Every mile you walk puts tons of stress on each foot. Your feet can handle a heavy load, but too much stress pushes them over their limits. When you pound your feet on hard surfaces playing sports or wear shoes that irritate sensitive tissues, you may develop heel pain, the most common problem affecting the foot and ankle.

Heel Pain

A sore heel will usually get better on its own without surgery if you give it enough rest. However, many people ignore the early signs of heel pain and keep on doing the activities that caused it. When you continue to walk on a sore heel, it will only get worse and could become a chronic condition leading to more problems.

Diagnosis

Heel pain can have many causes. If your heel hurts, see your primary care doctor or foot and ankle orthopedic surgeon right away to determine the cause and get treatment. Tell him or her exactly where you have pain and how long you’ve had it. Your doctor will examine your heel, looking and feeling for signs of tenderness and swelling. You may be asked to walk, stand on one foot, or do other physical tests that help your doctor pinpoint the cause of your sore heel. Conditions that cause heel pain generally fall into two main categories: pain beneath the heel and pain behind the heel.

Pain Beneath the Heel

If it hurts under your heel, you may have one or more conditions that inflame the tissues on the bottom of your foot:

• Stone bruise: When you step on a hard object such as a rock or stone, you can bruise the fat pad on the underside of your heel. It may or may not look discolored. The pain goes away gradually with rest.
• Plantar fasciitis (subcalcaneal pain): Doing too much running or jumping can inflame the tissue band (fascia) connecting the heel bone to the base of the toes. The pain is centered under your heel and may be mild at first but flares up when you take your first steps after resting overnight. You may need to do special exercises, take medication to reduce swelling, and wear a heel pad in your shoe.
• Heel spur: When plantar fasciitis continues for a long time, a heel spur (calcium deposit) may form where the fascia tissue band connects to your heel bone. Your doctor may take an X-ray to see the bony protrusion. Treatment usually is the same as for plantar fasciitis: rest until the pain subsides, do special stretching exercises and wear heel pad shoe inserts. Having a heel spur may not cause pain and should not be operated on unless symptoms become chronic.

Hammertoe

A hammertoe is a deformity that causes a toe to become bent upward in the middle so it resembles a hammer. This can cause the toe to rub against the top of the shoe or irritate the end of the toe by jamming it into the ground. A hammertoe also can be associated with a contracture of the joint at the base of the toe and can often occur in conjunction with a bunion or other foot problems.

Non-surgical treatment for a hammertoe include padding the toe and changing or stretching shoes. If you still have pain, cannot participate in your normal activities, and/or cannot wear shoes comfortably, surgery may be an option. The main goal of hammertoe surgery is to correct the deformity, which will relieve the pain.

The hammertoe can be flexible or stiff. Depending on the flexibility of the toe and the preference of your foot and ankle orthopedic surgeon, several different surgical procedures can be used to treat the hammertoe.

Treatment

If you have active infections, poor circulation, or a serious illness (for example, heart disease), surgery may not be recommended. You should discuss your health history with your foot and ankle orthopedic surgeon prior to considering hammertoe surgery.

Most often, hammertoe correction is done as an outpatient procedure, meaning you can go home the same day. You may be fully asleep during surgery or given an injection (nerve block) that makes the foot go numb temporarily. This is similar to what a dentist does to your tooth when filling a cavity.

If you have other toe problems in addition to the hammertoe, you should consider addressing the other deformities at the same time as one problem may contribute to the other.

Specific Technique

The type of surgery depends to a large degree on whether the toe can be easily straightened during your examination.

Flexible Hammertoe: If your toe can be straightened, it is called a flexible hammertoe. A flexible hammertoe can be corrected with ligament and tendon lengthening or detachment procedures. One of the most common procedures involves transferring a tendon from the bottom of the toe to the top of the toe. This procedure stops the tendon from pulling the joint into a bent position and places the tendon in a position where it will help hold the toe down.

