Damage to the articular cartilage between the tibia and the ankle bone can be the result of trauma, overload, or a deviation of the position of the foot or ankle. In some cases, it can develop spontaneously as a result of the natural aging process, however, this is less frequent compared to the hip or knee.
Characteristic is the pain that progressively increases over the years. It especially bothers you while walking, and gradually you can walk less and less. Often, we also see swelling around the ankle. The ankle also becomes stiffer.
A classic X-ray helps to assess the severity of the condition. Additional investigations such as CT scans, bone scans, and MRIs are often needed.
In general, the first step in treatment consists of painkillers or anti-inflammatories combined with good supportive footwear and adjustment of activities. Arch support can help with a deviation in posture. In later stages, infiltration into the joint may provide a solution. When insufficient control over the complaints is obtained using these conservative treatments, surgery is sometimes necessary. This can consist of an arthroscopic debridement (with keyhole surgery), a corrective osteotomy or securing the ankle, or placing a prosthesis. Your orthopedic surgeon will discuss the options with you.
Heel Spurs – Plantar Fasciitis
Heel spurs are inflammation of the tendon of the sole. This gives stabbing pain at the bottom of the heel, often with the first steps. Over time, the symptoms improve, but usually, the pain returns by the end of the day. The triggering factor can be standing or walking for a long time, new footwear, or being overweight, but it is not always obvious.
Heel spurs are a clinical diagnosis. Additional ultrasound and radiography can provide additional information and rule out other pathology but is not always necessary.
The treatment focuses on stretching the sole and the Achilles tendon. This stretching is done with the help of orthotics and physiotherapy. In addition, a night splint may be prescribed. Walking barefoot is not recommended.
The next step consists of corticoid injections into the inflamed tendon attachment. Shockwave therapy can help in certain cases. Rarely is surgery required?
With hammertoes, there is a certain curvature in the smaller toes. This can be flexible, passively straightening the toe, or it can be rigidly curved. It is often caused by an insufficiency of the transverse vault (spreading foot), whether or not combined with a hallux valgus.
A radiographic recording is not always necessary for diagnostic purposes.
The first step in the policy consists of adjusting footwear in combination with arch support in which the transverse vault is restored. Optionally with silicone toe caps.
If this does not sufficiently improve the symptoms, surgery is often necessary. There are various options for this, depending on the flexibility and possible deviations in the other toes.
Your orthopedic surgeon will discuss the options with you.
Forefoot Pain – Metatarsalgia
Forefoot pain or pain under the ‘ball of the foot can have various causes. However, in most cases, the complaints are the result of a sagging transverse arch of the foot. As a result, a splay foot develops, in which the heads of the metatarsal bones are overloaded. The reason why people develop a splay foot is not always known. This can be a result of standing for a long time, being overweight, weakening the foot ligaments, or the context of rheumatic diseases. As a result of this overload, calluses form in this place on the sole.
The complaints can often be brought under control by wearing orthotics with a metatarsal pad, in which the transverse vault is corrected. In exceptional cases, surgery should be performed.
If the complaints persist despite adapted orthotics, sometimes further diagnosis with specific imaging has to be done.
Misalignment of the big toe – Hallux valgus
In hallux valgus, the metatarsal bone of the big toe grows inward and the toe itself points toward the little toes. This creates a lump (bunion) on the inside of the foot. It is often this nodule that first causes complaints, especially in shoes that are too narrow, which cause pressure and friction over this nodule. After prolonged irritation, it can become inflamed with more pain and redness. Over time, a deformity of the other toes (eg hammertoes) can occur, with pain both on the toes and under the ball of the foot. The cause is unknown. However, this condition is seen more often in women, with flat feet, who wear high heels. There is a family predisposition.
A standing X-ray of the foot determines the severity of the deformity and is especially necessary if surgery is necessary.
In mild or moderate cases, modified shoes (wider toe box, which reduces pressure on the lump) with arch supports will be tried first. This is to get the complaints under control as well as slow down the progression.
In severe cases or when non-surgical measures do not help, surgery is necessary. This procedure can consist of straightening or securing the toe.
When surgery poses too many risks for the patient or when he does not want surgery, orthopedic shoes can be an alternative solution.
Hollow feet – Pes cavus
In hollow feet, there is an elevation of the middle arch of the foot. This limits the load on the foot to the heel and forefoot. It is about these zones of too high pressure that complaints arise. This can be accompanied by claw toes or pain on the outside of the ankle or foot as a result of a deviation of the heel bone, where the heel is too much outward.
