Watch this video of Mr James Walsh, Consultant Orthopaedic Surgeon specialising in the foot and ankle discussing ‘Foot and ankle surgical treatment update.’
This video was recorded as a part of SSC Online Public Information Meeting focusing on the Foot & Ankle.
Hi my name is James Walsh, I’m a consultant trauma and orthopaedic surgeon working in Beaumont and the National Orthopaedic Hospital in Kappa and I’ve been working in the Sports Surgery Clinic for the last seven or eight years now since 2015. My talk this evening is going to be a bit of a whistle-stop tour around the foot and ankle. We don’t want to get too much into the weeds on this, but just to augment what David’s been saying and hopefully add a few other conditions that we might talk about also. I’m going to talk about common conditions that we might operate on in foot and ankle surgery.
Just to give you an overview, we’re going to start off with ankle instability probably the most common thing that happens in foot and ankle surgery. We’re going to talk about classic sprains high ankle sprains which really refers to a thing called the syndesmosis that is explained in a few minutes. Then we’re going to move to the Achilles tendon and talk about tendinosis or inflammation of the achilles tendon. I’m going to talk about a thing you may not have heard of called the plantaris tendon and how much that causes a significant amount of apparent Achilles problems. I’m going to talk about achilles tendon tears. We’re then going to move to the posterior aspect of the back of the heel which is the source of a lot of pain for a lot of patients and we’re going to talk about that before moving deep into the actual ankle itself to talk about ankle impingement at the front and at the back and then talk about deep ankle degeneration or osteochondral defects. We’re going to talk about plantar fasciitis bunions or hallux valgus and then finish off with just a bit on big toe joint pain and then we’ll summarize our findings and there’ll be time for questions afterward.
So to start off ankle instability we all saw this recently at the French open Alexander Zverev had a severe ankle sprain and actually underwent surgery in Germany about two days ago for this injury. So you can see there’s a pretty extreme version of an ankle sprain but most of us have done this, we’ve all torn our lateral ligaments at some stage in our careers so I suppose the question is who needs treatment for this and what exactly is happening. Well this is a classic inversion injury and conservative management is the mainstay of treatment the vast majority of these people will never present to a surgeon and certainly never need surgery a ligament called the anterior talofibular ligament is the most commonly injured ligament here and that spans from the fibula to the talus and that’s why it’s called the anterior talofibular ligament. There’s other ones such as the calcaneofibular ligament and the posterior telophibular ligament but we don’t really need to worry about those. The anterior ligament is the one that’s most commonly torn and is the one that is most commonly a problem, so what do we need to do with these well in the initial phases the classic rest, ice compression, and elevation works very well for the vast majority of patients that refers to non-steroidal anti-inflammatory drugs so drugs such as diphen, vimovo, archoxia and basic analgesics such as paracetamol works really well I find a combination of oral anti-inflammatories and analgesics and topical anti-inflammatory gels works really well for the majority of patients. In terms of intermediate things in patients that aren’t really settling down acutely, well then physiotherapy is the mainstay of treatment for lateral ligament injuries. You can consider injection therapy if you need to but other adjuncts such as an air cast or brace I find really useful. I prefer these to the soft neoprene braces that you can buy in most pharmacies this brace is available online. It’s also called an Andy Murray brace because if you notice his ankles he wears them when he’s playing tennis and it’s a semi-rigid brace that comes in three different sizes and it’s side specific and it’s really useful to augment physiotherapy it doesn’t replace it of course but it’s a very useful thing to use for patients who have ongoing problems or aren’t getting over the line with physiotherapy.
So in terms of surgery if these modalities don’t work what can I do if a patient is sent to me by a physiotherapist or by their general practitioner, well if the above modalities haven’t worked then we’re going to perform an ankle arthroscopy and that’s where we make two small incisions at the front of the ankle usually under general anaesthesia and look inside the ankle with a camera and see and assess any joint problems if I need to stabilize the ligaments I’ll have to make an incision on the side of the ankle and then I’ll sew suture anchors which are metal anchors with some stitches coming out of them that I can use to stabilize the ligaments or I can use a product called an internal brace which is a much stronger construct and I’ll use that sometimes in patients who have really severe ligament injuries or in certain patients who aren’t suitable for just suture anchors.
