Diagnosis & Treatment of Foot & Ankle Conditions

Foot and ankle conditions and treatment options

• Ankle fractures

  Ankle fractures are generally due to twisting or rotational injuries when the foot is turned one direction while the leg remains stationary. The range of injuries vary from “chip” or “avulsion” fractures to multiple fractures of the bones of the ankle. Because of the unique configuration of the ankle, its small size, and the significant weight or pressure on it, many ankle fractures must be checked for proper alignment. If the bones of the ankle heal in poor alignment, arthritis or other long-term disabilities may result. Some ankle fractures can be treated in a walking boot, while others must be strictly non-weight-bearing in a cast. Certain fractures may require surgery to restore stability to the ankle.

• Ankle sprains

  A sudden twisting of the ankle causes injury to the ligaments, and occasionally the tendons that stabilize the ankle joint. The inability to place weight on the foot can sometimes mean a fracture, and urgent treatment should be sought.

  Fortunately, most ankle sprains can be treated by a combination of rest/ice/compression/elevation (“RICE”) and heal in one to two weeks. However, severe sprains can result in partial tearing or rupture of ligaments and require a brace or walking boot. These sprains can take one to three months to heal and involve more aggressive treatment with physical therapy to retrain proper balance in the ankle. Steroid injections are occasionally used to assist in pain relief and improve mobility.

  In rare cases, sprains can cause complete rupture of ligaments or tearing of tendons that can lead to “chronic ankle instability.” The tendency to re-roll the ankle repeatedly under trivial conditions can be disabling and could require surgical reconstruction to repair and tighten those ligaments or tendons.

  Some ankle sprains can cause chronic pain despite proper healing of tendons and ligaments. In these cases, scar tissue formation, or cartilage fragments or defects (“osteochondral defects”) may lead to chronic pain. Some of these conditions respond to cortisone injections, while others may need to be treated surgically.

• Arthritis

  There are several forms of arthritis. The most common is osteoarthritis, or degenerative joint disease. This is the typical “wear and tear” or old-age arthritis that causes stiffness and painful joints. Excessive load and strain on joints over time can speed up the thinning of cartilage in joints, and a higher percentage of arthritic joints is found in overweight or highly athletic populations.

  Because there is no way to restore missing cartilage to its original state, arthritis is typically managed, not cured. Stress on joints can be reduced by diet and weight loss and modifying activities to low-impact exercises (swimming, cycling). Pain can be managed with anti-inflammatory, over-the-counter medications such as ibuprofen, naproxen or aspirin. Ice is useful when joints are inflamed, while warmth can help when they feel stiff. Rigid orthotics (shoe inserts) and stiff, thick-soled shoes support arthritic joints well. Flimsy sandals or canvas shoes promote instability, and therefore pain. When arthritic pain is no longer manageable with conservative therapy, surgery can significantly improve function either by removing unwanted bone spurs, or by preventing the joint from grinding via a joint fusion.

  Traumatic injuries to joints, such as fractures, or joint contusions (stubbing), can cause direct injury to the cartilage, leading to “post-traumatic arthritis.” Unfortunately, this form of arthritis becomes problematic at an earlier age than might be expected.

  Inflammatory arthritides (joint disorders) are unique, and include rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout, and systemic lupus erythematosus, among others. Many of these disorders are caused by your own immune system and can involve multiple joints, and even organs. Treatment is generally a multidisciplinary approach involving the guidance of a rheumatologist. Medications play an important role in slowing the progression of many of these arthritides. The role of the podiatrist and foot and ankle surgeon is to assist in relieving pain via orthotics, injections, or occasionally, surgical reconstruction when all else has failed.

• Bunions

  Bunions are technically known as “hallux valgus.” While this bump on the inner aspect of your big toe joint can be unsightly, many people do not have pain, and treatment is unnecessary. The cause of bunions is likely a combination of genetic factors (hereditary), choice in shoes and activity. These factors create biomechanical instability in the foot, resulting in the great toe moving out of alignment. When It's painful, treatment consists of:

  • Wearing wider, roomier shoes
  • Avoidance of high heels (or shoes that create more pressure in the ball of the foot)
  • Various pads and splints
  • Surgical correction

  The typical bunion surgery is complex because it involves correcting alignment of the great toe joint, and not simply removing “the bump.”

• Corns and calluses

  Corns and calluses are a thickening of skin caused by repeated friction, or direct pressure, generally over bony bumps of the foot. In some instances, they can be caused by skin cells blocking a pore or sweat gland, forming a dense, painful core. Over-the-counter corn, callus or wart removers contain mild acid, which helps soften the skin and allow easy removal of the callus via filing or scraping with a pumice stone. Calluses that recur frequently can occasionally be managed with an orthotic by relieving the pressure point from contacting the ground.

