Foot & Ankle

Arthritis is inflammation resulting from the degeneration of cartilage in the joint causing pain, swelling, and stiffness in the joints resulting in restricted movements. Arthritis of the foot and ankle joint can occur due to fracture, dislocation, inflammatory disease, or congenital deformity. The foot joints most commonly affected by arthritis are:

• The joint between the shin bone (tibia) and ankle bone (talus)
• The three joints of the foot that include the heel bone, the inner mid-foot bone, and the outer mid-foot bone
• The joint of the great toe and foot bone

There are three types of arthritis affecting the foot and ankle and may include:

Osteoarthritis: Also called degenerative joint disease, this is the most common type of Arthritis, which occurs most often in older people. This disease affects cartilage, the tissue that cushions and protects the ends of bones in a joint. With osteoarthritis, the cartilage starts to wear away over time. In extreme cases, the cartilage can completely wear away, leaving nothing to protect the bones in a joint, causing bone-on-bone contact. Bones may also bulge, or stick out at the end of a joint, called a bone spur.

Rheumatoid Arthritis: This is an auto-immune disease in which the body's immune system (the body's way of fighting infection) attacks healthy joints, tissues, and organs. It can cause pain, stiffness, swelling, and loss of function in joints. Rheumatoid Arthritis affects mostly joints of the hands and feet and tends to be symmetrical. This means the disease affects the same joints on both sides of the body (both feet) at the same time and with the same symptoms.

Post-traumatic arthritis: Arthritis developing following an injury to ankle or foot is called as post-traumatic arthritis. The condition may develop years after the trauma such as a fracture, severe sprain, or ligament tears.

Rheumatoid arthritis is often caused when the genes responsible for the disease is triggered by infection or any environmental factors. With this trigger body produce antibodies, the defence mechanism of body, against the joint and may cause rheumatoid arthritis. Fractures at joint surfaces and joint dislocations may predispose an individual to develop post-traumatic arthritis. It is considered that your body secretes certain hormones following injury which may cause death of the cartilage cells. Uric acid crystal build-up is the cause of gout and long-term crystal build-up in the joints may cause deformity.

Symptoms of foot and ankle arthritis include pain or tenderness, swelling, and stiffness in the joint and limited range of motion.

The diagnosis of foot and ankle arthritis is made with a medical history, physical examination and X-rays of the affected joint. A bone scan, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans are also performed to diagnose arthritis.

Nonsurgical treatment options for foot and ankle arthritis include medications (anti-inflammatories), injections (steroids), physical therapy, ankle-foot orthosis (AFO), weight loss, orthotics such as pads or arch supports, and canes or braces to support the joints. Surgery may be required to treat foot and ankle arthritis, if your symptoms do not get better with conservative treatments. Surgery performed for arthritis of the foot and ankle includes:

Arthroscopic surgery: Arthroscopy is a surgical procedure during which the internal structure of a joint is examined for diagnosis and treatment of problems inside the joint. In arthroscopic examination, a small incision is made in the patient's skin through which pencil-sized instruments that have a small lens and lighting system (arthroscope) are passed. Arthroscope magnifies and illuminates the structures of the joint with the light that is transmitted through fibre optics. It is attached to a television camera and the interior of the joint is seen on the television monitor. Your surgeon can then use probes, forceps, knives, and shavers, to clean the joint area of foreign tissue, inflamed tissue, or bony outgrowths (spurs).

Arthroplasty or Joint Replacement: In this procedure, your surgeon removes the damaged ankle joint and replaces it with an artificial implant. It is usually performed when the joint is severely damaged by osteoarthritis, rheumatoid arthritis or post-traumatic arthritis. The goal of ankle replacement is to relieve pain and restore the normal function of the ankle joint.

Ankle injuries are the most common sports-related injury. An ankle fracture is a break in one or more bones that make up the ankle joint. Sometimes ligaments may also be damaged. Ankle fractures are most often caused by motor vehicle accident, rolling or twisting of ankle, and by tripping or falling. People participating in sports such as basketball, football, soccer and skiing are at a high risk of developing ankle fractures.

Common symptoms of an ankle fracture include pain and swelling around the ankle, bruising, tender to touch, inability to walk on the leg, and deformity if the ankle is dislocated.

Following an ankle injury, it is important to have the ankle evaluated by your doctor for proper diagnosis and treatment. Diagnosis is made based on the history of injury and physical examination of the ankle. In addition, the surgeon may order X-ray of the ankle to determine the extent of the injury.