Hollow feet are often hereditary. In some cases, hollow feet occur in the context of neurological disorders such as muscle diseases, spinal cord disorders, or paralysis.
In some cases, an X-ray of the foot is necessary. If an underlying neurological abnormality is suspected, an EMG examination will be requested.
Arch supports can increase the support surface and thus relieve the areas of overpressure. Sometimes orthopedic shoes are necessary.
In severe conditions, a surgical correction of the foot can be made to increase the support surface and stabilize the foot. The surgical procedure can range from tendon transfers, Achilles tendon lengthening, osteotomy (bone cutting and straightening) to arthrodesis (joint securing).
Flat feet – Pes Planus
With flat feet, there is a flattening of the arch of the foot, so that the inside of the foot partly or completely rests on the ground. With a flexible flat foot, the arch of the foot will correct itself when you stand on the toes, in contrast to a stiff flat foot. Flexible flat feet are the most common and often familial. Stiff flat feet are often caused by a congenital abnormality, such as deformities of the hindfoot bones, but these can also be the result of longer existing flat feet (developing arthrosis, tendon insufficiency, etc). A shortened Achilles tendon reinforces the flat foot deformity.
Flat feet do not always cause complaints. Sometimes there is a feeling of fatigue or pain on the inside or outside of the foot or ankle
In case of complaints, a standing X-ray examination of the foot should be performed.
In most cases, treatment with orthotics and adapted shoes is indicated. Learning Achilles tendon stretches is recommended.
Severe flat feet or stiff flat feet require surgical treatment to stabilize the foot. The procedure used depends on the underlying cause and extent of the injuries. This can range from tendon transfers, Achilles tendon lengthening, osteotomy (cutting and straightening the bone) to arthrodesis (fixing joints).
However, when the patient does not want surgery or there are too many risks of complications, orthopedic shoes can be a worthy alternative in some cases.
Stiff big toe – Hallux rigidus
Stiffening of the big toe is caused by osteoarthritis in the joint at the base of the toe. Due to wear and tear, whether or not after trauma or inflammation, or gout, the cartilage becomes thinner and extra bone is created around the joint, making the toe less mobile.
This causes problems with rolling off when walking, it is more difficult to wear higher heels, and painful lumps due to the extra bone growth.
We can determine how extensive the deviation is on a standing X-ray of the foot.
The first step in treatment consists of adjusting footwear and arch supports. If this does not provide sufficient improvement of the complaints, surgery will be performed. The orthopedic surgeon will decide based on the damage to the joint whether only the extra bone growth should be removed or whether the toe should be secured.
A Morton neuroma is an inflammation of the nerve between 2 metatarsal bones that arises as a result of a long-term entrapment. This causes a thickening of the nerve. Usually, the bugles are located between the 3rd and 4th toes. It is much more common in women because the inflammation is often caused by pressure on the nerve after wearing shoes that are too narrow or too high.
Typically, this gives e and sharp pain over the forefoot that subsides as soon as you take off the shoe and walk barefoot. Often this also gives pain and tingling or numbness to the toes.
The diagnosis is based on the story and the clinic where a painful ‘click’ is often felt when the forefoot is pinched. Additionally, an ultrasound or MRI scan can confirm the diagnosis.
Adjusting the footwear combined with arch supports so that the transverse vault is restored and the space between the metatarsal bones is enlarged so that there is less pressure on the thickened nerve is often sufficient. In some cases, an injection is necessary to get the inflammation under control.
If these conservative treatments do not provide solutions, surgery to remove the thickened nerve may be a permanent solution. This makes both toes partially numb, but the pain has disappeared. The rehabilitation of such an operation mainly consists of wound care, high quality, and rest for 2 weeks.
Ingrown Toenail – Onychocryptosis
An ingrown toenail mainly occurs on the big toe. However, it can occur on the smaller toes, but this is rather rare. The nail has grown into the skin and causes complaints there. Initially, this is when wearing narrow footwear, but this can also be done when walking barefoot. This ingrowth can be complicated by an infection.
The cause is not always known. Footwear that is too tight, the nails are cut too short or rounded, the general shape of the nail, deviation of the foot, etc. We often see this in adolescents, possibly because their nails are thinner because they grow faster.
A chiropodist or podiatrist can often prevent or initially treat the problem. However, if an infection develops, antibiotics should be started in combination with chloramine baths. Recurrent ingrowth of the nail sometimes requires surgery. During this procedure, the edge of the nail is removed together with the nail matrix (growth zone). This causes a permanent narrowing of the nail. In only very exceptional cases, the nail should be removed completely with the nail bed and nail root.
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