+ Limb Malalignment

Malalignment of the lower limb can be present since childhood or can be acquired due to a fracture which has healed in a mal-aligned position. Degenerative (wear and tear) changes in the knee joint can also contribute to the deformity.

Deformities include abnormal angulation when viewed from the front or the side, abnormal rotation in the axis of the bone (torsion), and a discrepancy in length of the bone. Malalignment can lead to problems with function, or result in an uneven distribution of load through the joints.

LIMB REALIGNMENT FOLLOWING TRAUMA

Limb malalignment after severe lower limb trauma is often multiplanar (made up of a combination of angulation in different planes, rotation, length discrepancy and translation). Minor deformity is amenable to non-operative treatment with physiotherapy, activity modification and the use of specialist footwear including heel raises. If there is malalignment causing problems which are refractory to non-operative management then surgery may be indicated.

KNEE REALIGNMENT

Sometimes in individuals who are bow-legged, as a consequence of uneven load distribution, there may be arthritis affecting the inner (medial) side of the knee joint whilst the outer (lateral) side has much lower loads passing through it and the cartilage is unaffected. Wear on the cartilage in the medial compartment can exacerbate bow-legged (varus) malalignment and result in further loading of the inner (medial) side. The converse is true in some individuals who have knock-knees (valgus deformity).

By realigning the knee joint the body weight is shifted away from the damaged side, onto the healthy side. This relieves the pain that is due to arthritis in the knee by offloading the damaged side and can delay the need for knee replacement in young active individuals.

Osteotomy can also help with symptoms of instability: By altering the slope of the tibia it is possible to reduce the dependence of the knee on the anterior or posterior cruciate ligament.

+ Complex deformity correction

WHAT IS THIS PROCEDURE?

After a major injury the broken bones sometimes heal in a less-than-perfect position. This can lead to deformity of the leg, for example a shortened leg (leg length discrepancy). Sometimes this does not lead to symptoms but sometimes it can be difficult to walk normally, or there can be joint pain.

Often as well as the break in the bone, there is significant damage to the skin, muscle and other soft tissues. Attempting to perform an osteotomy (cut in the bone) and plate fixation in such cases could result in inadequate correction of alignment, stretching of the nerves, wound breakdown and deep infection. In this situation, the deformity can be corrected by performing an osteotomy (cut in the bone) and using a frame to externally fix the fracture. The external fixation consists of a combination of pins going into the bone and tight wires which pass through the bone, typically attached to a series of rings around the outside of the leg. The rings are then held in position by rods running between them to make a rigid frame on the outside of the leg. If the amount of deformity is too large to correct in one go, then the rods can be adjusted to gradually correct the deformity, giving time for the nerves, muscles and other soft tissues to elongate. Often the frame will need to stay on for 4-6 months whilst the deformity is corrected gradually.

WHO SHOULD CONSIDER THIS OPERATION?

This operation may be of benefit if you malalignment of the lower limb and experience symptoms which are refractory to non-operative management. Good bone healing is important for this operation to be successful so if you smoke you are strongly advised to quit.

PREOPERATIVE PREPARATION AND EVALUATION

A full history and examination is required along with investigations to make the diagnosis and identify any other complications such as infection or nonunion (where the fracture has not healed). Full leg length, weight bearing X-rays allow the overall limb alignment to be assessed. CT or MRI scanning is a useful adjunct to physical examination if there is a rotational component to the deformity.

WHAT HAPPENS IN THE POST-OPERATIVE PERIOD?

After surgery you will be taught how to care for your leg whilst it is in the frame, including how to keep the pin-sites (where the wires or pins enter through the skin) clean. Full weight bearing is encouraged wherever possible to stimulate bone healing. If deformity correction is to take place gradually over several months, either you or a member of your family may be required to make gradual adjustments to the frame. If this is the case, written instructions will be provided. It is very common to have some inflammation around the pin sites and sometimes a course of antibiotics is required if the skin becomes infected. When the time comes for the frame to be removed, this is usually done as a day-case procedure under general anaesthetic.

+ Problem fractures

WHAT IS THIS PROCEDURE?

