Metatarsalgia

Pain in the ball of your foot, the area between your arch and the toes, is called metatarsalgia (MET-ah-tar-SAL-gee-ah). The pain usually centers on one or more of the five bones (metatarsals) in this area under the toes.

Causes

Calluses: If one of your metatarsal bones is long, the bone may take on extra weight. This extra pressure on the metatarsal bone can cause a callus, or buildup of skin, to form. The combination of the extra weight on the bone and the callus can cause pain; however, a callus does not need to be present for the patient to have pain.

Bunions: Metatarsalgia often is associated with a bunion deformity of the big toe. In this case, the big toe metatarsal bone cannot support the weight it needs to, and the weight shifts to the smaller metatarsal bones.

Hammertoes: A hammertoe is an imbalance of the tendons that support the toes. Hammertoes can push the metatarsal bone into the ground, which increases the pressure on the bone and may cause metatarsalgia pain.

Another cause can be shoes that don’t fit properly. Tight shoes squeeze the foot and increase pressure, while loose shoes let the foot slide and rub, which creates friction. Torn ligaments or inflammation also can cause metatarsalgia. Pain on the underside of the foot may indicate a torn ligament or inflammation of the joint. Your foot and ankle orthopedic surgeon can do some simple tests to assess joint stability.

Treatment

Most of the time, practical measures can help ease foot pain. Your doctor may recommend that you use a shoe insert (arch support) as a kind of shock absorber, or that you wear a different kind of shoe. Routinely, a pad is added to the orthotic to shift the weight off the painful metatarsal bones. Sometimes, simply buying shoes that fit properly can solve the problem. Shoes should have a wide toe box that doesn’t cramp your toes. Heels should never be higher than 2 1/4″ high.

Soaking your feet to soften calluses and then removing some of the dead skin with a pumice stone or callus file will relieve pressure. Note, however, that diabetics should not do this themselves. Calluses should be taken care of by your physician or someone your physician recommends for treating diabetic feet. This is a short-term solution that temporarily removes the callus but does not fix the problem.

Occasionally, surgery may be necessary to remove a bony prominence or correct a deformity.

Lisfranc Ligament and Joint

The Lisfranc ligament runs between two bones in the midfoot (middle of the foot) called the medial cuneiform and the second metatarsal. The place where these two bones meet is called the Lisfranc joint. The name comes from French surgeon Jacques Lisfranc de St. Martin (1790-1847), who was the first physician to describe injuries to this ligament.

Tearing of the Lisfranc ligament and other ligaments around the Lisfranc joint can lead to instability and disruption of the joints in the middle of the foot. The goals of Lisfranc surgery are to put the bones back into their original position and restore the foot’s normal alignment.

Diagnosis

Your foot and ankle orthopedic surgeon may recommend surgery for a Lisfranc injury if your midfoot joints are not lined up anatomically. Most commonly this misalignment is identified on X-ray; however, CT and MRI scans also can be helpful in diagnosis. Surgery will realign and stabilize the misaligned joints. Some injuries with noticeable cartilage damage may require fusion of the joints.

You do not need surgery for a Lisfranc injury if you have a sprain that does not create instability. Such injuries typically require you to restrict activity and use a boot or cast for 6-8 weeks. Surgery also should be avoided if you have significant soft tissue swelling, severe peripheral vascular disease, or fracture due to nerve dysfunction, which can be seen with diabetic neuropathy. You should speak with your surgeon prior to Lisfranc surgery if you have these conditions.

Treatment

Lisfranc surgery is usually an outpatient procedure, meaning you can go home the same day as surgery. You will receive anesthesia, such as general anesthesia, spinal anesthesia, an ankle block, or popliteal with sedation. A nerve block may be used to help control pain after the surgery. A tourniquet usually is used to reduce bleeding. Most patients will require at least one incision on the top of the foot, and a second incision may be needed if the injury is severe.

Specific Technique

Your foot and ankle orthopedic surgeon will make the first incision on the top of the foot, making a line between the big toe and second toe at the middle of the foot. They will carefully protect the tissues to minimize risk of injury to tendons or nerve structures.

