History of High Heeled Shoes

High heeled shoes have been historically apart of human culture. It was first documented on ancient Egyptian murals showing both men and women of royalty wearing heels for religious ceremonies and Egyptian butchers wearing them to walk above the blood of butchered animals. In Greece and Rome, heels were worn in theatrical plays to indicate social status. Regardless of its purpose, heels have been perpetually apart of daily life since ancient civilization.

Effects of High Heeled Shoes on the Body

High heels are unique compared to other footgear due to the shoes anatomy.   The structure of heels changes the positioning of bone orientation in the foot and ankle, resulting in postural changes of the body.

1. Narrow toe box

The shoe covering over the toes is called a toe box.  In the design of most high heels, the toe box tends to be narrow, decreasing the space inside the shoe and increasing friction between the foot and shoe. This results in increased risk of blisters and corns forming on the foot. Additionally, a narrow or pointed toe box squeezes the ball of the foot causing bones in this area to be forced closer together. This pressure increases the likelihood of irritating the nerves that run in close proximity to the bones. Constant use of heels can exacerbate nerve irritation leading to inflammation of the nerve called a neuroma. This condition is associated with a numbing or throbbing sensation at the ball of the foot and may radiate to the toes.  A narrow toe box in can also aggravate bunions and hammertoe deformities.

2. Heel Cup

The covering around the heel is called a heel cup and is often very hard and rigid in high heeled shoes. Additionally, the heel cup protrudes forward into the heel resulting in friction between the back of the wearer’s heel and the shoe. This increases the pressure on the back of the heel and overtime can create a bony protrusion in the area known as a “pump bump” or Haglund’s deformity, which can be painful when walking in shoes.

3. High Heel

The increased heel height places the ball of the foot lower than the heel. This position of the foot and ankle is called plantarflexion. As plantarflexion increases, the foot loses its shock absorbing ability and creates increased shock applied to the foot when the shoe hits the ground. This shock wave is transmitted through joints in the foot, knee, and hip causing leg and back pain when wearing heels.

Increased plantarflexion of the foot and ankle also shortens the calf muscle.  This shortening decreases the ability of the calf muscle to help lift the foot off the ground. Overtime, a shorten calf muscle can create a tight Achilles tendon, which strains the tendon and causes pain to the area when transitioning back to normal shoe gear. Additionally, heels change body posture by increasing pressure on the ball of the foot and decreasing pressure on the heel.  This results in increased pressure in the knee joint and strains the knee joint tendons, leading to arthritis of the knee. Studies have shown that even moderate heel heights of 1.5 inches can significantly increase strain to the knee. By distributing body weight unevenly and causing the wearer to lean forward, heels can increase the risk of falls.

Preventing Adverse Effects of High Heeled Shoes on the Body

Statistics has shown that 35-65% of women wear heels. However, there are preventive treatments that can alleviate pain and decrease adverse effects associated with wearing heels.

1. Custom Inserts

Custom made inserts that are placed inside heels can reduce the impact force the body experiences when wearing heels. Custom inserts support the arch and heel of the foot by increasing the area of foot contact to the shoe and distributing body weight to the middle of the foot. This can relieve some of the pressure from the heel and ball of the foot. Research studies have shown that custom inserts have been clinically proven to improve comfort.

2. Stretching

As mentioned above, higher heels tend to shorten and contract muscles in the foot and shorten the Achilles tendon and calf musculature, which results in increased workload on these muscles and tendons. Therefore, stretching these areas can relieve pain and aid in more comfortable transitioning between heels to flat shoe gear. Wrapping a towel around the ball of the foot and pulling the towel towards the body stretches the bottom of the foot. It is usually recommended to hold the stretch for 30 seconds and alternating between each foot 3-4 times.  A runner’s stretch is often recommended to stretch the Achilles tendon. This stretch entails pushing against a wall while one foot is forward and bent and the other foot placed back and straight. The foot placed back is stretching the muscles and tendons in the back of the lower leg. This stretch again is held for 30 seconds and is alternated with the other foot 3-4 times.

3. Rotating types of shoes

Alternating between supportive athletic shoes, flats and heels can decrease the potential problems associated with wearing high-heeled shoes.

Symptoms of Tarsal Tunnel Syndrome

Tarsal tunnel syndrome refers to the irritation and/or compression of a nerve called the posterior tibial nerve. This nerve is found behind the anklebone on the inner side of the foot.  (Same side as the big toe) As the nerve travels in this area it runs through small canal called the Tarsal Tunnel.

Symptoms of tarsal tunnel include:

1. Radiation, burning, or shooting pain on the bottom of the foot, along the arch and/or up into the leg

2. “Pins and needles” sensation to the bottom of the foot and into the toes

3. Disturbances in the perception of temperature (feelings of coldness)

4. Feeling like there is a tight band around the foot

5. Loss of sensation to the sole of the foot and/or heel

6. Pain getting worse with prolonged standing or walking

7. Rest and leg elevation can relieve symptoms

Causes of Tarsal Tunnel Syndrome

The main culprit of tarsal tunnel syndrome is the decrease in space in the tarsal tunnel, which results in compression of the posterior tibial nerve. There are multiple reasons that can cause narrowing of the tarsal tunnel.

