Emory at Decatur - Podiatry

About
The Achilles tendon is fibrous tissue that connects the heel to the muscles of the lower leg: the calf muscles. Leg muscles are the most powerful muscle group in the body and the Achilles tendon is the thickest and strongest tendon in the body. Contracting the calf muscles pulls the Achilles tendon, which pushes the foot downward. This contraction enables: standing on the toes, walking, running, and jumping. Each Achilles tendon is subject to a person’s entire body weight with each step. Depending upon speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subject to up to 3-12 times a person’s body weight during a sprint or push off.

Causes
Overuse, misalignment, improper footwear, medication side effects, and/or accidents can all result in Achilles tendon injuries. Multiple causes often contribute to the same Achilles tendon injury.

Treatment
Achilles tendonitis is an inflammation of the large tendon that connects your calf muscle to your heel. If Achilles tendonitis is diagnosed, anti-inflammatory medicine may be prescribed and/or heel lifts may be used. In particularly unresponsive cases, a walking cast may be helpful. Surgery is not usually necessary to treat Achilles tendonitis.

About
Sprained ankles are the most frequent type of musculoskeletal injury seen by primary-care providers. More than 23,000 people each day in the United States require medical care for ankle sprains. Ankle sprains are common sports injuries but also happen during everyday activities. An unnatural twisting motion of the ankle joint can happen when the foot is planted awkwardly, when the ground is uneven, or when an unusual amount of force is applied to the joint.

The ankle joint is made up of three bones:

• The tibia: the major bone of the lower leg. It bears most of the body’s weight. Its bottom portion forms the medial malleolus, the inside bump of the ankle.
• The fibula: the smaller of the two bones in the lower leg. Its lower end forms the lateral malleolus, the outer bump of the ankle.
• The talus: the top bone of the foot Tendons connect muscles to bones.

Several muscles control motion at the ankle. Each has a tendon connecting it to one or more of the bones of the foot. Tendons can be stretched or torn when the joint is subjected to greater than normal stress. Chronic inflammation of a stretched or torn tendon is called tendinitis. Tendons also can be pulled off the bone, called an avulsion injury. Ligaments provide a connection between bones. Sprains are injuries to the ligaments. The ankle has many bones that come together to form the joint, so it has many ligaments holding it together. Stress on these ligaments can cause them to stretch or tear. The most commonly injured ligament is the anterior talofibular ligament that connects the front part of the fibula to the talus bone on the front-outer part of the ankle joint.

Arthritis is the leading cause of disability in the United States. It can occur at any age, and literally means “pain within a joint.” As a result, arthritis is a term used broadly to refer to a number of different conditions.

Although there is no cure for arthritis, there are many treatment options available. It is important to seek help early so that treatment can begin as soon as possible. With treatment, people with arthritis are able to manage pain, stay active, and live fulfilling lives, often without surgery.

There are three types of arthritis that may affect your foot and ankle

Osteoarthritis
Osteoarthritis, also known as degenerative or “wear and tear” arthritis, is a common problem for many people after they reach middle age. Over the years, the smooth, gliding surface covering the ends of bones (cartilage) becomes worn and frayed. This results in inflammation, swelling, and pain in the joint. Osteoarthritis progresses slowly and the pain and stiffness it causes worsens over time.

Rheumatoid Arthritis
Unlike osteoarthritis which follows a predictable pattern in certain joints, rheumatoid arthritis is a system-wide disease. It is an inflammatory disease where the patient’s own immune system attacks and destroys cartilage.

Post-Traumatic Arthritis
Post-traumatic arthritis can develop after an injury to the foot or ankle. This type of arthritis is similar to osteoarthritis and may develop years after a fracture, severe sprain, or ligament injury.

About
A bone spur (osteophyte) is a bony growth formed on normal bone. Most people think of something sharp when they think of a “spur,” but a bone spur is just extra bone. It’s usually smooth, but it can cause wear and tear or pain if it presses or rubs on other bones or soft tissues such as ligaments, tendons, or nerves in the body. Common places for bone spurs include the spine, shoulders, hands, hips, knees, and feet.

Causes
A bone spur forms as the body tries to repair itself by building extra bone. It generally forms in response to pressure, rubbing, or stress that continues over a long period of time.

Some bone spurs form as part of the aging process. As we age, the slippery tissue called cartilage that covers the ends of the bones within joints breaks down and eventually wears away (osteoarthritis). Also, the discs that provide cushioning between the bones of the spine may break down with age. Over time, this leads to pain and swelling and, in some cases, bone spurs forming along the edges of the joint. Bone spurs due to aging are especially common in the joints of the spine and feet.

