A hammertoe is a deformity of either the second, third, or fourth toe. The toe becomes curled at the middle joint, resembling a hammer. Hammertoes can be classified as flexible (able to be easily straightened) or fixed (unable to be straightened). You may notice skin irritation or calluses where shoes rub the top of the toe.

What causes hammertoe?

The most common cause of hammertoe is wearing improper footwear, particularly shoes that are too tight in the toe box. Tight shoes force the toe to stay in a bent position. This causes the muscles to tighten and the tendons to shorten. When left in this position for extended periods of time, the toe muscles can no longer straighten appropriately. High heels can also cause hammertoe because they push your toes forward and crowd them in the toe box. Other causes of hammertoe include trauma, abnormal foot mechanics due to nerve and/or muscle damage from diabetes, arthritis, and stroke.

What is the treatment for hammertoe?

The first line of treatment includes lifestyle changes and conservative remedies when possible. Wearing proper footwear and low-heeled shoes with a deep toe box help. Also, you should choose a shoe made of flexible material with a half-inch space between your longest toe and the inside of the tip of the shoe. Additionally, there are exercises you can do to strengthen your toe muscles, like picking up marbles with your toes.

There are many cushions, straps, and non-medicated pads to relieve your toe symptoms, and your orthopedic foot and ankle surgeon can advise you on which of these suit your individual problem. Talk with your doctor before you attempt self-treatment to be sure that you are choosing the right measure.

Can surgery help my hammertoe?

Surgery is indicated for fixed hammertoe deformities that are painful. Surgery typically involves removing the middle joint of the toe (where the deformity exists) and fusing the toe into a straight position. Sometimes the tendon that pulls the toe up must be lengthened if it prevents complete correction of the deformity. Your orthopedic foot and ankle surgeon will discuss the appropriate procedure for your hammertoe condition. Surgery is typically done on an outpatient basis and can be done with local anesthetic if desired.

I initially looked at switching to the anterior approach (going into the hip from the front rather than the side or back of the hip) because the PAs (physician assistants), nurses, and physical therapists in my hospital all told me that they felt that the patients who had anterior approaches were having significantly less pain and were able to rehabilitate faster.

I have a partner who was one of the first people in the Seattle area to do anterior approach THR and the hospital staff could watch the difference in how the patients recovered after their surgery.

Anterior Approach

Finally one day I asked our head PA how she would want her total hip done and she said definitely by the anterior approach. At that point I knew I had to learn more about it and whether it was reasonable for a surgeon that has always done THR through a posterior approach to change to a dramatically different technique and still be confident that my patients would benefit.

I first observed the technique in the operating room and then studied the anatomy of the anterior approach. The first obvious benefit is that the approach to the hip from the front is anatomically easy and does not involve cutting any major structures to get to the hip. You simply spread the interval between two muscles and you are down onto the hip capsule.

When you go in from the back you have to divide the gluteus maximus (butt) muscle and split part of the ilio-tibial band on the side of the hip and then cut several small tendons off the back of the hip.

The thing that stops a lot of surgeons from doing this approach is that it is so different from what they are used to. The other thing that stops them is the special technique that is necessary to place the stem into the femur (upper thigh bone). When you approach the hip from the back, it is fairly easy to place the stem of the implant into the femur.

From the anterior approach most surgeons use a special table called a fracture table that allows you to position the leg in a very specific way. In my case, all of the operating room staff and my assistants were used to doing this approach and that made my job a lot easier.

Once I decided that I wanted to learn this technique, I went to a lab where you can practice on cadavers. I was surprised at how easy the approach was and how well I could get good exposure of the socket and the femur to do the surgery. Once I had the exposure, the actual placement of the implants was exactly what I had been doing from the posterior approach.

I have now been doing all of my hips using the anterior approach, and although the first few that I did made me a little anxious, after about 10 hips I knew that I would never go back. For me to switch, I had to feel that it was an advantage to my patients and that I could do as good or better job implanting the components. I have definitely found both to be true.

I have found that my patients have less pain and are ready to leave the hospital sooner. After an anterior hip there are no hip position precautions like there are after a posterior approach. This means no pillows between the legs and you can bend over as far as you want.

My patients who have had one hip done through the posterior approach and one through the anterior approach tell me that not having to follow specific hip position precautions is one of the biggest positive differences that they noticed and they feel that it helped them recovery more quickly.

