Great Toe Joint Replacement

One of the more common conditions seen in a podiatrist’s office is hallux limitus. In this condition, the range of motion of the first toe at the first metatarsophalangeal joint (MPJ) is limited to a number that is less than normal. A normal range of motion is generally considered to be approximately 65 degrees of dorsiflexion (motion of the toe upwards). Hallux limitus may be distinguished from hallux rigidus, using the latter of the terms to describe a condition where the toe is almost or completely fused, and little to no motion is available at the joint. Many will refer to the condition as Hallux Limitus/Rigidus, sometimes abbreviating it as HL/HR.

Hallux limitus is caused by jamming of the proximal phalanx into the first metatarsal. This may be caused by muscle imbalance, biomechanical deformity, trauma, osteoarthritis of the joint, and a number of other conditions. Regardless of the cause, hallux limitus can be very painful, and can lead to significant changes in gait.

Nonsurgical treatment of hallux limits and hallux rigidus typically involves the use of an orthotic device, often aimed at limiting the motion of the joint. This may prevent some of the pain associated with the condition. It may also be combined with modifications to the design of the shoe, range of motion exercises with physical therapy, anti-inflammatory medications, alteration of activities, and joint protective supplements such as glucosamine. However, with the failure of nonsurgical intervention, an attempt at surgical correction may become necessary.

It is quite common for the joint to be fused by a surgeon. This prevents any motion at all at the joint, with a goal of decreasing the level of pain. However, another option is to replace the joint.

The idea of replacing the first MPJ came into practice in the 1950’s as an alternative to fusing the joint. It became quite popular among foot and ankle surgeons, and has seen drastic improvement in the past 10-15 years with the advent of more sophisticated implant devices and materials.

Joint implants can be broken down into two basic categories; hemi-implants and total implants. Hemi-implants are not true joint replacements, but act more as a spacer for the joint. The spacer is usually placed into the head of the first metatarsal. This spacer allows the proximal phalanx to move more smoothly over the head of the metatarsal. By using a hemi-implant, more motion can be allowed at the level of the joint.

A total implant is placed into both sides of the joint. That is, it is inserted into both the head of the first metatarsal as well as the base of the proximal phalanx. Thus, a new joint is created at the first MPJ. A total implant may be used in cases of more severe arthritis at the joint, when neither of the articular surfaces that create the joint can be salvaged.

Both types of implants may be made of silicone or metal, or a combination of the two. Metals used in implants include titanium, stainless steel, cobalt chromium, and various alloys. Ceramic implants have also been used, but are less common.

A meta-analysis performed by Cook et al. in 2009 showed that the overall patient satisfaction in first MPJ replacement arthroplasty was approximately 85%. This study looked at 47 different clinical studies of first MPJ replacement, and the results from those surgeries. According to the research, when the follow-up time was increased, the patient satisfaction went up to over 94%. Thus, the procedure remains popular among foot and ankle surgeons.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Tailor’s Bunion

While many may be familiar with the classic bunion that appears at the base of the big toe, a very similar condition can develop at the base of the little toe. This condition is known as a tailor’s bunion, sometimes referred to as a “bunionette”. A tailor’s bunion is an enlargement of the fifth metatarsophalangeal joint (MTPJ) and the lateral aspect of the fifth metatarsal head, whereas a classic bunion is on the first MTPJ. The development of a tailor’s bunion is similar to that of a bunion, and they are often seen together.

The development of tailor’s bunions are most commonly attributed to pathological pronation, sometimes referred to as “over-pronation” or “pronation syndrome”. Due to improper biomechanics of the foot, muscle imbalances can occur, and the fifth toe can begin to rotate in a number of ways. This rotation can cause increased forces on the lateral side of the fifth metatarsal and fifth MTPJ, causing an increase in bony growth that results in a tailor’s bunion. Wearing tight and poorly fitting shoes can exacerbate the problem, leading to pain and deformity. It is also common to find corns and calluses in association with tailor’s bunions, which are often painful.

The diagnosis of a tailor’s bunion is made clinically, though an x-ray is often required to assess the extent of the deformity. Conservative treatment of tailor’s bunion is focused on pain reduction, as well as prevention of furthering of the deformity. This may include measures such as anti-inflammatory medications (usually NSAID’s), wider shoes, padding taping, and the use of custom orthotics.

When conservative treatment fails, or if a patient desires that the bump be removed, surgical treatment may become an option. Several different surgical procedures are available for tailor’s bunions, with the extent of the deformity dictating which procedure is selected by the surgeon. Most procedures focus on removing the protruding bump from the bone, as well as realigning the bone so that the painful deformity does not recur.