Bone spurs also form in the feet in response to tight ligaments, to activities such as dancing and running that put stress on the feet, and to pressure from being overweight or from poorly fitting shoes. For example, the long ligament on the bottom of the foot (plantar fascia) can become stressed or tight and pull on the heel, causing the ligament to become inflamed (plantar fasciitis). As the bone tries to mend itself, a bone spur can form on the bottom of the heel (known as a “heel spur”). Pressure at the back of the heel from frequently wearing shoes that are too tight can cause a bone spur on the back of the heel. This is sometimes called a “pump bump,” because it is often seen in women who wear high heels.

Treatment
Bone spurs do not require treatment unless they are causing pain or damaging other tissues. When needed, treatment may be directed at the causes, the symptoms, or the bone spurs themselves.

Treatment directed at the cause of bone spurs may include weight loss to take some pressure off the joints (especially when osteoarthritis or plantar fasciitis is the cause) and stretching the affected area, such as the heel cord and bottom of the foot.

Treatment directed at symptoms could include rest, ice, stretching, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Education in how to protect your joints is helpful if you have osteoarthritis. If a bone spur is in your foot, changing footwear or adding padding or a shoe insert such as a heel cup or orthotic may help. If the bone spur is causing corns or calluses, padding the area or wearing different shoes can help. A podiatrist (foot doctor) may be consulted if corns and calluses become a bigger problem. If the bone spur continues to cause symptoms, your doctor may suggest a corticosteroid injection at the painful area to decrease pain and inflammation of the soft tissues next to the bone spur.

Sometimes the bone spurs themselves are treated. Bone spurs can be surgically removed or treated as part of a surgery to repair or replace a joint when osteoarthritis has caused considerable damage and deformity. Examples might include repair of a bunion or heel spur in the foot or removal of small spurs underneath the point of the shoulder.

About
The common bunion is a localized area of enlargement of the inner portion of the joint at the base of the big toe. The enlargement actually represents additional bone formation, often in combination with a misalignment of the big toe. The misalignment causes the big toe to move outward (medically termed hallux valgus deformity). The normal position of the big toe (straight forward) becomes outward directed toward the smaller toes. The enlarged joint at the base of the big toe (the first metatarsophalangeal joint, or MTP joint) can become inflamed with redness, tenderness, and pain. A small fluid-filled sac (bursa) adjacent to the joint can also become inflamed (bursitis), leading to additional swelling, redness, and pain. A less common bunion is located at the joint at the base of the smallest (fifth) toe. This bunion is sometimes referred to as a tailor’s bunion.

Causes
Bunions most commonly affect women. Some studies report that bunions occur nearly 10 times more frequently in women. It has been suggested that tight-fitting shoes, especially high-heel and narrow-toed shoes, might increase the risk for bunion formation. Bunions are reported to be more prevalent in people who wear shoes than in barefoot people. While the precise causes are not known, there also seems to be inherited (genetic) factors that predispose to the development of bunions, especially when they occur in younger individuals.

Treatment
Nonsurgical treatments involve simply resting the foot by avoiding excessive walking and wearing loose (wider) shoes or sandals can often relieve the irritating pain of bunions. Walking shoes may have some advantages, for example, over high-heeled styles that tug the big toe outward.
Anti-inflammation medications, such as acetylsalicylic acid (Aspirin, Ecotrin), ibuprofen (Advil, Children’s Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever) and naproxen (Anaprox, Naprelan, Naprosyn, Aleve), can help to ease inflammation as well as pain. Local cold-pack application is sometimes helpful as well.

To reduce tension on the inner part of the joint of a bunion, stretching exercises are sometimes prescribed. A bunion splint is an orthotic device that is usually worn at night and can provide further relief. Depending on the structure of the foot, custom insoles might add further support and repositioning. Inflammation of the joint at the base of the big toe can often be relieved by local injection of cortisone. Any signs of skin breakdown or infection can require antibiotics.

When the measures above are effective in relieving symptoms, patients should avoid irritating the bunion again by optimizing footwear and foot care.

For those whose bunions cause persisting pain, a surgical operation is considered for removal of the bunion. The surgical operation to remove a bunion is referred to as a bunionectomy. Surgical procedures can correct deformity and relieve pain leading to improved function. These procedures typically involve removing the bony growth of the bunion while realigning the big toe.

