Archive for January, 2010

What is a Morton’s Neuroma?

January 31, 2010

Morton’s neuroma is a very common and painful condition that affects the furthest end of the foot toward the toes.The pain is felt in the front of the foot and may extend to the toes.  The word “neuroma” is misleading because the ending “-oma” is often thought of as a tumor. However, a Morton’s neuroma is the result of excessive tissue formation around a nerve that forms due to nerve irritation from ligaments exerting pressure on the nerve. These ligaments compress the nerve, and the body’s reaction to the compression is to form excess tissue. However, the excess tissue results in more irritation and compression to the nerve.

Signs and Symptoms:
The pain from a Morton’s neuroma is found on the ball of the foot usually between the 3rd and 4th toes to a lesser degree it is some time located between the 2nd and 3rd toes. The quality of the pain ranges from a burning/tingling pain to sharp/radiating pain.  Most of the time the pain can be felt in the toes as well as the ball of the foot. Sometime, the pain is worse with walking, when the front of the foot pushes off the ground, and therefore increases pressure on the ball of the foot.

1. Physical Exam: The podiatrist will perform a series of test to determine whether the cause of the pain is being caused by a Morton’s neuroma. One common exam is called a Mulder’s Click. The podiatrist will apply pressure with his/her fingers to the top and bottom of the foot where the pain is found and squeeze the front of the foot at the same time. The podiatrist will be looking for a clicking sensation in the area. Producing this click could cause
the irritated nerve to contact the ligament and recreate the symptoms. The term Tinel’s Sign is used to describe the sensation of pain that radiates from the sight of the neuroma (in the ball of the foot) toward the toes.

2. Imaging: The podiatrist will request X-rays to rule out other irregularities that may cause pain to the area, such as a stress fracture or a cyst or bone spur. Since these masses are soft tissue an MRI or diagnostic ultrasound maybe utilized to visualize a neuroma.

Conservative Treatment:
1. Anti-inflammatory medicines such as Mortrin can decrease the inflammation caused by nerve irritation and therefore, may decrease symptoms. However, this will only work on the symptoms and will not change the neuroma.

2. Padding may be recommended to relieve the pressure off of the neuroma. There are pads that are places between the bones to separate them in order to stop the neuroma from being compressed. Padding may also be added to a shoe insert at the ball of the foot to relieve pressure as well.

3. Custom shoe inserts (Orthotics) can alleviate the symptoms of a neuroma. The custom shoe inserts can stabilize the bone structures and improve foot function to prevent nerve compression by the ligaments.

4. Shoe gear modification can be helpful in the reducing neuroma pain. Rocker-bottom shoes reduce the flexing of the toes, and thus reduce the degree of pressure to the ball of the foot where the neuroma is located. Avoiding high-heeled shoes and wearing shoes with a wide toe box increases the space for the foot. The decreased external compression from the shoes may help to reduce the pain from the neuroma.

5. Injection therapy with combination of steroids and local anesthetics may be used to relieve the pain and symptoms caused by the neuroma. Since frequent steroid injection may cause damage to the fat pad found on the bottom of the foot, these injections can only be used in limited quantities.

Surgical Treatment:
If the pain from the neuroma is intolerable and the conservative management has failed to help, there are surgical options. There are surgical procedures designed to remove the neuroma and the portion of the nerve that is causing pain. There is also a surgery to sever the ligament that crosses over the nerve. This technique is called nerve decompression. These procedures are performed in an out patient facility so that the patient can return home right after the surgery is finished. Following the surgery there is a chance that the neuroma may grow again. However, studies have shown that this is infrequent and occurs in one percent of patients undergoing neuroma removal. If the there is neuroma regrowth and the pain persists, additional surgery may be needed.


Causes and Treatment of Bunions

January 15, 2010

Causes and Treatment of Bunions

What is a bunion?
A bunion is a structural bone deformity found in the area on the side of the foot behind the big toe. It often gives the impression that there has been an increase in bone growth; however, on X-ray, it is apparent that there is rarely an increase of bone. What actually occurs is a shifting of the big toe towards the smaller (lesser) toes and consequent shifting of the long bone behind the big toe, bending this joint at an angle. This bend or shift in the joint is similar to the bend of an elbow.

