John Goodner

It is always best to be proactive with ankle injuries. A delay in care can have harmful long-term effects on the ankle. I would recommend an X-Ray to rule out possible fractures and to receive proper ankle offloading equipment.
Call the Foot, Ankle & Leg Specialists at South Florida Institute of Sports Medicine.

Patients usually return to athletic shoes, or sneakers, anywhere between 4 to 8 weeks after toe surgery. With the guidance of your foot surgeon, the timing of the transition from offloading shoes/boots to athletic shoes is largely dependent on how extensive the toe surgery was, if the incision has completely healed and how the patient's post operative recovery has progressed.

Hammertoe surgery is typically performed in the outpatient surgical center setting, which means you will likely go home the same day of your surgery.

Tibial varum is a common structural deformity of the lower leg that results in a rearfoot varus, or internally rotated heel, that requires compensatory pronation or flattening of the arch for normal weightbearing and ambulation (as seen in image above). This type of pathology can often be treated with bracing and orthotics to maintain normal alignment of the lower extremity. Surgery is only indicated in the severe angular deformities resulting in frequent tripping/falls and painful ambulation.

X-RAYS are important to assess the overall injury. In some cases x-rays do not show the entire deformity and CT scans and/or MRIs are necessary to fully evaluate the area. Stress views are x-rays that are taken with the foot slightly manipulated to further evaluate the injury. They give us information regarding the ligaments that had been injured during the trauma.

Treatment of ankle fractures depends on the degree of injury to the soft tissue, ligaments and bones. Nondisplaced fractures can be treated effectively by a nonweightbearing cast in most cases. This may be necessary for a period of 6-8 weeks. Some fractures are stable and can be treated with a walking cast.

Fractures that are more displaced may require closed manipulation and casting. Sometimes this can be done in the physician’s office. At other times it may be necessary to have a general anesthetic to relax the muscles and allow manipulation of the bones into their proper position. At times this is accompanied by percutaneous pins or screws placed through the fracture site to give the fracture stability.

When fractures are grossly malaligned and the joint cannot be put into its normal position surgery is performed to place the bones and ligaments into their normal anatomical position. The procedure is called an open reduction and internal fixation. These procedures are done in most cases under a general anesthetic. Incisions are placed over the affected bone and small screws and plates are placed onto the bone to stabilize and fix the fracture. Sometimes ligaments may be repaired during the procedure. Ligaments would be fixed if expected to have ankle instability following the injury.

The prognosis of ankle fractures is dependent on the degree of injury. The more of the joint that has been affected determines the prognosis. High energy injuries to the ankle would cause more disruption to the joint surface. High energy injuries are commonly found in patients falling from a significant height or getting in a motor vehicle accident. The worse the cartilage damage at the time of injury, the worse the long-term prognosis.

Isolated fractures of the bones that have minimal to no disruption of the joint surface have an excellent long-term prognosis provided that there is excellent anatomic position of the fractures. In most cases the hardware placed on the bones can be left in the area unless they cause discomfort following the healing process.

Patients with ankle fractures are not uncommon. Chronic stiffness and pain in the joint can develop even after a perfect anatomic reduction and internal fixation. This is due to some disruption of the joint surface and the lining of the joint. This can be treated arthroscopically in most cases to lessen stiffness and pain and improve range of motion. Malunions can develop in the joint in which the bones do not heal in their perfect anatomical position. This can be corrected following the healing process. It is expected that the prognosis would be worse and arthritis would set in. Delayed union or nonunion are relatively uncommon following ankle fractures. If during the healing process the fractures appear to be healing very slowly, bone stimulators may be necessary to enhance healing. If the fracture goes on to a nonunion, surgery may be necessary to freshen the fracture and try fixation to stabilize the fracture and allow it to go on to uneventful healing.

If the fracture has completely disrupted the joint surface (pilon fracture) then at some point arthritis would set in, which may necessitate surgical procedures which can include an arthroscopy, total ankle replacement or an ankle fusion.

Yes, running can cause heel pain.

Plantar fasciitis or heel pain is an inflammation of the main ligament in the arch where it attaches to the heel bone and supports the foot.

CAUSES include but are not limited to:

Excessive activity over a short period of time. Flat or high arched feet. Tight muscles, especially the calf and hamstrings. Poor shoe gear or walking barefoot for prolonged periods of time.

