Second opinion on foot and ankle conditions

In everyday life, we don't pay attention to our feet until they hurt. It is only then, feeling discomfort with every step, one gets to realize how important it is to keep them healthy.

Foot disorders are manifested by various symptoms: pain, swelling, deformity, skin rashes, wounds, changes in skin color and temperature, etc. When such problems arise, it turns out that finding the right doctor is not so easy. Who should it be - an orthopedist, rheumatologist, dermatologist, or maybe a podologist? The correct answer is a foot and ankle specialist who can correctly identify the cause of the problem and a way to solve it, taking into account the peculiarities of the organs and systems of this complex part of the body. If such a doctor cannot be found nearby, a face-to-face appointment may well be replaced by a remote consultation.

Basic anatomy

The final part of the lower limb (the foot) is a complex structure consisting of 26 bones, 33 joints, 20 muscles and over 100 ligaments. It allows us to walk, run and jump and is made up in such a way that it can adapt to different surfaces.

When walking, the body weight is distributed mainly on the heel and the toe pads. The arch of the foot acts as a shock absorber. The multi-component structure and multiple joints allow for a variety of movements and heavy loads. Ligaments ensure stabilization and numerous muscles allow the foot and toes to turn in and out, bend and flex. This mobility is necessary for many everyday activities.

Foot and ankle conditions

Unfortunately, even the most perfect mechanism is subject to wear and tear and external stress. Therefore, pain and other complaints can occur as a result of age-related changes, as well as trauma or chronic diseases. Foot and ankle issues can be categorized into several groups.

Toe deformities

Some of the most common foot problems include improper position and shape of the toes, which can be acquired or congenital. As a result, pressure points and painful calluses form due to friction in shoes, and wounds can lead to severe inflammation.

Hallux valgus, i.e. a protruding ossicle on the foot (due to an outward deviation of the first toe) is a very common pathology of this type. One of the most convincing versions regarding the causes of such a defect is the hypermobility of the big toe, which is congenital, and therefore it can be observed even in small children and is sometimes traced from generation to generation. It is practically impossible to prevent the development of the disease, but there are effective methods of surgical correction. In all cases, we are talking about osteotomy - that is, correction of the bone, since it will not be possible to straighten the finger, affecting only the soft tissues. Among the available options, minimally invasive techniques are the most preferable, but they are offered only at specialized facilities.

Hallux rigidus is a degenerative disease of the metatarsophalangeal joint of the big toe. Unlike hallux valgus, in this case the big toe does not deviate towards the others, but remains mostly straight, with limited mobility of the metatarsophalangeal joint. This condition not only compromises the aesthetic appearance, but can also cause functional impairment and pain, which at first bothers only in motion, but later manifests itself at rest as well.

When symptoms are severe, intra-articular injections of steroidal anti-inflammatory drugs and/or hyaluronic acid and physical therapy are administered. Surgery is used if all conservative methods have been exhausted. Depending on the clinical situation and stage, cheilectomy (removal of bony growths), osteotomy or (in severe osteoarthritis) arthrodesis (i.e. fusion of the metatarsophalangeal joint) may be considered. Given the proper surgeon skills, all of these procedures can be performed through minimal incisions.

For other types of deformities (hammer toes, claw toes, overllapping toes), a variety of non-surgical and surgical treatment options are available at specialized facilities.

Hindfoot deformities

An imbalance of the various muscles of the foot and lower leg leads to the development of complex foot deformities. Heel misalignment or height shifts result in abnormal gait, improper weight transfer and severe pain.

The method of solving such issues depends on their nature (flat foot, hollow foot, varus foot/clubfoot, pointed foot, or so-called heel foot), the stage of the disease, the age of the patient and other individual circumstances. In some cases, wearing insoles or special shoes may be sufficient, while in others surgical procedures are necessary.

Joint arthrosis

Like the large joints (hips and knees), the joints of the feet are also subject to wear and tear. In some cases, this happens due to trauma, in other cases the cause is the incorrect position of the hindfoot that was formed for one reason or another. Either way, the loss of cartilage leads to friction between the joint surfaces with corresponding symptoms.

In particular, in ankle osteoarthritis, the main symptom is pain. In almost all forms of osteoarthritis, pain initially occurs only when the joint is under stress. A constant companion of the disease is joint stiffness, which increases as the cartilage wears away.

Symptoms develop in a wave-like fashion. At first, the painful phases are brief, but gradually they become more prolonged and frequent. They can be provoked by excessive physical activity or weather changes. At the last stage, they can occur even at rest.

Another sign of ankle osteoarthritis is swelling due to joint effusion. Bony growths (osteophytes) also occur, so shoes start rubbing the feet. Due to bone structure abnormalities, there is a misalignment of the foot and, as a consequence, unsteady gait, as well as a frequent ankle sprain.

Surgical treatment in the early stages may include removal of osteophytes, which is usually performed using minimally invasive arthroscopy. If ankle osteoarthritis is combined with foot defects, their correction has a positive effect. Although osteoarthritis itself is not eliminated in this way, the distribution of stress is normalized and the process of arthrosis development is slowed down.