1. As the tibial nerve travels behind the anklebone, it goes through the tarsal tunnel, which is a narrow canal bordered by a sheath of tissue and the heel bone.  As the tibial nerve goes through the tarsal tunnel, it usually splits into two nerves, the medial and lateral plantar nerves. If the tibial nerve splits into two nerves before entering the tarsal tunnel, it increases the number of structures going through the tarsal tunnel. This results in a relative decrease of space in the tunnel and compression of the nerve.

2. Several tendons and veins course through the tarsal tunnel with the tibial nerve. If these structures are enlarged or swollen the tibial nerve can be compressed.

3. Compression of the tibial nerve can also occur from bony prominences, spurs or fragments of bone in the tarsal tunnel.

4. Abnormal heel position with the heel positioned more inward or outward can stretch the tibial nerve or narrow tube of the tarsal tunnel again resulting in excessive pressure on the nerve.

Physical Examination in Tarsal Tunnel Syndrome

Tarsal tunnel syndrome can mirror other foot conditions, such as heel pain, arch pain, or neuropathy therefore, the podiatrist may need to utilize various examination techniques, imaging modalities and electro diagnostic studies to diagnosis tarsal tunnel and syndrome. The podiatrist will tap along the course of tibial nerve to reproduce the shooting sensation often associated with tarsal tunnel syndrome. The podiatrist will also examine if there is any swelling along the tarsal tunnel and the medial arch because this may indicate a mass that may be in the tunnel. The podiatrist may also try to increase the pressure on the tibial nerve by turning the foot outward and up and holding this position for 5-10 seconds. This exam produces a narrowing the space of the tarsal tunnel and can recreate the patient’s symptoms. Heel and foot position may also be examined to determine if that may be the cause of tarsal tunnel compression. In order to determine which nerve branches are involved, a pin prick test may be applied to the sole of the foot to determine which areas of the foot has decreased sensation.

Diagnostic Studies in Tarsal Tunnel Syndrome

If a bony prominence is suspected as the cause of tarsal tunnel syndrome, the podiatrist may request X-ray imaging of the foot and ankle. For soft tissue masses or increase tendon size/swelling, MRIs may be requested as well. Ultrasound may also be utilized to determine the tibial nerve split or tendon pathology. If vein enlargement is suspected, the podiatrist may use a tourniquet wrapped above the tarsal tunnel to increase fluid accumulation in the veins.  Other studies that may be ordered to study the function of the tibial nerve are nerve conduction studies or electromyography.

Non-Surgical Treatment of Tarsal Tunnel Syndrome

The podiatrist may recommend taping, bracing, orthotics, or shoe modifications to provide support to the feet and correct the heel position.  Correcting the abnormal foot movement that may cause stretching and pressure in the tarsal tunnel may prove to relieve the symptoms of Tarsal Tunnel Syndrome. Icing and oral anti-inflammatory may be suggested to decrease swelling in the area.

Surgical Treatment of Tarsal Tunnel Syndrome

The main purpose of tarsal tunnel surgery is to release structures that may be putting pressure on the posterior tibial nerve or removing bone or soft tissue masses that may cause narrowing in the tarsal tunnel. The incision is made behind the anklebone and in front of the Achilles tendon. During surgery, blunt surgical instruments are utilized in order to avoid damage to the nerves. The sheath of the tarsal tunnel is opened and the course of the tibial nerve and its branches are followed in order to remove any thickened structures and release any tight structures around the nerves. Following surgery, a bulky dressing is applied to the foot in order to decrease swelling. One week after surgery, simple motions of the ankle for 10-20 minutes twice a day may be recommended to prevent adhesions. After 2-3 weeks, sutures are removed and ambulation with tennis shoe may be allowed.  The average time for most patients to begin exercise and full activity is 2-3 months after surgery.  It is also important to note that tingling and pain may increase after surgery, and the pain and numbness may take up to one year or more to resolve

Anatomy of the Ankle

Ankle sprains, if not treated early, can create chronic ankle instability; (weak ankle) which leads to difficulty in sports activities and frequent recurrent ankle sprains. The ankle is composed of the joint, formed by three bones called the tibia (lower leg bone) and the talus as well as the fibula and ligaments that surround the joint.  The ankle ligaments support the joint and prevent excessive motion that may cause instability. There are two sets of ligaments in the ankle joint, the deltoid ligaments (found on the inside of the ankle joint on the same side as the big toe) and the lateral collateral ligaments (found on the outside of the ankle joint on the same side of the little toe).  The weakest of the fore mentioned and most commonly injured ankle ligaments are the lateral collateral ligaments. It is commonly injured by “rolling the ankle” or turning the foot inward, which stretches the ligament and results in tearing or rupturing of the ligament.