Lower limb fractures often require surgery in order to restore the alignment of the bones, promote healing and allow mobilisation. Sometimes ‘internal fixation’ (using a plate and/or screws or nail down the middle of the bone) is a good option but in some cases it is not ideal. For example if there is a severe injury to the skin and muscles around the fracture site there is a risk that a plate and screws would get infected. In this case ‘external fixation’ also known as a ‘frame’ might be recommended.

WHO SHOULD CONSIDER THIS OPERATION?

This procedure may be recommended as a first line treatment if the fracture you have sustained is more amenable to fixation with a frame than by other methods. This can include fractures with multiple fragments of bone as well as those with a severe soft tissue injury. Frame fixation can also be used where other methods have failed, for example in a fracture that has previously been plated but has not healed or has an infection.

WHAT HAPPENS IN THE POST-OPERATIVE PERIOD?

After surgery you will be taught how to care for your leg whilst it is in the frame, including how to keep the pin-sites (where the wires or pins enter through the skin) clean. Full weight bearing is encouraged wherever possible to stimulate bone healing. It is very common to have some inflammation around the pin sites and sometimes a course of antibiotics is required if the skin becomes infected. When the time comes for the frame to be removed, this is usually done as a day-case procedure under general anaesthetic.

+ Ankle distraction arthroplasty

WHAT IS DISTRACTION ANKLE ARTHROPLASTY?

Distraction ankle arthroplasty is a treatment option for ankle arthritis. A cage is put on the leg in order to stretch the ankle apart. By stretching the ankle apart by even a small amount, the cartilage cells of the ankle are rested and may start to form the critical type of cartilage required to correctly lubricate the joint.

It has been proven both in the laboratory and with patients that when the joint is stretched and weight is applied to the leg at the same time that the cartilage improves. This has a lot to do with the biology of the cartilage cells.

HOW IS A DISTRACTION ANKLE ARTHROPLASTY PERFORMED?

Prior to performing a distraction ankle arthroplasty, the ankle joint first needs to be cleaned out with a minor surgery called arthroscopy where small loose fragments, bone spurs and inflamed tissue inside the ankle are removed.

Either during the arthroscopy or a few weeks later, the cage (called an external fixator) is applied to the leg. This circular cage or a set of rings on the foot and leg allows the ankle to be stretched apart. The ankle is stretched only about 5mm (less than a quarter of an inch). The fixator device is left on the ankle for about 10 weeks.

During the time that the external fixator is on the ankle, the patient is encouraged to walk on the leg as much as possible to stimulate the cartilage. Initially, this is painful, but by about one week is tolerated quite well. Once the fixator is removed, physical therapy and exercises are very important to try to regain as much movement of the ankle as possible.

The ankle remains quite uncomfortable for about six months, but by one year, 80% of patients notice a significant improvement in pain in the ankle.

WHO SHOULD RECEIVE A DISTRACTION ANKLE ARTHROPLASTY?

The ideal patient for a distraction ankle arthroplasty is someone with:

• Advanced ankle arthritis
• Good alignment of the foot under the leg
• Not much deformity of the ankle
• A total ankle replacement most likely would be recommended for patients over the age of 50.

WHEN IS THE DISTRACTION ARTHROPLASTY THE BEST OPTION?

A distraction ankle arthroplasty is a one of the best treatment options when a fusion of the ankle joint in a younger patient is trying to be avoided.

+ Bone infection

Osteomyelitis is painful infection of the bone that can affect anyone. It's more common after a recent fracture, especially if you needed pins in your bone, if you have an artificial hip, or if you've had surgery or osteomyelitis before. A severely weakened immune system, diabetes or close contact with tuberculosis can also make it more likely.

If you have osteomyelitis, you are likely to experience pain, swelling, redness or a warm feeling around an area of bone. You usually feel it in the long bones of your legs. This may be combined with a high temperature or fever, although less so in young children. You should be especially aware of these symptoms if you've had osteomyelitis before.

If you have osteomyelitis, your consultant will prescribe you antibiotics, usually for at least six weeks. If the infection is severe, you may have to stay in hospital to have antibiotics intravenously, which is when they are given directly into your vein. In some cases, you may need surgery. This could be to remove bone damaged by the infection, to prevent possible deformity or to relieve pressure on the spinal cord.

