Foot & Ankle

With 10,000 steps a day, three quarters of all Americans will experience foot or ankle problems in their lifetime.

Ankle Sprains

The ankle joint is formed by three bones, the tibia, fibula, and talus. The bones are held together by several strong ligaments, which provide stability to the ankle joint. A sprain is a tear, or injury to a ligament, of varying severity.

Common Causes

Twisting injuries to the ankle. Seen with rapid pivoting in soccer and basketball. Stepping off of a curb or step can twist or rotate the ankle. Depending on the direction the foot is twisted, different ligaments can be injured.

Symptoms

Pain in the ankle, varying from mild to quite severe. Often there is swelling, especially in the outside of the ankle. Walking and weight bearing may be difficult, with pain and feelings of instability.

Physical Findings

Tenderness over ligaments of the ankle. Swelling may be noted. Stress of the involved ligaments is quite uncomfortable.

Workup

History, physical examination, and x-rays are usually adequate to make the diagnosis. Occasionally, special stress x-rays are used to determine chronic instability.

Non-Operative Treatment

Treatment depends on the severity, or grade of the sprain. For mild, or grade 1 sprains, support until symptoms resolve. Moderate, or grade 2 sprains are treated with functional bracing, for several weeks. Severe, grade 3 sprains may require immobilization in a cast or brace to heal.

Surgical Treatment

Ligament repair or reconstruction.

Injury Comment

Surgery is rarely indicated for an acute ankle sprain, except perhaps in the high-performance athlete. Ligament repair is effective for chronic instability.

Achilles Tendonitis

The Achilles tendon is a very strong tendon that connects the calf muscles to the heel. When the calf muscles contract, they pull on the heel, pushing the foot down. Thus the Achilles tendon lets us run, jump, and walk.

Common Causes

Typically an overuse injury, due to excessive jumping, or running up hills.

Symptoms

Pain in the back of the heel, increased with activity. Aching in the back of the heel when starting to walk.

Physical Findings

Tenderness along the Achilles tendon near its insertion into the heel. Often there is thickening or swelling of the tendon.

Workup

Diagnosis is made by history and physical examination.

Non-Operative Treatment

Rest, icing, avoidance of aggravating activity, and anti-inflammatory medications. Shoe heel lifts, and immobilization (casting or bracing) for severe cases. NO corticosteroid injections (can rupture the tendon-big problem).

Surgical Treatment

Debridement of the tendon, or repair of the tendon for an Achilles tendon rupture.

Injury Comment

Generally successfully treated with non-operative care.

Plantar Fasciitis

The plantar fascia is a broad band of tissue that runs from the heel to the base of the toes, on the sole of the foot. It helps to support the normal arch of the foot. It is usually under tension, much like the string that holds the bow part of a bow and arrow bent, or arched. The plantar fascia may become partially torn or inflamed at either end.

Common Causes

Overuse, seen with a change in running habits, poor running shoes, footwear with poor arch support, walking on hard floors. Associated with weight gain.

Symptoms

Pain in the sole of the foot, either at the base of the heel, or in the arch. Patients are generally comfortable sleeping, but report sharp or cramping pain with the first step in the morning. Often they find themselves hobbling around for several minutes. Symptoms typically ease during the day, but may become painful at the end of the day.

Physical Findings

Tenderness along the plantar fascia. Often patients have a tight Achilles tendon.

Workup

The diagnosis is made primarily by history and physical examination. X-rays of the heel may coincidentally show ‘heel spurs’, but the spur is not part of the problem (the fascia doesn’t even attach to the spur).

Non-Operative Treatment

A combination of plantar fascia and Achilles tendon stretching, anti-inflammatory medication, arch supports, good shoes, avoiding walking barefoot, and avoiding aggravating activities. Nighttime splints are irritating to wear, but are very helpful. A trial of a single corticosteroid injection may be helpful, but should not be done repeatedly.

Surgical Treatment

Plantar fasciotomy.

Injury Comment

The good news is that over ninety percent of patients can be successfully treated without surgery. The bad news is that it probably takes between six months and a year for a cure, and exacerbations are common.

Tarsal Tunnel Syndrome

The posterior tibial nerve runs down along the inside of the ankle, down to the foot. It passes between the inside of the ankle, and under a thick band of tissue. If the nerve gets compressed, or squeezed, then it will not work properly.

Common Causes

May be due to direct trauma, or following an ankle injury. Swelling or inflammation of the other tendons inside the tarsal tunnel besides the nerve also increase pressure on the nerve.

Symptoms

Usually a vague burning or tingling running down along the inside and sole of the foot. Usually aggravated by activity, and relieved by rest.

Physical Findings

Tenderness along the course of the nerve, with reproduction of symptoms by pressure on the nerve.

Workup

History, physical examination, and possibly nerve conduction studies. X-rays are generally negative.

Non-Operative Treatment

Rest, avoiding aggravating activity, orthotics, anti-inflammatory medication, and a trial of a corticosteroid injection may all be helpful in reducing symptoms.

Surgical Treatment

Decompression of the nerve by releasing the compressing structures, through a small incision, is generally curative.

Injury Comment

This is an uncommon injury, and is frequently confused with other foot conditions.

Interdigital Neuroma / Morton’s Neuroma

This condition develops when one of the nerves running along the sole of the foot becomes squeezed, or inflamed between two of the bones of the foot (metatarsals).

Common Causes

Usually related to poor shoe wear, or increase in running/standing. When the toes and foot are unnaturally squeezed, there is pressure created on the nerves in the foot. The nerve becomes chronically thickened and inflamed.

Symptoms

Pain in the ball of the foot, often described as burning, or numbness, that may radiate into the toes. The space between the third and fourth toes is most common, but may occur in the space between the second and third toes as well.

Physical Findings

Tenderness, pain, or numbness in the third or fourth webspace with direct pressure on the nerve.

Workup

Diagnosis is based almost entirely on history and physical examination. X-rays are usually normal. Ruling out other causes of foot pain is required.

Non-Operative Treatment

Modification of shoewear, with a wider toe box, and good arch and metatarsal support. Orthotics may be helpful. Non-steroidal anti-inflammatory medication , and rest. A trial of a corticosteroid injection may be of both diagnostic and therapeutic benefit.

Surgical Treatment

Excision of the swollen nerve (neuroma) is generally curative, also mild numbness between the involved toes may result.

Injury Comment

Often simple, inexpensive measures can relieve this problem, before it becomes a much more difficult situation.