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Mortons Neuroma An Overview

Overview

intermetatarsal neuromaPatients with Morton?s neuroma present with pain in the forefoot, particularly in the ?ball? of the foot. However, not all pain in the forefoot is a Morton?s neuroma. In fact, most chronic pain in the forefoot is NOT the result of a Morton?s neuroma, but rather is from metatarsalgia – inflammation (synovitis) of the ?toe/foot? joints. The symptoms from Morton?s neuroma are due to irritation to the small digital nerves, as they pass across the sole of the foot and into the toes. Therefore, with a true Morton?s neuroma, it is not uncommon to have nerve-type symptoms, which can include numbness or a burning sensation extending into the toes. There are several interdigital nerves in the forefoot. The most common nerve to develop into a neuroma is between the 3rd and 4th toes. With a true neuroma, the pain should be isolated to just one or two toes.

Causes

Poorly fitted footwear can be a cause. Shoes that have a tight and narrow toe box can cause the never to become entrapped causing the pain. High heeled shoes abnormally place the metatarsals under extreme pressure which can cause Morton?s Neuroma. In cases of abnormal pronation, there can be significant motion between the 3rd and 4th metatarsals which can cause an irritation to the nerve that runs between them. This inflammation causes the pain.

Symptoms

If you have a Morton?s neuroma, you may have one or more of these symptoms where the nerve damage is occurring, Tingling, burning, or numbness, pain, a feeling that something is inside the ball of the foot or a feeling that there?s something in the shoe or a sock is bunched up. The progression of a Morton?s neuroma often follows the following pattern. The symptoms begin gradually. At first they occur only occasionally, when wearing narrow-toed shoes or performing certain aggravating activities. The symptoms may go away temporarily by removing the shoe, massaging the foot, or by avoiding aggravating shoes or activities. Over time the symptoms progressively worsen and may persist for several days or weeks. The symptoms become more intense as the neuroma enlarges and the temporary changes in the nerve become permanent.

Diagnosis

Metatarsal bones will be examined clinically, and often an x-ray will be taken to assess the particular case and ensure against other conditions, including fracture. When the foot is examined by a doctor, he may feel a characteristic ?click,? referred to as Mulder?s sign, and the interspaces between toe bones will often be tender. The doctor may put pressure on these areas to localize the site of pain and test for other conditions, including calluses or stress fractures. Range of motion tests will also be applied to rule out arthritis or joint inflammations. X-rays may be required to ensure there are no stress fractures or arthritis within the joints that join the toes to the foot. Tenderness in one or more metatarsal bones may imply a pre-stress fracture or stress-fracture. An ultrasound scan may be used to confirm diagnosis of Morton?s Neuroma, as x-ray will not detect the condition, (but can confirm that the bones are uninjured).

Non Surgical Treatment

Depending on your overall health, symptoms and severity of the neuroma, the condition may be treated conservatively and/or with surgery. Non-surgical methods for neuroma are aimed at decreasing and/or eliminating symptoms (pain). Wear proper supportive shoes. Use an arch support. Wear shoes with a wide toe box. Modify your activities. Lose weight. Wear shoes with cushion. Prescribe an oral anti-inflammatory medication. Anti-inflammatory medication is useful to significantly reduce pain and inflammation. A physical therapist may perform ultrasound and other techniques to reduce inflammation. You will also be instructed how to stretch your foot and leg properly. Padding and/or cushioning of the ball of the foot is an effective method of preventing physical irritation with shoes. A custom foot orthotic is a doctor prescribed arch support that is made directly from a casting (mold) of your feet, and theoretically should provide superior support compared to shoe insert that you would purchase from a pharmacy. A cortisone injection is a powerful anti-inflammatory medication that is used to rapidly reduce the pain associated with an inflamed nerve. The pain relief that you may experience from the injection(s) is often temporary. Typically injection(s) are administered once every 2 months for a total of 3 injections or until the pain is resolved. A sclerosing alcohol injection is placed around the involved nerve to weaken its capacity to report pain. In other words, the alcohol injection will ?deaden? the affected nerve. The pain relief that you may experience from the injection(s) can be permanent. Typically injection(s) are administered once every week for a few weeks until the pain is resolved.interdigital neuroma

Surgical Treatment

If symptoms do not respond to any of the above measures then surgery may be suggested. This involves a short 30 minute operation to either remove tissue to take pressure off the nerve or to remove the nerve causing the pain. The surgery can be done as a day case but it will be two or three weeks before you can be fully active on your feet. There may be some lingering numbness afterwards if the nerve is removed. But surgery is successful in around 80% of cases. There is a small risk of complications such as infection and thickening of the skin on the soles of the feet.