• Cortisone injections

  The human body naturally produces steroid hormones, including cortisol, that have many functions in normal metabolism. Injectable corticosteroids are synthetic versions of cortisol, generally used to reduce inflammation and break down scar tissue. Common applications in the foot and ankle include joint injections for arthritis, plantar fasciitis (heel pain) and neuromas. Mild side effects include injection site pain, swelling, and warmth. Severe side effects of cortisone injections include thinning of tissue, tendon rupture and joint destruction. Luckily, when used appropriately, these side effects are rarely encountered.

• Diabetic foot complications

  Diabetic foot complications usually arise from poorly controlled diabetes, which leads to secondary problems such as poor circulation and nerve damage (peripheral neuropathy). The combination of these factors may lead to:

  • Foot deformity
  • Inability to feel injury
  • An open vulnerable wound (“ulcer”)
  • Infection
  • Inability to heal from that infection

  Unfortunately, the end result may involve amputation of the foot or leg in severe circumstances. Therefore, high-risk diabetic feet should be routinely evaluated by a doctor, and an open wound should be evaluated promptly by a foot and ankle specialist. Some podiatrists are trained specifically in managing diabetic feet and wound complications, while others specialize in limb salvage via surgical reconstruction. Devastating outcomes can be prevented through proper education, foot inspection and prescription diabetic shoes, specifically customized for the diabetic foot. Avoidance of walking barefoot and excellent blood sugar control remains the mainstay in keeping diabetic feet healthy.

• Foot fractures

  A foot fracture is generally caused by direct impact or sudden twisting, resulting in one or more broken bones. Severe pain, swelling, bruising, warmth, redness, and difficulty bearing weight are typical signs of a broken foot. An X-ray will help your doctor diagnose the problem and guide treatment.

  The foot is a complex piece of machinery, composed of 26 bones with precise anatomy and alignment. Foot fractures can disrupt proper alignment and should be evaluated by a foot and ankle specialist to determine appropriate treatment. Most foot fractures are treated with immobilization, rest, ice, elevation, and anti-inflammatory medications for four to six weeks. If the fracture involves a joint or is out of position (“displaced”), surgical intervention may be required to restore the normal anatomy of the foot.

  Stress fractures or stress reactions are the response to repetitive or excessive loads on the foot beyond what the body can tolerate. This results in a tiny break, or “hairline fracture,” of the bone that is invisible on early X-rays. Unlike typical foot fractures, pain and swelling is less, and is noticed gradually, rather than suddenly. A typical example of how a stress fracture becomes apparent is when a runner decides to increase mileage and notices a gradual onset of swelling, warmth and pain on the top of the foot. Stress fractures are generally treated the same as an acute foot fracture but may respond quicker.

• Hammertoes

  Hammertoes are essentially toes that are curled, crooked, rotated or angled sideways. The toe joints may become buckled and raised and prevent the toe from lying flat on the ground. This can become painful from shoe irritation, causing corns and calluses. Severe hammertoes can disrupt supportive ligaments and tendons and become dislocated, causing severe pain in the ball of the foot.

  Various causes of hammertoes include:

  • Genetics
  • Mechanical or tendon imbalances of the foot
  • Diabetes
  • Neuromuscular disorders
  • Inflammatory arthritis
  • Tight-fitting shoes and high heels are thought to promote the deformity, but are not necessarily the sole cause

  If the hammertoes are painful, avoid wearing tight shoes or high heels in favor of wider shoes with more depth in the toe box. The additional use of moleskin, or other over-the-counter pads and splints, can help alleviate discomfort. Painful corns or calluses that form over the bony bumps of a hammertoe can be managed with medicated corn or callus remover pads. In cases where hammertoes are caused by mechanical or tendon imbalances of the foot, orthotics (shoe inserts) may be helpful to prevent or slow progression of the deformity.

  Most hammertoe deformities are not reversible through conservative means, and surgery may be needed to realign the toe. Hammertoe surgery is extremely complex, with multiple procedures often involving bone resections and detailed reconstruction of tiny tendons.

• Ingrown toenails

  An ingrown toenail occurs when the edges of the toenail(s) become buried in the surrounding skin of the toe. It can be caused by genetics, tight shoes, physical development (e.g., teenagers) and trauma. Poor nail-trimming techniques are not always the cause. Conservative treatment includes wearing wider shoes and soaking the toe in Epsom salt and water. If the toenail remains problematic despite these measures, removal of portions of the nail may be required. In chronic, recurrent ingrown toenails, a permanent procedure called a “matrixectomy” may be performed to prevent a portion of the nail from returning indefinitely.

