Plantar Fibroma

A plantar fibroma is a benign (non-cancerous) nodule that grows in the arch of the foot and usually appears between ages 20 and 60. It usually is slow-growing and often less than one inch in size. Some can grow faster and are considered plantar fibromatosis. A plantar fibroma or fibromatosis is a disease of the fibrous tissue that grows between the skin and the underlying fascia.

Symptoms

The main symptom is a mass on the bottom of the foot, roughly in the middle of the arch or instep, between the heel pad and the forefoot (front of the foot) pad. The mass will cause a soft curve in the contour of the bottom of the foot that may be painful with pressure or shoe wear.

Causes

The cause is unknown but thought to have a genetic component. Plantar fibromas are commonly seen in people of white, Anglo-Saxon, Protestant backgrounds. Trauma to the foot does not seem to be a factor. Alcohol consumption may be a factor.

Plantar fibromas reside in the deep fascia of the foot between the skin and the first layers of muscle. The more aggressive condition of plantar fibromatosis may involve the skin and the muscle layers and may also wrap around the local digital nerves and arteries.

Diagnosis

Your foot and ankle orthopedic surgeon will conduct a physical exam. If a plantar fibroma exists, they will find a mass in the plantar fascia in the arch. The mass has no swelling, increased warmth, or redness. It is firm and does not move. There are no skin changes. Advanced imaging is usually not needed but MRI will show the fibroma in the plantar fascia layer.

There are a few conditions that can cause soft-tissue masses in the foot, including cysts, swollen tendons or tendon ruptures, nerve tumors (neurilemomas), or fat tumors. Foreign body reactions from previous penetrating trauma also can cause a mass in the bottom of the foot, as can an infection. A more serious synovial cell sarcoma, a malignancy, usually will show calcification on X-ray and a more worrisome appearance on MRI. Clinical exam, X-ray, and sometimes an MRI may be needed for diagnosis. Biopsy usually is not needed.

Pilon Fracture

The tibia (shin bone) and the fibula are the bones of the lower leg. Pilon fractures are injuries that occur at the lower end of the tibia and involve the weightbearing surface of the ankle joint. The fibula also may be broken. These injuries were first described more than 100 years ago and remain one of the most challenging problems for orthopedic surgeons to treat.

The word “pilon” comes from the French and means pestle. A pestle is a tool used for crushing or pounding things. This crushing describes what happens to the tibia and fibula bones at the ankle joint due to the high-energy impact of the injury.

Symptoms

Pilon fractures are very painful and debilitating injuries. Symptoms include pain and inability to bear weight on the leg. They often result in an obvious deformity of the ankle joint. Swelling occurs quickly and can be followed by bruising.

Causes

Pilon fractures occur when the talus (ankle bone) is driven into the leg with such force that the leg bones break at the ankle joint. Common causes of pilon fractures are falls from heights and car accidents.

Diagnosis

Your foot and ankle orthopedic surgeon will take your medical history and perform a physical examination of your leg and ankle. The results of this exam will help the surgeon to determine how best to treat the pilon fracture. Your surgeon will be watchful for other injuries that may be present.

In addition, your surgeon will take X-rays of your leg and ankle to see how badly the tibia and fibula are broken. The bones may be broken in multiple places. The surgeon also may get a CT scan of your ankle to view all of the broken areas of the tibia and fibula.

Treatment

Some pilon fractures do not need surgical treatment. These are typically lower-energy injuries to the tibia and fibula at the ankle joint. The bones are broken but simply shifted out of place and these injuries tend to be less severe. These lower-energy pilon fractures can be treated with a leg cast.

Most pilon fractures have multiple breaks. There often are large separations between fractured fragments and instability in the tibia and fibula at the ankle joint. These fractured bones often benefit from surgery.

The goals of pilon fracture surgery are to restore alignment and stability and allow healing of the tibia and fibula at the ankle joint. Once the fractures are healed, the goals are to restore your ankle’s movement and strength.

Specific Technique

Pilon fracture surgery usually is done in two steps to protect the skin and soft tissue. Orthopedic surgeons do not routinely perform incisions through areas of damaged skin because doing so may result in wound healing problems. Surgeons often must wait until a patient’s soft tissue improves before incisions can be made. A notable exception would be an open fracture where the bone has penetrated through the skin during the initial bone break.

