side shows a normal Achilles tendon.

How would I know if I had an Achilles tendon problem?

If you had a complete tear, you would probably feel a sudden pain in your heel or calf. Some people say this feels as though they had been kicked in the calf, or hit them with a squash raquet. Usually the heel becomes painful, swollen and bruised, and it becomes difficult to walk.

Tendonosis and tenosynovitis develop more gradually. The Achilles tendon and the heel become painful and a swelling may develop in or around the tendon. At first the problem is present mainly on running or playing sport, but later it may become increasingly difficult to walk because of the painful tendon.

Can I treat it myself?

Achilles tendonosis or tenosynovitis can be treated like any other athletic injury or overuse problem in the first instance. You may need to reduce your mileage or the frequency of your sports for a while. When you do run or play, warm up longer and do plenty of Achilles stretches. A change to a softer running surface and well padded running shoes may help. A 1/4″ raise on your shoe will reduce the stresses on the tendon (remember to raise the other side too, to keep yourself balanced). When the pain and swelling is bad, it will usually be helped by applying an ice pack (a small bag of frozen peas or corn is ideal). For the pain, try simple pain-killers such as paracetamol. Anti-inflammatory medicines may reduce the inflammaton in the tendon, but check with your doctor or pharmacist before taking these as they can have side-effects in some people.

Obviously, there is no self-help solution to a complete tear of the Achilles tendon!

When should I get professional advice?

If you think the tendon has torn completely, you should go to your local casualty department, as you may need to have it repaired.

If a painful tendon does not improve with the treatment recommended above, you should consider consulting your GP or physiotherapist.

How will my doctor or physiotherapist know what’s wrong?

Your doctor will listen to your complaints about your Achilles tendon and will examine you, paying particular attention to the tendon itself and looking for anything else that may be contributing to the problem.

Usually treatment can be started without further tests. However, if your doctor thinks the tendon problem is due to some other problem, other tests may be done, such as blood tests for arthritis or diabetes. If there is a possibility that the tendon is torn, a scan of the tendon may be arranged. Often an ultrasound scan will give enough information, but a magnetic (MR) scan is more useful in some cases. An X-ray of your heel is sometimes useful.

What can be done about it?

The first thing is to check that you have tried all the simple measures outlined above. If so, a physiotherapy programme aimed at reducing the inflammation in and around the tendon would be tried. Once the inflammation is improving, the physiotherapist will start exercises to strengthen and stretch the Achilles tendon.

If you have a foot shape that increases the stresses on your Achilles tendon, a moulded insole in your shoe may help.

Most people will improve with physiotherapy. A few continue to have trouble and in this case an operation may be considered.

Will I need an operation?

As explained above, most people will improve with simple measures or physiotherapy. A small number continue to have major problems which interfere with their lifestyle. In this situation an operation may be considered.


If an operation is being considered your GP will arrange for you to see an orthopaedic foot and ankle surgeon. The surgeon will interview you and examine you again and may want you to have further treatment before making a decision about an operation.

 The surgeon would probably want you to have a scan before any surgery, to show whether there is a problem in the tendon which can be corrected by surgery.

If there is tenosynovitis but the tendon itself is reasonably healthy, stripping out the inflamed tendon lining often gives good results. If the problem is tendonosis, surgery would involve removing the degenerate tendon and repairing the remaining tendon. If the degenerate area is localised this can give quite good results. However, often the degeneration involves quite a lot of the tendon and removing it all may leave quite a large gap in the tendon which may need a major operation to repair. A big repair usually needs tendon borrowed from somewhere else, either higher up the Achilles tendon or from another tendon. As you will appreciate, such a large operation may cause a lot of scarring and stiffness and the repaired Achilles tendon may not be very strong. Other possible problems with major Achilles tendon surgery include problems with the surgical wound (the blood supply to the heel area is not very strong and the wound may be very slow to heal). There is also the risk of stretching or damaging the nerve at the back of the ankle (the sural nerve) causing numbness and tingling along the side of the foot. For these reasons surgery for Achilles tendonosis is only advised when the tendon problem is disabling and extensive non-surgical treatment has been tried.