+ Limb Lengthening

Following trauma, bones can heal in a shortened and deformed position (mal-union). Sometimes the bone can even remain unhealed (non-union). Limb lengthening procedures address all of these issues. We have been able to successfully correct large deformities and equalize limbs with discrepancies of several inches. A segment of bone can be missing after a bone tumor, bone infection or severe fracture. We can transport new bone to fill in this defect.

Limb lengthening is possible and has been performed successfully for about 50 years in Kurgan, Russia. Gavriil A. Ilizarov developed the concept in 1951 after seeing many WWII veterans who had leg fractures that had not healed (non-unions).

Ilizarov first developed an external fixation frame that was placed around the leg. Knowing that compression of the fracture would help stimulate bone healing, he built a frame that had this capacity. He instructed a patient to gradually compress the non-union by turning a rod. However, the patient turned the rod the wrong way and caused distraction (separation) of the fracture. Ilizarov noticed that new bone had formed in the gap between the bone ends. This was the beginning of much research and development that showed that limb lengthening was possible, safe and effective.

Ilizarov and his colleagues performed thousands of limb lengthening procedures in Kurgan, Russia. Russian politics, however, made education and communication with the Western world very difficult. Finally, Italian surgeons started performing and improving the procedure in the early 1980s and a large center soon developed in Lecco, Italy.

The regenerated bone is normal and does not wear out. The muscles, nerves and blood vessels grow in response to the slow stretch like they do during a growth spurt or in pregnancy. The actual procedure is minimally invasive and requires only one or two nights in the hospital. Patients aren't in much pain since the distraction is so gradual and patients can continue to walk during the treatment.

Children and adults can be appropriate candidates for the procedure. Children with congenital deformities such as fibular hemimelia, congenital short femur and hemiatrophy will often have unequal leg length and this may be associated with deformity. Many adults have had this condition since childhood and have developed back pain and hip arthritis from the leg length discrepancy. Growth plate fractures and bone infections in children can cause stunting of growth that results in discrepancy.

Following trauma, bones can heal in a shortened and deformed position (mal-union). Sometimes the bone can even remain unhealed (non-union). Limb lengthening procedures address all of these issues. We have been able to successfully correct large deformities and equalize limbs with discrepancies of several inches. A segment of bone can be missing after a bone tumor, bone infection or severe fracture. We can transport new bone to fill in this defect.

Short stature can be very disabling in patients with dwarfism, for example. We can lengthen both legs simultaneously to increase stature.

Young adult patients with leg deformities are at risk for developing arthritis as a result of their malalignment. These same techniques can be used to correct severe deformities safely and avert the need for joint replacement.

These procedures can be performed with ilizarov frames, monolateral frames or more recently, with lengthening nails such as the PRECICE STRYDE nail.

+ Heel Pain

Symptoms

The underneath of the heel, towards the inner side, is where the pain of plantar fasciitis (Policeman’s heel) is commonly felt. It may start gradually or come after injury or overuse. Ten percent of people get this at some stage in their life, and notice that they hobble on rising from bed, but then warm up. The pain may return after prolonged standing or walking. Sometimes the pain is further down the arch.

Treatment

Most patients with plantar fasciitis that persists for more than a few weeks are helped by the right sort of Physio stretches – for the calf and for the toe/arch. Stubborn cases (more than a few months) require careful assessment, often an ultrasound scan and then the right treatment can be selected. Shockwave therapy is highly beneficial in most cases. The exception tends to be where an overly tight calf muscle is causing extra strain on the foot all the time. A small calf release operation may therefore be recommended if diligent stretching does not improve symptoms. Expert assessment and, if needed, an ultrasound scan, is available all in one visit via our unique One Stop Heel Pain Clinic.

+ Achilles pain / swelling

Symptoms

The large Achilles’ tendon, at the back of your heel, can tear suddenly or become painful, stiff and swollen. Usually this is just above the heel bone, but where the tendon joins the bone it can also be painful. Patients often feel “30 years older than their years” when first walking in the morning or after prolonged rest.

