Claw Toe

Claw toe is a common foot deformity in which your toes bend into a claw-like position, digging down into the soles of your shoes and creating painful calluses. People often blame claw toe on wearing shoes that squeeze your toes, such as shoes that are too short or high heels. However, claw toes often are the result of nerve damage caused by diseases like diabetes or alcoholism, which can weaken the muscles in your foot. Claw toes can get worse without treatment and may become a permanent deformity over time.

Symptoms

There are several signs of claw toe:

• Your toes are bent upward (extension) from the joints at the ball of the foot.
• Your toes are bent downward (flexion) at the middle joints toward the sole of your shoe.
• Sometimes your toes also bend downward at the top joints, curling under the foot.

Corns or calluses may develop over the top of the toe, under the end of the toe or under the ball of the foot.

Diagnosis

If you have symptoms of a claw toe, see your foot and ankle orthopedic surgeon for evaluation. You may need tests to rule out neurological disorders that can weaken your foot muscles, creating imbalances that bend your toes. Trauma and inflammation also can cause claw toe deformity.

Treatments

Non-surgical Treatment

Claw toe deformities are flexible at first, but they harden into place over time. If you have claw toe in early stages, your doctor may recommend a splint or tape to hold your toes in correct position.

Non-surgical treatments should be tried first to correct claw toe. Wear shoes with soft, roomy toe boxes and avoid tight shoes and high heels. Use your hands to stretch your toes and toe joints toward their normal positions. Exercise your toes by using them to pick up marbles or crumple a towel laid flat on the floor.

If you have claw toe in later stages and your toes are fixed in position, a special pad can redistribute your weight and relieve pressure on the ball of your foot. Try special “in depth” shoes that have an extra 3/8-inch depth in the toe box or ask a shoe repair shop to stretch a small pocket in the toe box to accommodate the deformity.

Surgical Treatment

If the above treatments don’t help, you may need surgery to correct the problem. The type of surgery often depends on the severity of the deformity. If the claw toe is still in the early stages or flexible (able to be manually corrected with passive stretching), your foot and ankle orthopedic surgeon may recommend a procedure to reroute a flexor tendon to the toe to correct the deformity. If the deformity has been present for a long time and is now rigid (not correctable), your surgeon may recommend a toe fusion.

Chronic Lateral Ankle Pain

Chronic lateral ankle pain is recurring pain on the outer side of the ankle often develops after an injury such as a sprained ankle. However, several other conditions also may cause chronic ankle pain.

Symptoms

Pain, usually on the outer side of the ankle, may be so intense that you have difficulty walking or participating in sports. In some cases, the pain is a constant, dull ache. Patients may also experience difficulty walking on uneven ground or in high heels, a feeling of giving way (instability), swelling, stiffness, tenderness, or repeated ankle sprains.

Causes

The most common cause for a persistently painful ankle is incomplete healing after an ankle sprain. When you sprain your ankle, the connecting tissue between the bones is stretched or torn. Without thorough and complete rehabilitation, the ligament or surrounding muscles may remain weak, resulting in recurrent instability. As a result, you may experience additional ankle injuries. Other causes of chronic ankle pain include:

• An injury to the nerves that pass through the ankle. The nerves may be stretched, torn, injured by a direct blow, or pinched under pressure (entrapment).
• A torn or inflamed tendon
• Arthritis of the ankle joint
• A fracture in one of the bones that make up the ankle joint
• An inflammation of the joint lining (synovium)
• The development of scar tissue in the ankle after a sprain. The scar tissue takes up space in the joint, putting pressure on the ligaments.

Prevention

Almost half of all people who sprain their ankle once will experience additional ankle sprains and chronic pain. You can help prevent chronic pain from developing by following these simple steps:

1. Follow your doctor’s instructions carefully and complete the prescribed physical rehabilitation program.
2. Do not return to activity until cleared by your physician.
3. When you do return to sports, use an ankle brace rather than taping the ankle. Bracing is more effective than taping in preventing ankle sprains.
4. If you wear high-top shoes, be sure to lace them properly and completely.