The best treatment for a ruptured Achilles tendon is not known for certain. Most ruptures will heal if protected in a plaster for 6-8 weeks. After plaster treatment there is a higher risk of another rupture (about 15% as against 5% after surgical repair) and the tendon is often weaker than after surgical repair. Nevertheless many people get a good result after plaster treatment and, obviously, avoid the risks of surgery. This may be the best treatment for less physically active people. The greater strength and quicker recovery after tendon repair may be more useful to those who expect to play a lot of sport again. Your surgeon will discuss the options with you to help you decide what is best for you.

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Will I have to give up running?

Usually not. You may need to reduce your distance for a while to allow your tendon to heal. Some people who have surgery will not get enough tendon strength or flexibility to allow them to return to running or sport.

Bunion Surgery (Hallux Valgus)

What is Bunion Surgery(Hallux valgus)?

Hallux valgus or “a bunion,” is a deformity of the big toe. The toe leans over towards the smaller toes and a bony lump appears on the inside of the foot. (A bony lump on the top of the big toe joint is usually due to a different condition, called hallux rigidus or “arthritis of the big toe”.) Sometimes a soft fluid swelling develops over the bony lump. The bony lump is the end of the “knuckle-bone” of the big toe (the first metatarsal bone) that becomes exposed as the toe tilts out of place.

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What causes a bunion?

Bunions can run in families, but that does not mean that if you have a bunion, your children will inevitably have one too. The connection may be that bunions are a bit commoner in people with unusually flexible joints, and this can be hereditary. They are also commoner in women than in men. Bunions do occur in cultures in which shoes are not worn, but much less commonly. Shoes that squeeze the big toe or do not fit properly, or have an excessively high heel, may worsen the deformity, particularly in people who are at higher risk anyway.

Clinical features of a bunion

Lots of people have bunions that do not cause them any pain or symptoms at all. Many people with bunions are quite comfortable if they wear wide, well-fitting shoes and give them time to adapt to the shape of their feet. A small pad over the bony prominence, (bought from a chemist or chiropodist), can take the pressure of the shoe off the bunion. High heels tend to squeeze the foot into the front of the shoe and should be avoided. It is often worthwhile seeing a chiropodist if these simple measures are not quite enough.

If bunions are causing some problems, the main issue is usually the pressure of the shoe over the bony prominence, which causes discomfort or pain. Sometimes the skin over the lump becomes red, blistered or infected. The foot may become so broad that it is difficult to get wide enough shoes.

The big toe sometimes tilts over so much that it rubs on the second toe, or pushes it up out of place so it presses on the shoe. Also, the big toe does not work as well with a bunion, and the other toes have to take more of the weight of the body as you walk. This can cause pain under the ball of the foot (“metatarsalgia”).

Sometimes arthritis develops in the deformed joint, causing pain in the joint.

What can I do about my bunion?

If the above simple measures do not make you comfortable, an operation may improve the situation. An operation will not give you an entirely normal foot, but it can correct the deformity of the big toe and narrow your foot back towards a more desirable shape.

There are a lot of different operations for bunions, depending on the severity of the deformity, the shape of your foot and whether arthritis has developed in the big toe joint. An orthopaedic surgeon who specialises in foot & ankle surgery can advise you on the best operation for your foot.

However, an operation may not make your foot narrow enough to wear tight shoes, nor can it fully restore the strength of the big toe.

The main reason for having an operation for your bunion is to help with pain relief and prevent further deformity of the lesser toes. It may also help with shoe wear. This operation is not performed for cosmetic reasons alone.

What does the operation involve?

Firstly, an X-Ray of your bunion will be taken in clinic so that the surgeon can assess the severity of the bunion. The most common type of operation for bunions involves cutting the bone (osteotomy) and shifting the bone across to correct the bunion deformity. The 2 pieces of bone are then held in the correct place by metal screws and/or a metal staple. The bone cuts usually take 6-8 weeks to heal up and unite together. 