From my standpoint as a surgeon, I love the approach because I don’t have to cut any major structures to get to the hip, and also when it is done through the anterior approach it is easy to use fluoroscopy (real time x-ray) to check the position of the hip components while you are putting them in. This allows the cup position to be optimal and allows the surgeon to check the leg length to be sure it is the same as the other leg.

I am very happy that I was pushed to learn this new approach to THR. Total hip replacement surgery is one of the most rewarding surgeries that we do. No matter how it is done, as long as it is done well, patients have wonderful results. This is exactly why many surgeons don’t feel the need to change. They are doing an operation with excellent results and they don’t want to take a chance on having problems while learning a new way of doing it.

Fortunately for me, I was able to see a good surgeon and support staff doing this procedure and it convinced me to change.

My last thoughts for anyone reading this who is contemplating having their hip replaced is to know that the most important thing for a successful hip replacement is having a good surgeon and a hospital that does hip replacement surgery routinely. I do think the anterior approach has advantages over the posterior approach for both the patient and the surgeon and that’s why I switched.

Ulnar nerve entrapment at the elbow, also known as cubital tunnel syndrome is a condition where the ulnar nerve in your arm becomes irritated or compressed. This nerve is one of the three important arm nerves that travel from your neck all the way down into your hand. Constriction can occur in a number of places along this path, and depending on the site of irritation or compression, this pressure causes numbness, elbow pain, hand and wrist discomfort, or finger pain. When the ulnar nerve is compressed at the elbow, it is called, Cubital Tunnel Syndrome.   This condition is now also commonly called “cell phone elbow”.

Causes of Cubital Tunnel Syndrome

The ulnar nerve gives you feeling in your little finger and half of your ring finger. Additionally, it controls the muscles of the hand that allow you to pick stuff up and do other fine movements. It also controls bigger muscles of the forearm that allow you to grip objects.  The exact cause of cubital tunnel syndrome is not completely understood, but it is believed that the ulnar nerve is susceptible to compression at the elbow because it passes through a narrow space where there is not much tissue for protection.

Keeping your elbow bent for long periods of time (like when you hold a cell phone to your ear) may cause ulnar nerve irritation and symptoms.   Other common reasons for this condition include:

• -A direct blow to the inside of the elbow or “hitting the funny bone”
• -Fluid buildup in the elbow that leads to swelling and nerve compression
• -Irritation when the nerve slides in and out of place with bending
• -Pressure on the nerve from prolonged leaning on your elbow
• -Sleeping with your elbow bent

Home Remedies for Cubital Tunnel Syndrome

The simplest thing you can do is to lay down your cell phone and avoid other activities that require you to bend your arm for long periods of time. Also, make sure your computer chair is not too low, and do not rest your elbow on the armrest a lot. Keep your elbow straight when sleeping, if possible, by wrapping a towel around your elbow region or wear an elbow pad backwards.

What the Doctor May Do at Your Visit

If the orthopedic specialist suspects you have cubital tunnel syndrome, he may order special X-rays to see if bony deformities are the cause of the problem.  Additionally, he may order electrical nerve conduction studies to determine how well your ulnar nerve is working and to identify exactly where the compression site is located.

Nonsurgical Treatment

Sometimes, non-steroidal anti-inflammatory medicines can alleviate your symptoms. The orthopedic specialist will want to decrease the swelling around the nerve with these medications. Also, he may inject a “steroid”, like cortisone around the ulnar nerve area of compression. It is not uncommon for the doctor to recommend a brace or splint for you to wear at night to keep your elbow straight. Finally, there are certain nerve gliding exercises that may help your nerve slide through the cubital tunnel so that symptoms can improve or resolve completely. These special exercises help keep the wrist and forearm from getting stiff and sore.

Surgical Treatment

For some people, nonsurgical measures are not enough to relieve the symptoms of cubital tunnel syndrome. In these cases, the orthopedic specialist recommends surgery to take the pressure off the ulnar nerve. Also, surgery is indicated for those who have severe nerve compression or muscle wasting due to the condition. The surgical procedures available include:

Endoscopic or Open Cubital Tunnel Release:  In this surgery, the ligament “roof” of the cubital tunnel is divided. This allows for an increased tunnel space and a decreased nerve pressure.   This procedure minimizes the dissection around the nerve and allows for the quickest recovery.  Dr. Weil is one of the only surgeons in the northwest performing Endoscopic Cubital Tunnel Ulnar Nerve Decompression surgery.  This method is the least invasive and allows for the fastest recovery of all ulnar nerve decompression surgeries.  Dr. Weil was highlighted on King 5 news Health Link for his treatment of cubital tunnel syndrome.

