DR ANDREW KINGSFORD

B.App.Sc.(Pod), Grad.Dip.Pod., F.A.C.P.S.
PODIATRIC FOOT & ANKLE SURGEON

03 9532 7600

Conditions

Conditions that may require Surgery:

Bunions (Hallux Valgus)

The term bunion refers to the misalignment of the big toe in relation to the foot. The assumption that a bunion is a bony growth on the side of the big toe joint is incorrect, as the bump on the side of the big toe joint is the joint itself protruding outwards.

A bunion is a progressive deformity that may lead to arthritis of the big toe joint and is especially prevalent in people over 50 years old. The pain and reduction in mobility associated with bunions can have a profound effect on a person’s quality of life.

It is now generally understood that bunions are more a result of genetic inheritance than poor choice of footwear, although footwear may be a contributing factor.

In certain cases, symptomatic improvement can be achieved through change of footwear, padding around the bunion, anti-inflammatory medication and the use of orthotic devices, however surgery has been found to offer superior patient outcomes in most moderate to severe cases.

There are different methods of bunion surgery that treat different presentations of the complaint.

The age, health, lifestyle and activity level of the patient may also play a role in the choice of surgical approach.

Contact Kingsford Podiatry Group for further information or to arrange a consultation.


Tailor’s Bunion

A tailor’s bunion or bunionette deformity is similar to a bunion of the big toe joint, except that a tailor’s bunion affects the little toe joint. It involves deviation of the little toe toward the lesser toes and enlargement of the outside of the fifth metatarsal head (where the little toe joins the foot). Tailor’s bunions can cause redness, swelling and pain due to footwear irritation over the prominent bump. The term tailor’s bunion was coined following the common presentation of these deformities in tailors who would sit cross-legged and put pressure on the outside edge of their foot. This constant rubbing led to the bump at the base of the fifth toe.

Tailor’s bunions are generally considered to be caused by either a family predisposition or foot function. The diagnosis of the tailor’s bunion is generally apparent upon inspection of the foot – a lump can be seen on the side of the little toe joint.

The treatment of tailor’s bunions generally involves attention to footwear that does not rub over the bump of the fifth toe. Medication, such as non-steroidal anti-inflammatory drugs, can afford symptomatic relief. Padding over the area can help reduce the pressure over the bump.

Arthritis of the big toe joint (Hallux Rigidus)

Arthritis of the big toe joint is a condition characterised by pain, swelling and stiffness of the big toe joint. Big toe joint arthritis is generally caused by poor foot function or from trauma i.e. badly stubbing a toe. Both result in a cartilage damage within the joint and inflammation of the joint capsule. As the cartilage damage progresses over a period of time, bone spurs form around the joint and it becomes progressively more stiff. Big toe joint arthritis can also be caused by inflammatory arthritis such as rheumatoid arthritis or gout.

This condition can cause difficulty with daily activities, such as walking and running. Like all arthritis it can be aggravated by cold and damp weather. In addition, lumps that develop around the top of the joint can make certain footwear difficult and painful to wear.

Shoe modifications, such as a spacious toe box or stiff rocker-bottom soles may be necessary. Orthotic devices to improve foot function or to limit the motion of the big toe can also help.

Medications such as nonsteroidal anti-inflammatories or paracetamol may help with symptomatic relief. Supplements such as glucosamine and fish oil may prove helpful. Injections into the joint of corticosteroids can help afford short term relief, but are generally not recommended.

Surgical management of this condition is dependent on the extent of arthritis in the joint. If there is only a small amount of arthritis in the joint and pain is related to spurring around the top of the joint, then removal of the bone spurring around the joint can provide symptomatic relief.

In more advanced cases, where there is more extensive cartilage wear and stiffness in the toe, fusion (termed arthrodesis) of the big toe joint is necessary. Often, patients are reluctant to consider fusion of the big toe joint, however, this procedure essentially creates a painless stiff toe (from a painful stiff joint!).


Ganglion (Ganglionic Cyst)

A ganglion is an out-pouching from a tendon sheath or a joint capsule. They are very common and frequently occur in the foot. They can often fluctuate in size and resolve spontaneously without treatment. There is debate over the origins of a ganglion, however it is generally believed that a weakness or tear in the lining of a joint capsule or a tendon sheath allows for the escape of fluid into a balloon like mass. Ganglions can become painful if they are large, subjected to pressure from footwear or a bony prominence and if they reside next to a nerve.

Treatment for ganglions varies from watchful waiting to surgical excision. Shoe modifications or padding may help redistribute pressure away from the ganglion. A common clinical treatment involves aspiration (drawing out) of the fluid within the ganglion and injecting steroid into the area to help prevent its recurrence. However, ganglions can recur despite this treatment and often several courses of aspiration may be required. Surgery to remove the ganglion can be considered if conservative options fail.

Hammertoes

A hammer toe or claw toe deformity refers to buckling and contracture of one or two joints of the lesser toes of the feet. Digital deformity is progressive and begins as mild and flexible and can progress to severe and rigid over time.