Fixed (Stiff) Hammertoe: If your toe cannot be straightened by the foot and ankle orthopedic surgeon during the examination, it is called a fixed hammertoe. This means that the joint has become so contracted that releasing and lengthening the tendons and ligaments alone cannot restore the toe to a straight position. Some bone needs to be removed as well to get the toe to be straight. Usually, the end of the bone at the fixed (stiff) joint is removed to allow the toe to straighten completely.

Once the bone is removed, there are two options to stabilize the area:

• Pins can temporarily hold the toe in a straight position. This allows the area to fill in with scar tissue after the pins are removed.
• Fusing the joint is done by using pins, screws, or other implants to keep the toe straight. The goal is for the bone ends to heal together to become a solid bone rather than scar tissue.

For either option, as well as the flexible hammertoe treatment, your surgeon may need to release the joint and lengthen the tendon at the base of the toe to allow the toe to lay completely flat.

Recovery

Usually, you are able to place your full weight on your foot after surgery without the need for crutches or a walker. You may also have a special shoe or boot to wear after surgery. You will need to lie down with your foot elevated at the level of your heart for the first few days after surgery.

Stitches usually are removed 10-14 days after surgery. If pins were placed, these will be taken out in the office 4 weeks after the surgery. This usually is not painful because the pins loosen over time after the surgery and come out easily. You may not put your foot under water until the stitches and pins are removed.

Recovery usually takes several weeks depending on the type of surgery that was done. If the hammertoe is on your right foot, you may not be able to drive a car for several weeks.

Your foot and ankle orthopedic surgeon may ask you to do exercises to stretch and move the toe at home after surgery. This can help with flexibility and motion.

It is normal to have swelling after surgery. It may take many months for the swelling and symptoms to fully resolve.

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.

Complications specific to hammertoe surgery include the chance that the hammertoe may come back after your surgery. There is a risk that after the surgery you may feel like the toe is unstable. This is due to the cutting of bone, ligaments, and tendons. If you have a fusion there is a risk of the bones not healing. These complications are not common. Discuss the potential complications with your foot and ankle orthopedic surgeon prior to undergoing hammertoe correction.

FAQs

If I am treated with surgery will the hammertoe ever come back?

A hammertoe usually develops as a result of progressive muscle imbalance that deforms the toe. This progression does not necessarily stop at the time of surgery. It is therefore possible but unlikely that your hammertoe may come back after surgery. If this happens and you have discomfort in the toe, reevaluation and possible surgery may be an option.

Can I bend my toe after surgery?

Most hammertoe surgical procedures will result in some stiffening of your toe. Depending on the specific surgery performed, you may or may not be able to bend your toe once it has healed. The goals are to have a toe that is not painful and that you can place into a shoe easily. Your foot and ankle orthopedic surgeon can discuss your surgery and possible outcomes in more detail.

Hallux rigidus is arthritis of the joint at the base of the big toe. It is the most common arthritic condition of the foot, affecting 1 in 40 people over the age of 50 and typically developing in those over age 30. Big toe arthritis tends to affect women more than men.

The big toe joint is called the hallux metatarsal phalangeal (MTP) joint. This joint connects the head of the first foot bone (metatarsal) with the base of the first toe bone (proximal phalanx) and the two tiny bones (sesamoids) underneath the metatarsal. Usually the greatest area of wear is at the top of the joint.

Symptoms

Most patients feel pain in the big toe joint while active, especially when pushing off to walk. Often, there is swelling around the big toe joint or difficulty moving and bending the toe. A bump, like a bunion or bone spur, can develop on top of the big toe joint and be aggravated by rubbing against the inside of a shoe.

Causes

The cause of hallux rigidus is not known; however, there are several risks factors, including a long or elevated first metatarsal bone or other differences in foot anatomy, prior injury to the big toe, and family history. These can lead to excessive wear of the joint, which in turn leads to arthritis.