About
Bursitis is inflammation of a bursa. A bursa (the plural form is bursae) is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body. There are 160 bursae in the body. The major bursae are located adjacent to the tendons near the large joints, such as the shoulders, elbows, hips, and knees. Runners, athletes and others who spend a significant amount of time on their feet may develop bursitis where the Achilles tendon inserts into the heel bone. A thorough exam will help our foot and ankle specialists be sure you haven’t also developed a heel spur.

Causes
A bursa can become inflamed from injury, infection (rare in the shoulder), or due to an underlying rheumatic condition. Examples of bursitis include injury as subtle as lifting a bag of groceries into the car to inflame the shoulder bursa (shoulder bursitis), infection of the bursa in front of the knee from a knee scraping on asphalt (septic prepatellar bursitis), and inflammation of the elbow bursa from gout crystals (gouty olecranon bursitis).

Treatment
If a change of shoes and the use of orthotics are not successful in relieving the pain, cortisone injections may be tried. Surgery is a last resort and is seldom necessary to treat bursitis.

About
A callus (tyloma) is an area of skin that thickens after exposure to repetitive forces in order to protect the skin. A callus may not be painful. When it becomes painful, treatment is required.
When a callus develops a mass of dead cells in its center, it becomes a corn (heloma). Corns generally occur on the toes and balls of the feet. Calluses occur on the feet, hands, and any other part of the skin where friction is present.

Treatment

• Antibiotics for any infected corn or callus
• Removal by surgical means or with keratolytic agents (medicines that break up hardened areas of skin)
• Surgically removing areas of protruding bone where corns and calluses form
• Shaving or cutting off the hardened area on the skin

About
Gout occurs when too much uric acid builds up in the blood and uric acid crystals precipitate in the cooler parts of the body such as the joints of the hands or feet. High levels of uric acid may also build up as lumps under the skin called tophi, or as kidney stones. Uric Acid is a waste product of the oxidation of purines which are constituents of nucleic acids such as DNA. Uric acid is normally excreted in the urine to maintain a concentration of uric acid in the blood of approximately 4 mg/dL. When the concentration exceeds 7 mg/dL, crystals of monosodium urate start to form in the tissues. This condition is known as hyperuricemia.

The symptoms of gout are redness of a joint, accompanied by inflammation, stiffness, and intense pain. Many people experience their first gout attack in the big toe, but other joints such as the ankles, wrists, fingers, or elbows may be affected. The pain may be so severe that even the pressure of bed sheets may be unbearable.

About
A hammer toe is a deformity of the second, third or fourth toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.

People with hammer toe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.

Causes
Hammer toe results from shoes that don’t fit properly or a muscle imbalance, usually in combination with one or more other factors. Muscles work in pairs to straighten and bend the toes. If the toe is bent and held in one position long enough, the muscles tighten and cannot stretch out.

Shoes that narrow toward the toe may make your forefoot look smaller. But they also push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. A higher heel forces the foot down and squishes the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles become unable to straighten the toe, even when there is no confining shoe.

Treatment
Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. (Note: For many people, the second toe is longer than the big toe.) Avoid wearing tight, narrow, high-heeled shoes. You may also be able to find a shoe with a deep toe box that accommodates the hammer toe. Or, a shoe repair shop may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.
Your doctor may also prescribe some toe exercises that you can do at home to stretch and strengthen the muscles. For example, you can gently stretch the toes manually. You can use your toes to pick things up off the floor. While you watch television or read, you can put a towel flat under your feet and use your toes to crumple it.

Finally, your doctor may recommend that you use commercially available straps, cushions or non-medicated corn pads to relieve symptoms. If you have diabetes, poor circulation or a lack of feeling in your feet, talk to your doctor before attempting any self-treatment.

Hammer toe can be corrected by surgery if conservative measures fail. Usually, surgery is done on an outpatient basis with a local anesthetic. The actual procedure will depend on the type and extent of the deformity. After the surgery, there may be some stiffness, swelling and redness and the toe may be slightly longer or shorter than before. You will be able to walk, but should not plan any long hikes while the toe heals, and should keep your foot elevated as much as possible.

When plantar fasciitis goes untreated, calcium deposits known as “heel spurs” can form on the heel bone. Our foot and ankle specialists offer surgical and nonsurgical treatment, including computer-enhanced orthotics, injection therapy, physical therapy and medication, to relieve pain caused by heel spurs.

Treatment
Because gout episodes are so painful, patients demand some kind of gout treatment, even though the treatments for gout are not very effective and have undesirable side effects. The most common treatments include the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, indomethacin and naproxen. Aspirin is not used because it aggravates hyperuricemia by increasing uric acid retention. These medications can cause stomach pain, bleeding and ulcers, and beyond a certain dosage, they do not provide additional relief.