Treatment

Most patients with a grumbling Achilles complaint are helped by the right sort of Physio stretches, called Eccentric Loading. Stubborn cases (more than a few months) require careful assessment, often an ultrasound or MRI scan and then the right form of therapy can be selected. Injection prolotherapy, Shockwave and high volume injections are all available through our unique One Stop Heel Pain Clinic where we offer assessment, scan and (often) treatment all in one visit.

+ Achilles tendon rupture

Symptoms

Ruptured Achilles tendon is a condition that usually affects people in their mid-thirties/forties. It is particularly prevalent in sports people, both unconditioned and elite athletes. The rupture usually occurs during activity without warning. A loud snap may be heard. People can still walk and move the ankle, which may confuse A&E staff.

Treatment

Treatment is either with a plaster and crutches or with an operation. The benefits of an operation include a lower rate of re-rupture and the opportunity to re-tension the tendon. However, patients need to consider the risks involved with surgery. Any delay in diagnosis or casting may mean that an operation is required, rather than optional, so prompt and expert assessment is recommended.

+ Peroneal tendinopathy/subluxation

Symptoms

Through wear and tear, or repeated sprains, the tendons passing behind the outside of the ankle and heel can split, fray or slip out of place. This causes pain, swelling and difficulty walking. Increasing sporting activities or training can cause the condition. Skiers are frequently affected (overuse with “edging”) and people with naturally high arches are also prone to peroneal tendon wear and tear.

Treatment

Treatment options include modifying or reducing sports, and physiotherapy. Orthotics to correct the foot posture or even an ankle sports splint may be beneficial. Sometime surgery to tidy up (debride) the damage is needed. The tendons run in a tunnel and are kept there by a special ligament (the retinaculum), which is like a seatbelt holding them in place. If the “seatbelt” has been damaged then the tendons may pop out from behind the bone or click, by dislocating. An operation is usually advised to repair the retinaculum in this situation because natural healing is generally poor. After surgery the ankle is placed in a plaster cast for 6-8 weeks before physiotherapy is commenced.

+ Tendonitis

Symptoms

Tendons are “sinews” running from the end of muscles to bones. They act as a rope on which the muscle pulls to move the bone. (Ligaments are similar but are to hold 2 bones together, and so do not have a muscle on one end). Injury or wear and tear to a tendon can cause pain, swelling, redness and walking problems. Sometimes this may be misdiagnosed as a skin infection (cellulitis). Typical causes are wearing incorrect sports footwear (training errors) and being ill-prepared for a particularly intensive training programme (overtraining).

Treatment

A scan such as an ultrasound or an MRI is useful for confirming the diagnosis and assessing the severity. Activity modification and physiotherapy can help but recovery is often slow. Some patients may be suitable for targeted tendon injections.

+ Heel spurs

Heel spurs can occur on the back of the heel where they are part of a combination of problems arising where the Achilles tendon meets the heel bone. Spurs under the heel are often blamed for “policeman’s heel”, another name for plantar fasciitis, but this is really a problem with the ligament that supports the arch of your instep.

The ligament and tendon problems near these spurs can be difficult to resolve without a proper assessment and accurate diagnosis. Our specialist Heel Pain Clinic has unrivalled expertise in this field.

+ Ankle pain persisting after sprain

Symptoms

Forty percent of patients do not recover properly after an ankle sprain. Pain, swelling, stiffness or the ankle collapsing are the common problems that can persist, even months after an injury. Proper assessment at the time of injury minimises the risk of problems later on. X-rays to rule out a fracture and then Physio treatment are important at an early stage. Where recovery is incomplete an expert assessment will reveal whether there is an undiagnosed fracture, damage to the surface of the ankle bone, tendon problems or chronic loosening of the ligaments. Most of these conditions can be improved on with further physiotherapy or (less often) surgery, once a proper diagnosis is reached.

Treatment

Enough of the right sort of physiotherapy helps many patients where recovery is slow. A proper ankle support brace may facilitate a return to sport. Where surgery is required it is usually with keyhole methods, and with very worthwhile results.

