Not all bunions are the same!!

Must read - Bunions

A bunion is essentially a shift of the toe bones into the improper position causing pain and loss of function. The deformity involves the big toe and the long bone behind the big toe, the 1st metatarsal. Over time, the 1st metatarsal will begin to move towards the other foot (medial) while the big toe will move out of joint towards the 2nd toe (lateral). As the end of the 1st metatarsal bone begins to stick out, it will be under pressure from shoes and the ground. This constant pressure and friction will cause extra bone formation, leading to the bump that is seen on the side of the foot. The big toe will continue to shift towards the second toe causing an unbalanced big toe joint. Over time arthritis can develop in the joint due to the mal-positioned joint. 

A bunion deformity is always progressive. It will always get worse over time.



Severe bunion deformity with shift of the great toe under the second toe and hammertoe of the second toe.


Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Causes:
Bunions are usually a genetic deformity. There is an imbalance of the muscles and the ligaments that are holding the 1st metatarsal in place. As this joint becomes weaker over time, the long metatarsal bone will begin to shift medially. The big toe is then under stress and begins to shift laterally under the pressure of the joint and shoes. Shoes with a tight and narrow toe box can help to create and make a bunion worse over time. High heeled shoes can also worsen and cause a bunion. Patients will a flat foot type (pronation) have a higher chance of having a bunion in the future.

Symptoms:
A bunion deformity does not always have to be associated with pain. Some patients have a very severe deformity and no pain, while others with a mild deformity have severe pain. Patients usually will have pain right over the bump with continued irritation and bruising to the bone from shoe gear and the ground forces. As the deformity progresses, pain will then be noticed in the joint itself when the big toe is moving. The big toe is very important during the gait cycle for pushing off the ground. With this imbalance of the joint there is a loss of the proper range of motion of the big toe joint leading to an inefficient gait. Over time arthritis will develop in the joint as the cartilage is scraped away each time the joint moves. The pain can be of different degrees depending on the degree of deformity, shoe gear, and activity level.

Diagnosis:

A clinical examination of the foot is done first. It is very important that the structure and biomechanics of the patient’s entire foot is examined. In order to identify the severity of the deformity, the stability of the joints around the bones involved is essential. The doctor will analyze the gait pattern of the patient. The doctor will identify if there is pain with joint movement and if the big toe can easily be re-located back into the joint. X-ray evaluation is essential in order to determine the degree of the bone shift and specific angles and the relationships between the bones.

Treatment Options:
Conservative treatments for bunions are limited. Wider shoe gear and accommodation for the deformity can be used to take the pressure off the area. Bracing and spacers are often used to brace the big toe back into position and can take some of the pressure of the big toe. However, this does not address the deformity and shift in the metatarsal bone. Furthermore, the bracing techniques are only work when used, once the brace is removed, the big toe will immediately go back into its deformed position. Custom molded Orthotics can take some pressure off the big toe and redistribute the forces of the ground through the rest of the foot. Orthotics can slow the progression of the deformity. There is no way to stop the progression or reverse the deformity without literally moving the bones back into the correct position and realigning the joint. This can only be accomplished through surgery.

We know that in order to realign the joint, the first metatarsal must be repositioned and fixated in the proper position. This can be accomplished by three basic types of procedures. First MPJ fusion, Offset Austin and Lapidus bunionectomy are the ideal procedures as they limit the chance of the bunion deformity from returning.

The choice of the procedure to be performed will be dictated by the severity of the deformity.


Mild Bunion Deformity 
In mild and moderate bunion cases, we try to allow patients to have a more rapid recovery and limit the amount of time they need to spend off their feet. The Tightrope and Offset Austin bunion procedures allow immediate weight on the foot in a boot and also allow for rapid return to shoes. The choice of procedure best for each patient depends on the deformity size, the stiffness of the 1st metatarsal and the ease of realignment of the 1st metatarsal during the clinical exam.



Drawing of a bunoin prior surgery. Note poor alignment of the great toe and the 1st metatarsal. Grey shaded are will be removed during surgery and dotted line shows the region of bone cut.



Drawing of bunion after surgery. Note the shift of the 1st metarsal towards the second meatarsal for realignment of the column and fixation of the bones together with the two screws from top to bottom.