Diagnosis

The first step in identifying the cause of chronic ankle pain is taking a history of the condition. Your foot and ankle orthopedic surgeon may ask you several questions, including:

• Have you previously injured the ankle? If so, when?
• What kind of treatment did you receive for the injury?
• How long have you had the pain?
• Are there times when the pain worsens or disappears?

Because there are so many potential causes for chronic ankle pain, your doctor may do a number of tests to pinpoint the diagnosis, beginning with a physical examination. Your surgeon will feel for tender areas and look for signs of swelling. He or she will have you move your foot and ankle to assess range of motion and flexibility. Your surgeon also may test the sensation of the nerves and administer a local anesthetic to help pinpoint the source of the symptoms.

Your surgeon may order several X-ray views of your ankle joint. You also may need to get X-rays of the other ankle so the doctor can compare the injured and non-injured ankles. In some cases, additional tests such as a bone scan, CT scan or MRI may be needed.

Treatments

Treatment will depend on the final diagnosis and should be personalized to your individual needs. Both non-surgical and surgical treatments may be used. Non-surgical treatments include:

• Anti-inflammatory medications such as aspirin or ibuprofen to reduce swelling
• Physical therapy, including tilt-board exercises, directed at strengthening the muscles, restoring range of motion and increasing your perception of joint position
• An ankle brace or other support
• An injection of a steroid medication
• In the case of a fracture, immobilization to allow the bone to heal

If your condition requires it, or if conservative treatment doesn’t bring relief, your doctor may recommend surgery. Many surgical procedures can be done on an outpatient basis. Some procedures use arthroscopic techniques; other require open surgery. Rehabilitation may take 6-10 weeks to ensure proper healing.

Surgical treatment options include:

• Removing (excising) loose fragments
• Cleaning (debriding) the joint or joint surface
• Repairing or reconstructing the ligaments or transferring tendons

Chronic Exertional Compartment Syndrome

Chronic Exertional Compartment Syndrome (CECS) is an unusual cause of pain in the legs of people who participate in physical activity. It is caused by too much swelling of the muscles in the leg during exercise. This causes a decrease in blood flow to the muscles, resulting in pain and sometimes numbness and weakness of the leg.

Symptoms

Patients with CECS notice a dull ache in the leg with activity. If ignored, the pain becomes so bad that the activity must be stopped. The pain begins at the same time during activity. The pain usually goes away with rest, but it takes some time. It is often easy for someone with this problem to point to the exact location where the pain is.

Sometimes there is numbness, cramping, or weakness in the leg. On rare occasions, the condition will cause shrinking of the muscles in the affected area.

Diagnosis

The diagnosis is confirmed by measuring pressure in the leg with a special device.

Treatments

Non-surgical treatment options include stretching, changing your activity level, and sometimes giving up the activities that cause CECS.

If these options don’t work or are unacceptable, surgery may be the best way of dealing with the issue. The surgery of choice is called a compartment release. Your foot and ankle orthopedic surgeon makes one large or two small incisions in the outer tissue of the muscle compartment so that it will decompress. This decompression relieves pressure and increases blood flow to the muscle. The skin is then closed over the muscle. Sometimes a small camera is used during surgery, which allows for smaller cuts to be made on the skin.

Recovery

After surgery, the leg is kept elevated for 3-5 days to limit pain and swelling. Knee and ankle joint motion is allowed immediately, as is walking and light activities. You can restart normal activities four weeks after surgery.

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. Other problems include injuries to the leg’s blood vessels or muscle nerves. Some patients may lose strength in the leg after the tissue covering the muscle is opened.

FAQs

Will I be able to return to my physical activities?

Most patients are able to return to their activities that the CECS was preventing them from doing.

Will the problem come back after surgery?

Generally the problem does not come back.

Cavus Foot

A cavus foot has a high arch. The cavus can range from being slightly high to severely deformed, causing you to walk on the outside of your foot. Surgery sometimes is needed to realign the foot.