Prevention

How can Morton?s neuroma be prevented? Do not wear tight shoes or high-heeled shoes for prolonged periods. Do wear shoes with a wide toe box so that your toes are not squeezed or cramped. Do wear athletic footwear with enough padding to cushion the balls of the feet when exercising or participating in sports.

Hammer Toe

Hammer ToeOverview
Hammertoe affects both joints of a toe, causing the toe to bend upwards at the proximal joint (the joint closest to the foot) and down at the distal joint (the one farthest away from the foot). The resulting unnatural bend is often compared to an upside down “V” and also to a hammer or a claw (The condition is sometimes referred to as clawtoe or clawfoot). A similar condition, in which the first joint of a toe simply bends downward, is called mallet toe. Since the arched bending of hammertoe often causes the toe to rub against the top of the shoe’s toe box and against the sole, painful corns and calluses develop on the toes. Hammertoe can also be a result of squeezing within a too-small or ill-fitting shoe or wearing high heels that jam your toes into a tight toe box inside your shoe, arthritis, trauma and muscle and nerve damage from diseases such as diabetes. Probably because of the tight-shoe and high-heel shoe factors, hammertoe tends to occur far more often in women than in men.

Causes
Most hammertoes are caused by wearing ill-fitting, tight or high-heeled shoes over a long period of time. Shoes that don’t fit well can crowd the toes, putting pressure on the middle toes and causing them to curl downward. The condition may be more likely when the second toe is longer than the first toe or when the arch of the foot is flat. Hammertoe can also be present at birth (congenital). Hammertoe also can be caused by a bunion, which is the knobby bump that sometimes develops at the side of the big toe. A bunion causes the big toe to bend toward the other toes. The big toe can then overlap and crowd the smaller toes. Occasionally, a hammertoe is inherited or caused by arthritis in the toe joint.

Hammer ToeSymptoms
The symptoms of a hammer toe are usually first noticed when a corn develops on the top of the toe and becomes painful, usually when wearing tight shoes. There may be a bursa under the corn or instead of a corn, depending on the pressure. Most of the symptoms are due to pressure from footwear on the toe. There may be a callus under the metatarsal head at the base of the toe. Initially a hammer toe is usually flexible, but when longstanding it becomes more rigid.

Diagnosis
The exam may reveal a toe in which the near bone of the toe (proximal phalanx) is angled upward and the middle bone of the toe points in the opposite direction (plantar flexed). Toes may appear crooked or rotated. The involved joint may be painful when moved, or stiff. There may be areas of thickened skin (corns or calluses) on top of or between the toes, a callus may also be observed at the tip of the affected toe beneath the toenail. An attempt to passively correct the deformity will help elucidate the best treatment option as the examiner determines whether the toe is still flexible or not. It is advisable to assess palpable pulses, since their presence is associated with a good prognosis for healing after surgery. X-rays will demonstrate the contractures of the involved joints, as well as possible arthritic changes and bone enlargements (exostoses, spurs). X-rays of the involved foot are usually performed in a weight-bearing position.

Non Surgical Treatment
Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. For many people, the second toe is longer than the big toe.) Avoid wearing tight, narrow, high-heeled shoes. You may also be able to find a shoe with a deep toe box that accommodates the hammer toe. Or, a shoe repair shop may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.

Surgical Treatment
If conservative treatments don’t help, your doctor may recommend surgery to release the tendon that’s preventing your toe from lying flat. In some cases, your doctor might also remove some pieces of bone to straighten your toe.

Hammer ToePrevention
Certain exercises such as moving and stretching your toe gently with your hands and picking up small or soft objects such as marbles or towels can keep your toe joints flexible, simple exercises can stretch and strengthen your muscles. Limit high-heel use, well-designed flat shoes will be more comfortable than high heels. Don’t wear shoes that are too short or too narrow, or too shallow, this is especially important for children going through periods of rapid growth, the toe area should be high enough so that it doesn’t rub against the top of your toes.

Bunions All You Want To Learn

Overview
Bunions Hard Skin
Even though bunions are a common foot condition, they are probably the one with the most misconceptions. Many people suffer unnecessarily with the pain of bunions for years before seeking treatment out of fear about the ?surgery?. The good news is that most bunion pain can be resolved without surgery.