Clinical representations of pre and post surgery of mild bunion corrections.

Severe Bunion Deformity 
In severe bunion cases, the 1st metatarsal is dramatically shifted away from the second metatarsal and there is looseness of the 1st metatarsal at the base of the bone. This is a difficult problem to correct unless the entire 1st metatarsal is realigned and held stable so it does not shift again. The Lapidus procedure allows for the 1st metatarsal to be repositioned with ideal correction and limited to no chance of bunion return. Recovery is slightly more difficult due to the need for crutches but the result is well worth it in difficult and severe cases. Some patients even require fusion of the first metatarsophalangeal joint secondary to this variation of deformity.

Hypermobility

The underlying cause of severe bunions is thought to be at the medial cuneiform joint and not at the great toe joint. If there is looseness of the medial cuneiform joint, there is motion of the metatarsal allowing the metatarsal to move out of position resulting in a bunion. The metatarsal may also move up resulting in poor position on the ground and collapse of the arch.

Clinical Pictures

Smokers Beware

Smoking and Bone Healing

Why are bones affected by smoking?


Bones are nourished by blood much like the other organs and tissues in your body. Nutrients, minerals, and oxygen are all supplied to the bones via the blood stream. Smoking elevates the levels of nicotine in your blood and this causes the blood vessels to constrict. Nicotine constricts blood vessels approximately 25% of their normal diameter. Because of the constriction of the vessels, decreased levels of nutrients are supplied to the bones. It is thought that this is the reason for the effect on bone healing, as the impending need for more oxygen and nutrients during fracture and osteotomy healing are not met, causing prolonged union time.

Evidence Based Medicine Review

"Cigarette smoking is detrimental to bony healing," said Dr. Franklin Chen, an orthopedics instructor at Northwestern University Medical School in Chicago, Illinois, and lead author of a report presented at the recent annual meeting of the American Academy of Orthopedic Surgeons (AAOS), held in New Orleans, Louisiana.
He and his colleagues focused on the 13-month healing rates of 54 patients who underwent surgery to help correct a specific type of (often work-related) wrist injury called symptomatic ulnar impaction syndrome. Chen says "95% of nonsmokers healed compared to 68% of smokers; this difference is statistically significant. The mean time to healing was 5 months for nonsmokers and 7.2 months for smokers." Previous studies have shown similar slower healing rates among smokers who have undergone spine or ankle fusion surgeries.

In essence: it is important to note that when I or any of the physicians at our office "lecture" to you about the cessation of smoking and it's direct impact on your healing potential, we are not just being mean. It's based on clinical evidence that is monumental for your optimal outcome. This can impact healing time in stress fractures and wound healing as well, so cessation is your best bet!!

We have even started a policy whereby we will NOT perform ANY elective surgery on a smoker unless you either stop smoking 1 month prior to date of surgery and stop for 3 months after the surgery is completed, or sign a "WAVER" which specifically states that you understand you are directly impacting your outcome and any and all unforseen complications (such as infection, ampuatation, nonunion, etc) are DIRECTLY related to NON COMPLIANCE.

Dr Timm

What you need to know about "Turf Toe"

Turf Toe

The simplest definition of turf toe is that it is a sprain of the main joint of the big toe. It happens when the toe is forcibly bent up into hyperextension, such as when pushing off into a sprint and having the toe get stuck flat on the ground.

Sprains of the big toe joint became especially prevalent in American football players after artificial turf became more common on playing fields - hence the term "turf toe." Artificial turf is a harder surface than grass and does not have much "give" when forces are placed on it.

Although often associated with football, turf toe occurs in a wide range of sports and activities.

The typical position of the foot when a turf toe injury occurs.

Anatomy

The big toe is made up of two joints. The largest of the two is the metatarsophalangeal joint (MTP), where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx). In turf toe, the MTP joint is injured.

The MTP joint is the large joint closest to the base of the big toe.

The joint is surrounded by important structures that hold it in place and prevent it from dislocating. Together these structures are referred to as the "plantar complex."