The type of anaesthetic you will have can vary. There is the option of a general anaesthetic (GA), in which you will be put to sleep or a regional/local anaesthetic, where you will be awake but can have sedation to make you drowsy. 

The final decision on the type of anaesthetic will be up to the anaesthetist, who will be responsible for your care during the operation. Please discuss any concerns you may have about the type of anaesthetic you would like with the anaesthetist when they see you before your operation.

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Complications of surgery

As with any operation, there are always potential complications associated with bunion surgery. The risk of complications is very low but can include:

  • Recurrence of the bunion
  • Infection
  • Damage to nerves or blood vessels or tendons
  • Persistent pain in the great toe or other lesser toes
  • Bone does not heal at all (non-union) or takes longer to heal than expected (delayed union)
  • Risk of an anaesthetic
  • Stiffness in the great toe
  • Risk of blood clots in the leg or lungs

What usually happens after the operation?

This operation is usually done as a Day Case operation and you will normally be able to go home the same day. You will have a bulky dressing around your foot after the operation which looks like this.

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You will be fitted with special shoes (Darco™ shoe) that will allow you to walk on the heel of the foot which has had the bunion operation, with crutches for support.

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You will be sent home with pain-killers to help with any pain you may have. You will be seen 2 weeks after your operation in clinic to look at the operation site and to make sure that there are no problems or concerns. At 6 weeks, you will be seen again in clinic and have an X-Ray done to check that the position of the bone and healing of the bone has taken place.

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How long will it take for me to fully recover?

Most patients after their bunion operation take between 6 weeks to 3 months to recover fully. Driving can usually start after 6-8 weeks. If all has gone well, you will usually be discharged from clinic between 6 weeks and 3 months or so

Morton's Neuroma

What is Morton’s Neuroma?

If you sometimes feel that you are “walking on a marble,” and you have persistent pain in the ball of your foot, you may have a condition called Morton’s neuroma. A neuroma is a benign (non-cancerous) tumour (“growth”) of a nerve. Morton’s neuroma is not actually a tumour, but a thickening of the tissue that surrounds the digital nerve leading to the toes.

Morton’s neuroma occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. Morton’s neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma or excessive pressure. Morton’s neuroma occurs in women much more commonly than in men (8 to 10 times more).

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What are the clinical features?

  • Normally, there are no outward signs, such as a lump.
  • Burning pain in the ball of the foot that may radiate into the toes. The pain generally intensifies with activity or wearing shoes. Night pain is rare.
  • There may also be numbness in the toes, or an unpleasant feeling in the toes.

Runners may feel pain as they push off from the starting block. High-heeled shoes, which put the foot in a similar position to the push-off, can also aggravate the condition. Tight, narrow shoes also aggravate this condition by compressing the toe bones and pinching the nerve.

Diagnosis

During the examination, your surgeon will feel for a palpable “lump” or a “click” between the bones. He or she will put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot. Usually, an ultrasound scan or Magnetic Resonance Imaging (MRI) scan will confirm the diagnosis.

Treatment options

Initial therapies are nonsurgical and relatively simple. They can involve one or more of the following treatments:

  • Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.
  • Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.
  • Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.

Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton’s Neuroma.

Operation

If conservative treatment does not relieve your symptoms, your orthopaedic surgeon may discuss surgical treatment options with you. Surgery can resect a small portion of the nerve or release the tissue around the nerve, and generally involves a short recovery period.

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Morton’s neuroma surgery can be done as a day surgery procedure unless you have other medical problems that mean you may need to stay in hospital overnight. The surgery is performed under general anaesthetic (whilst you are asleep). A cut is made over the top of the foot, at the base of the affected toes. The operation involves removing the part of the nerve that is causing the pain and discomfort. The foot and ankle are then bandaged.

What are the potential complications of surgery?