Diagnosis

In many cases, the diagnosis of hallux rigidus can be made with a physical examination. Your foot and ankle orthopedic surgeon will examine the MTP joint to see how much you are able to move and where the pain occurs. Your surgeon also will check your foot for evidence of bone spurs. X-rays will be taken to identify the extent of joint degeneration and to show the location and size of bone spurs. These X-rays are best done with you standing and putting weight on your foot. MRI and CT scans usually aren’t needed.

Treatments

Non-surgical management is always the first option for treatment of hallux rigidus. A physician may suggest pain relievers and anti-inflammatory medicines and ice or heat packs to reduce pain. Platelet-rich plasma injections and similar injections into the joint are promising but vary in effectiveness.

Changes in footwear also may help. Avoiding thin-soled or higher-heeled shoes can minimize the pressure at the top of the joint. Shoes with a stiff sole (like Hoka), curved sole (rocker bottom), or both also may minimize joint pain. Shoe inserts as well as arch supports that limit motion at the MTP joint also can help.

Although these treatments may decrease the symptoms, they do not stop the condition from worsening.

Surgery may be required if non-surgical management fails to fully address symptoms. The type of surgery would be determined by the extent of arthritis and deformity of the toe.

Bone Spur Removal (Cheilectomy): For mild to moderate damage, removing some bone and the bone spur on top of the foot and big toe can be sufficient. This procedure is called a cheilectomy. Removing the bone spur allows more room for the toe to bend up and relieves pain caused when pushing off the toe. The advantages of this procedure are that it maintains stability and motion, and preserves the joint itself.

Joint Fusion (Arthrodesis): Advanced stages of hallux rigidus with severe joint damage are often treated by fusing the big toe joint. In this procedure, the damaged cartilage is removed and the two bones are fixed together with screws and/or plates so they can grow together.

The main advantage of this procedure is that it is a permanent correction to reduce pain. The major disadvantage is that it restricts movement of the big toe, although most patients can still be active.

Recovery

The length of recovery depends upon the type of surgery performed, and is shorter for cheilectomy and longer for fusions. You can expect some foot swelling, stiffness, and aching for several months after the procedure, depending on your level of activity. After recovery, most patients are able to exercise, run, and wear most shoes comfortably.

Foot Fractures

There are 26 bones in each of your feet, all of which can break. There are several different types of fractures:

• Non-displaced: The bone breaks but stays in place
• Displaced: The bone breaks into two pieces that move apart from one another
• Comminuted: The bone is broken in multiple places
• Open fracture: The bone breaks through the skin after fracturing

If you injure your foot, your foot and ankle orthopedic surgeon will take X-rays to see if you have a broken bone. X-rays will identify most fractures but some smaller and more subtle fractures may require CT or MRI scans. Not all fractures require surgery, and your surgeon will help determine how your fracture should be treated.

If you need surgery for your foot fracture, the goals are to restore the fractured bone to its correct position, stabilize the bone in this position, encourage healing, restore function, and reduce the risk of future problems such as persistent pain, loss of motion, and arthritis.

Diagnosis

All foot fractures are different, but generally speaking if a fracture is significantly displaced it is likely to benefit from surgery. This is especially true if a fracture enters a joint and the joint surface is disrupted and displaced. Restoring the alignment and stabilizing the fracture in its correct position will decrease the risk of future problems, such as pain, swelling, deformity, and arthritis.

In some cases, surgery may be appropriate for non-displaced or minimally displaced fractures if the broken bones are likely to be unstable. In such cases surgery can maintain the alignment and encourage healing in the right position.

Even some non-displaced and stable fractures may benefit from surgery. One such fracture, called a Jones fracture, often is treated surgically in active and athletic individuals because it is likely to get them back to their activities more quickly than non-surgical treatment.