+ Achilles Problems

Symptoms

The large Achilles’ tendon, at the back of your heel, can tear suddenly or become painful, stiff and swollen. Usually this is just above the heel bone, but where the tendon joins the bone can also be painful. Patients often feel “30 years older than their years” when first walking in the morning or when starting up after prolonged rest.

Treatment

Most patients with a grumbling Achilles complaint are helped by the right sort of Physio stretches, called Eccentric Loading. Slant board exercises are also extremely beneficial. Stubborn cases require careful assessment, an ultrasound or MRI scan and then the right form of therapy can be selected. Injection prolotherapy, Shockwave and high volume injections are all available through our unique One Stop Heel Pain Clinic where we offer assessment, scan and (often) treatment all in one visit.

+ Posterior ankle impingement (including Os Trigonum)

Symptoms

Posterior ankle impingement is a pinching pain that typically affects people involved in activities like dancing and windsurfing. At the back of the ankle joint and in front of the Achilles tendon is a natural spur of bone. Damaging or injuring this bone can cause the foot to hurt when pointing the toes downwards. Some people also have an extra bone at the end of this spur, called the os trigonum.

Treatment

Treatment options include: physiotherapy, selective X-ray guided joint injections, an operation called posterior hindfoot endoscopy (keyhole surgery to remove the spur/extra bone) or simply limiting activities that exacerbate the condition.

+ Anterior ankle impingement

Symptoms

Anterior ankle impingement is when soft tissue inflammation and/or scar tissue in the front of the ankle joint is ‘pinched’ by the joint when the foot is flexed upwards (as when squatting down) causing pain. This can also be caused by spurs of bone which develop across the front of the ankle joint after repeated minor injuries. This is called “Footballer’s ankle”. Wear and tear (very early osteoarthritis) is often the cause of these spurs, however, sporting activities can also play a part. The spurs can be painful, particularly when the foot bends upwards, for example, when walking uphill.

Treatment

Treatment options include injections to settle scar tissue around the spurs, or surgery to remove the spurs – an ankle arthroscopy using keyhole surgery. However, occasionally large spurs require a surgical procedure called an open cheilectomy. Regrowth of spurs is extremely slow.

+ Peroneal tendinopathy/subluxation

Symptoms

Through wear and tear or repeated sprains, the tendons passing behind the outside of the ankle and heel can split, fray or slip. This causes pain, swelling and even difficulty walking. Increasing sporting activities or training can cause the condition.

Treatment

Treatment options include modifying or reducing sports, physiotherapy. Sometime surgery to tidy up (debridement) the damage is needed. The tendons run in a tunnel and are kept there by the retinaculum, which is like a seatbelt holding them in place. If the “seatbelt” has been damaged then the tendons may pop out from behind the bone or click, by dislocating. An operation is usually advised to repair this because natural healing is generally poor. After surgery the ankle is placed in a plaster cast for 6 weeks before physiotherapy is commenced.

+ Subtalar joint osteoarthritis

Symptoms

The subtalar joint is just below the ankle joint. It is the joint that allows the foot move from side to side, and is especially important when walking on uneven ground like cobblestones. It can develop arthritis, causing pain usually felt on the outerside of the ankle.

Treatment

While symptoms may improve with time, anti-inflammatory painkillers, physiotherapy and selective X-ray guided joint injections can all be helpful.

If these treatments are unsuccessful, a subtalar joint fusion operation (arthrodesis) welds the joint shut and is an excellent way of abolishing pain. Recovery is, however, very long and so surgery like this – although very effective – is a last resort.

+ Ruptured Achilles tendon

Symptoms

Ruptured Achilles tendon is a condition that usually affects people in their mid-thirties/forties. It is particularly prevalent in sports people, both unconditioned and elite athletes. The rupture usually occurs during activity without warning. A loud snap may be heard. People can still walk and move the ankle, which may confuse A&E staff.

Treatment

Treatment is either with a plaster and crutches or with an operation. The benefits of an operation include a lower rate of re-rupture and the opportunity to re-tension the tendon. However, patients need to consider the risks involved with surgery. Any delay in diagnosis or casting may mean that an operation is required, rather than optional, so prompt and expert assessment is recommended.