  • Swelling
  • Recurrence of the neuroma
  • Numbness
  • Persistent or recurrent pain
  • Damage to blood vessels or tendons around the foot
  • Infection

What happens after my operation?

2 weeks

You will be seen by the specialist nurses in the outpatient clinic for removal of the dressings and a wound check. Any stitches present still will be removed. You should usually be able to start driving at this stage although the final responsibility rests with the patient. The Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. You should contact your doctor or the DVLA if you are concerned about this.

6 weeks

You will be seen by the surgeon in outpatient clinic to assess your recovery and to ensure that you have not developed any problems and that you are making a good recovery.

Ingrowing Toenails

What is an ingrowing toenail?

When the edge of the toenail digs into the skin fold beside the nail, the skin becomes red, hot, tender and swollen. This is an ingrowing toenail. Sometimes bacteria from the skin get into the inflamed skin and an infection begins. This results in much more inflammation, which may spread throughout the toe, or into the foot. Pus may also discharge from the edge of the nail.

The nail edge may dig in because it is excessively curved, because it becomes ragged and sharp or because of an injury. Often it seems to happen for no particular reason. It has been suggested that people with ingrowing toenails have abnormally shaped nail beds, but this has not been proven.

Can an ingrowing toenail be prevented?

Not absolutely! If you look after your toenails well and prevent them from getting ragged or developing painful spikes, you can reduce the chance of getting an ingrowing toenail.

Is there a right way to cut my nails?

If you cut your nails straight across, and not curved like the end of the toe, they will not grow into the skin fold of the nail, and hence there is a reduced chance of developing an ingrowing toenail. The end of the nail should be allowed to grow clear of the skin, such that any ragged ends do not dig into the skin.

Toenail cutting diagram

However, even this will not guarantee that you cannot get an ingrowing toenail. It may still happen in well-kept nails, especially if you have had one before or are diabetic.

Can I treat an ingrowing toenail myself?

If the nail is only mildly inflamed, trimming it straight across and easing the nail out of the irritated area in the nail fold can help. Salt baths can help reduce the inflammation. Salt water, or saline solution, can be made by boiling a pint of water and then adding a teaspoon of salt. The solution lasts 24 hours, and should obviously be allowed to cool before use.

When should I take professional advice?

If redness and tenderness go beyond the toe, it may be infected and you should see your doctor as soon as possible.

If you have an ingrowing toenail that is not getting better with simple treatment and is interfering with your life it is worth contacting your GP or a chiropodist.

How will my doctor or chiropodist know what’s wrong?

The doctor or chiropodist will listen to your complaints about your nail. Then he or she will examine you, to see how bad your nail is and to see if there is a reason that it has failed to heal. Tests for medical conditions, which may interfere with healing of your toenail, such as diabetes, may be advised.

What can be done about it?

First the chiropodist will want to check that you have tried all the simple measures outlined above. If so, and if the nail is not getting better, it is usually best to partially or completely remove the nail to allow the nail to heal. This is usually done under local anaesthetic injected at the base of your toe.

Following surgery it is necessary to clean the nail bed with salt water, and dress it regularly, daily to start with. Many ingrowing toenails will heal after this treatment, but many others will not. If the ingrowing toenail recurs it is often best to remove the corner of the nail bed to stop the edge of the nail growing again. This may be done either by burning the nail bed out with a chemical (phenol) or by cutting it out surgically.

This operation is successful in 95% of people. Again, it is usually done under local anaesthetic. The complications of this procedure include infection, slow healing of the skin (approximately 6 weeks), and occasional regrowth of the nail, despite the chemical treatment.

What will the toe look like after it has been removed?

If only the edge of the nail has been removed, the nail will look similar to before treatment, although it will be a little narrower.

If the whole nail has been removed the “bed” where the nail has been removed will just be a flat area of skin. It is harmless, and quite acceptable, to paint the nail bed with nail varnish, and this camouflages the fact that the nail is absent very effectively.

Heel Pain and Plantar Fasciitis

What causes pain in the heel?

