Do your toes have a mind of their own?

Question and Answer forum on Hammer Toes

We are performing most of these corrections in office with a variety of techniques which may not even require hardware. Depending on the severity of the symptoms and the extent of deformity we can successfully implement a sound strategy to reduce or eliminate the deformity and allow for quick return to shoes/activity.

Brian Timm, DPM, FACFAS

Hammer toe
Hammertoes occur when the smaller toes of the foot become bent and prominent. The four smaller toes of the foot are much like the same fingers in the hand. Each has three bones (phalanges) which have joints between them (interphalangeal joints). The toes form a joint with the long bones of the foot (metatarsals) and it is this area that is often referred to as the ball of the foot.
Normally, these bones and joints are straight. A hammertoe occurs when the toes become bent at the first interphalangeal joint, making the toe prominent. This can affect any number of the lesser toes. In some cases, a bursa (rather like a deep blister) is formed over the joint and this can become inflamed (bursitis). With time, hard skin (callous) or corns (condensed areas of callous) can form over the joints or at the tip of the toe.

What causes hammertoes?There are many different causes but commonly it is due to shoes or the way in which the foot works (functions) during walking. If the foot is too mobile and / or the tendons that control toe movement are over active, this causes increased pull on the toes which may result in deformity.
In some instances trauma (either direct injury or overuse from walking or sport) can predispose to hammertoes. Patients who have other conditions such as diabetes, rheumatoid arthritis and neuromuscular conditions are more likely to develop hammertoes.

Are women more likely to get the problem?It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity. It is common for patients to wear shoes that are too small and this can predispose to the problem. In a study we have performed, 95% of patients were in the wrong size shoes.
Will it get worse?
At the start of the deformity, it is generally mobile which means that the toe can be straightened. However, with time, the joint become fixed or rigid. This can then affect the joint at the ball of the foot and, in severe cases, the joint capsule ruptures (tears) so that the joint becomes dislocated and the toe sits up in the air.

What are the common symptoms?
Deformity / prominence of toe
Pain
Redness around the joints
Swelling around the joints
Corn / Callous
Difficulty in shoes with deformity of the shoe upper
Difficulty in walking
Stiffness in the joints of the toe

How is it identified?

Clinical examination and a detailed history allow diagnosis. X-rays are often not required but can help to evaluate the extent of the deformity and the degree of arthritis within the joint.

What can I do to reduce the pain?
There are several things that you can do to try and relieve your symptoms:
Wear good fitting shoes with a deep toe box
Avoid high heels
Use a toe prop to straighten the toe if it is still mobile
Wear a protective pad over the toe
See a doctor at the Family Foot and Leg Center.

What can we as a specialist do to correct or reduce your symptoms?If simple measures do not reduce your symptoms, there are other options:
Advise appropriate shoes
Advise exercises if the toes are still mobile
Show you how to strap the toe in a corrected position
Provide a splint or protection
Consider orthotics

Advise on surgery
The way in which your foot loads during walking can place increased stress on the ball of the foot and cause increased toe activity. Special shoe inserts (orthoses) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the ball of the foot.

Will this cure the problem?
If the deformity is mobile, then this may help prevent progression although there have been no scientific studies to analyse the benefit. If the deformity is fixed, then orthotics will not cure the problem but may reduce the associated symptoms.

What will happen if I leave this alone?Generally, the deformity becomes worse with time and slowly becomes fixed (stiff). This can cause discomfort in shoes. The position of the toe places increased stress on the ball of the foot and this can become painful. Corn and callous formation on the ball of the foot is not uncommon. In some cases, the metatarsophalangeal joint capsule ruptures, causing the toe to sit up in the air.

Can the deformity be reversed or cured?
The only effective way of correcting the deformity is to have an operation.

How does the operation correct the deformity?
There are a number of different operations. However, the most common operations are:
Tendon transfer
Digital arthroplasty
Digital arthrodesis
Tendon transfers involve taking the tendon from under your toe and re-routing it to the top of the toe so that the toe is pulled down. This can be used alone if the toe is mobile or in combination with the other two procedures. This can leave the toe a bit swollen and stiff.
Digital arthroplasty and arthrodesis involve the removal of bone from the bent joint to allow correction. An arthroplasty removes half the joint and leaves some mobility whilst an arthrodesis removes the whole joint and, following a period of time with a wire/pin protruding from the end of the toe, leaves the toe rigid.
In more severe cases, the tendon on the top of the toe and the joint at the ball of the foot need to be released to allow the toe to straighten. If there is severe stiffness at this joint, then the base of the bone at the bottom of the toe (phalanx) may need removing (basal phalangectomy) or the metatarsal shortened (Weil osteotomy).