Causes of Ankle Sprains

Stretching the ankle ligaments beyond their maximum ability causes ankle sprains. This results in tearing or rupturing. Stretching of the ankle ligaments can occur when missing a step on a curb or physical activity that results in turning the foot inward or outward. Certain factors can increase the likelihood that ankle sprains occur.  Skeletal deformities of the foot where the heel is turned inward places the foot in a position that encourages the ankle to roll. Increased laxity and flimsiness of the ligaments will create a situation in some people where the supporting ligaments cannot stop the twisting motion, which leads to the ankle injury.  Impaired proprioception, a condition where the body has difficulty sensing the position of the ankle and impaired muscular control of the ankle joint, can also lead to more frequent sprains. Additionally, the incidence of ankle sprains can also increase if there are loose bone fragments found in the ankle joint associated with arthritis.

Symptoms of Ankle Sprains

Ankle ligament injures are classified by grades from grade I to grade III. Each grade is treated differently and the classification enables the podiatrist to provide the best treatment for the patient. Grade I ankle ligament injuries do not involve ligament rupture and only have minor swelling and tenderness. Grade II injuries have partial rupture of the ligaments, with moderate tenderness, swelling and loss of motion. Grade III injuries include a complete rupture of the ligament, severe bruising, swelling, pain, and major loss of function and motion of the ankle joint. Patients with ankle instability complain of persistent pain, recurrent sprains, and repeated instances of the ankle giving way.

Diagnosing Ankle Sprains:

When visiting a podiatrist for evaluation of an ankle sprain, the doctor will ask if the patient can recall the position the foot was in when the injury occurred. This will allow the podiatrist to determine which ligament was most likely injured. Additionally, the podiatrist will perform a physical exam. The exam will include pushing along both sides of the ankle where the ligaments attach, as well as distracting and moving the ankle to determine which ligaments have been injured. The podiatrist will perform X-rays of the foot and ankle in order to determine if the ankle sprain is accompanied by a fracture.  This may occur when the ligament has pulled off a bone fragment from the ankle and/or foot. Diagnostic ultrasound may be done to visualize the extent of the soft tissue injury.

Non-surgical Treatment for Ankle Sprains

Simple sprains can be treated non-surgically with: resting the foot and ankle, ice, compression, and elevation— especially during the first few days. Early weight bearing without crutches is encouraged if possible to prevent stiffness of the ankle joint.  It is usually recommended to start range-of-motion exercises of the ankle followed by coordination training with balance boards and trampoline, as well as strengthening exercises. An external ankle brace or ankle taping may be used to control the motion of the joint to reduce symptoms of the sprain and to prevent additional injury during the healing phase. With more severe ligament injuries, treatment can consist of cast immobilization, rehabilitation and possible surgical repair.

Platelet Rich Plasma Treatment:

Also known as PRP, is another treatment method that can be used to treat this condition. The procedure can be performed in the office and takes about 45 minutes. This is performed by taking a small sample of blood from the patient. This blood is then processed and a concentrated smaller amount of blood is produced with a very high quantity of platelets. Then, using ultrasound to guide the needle to the exact location of the injury the platelet-rich compound is injected. When the platelets are placed at the injured area they release a growth factor that attracts the patients stem cells. These stem cells then infiltrate the area and form new tissue to aid in healing the injured tissue.

Surgical Treatment for Ankle Sprains

When nonsurgical treatment does not resolve the ankle sprain, surgical treatment is the next option. There are three main types of surgical repair of ankle ligaments:

1. Tendon reconstruction: uses tendons to function similarly to the ligaments and since the long-term outcome is not as successful as other procedures, it is commonly used as secondary procedures in repairing ankle injuries.

2. Anatomic repair of the ligaments: restores the original ligament attachment and length by shortening and stitching the rupture ligaments.

3. Anatomic reconstruction: uses tissue flaps and grafts to reinforce and strengthen the ankle ligaments. This type of procedure is commonly used if anatomic repair of the ligament cannot be performed due to weakness and damage to the ends of the original ligament, failure from previous repair, increased ligament slack, or longstanding ankle stability of greater than 10 years.

After surgery, it is usually expected that the patient will be in a weight-bearing cast for about 6 weeks, followed by physical therapy and range-of-motion exercises.

Pain can interfere with normal daily activity and can prevent us from enjoying life fully. However, pain is the body’s alarm system to alert us when something is wrong, and it is a normal response produced by the body.

How does pain work?
There are four major stages with which pain will begin in our body. The first is the actual stimulus, which starts the pain information pathway to the brain. The stimulus is usually negative and results in tissue damage. The damage can be a cut of the skin, a broken bone or a tear or crush of soft tissue.
During the transmission stage, this negative stimulus is converted by the nerves to an electrical signal. This information is then carried by nerves toward the brain.
Before the electrical information finally enters the brain, the body has a third step in the pain route, called modulation. The modulation step works like a gate, where the brain sorts out the various stimuli that the body receives and determines whether or not the signal is strong enough to be recognized.
Once the brain accepts the electrical signal and final process begins, which is the awareness of pain in the body.