Depending on which surgery is performed, it may or may not be possible to be walking on the foot right away. Typically when the fifth metatarsal is realigned at the head (the area closest to the toe) the patient will be able to walk in a surgical shoe right away. For surgeries performed at the shaft or the base of the metatarsal, crutches or a non-weight bearing shoe may be required for two weeks. Minimal pain and swelling is anticipated in most cases, and studies show a predictable and effective outcome for most surgeries.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Visual Gait Analysis

One of the greatest tools of the podiatric physician is an acute eye for disturbances in gait. Walking requires an enormous amount of input from the central and peripheral nervous systems, the musculoskeletal system, and the vestibular and visual systems. A change to anyone of these inputs may alter the gait, and a keen eye for changes may lead the observer to a diagnosis.

Most commonly, described changes to gait are attributed to disorders of the nervous system. These compensatory gait patterns include:

• The shuffling, slow, festinating gait seen in Parkinson’s disease

• Steppage gait with foot drop commonly attributed to stroke, peripheral neuropathy, or lumbar radiculopathy

• “Scissors” gait often seen in cerebral palsy

• Cerebellar ataxic gait seen with alcoholism, neurotoxic poisoning, and inherited ataxia

• Stooped gait from a history of lumbar spinal stenosis

Changes in gait may also be due to disturbances of the musculoskeletal system. These changes are often much more subtle than the changes attributed to neurological disorders.

To understand the changes in the musculoskeletal system that cause gait disturbances, a thorough understanding of biomechanical function is required. The human body can be thought of as a chain of linked joints that help us move, from the tips of our toes all the way up to the head. A minor change in one of the joints, bones, muscles or ligaments can have a rippling effect through the body.

Proper visual gait analysis uses a methodical approach, analytically evaluating key elements to the gait pattern. Areas of interest include the head, shoulders, pelvis, hips, knees, ankles, joints of the foot, heels, and toes. The observer will take note of things like range of motion, symmetry, speed, stride length, position of body parts, and other factors. The changes can often be very subtle, but may cause great disturbances in gait as well as painful or limited ambulation.

For the podiatric physician, musculoskeletal changes are often the area of most interest. Gait changes and positional deformities of the musculoskeletal system can often cause pathological conditions to develop in the foot and ankle, as well as the exacerbation of existing conditions. To combat these problems, orthotic devices and shoe modifications are often prescribed to the patient.

The vestibular system and visual system are the two special sensory systems that have the greatest influence on the gait cycle. The vestibular system, which is located in the inner ear, gives us the ability to balance. Disturbances to the vestibular system can cause vertigo and a los of balance, as well as dizziness, nausea, and other physical findings.

The visual system, stated quite simply, allows us to see where we are going. It relays information to the vestibular system, as well as to a number of areas of the brain that aid in walking.

Gait analysis is a vital tool, and can often help in the diagnosis of different disorders and diseases. A keen eye and understanding of the body are essential to proper gait analysis. Inversely, an understanding of gait analysis is essential to the understanding of the body.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Diabetic Peripheral Neuropathy

One of the commonest complications of diabetes is the development of neuropathy. A neuropathy is a problem with the nerves of the body. This can have an effect on all of the nerves of the body, including the sensory, motor, and autonomic nervous systems.

Symptoms and types of neuropathy - The symptoms of diabetic neuropathy are dependent on the nerves involved. The sensory system relays signals from the external environment to the brain. If there is a problem with this division of the nervous system, one may experience numbness or tingling in the extremities, pain in the hands and feet, or a loss of balance.

The motor system allows us to move our muscles, and to keep the proper tone required for healthy limbs. Neuropathy to the motor system may cause muscle weakness and loss of tone to the muscles.

Sensorimotor neuropathy is commonly seen in a “glove and stocking” pattern. This means that the areas affected first are the hands and feet, and the symptoms will travel towards the body from the distal most point in each. Symptoms include pain, burning, tingling, prickly, achy, or dull sensations of the extremities.

Diabetic patients are at an elevated risk for infections of the feet in particular, due to ulcerations of the skin. The loss of feeling in the feet leads to a loss of protective sensation. This means that a diabetic patient with sensorimotor neuropathy in the feet (often referred to as peripheral neuropathy) will never feel that their shoes are too tight or that they have walking on a pebble inside their shoe all day, causing an irritation and perhaps a break in the skin. Compounded with a weakened immune system, the diabetic neuropathic patient is a prime target for infections of the foot.

Loss of motor control in the diabetic neuropathic patient can also lead to a loss of muscle mass and strength in the foot. This may be seen as contractures of the extensor muscles of the toes, which will result in the formation of hammer toes.