SYMPTOMS include but are note limited to:

Pain first thing in the morning when getting out of bed and putting the foot down to the ground. With walking the pain usually diminishes. Pain after sitting for a prolonged period of time or getting out of a car and starting to walk. Occasionally burning, numbness, shooting or tingling into the heel. Extreme tenderness to touch the heel or arch region. Commonly associated with lower back pain.

TREATMENT options include but are not limited to:

Avoid going barefooted and good supportive shoe wear. Anti-inflammatory medications to reduce the inflammation. Taping the foot to support it and give immediate relief. Custom molded orthotic (shoe insert) to permanently support the foot and prevent reinjury. Frequent stretching of the calf and hamstring muscles to improve overall flexibility. Splinting the foot at night to stretch the muscle in the back of the leg. Occasionally immobilization in a cast or a boot to completely rest the foot. Shockwave therapy if pain persists. Surgery is a last resort to release a small portion of the ligament from the heel.

Lower impact exercise should be performed as an alternative to running until pain free. Participate in swimming, free weight training, weight resistance training, elliptical, stationary biking, rowing and yoga. Avoid running, jumping, plyometrics, uphill walking, stair climbing, hiking, olympic weight lifting, sprinting, spinning, fitness class and boot camps; until the heel pain is completely resolved.

Hammertoe is a deformity of the second, third, fourth or fifth toes. In this condition, the toe is bent at one of the middle toe joints, causing it to resemble a hammer. If left untreated, hammertoes can become inflexible and require surgery. People with hammertoe 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 of hammertoe include improperly fitting shoes and muscle imbalance.

Surgery is indicated if a patient is unable to ambulate without pain, unable to wear normal footwear, and unable to perform activities of daily living without pain from the hammertoe deformity.

Non surgical options include but are not limited to: Toe spacers, crest pads, corn pads, moleskin, silicone toe sleeves and caps, splints and wider toe box shoes.

An X-ray is recommended to evaluated any presence of arthritis and determine underlying causes for hammertoe contracture.

I would recommend an X-ray with a foot and ankle specialist to rule out a stress fracture. Peroneal tendonitis is common in the anatomic area you are describing as well. If initial x-rays are negative, an MRI may be necessary. A stress fracture is defined as a hairline crack in a specific bone, which is a result of excessive stress in a particular area of the lower extremity. There are three types of stress fractures commonly encountered in the lower extremity.
Overuse Injury: Overuse injuries are the most common type of stress fracture encountered in our practice. This type of stress fracture occurs due to overuse and an increase in demand on a particular bone in the lower extremity. An overuse stress fracture either occurs in athletes (i.e. running, aerobics) who consistently place stress in a particular area of the lower extremity until the bone fatigues due to over demand or when an individual begins a particular exercise (i.e. walking) and begins to place stress in a particular area that has not been properly conditioned. These types of stress fractures usually occur in the metatarsal bones in the forefoot, in the heel bone, and in the tibia (leg bone).
Structural Deformity: Stress fractures due to structural deformities are more common in the tibia and second metatarsal. When the ankle has an inner twist (varus) the talus in the ankle hits the tibia and causes a small crack. This crack if untreated can lead to a displaced fracture and arthritis in the ankle joint. Second metatarsal stress fractures can also occur when the metatarsal itself is very long and associated with a bunion deformity. The long second metatarsal takes on more of its share of body weight and cracks can develop, especially in an unconditioned athlete or when performing an exercise that a person is unaccustomed to over a period of days. They can also occur in women who wear high-heeled shoes and are not accustomed to it and put stress on the second metatarsal bone.

Pathological Stress Fractures: These types of stress fractures occur due to an underlying bone condition causing weakness to the bone, which may eventually result in a stress fracture due to the bone’s inadequacy to support daily activities. Individuals with osteoporosis most commonly encounter these types of stress fractures. Other systemic conditions and certain medications can also cause demineralization of bone, which predisposes an individual to a stress fracture. On rare occasions, a bone tumor may be present, which may also result in a pathologic stress fracture of a bone.
Symptoms: The most common symptom is a dull aching type of pain well localized to a specific area in the lower extremity. The condition is usually exacerbated by the increase in weight-bearing and walking-type activities. Pain is decreased with rest and a decrease in activity level. The onset of symptoms is usually gradual and nonspecific. Often when unrecognized, individuals may experience compensatory pain in other areas, trying to avoid the area of initial pain.