What are the goals of treating pain?
The two main goals that a podiatrist wants to achieve in treating pain are to eliminate the source of the problem and also to treat the symptoms caused by the problem. In order to do so, the podiatrist will need to investigate the cause of the pain by first asking the patient a series of questions regarding the problem. Below is a series of questions that podiatrists commonly ask in order to find the source of the pain and how to better treat it. Patients should think about some of the answers to the following questions before and during the appointment in order to better assist the podiatrist in finding the source of the problem.

1. Where is the pain located?

2. How would you describe the pain?
There are different types of pain in the body. If the pain is tingling or burning, the problem is most probably associated with the nerve. Most likely, achy, dull, throbbing, or sharp pain, more often indicates more of a muscle or bone problem.

3. On a scale of 1-10, 10 being the most painful, what is your pain level?
Knowing the level intensity of the pain can help determine what type of medication to alleviate the pain. Stronger pain intensity may mean that a stronger strength of pain medication may be needed.

4. How long has the pain been occurring?
The duration of the pain can help the podiatrist determine whether the pain is acute, lasting for a few days to weeks, or chronic, which lasts for a period longer than 3 months. If the pain is acute, it may signify that there was trauma that occurred to the area. Chronic pain may indicate arthritic changes or overuse injuries of the foot.

5. Did you injure your foot or was there anything different that occurred before the pain?
Knowing the incidences before the occurrence of pain can help determine what structures in the foot are injured.

6. What makes the pain worse or better?

7. What treatments have you done to alleviate the pain?
Knowing what type of treatment a patient has tried helps the podiatrist know how to better treat the patient, especially in avoiding treatments that have already been tried. Additionally, if there may be two causes to the pain, it can help a podiatrist eliminate one of the two sources of the pain.

What are the common treatments for pain?
Aside from treating the source of the problem, the podiatrist may offer treatment that can alleviate pain.

1. Icing and compression. Increased swelling and inflammation to the foot caused by trauma can make the pain worse. Accordingly, icing and compression of the foot may be recommended.

2. Topical Anti-inflamatories: Botanical anti-inflammatories can also be used to reduce swelling and therefore reduce pain. Arnica is one of these topical plant products that can help. It comes from the Arnica Montana plant. It was discovered and used my native Americans before the arrival of Columbus and is still used successfully today

3. Non-steroidal anti-inflammatory drugs (“NSAIDS”). NSAIDS are commonly prescribed to control inflammation and swelling. They are often recommended for mild or moderate pain level intensities. Caution must be taken when using “NSAIDS”. If the patient has a history of stomach ulcers this class of drugs can increase the chance of a gastric bleed. It is important for everyone taking this class of medicine to take the pill with food. If stomach discomfort occurs, it is best to change the medication.

4. Opioids. Opioids do not decrease inflammation. However, they do decrease the amounts of chemicals that need to be released to start the electrical signal for pain. This prevents pain signals from entering into the brain. Opioids are often recommended at higher pain level intensities. When using, opioids caution must be taken to avoid drug abuse.

5. Capsaicin. This is a topical cream or solution that is applied to the skin and recommended more for chronic pain. Capsaicin has chemicals that are made from chili peppers. It decreases the chemicals that are needed for the nerves to transmit pain signals to the brain. Caution must be taken to avoid eyes, mouth, and genital areas when using this medication because it causes a severe burning sensation.

6. Local anesthetics injections. This type of treatment directly affects the nerves and prevents the nerves from sending signals to the brain. Local injections, however, only produce temporary relief.

7. Steroid injections. This type of injection is given in combination with local anesthetics and is another form of treatment to decrease inflammation. Depending on the problem, this type of injection can alleviate pain anywhere from a few weeks to a few months.

X-rays are used in podiatry for many reasons. For example, X-ray can be used to monitor the healing progress of a surgical procedure, confirm a suspected fracture or to confirm a bone infection. In other words, X-ray images are tools to assist and improve patient care. There are, however, potential harmful effects of X-ray radiation. Therefore, the process of taking X-rays and common precautions must be understood.  With an understanding of the mechanism and nature of X-ray concerns, potential negative effects can be lessened.

Properties of X-rays:

The nature of X-rays can be perplexing because it is a form of energy similar to light. However, unlike light, there is nothing directly or physically seen. A main component in creating X-ray images is radiation, which is the transmission of energy as waves or particles akin to light. There are different types of radiation, ranging from lower energy radiation like radio, television, microwaves, and visible light to higher energy radiation like X-rays. Unlike low energy waves, X-ray radiation can change the properties of particles of an object that are exposed to the high-energy emission.

Categorizing X-ray Radiation:

There are three categories of radiation that are found where X-ray radiation is used.

The strongest is called the primary beam. This is the radiation that is made inside the X-ray tube which is located in the X-ray machine. The tube is made of glass that is lined with lead. This is meant to contain the X-ray waves and prevent X-ray overexposure to the patient and personnel that are near the machine. The primary radiation exits the tube and is directed toward the area of the patient being examined.  Of the three categories of X-ray radiation, primary radiation is the most dangerous and most intense.

The second type of X-ray radiation is referred to as secondary radiation, made of scatter or leakage radiation. Scatter radiation comes mostly from the patient when the primary beam is reflected off of the patient’s body. This type of radiation emission is most dangerous to personnel in the room. Leakage radiation is the energy waves that escape out of the X-ray tube.