+ Tendonitis

Symptoms

Tendons are sinews running from the end of muscles to bones. They act as a rope on which the muscle pulls to move the bone. Injury or wear and tear can inflame the tendons causing pain, swelling redness and walking problems. Sometimes it is misdiagnosed as a skin infection (cellulitis). Typical causes are wearing incorrect sports footwear (training errors) and being ill-prepared for a particularly intensive training programme (overtraining).

Treatment

A scan such as an ultrasound or an MRI is useful for confirming the diagnosis and assessing the severity. Activity modification and physiotherapy can help but recovery is often slow. Some patients may be suitable for targeted tendon injections.

+ Traction periostitis - Shin Splints

Symptoms

Inflammation of the fibres attaching muscles to the edge of bones in the leg can cause pain along the shin. We often diagnose this condition without tests, however, scans may occasionally prove useful. The condition is related to athletic activity and may be brought on by a sudden change in shoes or training regime.

Treatment

Treatment options include rest, avoiding sporting activity and rehabilitation with physiotherapy. Abnormal foot posture needs to be identified and sometimes corrected with appropriate orthotics. During our assessment we also typically check for chronic compartment syndrome and stress fractures.

+ Chronic compartment syndrome – Shin Splints

Symptoms

TShin pain during sporting activities is known as shin splints. Two of the commonest causes are traction periostitis and exercise-induced compartment syndrome. The former is felt along the inside edge of the shin bone and aches for a while after stopping the activity. The latter causes cramp-like calf or shin pains at a predictable running distance or time, which tend to improve fairly quickly upon stopping.

Shin pains which occur suddenly and persist, preventing any further participation in the sport, might indicate a hairline stress fracture through the shin bone (tibia).

Chronic compartment syndrome is due to activity related muscle swelling causing the muscle to become tight beneath the tough fascia (a layer of gristle beneath the skin) causing shin pain. We may diagnose the condition without tests however, specialist testing equipment to measure the pressure in the muscle is useful if there is any uncertainty.

Treatment

When assessing shin pains it is important to consider every possible cause and make a precise diagnosis. For example, a slipped disc or arthritic spur in the spine resulting in pressure on the nerves (radiculopathy) and sciatica in the leg, perhaps with little or no pain in the back itself, is a potential “catch”. Careful clinical examination and tests will provide the answer.

If moderating activities, physiotherapy and/or orthotics are unsuccessful in alleviating the symptoms then occasionally surgery is needed and can provide excellent relief. Results are best when a firm diagnosis has been established.

+ Bunions

Symptoms

A swelling at the base of the big toe, associated with the toe leaning towards its neighbour, is commonly called a bunion. The lump may be painful, and makes shoe-fitting problematic. Furthermore, the toe is weak and so the smaller toes have to work harder. Pain and/or curled up “hammer toes” may result. Eventually arthritis may develop at the big toe joint or in the middle of the foot.

Treatment

In certain cases advice about shoes and a discussion concerning the likely future for the foot allow surgery to be postponed or avoided altogether. Where surgery is required it is essential that the recovery time is not underestimated. Breaking and resetting the bone is extremely reliable and thanks to modern methods is not the painful ordeal that it once was but swelling takes a long time to resolve. Driving (unless the surgery is only on the left and the car automatic) is not advised for 6 weeks. In carefully selected cases foot surgery can be performed with keyhole operations, which carries potential short-term advantages.

+ Flat foot / flexible pes planus

Symptoms

Commonly known as ‘flat foot’, flexible pes planus affects many people and is often hereditary. Children under six nearly all have flat feet. However, provided they are flexible flat feet, this is usually not a problem, since they correct with growth. It is important to distinguish harmless flexible flat feet from other causes of flatfoot, which may be stiff and painful.

Treatment

Increasingly flat feet may indicate an underlying condition which requires treatment. As there may be many causes, only by fully assessing you can we recommend the most appropriate treatment or procedure.