Patients will often tell me this: "I have heard it is very painful."
The nature of surgery means that there will be pain and swelling, usually worse the night after surgery. However, with modern anaesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort.

Will I have to have a general anesthetic (be asleep)?Not if you did not want one. Many of these procedures are performed perfectly safely under local anesthetic (you are awake). Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case. We often perform these procedures at our surgical suite over at the Gridley Building location, where often times these procedures are done within 30 minutes, and you leave right then in a surgical shoe with the dressing applied immediately after the procedure is completed.

Will I have to stay in hospital?
No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.

Will I have to have a plaster cast?
Plaster casts are generally not required for this type of surgery.

Are there a lot of complications?
There are risks and complications with all operations and these should be discussed in detail with your specialist. However, with most foot surgery it is important to remember that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot and general health is important so that these complications can be minimised.
Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with toe surgery:
Persistent swelling which may be permanent
Recurrence of deformity / corn (this tends to be more of a problem with the little toe)
Regrowth of removed bone
Residual pain
Stiffness or flail (floppy) toe
The toe may not sit on the ground – floating toe (there is an increased risk of this with arthrodesis)
You may get discomfort in other parts of your foot during the recovery period. This generally settles.
There is always a possibility that the deformity may return in later life.

When will I be able to walk again and wear shoes?In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks.
Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks. This period is longer for arthrodesis as shoes cannot be worn until the wire/pin has been removed (generally 3-6 weeks).
Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1 year.

When will I be able to drive again?When you feel able to perform an emergency stop. This is generally between 4-8 weeks post operatively but you should always check with your insurance company first.
When will I be able to return to work?
If you are able to get a lift and have a job that is not active and you can elevate your foot, you may be able to return after 1-2 weeks. Generally, patients return to work between 4-8 weeks depending on the type of job, activity levels and response to surgery.
When will I be able to return to sport?
Although the healing process continues for up to 1 year, you should be able to return to impact type activity at around 3 months. This will depend on the type of operation you have and how you respond to surgery

Secrets to Fresher Feet

Method 1 of 3: Cleaning Your Feet

1. 
   1
   Scrub your feet. It sounds obvious, but a quick rub with soapy water in the shower isn't enough. The objective here is to get rid of any bacteria and dead skin cells that bacteria like to feed on. So when you wash your feet, exfoliate the entire surface of your foot with a washcloth, brush, or any other abrasive mechanism and use anti-bacterial soap. Don't forget to scrub between your toes, either.
2. Ad
   
   
   2
   Dry your feet. When you dry your feet, dry them completely. Moisture, whether it's water or sweat, is what creates a fertile breeding ground for bacteria, Take the time to dry your feet thoroughly and don't neglect the space between your toes.
3. 
   3
   Use hand sanitizer. It may sound weird, but a good scented (or unscented) hand sanitizer can kill germs on your feet and inhibit bacterial growth.
4. 
   4
   Use antiperspirant. The same type of antiperspirant you apply under your arms could also be used for your feet. Just make sure to get a separate stick for each area. Apply it to clean, dry feet at night, then put your socks and shoes on as usual in the morning. It will help keep your feet dry and fresh during the day.
   • Antiperspirant actually reacts with the electrolytes in sweat to form "gel plugs" that block off your sweat ducts. Since each one of your feet has over 250,000 sweat glands (more sweat glands per inch than any other part of your body) a little antiperspirant can go a long way.
   • Don't apply it right before going out, or you'll be slipping and sliding in your shoes.
5. 
   5
   Keep a mixture of 1/2 regular vinegar and 1/2 isopropyl alcohol. Dribble this daily (use a medicine dropper) over and between your toes and irritated skin on the feet and spread it. Both products are harmless to your skin, but the vinegar kills fungus and the alcohol inhibits or kills bacteria. It also helps get rid of toe fungus on contact.
   • You can soak your feet in a solution of 1/2 vinegar, 1/2 water as a way to stave off bad odors. Add a few scoops of baking soda and thyme oil drops, both of which also help get rid of stinky smells.
6. 
   6
   Rub your feet with one or more of the following powders. Do this between your toes as well. This is what most foot powders and sprays contain to combat foot odor:
   • Talcum powder. It's an astringent, so it'll dry out your feet.
     
   • Baking soda. This creates an alkaline environment that's not bacteria-friendly.
     
   • Corn starch. This helps absorb sweat.
     

Method 2 of 3: Freshening Your Footwear

1. 
   1
   Wear sandals or open-toed shoes. Wearing open shoes lets the air flow around your feet, keeping them cool and keeping you from producing as much sweat. When you do sweat, it will evaporate quickly due to air circulation.
   • During colder months, wear leather or canvas shoes which allow your feet to "breathe." Steer clear of rubber and plastic shoes.
2. 
   2
   Change your socks daily. Socks absorb your sweat when you wear them, and it dries when you take them off. Putting on a dirty pair of socks for a second day in a row is essentially going to reheat that sweat, leading to a foul smell. Change your socks every day, especially if your feet tend to get sweaty.
   • Unless you're wearing open shoes, you should always wear socks. Try two pair of socks to help with the wicking of moisture away from the foot.
     