• Plantar plate. This thick, fibrous tissue under the MTP joint prevents the big toe from bending too far (dorsiflexion).
• Collateral ligaments. Located on each side of the big toe, collateral ligaments connect the phalanx bone to the metatarsal and prevent the toe from going too far side-to-side.
• Flexor hallucis brevis. This tendon runs under the first metatarsal bone and attaches to the phalanx. It provides strength and stability to the big toe during push-off motions.
• Sesamoids. These two small bones are enveloped in the flexor hallucis tendon, and help it to move more easily. In addition, the sesamoids provide stability to the MTP joint by helping to bear weight placed on the forefoot.

Several structures work together to protect and stabilize the MTP joint.

Description

The term "turf toe" refers to an injury of any soft tissue structure in the plantar complex, such as the plantar plate or a collateral ligament. These injuries can vary in severity — from stretching of the soft tissue to partial tearing, and even total dislocation of the MTP joint.

To help them plan treatment for turf toe, doctors grade the injuries from 1 to 3 - mild to severe.

• Grade 1. The plantar complex has been stretched causing pin-point tenderness and slight swelling.
• Grade 2. A partial tearing of the plantar complex causes more widespread tenderness, moderate swelling, and bruising. Movement of the toe is limited and painful.
• Grade 3. The plantar complex is completely torn causing severe tenderness, severe swelling, and bruising. It is difficult and painful to move the big toe.

We have treated this injury on and off over the years with similar therapy. Rarely does this require surgery, and there is sparse literature which can be referenced to delineate whether grade 1 and grade 3 injuries are specifically nonsurgical or surgical.  We have used a combination of PRP injections with hallux extension BK casting for this injury and have found good success. This is a non surgical approach and has had with it some good short term success. But this may still be a devastating injury for most athletes. (Even notable pros such as Deion Sanders, have had career ending versions of this injury). 

Secrets of foot pain: Arthritis is PROGRESSIVE

The patient above was seen initially in this office back in 2011, and those images are on the right hand side. The left side images show 2013 radiographs. This demonstrates the progressive nature of the arthritic condition in the first toe joint. The left shows a joint space of 0.6mm versus 1.92 mm joint space on the right, and this implies cartilage thinning, a mainstay of osteoarthritis. On the side views, we see increased calcifications and spurring on top of the joint which is outlined with a red circle to the image on the left.

This can progress slowly, but whenever we see this sort of progression in 2 years time, we can be certain this patient may require surgical intervention. I always strive to treat with nonsurgical care, but in circumstances such as this, often times an arthrodesis or total joint replacement can be undertaken depending on nature of symptoms and activity level of the patient.

Joint supplementation, such as chondroiten sulfate,  along with flavanoids for anti oxidant nonsteroidal anti inflammatory relief may benefit for osteoarthritis pain as well.

Sometimes even cortisone injections (maximum of 3 in a 12 month period) may be useful for pain relief, along with orthosis with rigid first ray advancement.

Dr Timm

Diplomate American Board of Podiatric Surgery

Secrets of foot pain: Not all foot pain is arthritis!

"Doc, my foot and leg are cramping lately."

Do I have arthritis?

Probably. But in many cases, especially in diabetics and patients with a strong smoking history, that is not the root cause of the pain. We will listen to the pulses, and if there are abnormalities in this examination, I will order an on site screening dopplar to rule out extensive or significant arterial and venous disease.





Most people are aware that cholesterol is bad (especially LDL) because it leads to heart disease. Lesser known vascular diseases include peripheral arterial disease of the legs and feet. This is a common finding in our office which can be identified with on site arterial dopplar testing and on physical examination with the "claudication" history.






Often times patients will present with generalized leg and foot pains which are not very responsive to NSAIDs. There may be significant color changes like on the right, or none like on the left of the above pictures.




For significant enough findings, we will refer for angiography, and the vascular interventionalist may be able to open the vessels without open surgery in many cases, which reduces or eliminates much of the pain associated with vascular disease. This also effectively is a form of limb salvage, which ultimately prevents leg amputations.

Dr Timm, DPM FACFAS

Board Certified by the American Board of Podiatric Surgery 

Why is Podiatry Better?