Ulnar Nerve Anterior Transposition:  With this procedure, the nerve is moved from the cubital tunnel and placed in front of that region. Ulnar nerve anterior transposition allows the nerve to lie under the skin and fat but on the muscle, within the muscle, or under the muscle. Placement will depend on your particular problem and the surgeon’s choice.

Medical Epicondylectomy:  One great option to release the ulnar nerve is to remove part of a bony section called the medial epicondyle. This technique prevents the nerve from becoming caught on one of the bony ridges so that it can adequately stretch with bending motions.

Surgical Recovery

If you must undergo a surgical procedure, the orthopedic specialist may put you in a splint following the surgery. For the endoscopic technique no splint is required, for the transposition technique, you may have to wear it as long as 6 weeks. Also, your doctor may recommend that go to physical therapy to learn exercises that will help you regain strength and motion in your arm.

I see three major types of arthritis that affect the elbow and shoulder joints. Osteoarthritis is the “wear-and-tear” arthritis caused from degenerative conditions, and occurs most frequently. Rheumatoid arthritis is less common and is a systemic inflammatory condition of the joint lining (the synovium). Posttraumatic arthritis is a form of arthritis that develops from an injury, such as a dislocation or fracture.

Elbow Arthritis

Many patients wonder, “What is arthritis”. For any joint, arthritis means, “joint inflammation”. In the case of the elbow, if the cartilage surface of the elbow becomes worn from age or damaged, elbow arthritis occurs. If you have elbow arthritis, you probably have pain, swelling, stiffness, and loss of normal range of motion. Some people complain of a “locking” or “grating” sensation in the joint.

These sensations are related to the loss of normal smooth joint surface and when pieces of loose bone or cartilage lodge between the joint surfaces interfering with normal movement. Often, my patients may notice numbness of the ring finger and pinky finger. This is related to the pressure placed on the ulnar nerve or funny bone from the swelling.

How is elbow arthritis diagnosed?

I can diagnose elbow arthritis based on your symptoms, a simple physical examination, and standard X-rays. This disease tends to be more common in men than women, and it generally occurs in people over the age of 50 years. You are at increased risk for elbow arthritis if you have a history elbow injury, inflammatory arthritis, or a family history of arthritis. Others at risk for elbow arthritis include people who have jobs or participate in activities that place demands on the elbow joint, such as professional baseball pitchers.

How is elbow arthritis treated?

I treat elbow arthritis predominantly based on your symptoms. Factors to consider include the stage of the disease, patient goals, and your overall medical condition and physical health. Nonsurgical treatment for elbow arthritis involves measures to alleviate or reduce pain, increase range of motion, and restore function. This includes physical therapy, activity restrictions and limitations, and oral anti-inflammatory or pain medications. If these conservative measures do not work, many patients benefit from corticosteroid injections, which can give several months of relief and can be both therapeutic and diagnostic.

Surgery may be necessary if nonsurgical measures do not control and alleviate symptoms. If the damage is not too severe, I can do minimally invasive and sometimes even arthroscopic procedures to remove loose bodies and degenerative, inflammatory tissue from the joint. This smoothes out the irregular joint surfaces and provides symptom relief. If the joint space is severely worn, I may suggest a joint replacement for you.

Shoulder Arthritis

The shoulder is made up of two joints. One of these is the acromioclavicular (AC) joint, located where the collarbone (the clavicle) meets the tip of the shoulder blade (the acromion). The other is located at the junction of the upper arm bone (the humerus) and the shoulder blade (the scapula), and this is called the glenohumeral joint. Both of these shoulder joints are often affected by arthritis. The symptoms of shoulder arthritis include pain, stiffness, decreased or limited range of motion, and crepitus. Crepitus is a “clicking” or “snapping” sound made with shoulder movement.

How is shoulder arthritis diagnosed?

I diagnose shoulder arthritis based on a thorough physical examination, symptoms, and basic X-rays. Most people with shoulder arthritis have a narrowing of the joint spaces, formation of bone spurs, and changes in the bone structure. People over the age of 50 years are at increased risk for shoulder arthritis. Also, having a history of an injury to your shoulder joint puts you at risk for developing this condition.