+ Tarsal coalitions

Symptoms

The foot has many bones that begin to develop in the womb. Beginning as a single lump of cartilage, they separate into the various parts that constitute the foot. However, occasionally this natural process fails resulting in an abnormal connection between two foot bones. This causes a stiff flat foot. For many people, this does not cause pain or problems. However, should such individuals suffer, injury, pain and walking difficulties may arise in later years.

Treatment

Treatment options include physiotherapy, specialist insoles or occasionally, a period of casting. If these prove unsuccessful, removing the coalition will sometimes make the foot virtually normal. If there is joint damage then subtalar joint fusion may be needed. Our specialist team will advise you on the most appropriate treatment for you. Treatment options include physiotherapy, specialist insoles or occasionally, a period of casting. If these prove unsuccessful, removing the coalition will sometimes make the foot virtually normal. If there is joint damage then subtalar joint fusion may be needed. Our specialist team will advise you on the most appropriate treatment for you.

+ Midfoot osteoarthritis

Symptoms

Hard lumps on the top of the foot or base of the big toe are often ‘spurs’ at the edge of an arthritic joint. A pad of tissue (bursa) which develops to protect the area from shoe friction makes the bump seem even larger. Despite the arthritic change, the joint may not feel painful, and we therefore only need to remove the bumps. Alternatively, examination may reveal that the joint is causing some of the pain and our treatment must then address the bump and the joint arthritis.

Treatment

Lumps on the sole of the foot are often treated without surgery, as the scar can make walking painful and the lump may return.

Treatment options include supportive orthotic devices, physiotherapy, anti-inflammatory medicines, and selective X-ray guided joint injections. If these treatments are unsuccessful, we may consider fusion of midfoot joints. This provides good pain relief but carries a long recovery period.

+ Big toe sesamoid conditions

Symptoms

In the foot, the sesamoids comprise two bean-shaped bones that reinforce the tendons in the ball of the big toe (they are like miniature knee caps). Sometimes, these bones can become inflamed or damaged, causing pain and discomfort.

Treatment

Treatment options include rest, physiotherapy, specialist insoles, X-ray guided injections. Surgical removal of part or one of the the big toe sesamoids is only considered if all non-surgical treatments fail. Alternatively, if the sesamoid has thickened, we can reduce its size through sesamoid debulking/shaving.

+ Morton's Neuroma

Symptoms

Pain in the ball of the foot, often radiating into the central toes, may be due to swelling of the nerve between two adjacent toes. Often the symptoms are worse in closely fitting shoes. Swelling around the base of the toes is more usually associated with a stress fracture or formation of a hammer toe – and correctly diagnosing the cause of the problems is important for proper treatments to be chosen.

Treatment

Most cases can be managed by better shoes, insoles, physiotherapy and injections. In stubborn cases surgery gives very good results.

+ Morton's Neuroma

Symptoms

Pain in the ball of the foot, often radiating into the central toes, may be due to swelling of the nerve between two adjacent toes. Often the symptoms are worse in closely fitting shoes. Swelling around the base of the toes is more usually associated with a stress fracture or formation of a hammer toe – and correctly diagnosing the cause of the problems is important for proper treatments to be chosen.

Treatment

Most cases can be managed by better shoes, insoles, physiotherapy and injections. In stubborn cases surgery gives very good results.

+ Ingrown toenail

Symptoms

Ingrowing toenails can cause severe pain and even walking problems. Often the nail digs into the skin, causing irritation, swelling and infection.

Treatment

Chiropodists and podiatrists deal with most ingrowing toenails, treating skin swelling and infection by cleaning, padding and with antibiotics. The cause is often unclear. However, the cycle of the nail digging in, then infection with skin swelling which creates further digging in and swelling, can be difficult to break. Careful instruction on correct nail clipping and foot hygiene can reduce the chances of recurrence. The advice of a chiropodist or podiatrist should be sought on the correct technique of cutting toenails and they can also advise on attempting to encourage the nail to grow away from the skin edge.

Non-surgical treatment is always tried first. A short course of antibiotics may be needed to control infection and swelling. If symptoms are not cured in this way, it may be necessary to consider surgery.

