Common Disorders
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Did you know the foot has 28 bones, 37 joints, 107 ligaments, 19 muscles, and numerous tendons? These parts all work together to allow the foot to move in a variety of ways while balancing your weight and propelling you forward or backward on even or uneven surfaces. It is no wonder that most Americans will experience a foot problem that will require the care of a specialist at one point or another in their lifetime.

Description

Plantar fasciitis is an inflammation of a thick, fibrous ligament in the arch of the foot called the plantar fascia. The plantar fascia attaches into the heel bone and fans out toward the ball of the foot, attaching into the base of the toes. If this ligament is stretched excessively it will become inflamed and begin to cause pain. In severe instances the ligament can rupture resulting in immediate severe pain. If the ligament ruptures the pain is so great that the patient can not place weight on the foot. Should this happen, the foot should be elevated and an ice pack applied. An appointment with your foot doctor should be made at your earliest convenience. Sports such as tennis, racket ball, and aerobics can cause extreme tension on the plantar fascia resulting in small tears or rupture of the ligament. However, other less stressful activities can result in tears or rupture of the plantar fascia under the right set of circumstances. (For a more through discussion of the cause of plantar fasciitis see heel pain) One consequence of small tears in the plantar fascia is the formation of firm nodules within the plantar fascia, called fibromas.

Diagnosis

Taking a through history of the course of the condition and physical exam makes the diagnosis of plantar fasciitis.

Treatment

Treatment of plantar fasciitis is similar to that for heel pain. Cortisone injections, used in the treatment of heel pain, are not commonly used for the treatment of plantar fasciitis. The main emphasis of treatment is to reduce the forces that are causing the plantar fascia to stretch excessively. This includes calf muscle stretching, over the counter arch supports, andorthotics. Oral anti-inflammatory medications may be useful in controlling the pain.

 

The common cause of a painful bump on the back of the heel is called Hagland's deformity. This is due to an enlarged bony prominence on the back of the heel. It can involve the entire back of the heel or just a portion of the back of the heel, usually on the outside portion of the heel. Also called the Pump Bump, it is most common in women and is frequently a result of pressure from the back of the shoe. As the shoe rubs on the back of the heel bone it begins to swell and enlarge. Quite often a bursa will form. A bursa is a sack that is created over any bony prominence when excessive pressure or friction to the areas occurs. Bursae can be filled with a thick watery like fluid.

Treatment

Treatment consists of removing the pressure and avoiding shoes that rub on the back of the heel. Orthotics, custom molded shoe inserts, can be useful because they reduce the rocking motion side-to-side of the heel while walking which aggravates the painful area. Cortisone injections can temporarily reduce the pain or eliminate the pain. Surgery can be the treatment of choice if other means to reduce the pressure are unsuccessful.

Dislocating peroneal tendons are an uncommon injury to a group of two tendons whose muscles originate on the outside of the calves. These two muscles are named the Peroneus Brevis and Peroneus Longus. These two muscles are responsible for eversion of the foot. This movement of the foot is demonstrated by standing and then rolling to the outside of the foot. These tendons are also called "stirrup" tendons because as they pass into the foot they act as a stirrup to help hold up the arch of the foot. As these tendons pass behind the outside ankle bone, called the fibula, they are held in place by a band of tissue called the peroneal retinaculum. Injury to the retinaculum can cause it to stretch or even tear. When this occurs the peroneal tendons can dislocate from their groove on the back of the fibula. The tendons can be seen to roll over the outside of the fibula. This will cause the tendons to function abnormally and can cause damage to the tendons. Dislocating peroneal tendons most commonly occur as a result of injury during participation in athletic activities. The most common sport causing injury is snow skiing. It can also occur while playing football, basketball, and soccer. This injury can occur in non-athletes, as a result of a severe ankle sprain. The injury typically results in a popping or sharp pain on the outside of the ankle. The outside of the ankle is called the lateral malleolus. Commonly however, there may be little to no discomfort at the time of injury, which later becomes symptomatic.

Diagnosis

Physical examination will reveal swelling behind the outside of the ankle if it is an acute injury. If the injury is chronic there may be little to no swelling. There is usually tenderness particularly when pressure is applied behind the outside of the ankle. Having the patient forcefully turn the foot outward against the physician's hand can demonstrate dislocation of the peroneal tendons. This will cause the peroneal tendons to dislocate over the outer edge of the lateral malleolus.

When excessive stress is placed upon the ball of the foot, a hairline break (fracture) of a long metatarsal bone may occur. This occurs most frequently to the second, third, or fourth metatarsal but can occur in any bone. Frequently, the injury is so subtle that you may not recall any specific occurrence. These fractures were at one time referred to as “March Fractures” in soldiers, who developed foot pain after long periods of marching. Stress fractures can occur during sports activities, in overweight individuals, or in those with weakened bones such as osteoporosis.