Causes
Essentially, bunions are caused by a disruption of the normal interworking of the bones, muscles, ligaments and tendons that comprise your feet, often from wearing shoes that squeeze the toes or place too much weight-bearing stress on them. However, it should be pointed out that other causes or factors in the development of bunions can include flat feet or low arches in the feet, some forms of arthritis, problems with foot mechanics, foot injuries and neuromuscular disorders such as cerebral palsy. Arthritis in the MTP joint, for example, can degrade the cartilage that protects it, and other problems may cause ligaments to become loose. Pronation, walking in a way that your foot rolls inwards, increases your risk for developing bunions.
SymptomsThe most obvious symptoms of a bunion are. Pain in the area of the MTP joint, the joint where your big toe connects to your foot. Bending of the big toe in towards the other toes. An enlarged bump of bone or tissue at the MTP joint. Each symptom can range in degree from small to severe. Sometimes the pain can be sufficient to make it difficult to walk in normal shoes. Other symptoms may include. Swelling and inflammation of the skin around the MTP joint. Thickening of the skin in the area of the joint. Restricted motion in your big toe. Pressure from the inward bending of your big toe can affect your other toes, leading to corns on your smaller toes. Ingrown toenails on the smaller toes. Development of hammertoes in the other toes. Calluses on the bottom of your foot. If you have any of these symptoms, especially pain, displacement of your big toe or development of a bulge, you should consider consulting your physician. Even if you’re not significantly bothered by some of these symptoms, bunions tend to continue getting bigger and more serious over time and should be taken care of before they do so.

Diagnosis
Before examining your foot, the doctor will ask you about the types of shoes you wear and how often you wear them. He or she also will ask if anyone else in your family has had bunions or if you have had any previous injury to the foot. In most cases, your doctor can diagnose a bunion just by examining your foot. During this exam, you will be asked to move your big toe up and down to see if you can move it as much as you should be able to. The doctor also will look for signs of redness and swelling and ask if the area is painful. Your doctor may want to order X-rays of the foot to check for other causes of pain, to determine whether there is significant arthritis and to see if the bones are aligned properly.

Non Surgical Treatment
There are many treatment options for bunions and they will vary with the type and severity of each bunion and will also depend on what is causing the symptoms. Bunions are almost always progressive and tend to get larger and more painful with time, how fast this happens may be a function of the fit of the footwear. The initial goal of treatment options is to relieve pressure on the bunion and any symptoms that may be present and to halt or slow the progression of the joint deformity. There is no effective may be “get rid off” a bunion without surgery. There are a number of things that individuals and Podiatrists can do to help the symptoms and slow (if not halt) progression.
Bunions Hard Skin

Surgical Treatment
The operation involves removing the enlarged portion of bone. Ligaments and tendons that are too tight around the joint are released. The metatarsal bone in the big toe is then cut and shifted to a normal alignment that also makes the forefoot narrower. The cut bone is held in place with a screw or wire, which is not removed unless it causes problems. The loose, stretched out joint capsule is then tightened completing the soft tissue balance required for your deformity. Both feet can be operated on at the same time, but this does further limit mobility after surgery.

Prevention
Here are some tips to help you prevent bunions. Wear shoes that fit well. Use custom orthotic devices. Avoid shoes with small toe boxes and high heels. Exercise daily to keep the muscles of your feet and legs strong and healthy. Follow your doctor?s treatment and recovery instructions thoroughly. Unfortunately, if you suffer from bunions due to genetics, there may be nothing you can do to prevent them from occurring. Talk with your doctor about additional prevention steps you can take, especially if you are prone to them.

Over-Pronation

Overview

Over Pronation (Flat Feet) refers to the biomechanical shock-absorbing motion of the ankle, foot and lower leg. It is the natural inward flexing motion of the lower leg and ankle. Standing, walking, and running cause the ankle joint to pronate which in turn helps the body to absorb shock and allows it to control balance. An ankle joint that is too flexible causes more pronation than desired. This common condition is called Over- Pronation (sometimes referred to as “Flat Feet”). This foot condition places an extreme degree of strain on various connective tissues of the ankle, foot, and knee. If this condition is not addressed foot pain and toe deformities such as bunions and hammer toes (just to name a couple) may develop. Hip and lower back pain may also be residual results from this condition.Overpronation

Causes

Generally fallen arches are a condition inherited from one or both parents. In addition, age, obesity, and pregnancy cause our arches to collapse. Being in a job that requires long hours of standing and/or walking (e.g. teaching, retail, hospitality, building etc) contributes to this condition, especially when standing on hard surfaces like concrete floors. Last, but not least unsupportive footwear makes our feet roll in more than they should.