Your surgeon will realign the medial cuneiform bone to the base of second metatarsal bone and then realign the other joints around this joint. An X-ray will verify that the joints are aligned. A second incision often is necessary for more severe injuries. This second incision is typically made on the top of the foot but more toward the little toe side.

A series of screws or plates placed beneath the skin will help hold the bones in place. One of the screws often placed is known as a “home run” screw. It runs between the medial cuneiform and the second metatarsal bones. This screw mimics the path of the injured Lisfranc ligaments. Some injuries require wires to be left in place. These wires are left partially exposed outside of the skin.

A fusion surgery involves a similar technique. The main difference is that the cartilage is removed from the joint surfaces prior to inserting plates or screws. The goal is to make the bones grow together to eliminate arthritis.

X-ray after Lisfranc surgery

This X-ray shows a patient who had surgery to realign the bones of the foot. A plate and several screws are holding the bones in place. The arrow points to the “home run” screw that mimics the injured Lisfranc ligament.

Recovery

You will be placed into a non-weightbearing splint immediately after surgery. This protects the bones and incisions. You should elevate the foot as much as possible to help reduce swelling and pain. Pain will typically be controlled with pain pills.

Sutures will be removed about two weeks after surgery and you will have a cast or CAM boot. No weightbearing is allowed for 6-8 weeks after surgery. A walking cast or boot is then used for another 4-6 weeks. If pins were used to hold the fourth and fifth metatarsals in place, they are removed 6-8 weeks after surgery.

Patients usually are able to wean out of the boot and into an athletic shoe in 10-12 weeks. A more rigid shoe with an arch support insert will help reduce stresses through the middle of the foot. Physical therapy may be prescribed for strengthening and improvement in function. It can take longer than one year for full recovery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

With Lisfranc surgery, there is a nerve that runs very close to the site of the incision. Injury of this nerve can result in numbness. If numbness occurs it typically is not painful and the foot recovers with time. Another common problem after a Lisfranc injury is the development of post-traumatic arthritis in the joints of the middle of the foot. This is due to degeneration of cartilage in the area of the injured joints. This can lead to pain and stiffness in the middle part of the foot.

FAQs

Will the plates and/or screws stay in my foot forever?

The hardware that is placed during surgery is sometimes removed 4-6 months after surgery. Hardware placed for a fusion typically is not removed unless it becomes bothersome.

Should I have my injured foot realigned or fused?

This is a debated topic. For simple Lisfranc injuries, a patient typically will do well with realignment of the bones. More substantial injuries that result in obvious displacement of the joints or a fracture involving the joint surfaces may be better treated with a fusion. Other factors to consider include your age and any existing foot arthritis. Discuss your treatment options with your foot and ankle orthopedic surgeon to find the best solution for your problem.

Metatarsals

Each foot has five metatarsals. These are the long bones of the foot. They connect the toes to the rest of the foot. They also make the ball of the foot. The lesser metatarsals are the bones that connect to the second through fifth toes (not the first, or big toe).

An osteotomy is a cut made in the bone. It is similar to breaking the bone but in a very controlled manner. A lesser metatarsal shortening osteotomy changes the pressure distribution under the ball of the foot, relieving pain. It also can be used to put a chronically dislocated toe back in position.

Diagnosis

Surgery is appropriate if non-surgical methods have not adequately relieved pain. This procedure is used to alter pressure across the ball of the foot as well as correct toe angulation or dislocation. This is most commonly seen when the toes are abnormally bent (hammertoe or claw toe deformities). Other less involved options may be more appropriate depending on the deformity and symptoms of the patient. However, when the toe is dislocated, the deformity usually is addressed with a metatarsal shortening osteotomy, as just straightening the toe (without shortening) can cause loss of adequate blood flow to the toe which could cause gangrene. Another reason to perform the procedure is to relieve pressure under a metatarsal head. In this case, there is usually a callus and pain in the ball of the foot.

Reasons to avoid this surgery include lack of attempted non-surgical treatment, active infection around the surgical site, lack of adequate blood supply to allow healing, or arthritis at the joint next to the osteotomy. The shortening osteotomy would correct the toe’s position, but the patient would likely have continued pain due to the arthritis.