Stage One

In many cases the first stage in treating pilon fractures is by surgically applying an external fixator to the patient’s leg. This fixator is a frame applied outside of the leg that holds the leg and ankle in proper position. This allows both the patient and surgeon to regularly inspect the soft tissue of the leg and ankle without frequent splint changes. The fibula fracture may be treated at the same time the external fixator is placed. This part of the procedure is known as open reduction and internal fixation of the fibula (ORIF).

It may take several weeks after the first surgery before the patient’s soft tissues improve and the leg is ready for the second stage of surgical treatment. This delay can be frustrating for the patient, but it may be necessary to minimize the risk of a wound healing problem. The wait does not affect overall results. In some cases the external fixator is used as the final treatment and is kept in place for many weeks to months. Patients often are asked to elevate their leg to quickly reduce their swelling to prepare for the second stage.

Stage Two

The second stage of surgical treatment is to remove the external fixator and fix the tibia fracture using plates and screws. The fibula may also receive an ORIF if it was not fixed in the first stage.

When an external fixator is applied surgically to the patient’s leg, steel pins are placed in the tibia far above the fracture and also in the heel (calcaneus) and foot (metatarsals) bones far below the fracture. The pins are placed through small incisions that minimize damage to the soft tissues. They attach to metal bars outside the skin. The external fixator helps to hold the leg and ankle in proper position while the patient’s soft tissues improve.

The fibula may be fixed at the same time if the skin is not damaged. ORIF of the broken fibula involves an open incision over the bone. The broken fragments are put back together and held in place with a metal plate and screws. Special care is taken to restore the length of the fibula. The incision is then sewn together in layers. Deep tissue over the bone is closed with sutures and the skin is closed with sutures or staples.

This next step is an ORIF of the tibia bone. This step may be delayed several days or even weeks after the initial surgery. The incisions typically are at the front or the inner side of the ankle. Other incisions may be made depending on the injury. The broken fragments are put back together and held in place with metal plates and screws. Special care is taken to restore the shape and stability of the ankle joint. The fibula may be fixed with an ORIF if it was not previously treated. The incisions are then sewn together. The external fixator is typically removed and the leg is placed in a splint. This involves slabs of plaster that are applied to the rear and sides of the leg, ankle and foot. Special care is taken to cushion the leg with appropriate padding.

Recovery

It often takes 3-6 months for the breaks in the tibia and fibula bones to heal. Until the bones fully heal, the patient’s leg and ankle cannot be stressed or worked too hard. Advancing activity too soon before the tibia and fibula bones are healed can jeopardize the repair and ultimately bone healing.

The surgeon also must schedule regular visits to monitor healing of the fracture and advance the patient’s activity accordingly. Many surgeons have a specific schedule for patients to see them in the office for post-surgical follow-up until the pilon fracture is fully healed.

The patient’s first post-surgical visit is usually about two weeks after surgery. The splint is removed and the patient’s leg is examined. The sutures/staples are removed if the incisions are healing well. If there is more severe leg swelling, the surgeon may wait longer before removing the sutures/staples. X-rays of the leg and ankle are performed to confirm that the tibia and fibula fractures are still in place. The leg in then placed in either a cast or a removable boot.

Patients usually received monthly follow-up with their surgeon. At each of these regular visits, the surgeon checks on the patient’s leg’s soft tissue, bones and ankle joint. The soft tissue is checked for swelling and wound problems, while the bones are checked on X-rays for the progression of healing. The ankle joint is checked for movement, strength, and stability.

Patients are restricted from full weight bearing on their operated leg until there is complete healing of the tibia and fibula bones. Patients are not allowed to bear weight on their leg in their post-surgical splint. Patients are not allowed to bear any weight on their operated leg until there is evidence of bone healing. This period of non-weight bearing is with the leg in either a cast or boot. It usually takes 6-12 weeks to see initial bone healing on X-rays.

So long as the patient’s tibia and fibula are healing with each subsequent visit, weight bearing activity gradually can be increased in the protective boot. Patients ultimately can remove the boot and gradually resume activities in normal shoes.

The time to achieve full bone healing of a pilon fracture typically occurs 3-6 months after surgery, but it often takes patients 12 months or more to fully recover from the injury. These are serious ankle injuries. Most patients do not return to the same function that they had before getting hurt. It is common for patients to have residual aches, swelling, stiffness, and weakness even after the tibia and fibula bones are healed. Some patients may need physical therapy to help in their recovery.