The final and third category of X-ray radiation is remnant radiation, which is the energy waves that exit the patient and produces the image on the film.

Potential Dangers of X-ray Radiation:

X-ray radiation passes through body tissue and has enough energy to change the genetic make-up of cells that make up the tissues in the body. This can result in the overgrowth of cells. Of all the organs in the body, the lens of the eyes, sexual organs, white blood cells, and the thyroid gland are most sensitive to X-ray radiation. However, it takes an exceedingly large amount of radiation to damage the genetic components of cells and tissues.

In the case of pregnant women, the brain and spinal cord of the fetus is most sensitive to radiation and thus X-ray exposure is avoided during the 10^th to 17^th week of pregnancy. This time period corresponds to the growth period of these structures in the developing child. There are industry-accepted doses of radiation that can be exposed to a patient and rarely, if ever, does the amount of X-ray radiation performed exceed the maximum amount. In podiatry, it would require 5,000 X-ray exposures to be considered harmful to a pregnant woman, and this number is even higher for non-pregnant patients. Despite research showing low-risk from X-ray radiation, precautions and safety procedures are still practiced to fully protect the patient from potential damages.

Protection from X-ray Radiation:

There are two main forms of protection against overexposure of X-ray radiation, distance and shielding. Increased distance between a person and the X-ray machine decreases the amount of exposure to X-ray radiation. This is important for health care personnel, who frequently administer X-ray imaging.

The second form of protection against radiation is shielding. Commonly, a lead apron is worn by the patient to protect against unnecessary exposure to radiation to other parts of the body.

What to Expect When Taking X-rays:

A state certified radiology healthcare personnel places the lead apron on the patient. If the patient is female of childbearing age, she will be asked if she is pregnant. Then the strength of the X-ray beam is adjusted. Next the body part being studied will be correctly positioned. The person taking the X-ray will make sure everyone has cleared the area. A button is pushed to take the image accompanied by a buzzing sound. This sound indicates that the image is taken. In podiatry, there are at least two images taken for each X-ray study. The reason for this is that the foot is a three-dimensional object, but X-ray images are only a two-dimensional representation of the foot. Therefore, more than one X-ray view is needed to provide the podiatrist with a better visualization of the possible problems in the feet. Once the film has been processed, the film will have areas of black, which represent the soft tissues.  The X-ray beam has passes through these areas of the body and strikes the film or sensor at near full strength causing these areas to become fully exposed and appear black.  The image will also have areas that appear white. This represents areas where X-ray beams are stopped and absorbed therefore they do not reach the film or sensor. This occurs when the X-ray strikes hard tissue such as bone.

Where and what is the sinus tarsi:

The word “sinus” refers to a cavity, most often in bone. The cavity known as the sinus tarsi is located on the outside of the foot in front of and below the outside anklebone. The cavity is formed at the junction between the heel bone and the bone that sits over the heel bone called the Talus.  The heel bone forms the floor of the cavity and the talus creates the roof.

Within the cavity there are blood vessels, nerves and ligaments.  The ligaments function to hold the two bones together.

Symptoms:

“Sinus Tarsi Syndrome” refers to a painful condition located in this cavity in the rear portion of the foot. The pain is made worse with weight bearing. The pain can become much more intense when walking, running or hiking on uneven surfaces.

Causes of Sinus Tarsi Syndrome:

The most common cause of sinus tarsi syndrome is an inversion injury to the foot. This occurs when the foot rolls inward and stretches the soft tissue in the cavity.  When the foot is stressed by this inward motion a tear or strain occurs to the ligaments. The injury to these ligaments results in inflammation, swelling and thickening.

The other causes of this condition are structural as apposed to the injury noted above. One of these structural abnormalities that can occur is growths or masses of soft tissue.  Over growth of nerve or fat tissues in the cavity can cause increased pressure and result in pain. The pain in this area can also be caused by deviations in the bone structure. For example, bone spurs; arthritis and bone bridges can be responsible for the development of sinus tarsi syndrome.

Another helpful procedure to determine the exact location of the pain is to inject the sinus tarsi with a small amount of local anesthesia. If upon examination after the injection the pain is gone the diagnosis is confirmed. If however, the pain is still present following the injection the injury may be in another location in the foot.

Non-Surgical Treatment:

Research has shown that a majority of the people with sinus tarsi syndrome will respond favorably to conservative management. Rest, ice and compression are suggested to reduce the inflammation. Oral anti-inflammatory medications can be prescribed to further decrease the pain and swelling.

Another treatment option is to tape the foot to attempt to limit the motion at the subtalar joint. If the taping successfully reduces the pain long term treatment with a custom orthotic can be used to control the motion of the rear foot. In most cases foot orthotics are sufficient to treat this condition, however in some cases an ankle foot orthotic may be necessary to fully control the motion.

Finally, a steroid injection into the sinus tarsi may be effective at relieving the pain.