Treatment

This procedure typically is performed with the patient going home the same day. General and/or regional anesthesia (a block) can be utilized. The surgeon uses a saw to cut the bone. The two bone ends are shifted so that the bone shortens. This shortening gives “slack” to the toe and allows the toe to be placed in the correct position. Other soft tissue procedures often are performed at the same time to correct toe deformities.

Specific Technique

A one to two inch incision is made over the top of the foot. There are many types of metatarsal shortening osteotomies. Where the incision is made depends on the location of the osteotomy. A bone cut is made using a saw at the end of the metatarsal. The cut is made completely through the bone. After the appropriate amount of sliding has occurred, the osteotomy is held in that position with either pins or screws. The surgeon may also place a temporary wire through the toe itself. The skin is then closed.

Recovery

Immediately after surgery, a padded soft dressing is placed around the foot. The patient is given a hard-soled shoe or boot and allowed to place weight only on the heel.

Instructions are given to keep the dressing clean. Showers/bathing can be done with either a plastic bag or commercially available cover to keep the dressings dry. The patient should keep the foot elevated as much as possible to avoid swelling. Excess swelling can lead to problems with wound healing.

The patient usually is seen in the office one to two weeks after surgery. The dressing is changed and when skin has adequately healed, the stitches are removed. Range-of-motion exercises with the toe may be started. If a wire was placed in the toe, it typically is removed in the office four to six weeks after surgery. At 4-6 weeks, weight bearing usually is allowed as tolerated.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. There also are complications specific to metatarsal osteotomies. Failure of the bone to heal after it has been cut may result in continued pain. This complication typically requires another surgery to get the bone to heal in order to alleviate the pain. Excessive scaring can occur as can recurrence of the deformity.

FAQs

Will I have normal function of my toes after this surgery?

You should expect some degree of stiffness of the operative toes after this procedure. The amount of motion regained depends on the severity of the deformity before surgery and any other procedures done. Range-of-motion exercises after surgery can help to decrease stiffness.

How long will my toe be swollen after surgery?

Even with appropriate healing, toes may remain swollen for months after surgery.

Lateral Ankle Ligament Reconstruction

Ankle sprains are one of the most common sports-related injuries. They affect 10,000 people per day. When the ligaments on the outside of the ankle are stretched or torn, patients can have pain and feelings of instability. If symptoms persist after non-surgical treatment, surgery may be required. The goal of this surgery is to restore normal stability to the ankle. This should also fix your feeling that the ankle “gives way” and any pain that is associated with an unstable ankle.

Diagnosis

Surgery is considered when you have an unstable ankle that does not respond to non-surgical treatment. Six months of non-surgical treatment is often recommended before surgery. A physical examination will show that the ankle is unstable, and X-rays are sometimes used to help with the diagnosis. Patients who have failed physical therapy and bracing and have instability of the ankle may consider surgery.

Your general health plays a role in any decision to have surgery. Patients with nerve or collagen diseases may not be helped by this type of surgery. Patients should not have this surgery if they have certain medical issues or poor circulation or are unable to follow the recommended post-surgery rehab. You should discuss any medical concerns with your foot and ankle orthopedic surgeon.

Other diagnoses, including ankle arthritis, may require different surgeries that treat the bones and joints. Patients with chronic pain may benefit most from non-surgical management with a pain specialist. Surgery is not recommended for treatment of a single ankle sprain.

Treatment

Ankle ligament reconstruction (ALR) typically is an outpatient surgery, meaning the patient can go home the same day as the procedure. It is most often done under general or regional anesthesia. Other surgeries may be performed at the same time, most often arthroscopic surgery of the ankle joint. At least one larger incision is required for the ligament reconstruction.

Several different techniques can be performed depending on the individual patient. One option is to repair the patient’s own existing ligaments with stitches. This repair is called a modified Bröstrom procedure and can result in a stronger repair because of support from other tissues. Another option is to use a tendon to replace the torn ligaments. This technique is similar to what is done in knee ligament reconstructions.

Specific Techniques

The modified Bröstrom procedure is the most commonly performed surgery for this problem. The surgeon begins by making a C- or J-shaped incision over the outside of the ankle. The ankle ligaments are identified if possible. They are then tightened using either stitches or anchors that are placed into one the bones of the ankle (the fibula bone). Stitching other tissue over the repaired ligaments further strengthens the repair.