Treatment varies with the type and severity of the injury. The common method of treatment of ankle fractures is adequate rest, ice application, leg elevation, and medications to reduce swelling and pain. A short leg cast or a brace may be applied over the fractured ankle to provide support. If there is severe injury, excessive swelling or severe pain, you should seek immediate medical treatment.

Some ankle fractures are treated with a splint, which is placed on the ankle for few days until the swelling subsides. Once the swelling decreases a cast may be placed on the ankle to hold the broken bone in a specific place. Surgery may be needed to realign the bones before placing the splint. During surgery, your doctor may place metal screws, plates, or rods to hold the broken bone intact until the healing happens. In some cases, crutches may be used to prevent the ankle from bearing weight.

It is important to use proper fitting shoes for the particular sports activity to reduce the chances of injury.

Achilles tendon is a strong fibrous cord present behind the ankle that connects the calf muscles to heel bone. It is used when you walk, run and jump. When the Achilles tendon becomes thin, weak, or if it is not used, it may be susceptible to injury or damage. Achilles tendon rupture occurs most often in middle-aged athlete participating in sports that involve running, pivoting, and jumping. Recreational sports that may cause Achilles rupture include tennis, racquetball, basketball, and badminton.

If Achilles tendon is ruptured you will experience severe pain in the back of your leg, swelling, stiffness, and difficulty to stand on tiptoe and push the leg when walking. A popping or snapping sound is heard when the injury occurs. You may also feel a gap or depression in the tendon, just above heel bone.

Your doctor diagnoses the rupture based on symptoms, history of the injury and physical examination. Your doctor will gently squeeze the calf muscles, if the Achilles tendon is intact, there will be flexion movement of the foot, if it is ruptured, there will be no movement observed.

Achilles tendon rupture is treated using non-surgical method or surgical method. Non-surgical treatment involves wearing a cast or special brace which is changed after some period of time to bring the tendon back to its normal length. Along with cast or brace, physical therapy may be recommended to improve the strength and flexibility of leg muscles and Achilles tendon. Surgical procedure involves opening the skin and suturing the torn tendon together. Surgery helps to decrease the recurrence of the Achilles tendon in comparison to the non-surgical treatment.

To help prevent an Achilles tendon injury, it is a good practice to perform stretching and warm-up exercises before any participating in any activities. Gradually increase the intensity and length of time of activity. Muscle conditioning may help to strengthen the muscles in the body.

A sprain is stretching or tearing of ligaments, which connect adjacent bones in a joint and provides stability to the joint. An ankle sprain is a common injury and occurs when you fall or suddenly twist the ankle joint or when you land your foot in an awkward position after a jump. It most commonly occurs when you participate in sports or when you jump or run on a surface that is irregular. Ankle sprains can cause pain, swelling, tenderness, bruising, and stiffness, numbness in the toes, and inability to walk or bear weight on the ankle.

The diagnosis of an ankle sprain is usually made by asking the history of injury and physical examination of the ankle. X-ray of your ankle may be needed to confirm if a fracture is present.

The most common treatment recommended for ankle sprains is rest, ice, compression and elevation (RICE).

• Rest: You should not move or use the injured part to help to reduce pain and prevent further damage. Crutches may be used that help in walking
• Ice: An ice-pack should be applied over the injured area up to 3 days after the injury. You can use a cold pack or crushed ice wrapped in a towel. Ice packs helps to reduce swelling and relieve pain. Never place ice directly over the skin
• Compression: Compression of the injured area helps to reduce swelling and bruising. This is usually accomplished by using an elastic wrap for few days to weeks after the injury
• Elevation: Place the injured part above heart level to reduce swelling. Elevation of an injured leg can be done for about 2 to 3 hours a day

The doctor may also use a brace or splint to reduce motion of the ankle. Anti-inflammatory pain medications may be prescribed to help reduce the pain and control inflammation.

You may need to use an ankle brace or wrap to support and protect your ankle during sports activities. Avoid pivoting and twisting movements for 2 to 3 weeks.

To prevent further sprains or re-injury you may need to wear a semi-rigid ankle brace during exercise, special wraps, and high-top tennis shoes. A program of ankle exercises will also help to prevent re-injury by making the ankles strong and flexible.

Tendons are strong fibrous tissues that attach muscles to bones. The peroneal tendons are two tendons in the foot that run side-by-side behind the outer bone of the ankle. One tendon runs under the foot and attaches near the arch, while the other attaches to the outside of the midfoot. These two tendons are responsible for supporting the foot and ankle and protecting them from injury.