Surgery:

In conservative measures have not helped to relieve the pain surgery may be needed.  A common surgical procedure to threat this condition is decompression or removing the abnormal tissues from the cavity. If the MRI scans shows a soft tissue mass present in the sinus tarsi surgical removal of the mass will be needed.

After the surgery, protected weight bearing in a post-operative shoe or walking boot will be required for a period of approximately 2-4 weeks.

If this surgery fails or the patient has severe arthritis the bone in the rear foot may need to be fused.

Most people know that a classic “bunion” appears as a bump on the side of big toe joint. A Bunionette or tailor’s bunion is like the big toe bunion, but in this case there is a bony prominence on the outside of the foot at the base of the small toe. The term ‘tailor’s bunionette originated from tailors in Asia who sat on the ground with their legs crossed resulting in increased pressure on the outside of their feet. This increased pressure caused thick skin formation on the outer aspect of the foot.

Anatomy of a Tailor’s Bunionette:

The fifth or little toe sits at the end of a long bone called the fifth metatarsal.  At the junction of these bones is the joint where the bunionette forms.

Causes of Tailor’s Bunionette:

There are many factors that cause a tailor’s bunion. Structural causes of tailor’s bunion can be an enlarged fifth metatarsal head. Increased angles between the fourth and fifth metatarsals can also cause this deformity. Finally, bowing of the fifth metatarsal may also lead to a Tailor’s bunion.  Or some combination of the above may contribute to the cause.

Symptoms:

Tailor’s bunions may or may be painful deformities. If pain is present, it usually occurs with shoes. The area becomes painful when the bony prominence of fifth metatarsal head rubs against the shoe, resulting in pain and inflammation. Continued shoe friction against the tailor’s bunion can cause swelling, redness and callus formation. On examination, there is pain when pressure is applied to the outside or bottom of the fifth metatarsal head. A fluid-filled pouch, called a bursa, may be found between the bone bump and the skin. This forms as a process of the body’s protective mechanism to protect the bone against the friction from the shoe.

Diagnosing:

The diagnosis of a tailor’s bunion is based on physical exam and imaging. X-ray imaging is performed to evaluate the increase angle between the fourth and fifth metatarsals. This diagnostic tool is also used to determine how much of the bump is composed of bone and how much is do to the swelling from the above mentioned bursa sac.

Conservative Treatment:

Non-surgical treatment is used to decrease the pain and inflammation from a tailor’s bunion. This includes anti-inflammatory medicines, steroid injections. Pads and shoe modification such as a wider toe box or softer materials are used to decrease pressure on the area.

Surgical Treatment:

Surgery is indicated when conservative treatment fails to eliminate the pain. There are several surgical techniques used for the treatment of this deformity. The type of surgery performed will depend on a patient’s medical condition, findings on physical exam and the structure of the fifth metatarsal as determined by X-ray imaging. Surgery for a tailor’s bunion can be performed on the metatarsal head (the end toward the toe), shaft (the middle of the bone), or metatarsal base.

If the problem is found to be an enlarged metatarsal head then this area can simply be shaved down. If there is an increased angle between the fourth and fifth metatarsal bones this angular relationship may need to be changed. Therefore, this condition may need further modification by making a cut across the metatarsal and shifting the end of the bone. After shifting the cut section of the metatarsal, a screw may be used to maintain the position. If there are significant angular abnormalities between the fourth and the fifth metatarsals, then a surgical procedure at the base of the bone with screw fixation may be required.

Expectations After Surgery:

When the procedure is performed on the metatarsal head or shaft, immediate weight bearing in a post-op shoe is allowed. However, procedures performed on the metatarsal base are more disabling and need to be non-weight bearing with crutches. After surgery when returning to the doctors office for post operative care, follow-up X-rays to evaluate bone healing will determine when walking may begin. Additionally, as with all surgeries there will be swelling, pain and tenderness after the procedure. Medicines to control the post-operative pain and swelling will be available to the patient. Some of the inherent risk associated with this surgery are that the deformity may return or that there may be an under correction of the deformity.

Almost all feet have two sesamoid bones found on the bottom of the big toe joint.  These two sesamoids are oval, seed-shaped bones. Their purpose is to absorb weight-bearing forces to protect the tendon that runs on the underside of the big toe. They elevate the big toe, which is also known as the hallux, thus assisting in increasing the mechanical advantage of the tendon that bends the hallux toward the floor.

Anatomy of the Sesamoid

Each of the two sesamoids found under the big toe joint have specific names. The sesamoid closer to the little toe side of the foot is termed the fibular sesamoid, and the sesamoid found on the big toe side of the foot is called the tibial sesamoid.  If one of the oval shaped bones is in two pieces, it is termed bipartite and if the sesamoid is found in many pieces, it is termed a multipartite.  Finally, the sesamoids are anchored to each other, also to the hallux and the first metatarsal by various ligaments and tendons.

Symptoms of Sesamoid Disorders

The most common disorder is called sesamoiditis.  This is inflammation of the sesamoid bone and is usually caused by repetitive trauma. It is commonly seen in young adults, athletes, dancers and women that wear high heel shoes. Most of the time, the pain from sesamoiditis is worse with shoes when weight bearing. The pain is located directly under the sesamoid where swelling and redness maybe noted.

