Posts Tagged ‘bunion’

Treatment of Hallux Limitus

December 29, 2013

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This is an example of an orthotic with a Kinetic Wedge

When a patient presents with symptoms of hallux limitus, it is important to take into account the severity of their deformity as well as the level of pain and how the pain limits daily activities in order to determine what treatment would be most appropriate. A variety of treatment options can be considered, including both conservative and surgical procedures.

Early stages or minimal discomfort from hallux limitus are often approached using conservative treatments. One popular method of conservative pain control is to take oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil or Motrin. Keep in mind that taking this medication does not cure the condition causing the pain. This method of treatment can be used to treat acute flair-ups of pain and swelling.

Foot orthotics are another conservative option to treat hallux limitus and have been shown to relieve pain better than the use of oral anti-inflamatories alone (1). Examples of custom modifications of orthotics used to treat this condition include the Kinetic Wedge and Morton’s extensions. These specialized foot orthotics can help alleviate pain in the 1st MTPJ. By providing functional correction of deformities with the proper orthotic, 1st MTPJ discomfort can be improved. Foot orthotics are inserted into shoes and can be moved from shoe to shoe.

Physical therapy is also another conservative option that may be of some benefit in early stages of the condition.

Steroid injections can be administered in the doctor’s office. A steroid or cortisone shot is given into and around the joint this may help to relieve pain.  The reduction in swelling and pain from this type of injection may not last long. The injection can be repeated, however since over use of steroid can breakdown tissue there is a limit to the number of injects patients can receive.

If the conservative therapy that has been reviewed does not reduce pain, then surgical intervention may be necessary. The major goals of surgery are to reduce pain and improve daily function. Depending on the nature of the patient’s foot and the degree of joint destruction, other goals could include improving joint motion, recreating a joint space in the 1st MTPJ and reducing deformities of bone.

Operations that are able to preserve the joint involve removing any abnormal bone formations around the joint in order to improve mobility. However, there are instances in later stages of hallux limitus and hallux rigidus where preservation of the joint is not possible. In this case, the joint articulations or cartilage may be removed and replaced by an artificial joint or the joint may require to be permanently locked together also known as joint fusion.

If you believe you are feeling symptoms of hallux limitus or hallux rigidus, it is important to address the pain with your doctor as early as possible. May people that have pain in this area assume that they have a “bunion”.  An earlier and accurate diagnosis opens the possibility of a variety of noninvasive, conservative treatments that can help reduce pain while walking.

References:

1. Shurnas PS. Hallux limitus: etiology, biomechanics and nonoperative treatment. Foot Ankle Clin. 2009 Mar; 14(1):1-8.

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Tailor’s Bunionette and its Treatment

September 5, 2010

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.

Behind the Scenes of Foot Surgeries

June 30, 2010

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.

GOUT: Causes and Treatment

May 2, 2010

Gout is a very painful and sometime debilitating joint disease caused by uric acid crystal formation in the joints. However, early diagnosis, management and treatment, can result in decreasing the severity and the frequency of gout attacks. Most patients who are experiencing a gout attack usually complain of severe pain in the affected joint. This pain tends to be worse at night. One of the most common areas affected is the big toe joint at the ball of the foot.  Typical symptoms that occur in a gout attack are hot and extremely swelling and redness. The pain can be very excruciating to the point that even light touch from bed sheets can cause pain.

Interestingly, the painful symptoms of gout usually occur during the night when the body temperature drops. Once the body temperature is lower, there is a higher occurrence of uric acid crystals that slowly begin to form in the joints. This process is very similar to dissolving sugar in hot water. When the hot water cools, the dissolved sugar slowly begins to reform similar to uric acid crystals formation in the foot when the body temperature decreases.

Origin of gout:
Gout is a disease commonly found in older men and postmenopausal women. The causes of gout is divided into two categories, either the body overproduces uric acid, which is the main component of uric acid crystals, or the body under excretes uric acid. Under excreting uric acid is the most common cause of the two categories. However, in both cases, there is a high uric acid concentration in the body and thus increased formation of the uric acid crystals into the joints.

Diagnosis of gout:
If gout is suspected, an X-ray may be taken of the foot to evaluate the joint. In a patient with chronic gout, the uric acid crystals can cause bone erosions that can be visualized on X-ray. Also, x-rays are taken to rule out the possible other causes for this type of pain, such as a fracture or arthritis. Blood tests may be performed to determine the amount of uric acid in the body. It should be noted, however, that there could be normal uric acid levels in the blood even though the patient has gout or symptoms of gout. Also, gout can be diagnosed by aspirating the joint. This procedure requires local anesthetic to numb the joint, then using a needle and syringe; a sample of joint fluid is removed for analysis. The joint fluid in gout has a white cottage cheese appearance as opposed to a normal joint that has clear joint fluid. This joint fluid is then sent to the lab for analysis.  Uric acid crystals can be visualized in the lab using a microscope.

Conservative treatment:
One way to decrease the incidence of gout attacks is by changing to a diet that is low in foods such as red meats and wine because these types of food are high in purine.  Purine, is a chemical that is broken down into uric acid in the body when the amount of uric acid becomes to high the crystal of acid collect in the joint and cause the painful attack.  Decreasing purine consumption results in less uric acid build-up.

Oral medication can also decrease the incidence and severity of gout attacks. Indomethacin, a non-steroidal anti-inflammatory, is used to decrease the swelling and inflammatory symptoms of gout. Another medication called Colchicine may be recommended to prevent the inflammatory reaction caused by the acid crystals.

In order to decrease the amount of uric acid in the body, allupurinol may be used. This medication inhibits the conversion of purine to uric acid crystals and thus prevents crystal formation in the joint.

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
surgery.