Foot & Ankle

Ankle Fractures

One of the most common orthopedic injuries is an ankle fracture. This simply means that at least one of the bones in the ankle joint is broken. There are many different culminations of an ankle fracture, ranging from a simple, single-bone break, to a more complex multi-bone break. Since there is such a wide range of severity in ankle fractures, treatments differ from patient to patient. Some ankle fractures will require surgical treatment to achieve the most desirable outcome, while others may be treated with immobilization measures/offloading.

There are several things that can lead to an ankle fracture. Some of the most common incidences include twisting or rotating of the ankle, falling, high impact to the ankle joint, and rolling of the ankle. Following an injury, some symptoms that would suggest an ankle fracture include pain, swelling, or abnormal appearance or position of the ankle and foot.

Midfoot fractures

The midfoot can be identified as the center region of the foot where several bones form the arch of the foot. There are five long bones, called metatarsals, that extend from the midfoot area to the toes. There are connective tissues (ligaments) that stretch throughout the foot to hold the metatarsals in place. Several injury types can lead to tears and strains of the ligaments, and dislocations and fractures of the bones.

A midfoot fracture is categorized by broken bones or injury to the joints in the midfoot. There are a variety of injuries that can lead to a midfoot fracture. These injuries could range from a motor vehicle accident to a sporting injury. A common type of midfoot injury is known as a Lisfranc fracture/injury. This occurs when one of the metatarsal bones is displaced from the bones in the arch (tarsus).

Causes of a midfoot fracture include anything from a twist and fall or a stumble over a foot that is downward flexed, to direct trauma. Following an injury, common symptoms that would indicate a midfoot fracture are swelling and pain on the top of the foot, bruising on the top and/or bottom of the foot, and increased pain when weight-bearing. Depending on the particular pattern of injury and alignment of the bones, some of these injuries may require surgery to obtain an optimal outcome while others may be treated more conservatively with protective measures.

Stress Fractures

A stress fracture is categorized as an overuse injury that is most commonly seen in athletes. It occurs when someone increases intensity or amount of an activity at a rapid pace and the muscles become fatigued. The stress from overuse is transferred from the overused muscles to the bone, resulting in the bone breaking, or almost breaking, which is known as a stress fracture.

A stress fracture can occur in any bone, but it is more common in weightbearing bones, such as those in the lower leg and foot. They are often seen when there is a significant increase in use involving the bone. Athletes that do a lot of running and jumping are most susceptible to this type of injury.

A common symptom involves increasing pain with use that improves with rest. Typically, a stress fracture is treated with rest to avoid making the injury worse by continuing activity.

Calcaneus Fracture

A calcaneus (heel) fracture is typically a more severe injury that can be rather painful and disabling. The bones in the foot can be divided into three sections called the hindfoot, midfoot, and forefoot. The hindfoot and midfoot are made up of a group of seven bones (tarsals). The largest of the tarsals is the calcaneus bone, located in the hindfoot, just below the ankle.

The most common cause of a calcaneus fracture is a fall from a height in which the person lands on their feet. Symptoms usually seen with this type of injury include bruising, pain and swelling, the inability to bear weight, and deformity of the heel. Treatment for calcaneus fractures range depending on the severity of the injury. In some situations, immobilization is appropriate, but many of these injuries may warrant surgical treatment to increase the likelihood of a positive outcome.

Fifth Metatarsal Fracture

The group of bones that connects the phalanges (toe bones) to the tarsals (midfoot bones) is known as the metatarsals. There is one long metatarsal bone connected to each toe. The fifth metatarsal is the outermost bone on the foot. A fifth metatarsal fracture is quite common, especially in athletes.

Direct blows to the foot are the most common cause of a fifth metatarsal fracture. Bruising and discoloration of the area is often seen with this kind of fracture, along with pain when walking and weight bearing. Treatment is determined based on the severity of the fracture and the symptoms present. In some extreme cases, surgery may be necessary, while in other cases immobilization may be all that is necessary.  

Ankle Sprain

Ankle sprains are some of the most common injuries that can occur in all groups of people. Ligaments are the strong tissues that connect bones to other bones. There are numerous ligaments that connect the bones of the foot and the ankle to provide support and stability. An injury to one of these ligaments is known as a sprain.

