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.

Brief Description

An uncommon cause of small lumps in the Achilles tendon is an excessively high cholesterol level in the blood stream. This is a hereditary disorder that results in the deposition of cholesterol in the Achilles tendon. Frequently people will also have yellowish plagues on the lower eye lids, This is a serious condition and requires aggressive treatment by a physician to lower the cholesterol levels. Left untreated the high cholesterol levels can lead to premature heart attack and death.

Diagnosis

Diagnosis is made by clinical exam. Palpation of the Achilles tendon will reveal multiple small nodular masses. Noting excessively high blood cholesterol levels on routine lab tests provides confirmation of the condition. A biopsy of the lesion will also make the diagnosis.

Treatment

The nodules in the Achilles tendon should be left alone. There is no value in removing them. Treatment should be directed at lowering the blood cholesterol levels.

Within the arch of the foot, firm, nodular masses may form. These can occur as a single mass or in clusters. They are called plantar fibromas and are a non-cancerous tumor that forms within a ligament in the arch of the foot called the plantar fascia. Frequently, they will slowly enlarge causing pain while walking. Their cause cannot always be determined. Damage to the ligament will cause their occurrence and there is an association with taking the drug Dilantin. In 10% of the cases, patients will also demonstrate similar lumps in the palms of the hands calledDupuytren's Contracture.

Diagnosis

Diagnosis is made by clinical exam. Biopsy of the masses is not recommended. The act of biopsy may cause the fibroma to enlarge. When the mass is removed a definitive diagnosis is provided by examination by microscopic examination by a pathologist

Treatment

Treatment consists of padding the area to reduce pressure. Functional foot orthotics will take the strain off of the plantar fascia ligament and sometimes cause the fibromas to shrink in size. Surgical excision of the mass requires removal of most of the plantar fascia. Simple excision of the mass without removal of the entire ligament generally results in recurrence of the mass. Whenever surgery is contemplated, the patient should wear a functional foot orthotic following the surgery. The orthotic helps to accommodate for the loss of the plantar fascia and its effect on foot function. (See surgical excision of plantar fibromas)

A small nodular single mass that can form on the top of the toe is often times a Muco-Cutaneious Cyst. These occur most frequently at the joint just behind the toenail. These are caused by a weakening of the joint capsule, which allows a swelling to occur. They are firm and rubbery to the touch. Sometimes as the skin thins due to the stretching pressure of the mass it will appear translucent. When the mass is broken or punctured, a thick clear fluid will leak out. If the mass does break open, the area should be kept clean and free of infection. Once the skin heals the mass will reappear.

Treatment

A ganglion is a soft tissue mass that most commonly occurs on the wrist in women between 25 and 45 years of age. They are also seen commonly on the foot. A ganglion is a firm, rubbery mass that occurs on the top of the foot. On the foot, the most common area of involvement is in front of the ankle or on the outside of the ankle. A common characteristic of a ganglion is that they will enlarge and then shrink is size. They generally occur without any apparent cause. Ganglions arise spontaneously from a weakness in the soft tissue covering of a joint or tendon sheath. Ballooning out of the tissue occurs and it fills with a thick mucoid fluid. In many instances, ganglions are not painful until they reach a size that causes irritation from shoe pressure. On occasion they will compress a nearby skin nerve and cause tingling into the top of the toes. Tapping on the ganglion will often result in this same tingling sensation into the toes. Other common masses on the foot are giant cell tumorsfibromas and lipomas.

A flatfoot deformity is where the arch on the inside border of the foot is more flat than normal. Flatfoot deformities can occur in all age groups, but appear most commonly in children. Some of these children grow up into adults who have feet with normal arches, but many of these children have pain related to their flatfoot deformity throughout their lives. It is very important that children with flatfoot deformity be evaluated by a podiatrist to determine if they need treatment to prevent future pain or deformity in their feet.

When the young child starts to first walk at about the age of 9-15 months of age, the foot has a fat or chubby appearance where there is a less bony architecture apparent in the foot. At this point in the development of the foot, it is very difficult to evaluate whether the child will have future problems with a flatfoot deformity.

At the ages of two and three, the child's foot starts to show more of its characteristic shape since the foot is less fat and the bones are more prominent. If the child has a flatfoot deformity at the ages of two to three, then it is wise to have the foot examined by a foot specialist such as a podiatrist. The reason that it is important to have the feet examined at this age is because the young foot is still largely made of cartilage, with less bone than would be present in the adult foot. Since cartilage is relatively soft, the abnormal forces caused by a flatfoot deformity may cause permanent structural alterations to the bones and joints of the foot that will persist into adulthood.

This tumor was once thought to be a cancer of a tendon sheath. It is now known to be a benign non-cancerous tumor of a tendon sheath. These masses are generally found on the toes, top of the foot or sides of the foot. They are always closely associated with a tendon sheath. They can also occur deep inside the foot. They slowly enlarge but never grow any larger than 4cm in size. They are firm irregular masses that are commonly painful. The pain seems to be a result of the tumor pressing firmly on the surrounding tissues and due to the interference with the function of the tendon that the mass is growing from. As the tendon grows it can press so firmly on the bone it lays next to, that it can cause erosion of the bone. It is because of this erosion of bone that the tumor was once thought to be cancerous. Cancerous tumors can have the characteristic of invading bone through aggressive and destructive means. The erosion of the bone associated with giant cell tumors is due to pressure on the bone and not due to the invasion of the bone by the tumor. Other common soft tissues masses that may occur in the foot areganglionsfibromas.

A ganglion is a soft tissue mass that most commonly occurs on the wrist in women between 25 and 45 years of age. They are also seen commonly on the foot. A ganglion is a firm, rubbery mass that occurs on the top of the foot. On the foot, the most common area of involvement is in front of the ankle or on the outside of the ankle. A common characteristic of a ganglion is that they will enlarge and then shrink is size. They generally occur without any apparent cause. Ganglions arise spontaneously from a weakness in the soft tissue covering of a joint or tendon sheath. Ballooning out of the tissue occurs and it fills with a thick mucoid fluid. In many instances, ganglions are not painful until they reach a size that causes irritation from shoe pressure. On occasion they will compress a nearby skin nerve and cause tingling into the top of the toes. Tapping on the ganglion will often result in this same tingling sensation into the toes. Other common masses on the foot are giant cell tumorsfibromas and lipomas.

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.

Underlapping Toes