Diagnosis of Sesamoid Disorders

To diagnose sesamoiditis the doctor will press on the bottom of the foot in the area of both sesamoids. If pain is elicited when one or both of these bones is palpated the doctor will know that the patients pain is coming from an injured sesamoid bone.  An important part of diagnosing sesamoiditis is to evaluate the bones with X-ray imaging.  Sesamoiditis cannot be seen on x-ray.  The x-ray is used for ruling out other conditions in this area such as fracture, bone tumor or arthritis.  If on the x-ray image the sesamoid appears fragmented and the pieces have sharp edges with wide separation relative to each other, it may be indicative of a sesamoid fracture.

Non-surgical Treatment of Sesamoid Disorders

Before surgical treatment is considered, non-surgical treatments are always tried. If the pain on the sesamoids is due to the presence of callused skin, the podiatrist may remove the callus with a scalpel.  In the case of sesamoiditis, the first line of treatment is to get the pressure off of the bone.  This can be accomplished by applying a Dancer’s pad to the foot.  This is a pad made of felt or silicone; it has a curved cut out to allow the sesamoid to float. In the case of fractures or dislocations immobilization of the sesamoid is essential for healing.  Depending of the severity of the sesamoid disorder, the immobilization can be accomplished with the use of a CAM or boot walker to decrease pressure to the sesamoid.  Treatment using ice and non-steroidal anti-inflammatory medication may also be recommended. If the padding helps relieve the pain custom orthotics can be made to off-weight the sesamoids. Corticosteroid injections to the joint can also help alleviate pain.

Surgical Treatment of Sesamoid Disorders

If the sesamoid pain is not alleviated by non-surgical care, then surgical treatment is considered. The most common surgical procedure for sesamoid disorders is a sesamoidectomy (removal of a sesamoid).

Recovery after Sesamoidectomy

After a sesamoidectomy, it is recommended that the patient is non-weight bearing with crutches for 2 weeks, followed by 4-6 weeks in a post-op shoe with protected walking.  The podiatrist may recommend joint exercises to prevent stiffness in the joint and custom orthotics to decrease pain and maintain function of the foot. Since sesamoids are important in the function of the big toe, sesamoid removal can change the mechanical balance in the foot. Therefore, removing the sesamoid can result in a decrease of hallux strength, limited big toe joint motion, and positional changes of the big toe.

What is a ganglion cyst?

It is a single or multi-chambered soft tissue mass with thin walls that is filled with high-protein fluid. The fluid color ranges from amber to clear and located beneath the skin and can be attached to muscle tendons, joint capsules or nerves.

What causes a ganglion cyst?

The causes of ganglion cysts are still unknown. However, it is suggested that they are caused by repetitive trauma or joint fluid projecting out of its contained area. In the case of repetitive trauma, ganglion cysts may form if there is friction or excessive rubbing between a bone and/or shoe against a tendon.

What are the symptoms of a ganglion cyst?

Ganglion cysts can be found all over body. Most commonly, on the hand and wrist, then followed by the foot. In the case of the foot, ganglion cysts are the most common soft tissue masses found in the foot and ankle; in addition most are located on top of the foot. When a ganglion cyst becomes large, it may appear frightening and worrisome because patients may believe they have developed a cancerous growth. Fortunately, ganglion cysts tend to be harmless and painless and may even resolve on it’s own.  However, if the ganglion cysts become large enough, it can begin to cause pain. This is because the enlargement produces increased pressure on the surrounding tissues such as skin and nerve.  Additionally, large ganglion cysts can interfere with shoe gear.

How do you diagnose a ganglion cyst?

Ganglion cysts are usually diagnosed clinically. The podiatrist will test if the soft tissue mass has characteristics of ganglion cysts. These characteristics are that the mass is movable and soft.

X-ray studies are occasionally used in examining a ganglion cyst. The cysts are soft tissue and do not appear on x-ray, however, x-rays can rule out other diagnostic possibilities, such as calcified masses or bone invading tumors.

Diagnostic ultrasound is inexpensive and very effective at diagnosing and revealing the nature of the ganglion cyst.  By studying the cyst with the ultrasound, the doctor can see the size, shape and the number of chambers in the mass.

MRIs may also be requested usually to determine the size and the degree of how much soft tissue is involved with the ganglion cyst. This is an expensive test and is most often used for surgical planning.

How do you treat a ganglion cyst?

Non-surgical treatment:

It is often difficult to treat ganglion cysts without surgery. However, non-surgical treatment can help relieve pain and symptoms from the ganglion cysts. Padding may be placed around the ganglion to decrease pressure and irritation to the area. Change in footwear may also be suggested to reduce friction and pressure to the area as well.

Aspiration of a Ganglion Cyst:

This is done by first numbing the area with local anesthesia.  Next, the site of aspiration is cleansed with antiseptic skin cleaner. Then, using an empty syringe and needle the fluid is pulled out of the ganglion cyst. After aspiration of the ganglion cyst, a syringe with steroid maybe injected. Also, it must be noted that there is a high risk of recurrence of the ganglion cyst after aspiration.