Orthopedics versus Podiatrics

This is a common question that I will encounter, and I thought I would enlighten our readers about how I tend to answer this:

Who is better for foot and ankle treatment, a podiatric surgeon or orthopedic surgeon ?

This is a long debated topic which spans several other forums, and may actually not have a defined answer in general. I feel this question would be best answered in paragraphs headed, "it depends".

"It depends" on training.

I will offer several reasons for this statement. The first being that not all orthopedic surgeons have the same training. The same holds true for podiatric surgeons. Some podiatrists are not surgically trained, and a pathology may require such an intervention. Many orthopedic doctors tend to spend more time on knees and hips, some have fellowships in shoulders and foot and ankle surgery training is minimal as a general rule. Surgically trained podiatrists must have ABPS board qualification or certification for adequate credentials, especially for more complex surigcal needs of patients, such as ankle fusions or calcaneal fracture open reductions. These podiatrists spend 3 years doing complex foot and ankle surgery and some even have an additional year of fellowship training as well.

Most podiatrists feel comfortable treating forefoot deformities like bunions and hammertoes, and if they have surgical priveleges they may treat these conditions quite well. Many orthopedic surgeons will not routinely treat foot and ankle conditions that podiatrists see in their offices every day. The few that are fellowship trained in foot and ankle surgery are more apt to treat these various conditions without too much trouble. Overal, if you are researching a new doctor for your feet, I believe it is necessary to know the qualifications of your doctor prior to making the appointment.

"It depends" on your problem.

If you suffer from heel pain, or nail issues, most podiatrists are able to effectively treat these conditions quite efficiently without surgical interventions. Again, if a blade is part of the treatment protocol needed to relief painful symptoms, it may be necessary to know what boards your doctor is part of. All of the podiatrists at FFLC are ABPS qualified, and that means we are able to surgically treat any foot and ankle condition. If you choose to go the orthopedic route for your care, you may need to know whether the physician has a fellowship in foot and ankle and is commonly seeing people for their feet issues.

We see the most common problems for foot and ankle pain here, as well as some of the most complex problems. We do this every day and that's all we do. Experience and volume speaks well for the abilities of our doctors to not only treat these conditions well, but treat them often.

Metatarsalgia Secrets

Futura™ LMP Lesser Metatarsal Phalangeal Implant

Concept: First prosthesis designed specifically for lesser metatarsophalangeal joint arthroplasty.

Made from UltraSIL™ silicone, the LMP prosthesis is monoblock and comprises two specially-designed stems for optimum fit in the proximal phalanx and lesser metatarsal intramedullary canals. Indications The LMP implant is indicated for treating lesser metatarsophalangeal joints in cases of: Avascular necrosis and for surgery to reduce arthritic joint pain.

This sort of implant technology may serve as a cornerstone for severe pain which may not be readily diagnosed initially in the case of this patient. This has been present for years and seemingly no treatment up to this point has been administered. There is little to offer outside of surgery when it gets this advanced. 

Come in to see your specialist, because the longer you wait, the less is able to be done to reduce your pain.

Dr Timm

Board Certified 

Diplomate American Board of Podiatric Surgery

What you need to know about Vitamin D

JT Smith, et al. at the Brigham hospital conducted a study which correlated vitamin D deficiencies
 with certain types of foot and ankle fractures. 

In our practice, we may order Vit D 25 studies on any patient presenting with signs of pedal osteopenea, with or without a history of foot or ankle fractures or sprains, who demonstrate a very light bone mineralization pattern on a plain radiograph. This is not age dependent, and even though most female patients are more likely to present in this manner post menopausal age, we have found this in both male and female patients in their early thirties.

In almost all cases, if we see it in the foot, the lab tests come back positive for a vitamin D deficiency globally in the body and we may initiate Vitamin D supplementation along with primary care and nutritional consultation.


If the levels are below 20, we prescribe 50,000 units of Vit D to be taken one per week along with a daily
OTC supplement of three to five thousand units of vitamin D 3 to be taken daily. Because the research in how to raise the levels and whether doing such will prevent foot injuries is scant, it is likely that different
doctors will have different protocols for raising vitamin D levels in order to prevent pedal osseous pathology.

Kobe Bryant is still recovering...