Sprains can range in severity, from a minuscule tear in the ligament to a tear completely through the tissue. An ankle sprain is usually caused by an unexpected twist of the ankle that can happen in a variety of activities. Symptoms commonly seen with a sprained ankle include bruising, swelling, pain with touch and weight bearing, and instability.

The most common treatment for ankle sprains involves supportive bracing and progressive rehabilitation to allow for the return to activities and sports. Typical aspects of the treatment process include resting, icing, compression, and elevation.  When these measures are not successful, surgical treatment may be needed to provide stability and minimize pain for the patient.

Achilles Rupture – Tendons are the tissues that connect muscles to bones. The Achilles tendon connects the calf muscle to the heel bone and enables you to push off during your stride, stand on your toes, and run effectively.  A rupture, or tear, of this tendon may occur during use when the tendon is under significant stress or is overstretched. Sudden or forceful jumping, running, or pivoting movements can cause a tear in the Achilles tendon. This injury is most common in the “weekend warrior.”

Some symptoms of an Achilles rupture include a sudden pain in the back of the ankle or calf, a popping feeling, swelling, and difficulty walking. Treatment of this injury ranges from protected splinting to surgical repair of the torn tendon. The type of treatment chosen is individualized based on many factors, including a patient’s level of activity and the type/severity of the tear.

Tendinitis

Tendinitis about the foot and ankle is a common complaint among active patients. It most typically involves the tendons passing from the lower leg (in the area of the calf musculature) into the foot, crossing the ankle. Tendinitis is essentially the inflammation of these tendons.  

The most common cause of tendinitis is due to overuse, though it may be caused by inflammatory/auto-immune conditions as well. Tendinitis usually produces symptoms that include pain that increases with exercise or use, swelling that increases with exercise or use, and thickening of the tendon.  Treatment typically involves efforts to decrease inflammation including anti-inflammatories and rest or immobilization.

Turf Toe

Within the big toe, there are two joints. The larger joint (metatarsophalangeal joint – MTP) is where turf toe occurs. It is the joint that connects the toe (phalanx) to the long bone (metatarsal) in the foot. There are several tissues, ligaments, tendons, and bones that surround this joint. This group of structures is known as the plantar complex.

Turf toe is defined as an injury to any of the tissues in the plantar complex. It is often seen in sports when an athlete plants hard on their toe while their heel is off the ground. The injury ranges from simply stretching the tissue to a total dislocation of the joint.

Some symptoms can include swelling, bruising, tenderness, and difficulty moving the big toe. This painful injury can also interfere with the ability to run.  Treatment most commonly involves protected immobilization and gradual return to activities though some severe cases will be best treated with surgical intervention.

The Flatfoot

Flatfoot, or pes planus, is a condition of decreased height of the arch of the foot.  There is a spectrum of arch height among individuals ranging from very low arches and very flat feet to very high arches and other feet.  Arch height may be determined somewhat genetically or can be related to degenerative conditions or past trauma.  

A flatfoot may be caused by loss of function of one of the tendons (posterior tibial tendon) that helps hold the arch of the foot up.  It is not uncommon for this tendon to lose its strength and function. This is most often seen in middle age or older individuals. With tendon function loss or other conditions that cause loss of arch height, some patients experience pain along the inside and/or the outside of the ankle and hindfoot region.

A flatfoot may be normal for some individuals and may not cause any problems. However, for other individuals, it may be painful due to structures impinging on one another or possible rubbing and poor shoe fitment. Common symptoms include aching/pain on the inside of the foot and ankle, along with pressure and pain possible around the outside of the ankle.

There are many treatments for this condition, ranging from arch supports and medications to surgical procedures to realign the foot or fuse bones in the foot to hold the shape of the foot.  Evaluation of the specific cause of this issue in each individual helps to guide treatment plans.

High Arch

An increased arch height may be genetically driven and part of development, or may be driven by certain conditions. Some of these are related to abnormal nerve and muscle conditions such as strokes or various other neuromuscular disorders. This can sometimes lead to pain along the outside of the foot, because the foot is driven to the outside by the increased arch height.  