At later stages, arthrodesis is recommended, i.e. artificial immobilization of the upper part of the ankle joint, which restores the limb's supporting function. Ankle replacement (i.e. implantation of an endoprosthesis) has very limited indications and is suitable only for elderly patients who lead an active lifestyle. Although modern endoprosthesis models show very good results, the problems are still the need for frequent replacement of the implant, which is associated with a large loss of bone substance.

Achilles tendon disorders

The Achilles tendon is the strongest tendon in the human body. By tensing the calf muscles, it lifts the weight of the entire body with each step. Excessive strain causes its damage and, in some cases, rupture.

Achillodynia

Pain along the Achilles tendon caused by inflammatory changes (achillodynia) is an inflammation of the tendon about 5 cm above its insertion in the heel. It is important to distinguish it from heel pain in Haglund's exostosis because of the completely different therapeutic approaches.

The goal of treatment is to reduce inflammation and restore the architectonics of the tendon. It almost exclusively involves conservative measures.

In the acute phase, it is recommended to reduce the stress on the tendon. For this purpose, the ankle joint is immobilized in a walker or plaster splint and, if necessary, partial crutch support is used. Oral analgesic therapy with anti-inflammatory drugs and periodic cooling also help to relieve inflammation. Deep stimulating radiotherapy, shock wave therapy and autologous conditioned plasma (ACP) have also proven effective. In the chronic phase, physiotherapy plays a central role. Exercise stimulates tendon regeneration and inflammatory adhesions of the tendon to the tendon sheath are eliminated with deep massage.

Achilles tendon rupture

About 11 to 37 per every 100,000 people get the injury every year. Men are affected 2-12 times more often than women. Two patient groups are at most danger, including young athletes aged 25-40, or patients with chronic tendon disease over the age of 60.

Traumatic Achilles tendon ruptures in young athletes often respond well to conservative treatment. Achilles tendon ruptures in elderly patients with chronic tendinopathies, as well as ruptures with a residual defect on a pointed foot ultrasound scan, require tendon suture. Conventional procedures were performed through a long incision and were often accompanied by impaired wound healing and infection. Modern techniques allow suturing through mini-accesses or even percutaneously. This means that severe complications can be avoided.

Heel pain

Every kilometer that you walk is a 60-ton load on your feet. Those can take a lot, but only up to a point. Eventually, repeatedly hitting hard surfaces and wearing insufficiently soft shoes can cause heel pain, the most common foot problem. It can occur due to inflammation of the ligaments and tendons around the heel, or bony overgrowths. Unfortunately, many patients ignore such symptoms. As a result, the pain eventually becomes chronic and much more difficult to treat.

Heel spur (plantar fasciitis)

Plantar fasciitis (also known as heel spur) is an irritation or inflammation of the ligament that runs along the sole of the foot (the plantar fascia). One in 10 people on the planet faces this problem at least once in their lives.

The word "spur" refers to a small bulge on the heel bone clearly visible on X-rays. However, it is not the true cause of the painful symptoms, which actually occur due to a chronic tension on the plantar fascia insertion. It leads to inflammatory changes with swelling and tenderness. Therefore, in some patients, a spur detected on x-ray does not cause complaints, and in others, on the contrary, pain is manifested in the absence of a bony protrusion. So, the medically correct diagnosis is "plantar fasciitis," that is, inflammatory irritation of the plantar fascia under the sole of the foot.

Initially, heel pain occurs only with prolonged stress, such as walking for long periods of time, but then it begins to bother even during everyday activities. Without treatment, it can become a troublesome constant condition even at rest and at night, which is very difficult to handle.

Therapy for this condition is almost always limited to conservative measures and may include:

• Wearing a soft pad under the heel to absorb the shock.
• Achilles tendon stretching exercises or night splints to reduce tension on the tendon tissue.
• Daily massage with a golf ball, glass bottle or roller (rolling over the painful area stimulates healing).
• Ultrasound and shockwave therapy on the irritated tissue to improve circulation and stimulate tissue regeneration.
• Local injections of corticosteroids for very severe pain (reduces inflammation and makes it possible to administer physical therapy).
• Botox injections (if other methods are ineffective).

This procedure can be performed either as open surgery or endoscopically. The choice of the type of surgery in each case depends on the individual anatomical features of the tissue. Sometimes it is also necessary to "release" the nerve that runs under the heel. This is a minor procedure that is usually performed on an outpatient basis.

Haglund's exostosis

This term refers to heel pain caused by chronic inflammation of the Achilles tendon attachemnt site. Patients often feel a "bump" on the back of the heel and complain of pain in the back of the heel and inability to wear closed shoes.

The acute phases of the disease can be treated with symptomatic pain therapy (anti-inflammatory drugs such as ibuprofen). Cryotherapy, immobilization in special walkers and reduction of physical activity also help.

In the chronic phase, X-ray therapy, shockwave therapy, as well as infiltration of local anesthetics are given. However, conservative measures are often insufficient, especially if the bony protrusion is very severe. In such cases, removal of the exostosis is recommended.

In the early stages, this can be done by a minimally invasive procedure, but in later stages, when calcifications appear in the tendon structure or the so-called posterior calcaneal spur, open surgery (open calcaneoplasty) is indicated.