To those of us who routinely see and treat Achilles tendon tears/ruptures/tendonosis, we are not surprised. In fact, most patients will take up to 12 months before they are able to fully utilize their leg in the similar manner that was done prior to the injury. I have found that 8-9 months is possible for a recovery after open Achilles repair for healthy patients, but these are not people who are dunking basketballs and chasing down 24 year old players as a shooting guard in the NBA. Kobe is an amazing athletic specimen, and it should not be too long before someone with drive and determination can beat any injury with the proper training and realistic expectations, but patience is key. Mere mortals require the time to get their strength, endurance, and collagen reorganization of the tendon fibers to fully become tensile again.

Notice that in his Twitter picture, he has a syringe with a needle penetrating into his achilles operative site. This is a PRP injection. We have the technology to perform this without an incision right in office for any tendonopathy or other foot and ankle concern. If you are a candidate (based on diagnosis) we can plan for 30 minutes without sedation a quick and proper recovery.

Dr Timm

Your feet can cause pain to your whole body.

When your Feet Hurt your whole body hurts

Answer these Questions:

If you said yes to 2 or more, you need to see us now

1) Painful, flattening of your arch

2) Sharp, stabbing pain bottom of your heel

3) Ankle / Foot pain in the morning

4) Numbness / burning feet / ankle

5) History of Diabetes in your family

6) Have a child with heel pain

7) Embarrassed about appearance of your feet

8) Recent ankle sprain, instability

See me today

Brian Timm, DPM, FACFAS

Diplomate; American Board of Podiatric Surgery

Try Try Again

Top image (Preop from previous surgeon)

After revisional surgery for realignment and stability.

Revision surgery is sometimes very complicated, sometimes very difficult, and often times is not a guaranteed outcome just as the first procedure. However at FFLC we will tackle most difficult cases with very good or excellent results. If you have had any foot or ankle procedure and are not entirely satisfied or have had sub optimal results, it would benefit you to seek another opinion prior to seeking litigation, as often times surgery is not a perfect science. Therefore it is better to have the procedure ultimately corrected rather than seeking some ransom money from your initial surgeon. Most doctors if not all are not seeking to harm anyone and if an outcome does occur whereby pain or disability ensues, it is very often reversible our field. We can never guarantee perfection, but we may be able to enhance the original outcome.

Dr Timm

Back Pain May Cause Heel Pain

We have a select group of patients in our practice who have been treated for years with little improvement for what they were told or were led to believe was the common foot ailment known as "plantar fasciitis" and come into our door seeking a third or fourth medical opinion on the topic.
Many times MRI are negative or for pathology in the foot, or will show mild plantar fascia inflammation, but without real significant findings overall. They undergo countless hours of physical therapy centered at the foot and ankle, or purchase needless and numerous pairs of orthosis for their shoes without gaining any real improvement. They may have even had surgery for this and come out of it with minimal reduction in pain. Often these patients will end up with another diagnosis labeled "neuralgia" and feel as though they are hopeless.

Simply put: Not all heel pain is PLANTAR FASCIITIS

I will ask questions directed at the chief complaint, and usually even the answers to these questions will lead me away from plantar fasciitis if you say yes to any of them....  here are some examples:

Does it hurt first step in the morning? Usually they say 'no'.
Is the pain worse at night? Most often they say YES!!!
Does if feel like fire and tingling pain in the foot or heel?  YES again!!
Do you notice that it is worse at the end of the day? Definitely YES!!
Does IBUPROFEN or other NSAID seem to help at all? This is ambiguous, but can be useful to know.

These questions along with a simple physical examination can lead me in the right direction even more. Positive TINELS sign or Lesegue sign can indicate neuropathic findings suggestive of either lumbar impingement or tarsal compression. These may also be exacerbated by lymphedema and venous stasis swelling of the lower extremities, which I find to be very much under treated in these individuals.

We have a spine center upstairs at our EAST office location and if lower back pain is the root cause of the heel pain we are able to get direct referral to this location as well for faster improvement in symptoms. Disc bulging, spinal stensosis, radiculopathy, and sciatica are all possible causes of foot and heel pain as well. This needs to be differentiated from traditional plantar fasciitis and at FFLC we look at the whole patient, not just their foot and ankle to determine a sound treatment plan and better outcomes are inevitable with proper physical examination and history taking alone.