Diagnosis

A typical presentation for someone with a metatarsal stress fracture would be pain and swelling in the ball of the foot, which is most severe in the push off phase of walking. Pressing on the bones in this area of the foot will reproduce the pain. X-rays taken during the first two to three weeks after the injury often will not show any fracture. A bone scan at this stage will be much more sensitive in diagnosing the early stress fracture. The decision to order a bone scan will be up to your doctor. Often times the diagnosis can be made based upon clinical findings, thus making the bone scan unnecessary. After several weeks, an x-ray will show the signs of new bone healing in the area of the stress fracture.

Metatarsal fractures represent common injuries of the forefoot. The fifth metatarsal is the most common metatarsal to be fractured. Most commonly, it is injured during inversion type injuries (ankle sprains). Fractures to the fifth metatarsal may also occur from direct or crushing types of injuries, as well as from stress or fatigue fractures.

In general, fifth metatarsal fractures may be grouped into three basic types. The first is known as an avulsion fracture. This type of fracture is common with ankle sprains or other inversion type foot injuries. The fracture occurs at the base, or styloid process of the fifth metatarsal. It is caused by the traumatic pulling of the peroneal brevis tendon (or a ligament) from the end of the metatarsal. The fracture is always transverse in nature and usually results in very little displacement or malalignment. The second type of fracture is often referred to as aJones fracture. The fracture is also transverse in nature. However, it occurs further down on the metatarsal, in a region known as the metaphyseal-diaphyseal junction. This injury is usually caused by stress placed across the bone when the heel is off the ground and the forefoot is planted. This type of fracture my also represent an old stress fracture which has progressed to a complete fracture. This type of fracture is significant because it occurs in an area where the blood supply to the bone is less than adequate, causing healing problems. The final type of fracture is the spiral or oblique shaft fracture. This type of fracture is located closer to the fifth toe. It may be caused by either direct trauma or by mechanical stresses placed across the bone. This type of fracture pattern is very unstable resulting in a fracture, which is often displaced.

The Lis Fran's joint is a combination of joints in the middle of the foot. At the point where the long bones behind the toes, called metatarsals, connect with a grouping of small cube shaped bones, called cuniform bones, there are several joints the move together in an interlocking fashion. This grouping of interlocking joints is referred to as the Lis Franc's joint. The Lis Franc’s joint are bound together by a series of transverse ligaments on the top and bottom of the joint, as well as an intermetatarsal ligament. This grouping of joints is clinically called the tarsometatarsal joints. Fracture-dislocations of the tarsometatarsal joint are named for Lis Franc who was a field surgeon in the Napoleonic army. Fracture-dislocations of the tarsometatarsal joint (Lis Franc’s) is extremely significant in that it is a commonly missed diagnoses with a great potential for long term disability.

Lis Franc’s fracture-dislocations can occur in many different ways. It can be caused by both a direct crushing type injury or a force applied to the metatarsal heads (ball of the foot) which both can result in displacement of the Lis Franc’s joint or fractures that in involve the joint. Common causes are motor vehicle accidents, falls from heights, severe foot and ankle sprains, crushing force to the top of the foot. These injuries can occur during strenuous and competitive athletic activities. The athlete who complains of sudden onset of pain, in the middle of the foot during the course of an athletic event should be carefully evaluated for a possible Lis Franc's injury.

The Lis Franc,s joint is a combination of joints in the middle of the foot. At the point where the long bones behind the toes, called metatarsals, connect with a grouping of small cube shaped bones, called cuniform bones, there are several joints the move together in an interlocking fashion. This grouping of interlocking joints is referred to as the Lis Franc's joint. The Lis Franc’s joint are bound together by a series of transverse ligaments on the top and bottom of the joint, as well as an intermetatarsal ligament. This grouping of joints is clinically called the tarsometatarsal joints. Fracture-dislocations of the tarsometatarsal joint are named for Lis Franc who was a field surgeon in the Napoleonic army. Fracture-dislocations of the tarsometatarsal joint (Lis Franc's) is extremely significant in that it is a commonly missed diagnoses with a great potential for long term disability.

Lis Franc's fracture-dislocations can occur in many different ways. It can be caused by both a direct crushing type injury or a force applied to the metatarsal heads (ball of the foot) which both can result in displacement of the Lis Franc's joint or fractures that in involve the joint. Common causes are motor vehicle accidents, falls from heights, severe foot and ankle sprains, crushing force to the top of the foot. These injuries can occur during strenuous and competitive athletic activities. The athlete who complains of sudden onset of pain, in the middle of the foot during the course of an athletic event should be carefully evaluated for a possible Lis Franc's injury.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toesoverlapping toesflexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.