When such measures fail, the nail is sometimes cut along the edge to prevent pressure on the skin. This simple “wedge resection” has usually been attempted before the patient is referred to us. More formal surgical methods involve excising the side of the nail and permanently removing the corresponding part of the nail bed and root from which the nail edge is growing. We can perform both by surgical excision (Winograd procedure) or by applying a chemical (phenolisation).

+ Fungal nail infection

Symptoms

Over time nails often discolour and thicken. While there is often no obvious cause, the nails can become infected. Usually this is because of a fungus. This can be difficult to eradicate and may spread to other nails.

Treatment

Chiropodists and family doctors usually deal with this condition and may test nail trimmings for fungus. Treatment usually involves prescribing anti-fungal medicines and ointments. Occasionally removing a nail is necessary. We then have to decide whether to “see what grows back” or try to prevent any regrowth at all by removing the nail root at the same time.

+ Onychogryphosis

Symptoms

When toenails curve over at the edges in a very exaggerated curve and difficulty with nail care is prevalent. There is usually no obvious cause for the deformity of the nail.

Treatment

A chiropodist can trim and shape the nail to alleviate pain and discomfort. If this is unsuccessful, we can recommend nail root ablation to remove the nail and prevent the condition returning.

+ Accessory navicular

Symptoms

There are usually 28 bones in the foot and ankle, but extra “accessory bones”, usually within tendons, are common. The accessory navicular bone is situated on the inside edge of the foot (near the apex of the arch) where it may protrude as a bump. In time, or through injury, this bone can become painful and rub against your shoes. As it is attached to a tendon, the condition can also cause a painful flat foot.

Treatment

Treatment options include insoles and physiotherapy. Sometimes an injection can be helpful either as a test, as a treatment or as both. If these strategies are unsuccessful we occasionally recommend removal of the accessory navicular and reattachment of the tendon (Kidner procedure).

+ Hammer toes and Clawed toes

Symptoms

Some people are born with clawed or curly toes while others develop them. In some children, clawed toes occur when the tendons underneath the digit, attaching to the tip, are a little too tight. With growth, the toes may straighten spontaneously. You should seek advice if a child’s normal toes become curled during growth – especially if the arches become deep and walking is affected. This is because abnormalities in the nerves of the spine are a rare but important cause of these toe changes.

Normal toes can become clawed later in life. This leads to pressure that feels as though there are pebbles under the ball of the foot. There may be a big toe problem that is the underlying cause of the toe clawing, because even a mild big toe problem causes you to lean over onto the outer part of the foot subconsciousl

Treatment

For treatment to be successful, the underlying cause must be identified and addressed. Insoles, physiotherapy and injections help over half of sufferers. Surgery successfully straightens toes, but at the expense of a degree of stiffness. Key-hole surgery methods can be very helpful with straightening smaller toes that are clawed.

+ Biomechanical problems

Symptoms

Feet come in a wide range of shapes and sizes. While these usually cause no problems, sometimes flat feet or deep (high) arches can be the cause of pain. Foot problems can lead to knee complaints too. A thorough assessment is required to check the whole lower limb.

Treatment

Following a thorough assessment of any underlying conditions, physiotherapy can often alleviate the symptoms. Orthotics to correct abnormal foot posture are sometimes required too. A tight calf muscle may be the principal problem, and in certain circumstances a minimally invasive operation is needed to address this (gastrocnemius muscle release).

+ Fractures and crutches

Many fractures in the ankle and foot are best treated with early rehabilitation. Crutches and casts may be useful in the early days after injury, but all too often recovery is then hampered by “hopping for too long”. Most ankle and metatarsal fractures, ligament sprains and the majority of tendon injuries recover faster and get back to sport sooner through walking on the injured leg and starting physiotherapy. Even when support is needed for the injury a modern “Airboot” or splint is lighter, more comfortable and more convenient than a cast.

+ Non-union of fracture

Symptoms

Most fractures heal with rest and time. However, occasionally, bones fail to rejoin, causing pain during activity. Often this is not clear on X-rays, and the problem is only revealed by a CT or MRI scan.

Treatment

For symptomatic patients an operation to remove the scar tissue, which is preventing the bone from healing, and to fix the fracture is recommended. A cast or boot is usually required until the bone has joined.