Peroneal tendonitis refers to the inflammation of the peroneal tendons. The common cause of peroneal tendonitis is overuse injury, a direct blow or sudden stress to the tendon, and playing sports that involve repetitive ankle motions.

Symptoms of peroneal tendonitis include tenderness, pain, swelling, redness or warmth in the outside and back part of the ankle. There may be a popping sound when the ankle is moved.

Diagnosis is based on the following:

• Physical examination of the foot and ankle to assess the movements and condition of the tendon
• Radiological investigations such as foot or ankle X-rays or MRI may be ordered

Treatment options include:

• Adequate rest and restricting activities that causes pain and stress
• Medications to relieve pain and inflammation
• Applying ice bags over a towel on the affected area for about 15-20 minutes to reduce swelling and inflammation
• Physical therapy: Stretching and strengthening exercises may be recommended to reduce pain.
• Surgery is indicated only in severe cases and involves removing the inflamed tendon lining.

Contact your doctor if symptoms do not improve after two to four weeks of treatment or if new symptoms develop.

Toes are the digits in your foot and are associated with walking, providing balance, weight-bearing and other activities. A variety of toe deformities occur in children's feet. They are as follows:

• Hallux Valgus: Hallux valgus is a common toe deformity in which the child's great toe is shifted laterally and lies over the second toe. The first metatarsal bone is deviated towards the medial side causing a prominence over the medial aspect of the metatarsophalangeal (MTP) joint. A fluid filled sac (bursa) may form over this prominence which may result in a painful bunion caused by continuous irritation and inflammation. Foot pronation (flat feet) may sometimes be associated with this condition.
  
  The factors that cause hallux valgus include structural foot anomaly that may or may not be hereditary and use of narrow shoes that curl or fold the toes. Children having hallux valgus may not have any symptoms most of the times and do not require any treatment. Your doctor may advise shoes that have good amount of space for the toes and no heels. If there is flat foot then a shoe insert may help to prevent its progression. Surgery may be recommended only in severe cases
• Hammertoe: Hammertoe is a deformity in which there is downward bending of the middle joint of the toe or the proximal interphalangeal joint (PIP). Although it can affect the other toes, it most commonly affects the second toe. It may be present at birth or may result from wearing shoes that are too tight which forces the toe to bend forward. It causes no pain and does not require any specific treatment. Hammer toe can be treated by ensuring that your child wears well-fitting shoes that has enough space for the toes to stretch
• Mallet Toe: Mallet toe refers to the downward bending of the third joint or distal interphalangeal joint (DIP) giving it a mallet-like appearance. Corns or calluses may develop over the deformity as a result of constant friction against the footwear. Mallet toe can be inherited or may develop from wearing shoes that are too tight or high-heeled
• Claw Toe: Claw toe is a rare deformity but occurs in association with cavus foot, Charcot-Marie-Tooth disease or myelomeningocele. It affects all the toe joints and results from hyperextension of the metatarsophalengeal (MTP joint or 1st joint) and flexion at the PIP (2nd joint), and DIP (3rd joint) joints. It results from altered structural anatomy and /or neurologic disorder that cause muscle imbalances
• Curly Toe: Curly toes are present at birth and affect the third, fourth and fifth toes of one or both the feet. It is caused by tightening of the tendon that runs below the toe which results in pulling of the tip of the toe under the next toe towards the sole. Your child may develop areas of hard skin on the sole of the foot and may have difficulty in selecting suitable shoes that fit properly.
  
  Generally, no treatment is needed if curly toes do not cause any symptoms but if the condition becomes severe and causes irritation, then surgery may be performed to release and transfer of toe flexor
• Polydactyly: It is a condition in which there is an extra digit present in the feet. The great toe or the fifth toe is usually affected. It may occur in association with other congenital anomalies or as an isolated problem. If the extra digit does not cause any problem, it may be left alone without any treatment. Surgical excision of the extra digit will be done in cases where there is an extra little or big toe that is prominent causing difficulty in wearing shoes. Surgery is usually done after the age of 9-12 months
• Syndactyly: Syndactyly is the presence of fused digits and may occur along with other congenital anomalies or as an isolated problem. It rarely causes any problems and does not need any treatment. The connection between two or more toes varies from a thin skin attachment to a bony attachment (synostosis) between the phalanges
• Bunionette (Tailor Bunion): Bunionette is less common and occurs at the fifth MTP joint. When this occurs, the fluid sac over the lateral side of the fifth MTP joint becomes prominent and inflamed causing pain. Padding is done to relieve the discomfort. If this does not help, surgical correction will be needed