-Dr Timm

FOOT PROBLEMS MAY LEAD TO LOWER BACK PAIN AND VICE VERSA

Foot Deformities Can Cause Back Pain!

Back pain can be caused by a number of things from injury to stress to poor posture! The difficulty lies in diagnosing the proper cause and attempting to rectify the situation!

But did you know a misalignment of your body no matter how small, can wreak havoc from your head to your toes!

Pain is a sign that something is wrong, and should never be ignored! A complete evaluation from your physician is always recommended to rule out any significant problems! Still plagued with back pain after a clean bill of health? Take a look at your feet! Ask yourself these questions -

* Does one side of your shoe wear out before the other?
* Are your toes crooked?
* Do your feet point in or out excessively when you walk?
* Do you suffer from heel pain, knee pain or shin pain in addition to your back pain?
* Do you frequently sprain your ankle?
* Do your feet hurt in general?

If you answered yes to any of these questions, perhaps it's time to look more closely at your feet!

The main function of your feet is to act as shock absorbers as you shift your weight with each step you take. Structural problems, such as your feet rolling inward, called over pronation, can cause problems all the way up to your back!

The rolling of your foot inwards causes the arch to flatten and collapse under the body's weight. This continued stress could cause deformities of the foot over time, such as misaligned bones, hammertoes, bunions, knee pain and back pain.

With the inward rolling of the foot, the lower leg begins to rotate internally. This rotation may cause the pelvis to tilt forward, thus increasing the curve of the low back. Excessive curvature can create tightness and stiffness in the low back resulting in pain!

Foot orthotics can control the over pronation of your feet,  which has been shown to aide in decreasing back pain in select individuals!

What Are Orthotics?

Orthotics are mechanical devices to assist in the correction of deformities or disabilities. Foot orthotics are things like heel cups and shoe inserts, which help realign the foot through compensation and stabilization techniques.

Many types of shoe inserts are available over-the-counter. Shoe inserts provide complete foot support coupled with padding for comfort. But, the best solution for poor foot positioning resulting in low back pain is custom-made orthotics.

Custom orthotics are made by a trained orthotist, who makes an impression of your feet to determine and duplicate the deformities. Then they can custom make an appropriate orthotic to help correct the misalignments.

Types Of Orthotics

1. Early childhood orthotics. These devices are utilized in children who demonstrate biomechanical walking problems.
2. Functional orthotics. These devices are often utilized to correct defects in the foot, such as high arches or flat feet (also known as planus). These inserts use specialized techniques such as wedges to adjust the heel and alignment.
3. Weight-dispersive or accommodating orthotics. These devices utilize special padding to relieve pain in the feet.
4. Supportive orthotics. These devices are commonly used to treat problems with the arches.

Nobody's perfect! But even the smallest of misalignments can cause pain! And wouldn't it be nice for back pain to disappear with something as simple as placing an insert in your shoes? Orthotics are not the answer for all types of back pain, but they certainly can't hurt to attempt to keep your foot in the best possible alignment!

It is best to attain advice from a qualified medical professional before attempting to correct major foot deformities on your own, but typically the over-the-counter products are not designed for the purpose of major corrections.

What To Expect

Typically, I will have  a custom-made orthotic created from a mold of your feet. Once the mold is taken, a trained orthotist will create a unique insert especially for your foot.

But once the orthotic is made, the work is not done. Care must be taken to avoid further discomfort. Sometimes adjustments must be made for comfort. And you must keep in mind that now your foot is in the correct alignment, it will take time for your body to adjust.

Frequent skin checks are often recommended, especially in the beginning to avoid skin breakdowns and irritation. And, don't be surprised if your back pain feels worse - any change in your alignment may cause temporary discomfort. But, keep on your wearing schedule and inform us of any changes in pain or skin integrity. But, with a little persistence, your back pain may dissipate over time, once your body gets used to correct alignment.

Also the reverse can be true. Only a physician can determine if your lower back problems are causing foot pain, and this is usually related to radiculopathy. I will write more about this next week. 