Tendons may also be used to replace the ligaments. The surgeon weaves a tendon into the bones around the ankle. The tendon is held in place with stitches and possibly a screw in the bone. One option is to use the patient’s own hamstring tendon, which is taken through a separate incision on the inside part of the knee. Another option is to use a cadaver tendon. A different method is to take a portion of one of the tendons from the side of the ankle and weave it into the fibula bone.

Recovery

You can expect to be in a splint or cast for a minimum of two weeks. It may be up to six weeks before weight can be placed on the ankle. Weight bearing is gradually advanced in a removable walking boot. An athletic ankle brace typically is used after the boot.

Ankle strengthening begins after six weeks as pain and swelling allow. This may involve formal physical therapy. Straight-line running is allowed when the ankle is strong enough for it. Sport-specific exercises can then start gradually. The total expected recovery time is 6-12 months. It is recommended that patients wear a brace for sports activities for up to a year.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Patients having ALR commonly have decreased feeling around their incision. It also is common to have decreased feeling that extends to the top of the foot. This occurs up to 20 percent of the time and ranges from increased sensitivity to complete loss of sensation. Other less common problems include delayed wound healing and infection. Blood clots in the leg veins also can occur. Recurrent ankle instability or stiffness also may occur.

FAQs

What are the alternatives to surgery?

Treatment for ankle instability typically involves bracing and physical therapy. Many patients will respond to this treatment.

What can happen if ankle instability goes untreated?

Repeat ankle sprains can occur. This can lead to ankle joint damage, bone and tendon injuries, and arthritis.

What is the risk of retearing my ligament after it has been repaired?

Tearing of the ligament can have many definitions. Complete tearing can occur but usually only after repeat injury. However, repaired ligaments can stretch out over time. Long-term studies that look at these surgeries and patient satisfaction have shown that more than 90 percent of patients have a good or excellent outcome.

What if my ankle instability does not improve after surgery?

The results of surgery vary based on the severity of the initial injury. Outcomes will vary as well. Patients who have persistent instability after surgery may improve with physical therapy or by wearing a brace. Additional surgeries to reconstruct the ligaments may be an option. Ankle fusion could also be considered.

Insertional Achilles Tendinitis

The Achilles tendon is the largest tendon in the body. Insertional Achilles tendinitis is a degeneration of the Achilles tendon fibers where the tendon inserts into the heel bone. It may be associated with inflammation of a bursa or tendon sheath in the same area.

Symptoms

Most patients report a gradual onset of pain and swelling at the back of the heel bone without specific injury. At first, the pain may only be noticeable after activity, but it becomes more constant over time. The pain increases with jumping or running and especially with sports requiring short bursts of these activities. Patients experience tenderness over the back of the heel bone and the bone often becomes more prominent. It is painful to position the ankle above a 90 degree position.

Causes

Insertional Achilles tendinitis primarily is caused by degeneration of the tendon over time. The average patient is in their 40s. Conditions associated with increased risk include psoriasis and Reiter’s syndrome, spondyloarthropathy (generalized inflammation of joints), gout, familial hyperlipidemia, sarcoidosis, and diffuse idiopathic skeletal hyperostosis as well as the use of medications such as steroids and fluoroquinolone antibiotics.

Diagnosis

Your foot and ankle orthopedic surgeon will perform a clinical exam to determine if you have insertional Achilles tendinosis. They may order X-rays to look for calcification (bone) deposits within the tendon at its insertion into the heel. These deposits are present approximately 60 percent of the time and are associated with a more guarded success rate for non-surgical treatment and a much longer recovery time for surgical treatment. X-rays also may reveal a Haglund’s deformity.

MRIs may be used to determine the extent of tendon degeneration as well as other factors such as bursitis, which may contribute to heel pain.

Treatments

Non-surgical Treatment

Non-surgical treatments, including liberal use of nonsteroidal anti-inflammatory drugs, heel lifts, stretching, and switching to shoes that do not put pressure over this area, are effective for the majority of patients. If symptoms persist, your surgeon may recommend night splints, arch supports, physical therapy, or the use of a cast or brace. Nitroglycerin patches also may be of benefit to increase the blood supply to this area.