Signs: Pain with direct pressure to the area as well as with ambulation. Pain is worse with an increase in activities and decreases with rest and a decrease in activities. Local swelling with mild discoloration in the area may be seen. When it occurs early it may be subtle. However, when the bone is fractured the swelling and the pain increase.

X-rays: Initially x-ray findings are negative and a diagnosis is made on the patient’s history and the physician’s clinical evaluation. Radiographic signs of a stress fracture may not appear for up to 21 days after the initial onset of symptoms. When a fracture callus develops it is easily seen on the x-ray and is an indication that the fracture is healing.

A flat foot or fallen arch is referred to medically as pes planus. Foot and ankle specialists understand that flatfoot is a frequently encountered problem in children. In this condition, the foot collapses or loses the gently curving arch on the inner side of the sole. Pediatric flatfoot is generally divided into 2 sub-groups. The first, a flexible flatfoot is characterized by a normal arch during non-weight-bearing and a flattened arch while standing. The flexible flatfoot may be painful (symptomatic) or not painful (asymptomatic). The second subgroup is referred to as a rigid flatfoot which is characterized by a stiff flattened arch regardless of whether the child is weight-bearing or not. Such deformities include a congenital vertical talus, a tarsal coalition (a condition where the bones in the foot did not separate properly by childbirth), peroneal spastic flatfoot, or traumatic causes. A flatfoot may exist as an isolated problem, or as part of a larger clinical entity. This may include genetically lax ligaments, neurologic or muscular problems, genetic syndromes, and other collagen vascular disorders such as rheumatoid arthritis.
Flexible flat feet are generally considered normal in young children as babies lack a normal arch. The arch subsequently forms fully between the ages of 7 and 10. A study published in a reputable medical journal evaluated 835 children, approximately half of which were boys and girls equally. Using a laser surface scanner, the children’s feet were measured carefully. The results indicated that the prevalence of flexible flatfoot in the group of 3-6-year old children was 44% but the prevalence of symptomatic (painful or pathological) flatfoot was less than 1%. Additionally, 13% of the children were overweight or obese. During adulthood, 15-25% of people may have flexible flatfeet. Most of these adults never develop symptoms. Adults with flexible flat feet likely inherited their condition due to the laxity of their ligaments.
Pediatricians and parents are often the first to recognize foot deformities in infants and children, but too often the problem may go unrecognized for a long period of time.
When a flatfoot is being evaluated, a foot and ankle specialist would include a thorough family history which involves a review of the medical conditions including a history of trauma or problems during childbirth. Investigating the progressive flatfoot in a child’s family often gives a physician an idea of how the condition will evolve. After this, a comprehensive physical exam should be conducted. The foot and ankle specialist will want to evaluate the foot for areas of tenderness and observe the child during gait (walking). There is a prominent bulge in the arch, a heel that leads to the outside resulting in toes that are easily visualized from behind and referred to as the "too many toes sign". Besides evaluating the foot, the child with a flat foot must be examined for possible contributing factors occurring above the level of the foot and ankle which would cause the foot to compensate by becoming flat. This would include the hip and knee, and lower leg. At times a leg length discrepancy may result in a flatfoot condition as well.
The flatfoot is often associated with a number of subjective symptoms which would include pain in the foot leg and knee as well as other postural complaints. Interestingly a flatfoot has been shown to have a direct relationship with medial compartment knee arthritis and bunion deformities later in life. Additionally, a study published in a pediatric journal indicated that the relationship between adolescent bunions and flat feet was 8 to 24 times greater than expected. Flatfoot can result in decreased endurance and voluntary withdrawal from physical activities. At times a parent may relate that the child is clumsy and prone to falling frequently. Children may find it difficult to climb or run and prefer not to participate in sports.
Imaging studies may include standing x-rays, CT scans, or magnetic resonance imaging. This will help make a determination as to what the cause of the flatfoot deformity is, particularly if it is rigid. Additionally, a blood test can be ordered to rule out certain arthritic or inflammatory conditions if a larger clinical picture is suspected.
The nonpainful or asymptomatic flexible flatfoot may be physiologic or non-physiologic. Most flexible flat feet are physiologic, asymptomatic, and require no treatment. Physiologic flat feet follow a natural history of improvement over time. Periodic observation may be indicated to monitor for signs of progression. In these patients, treatment is generally not indicated and patients often do very well.
The non-physiologic flatfoot is characterized by progression over time. The degree of deformity is much more severe in non-physiologic than in physiologic flexible flatfoot and is visibly much more evident causing the patient to compensate in several ways. Pain and symptoms resulting from flexible flat feet include discomfort on the inside of the foot pain, on the outside of the ankle, leg, and knee.
Initial treatment for the flatfoot deformity includes stretching exercises, orthotics, at times immobilization if the child is limping, physical therapy to strengthen muscles and tendons which hold up the arch, and stretching exercises for the heel cord which is often very tight. Nonsteroidal anti-inflammatories may also be used, but not advised on a chronic basis. If there is a positive clinical response and symptoms improve the patient will just be monitored.
Lastly, when all nonsurgical treatment options have been exhausted surgical intervention can be considered. This may be provided in a variety of ways depending on the diagnosis and degree of deformity. Surgical treatment may consist of tightening of the ligaments and lengthening of tendons, a technique referred to as arthrodesis which involves the insertion of a small metallic implant through a small incision between the joints of the foot to restore the arch, to more aggressive traditional treatments such as cutting and realigning bones, known as osteotomies, or fusing the bones in the hindfoot together to stabilize the very deformed unstable flatfoot. In conditions such as a tarsal coalition, the area involved in the coalition is cut away so the bones can move more freely on each other.