Risks and Complications

Early potential complications are problems that can occur within the first few weeks after surgery. Many of these are wound-related, whether these are healing problems or infection. Some of these are superficial problems or infections that can improve with wound care and oral antibiotics. Deeper wound problems or infections can occur and are more severe. These problems often need further surgery or stronger antibiotics to eliminate the infection.

Other potential complications can occur within several months after surgery. Many of these involve difficulties with bone healing at the fractured areas. Some patients experience “delayed unions” in which the bones ultimately heal but take longer than six months to do so. Many delayed unions can improve by immobilizing the leg and limiting full activities for the longer amount of time it needs to heal. Some surgeons may recommend that the patient use a bone stimulator. This is a removable device that is worn on the patient’s leg that uses ultrasound or electrical impulses to help stimulate bone healing.

Another potential problem is a nonunion. This is when the bones do not fully heal. Some nonunions develop when the blood supply to the bones has been damaged from the injury. Other nonunions occur if there is too much movement between fractured pieces of bone. Some of these can be treated in the same way as delayed unions. Other nonunions may need surgery. The surgery to treat the nonunion depends on an individual’s situation. It may involve procedures like adding healthy bone from other parts of the body or chemicals to help stimulate bone healing.

Long-term complications can occur many years after the patient’s pilon fracture is healed. The most common is ankle arthritis. Restoring tibia and fibula bone and ankle joint alignment lessens the chances of patients developing ankle arthritis. However, the cartilage at the tibia that helps to cushion the ankle joint can be irreversibly damaged during the initial injury. Arthritis can result in pain, swelling, stiffness, and weakness at the leg and ankle.

FAQs

If my ankle is at risk for developing arthritis from the pilon fracture itself, why should I have surgery?

It is true that your ankle is at risk for developing arthritis after sustaining a pilon fracture, but the chances of developing ankle arthritis generally are lower with surgery compared to non-surgical treatment. Surgery offers the advantage of putting the broken pieces of the tibia and fibula back together. The chances of developing arthritis are reduced if the shape of the joint is restored than if the joint heals in an abnormal shape without surgery.

Do the implants that have fixed my pilon fracture ever need to be removed?

There are very few reasons to remove any internal plates or screws from the tibia and fibula bones. One reason would be if they are painful after the fracture is healed. This involves surgery on your leg to get them out. Another reason for implant removal would be if they became infected. This can happen while your fracture is healing or after it has already healed. The treatment for infection can be very complex and depends on your specific situation.

Is there anything I can do to improve bone healing?

What helps your tibia and fibula bones heal best after your pilon fracture surgery is to follow your surgeon’s post-surgical instructions. Advancing activity too soon after surgery can jeopardize the implants fixing the bones and ultimately bone healing. The surgeon must restrict the patient in certain ways after surgery for the bones to heal properly.

There are things that you can do to improve the chances of the ankle joint and bones healing properly. A diet that is too low in protein can result in decreased bone and wound healing. Increasing your calcium and vitamin D intake may help with bone healing. Taking the recommended daily allowance of both (1,000 to 1,200 mg of calcium and 600 to 800 IU of vitamin D) may help your body to heal. Up to 2,000 mg of calcium per day may help broken bones to heal.

Drinking alcoholic beverages should be limited to no more than two drinks a day. Cigarette and cigar smoking should be stopped completely as they can be harmful to bone and wound healing.

Navicular Stress Fracture

A navicular stress fracture is a crack or break in the navicular bone, which is a boat-shaped bone in the middle of the foot. These fractures often are due to overuse, ongoing forces, and/or stress on the bone rather than a sudden injury.

Symptoms

Patients with navicular stress fractures usually have gradual onset of aching pain across the top and/or middle of the foot. Pain usually improves with rest and support but then returns when activity resumes.

Causes

The navicular bone helps transfer force from the ankle to the forefoot (the ball of the foot). The navicular is covered by cartilage and lacks a rich blood supply, especially at its center. This makes it more susceptible to repetitive forces that can cause damage. The bone may break down because of excess force, underlying bone weakness, or a combination of these two factors.

Repetitive forces that could result in a navicular stress fracture include running/jumping sports (such as basketball) and similar activities, increased exercise, or even walking after a period of inactivity.