Pain in the heel can be caused by many things. The commonest cause is plantar fasciitis. Other causes include:

  • being overweight
  • constantly being on your feet, especially on a hard surface like concrete and wearing hard-soled footwear
  • thinning or weakness of the fat pads of the heel
  • arthritis in the ankle or heel (subtalar) joint
  • irritation of the nerves on the inner or outer sides of the heel
  • fracture of the heel bone (calcaneum)

What is plantar fasciitis?

The function of the heel in walking is to absorb the shock of your foot striking the ground and to start springing you forward on the next step. The heel bone, or calcaneum, is cushioned by specialised fat, contained in elastic pockets, within the thickened skin of the heel. It contains a strong bone (the calcaneum).

Heel Pain and Plantar Fasciitis

There are a number of strong ligaments, which run between the calcaneum and the toes. Amongst other things this ligament helps support the arch of the foot. The strongest of these ligaments is the plantar fascia. The plantar fascia takes a lot of stress as you walk, or even just standing.

In some people the plantar fascia becomes painful and inflamed. This usually happens where it is attached to the heel bone, although sometimes it happens in the mid-part of the foot. This condition is called plantar fasciitis.

Causes include:
• Constant stress. Plantar fasciitis is therefore commoner in people who spend all day on their feet, or are overweight.
• Stiffness of the ankle or tightness of the Achilles tendon increase the stresses on the heel. Most people with plantar fasciitis have a rather tight Achilles tendon.
• People who have high-arched (‘cavus’) feet or flat feet are less able to absorb the stress of walking and are at risk of plantar fasciitis
• Occasionally plantar fasciitis starts after an injury to the heel.
• People who have a rheumatic condition such as rheumatoid arthritis or ankylosing spondylitis may get inflammation anywhere a ligament is attached to bone (enthesopathy), and plantar fasciitis in these people is part of their general condition.

Usually plantar fasciitis eventually gets better itself, but this can take months or even years. If you have it once you are more likely to get it again.

I’ve been told my pain is caused by a bone spur. Is this likely?

Near the inflamed plantar fascia attachment, but not in it, some extra bone may form, producing a small ‘spur’. In fact, it is a shelf of bone, not a sharp spur. These ‘heel spurs’ are commoner in people with plantar fasciitis, but they can be found in people with no heel pain. The heel spur is caused by the same process as the heel pain, but the spur is not itself the cause of the pain.

Can I do anything about heel pain myself?

You can try to avoid the things that cause heel pain to start:

• Lose weight
• Where your job allows, minimise the shock to your feet from constant pounding on hard surfaces, both by reducing the time you spend on your feet, and wearing shoes with a soft, cushioned heel (such as training shoes).
• Reduce the shocks on your heel by choosing footwear with some padding or shock-absorbing material in the heel. Heel pads can be bought in most chemists. These pads can be put in standard shoes to reduce the impact of walking.
• If you have an injury to your ankle or foot, make sure you exercise afterwards to get back as much movement as possible to reduce the stresses on your foot and your heel in particular

If you start to get heel pain, doing the above things may enable the natural healing process to get underway and the pain to improve.

When should I take professional advice?

If your heel pain is affecting your normal activities and not getting better with simple self-treatment you may wish to consult your GP. (You may prefer to put up with it, knowing it will probably get better eventually.)

How will my doctor tell what is wrong?

Your doctor will listen to your complaints about your heel and examine you to see what is causing the pain, and whether anything else has started it off. If the cause of your pain seems obvious, your doctor may be happy to start treatment straight away.

However, some tests may be helpful in ruling out other problems. Blood tests may be done for arthritis. An X-ray will show any arthritis in the ankle or subtalar joint, as well as any fracture or cyst in the calcaneum. (It will also show a spur if you have one, but as we know this is not the cause of the pain.) Occasionally a bone scan may be used to help spot arthritis or a stress fracture.

What can be done about heel pain?

As heel pain is basically a stress problem in the tissues of the heel, the main treatment is to reduce stress.