Individuals may sometimes develop pain or fractures of the bones along the side of the foot due to this overload.  When this is the case, treatments including orthotics or surgical intervention to realign the foot or fuse the bones of the foot into a more appropriate alignment are sometimes warranted.  An individual evaluation of the cause of the elevated arch and painful process is necessary to guide treatment.

Bunion

A bunion deformity involves the big toe and is typically a slowly progressive angling of the toe away from the other foot and towards the other toes of the same foot.  With a bunion, there is a change in the alignment of the bones of the big toe. There are many causes of a bunion ranging from genetic predisposition to shoe wear, such as high heels with a narrow toe box.

Bunions can affect shoe wear sizing as the foot is wider at the forefoot and can create rubbing points along the inside aspect of the great toe. There is typically an obvious bump noted on the inner side of the foot. It is also common for the big toe to begin rubbing against the lesser toes.

While bunions can be concerning for a patient with regard to the cosmetic appearance, treatment is typically aimed at elimination of pain. Spacers or pads may be all that is needed to treat this.  When these measures are not helpful, surgical correction of a bunion may be necessary.  Bunion surgery typically involves realigning the bones by cutting or fusing them to improve the alignment of the big toe.  Bunions range from mild to severe and the specific surgery indicated depends on the type of bunion.  Discussion with your surgeon will help decide the best treatment for you.

Hammertoes and Other Smaller Toe Deformities

The smaller, or lesser toes, may develop abnormal appearance or alignment.  This is commonly seen as individuals continue to age and involves an imbalance of the muscles and tendons to the toes.

A hammertoe is among the most common deformities of the toes and involves an abnormal bending of the joints in the toe.  The second toe is the most commonly affected by this deformity, followed by the third and fourth.  Sometimes the toes become angulated towards other toes and may overlap them.

Hammertoe sleeves and splints may be useful to improve the alignment of the toe and reduce blisters.  If the affected toe is rubbing against the top of the shoe or is rubbing against the other toes and creating sores at either site or is painful, surgery may be indicated to correct the alignment of the toe.  Hammertoe surgery usually involves a slight shortening of the toe with fusion of the abnormally angulated joint as well as soft tissue realignment to aim the toe in the correct direction.

Arthritis of the Foot

As with many other joints in the body, the various joints of the foot are subject to arthritis as well.  This arthritis can come in many forms, including osteoarthritis (wear and tear from use over time) or from autoimmune sources such as rheumatoid arthritis or other autoimmune diseases.  

Symptoms of arthritis range in severity from patient to patient. Some common symptoms include inflammation, or enlargement of the joint, and a pain or aching feeling. Stiffness or difficulty moving the joint are often seen as well.

Treatment for arthritis in the foot depends on the source.  If an autoimmune source is the underlying reason for the arthritis, treatment that can include physical therapy may improve the symptoms.  If abnormal wear is causing excess stress on the joint, as is sometimes seen in certain deformities, corrective orthotics or bracing may improve the conditions.  Medication or injection may also be useful to help treat symptoms.  When conservative measures are no longer helpful, surgery may be indicated and often involves fusion of that joint.  Fusing a joint will eliminate the motion at a painful or dysfunctional joint.  By removing the motion, joint pain is improved.

Arthritis of the Ankle

Similar to other joints, the ankle joint is also subject to arthritis of many forms. This arthritis can come in many forms, including osteoarthritis (wear and tear from use over time) or from autoimmune sources such as rheumatoid arthritis or other autoimmune diseases.  

Symptoms of arthritis range in severity from patient to patient. Some common symptoms include inflammation, or enlargement of the joint, and a pain or aching feeling. Stiffness or difficulty moving the joint are often seen as well.

Treatment of this arthritis includes medications or bracing. If these factors are not helpful, surgery may be necessary.  Surgical treatment of ankle arthritis typically involves either a fusion or arthroplasty (joint replacement). Fusion of the ankle joint means eliminating the joint, and therefore the motion that is painful at this joint.  This is often very helpful in treating the pain of arthritis.  Ankle arthroplasty involves replacing the joint surfaces of the ankle with metal and plastic components to eliminate pain and to help maintain normal ankle function.  Some patients are better served with ankle fusion over ankle replacement and vice versa.  The decision is based on factors specific to the patient and a discussion with your surgeon will help decide which treatment is best for you.