When the risks of surgery outweigh potential benefits, your foot and ankle orthopedic surgeon may recommend non-surgical treatment. This decision is based on an understanding of your entire body and pre-existing conditions. For example, if you have a history of heart problems, your surgeon may recommend non-surgical treatment or that you see your cardiologist to determine if surgery is safe before proceeding.

Treatment

Foot fracture surgery involves making an incision in the skin centered over the fractured bone. The bone is then exposed so the orthopedic surgeon can see the fracture. The fractured bone fragments are realigned as well as possible and secured with implants such as pins, wires, screws, and plates. After stabilizing the fracture your surgeon will stitch the incision closed, apply a sterile bandage, and place your foot in a cast, splint, boot, or post-operative shoe.

With some fractures, the surgeon can restore the alignment of the fractured bone without a large incision. In this method, the fracture is fixed with appropriate implants through one or more small incisions. This is called a percutaneous fracture fixation. The advantages of this technique include smaller incisions, less trauma to the tissues, less disruption of the blood supply to the bone, and less pain after surgery.

Recovery

After surgery your foot and ankle orthopedic surgeon will place your foot into a cast, splint, boot, or post-op shoe. It is important to keep your foot elevated as much as possible to reduce pain and swelling. In most cases your doctor also will want you to stay off your foot completely for 1-3 months, depending on the injury.

A few weeks after surgery your surgeon will check the wound and remove the stitches. Your surgeon may have you begin working on range-of-motion exercises of the ankle, foot, and toes. They may also refer you to a physical therapist.

Your doctor will see you at regular intervals and check X-rays to see how well the fracture is healing. Based on your fracture type and this evaluation, your surgeon will decide when you can begin to bear weight on the injured foot. They may have you begin weightbearing with a special boot and allow you to advance slowly to your normal footwear as symptoms allow. In most cases you can expect 3-6 months or more before you return to full activity without restrictions, and up to a year before you reach maximum improvement.

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. To minimize the risk for blood clots, you may be placed on aspirin or a blood thinning medication for several weeks after surgery. Unfortunately, even when on these medications, blood clots can occur post-operatively.

Potential complications of foot fracture surgery include wound breakdown, failure of the fracture to heal (nonunion), fracture healing in a bad position (malunion), loss of fracture alignment prior to healing, implant failure, persistent pain, loss of motion, and arthritis. Smoking is a significant risk factor for multiple complications. If you are a smoker, your surgeon will discuss this with you before operating.

Foot and ankle orthopedic surgeons are uniquely qualified to identify and treat fractures of the foot and should be your first resource when you experience a foot injury.

Foot Drop

Foot drop occurs when the muscles and tendons that flex the foot up are no longer working. Commonly, it is the result of a nerve injury, stroke, or nerve disease (neuropathy). It also can occur after an injury to a muscle or tendon. If a person is unable to flex the foot up when walking, the foot or toes can drag on the ground. This can make walking difficult and lead to frequent falls.

The goal of a foot drop procedure is to improve a patient’s ability to actively flex the foot and ankle up in situations where this function is weak or lost completely.

Symptoms

When the muscles that flex the foot up are not working, but other muscles around the foot and ankle still function, tendon transfer surgery can be helpful. If there is no muscle function at the ankle, this procedure cannot be performed. A patient must have some working muscles for a tendon transfer procedure to be successful.

Treatment

Usually, initial treatment involves use of an off-the-shelf or custom brace called an AFO (ankle foot orthosis), which helps to improve the position of the foot while a person is walking. When this brace is no longer helpful, surgery can be considered. You should discuss your options with your foot and ankle orthopedic surgeon before proceeding with surgery.

The surgical procedure for a foot drop is called a tendon transfer. In general, a tendon transfer is a procedure in which a tendon (and attached muscle) that is still working is taken from one part of the foot and moved to another part of the foot to try to replace the missing muscle function. The most common tendon transferred is the posterior tibial tendon.