 

Self help:
• Your doctor will advise you about weight-loss and appropriate footwear.
• A soft heel pad is useful to wear in your shoe to act as a shock-absorber when you walk.
• If you have a stiff ankle or tight Achilles tendon simple exercises can be used to stretch the heel cord. Stretching the Achilles tendon and plantar fascia is very effective general treatment for many patients, however it is important that you undertake the exercises regularly.

Self help exercises

1. Lean your arms against a solid and secure table
2. Put one leg behind the other as shown.
3. By bending the front knee, and keeping the back knee straight (arrow) you should feel the calf muscles (star) get tight.
4. Hold this position for 30 seconds (timed). Do not rock back and forth.
5. Change your legs over, so that you stretch the opposite calf. Plantar fasciitis can affect both legs, and so stretch both legs.
6. Perform the exercise on both legs twice – the whole exercise takes 2 minutes.
7. Repeat the exercise 4 times per day.

Simple pain-killers such as paracetamol or anti-inflammatory medicines ( for example Brufen, Nurofen) can help reduce the pain. Ask advice from your doctor or pharmacist before taking anti-inflammatory medicines as they can have troublesome side-effects in some people.

The simple measures above will help the majority of people with heel pain. In fact after about one year 95% of people’s symptoms settle. It is improtant to be patient, and stick to the treatment programme.

If the pain continues, specialist treatment may be required. There are numerous options, these include:

• Wearing a splint at night to stretch your Achilles’ tendon, while you are asleep
• Injection of steroid (an anti-inflammatory agent) into the attachment of the plantar fascia to damp down the inflammation.

These measures will reduce the pain in most people who are not helped by simple treatment.
If you still have pain after one or two injections, your doctor may want to investigate your problem a bit further. If no other medical problem or cause of stress in your heel is found, a number of other treatments can be tried:

• Further physiotherapy
• Resting the foot in a plaster cast to rest the inflamed tissues
• Shock wave treatment

Only if all non-surgical treatments fail would an operation be considered – this is because surgery has risks attached to it, and is not always successful.

Do I need an operation?

It is rare to need an operation for heel pain. It would only be offered if all simpler treatments have failed and, in particular, you are a reasonable weight for your height and the stresses on your heel cannot be improved by modifying your activities or footwear.

The aiThe aim of an operation is to release part of the plantar fascia from the heel bone and reduce the tension in it. Many surgeons would also explore and free the small nerves on the inner side of your heel as these are sometimes trapped by bands of tight tissue. This sort of surgery can be done through a cut about 5cm long on the inner side of your heel. Recently there has been a lot of interest in doing the operation by keyhole surgery, but this has not yet been proven to be effective and safe, and key hole surgery does not allow the nerves to be released.

Most people who have an operation are better afterwards, but it can take months to get the full benefit from the surgery and the wound can take a while to heal fully, for this reason a plaster cast is often used post-operatively.

Surgery is between 70% and 90% successful, however, there are risks, including a
small number of patients who are worse following surgery. The principle complications of surgery include:

• The pain fails to settle
• Dividing the plantar fascia can lead to a flat foot, which is painful, and difficult to treat
• Tingling or numbness in the heel or foot, caused by damage to the small nerves in the heel
• Infection of the wound, slowing down healing
• Excessive bruising
• Swelling of the ankle and foot

In the majority of cases the problems settle, but slow the healing process, occasionally the damage is irreversible. Certainly if you do require surgery your recovery will be helped by keeping your foot up for at least a fortnight after surgery, and following the recovery protocol outlined by the surgical team.

Wouldn’t it be better to take out my heel spur?

As you will have seen from reading the section above ‘I’ve been told my pain is caused by a bone spur’, the pain is not caused by the spur. Rather, both the pain and the spur are caused by inflammation in the plantar fascia. Simple removal of the spur has been known to be ineffective in relieving the pain since the 1960s.

However, if you are one of the rare people who do not respond to simple treatment and end up having an operation to release the plantar fascia, the surgeon may also remove any bone spur at the same tim

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