   • When you wash your socks, turn them inside out in the washer so the dead flakes of skin have a better chance of being washed away.
     
   • Go for absorbent socks made of cotton or wool. Non-absorbent socks (like nylon) trap moisture around your foot, making a cozy little nook for bacteria.
3. 
   3
   Lightly powder shoes and socks daily with baking soda. Dust out yesterday's baking soda before adding in the fresh amount. Baking soda absorbs moisture and odors.
4. 
   4
   Use cedar wood or cloves to freshen shoes. Put cedar wood shavings or whole cloves inside your shoes for a few days when you don't need to wear them. The odor will disappear after a few days.

Exerpt from Wiki How's Website.

Richard Sherman ankle update

Everyone watched the "Ball Hogs" take out Peyton Manning and company in Super Bowl 48. What we did not get to see was the fact that Richard Sherman injured his ankle. He was diagnosed with a "high ankle sprain" and that is not because Seattle was playing Denver in the Super "Bowl" between two states which have passed legalization of marijuana legislation. He had twisted his ankle so that the ligaments above the ankle joint were either strained (meaning partially torn) or sprained (meaning stretched just beyond their mechanical end point). Either way, he will likely only require CAM boot immobilization and physical therapy, and probably won't miss a step for next season.

Dr Timm
Diplomate American Board of Podiatric Surgery

3 Myths about Ingrown Nails:

1) Ingrown nails can be treated with a PEDICURE.

As the image above shows, some patients will develop a deformity of the edge of the nail which extends underneath the skin and leads to pain and puncture of the skin eventually leads to infection. A pedicure only treats the exposed nail, and they are generally not able to relieve the symptoms entirely because of sensitivity to the area. In most cases, it is required to use local anesthetic to completely allow access to this painful area and this can only be accomplished in the office of a trained medical professional.



2) Ingrown nail surgery is painful.
It is actually more painful to allow this infection to become what is shown by the clinical picture above. This sort of infection is more painful secondary to the pressure from the underlying purulence, and pressure from the nail tissue pressing into the surrounding skin. After your procedure is completed, you will leave the office in no pain and after the lidocaine wears off, the pressure and sharp pains you were experiencing prior to the intervention will be minimal, and in most cases can be relieved by over the counter Alleve medication or variant.




3) After nail surgery my nail will be narrow

This is immediately after the nail is removed post procedure. The reddened area is raw tissue which is exposed post partial matrixectomy and prior to the chemical cauterization. As you can see, the nail that is visible is very normal looking, and most of the nail which is removed is not usually visualized as it is beneath the skin layer.


After several weeks, the nail tissue will heal, and the new nail border will attach to the side and appear very natural. In this clinical example it is the same procedure just a few weeks after, and the area that looks like a deficit in skin will fill in over time and the new nail fold will attach without any further intervention.


Brian Timm, DPM, FACFAS
Diplomate American Board of Podiatric Surgery 

My Ankle Hurts !! Chronic ankle pain and you.

Chronic lateral ankle pain symptoms

Chronic lateral ankle pain is characterized by swelling and stiffness near the ankle joint, as well as recurring pain on the outside of the ankle that worsens with exercise. The pain can be brought on by walking and playing sports, or it can manifest as a dull and constant ache. One of the more distressing symptoms of chronic lateral ankle pain is a constant feeling of ankle instability. People with chronic lateral ankle pain often have difficulty walking in high heels or on uneven ground and are prone to repeat ankle injuries.

Treatment of chronic lateral ankle pain 

Treatment for chronic lateral ankle pain will depend on the final diagnosis by your physician. Conservative treatments include:
Ankle brace (to fascillitate immobilization and prevent further injury).
Ankle arthroscopy (surgical exploration and repair of damaged cartilage)
Anti-inflammatory medication (to reduce swelling).
Physical therapy (designed to strengthen muscles and restore joint motion).
PRP injections (Natural autograft to enhance isolated tendon healing)
MRI examination (Typically for surgical planning to see the extent of the damage and planning for open repair)

Not all pain is arthritis based. And not all pain is attributable to a definitive trauma or injury. The history of chronic ankle pain and instability is usually multifactorial, and is often under treated and not diagnosed very well which may lead to tendon tears and progressive degenerative arthrosis. We will perform a complete examination which will allow for more accurate diagnosis and improved prognosis.

Dr Timm
Diplomate American Board of Podiatric Surgery

Does weather worsen arthritis?