Symptoms

Overpronation can lead to injuries and pain in the foot, ankle, knee, or hip. Overpronation puts extra stress on all the bones in the feet. The repeated stress on the knees, shins, thighs, and pelvis puts additional stress on the muscles, tendons, and ligaments of the lower leg. This can put the knee, hip, and back out of alignment, and it can become very painful.

Diagnosis

Look at the wear on your shoes and especially running trainers; if you overpronate it’s likely the inside of your shoe will be worn down (or seem crushed if they’re soft shoes) from the extra strain.Overpronation

Non Surgical Treatment

Overpronation is usually corrected with orthotics and/or strengthening exercises for the tibialis posterior. Massage treatment can relieve myofascial trigger points in the tibialis posterior, and other muscles, and address any resulting neuromuscular dysfunction in the leg or foot. Biomechanical correction of overpronation might require orthotics, neuromuscular reeducation, or gait retraining methods, as well. Stretching the gastrocnemius and soleus muscles will reduce hypertonicity in these muscles and also is essential for effective treatment. Because of impacts throughout the remainder of the body, the detrimental effects of overpronation should not be overlooked.

Surgical Treatment

Subtalar Arthroereisis. Primary benefit is that yje surgery is minimally invasive and fully reversible. the primary risk is a high chance of device displacement, generally not tolerated in adults.

An implant is pushed into the foot to block the excessive motion of the ankle bone. Generally only used in pediatric patients and in combination with other procedures, such as tendon lengthening. Reported removal rates vary from 38% – 100%, depending on manufacturer.

Physical Therapy And Severs Disease

Overview

Sever’s Disease, otherwise known as calcaneal apophysitis is an inflammation of the growth plate in the heel of growing children, typically adolescents. The condition presents as pain in the heel and is caused by repetitive stress to the heel and is thus particularly common in active children. It usually resolves once the bone has completed growth or activity is lessened.

Causes

There are several factors which may increase the likelihood of developing this condition. These need to be assessed and corrected with direction from a physiotherapist to ensure an optimal outcome. Some of these factors include inappropriate footwear, calf tightness and/or weakness, joint stiffness (particularly the foot and ankle), poor lower limb biomechanics, inappropriate or excessive training, inadequate recovery periods from training or activity, inappropriate training surfaces, inadequate warm up, poor core stability, a lack of lower limb strength and stability, poor proprioception or balance, rapid growth and age.

Symptoms

Sever?s disease is a clinical diagnosis based on the youth?s presenting symptoms, rather than on diagnostic tests. While x-rays may be ordered in the process of diagnosing the disease, they are used primarily to rule out bone fractures or other bone abnormalities, rather than to confirm the disease. Common Characteristics of Sever?s Disease include Posterior inferior heel pain. Pain is usually absent when waking in the morning. Increased pain with weight bearing, running, or jumping (or activity-related pain). Area often feels stiff or inflexible. Youth may limp at the end of physical activity. Tenderness at the insertion of the tendons. Limited ankle dorsiflexion range that is secondary to tightness of the Achilles tendon. Activity or sport practices on hard surfaces can also contribute to pain, as well as poor quality shoes, worn out shoes, or the wrong shoes for the sport. Typically, the pain from this disease gradually resolves with rest.

Diagnosis

A doctor or other health professional such as a physiotherapist can diagnose Sever?s disease by asking the young person to describe their symptoms and by conducting a physical examination. In some instances, an x-ray may be necessary to rule out other causes of heel pain, such as heel fractures. Sever?s disease does not show on an x-ray because the damage is in the cartilage.

Non Surgical Treatment

The doctor might recommend that a child with Sever’s disease. perform foot and leg exercises to stretch and strengthen the leg muscles and tendons, elevate and apply ice (wrapped in a towel, not applied directly to the skin) to the injured heel for 20 minutes two or three times per day, even on days when the pain is not that bad, to help reduce swelling, use an elastic wrap or compression stocking that is designed to help decrease pain and swelling, take an over-the-counter medicine to reduce pain and swelling, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin).