These deformities can cause pressure from footwear or the ground on the tips of the toes resulting in callus and corn formation.

There are many reasons a hammer toe or claw toe deformity can develop. They are commonly associated with bunions due to muscle and ligament imbalances in the forefoot.

Conservative care of lesser digital deformity includes regular podiatry care to debride corns and calluses. In addition, changes to footwear and the implementation of padding or orthotic devices can help. Strapping or splinting of the digits may also be necessary.

Surgery is often indicated for recurrent and painful corn or wound formation over the digital deformities. Surgical management of hammer or claw toes can be simple or complex. It depends on the overall structure of the forefoot and the flexibility or rigidity of the deformity.

Straightening of the toe via fusion of one of the joints or by removing a portion of bone from the toe can enable the toe to be straightened.

In more complex cases shortening of one or more metatarsal bones in the forefoot may be required to enable the toes to be straightened.


Ingrown Toenails (Onychocryptosis)

Ingrown toenails which are one of the most common foot complaints, occur when the nail plate aggravates the surrounding nail fold or skin. They can cause intense pain, redness and swelling, and can lead to infection.

It is most common in the big toe, but they can occur on any toe. Some of the more common causes for ingrown toenails to develop are: trauma or injury to the nail; the structural shape of the toe or nail; poor cutting technique; and ill-fitting footwear.

Surgical management of ingrown toenails is aimed at providing permanent resolution of the ingrown toenail. The most common procedures performed for the management of ingrown toenails includes removing a small portion of nail (partial nail avulsion) and cauterisation of the nail root, or via excision of the nail and nail root with stitches.

Morton’s Neuroma

A neuroma is a painful and thickened nerve. This occurs when scar tissue (fibrosis) is formed around a nerve. This process can occur anywhere in the body, including the foot. The most common neuroma of the foot occurs in the webspace between the third and fourth toes (termed Morton’s neuroma).

Neuromas can form elsewhere, for instance, in the webspace between the second and third toes. The thickened nerve is considered to be a result of compression and continual irritation to the nerve.

Symptoms associated with neuromas include tingling, burning, numbness or sharp-shooting pain into the toes. Additionally, some people feel as if there is something in the ball of their foot, as if they are “walking on a pebble”.

Commonly, a swelling of a bursa, termed bursitis, occurs overlying a thickened nerve in the webspace. It is not uncommon that this bursitis is more symptomatic than the actual thickened nerve.

Treatment for a Morton’s Neuroma (and accompanying bursitis) includes wearing capacious shoes with a square toe box. This relieves the compression on the forefoot and pressure on the thickened nerve and bursa.

Injection therapy can result in significant symptomatic improvement, when combined with footwear and activity changes. Injection therapy includes a range of medicines from plain local anaesthetic to corticosteroid or sclerosing alcohol injections. Single or multiple local anaesthetic injections can afford significant early relief of the symptoms of bursitis through laceration of the bursa and stretching of the tissue around the neuroma.

Surgical management of an intermetatarsal neuroma involves removal of the neuroma (and affected nerve) from the webspace of the foot. Alternatively, the nerve can be released, whereby the ligamentous tissue overlying the nerve is cut, similar to decompression of carpal tunnel syndrome in the wrist.

Padding or orthotic devices can redistribute pressure from the affected webspace. Activity modifications to avoid repetitive pressure on the forefoot and medications such as non steroidal anti-inflammatories can help with the symptomatic relief of pain.


Plantar Plate Injury

The plantar plate (syn. flexor plate) is a specialised ligament that is composed of fibrous tissue and cartilage. It is the main stabilising ligament of the joints in the ball of the foot (i.e. where the toes meet the foot) and functions like a ‘pad’. Injury to the plantar plate can be caused by tripping or hyper-extending the toes, but occurs more commonly when the ball of the foot is subjected to daily repetitive weight bearing pressure or overload. This causes attrition of this specialised ligament and eventual tearing. Certain foot types and occupational duties can lead to a gradual overload and rupture of the plantar plate(s). Injury or attrition of the plantar plate is a common cause of hammertoe deformity.

Patients often describe a ‘lump’ or bruise-type discomfort under the ball of the foot (usually under the second digit). It typically becomes worse with prolonged weight bearing and is relieved with rest. Mild swelling may be present, both underneath and on top of the foot. Patients may also notice the second digit gradually moving up or out of alignment.

Depending on the severity of injury, treatment can include rest, massage, padding and strapping. Strapping is considered an important part of treatment. A 6-8 week course of toe-strapping can reduce the severity of hammertoe deformity. Strapping will hold the respective toe in an appropriate position and allow the damaged plantar plate to heal (this process is not unlike strapping of the ankle after ankle ligament injury). Furthermore, orthotics may be required to address foot function causes. In rare cases, walking boots may be considered.

Surgical management of plantar plate injury is varied. Direct repair of the plantar plate (sewing the torn ligament ends together) can be performed. However, a torn plantar plate is often associated with hammertoe deformity and other foot structural problems, such as long metatarsals (these are bones in the fore foot), which commonly need to be corrected to prevent recurrent plantar plate injury from occurring.