• Neuromas

  A neuroma is an inflamed nerve that eventually becomes substantially enlarged and prone to irritation by the adjacent bones in the ball of the foot. Neuromas are the most common cause of discomfort in the ball of the foot, associated with sharp stabbing pain, burning, numbness, tingling, and electrical radiation, often into the toes. When the neuroma is between the third and fourth base of the toes, It's called “Morton’s neuroma.”

  Treatment includes reducing impact on the ball of the foot by avoiding high-heel shoes in favor of flat, thick-soled or cushioned shoes. Over-the-counter gel cushions or neuroma pads can help reduce pressure and pain. Orthotics (shoe inserts) may work similarly and sometimes more effectively to offload the weight on the neuroma. Ice and anti-inflammatory medications may help reduce nerve inflammation in early stages; however, in long-standing neuromas, the enlarged nerve generally requires more aggressive treatment with cortisone injections. In some cases, the neuroma may need to be removed surgically.

• Pes cavus (high arches)

  The high-arched foot is generally inherited, although neurologic disorders can cause it as well. High-arched feet have poor shock absorption and may be prone to stress fractures and Achilles tendon problems. The increased pressure on the ball of the foot causes pain, and tendon imbalances can cause severe hammertoes over time. The pes cavus foot structure can also cause ankle instability, with a tendency for ankle sprains and tendonitis (peroneal tendonitis).

  The treatment of painful high-arched feet ranges from appropriate shoe recommendations and inserts to reconstructive surgery, depending on the symptoms experienced.

• Pes planus (flat feet)

  Flat feet can be inherited or acquired over time and are occasionally the result of neurologic disorders. The loss of arch height creates an unstable foot, which exhibits excessive motion called “hyperpronation.” Flat feet are believed to cause many problems, including arch pain, heel pain, bunions, hammertoes, neuromas, Achilles tendonitis, and shin splints. Flexible flat feet are generally well managed with appropriate shoes and inserts that limit hyperpronation and create a more stable foot with less pain. People with severe or rigid flat feet may encounter significant tendon and joint problems, including arthritis, which could require flat-foot reconstructive surgery.

• Plantar fasciitis (heel pain)

  The most common cause of heel pain is plantar fasciitis—an inflammation of a long “ligament” that runs from the heel to the ball of the foot. Symptoms include pain in the bottom of the heel, particularly after periods of inactivity such as sleep or sitting and may worsen with activities. Fortunately, this condition is usually resolved with a combination of rest, ice, anti-inflammatory medications, and support for the foot. People with plantar fasciitis should never walk barefoot. Wearing supportive shoes and arch supports is best for treating this condition. Calf stretching is recommended for relaxing the Achilles tendon and minimizing strain on the plantar fascia.

  Massage and physical therapy can be considered in long-standing cases to help break up scar tissue in the plantar fascia. Occasionally, a walking boot and steroid injections may be used in chronic or severe plantar fasciitis. Surgical intervention is rarely recommended, although it's an option. 

  The term “heel spur syndrome” is an unfortunate misnomer since heel spurs are common in the average population and are generally not painful. Rather, heel spurs are thought to be secondary to traction or “pull” of the plantar fascia, and therefore the result, and not the cause, of plantar fasciitis.

• Tendonitis

  True tendonitis refers to swelling, warmth and pain of a tendon secondary to inflammation. The cause of most tendonitis is overuse. Therefore, some form of rest or reduced activity is required to resolve the condition. Ice and anti-inflammatories may assist in resolving inflammation. Occasionally, severely inflamed tendons may need to be immobilized in a walking boot to allow the tendon to rest more effectively.

  Some forms of tendonitis are secondary to mechanical abnormalities, alignment problems, or weakness of the tendon. In these cases, orthotics (shoe inserts) may be useful to restore normal alignment, and physical therapy may be prescribed to assist in retraining weak muscles or imbalances.

  If tendonitis recurs, or becomes chronic, a tendon may degenerate and become scarred, weakened, and prone to tearing or even rupture. Chronic tendonitis is more appropriately termed tendinosis and may require surgical intervention to resolve symptoms.

• Total ankle replacement

  Virginia Mason Franciscan Health’s world-class Orthopedics and Sports Medicine specialists offer total ankle replacement. If you’ve been living with ankle arthritis and chronic pain not alleviated by medication, total ankle replacement may be for you. Performed by our specially trained orthopedic surgeons, total ankle replacement can provide a reduction in—or complete relief of—pain along with an increased range of motion.

• Warts

  Warts are a completely benign (nonharmful) infection from a strain of the human papillomavirus (HPV). The virus resides in the first layer of the skin, and it causes tiny blood vessels to clot, accounting for the “black dots” characteristic of a wart. Treatment requires care, with a combination of frequent shaving or filing of callus tissue covering the wart and use of medicated corn or wart removal pads. Occasional freezing with liquid nitrogen can help destroy the wart virus. More stubborn warts may be candidates for injection therapy or surgical excision.