Achilles Tendon Injury Rehab

Overview
Achilles Tendonitis
Rupture of the Achilles tendon is a common injury in healthy, young, active individuals. The rupture is typically spontaneous and most commonly observed in individuals in between 24-45 years of age. The majority have had no prior history of pain or previous injury to the heel. In the majority of cases, rupture of the Achilles tendon occurs just a few centimeters above the heel bone. Common causes of Achilles tendinitis or rupture include advanced age, poor conditioning, and overexertion during exercise. In most cases, the individual rapidly performs activity like running or standing on the toes, which generates intense force on the tendon, leading to rupture. Achilles tendon rupture is often described as an abrupt break with instantaneous pain that is felt in the foot or heel area. The pain may radiate along the back of the leg and is often intense. Generally, walking may be difficult and the foot may drag. Most individuals claim that they felt like they were kicked in that area or even shot at. These symptoms lead to a suspicion of rupture of the Achilles tendon. Sometimes the tendon does not fully rupture but only a partial tear develops. The partial tear can also present with pain, and if not recognized, can rapidly develop into a full-blown rupture. In the majority of cases, the Achilles tendon rupture occurs just above the heel, but it may occur anywhere along the length of the tendon.

Causes
As with any muscle or tendon in the body, the Achilles tendon can be torn if there is a high force or stress on it. This can happen with activities which involve a forceful push off with the foot, for example, in football, running, basketball, diving, and tennis. The push off movement uses a strong contraction of the calf muscles which can stress the Achilles tendon too much. The Achilles tendon can also be damaged by injuries such as falls, if the foot is suddenly forced into an upward-pointing position, this movement stretches the tendon. Another possible injury is a deep cut at the back of the ankle, which might go into the tendon. Sometimes the Achilles tendon is weak, making it more prone to rupture. Factors that weaken the Achilles tendon are corticosteroid medication (such as prednisolone), mainly if it is used as long-term treatment rather than a short course. Corticosteroid injection near the Achilles tendon. Certain rare medical conditions, such as Cushing?s syndrome, where the body makes too much of its own corticosteroid hormones. Increasing age. Tendonitis (inflammation) of the Achilles tendon. Other medical conditions which can make the tendon more prone to rupture, for example, rheumatoid arthritis, gout and systemic lupus erythematosus (SLE) – lupus. Certain antibiotic medicines may slightly increase the risk of having an Achilles tendon rupture. These are the quinolone antibiotics such as ciprofloxacin and ofloxacin. The risk of having an Achilles tendon rupture with these antibiotics is actually very low, and mainly applies if you are also taking corticosteroid medication or are over the age of about 60.

Symptoms
The most common symptom of Achilles tendonitis is a sudden surge of pain in the heel and back of the ankle at the point of injury which is often described as a snapping sensation in the heel. After the injury has occurred, patients then struggle or find it near impossible to bear any weight on the affected leg. Pain can often be most prominent first thing in the morning after the injury has been rested. Swelling and tenderness is also likely to appear in the area.

Diagnosis
A detailed history, and examination by an appropriately qualified health professional, will allow a diagnosis to be made. An ultrasound or MRI scan can confirm the diagnosis. Other causes of symptoms in the area, such as those referred from the lumbar spine and local infection, should be excluded.

Non Surgical Treatment
The best treatment for a ruptured Achilles tendon often depends on your age, activity level and the severity of your injury. In general, younger and more active people often choose surgery to repair a completely ruptured Achilles tendon while older people are more likely to opt for nonsurgical treatment. Recent studies, however, have shown fairly equal effectiveness of both operative and nonoperative management. Nonsurgical treatment. This approach typically involves wearing a cast or walking boot with wedges to elevate your heel; this allows the ends of your torn tendon to heal. This method can be effective, and it avoids the risks, such as infection, associated with surgery. However, the likelihood of re-rupture may be higher with a nonsurgical approach, and recovery can take longer. If re-rupture occurs, surgical repair may be more difficult.
Achilles Tendon

Surgical Treatment
Debate remains regarding the best form of treatment for a ruptured Achilles tendon. The 2 options are:immobilisation or operation. A recent meta-analysis of scientific studies showed that compared to immobilisation, an operation reduces the risk of re-rupture and allows a quicker return to work. An operation is not without risk and these must be balanced against the benefit of a lower re-rupture rate. Both treatments involve immobilisation for 8 weeks.

Prevention
There are things you can do to help prevent an Achilles tendon injury. You should try the following. Cut down on uphill running. Wear shoes with good support that fit well. Always increase the intensity of your physical activity slowly. Stop exercising if you feel pain or tightness in the back of your calf or heel.