So moving to a different part of the ankle this is called a high ankle sprain it’s a slightly different mechanism you can see from the injury we showed you previously when you roll or invert your ankle. You get one type of ligament injury this ligament injury is higher and it’s called a high ankle sprain and it’s between your tibia and your fibula and this is referred to as the syndesmosis which is the joint at the top of the ankle these can be a lot trickier to diagnose and the history is really important. You can see from this picture below there’s a tackle going on here and it’s a dorsiflexion or the ankle going upwards and rotating externally. This is the type of injury that will cause a synthesmatic injury, an x-ray can easily miss this and it’s actually more of a clinical or MRI diagnosis. If you’re in doubt we’ll sometimes have to put a camera in and just check anyway because these much more commonly need surgery than do a lateral ligament repair. What surgery can we do for them? Well, the most common thing again is we put a camera in an arthroscope and have a look inside the ankle and see if there’s any other pathology and then we can use a product called a tightrope which is a simple band with two buttons on it that brings these two bones together and repairs the ligament indirectly and it works really well in the vast majority of patients.
Who needs to see a surgeon if they’ve got a lateral ligament or ankle ligament injury? Well again as I said the vast majority of these patients never need an operation so it’s only for patients with ongoing instability despite non-operative modalities patients often say i just don’t trust my ankle, I’ve had physio for six – eight sessions and I still don’t trust my ankle. Ongoing pain, do they have high ankle pain? This is something that the physios would send to us quite regularly and do they have associated deep ankle pain because that could suggest to you that there’s something more sinister going on and that might prompt either a basic x-ray or indeed an MRI scan so moving to the back of the ankle to look at the Achilles tendon we’re all familiar with the Achilles tendon but it’s actually made up of a number of different muscles your gastrocnemius muscles the pear-shaped muscle of the back of your calf and your soleus muscle which is a bigger thicker muscle beneath that and they form together to form your achilles tendon you can’t talk about the achilles tendon without talking about the posterior chain or the posterior kinetic changes, we often refer to it and that goes from our gluteals, the biggest muscle in our bodies and our backside our gluteal muscles, then our hamstrings, then the gastrocelius complex. As we refer to those muscles as this then becomes the achilles tendon sweeps down the back of your heel to become your plantar fascia, so it’s all connected in one big long chain and we call it the posterior kinetic chain.
Why is that important? Well, it’s implicated in a whole heap of the ankle, hindfoot, midfoot and especially forefoot conditions in the foot macro and it can help us to treat or help to diagnose a lot of problems in these areas so we always think about this when we’re looking at it and especially with the achilles you need to think about this. So, achilles tendinosis or inflammation of the achilles again physiotherapy is the main state of treatment you can use an ultrasound-guided injection as an adjunct. You’ve got to be very careful in this region you don’t want to blindly inject it because you can cause problems with the tendon, this is what a more or less normal or slightly inflamed Achilles tendon looks like and this is what a much thicker or more inflamed Achilles tendon looks like, with these the vast majority of these do not require direct surgery for Achilles tendinosis those that do we often see a small area at the back and it’s on the middle or the inside of your Achilles tendon if you have Achilles tendinosis and you’ve got pain in your Achilles, if you palpate the middle side of your Achilles tendon this might be the most painful area and if this is the case it can often be this tendon called your plantaris tendon which is what we call an accessory tendon, it doesn’t really have any function you know so we’ve kind of evolved out of it essentially, it’s a very small and rather insignificant piece of anatomy but it causes a lot of irritation and if this doesn’t settle we can inject the area with a high volume of local anesthetic or we can debride it as a day case procedure and in patients with achilles tendinosis in this region this surgery works extremely well.