Corticosteroids, such as prednisone, are prescribed for severe cases of gout.

Along with specifically prescribed medications, patients are advised to drink plenty of water and avoid alcoholic beverages and purine-rich foods such as fish roes, herring, organ meats, legumes, and meats.

About
An ingrown toenail, also known as onychocryptosis or unguis incarnates, is a painful condition of the toe. It occurs when a sharp corner of the toenail digs into the skin at the end of or side of the toe. Pain and inflammation at the spot where the nail curls into the skin occurs first. Later, the inflamed area can begin to grow extra tissue or drain yellowish fluid. If left untreated, an ingrown toenail can progress to an infection or even an abscess that requires surgical treatment. Osteomyelitis is a rare complication of an infected toe, in which the bone itself becomes infected. Ingrown toenails are common in adults but uncommon in children and infants. They are more common in men than in women. Young adults in their 20s or 30s are most at risk. Any toenail can become ingrown, but the condition is usually found in the big toe.

Treatment
If no acute infection is found, then the nail will be elevated and conservative treatment recommended. This consists of warm soaks, proper shoes, and frequent cleaning of the nail.
Sometimes, your doctor will choose to use a splint. Several types of splints can be used. These vary in type, but they all protect the skin from the sharp corner of the nail. Some of the most common types of splints include cotton wicks, plastic strips, plastic tubes down the side of the nail, and various glue-like substances (resins).

Occasionally, a doctor may try to file or cut the nail down the center in order to change the shape of the nail as it grows.

If any extra tissue has grown up around the inflamed area of skin, your doctor may choose to remove the extra tissue to help it heal faster. He or she will numb the area before removal of any tissue.

About
There are many species of fungi that can affect nails. By far the most common, however, is called Trichophyton rubrum. This type of fungus has a tendency to infect the skin (known as a dermatophyte) and manifests in the following specific ways.

• Starts at the ends of the nails and raises the nail up: This is called “distal subungal onychomycosis.” It is the most common type of fungal infection of the nails (90%). It is more common in the toes than the fingers. Risk factors include older age, swimming, athlete’s foot, psoriasis, diabetes, family members with the infection, or a depressed immune system. It usually starts as a discolored area at a corner of the big toe and slowly spreads toward the cuticle. Eventually the toenails will become thickened and flaky
• Starts at the base of the nail and raises the nail up: It is called “proximal subungal onychomycosis.” This is the least common type of fungal nail (3%). It is similar to the distal type, but it starts at the cuticle (base of the nail) and slowly spreads toward the nail tip. This type almost always occurs in people with a damaged immune system.
• Yeast onychomychosis: This type is caused by a yeast called Candida and not by the Trichophyton fungus named above. It is more common in fingernails and may be the most common cause of fungal fingernails. Candida can cause yellow, brown, white, or thickened nails. Some people who have this infection also have yeast in their mouth or have a chronic paronychia (see above) that is also infected with yeast.

Treatment
Oral antifungal therapy works about 50%-75% of the time. It can take nine to 12 months to see if it has worked or not, because that is how long it takes for the nail to grow out. Even when therapy works, the fungus may come back about 20%-50% of the time.

About
A neuroma is the swelling of nerve that is a result of a compression or trauma. They are often described as nerve tumors. However, they are not in the purest sense a tumor. They are a swelling within the nerve that may result in permanent nerve damage. The most common site for a neuroma is on the ball of the foot. The most common cause of neuroma in ball of the foot is the abnormal movement of the long bones behind the toes called metatarsal bones. A small nerve passes between the spaces of the metatarsals. At the base of the toes, the nerves split forming a “Y” and enter the toes. It is in this area the nerve gets pinched and swells, forming the neuroma. Burning pain, tingling, and numbness in one or two of the toes is a common symptom. Sometimes this pain can become so severe, it can bring tears to a patient’s eyes. Removing the shoe and rubbing the ball of the foot helps to ease the pain. As the nerve swells, it can be felt as a popping sensation when walking. Pain is intermittent and is aggravated by anything that results in further pinching of the nerve. When the neuroma is present in the space between the third and fourth toes, it is called a Morton’s Neuroma. This is the most common area for a neuroma to form. Another common area is between the second and third toes. Neuromas can occur in one or both of these areas and in one or both feet at the same time. Neuromas are very rare in the spaces between the big toe and second toe, and between the fourth and fifth toes. Neuromas have been identified in the heel area, resulting in heel pain.

A puncture wound or laceration that injures a nerve can cause a neuroma. These are called traumatic Neuromas. Neuromas can also result following a surgery that may result in the cutting of a nerve.