-Dr Timm

3 Things you Need to Know about Neuromas

1. WE ARE ALL AT RISK.
We all have the propensity to form them. These lesions of the digital nerves on the bottom of the foot are directly related to environmental causes, such as tight fitting shoes, long hours on your feet every day, and even lack of tactile stimulation (such as massages). That being said, we are certain that everyone who walks on their feet are at risk to form this annoying and painful scenario. Therefore, you need to know if you actually have a neuroma in order to decide if treatment is in order. Pain, feeling of bunched up stocking, tingling and numbness to the toes. Worse in closed shoes. Feels better with massage. This sounds like a neuroma.

2. SURGERY IS NOT NEEDED.
All too often patients are deterred to see their doctor for reasons of fear. Fear drives the most powerful decisions, and is responsible for most things that are avoided. I can assure anyone reading this article that surgery is not needed for most neuromas. In fact, we are able to use a variety of ablation techniques, such as neurolytic injections, and radiofrequency ablation without an incision. These techniques help patients to avoid surgery, and can lead to excellent pain relief, with the replacement of numbness to the painful area. This is normal and is a good trade off for patients who are dealing with very symptomatic neuromas.

3. DIAGNOSIS IS PAINLESS.
Pain and discomfort are never acceptable. In fact, these are two of the sensations we try to avoid on a daily basis. Most times, whenever you seek aide from a physician, there are painful tests to be undertaken. At FFLC, we are able to calmly and painlessly diagnose many foot and ankle conditions, and have the equipment necessary to fully enhance the likelihood of a correct and timely diagnosis. Ultrasound, radiography, fluoroscopic imaging, and physical examination are readily accurate means to assure that we are correctly receiving the necessary information to treat your condition. Even if you want to delay any interventions at the time of your initial encounter, we can deliver a timely diagnosis so when it becomes more painful or if things need to become more invasive, we are ready to deliver the necessary treatments. So there are no reasons to avoid seeking an appointment today.


-Dr Timm

3D Images of High Heels you MUST SEE.

The 3D scan that will shock every high heel loving woman

• by: STEPHEN ADAMS
• From: Daily Mail
 
• August 19, 2013 10:07AM

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The high heel pedCAT scan. Picture: Screengrab, YouTube

THE first 3D scan of a female foot in high heels has highlighted the painful price fashion- conscious women may pay for tottering around in towering Christian Louboutins or Jimmy Choos.

Consultant orthopaedic surgeon Andy Goldberg says all the body weight gets forced on to the front of the feet, eventually causing unsightly clawed toes that can become arthritic.

Wearing stilettos pushes and twists bones out of line, resulting in knobbly bunions and other painful conditions.

The picture above was taken with a new $340,000 scanner at the Royal National Orthopaedic Hospital in North London. The PedCAT machine, the first of its kind in the UK, does a 360-degree scan of the patient's feet in just 60 seconds.

Doctors can then view the resultant 3D image from every angle, spinning it around to view the foot from above, below and the side. It also takes 600 2D views of the foot.

Mr Goldberg, a foot and ankle specialist, said the technology was a major advance over traditional 2D X-rays, which could lead to misdiagnoses.

"The scanner gives us much more information"' he said.

'It shows the deformity caused by wearing high heels is much more complicated than we previously thought.

"With high heels, the toes are squashed inside the shoe. The more stiletto-shaped they are, the worse it is. The toes not only get squashed, but they become clawed too." The base of the big toe becomes 'deviated outwards', forming a bunion, while the scanner also shows how these bones can become 'rotated and dropped'.

Pea-shaped bones under the base of the big toe - called sesamoids - get dislodged by the immense pressures put on them.

"There's nothing wrong with being in this high heel position temporarily - it forms a part of your normal stride. And if you wear heels for an hour or two at an evening party, it's not a problem" Mr Goldberg said.

"But if you wear them for eight hours a day for years on end, you will develop problems."

Before the high heel pedCAT scan. Picture: Screengrab, YouTube

It wasn't just middle-aged women who suffered, he said. "It's not uncommon for me to see teenage girls in my clinic. They are usually accompanied by their mothers, who tell them, 'Look, the doctor says you should be wearing sensible shoes!' But I try not to get involved with family politics too much.