Moving to Achilles tendon tears, something a lot of patients with Achilles tendinosis are terrified they will get but actually only about three percent of people will rupture an Achilles tendinosis tendon. This usually presents as a sudden pain in the Achilles and despite popular belief that this is because you didn’t warm up it actually usually occurs right relatively late in the activity and rarely at the start of the activity. This needs urgent assessment if you think you’ve ruptured your Achilles tendon you shouldn’t wait around on this, if in doubt if you’re not sure it needs urgent soft tissue imaging the mistake to make here if you’ve had a sudden sharp pain at the back of your Achilles usually during activity don’t get an x-ray, an x-ray isn’t going to help you here an ultrasound or an MRI scan is the diagnostic imaging of choice but an experienced clinician being a physiotherapist primary care practitioner or an emergency department doctor should be able to diagnose this quite easily without any imaging.
So what can we do with these? Well, we can manage them non-operatively provided you catch them early and that’s why it’s important to catch these early, if you do catch them early you have the choice of non-operative versus operative modalities and open surgical repair can be considered. Why do we do this if we can manage them non-operatively? Well, they’ve similar results in the long term but you’ve got a faster return to activity and a lower chance of re-rupture if you repair it surgically, that’s a very safe and reliable procedure. If you don’t treat this or you don’t realize that you’ve had an Achilles tendon rupture, because no one wants to rupture their tendons, so we’ll often pretend to ourselves that we’ve had a sprain.
What can we do for these? Well, they’re usually seen late on about three months, usually in a more elderly population. What we do is, we lay the patient down in the bed we take a look at the back of the patient that you can see here and on the left hand side you can see a chronic tear and on the right hand side we have a nice healthy looking Achilles tendon. We can still manage some of these non-operatively but the majority of these would be offered operative modalities provided they have nothing else. That means we can’t operate on them actually what we do with these tears you can see this chronic thickened area in the Achilles tendon on the left we take the tendon from your big toe called your flexor hallucis longus and we re-root it through the back of your heel and this works really well for these patients but it isn’t quite as good as your Achilles tendon as you would imagine. What do we do to rehabilitate these well doesn’t matter which way whether you treat them non-operatively or operatively you need to match them with early active range of motion and we start this at two weeks and progressively decrease your heel raises over the next few weeks but generally patients will wear some form of heel raise for about three months after surgery moving to the back of the heel posterior. Heel pain is another thing that’s commonly sent to physiotherapists and even orthopaedic surgeons at an early stage, what’s going on here, well it’s either the Achilles tendon as we’ve seen previously as it inserts into the calcaneus, your heel
bone or it’s a little bursa which is a fluid-filled sac behind your heel and it’s either in front of the Achilles which it’s called a retro calcaneal bursa or it’s a subcutaneous bursa as you can see in this case this photograph on the left-hand side. These can be treated with rest anti-inflammatories some physiotherapy and injections under image guidance but sometimes it’s caused by a body problem and this is called a Haglund’s deformity. You can see this rose torn a pin appearance of the headlines at the back of the heel and you can see this essentially eroding into the back of the Achilles tendon this causes a lot of pain and a lot of difficulties, typically these patients won’t respond well to physiotherapy and when they do get to see us they’re really in quite a lot of chronic pain.
The treatment for this is primarily surgical, what you do is you actually lift the Achilles tendon off the back of the heel, again under general anaesthesia, reconstruct it and shave the bone away that’s impinging at the back of the heel and then we reconstruct it using a thing called an Achilles speed bridge which is a really strong product and works really well and has changed radically changed our management of these conditions. It is a bigger injury than an Achilles tendon irritation and it needs a longer time to rehabilitate this will take you at least six months to settle down. When do I need to see a surgeon with regard to my Achilles? Well if you’ve got long-term irritation physiotherapy hasn’t worked here chronic limitation of activity in terms of normal domestic tasks or recreation or indeed work tasks, if you think you have an acute Achilles tendon rupture don’t delay go to an emergency department, if you think you’ve got your Achilles of course if you can see your primary care practitioner or you’ve got a relationship with a physiotherapist it’s very reasonable to see them provided they can act on it quickly and either send you to get imaging or send you to an emergency department if required.