Specific Technique

A posterior tibial tendon transfer procedure can involve the posterior tibial tendon alone or transfer with two other tendons, the peroneus longus and the anterior tibialis. When all three tendons are used it is called a Bridle procedure.

Multiple incisions are needed to move the tendon from one position to another. The posterior tibial tendon is taken off its insertion on the navicular bone on the inner side of the foot. This is the first incision. A second incision is made above the ankle and the tendon and muscle are identified. The tendon is pulled into this second incision and then transferred in between the tibia and fibula bones to the front of the ankle.

Another incision is made on the top of the foot at the bone to which the tendon is going to be transferred. The tendon is routed under the skin to this bone and fixed into a tunnel in the bone.

If a Bridle procedure is performed, a second tendon, the peroneus longus, is cut above the level of the ankle on the outer side of the leg. This tendon is then routed to the front of the ankle and the free end is attached to the posterior tibial tendon and the anterior tibial tendon in a bridle configuration. With this construct the posterior tibial muscle pulls on all three tendons to pull the foot up. The posterior tibial tendon is routed to the top of the foot as described above.

Occasionally, the ankle can be very stiff from long-standing weakness. If it is not possible to pull the ankle up for attachment of the tendon transfer, the Achilles tendon is lengthened to help bring the foot and ankle up. This is done either through an incision on the calf or an incision right over the Achilles tendon. The location of the incision is based on which portion of the Achilles is too tight.

Recovery

The ankle is placed in a splint in the operating room to hold the position of the foot and ankle and protect the newly transferred tendon(s). Strict elevation and non-weightbearing are enforced over the first 10 to 14 days. Stitches are removed in about two weeks, after which the foot will be in a cast for about six weeks. The patient usually is non-weightbearing during this time.

Once the cast is removed, the patient will be allowed to walk in a special boot. Physical therapy to retrain the tendon(s) in its new position continues for 8-12 weeks. A night splint is worn for three months after surgery to prevent premature stretching of the tendon transfer.

As swelling improves a custom-molded brace can be worn in an athletic shoe and the walker boot is discontinued. Once the patient’s strength and motion are improved with physical therapy, the brace may be discontinued. The goal of the surgery is for the patient to walk in a regular shoe without the need for a brace.

Risks and Complications

Potential complications of this treatment can include wound infection, deep infection that can compromise the tendon transfer, and failure of the tendon or tearing of the repair.

FAQs

Will I have “normal” ankle movement after this procedure?

A foot drop procedure changes the function of the ankle and allows a patient to walk without a brace. However, it is not possible to restore normal strength and full range of motion with this procedure.

Will I be able to pull up my toes?

Often a nerve injury that causes a foot drop also limits the ability to pull up the toes. The tendon transfer will not restore this function. If this is a concern, make sure that you mention it to your doctor.

Will I be able to walk without a brace?

The purpose of the procedure is to try to improve function of the ankle so that a patient can walk without a brace. However, with severe nerve injury it is not always possible to guarantee that a patient will be brace-free all the time.

Can foot drop surgery be performed if I have no working muscles at all?

The foot drop tendon transfer surgery only works if some of the muscles around the ankle are still working.

Is there a “best time” to have the procedure after a foot drop occurs? Is sooner better than later?

Nerve injuries can improve very slowly over time. At the initial time of injury, it is possible that over months to a year, the foot drop will actually improve and strength will return. By about one year, if no function has returned, a foot drop procedure is reasonable to consider.

For a long-standing foot drop (that is, the injury happened many years ago) a foot drop procedure can still work if the other muscles around the ankle are still working. So no matter how long ago it happened, it is reasonable to seek the opinion of a foot and ankle orthopedic surgeon to see if you are a candidate for this procedure.

Will I need physical therapy?

It is helpful to have formal physical therapy to help retrain the muscle for its new function. Therapy continues until progress is made in both strength and motion and you are able to transition out of the boot or brace.