Prevention

There are steps you can take to help prevent navicular stress fractures:

Select supportive footwear before you start an exercise or training routine and replace your shoes after 300 to 500 miles of use. Supportive shoes typically have a stiff sole with lots of cushioning in the shoe, especially at the arch.

Start your new training routine slowly, especially after a period of relative inactivity. Do not increase your walking or running distance increments by more than 10 percent per week.

Incorporate stretching, particularly of the calf muscles and Achilles tendon, prior to exercise.

Diagnosis

A history and physical exam are important ways for diagnosing a navicular stress fracture. Physical examination will show tenderness across the top of the foot. Standing X-rays may reveal a fracture line. However, X-rays may appear normal in the early stages of the stress fracture. Imaging beyond X-rays such as CT, MRI, and bone scans can be helpful in showing a stress fracture at the navicular if X-rays can’t do this.

Treatments

Your foot and ankle orthopedic surgeon may recommend surgical or non-surgical options to treat navicular stress fractures. First, you must stop the activity that results in the pain of the stress fracture. Non-surgical treatment includes wearing a cast or boot without weightbearing for 6-8 weeks. Research shows wearing a cast has an 80-100% success rate.

Certain patients, including professional athletes, may choose surgical treatment to allow them to return to activity more quickly and reduce the risk of developing another stress injury. Surgical treatment involves placement of an internal screw or screws across the fracture. Recovery after surgical treatment usually requires at least 6-8 weeks of limited weightbearing and foot immobilization in a cast or boot with a gradual return to activities.

Risks and Complications

The most common complication after treatment of a navicular fracture is a nonunion, or failure of the bone to heal. Continued pain with activity after cast removal is a sign that the bone did not heal. If a nonunion develops, the treatment can be surgery. This often involves using a bone graft in the fracture site can help with navicular bone healing.

Another potential complication is the development of arthritis, resulting from damage to the cartilage that covers the joint connecting the navicular bone to the hindfoot (rear part of the foot).

A less common complication of navicular fracture is avascular necrosis (AVN), which results from a loss of blood supply to the navicular bone. AVN causes a collapse of the navicular bone and affects function of the joints in the middle of the foot. It can be difficult to treat.

FAQs

How long should I experience pain before making an appointment with my foot and ankle orthopedic surgeon?

Patients should call after 1-2 weeks of persistent foot pain with walking or participating in activities.

Morton’s Neuroma

Morton’s neuroma is a thickening of the tissue that surrounds the small nerve leading to the toes. It occurs as the nerve passes under the ligament connecting metatarsal bones in the forefoot (front part of the foot).

Morton’s neuroma most frequently develops between the third and fourth toes. It often occurs in response to irritation, trauma, or excessive pressure, and is more common in women.

Symptoms

Morton’s neuroma may feel like walking on a stone or marble. You may have burning pain in the ball of your foot that radiates into the toes. The pain can worsen with activity or wearing shoes. You may also experience numbness or a “clicking” feeling in the toes.

Runners may feel pain as they push off. High heeled and narrow toe box shoes also can aggravate the condition.

Diagnosis

During the examination, your foot and ankle orthopedic surgeon will feel for a mass or a “click” between the metatarsal bones. They will squeeze the spaces between the toes to try to recreate the pain. Range of motion tests are used to rule out arthritis or joint inflammation. X-rays can help rule out a stress fracture or arthritis.

Treatment

Initial treatment can involve several non-surgical options:

Changing shoes: Avoid high heels or tight shoes. Wear wider shoes with lower heels and a soft sole. This helps to decrease compression of the nerve.

Orthotics: Custom shoe inserts and pads may help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.

Injection: An injection of a corticosteroid will reduce the swelling and inflammation of the nerve, which should provide relief.

Several studies have shown that a combination of shoe changes, oral anti-inflammatory medications, orthotics, and/or cortisone injections will provide relief in more than 80% of people with Morton’s neuroma. If conservative treatment does not relieve your symptoms, or if symptoms return, you may require surgery.

Surgery involves either removing a small portion of the nerve including the neuroma or releasing the tissue around the nerve to decompress it. It is an outpatient procedure, meaning the patient can go home the same day as surgery. Patients may be immobilized for 1-2 weeks to allow for healing of the incision, and then transitioned to regular shoes as tolerated.

