Bunion Awareness Month - Painful Bunions by Cherese Ramoutar, DPM

Bunions vary in severity from a small bump on the inside of the foot to a large bump with severe outward deviation of the first toe(hallux) sometimes even causing impingement of the first toe onto the second toe. Just as the severity of bunions may vary, so does the range of surgical treatment options for correcting bunions.

Minimal to moderate bunion deformities often require that the surgeon perform a procedure that involves reshaping the bone at the base of the first toe called the metatarsal. Following reshaping , the surgeon then makes a cut in that bone which allows them to move that fragment of bone closer to the second toe and return the first toe to a straighter alignment, as it was prior to the occurrence of the bunion. The cut in the bone is then secured in place with medical grade screws.

Patients who undergo this type of procedure to correct their bunion can expect to spend 3-5 days with no weight bearing on the affected foot. This is followed by full weight bearing in a walking boot or cast for a period of 4-6 weeks. After approximated 4-6 weeks patients are able to return to normal shoe gear and return to regular daily activities.

You will need to be evaluated by your surgeon to determine the procedure that is best for you. More severe bunion deformities may require further surgery and longer periods of non-weight bearing on the affected side.

Please check back for updates that will include descriptions of surgical procedures for the correction of severe bunions.

Tarsal Tunnel Syndrome

What is it?
Similar to carpal tunnel syndrome, it is a compression neuropathy of the posterior tibial nerve and its branches passing from the back of the leg along the medial malleolus (the interior side of the ankle) to the plantar foot. The nerve travels in a canal formed by the flexor retinaculum to the underside of the foot and splits into lateral, medial, and medial calcaneal (heel) branches. These branches form their own tunnels next to the tarsal tunnel and can also be the reason for the pain and discomfort. The causes are numerous and include: trauma, fractures, dislocation of ankle and rear foot, or sprain; basically anything that would cause compression of the nerve.

What are the symptoms?
The patient usually presents with sharp pain and numbness that radiates from the medial ankle down to the toes. There may also be burning and tingling at the heel that may occur at rest but become worse on standing or walking. The patient’s gait (how they walk) may become abnormal as they have a limp to ease the pain. Unfortunately because of the similarity in symptoms, the disorder could be mistaken with plantar fasciitis.

How is it treated?
Diagnosis of tarsal tunnel syndrome can be diagnosed with a positive Tinel’s sign. The area over the nerve is tapped along its distribution, which should create a tingling sensation. The most conservative treatment is to use an orthotic or device to keep the foot in an inverted position. Corticosteroid injections would also help with swelling and irritation of the nerve. In the end, the patient may need surgical intervention that involves a small incision to release the flexor retinaculum, which gives the nerve more space along its path to the plantar foot.

Plantar Faciitis

Recently a left fielder for the Chicago White Sox, Carlos Quentin, was put on the injured list because of plantar fasciitis, one of the most common causes of heel pain.

What is plantar fasciitis?
Plantar fascia, the deep fascia of the sole, functions to protect the heel from injury, provide support for the arch of the foot and evenly distribute the weight as one walks. Its length is from the heel of the foot to just below the beginning of the toes. This area can become very painful due to inflammation as the result of minute tears in the fascia. The pain is located in the heel and around the arch of the foot. Most patients complain that the pain is worse after sitting for long periods or upon walking after getting out of bed in the morning.

What activities contribute to this foot condition?
While this condition is common in many athletes, due to the high impact sports, the average person who visits the gym daily can be diagnosed, as well. Also, persons who stand on their feet for long periods of time are at risk.

How is it Treated?
Normally, the patient is treated with non-steroidal anti-inflammatory drugs (NSAIDs) or a corticosteroid to decrease the inflammation. The doctor may also prescribe either Night splints to stretch the fascia and prevent the arch from constricting or orthotics to evenly distribute the weight on the foot.

"Turf Toe"

At the end of March, there was news that Stephen Jackson, a forward of the Golden Warriors, would be out for the rest of the NBA season due to a left toe injury. He would have to undergo surgery to remove bone fragments from his big toe.

This type of injury, commonly called “turf toe”, involves the ligaments to the metatarsalphalangeal joint (MPJ) at the base of the big toe (ball of the foot). They can be torn when the toe is either hyper-extended or hyper-flexed as a person stops short to jump or turn, which is why it is a common occurrence in athletes. Another contributing factor is artificial surfaces and or shoes that are too flexible.

The MPJ is a synovial joint between the head of the metatarsal bone and the base of the proximal phalanges enclosed in a capsule. Collateral and plantar ligaments support the joint. It is responsible for flexion (toe down), extension (toe up), adduction (movement of toe away from the midline), and some abduction (movement of toe towards the midline).

Normally, the treatment is non-surgical consisting of controlling inflammation with NSAIDS, ice, and restriction of the toe’s range of motion. Proper healing can take weeks or at least a month depending on the extent of the injury, which is graded according to severity on a scale of I to III. Grade I is more like a sprain, when the ligaments and capsule are stretched. There is an incomplete tear in the ligaments and capsule in Grade II and Grade III is a complete tear of the ligaments and capsule. Regrettably, there can be a recurrence with the formation of bone spurs. At this point, surgery becomes the next option.

To Flip-Flop or Not?

I was walking around Town Square Sunday enjoying the warm weather and noticed that everyone, men, women, and children had their feet exposed in flip flops. This phenomenon began a couple of years ago and what was thought of as a fad has become a requirement for warm weather. They are very cute and vary in color and type of material leather, plastic, rubber etc. Unfortunately, these very comfy shoes that can be worn with anything from dresses to shorts are not very healthy for the feet.

Why, you may ask, are they unhealthy?

• There is potential for skin irritation from the materials used in flip flops
• Open toed shoes pose a greater risk of injury or infection
• Sweat and bacterial buildup are an issue in warmer weather, although some newer companies are putting silver and other chemicals in their materials to reduce bacterial load
• Instability and potential for falling/sliding is increased in “shoe gear” with a flimsy outer sole

The “shoe” does not provide enough arch support for walking long distances or for several hours of wear. It interferes with the wearer’s standard gait, which is the way that a person walks. The problem stems from the design of the sandal, which is essentially a flat foam or rubber sole with a thong. Flip- flops don’t provide much in the way of shock absorption when the heel hits the ground, due to the thin sole. This action can lead to foot pain, most commonly plantar fasciitis. Plantar fasciitis is one of the most common forms of heel pain that occurs in runners and wearers of shoes with inadequate support.