Treatment
Treatment for the neuroma consists of cortisone injections, orthotics, chemical destruction of the nerve, or surgery. Cortisone injections are generally used as an initial form of treatment. Cortisone is useful when injected around the nerve, because it can shrink the swelling of the nerve. This relieves the pressure on the nerve. Up to three cortisone injections can be given over a twelve-month period. Cortisone may provide relief for many months, but is often not a cure for the condition. The abnormal movements of the metatarsal bones continue to aggravate the condition over a period of time.

To address the abnormal movement of the metatarsal bones, a functional foot orthotic can be used. These devices are custom-made inserts for the shoes that correct abnormal function of the foot. The combination treatment of cortisone injections and orthotics can be a very successful form of treatment. If, however, there is significant damage to the nerve, then failure to this treatment can occur. When there is permanent nerve damage, the patient is left with three choices: live with the pain, chemical destruction of the nerve, or surgical removal of the nerve.

This type of heel pain is caused by inflamed fascia, the tissue bands that connect the heel to the toe at the bottom of the foot. Nonsurgical care includes custom orthotics, injection therapy, night splints, removable walking casts and physical therapy. Surgery is always our last resort when treating plantar fasciitis.

About
What is an Achilles tendon?

The Achilles tendon connects the calf muscle to the heel bone. It is the biggest tendon in the human body and allows you to rise up on your toes and push off while walking or running.

Tendonitis is an inflammation or irritation of a tendon, a thick cord that attaches bone to muscle.

Causes
Tendonitis is most often caused by repetitive, minor impact on the affected area, or from a sudden more serious injury. There are many activities that can cause tendinitis, including:

• Gardening
• Raking
• Carpentry
• Shoveling
• Painting
• Scrubbing
• Tennis
• Golf
• Skiing
• Throwing and pitching

Incorrect posture at work or home or poor stretching or conditioning before exercise or playing sports also increases a person’s risk

The two main problems found in the Achilles tendon are:

• Achilles tendinopathy. Achilles tendinopathy refers to one of two conditions:
  • Achilles tendon tear or rupture. An Achilles tendon can partially tear or completely tear (rupture). While a partial tear may cause mild or no symptoms, a complete rupture causes pain and sudden loss of strength and movement.
  • Related Tendonitis Termspatellar, relief, treatment, knee, biceps, de Quervain’s, tennis elbow, symptoms
• An abnormal or poorly placed bone or joint (such as length differences in your legs or arthritis in a joint) that stresses soft-tissue structures

Treatment
Initial treatment of tendinitis includes:

• Avoiding activities that aggravate the problem
• Resting the injured area
• Icing the area the day of the injury
• Taking over-the-counter anti-inflammatory drugs - If the condition does not improve in a week, see your doctor. You may need more advanced treatments, including:
  • Corticosteroid injections. Corticosteroids (often called simply” steroids”) are often used because they work quickly to decrease inflammation and pain.
  • Physical therapy. This can be very beneficial, especially for a “frozen shoulder.” Physical therapy includes range-of-motion exercises and splinting (thumb, forearm, bands).
  • Surgery. This is only rarely needed for severe problems not responding to other treatments.

About
Walking abnormalities are unusual and uncontrollable walking patterns that are usually due to diseases or injuries to the legs, feet, brain, spinal cord, or inner ear.

The pattern of how a person walks is called the gait. Many different types of walking problems occur without a person’s control. Most, but not all, are due to some physical condition.

Some walking abnormalities have been given names:

• Propulsive gait — a stooped, stiff posture with the head and neck bent forward
• Scissors gait — legs flexed slightly at the hips and knees like crouching, with the knees and thighs hitting or crossing in a scissors-like movement
• Spastic gait — a stiff, foot-dragging walk caused by a long muscle contraction on one side
• Steppage gait — foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking
• Waddling gait — a duck-like walk that may appear in childhood or later in life

Causes
Abnormal gait may be caused by diseases in many different areas of the body. General causes of abnormal gait may include:

• Arthritis of the leg or foot joints
• Foot problems (such as a callus, corn, ingrown toenail, wart, pain, skin sore, swelling, or spasms)
• Fractures
• Injections into muscles that causes soreness in the leg or buttocks
• Infection
• Injury
• Legs that are different lengths
• Myositis
• Shin splints
• Shoe problems
• Tendonitis

This list does not include all causes of abnormal gait.

Treatment
Treatment will vary depending on what kind of walking disorder is diagnosed. Come into Atlanta Podiatry Group and get an evaluation to determine the best course of action.