How is shoulder arthritis treated?

I treat shoulder arthritis based on the severity of the disease, health status and overall condition, activity level and work responsibilities, and prior history. Nonsurgical measures include oral medications, physical therapy, and activity restrictions and limitations. Patients that do not respond to these methods could have a corticosteroid or hyaluronic acid injection. When the joint is severely damaged or worn, or if the patient does not improve with conservative measures, the glenohumeral joint can be replaced with a prosthesis in a procedure called a total shoulder arthroplasty.

If necessary, the head of the humerus is replaced. For arthritis of the AC joint, a resection arthroplasty could help. I do this by taking a small piece of bone from the collarbone to leave room for movement.

A thumb sprain is an injury of the main thumb ligament at the base of the thumb, the ulnar collateral ligament. Skier’s thumb is another term for a thumb sprain. Ligaments are the soft tissue components that hold two bones together to stabilize a joint. You weaken your pinching and grasping abilities if you tear the ulnar collateral ligament. Because of the popularity of recreational skiing in the United States, skier’s thumb is a common orthopedic injury. When the ulnar collateral ligament is completely torn, the injury must be surgically repaired.

What is the cause of skier’s thumb?

It is normal to extend your arms in front of you when you fall. People do this to reduce the impact from hitting the ground. With skiers and other who pitch forward, falling on the hand can stretch or tear the ulnar collateral ligament. Another cause of this injury is an automobile accident, with the driver’s thumb being impacted over the steering wheel. Basically skier’s thumb can result from any injury where the thumb is abnormally bent backward or to the side.

What are the symptoms of skier’s thumb?

The signs and symptoms of skier’s thumb can occur minutes to hours after the initial injury:

• Swelling of the thumb
• Pain at the base of the thumb and in the space between the thumb and index finger
• Bruising of the skin over the thumb
• Inability to grasp or weak grasp
• Tenderness along the index finger side of the thumb
• Thumb pain that is worse with movement
• Pain in the wrist

How is skier’s thumb diagnosed?

To determine if you have a sprained thumb, I will examine your thumb in different positions to determine if your joint is stable. Also, diagnosis depends on your signs and symptoms as well as the history of your injury. I may perform X-rays to evaluate the joint with tension applied to the injured ligament. In addition, I check for normal functioning of the three major nerves of your hand.

What is the treatment for skier’s thumb?

Nonsurgical Treatment

Treatment depends on whether the ligament is stretched, partially torn, or completely torn. If only stretched or partially torn, I immobilize your thumb joint with a splint or bandage until it heals. For relief of pain and swelling, I recommend ice application 3 or 4 times each day. You will wear the splint or bandage for at least three weeks. After a specified amount of time, I encourage you to do strengthening exercises for your thumb. Physical therapy helps with this. This will continue for another 2 or 3 weeks. Most stretching and partial tearing injuries of this ligament heal after 4 to 6 weeks.

Surgical Treatment

When the ulnar collateral ligament is completely torn, surgery is often necessary. This procedure involves reconnecting the ligament to the bone to regain normal movement. With a skier’s thumb injury, the fragments of the bone may be pulled away with the torn ligament. These types of injuries require fixation with a pin or screw. After your surgical procedure, you will wear a short arm cast or splint for 6 to 8 weeks while the ligament heals.

What is my prognosis like with skier’s thumb?

The prognosis of this type of injury depends on the severity of the tear, how soon you get treatment, and your current bone and joint health. If a sprained thumb is treated promptly and properly, full normal function will be preserved and restored. If you delay treatment of skier’s thumb, however, chronic weakness, instability, and/or arthritis could develop. These late complications can be repaired with a joint fusion procedure or ligament rebuilding procedure.

Can I prevent skier’s thumb?

If you ski, you should discard the ski pole when you fall. Falling onto an outstretched hand without the pole will lessen your chance of a sprained thumb. Also, you should use a ski pole with finger-groove grips without restraining devices such as a closed grip or a wrist strap.

What should I do if I suspect I have skier’s thumb?

If you think you have sprained your thumb, I recommend you be evaluated as soon as possible in our office. While you are making your appointment, apply ice to the injury for around 30 minutes at a time. Avoid moving the thumb, and immobilize it with an ACE wrap. Take some ibuprofen for pain relief and anti-inflammation action.