What causes a bunion?
There is no specific cause of a bunion, but research has shown that there are certain factors that can increase the chance of bunion formation.

Common Causes of Bunions:
There is a strong genetic component that contributes to the formation of bunions. More specifically, this means that there are mechanical foot traits that are inherited and that can result in the tendency of bunion formations. With a genetically disposed foot type, overtime, adaptive changes of the bones and joints will occur, leading to a bunion. Statistically, there is an increase of bunion formation in women as well as patients that wear constricting shoes. The combination of the genetic and external factors increases the risks of bunion formation.

Other Causes of Bunions:
The foot is a dynamic machine that functions on carefully controlled and balanced movements of bones and muscles. Factors that disrupt this balance and increase the likelihood of bunion formation are trauma, asymmetrical leg length, neuromuscular disorders, muscle weakness, or arthritis.

What are the types of treatment for bunions?
Depending of the goals and symptoms of the patient, there are various ways of treating bunions. If the patient only wants to treat the symptoms of a bunion, a non-surgical or conservative treatment is considered. However, if the patient wants permanent treatment, surgical options are available.

Conservative Treatment:
Bunions usually present with an aching or shooting pain with redness and/or swelling at the bony prominence on the side of the foot just behind the big toe. The aching in this region is usually due to shoe pressure against the bony bump that produces friction against this area. Additionally, bunions can cause shooting pain along the big toe because the bump is pushing against and irritating a nerve that travels along the big toe.

To alleviate these symptoms, a shoe with a wider toe box is suggested. Also, shoes can be modified or stretched at a shoemaker shop to provide extra room for the bunion and toes in the shoes. Another treatment that may be suggested is custom insoles/orthotics. These devices are placed inside the shoe to correct the abnormal mechanics that may be causing the bunion. The orthotics may decrease the progression of the bunion. Icing the foot using a bunion pad and anti-inflammatory medications can reduce pain, redness, and swelling.

Surgical Treatment of Bunions:
If surgical treatment is desired to treat the bunion, the patient will first undergo a bunion examination. The podiatrist will evaluate the degree of joint motion, pain, and severity of the bunion deformity. Additionally, the podiatrist will take a series of X-rays of the bunion. There are many types of surgeries to treat a bunion deformity. The health and age of the patient as well as angle measurements found on the X-rays will indicate the type of surgical procedure performed.

Surgical Expectations:
Bunion surgery is usually done as an outpatient procedure where the patient leaves the hospital or surgical center the same day the surgery is performed. During the procedure, local anesthetics and sedative medications are administered to allow the patient to fall asleep. In some bunion surgeries, the head or shaft of the first metatarsal may be shifted and secured with a pin or screw. If a pin is used during the bunion procedure, the pin is typically removed at the third or fourth week after the procedure. If screws were used, they will remain inside the foot. Rarely, do screws cause irritation or problems to the feet, but if they do, the screws can be removed. If the joints of the big toe are destroyed due to arthritis, a fusion of the big toe or an implant surgery may be performed.

The recovery time of the bunion surgery will depend on the type of procedure performed. Walking in a post-surgical shoe or boot is allowed after some bunion procedures. However, following other bunion procedures, the patient is expected to be non-weight bearing with crutches for about six weeks, followed by cautious weight bearing with post-surgical shoe for another 6 weeks. In the first two weeks where there is a heeling incision with stitches, it is important to prevent the surgical site from getting wet because the damp bandage will increase the risk of infection. Stitches are usually removed after two weeks. Pain medication will also be prescribed for post-surgery recovery. Throughout the recovery period, a series of X-rays will be taken to monitor the bone healing.

Post-Surgery: How do you help healing?

1. Do not allow the surgery site to get wet when stitches are still in the foot or pins are exposed through the skin.
2. Do not change the bandage that has been placed on your foot by your surgeon u. Unless you have been instructed to by the doctor.
3. Stay off the surgical foot as much as possible in the first few weeks after surgery. Elevate your foot above the level of your heart as much as possible during the first week after surgery.
4. Be diligent in performing range of motion exercises.
5. Only walk in the post-op shoe or boot that has been provided for you by your surgeon.
6. Use ice packs on the operated foot 15 minutes every hour during the first 48 hours after