"Doc, my ankles hurt more in the cold. Why is that?"

I get this question often from patients who are seasonally living in this area.

But does the weather actually affect arthritis? If so, how?

First, there hasn't been much real research science addressing this question. In 1961, famous arthritis specialist J. Hollander, MD, conducted a study in which he built a climate chamber and demonstrated that high humidity combined with low barometric pressure were associated with increased joint pain and stiffness. Neither weather factor by itself seemed to influence joint symptoms. The study has been criticized because of the limited number of patients evaluated (12 patients). The theory of the study is that inflamed joints swell as the barometric pressure drops. This swelling irritates the nerves around the joints that sense pain and causes more stiffness.

Well, if this theory proved correct (and it is not universally accepted), should a person with arthritis move to a region with a dry climate?

The answer is no. Relocating to a different climatic environment does not seem to make a difference in the long run. Scientific studies have shown that no matter where people live their bodies seem to establish a new equilibrium to the local climate. As a result, changes in the weather affect the arthritis symptoms in the same manner regardless of the actual overall average weather. Moving is not likely to be beneficial long term. (To emphasize a point, I can tell you that there are plenty of busy rheumatologists in Florida!)

What is the bottom line?

It appears that there is some evidence that the symptoms of certain people with arthritis are influenced by changes in the weather. This is not true for all people with arthritis, nor is it predictable what type of weather alterations will bother people. For example, in one room I may have a patient complaining that last week, just before it rained, her joints began aching and now that the weather is warm and clear she feels better. Simultaneously, in the next room, a patient tells me that her joints are far worse today after it rained last week! What do I do with this information? Well, each patient must be evaluated (and evaluate themselves) uniquely. The bottom line is that while the exact cause(s) of the activation of arthritis symptoms may not yet be scientifically understood, each patient must make lifestyle and/or medication adjustments according to the particular weather conditions that they note influence their symptoms.

If a patient does experience joint pain and stiffness with weather changes, how harmful is this?

It is very important to appreciate that only joint symptoms (such as pain and stiffness) are influenced by weather. We do not have any evidence that weather changes lead to joint damage. Furthermore, weather changes have not been related to whether or not an individual develops arthritis.

So enjoy the warmth while you're here, and remember to bundle up if you are still in the cold, as this may otherwise precipitate painful swelling and stiffness of your joints. 

Flatfeet could slow you down

How is this possible?

The results conducted by the American Podiatric Medical Association concluded that a staggering 73 percent of people asked said that they are suffering from foot pain.

The question is: why has foot pain become one of the most common complaints in the examination room?

For many people, this problem can be caused by one of the following: the kinds of shoes they wear, what activities they participate in, or how their feet are formed. Wearing poorly-fitting shoes can turn minor problems into major ones. People who engage in athletic activities are another segment of the population that are mostly affected by foot pain. Factors such as fallen arches, overpronation, and poor support can all be contributing factors to lower extremity pain. Parents can also be the cause of foot-related problems, because genetics play a role how the foot was formed in the womb. This can enhance the likelihood that someone will suffer from an array of painful foot conditions.

The Mechanics of the Foot
Flat feet can cause abnormal rotation of the feet when walking or running. Our feet handle balance, stability, and bear the weight of the body. The parts of the foot that help to keep the foot in harmony with the body include the arch, heel, tarsals and meta-tarsals. The arch provides stability by the following structures: the tendons, ligaments, and muscles. Pain can result from raised arches or abnormally-low arches, which can cause the foot to rotate abnormally. With high arches, the body’s weight is abnormally emphasized on the outer edge of the foot (oversupination). Conversely, overpronation happens with fallen arches because the weight of the body is concentrated on the inside of the foot, causing the ankles to roll inward .

Serious Foot Issues May Occur with Flat Feet A quick way to see if fallen arches or high arches are an issue is to find a good area where a foot impression can be made, such as on concrete. Immerse on foot in cold water and then stamp your foot onto the dry surface. Then, lift the foot off the ground and see the impression that is left by the foot. A flat foot with overpronation will leave a complete mark where the entire foot has touched the ground. A high arch will leave just a part of the ball of the foot’s outside portion, and heel of the foot. Either of these arch conditions can cause painful bony growths in the heel because the foot has to deal with too much pressure in places it is not intended to handle.

Orthotics Provide Effective Relief for Therapy For Plantar Fasciitis
People suffering from fallen arches, heel spurs, or who need plantar fasciitis treatment can get relief by using the best orthotics available in their shoes. They offer the needed support to fix the weak structures in the foot, such as those that make up the arch. They also offer cushioning in areas where too much pressure occurs, such as in the heel or ball of the foot. Orthotics are available in an array of sizes and types and are made to keep up with anyone’s activity level.