Perhaps the piece of the diabetic neuropathy puzzle that is of greatest value mentioning is autonomic neuropathy. The autonomic (or involuntary) nervous system controls all of the functions that we don’t have to think about. This includes controlling the heart rate, tension/tone of the blood vessels, gastrointestinal control, and control of the urinary system, to mention a few. Autonomic neuropathy can result in a loss of control over any one of these systems, and in many patients it results in a loss of control of several.

Manifestations of autonomic neuropathy are seen with ease in the feet of a patient. Signs and symptoms include a loss of hair on the foot, ankle, and lower leg over time, increased prevalence of fungal nail infections and superficial fungal infections of the feet (tinea pedis, or athlete’s foot), feet that are cold to touch, and a general decrease in blood flow to the feet. The development of peripheral neuropathy in the feet of a diabetic patient is one of the first noticeable signs of diabetic complications.

How diabetic peripheral neuropathy develops – Evidence exists for several different mechanism of how the problem develops, all of which are related to each other.

Microvascular disease is a popular idea of how peripheral neuropathy develops. Interdependence of the vascular and nervous systems is a common theme in many disease processes of each system. As vasoconstriction (the tightening of a blood vessel) is one of the first functions lost, microvascular disease to the vessels that supply the long nerves (vasa nervorum) fits as an explanation.

Other explanations include advanced glycated end products altering the function of proteins and enzymes in the body, an increased level of protein kinase C that may alter the function of intercellular proteins, and the polyol pathway (sorbitol/aldose reductase pathway), which helps explain the microvascular component of peripheral neuropathy. Further explanations of these processes are beyond the scope of this article, but much more can be found about these biochemical processes online.

Treatment of peripheral neuropathy – Assessing and evaluating peripheral neuropathy is perhaps the simplest method of tracking the progression of the problem. This is done with very simple clinical tests that your doctor may perform in the office. These tests also aid in the diagnosis of peripheral neuropathy.

Simply put, each type of nerve in the legs and feet has a clinical test that evaluates the function of a particular nerve. The different types of nerve fibers include sensory fibers that conduct vibration, proprioception (the way your brain knows where your foot is in space), deep touch, light touch, cold/heat sensation, pain, and protective sensation.

Several medications may be prescribed by your doctor to treat painful peripheral neuropathy. These include agents such as tricyclic antidepressants, serotonin reuptake inhibitors, anticonvulsant medications, and other pharmaceuticals. Experimental treatments include the use of topirimate and carbemazepine, both of which are also used to treat epilepsy and other disease processes of the nervous system. It should be noted that the vast majority of products used to treat peripheral neuropathy are used off-label, meaning that they have not been FDA-approved to treat such conditions.

Other treatments include the use of transcutaneous electric nerve stimulation (TENS) and injection of methylcobalamin (activated vitamin B12). These have both been shown to be an effective method of treatment in patients with diabetic neuropathy.

Prevention and Epidemiology – The most effective method of treating diabetic neuropathy is a tight control on blood glucose levels. High blood sugar levels, or hyperglycemia, is the characteristic trait of diabetes mellitus and high levels of blood glucose correlate with an increase in complications. An aggressive approach to glycemic control us of utmost importance, and includes diet modification, regular and appropriate exercise, and medications to help control blood glucose and insulin levels.

The prevalence of diabetic neuropathy ranges in populations from 20-50%. There are numerous studies evaluating the prevalence in different populations, all with different averages. However, what remains consistent in these studies is that Type II diabetics are more likely to develop complications that Type I diabetics (insulin-dependent). To see how the Dellon Procedure can help curb neuropathy pain click HERE.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

What is a Bunion?

Bunions, those painful bony growths on the insides of your feet, are the result of a biomechanical deformity known as Hallux Valgus. While the exact etiology of the deformity is unknown, there is a strong familial connection. Hallux valgus and the resulting bunion deformity is much more prevalent in women than in men, most likely due to the difference in bone structure and center of mass.

Bunions can be a painful experience. Many women with bunions complain of not being able to wear certain shoes, especially shoes with a narrow toe box. Numbness is also a common complaint, as well as an overall dislike of the aesthetics of bunions. Rubbing of the bony prominence against a too-narrow shoe can cause a throbbing pain, with the affected area becoming red and swollen.

There are a number of treatments for bunion deformities, some much more effective than others. Conservative treatments typically focus on treating the symptoms, or preventing the deformity from progressing. Surgical treatment focuses on correcting the deformity, putting the bones of the foot into alignment.

Conservative treatments include:

· R.I.C.E. Therapy – Rest, ice, compression, and elevation make up the R.I.C.E. therapy. This is a sort of catch-all group of treatments used for a number of different complaints, from sprained ankles to sore knees. It may make the bunion-affected feet feel better temporarily, but offers little lasting effect.