"If you have got a family history of high heel wearers and you wear them a lot, you are pretty much guaranteed to develop bunions," he said.

"If you are not genetically predisposed, wearing high heels may accelerate bunions.

"Foot and ankle problems affect your walking and take over your life. There's a saying that if you want to take someone's mind off a problem, put them in tight shoes."

A survey of patients at the hospital's foot and ankle clinic found that 57 per cent had experienced severe pain as a result of wearing uncomfortable shoes such as high heels.

And 86 per cent claimed they found it difficult finding comfortable shoes. In truth, the internet is now awash with firms which offer sensible footwear in fashionable shades.

"People don't like doctors like me saying, 'Your shoes are a problem.' If I suggest they buy themselves some comfy shoes, I'm liable to get punched in the face." Mr Goldberg added. He also claimed some patients exaggerated the pain their bunions caused to get them surgically removed - so they could then continue to squeeze their feet into fashionable shoes.

Mr Goldberg said the damage caused by high heels was nothing new: "We have always been slaves to fashions that have led to deformity.

"But what we should be doing is fitting people's shoes around their feet, rather than the other way around.

"If a fashion icon such as Victoria Beckham designed a range of shoes that really fitted our feet, then that would be a real game-changer."

Victoria Beckham attends party to celebrate 40th anniversary of Range Rover. Picture: Supplied.

A HIGH PRICE TO PAY: HOW THE DEFORMITY AND PAIN DEVELOPS

- Prolonged 'hyper- extension' of these toe joints, under intense pressure, causes pain.

- High heels force women to throw their weight on to the front of the foot. Toes get squashed together and clawed up, eventually becoming rigid and arthritic.

- Big toe bones become pushed out, forming the trademark bunion of many high-heel slaves.

- Pea-shaped sesamoid bones are drawn underfoot and out of position, affecting how the foot bends and resulting in pain

We've indirectly known much of what this is saying but we are now exclusively certain the perils that feet are subjected to with regards to high heeled shoewear. These 3 dimensional scans give us an exact orientation to the deforming forces that women are subjecting their foot to on a daily basis, and it can give significant biomechanical insight to the resulting deformities and symptomatology associated with them. 

-DR TIMM

Is it a Bunion or Something Else?: How to Tell

"Is it a Bunion or Something Else?: How to Tell"

 

Many times, we will see a patient who is absolutely convinced they are suffering from pain related to a condition called a "bunion" deformity. Sometimes they are correct, other times we need to adjust this diagnosis.  Bunions typically are formed from biomechanical stresses which progress and lead to joint deviation and sometimes dislocation. This is accompanied by pain with motion and may lead to the need for surgery.

 

 

When the prominence is on TOP of the toe joint, it is not necessarily the same condition. We often refer to this as a "Dorsal bunion" or hallux limitus/rigidus. This is Latin for restriction of motion of the first toe joint. This is a very localized form of osteoarthritis and requires a different approach. Bunions tend to improve with padding and wider shoes. These sorts of issues are more likely to improve with coritsone injections and specific orthotics in the shoes. Other times it may require either a fusion, or an implant of the joint to maintain motion in specific cases. These are also progressive, and lead to limited motion and increased pain secondary to the arthritis in the joint space. We have a variety of holistic joint preservation techniques such as supplementation, PRP injections, and anti inflammatory cremes available to quell acute symptoms and maintain joint motion

 

This radiograph shows the excellent straight appearence of the toe joint, but also shows the absence of a joint space which can be an indication of severe degenerative joint disease (osteoarthritis). 

Observe the giant "lump" on top of this patients foot. Painful and inflamed this can be a source of debilitation and may require a cortisone injection for relief initially. 

 

 

One must be aware of the problem and it's nature, in order to obtain an excellent solution. Therefore, if there are any concerns or questions about what specifically is occurring in the foot and ankle, you should promptly be seen by your foot and ankle surgeon.

 

 

Brian Timm, DPM, AACFAS, DABLES
Board Certified by the American Board
of Lower Extremity Surgeons in
Reconstructive Foot and Ankle Surgery