While the cause of a high-arched foot it often unknown, a cavus could be caused by nerve disease, clubfoot, or injury. Treatment ranges from changes in shoes to surgeries, depending on the amount of deformity and related problems.

The main goals of cavus foot surgery are to reduce pain, improve function, and prevent further damage or injuries.

Diagnosis

Your foot and ankle orthopedic surgeon may recommend surgery if there is no relief with physical therapy, orthotics, changes in shoes, and/or changes in activity. Some patients also will experience tendon problems, ankle weakness, and foot fractures. These patients may require other procedures to address related problems.

If you have medical problems that make surgery unsafe such as any infections or blood vessel disease, cavus foot surgery may not be appropriate.

A patient with cavus foot.

Treatment

The surgical procedures involved with the correction of the cavus foot are varied and depend on the patient’s foot and ankle alignment and related problems. Typically, the foot is realigned by cutting and repositioning the bones (known as osteotomies). Repairing fractures, tightening ligaments, and transferring tendons also may be necessary. The goal is for the repaired foot to evenly distribute weight along both inside and outside edges. A variety of incisions may be needed to perform the procedures related to the correction of the cavus foot.

Specific Techniques

• Soft-tissue surgery: Cavus foot is caused in part by an over-pull of one of the lateral ankle muscles. A release of this tendon can be performed on the outside of the ankle. Additionally, a transfer of this tendon can be performed to help correct the deformity of the ankle joint. Often patients will have a tightness of their gastrocnemius muscle, one of the main muscles in the calf. This can increase the deformity or prevent a correction from working. It is addressed with a lengthening of a part of the calf muscle or Achilles tendon. This is often performed through one or more small cuts in the back of the leg/ankle. Finally, the plantar fascia may be tight. The plantar fascia is a cord-like structure that runs from the heel to the front part of the foot. Your surgeon may perform a partial or complete plantar fascia release.
• Dorsiflexion osteotomy of the first metatarsal: This procedure flattens out the arch.
• Calcaneal (heel bone) osteotomy: This procedure is performed to bring the heel bone back under the leg. This is needed if correcting the deformity in the front of the foot does not also correct the back of the foot or ankle. A calcaneal osteotomy can be performed several ways and often is held in place with one or more screws.
• Tendon transfers: Too much pull of certain muscles and tendons often is the cause of the deformity associated with a cavus foot. Moving one of these muscles or tendons may help the foot work better. In addition, patients with a cavus foot may have weakness moving the foot up, which is sometimes called a foot drop. In these cases, a tendon from the back of the ankle may be moved to the top of the foot to help improve strength.
• Bony surgery: Correcting the deformity of the foot may not be possible with soft tissue procedures alone. In these instances, one or more bone cuts (osteotomies) may be needed. Instead of a bone cut, your surgeon may perform a fusion (arthrodesis) procedure. A fusion removes the joint between two bones so they grow together over time. During a fusion the bones may be held in place with plates or screws.
• Joint fusion: Sometimes patients have a deformity that has caused damage to the joints. In these cases, soft tissue procedures or bone cuts may not be enough, and it may be necessary to eliminate the motion of the joint.
• Toe surgery: Clawed toes are a common problem in patients with cavus foot deformity. This can be treated with tendon surgery, fusion, or removal of part of the toe bones. Following surgery the toes may temporarily be held in place with pins.

Recovery

Recovery typically requires at least six weeks of non-weight bearing so the bones and other structures can heal. In many cases, an even longer period of protection or non-weight bearing is needed. Typically, the final results are not seen for approximately 6-12 months after surgery.

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. Particular complications associated with cavus foot surgery include incomplete correction of deformity, return of deformity, and incomplete healing of the bone.

FAQs

If I have cavus foot surgery, will my foot be totally normal?

Foot surgery is difficult, especially when large amounts of correction are needed. The ability to bring the foot into a new position may not be lasting, even if everything looks perfect in the operating room. The goal is to provide improved position and function of the foot and ankle. In some patients with very severe deformity, the goal is a foot that functions well in a brace.