Surgical treatment:

Surgery as a treatment for ganglion cysts is only considered if conservative treatment failed, the ganglion is recurring, or there is significant pain. Surgical removal of a ganglion cyst consists of removing the entire ganglion wall and surrounding soft tissue that is associated with the ganglion cyst. Since surrounding soft tissue needs to be removed, the incision site will need to be longer then ganglion cyst. Pain, swelling, numbness, or tingling may occur after the surgery. As with aspiration procedure noted above, it must be noted that there is risk of recurrence of the ganglion cyst after surgery as well.

This article will inform the reader about the various steps that will occur on the day of your surgery. Knowing the procedures and the processes and what goes on the operating room should help make you feel more comfortable. The following description details a patients experience from the time they come into the surgical facility through the surgery and finally the discharge back to your home.  You will also meet and understand the roles of the people who will help you and be involved with your care throughout your surgical day.

Before Surgery:
You will check in with the surgical facilities reception personnel. After filling out the appropriate forms you will be escorted to the changing area. In the changing area there will be a secure place to keep your property. Even though this is secure, it is advisable not to bring valuables to the surgery. In the changing area there will be a private room where the patient surgical gown will be provided for you to change into.  After this step, you will meet with the nurses who will perform a pre-surgical interview.  They will also take your temperature, review your chart and check your blood pressure and other vital signs.

Next you will be seated in the waiting area. When it is time for your surgery you will meet with the anesthesiologist. He or she will ask you questions regarding allergies, physical conditions and if you are a female of child bearing age they will ask if you are pregnant. At this time the anesthesiologist will have you sign a consent form to administer the anesthesia. The podiatrist will also meet with you and will mark the location on your foot where the surgery will be performed. At this time, the doctor will answer any last minute questions you may have.

During Surgery:

Next, you will be escorted to the operating room (OR).
The anesthesiologist will then start a connection through an IV into your arm to deliver the anesthesia. After you are in a dream-like state of anesthesia, the podiatrist will draw out the incision site on your foot, and inject the local anesthetics to the site of surgery.
The podiatrist will then go to the scrub station to disinfect their hands and lower arms.  Also at this time, the circulating nurse will use anti-bacterial sterilizing solution to clean your foot. The purpose of this cleaning is to create a sterile field on and around the surgical site so that it is free from bacteria and therefore minimize the risk of postoperative infection.
The podiatrist and first assistant will then be gloved and gowned by the scrub nurse. All the gloves and gowns are completely sterile, which is another way to reduce the possibility of infection that could enter your body.
The podiatrist and first assistant will place a sterile drape, with an opening for the foot, over your body. This further provides a surgical area is bacteria-free.
Before the podiatrist makes the skin incision, the circulating nurse will call a “Time Out.” This is when the nurse confirms your name, the surgical procedures and location, your allergies, and the names of the podiatrist and first assistant to everyone in the room. This may seem repetitive, but through research, this provides further safety for the patient.
The podiatrist may then wrap an Esmarch bandage (looks like a very wide rubber band) around your foot to squeeze the blood out of the foot. Inflating a tourniquet around the ankle then follows this and the Esmarch band is removed. This prevents bleeding during the surgical procedure and allows the surgeon to clearly see structures in the foot.
The designated surgery is then performed, whether it is to fix a hammertoe or bunion deformity or other foot condition.
At the end of the procedure the incision site is closed with stitches and bandages are applied on the foot. Depending on the type of procedure, you may leave with a walking boot or surgical shoe on your foot.
The anesthesiologist will slowly withdraw the medication and you will soon regain consciousness.

After Surgery:
You are transported to the recovery area.  The surgeon will meet with you again to follow-up on your status.
Depending on the type of anesthesia used, you may or may not be groggy at this time. Therefore, you may or may not remember seeing the surgeon in the recovery area.
In the recovery area the nurse will monitor your progress as you return to full conscientiousness. As soon as you are able, they will get you to out of the bed and into a chair. When you are fully aware and awake the nurse will go over your postoperative instructions. Once you are able to ambulate, you will be discharged and released to proceed to go home.

Who’s Who?

Circulating Nurse: Works outside the sterile field in the operating room. Cleans the surgical site with anti-bacterial solution and performs the “Time Out” before the incision is made. Also, the circulating nurse opens all instruments and stitches in a sterile fashion for the scrub nurse and brings in any instruments that may be needed for the surgery. Documents and counts all the instruments and stitches used during the procedure. At the end of the surgery, the circulating nurse assists the Scrub Nurse in making sure all the gauze and instruments are accounted for.

Scrub Nurse: Gloves and gowns the surgeon and first assistant and hands the surgeon and first assistant the instruments, stitches, and bandages needed during the procedure.

First Assistant: Assists the surgeon in holding back the soft tissue during surgery and helps with instrumentation and orienting the patient for the surgeon to access the surgery site easily.

Anesthesiologist: Provides pain medication and monitors breathing rate, blood pressure, and heart rate and rhythm during the surgery.