Mild cases: Braces - ankle, foot orthoses, (AFO’s) may help to decrease motion in the ankle joint, lessening the pain.

Moderate cases: When conservative case has not helped, arthroscopic surgery to remove the abnormal bone, soft tissue and cartilage may be of benefit. If the disease process is advanced, only temporary benefit may be achieved.

Severe cases: When the arthritis has advanced and has been unresponsive to conservative care and/or arthroscopy, fusion of the ankle joint is the gold standard. During the fusion the cartilage and the joint surface is completely removed. The bones are then put together and held in place with screws. This procedure can be performed arthroscopically if there is minimal deformity to the foot and ankle. If there is severe deformity the procedure may be performed open. Long-term outcome is excellent following the procedure with regards to eliminating the pain. Most patients can return to walking without discomfort.
Some cases of severe arthritis may be candidates for Total Ankle Replacement surgery. This is a technique where the ankle joint is replaced by a prosthetic (artificial) ankle.

A foot and ankle specialist may wait one to three weeks for swelling to resolve before an ankle is surgically repaired. After surgery, patients may be non weight bearing for a period anywhere from 4-6 weeks to a few months depending on the severity of the fracture. A graduated rehabilitative period is prescribed during the postoperative period to allow the patient to regain movement, strength, and balance. Full recovery can range from 3 months to a year depending on the severity of the fracture.

Dear Parent or Legal Guardian of 15 year old Male,

Tailor's bunion or bunionette with associated hammertoe has causes including but not limited to: Hereditary predisposition. Aggravated by shoe gear. Aggravated by flat feet and feet that point out. Symptoms often include the following but are note limited to: Pain in closed shoes on the tailor's bunion itself.
Occasional burning, numbness and tingling around the bunion and big toe area.
Painful hard skin (calluses) on the ball of the foot. Stiffness and swelling in the joint secondary to bursitis or cartilage damage.

If there was an acute injury 1 month prior, then a foot x-ray is necessary to rule out acute fracture.

If the pain is worsening in intensity or duration over the last month, a foot x-ray is necessary to rule out stress fracture or growth plate injury.

If the pain only occurs with a certain type of shoes, discontinue these shoes and try a wider toe box with mesh top cover; or open toed sandal to see if the pain alleviates. Under adult supervision, Ice and take anti-inflammatory medication as needed. This is likely a situation of joint bursitis. You should check the shoe size and fit; given the active growth of pediatric feet. Your child may be wearing older shoes or cleats that are too small.

If your child has flatfeet, then orthotic inserts may be a solution to minimize the pressure at the point of pain.

Given the duration of your condition, an office visit with a Pediatric/Sports Medicine Foot and Ankle Specialist is recommended to conduct biomechanical exam, gait exam, footwear exam and foot X-rays. Conservative and surgical treatment options could then be accurately diagnosed and discussed.