The calcaneus is the heel bone. Fractures or breaks of the calcaneus commonly occur after a fall from a height or car accident. Treatment of these fractures may require surgery.

Calcaneus Fracture Surgery

The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. Restoration of normal alignment and contour is considered the best way to restore function and minimize pain.

Diagnosis

Surgery is recommended when a broken heel bone has lost its alignment and contour. Identification of the fracture typically is made after a physical examination by obtaining standard foot and ankle X-rays. The specific type, pattern and classification of the fracture is best made by obtaining a CT scan. Your surgeon may require both X-rays and a CT scan to determine if surgery is your best option.

Not all heel fractures require surgery. If the shape of the calcaneus is generally maintained, surgery may not be needed. Patients with diabetes may be at increased risk for infection or wound healing problems. Patients with poor blood flow may also have difficulty healing properly. Elderly individuals may have difficulty with surgical rehabilitation.

Heel surgery often is delayed due to the swelling that typically accompanies these injuries. It may be severe enough to delay surgery for weeks or preclude it altogether. Surgery can safely proceed when the skin at the surgical site at the lateral heel wrinkles, indicating the dangerous swelling has gone away.

Medications such as immuno-suppressants or steroids may slow healing and delay or preclude surgery. Smoking is considered harmful for wound and fracture healing and smokers should quit before any planned calcaneus surgery.

Treatment

The most common surgical techniques utilized to treat a broken heel bone involve cutting through the skin to place the bone back together and using plates and screws to hold the alignment until the bones heal. A classic “open” procedure involves an incision over the lateral aspect of the heel. The incision is likened to a hockey stick or large “L” where the overlying nerve and tendons are moved out of the way. The fracture fragments are restored to the best possible position and a plate and screws hold the fragments in place.

The technique of “closed” reduction and percutaneous fixation can sometimes be utilized. Multiple small incisions are placed in critical areas around the heel. The broken fragments can be realigned with the help of X-rays. Screws are then placed through the skin to hold the position.

The size and location of the incision and the type of screws and plates used are based on skin quality and the surgeon’s judgment on how to best access and fix the broken fragments of bone.

Specific Technique

General anesthesia, used to put a patient to sleep during surgery, commonly is used along with a regional nerve block, which involves a local injection to help with pain control. The addition of a regional block can provide 12 to 24 hours of pain control after surgery. Surgery can be a same-day procedure or planned with a hospital stay.

A tourniquet is used to minimize bleeding and to ensure proper visualization of critical structures that are protected during the surgery. For the standard open approach, a hockey stick or “L” incision is made on the outside of the heel. The sural nerve and the peroneal tendons are moved out of the way and the skin is held back by placing wires in key positions. The bony fragments are then visualized. The general alignment of the heel is restored. The fragments are then placed into position.

All fragments are temporarily held in position with small removable wires. The wires are then removed, and a plate and screws are placed. The skin is then closed. Post-surgical dressings and a splint are applied.

Recovery

Expect a lengthy recovery after calcaneus fracture surgery. You will be given a splint or cast. You should not put weight on your foot for at least 6-8 weeks until there is sufficient healing of the fracture. The foot remains very stiff and some permanent loss of motion should be expected. Most patients have at least some residual pain despite complete healing.

Everyone who sustains a malaligned break of the calcaneus, particularly involving the joint, should expect to develop some arthritis despite having surgery. If arthritis pain and dysfunction of the foot become severe, then further surgery may be required. Heel bone fractures often are severe and can be life-changing.

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 from treatments for displaced calcaneus fractures can be severe. The most common early complications are in skin healing and nerve stretch. Most wound healing complications can be treated with wound care. Occasionally further surgical treatment may be required. The development of a deep wound infection often requires surgery and antibiotics. Nearly all nerve stretch complications will resolve over time.

FAQs

Do the plates and screws need to be removed?

No, plates and screws do not need to be removed. If they are causing pain or irritation, your surgeon may consider removing them, but he or she will make sure there is enough fracture healing before proceeding.