· Anti-Inflammatory Medications – Non-steroidal anti-inflammatory drugs (NSAIDs) are a commonly used treatment for not only bunions, but a number of problems involving inflammation. These too offer only temporarily relief of a painful bunion, and don’t do too much to correct the problem. Steroids, both injected and topical, may be used as well. Steroids may offer a longer lasting pain relief, but is still a temporary solution.

· Bunion Splints – Commercially available bunion splints, designed to prevent the deformity from rubbing against a shoe and prevent the progression of hallux valgus deformity, are also used. These have never been studied, and their effectiveness is questionable.

· Padding and taping – Your podiatrist may use a combination of padding and taping to both hold the foot in an optimal position, as well as protect the bunion from rubbing against a shoe. These methods usually work for several days, but require a re-taping and re-application of the padding frequently.

· Custom Orthotics – Custom orthotics may be the most effective conservative therapy, as the address the underlying deformity of the foot and not just the bony prominence at the big toe joint. A custom orthotic can be designed to prevent the hallux valgus deformity from expanding, thus preventing the progression of the bunion.

In addition to conservative therapies, many patients with hallux valgus and painful bunions undergo surgery to correct the deformity. This remains the definitive treatment for bunions, and the only treatment that actually can correct the problem.

Depending on the curcumstances, different surgical procedures typically involve cutting a small piece of the metatarsal bone out, and shifting the bones of the foot and toe into a straighter alignment. Additionally, some of the bunion itself may be removed surgically, so that it does not protrude from the foot.

Bunions may also form on the outside, or lateral side of the foot. When this happens, they are called Tailor’s Bunions. Tailor’s bunions are located on the fifth toe, at the metatarsophalangeal (MTP) joint. The development of Tailor’s bunions comes from a widening of the space between the fourth and fifth metatarsals, similar to the development of a bunion on the inside of the foot. Tailor’s bunions are typically less painful than regular bunions, but can be an equal nuisance. Tailor’s bunions are usually corrected at the same time in surgical cases.

If you have bunions, discuss the options with your podiatrist. Remember that pain in the feet is never normal. It is your body’s way of saying that something is wrong. There are a number of ways to deal with painful bunions and hallux valgus deformity, and a doctor can help guide you through the decision-making process.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

Pediatric Flatfoot

In the world of pediatrics, an often-misunderstood condition is pediatric flatfoot. What may be considered normal at one age may not be normal at a later age, and so there is a great deal of interpretation that comes with a diagnosis such as pediatric flatfoot.

From when a child begins to walk, usually somewhere around the 12 month mark, until around three years of age, a flattened foot with a lowered arch is ubiquitous. Nearly all children in this age range will have some degree of flatfoot, caused by pronation syndrome (the tendency of the foot to collapse medially).

For many parents, this can cause alarm, sending them straight to the pediatrician. A pediatrician may then refer the patient on to a podiatrist, who can help diagnose and quantify the degree of pronation, a measurement of flat-footedness.

For many children, a flexible flatfoot will resolve on it’s own. Once the child reaches a certain age, the bones begin to mature, and the flatfoot will go away.

For a small number of children, the degree of pronation is so severe that it is highly unlikely that it is due to normal development. These children usually are symptomatic, and may have pain or disturbances in their walking pattern.

Between these two ends of the spectrum are a vast number of children who may or may not need treatment. The doctor will decide if they need treatment based on a number of factors, including the progression of the condition. If the flatfoot is getting worse, they may treat it more aggressively. If the condition is resolving over time, they may treat it more conservatively and mainly observe the progression.

Some other symptoms that may alter the decision of whether to treat the condition or not include the presence or absence of pain (including foot, ankle, and knee pain), fatigue, and decreased activity because of the flatfoot. A more aggressive approach to treatment may also be taken if there are other orthopedic conditions associated with the flexible flatfoot.

The gold standard of treatment is the use of custom molded orthotics. These can be put into a variety of different shoes, and will generally help correct the deformity, particularly if there are gait disturbances.

Surgical intervention may be an option in more severe cases, but is usually not recommended until non-surgical treatment has failed.

A condition that must be differentiated from flexible flatfoot is rigid flatfoot. In rigid flatfoot, the deformity is due to a problem with the bone structure. This problem is most commonly a tarsal coalition, which is an abnormal fusion of the bones of the mid- and rear-foot. Ideally, the rigid flatfoot is recognized early, and corrected by surgery. Unfortunately, tarsal coalitions are usually not found until later in the child’s life, or even into adulthood. At this point, surgery may cause more harm than good. With older children and adults with rigid flatfoot caused by a tarsal coalition, custom-molded orthotics are usually the best method of treatment.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com