Lisfranc Injury

A Lisfranc injury involves the joints and/or the ligaments of the midfoot (middle of the foot). The Lisfranc is a ligament of the foot that runs between two bones called the medial cuneiform and the second metatarsal. The name comes from French surgeon Jacques Lisfranc de St. Martin (1790-1847), who was the first physician to describe injuries to this ligament.

There are a variety of causes for a Lisfranc injury such as a car accident, sports injury, or a simple slip and fall. Sometimes the injury can be mistaken for a foot sprain when X-rays do not show any broken bones. Delaying treatment can sometimes lead to more significant problems. Proper diagnosis from a foot and ankle orthopedic surgeon is key.

Symptoms

The common symptoms of a Lisfranc injury are swelling and pain on the top of the foot near the instep. Bruising is common, and a bruise on the bottom of the foot can be a clue that this injury has occurred. With a severe injury, the foot may be distorted and putting any weight on it may be very painful. With a mild injury, the foot may appear normal and you may be able walk on it with only mild pain.

Causes

Low-energy injuries can happen when the back of the foot twists or presses down with the ball of the foot planted on the ground. This can happen during athletic activities such as football but also can occur from a misstep or even missing a stair and stumbling over the top of the foot. High-energy injuries occur from direct trauma such as a car accident or a fall from a height.

Specialized ligaments in the midfoot hold the bones in this area together like puzzle pieces to maintain the arch of the foot. When the ligaments, joints, or bones in this area are injured, they may shift out of place, making the arch unstable.

Diagnosis

A Lisfranc injury diagnosis is made based on what happened at the time of injury, your symptoms, and an examination of the foot and ankle that compares the injured foot to your uninjured foot. Your foot and ankle orthopedic surgeon will examine the middle part of your foot to identify the location of your pain and perform tests to check the stability of this area. X-rays may show broken or shifted bones in the middle of the foot. Sometimes X-rays will be taken while you are standing in order to better identify the shifting of bones in the foot. An MRI scan may be helpful to see if the ligaments in the foot are damaged. A CT scan can help determine the extent of the bone injury and is useful when planning surgery if needed.

Treatments

Non-surgical Treatment

If the ligaments and the bones in the middle of the foot are not severely injured, and bones are not shifted out of their normal positions, non-surgical treatment can be successful. A cast or CAM boot may be needed for at least 6 weeks in order for the ligament and/or bone to heal. Your foot and ankle orthopedic surgeon will follow up regularly with X-rays to make sure the bones maintain good position during the recovery.

Surgical Treatment

If the bones or ligaments are injured in a way that causes them to shift out of their normal positions, Lisfranc surgery may be necessary to restore the anatomy of the foot. Surgery may involve the placement of plates and screws that may need to be removed later, once the bones and ligaments have healed.

Recovery

Recovery from Lisfranc surgery depends on the severity of the injury. Most patients will be in a non-weightbearing cast for 6 weeks, followed by 6 weeks in a walking boot. Physical therapy may be needed to strengthen the foot and ankle and help regain walking ability. Return to maximal function, running, and sports can take up to one year.

Risks and Complications

Lisfranc injuries may cause arthritis and chronic pain in the middle of the foot. This may require additional treatment. With surgery, injury to the nerves and tendons may occur. Because of the swelling that often occurs with this injury, complications such as wound opening, infection, and/or further swelling of the foot may occur after surgery.

The outcome for Lisfranc injuries depends on their severity. Some patients will not be able to return to their pre-injury level of functioning or athletic activities even with well-performed treatment. The cartilage joint surfaces commonly are injured and some patients may develop midfoot arthritis (arthritis of the middle of the foot). It is also common for pain to continue in the joints after this injury. For some patients, surgery such a fusion of the joints may be necessary to relieve arthritis pain.

FAQs

How can I tell if it’s a sprain or a Lisfranc injury?

Unrecognized and untreated Lisfranc injuries can have serious complications, including joint degeneration and a buildup of pressure within muscles that can damage nerves and blood vessels. If the standard treatment for a sprain (rest, ice, and elevation) doesn’t reduce the pain and swelling within a day or two, or there is extensive bruising on the bottom of the foot, see your foot and ankle orthopedic surgeon immediately.

How soon can I get back to normal activity?

It is important to follow your doctor’s orders and refrain from activities until you are given the go-ahead. If you return to activities too soon after a Lisfranc injury or surgery, you may suffer another injury that results in damage to blood vessels, arthritis, or an even longer healing time.