So moving deeper into the ankle to look at ankle pain we’re going to talk about anterior and posterior impingement pain is anterior at the front of your ankle and you’ll have decreased dorsiflexion meaning you’ve decreased the ability to move your ankle up, you won’t complain of deep pain unless there’s a coexistent deep degenerative injury and we’re going to talk about those in a minute and the treatment for this is primarily a camera an arthroscopy and we resect these but sometimes we have to perform an open resection of these injuries or these problems. Moving to the back, well there are loads of causes for this you might have heard of things called an ostrigonum or a state process and essentially these are just
bony outgrowths at the back of the ankle joint an MRI scan is very useful as is a clinical examination and the treatment of these depends on the underlying cause and again in the majority of cases we can treat these non-operatively with injection therapy and physiotherapy depending on what’s going on what’s causing the problem moving deep into the ankle joint.
We’re going to talk about osteochondral defects just very briefly the talus or the talar bone forms the bottom part of the ankle that lives beneath the tibia and an osteochondral defect of this is a defect in bone or osteo and cartilage chondral again these are commonly caused by inversion sprains people going over in the ankle you get what’s called a kissing lesion where one bit of bone bangs off another bone and it damages and erodes the cartilage. Patients will complain of deep pain particularly pain after activity and it’s typically on the middle side or medial side of the ankle. It’s often as I said associated with an inversion sprain and a history of a lateral ligament injury and classically these are patients who really just don’t settle down with physio and have ongoing deep ankle pain.
So again initially with these, we immobilize patients and give them non-steroidal and analgesia. We can try an image guided injection and if those modalities don’t work, then we can go in and have a look with the camera and you can see here our tibia normal tailless you can see this little rim here that’s an osteochondral defect so when we resect this we take away the cartilage we actually put holes into the bone here and that stimulates cartilage to regrow not quite as good as your original cartilage of course but it does settle down a very significant number of patients. These are quite tricky things to treat them.
So when do I see a surgeon if I’ve got deep ankle pain or decreased range of motion? Well ongoing limitation of movement despite physio analgesia and ongoing deep ankle pain that suggests you might have arthritis or an osteochondral defect moving further south. We’re going to talk briefly about plantar fasciitis now extremely common and nobody gets any credit for this it is extremely debilitating as anyone who has this will tell you and it’s often under-treated. Classically patients get early morning pain or they get pain in their heel following prolonged sitting or driving
and when they initiate activity and get up from a seated position whether they’re driving or sitting at their desk. It often eases a little bit with activity while you get up in the morning and brush your teeth and settles down but then it comes back later, particularly during prolonged exercise and that’s because of the inflammation in the plantar fascia. I see this as a symptom of a bigger problem and typically the big problem here is the posterior kinetic chain as we talked about earlier its tightness all the way up and this is the weakest link in the chain causing pain. Often we’ll get referrals for heel spurs on x-ray and it’s really important to note that these bear absolutely no relationship to the presence or indeed the absence of plantar fasciitis.
So what can we do to treat these? Stretch the posterior kinetic chain, that’s the underlying problem that’s causing this emphasizing the calf muscles that we talked about earlier. A simple heel raise will work really well and off an off-the-shelf one you can buy in boots for five euro custom orthotics are really rarely indicated for this, oral non-steroidal anti-inflammatory drugs, you can try ibuprofen over-the-counter or you could get prescribed dark coccia or vimovo or even diphene, massaging the plantar fascia with your big toe extended works really well and I find the easiest way to do this is to actually cross one leg over the other and use your hand to massage a tennis ball or golf ball into the area that’s painful and extending your big toe tightens this and makes it a bit easier to do injections.
We’re commonly referred patients to see can they get injections and I always say well have you tried all these other modalities before we think of that because the vast majority of these patients will settle down with non-interventional modalities. PRP has been trialed extensively for this and there’s very weak evidence to support this and I don’t typically use this in the vast majority of my patients because simply put it hasn’t been shown to be any better than injection therapy and indeed non-operative modalities shock wave therapy will sometimes be used by your physiotherapy for this and has some evidence when used for about three sessions.
So when do you see a surgeon if you’ve got plantar fasciitis? Well surgery is almost never required for this condition this is an entity that should be treated by physiotherapists or sports medicine practitioners with non-steroidal anti-inflammatory drugs a simple heel raise to just settle symptoms down. While you’re engaging with physio an injection therapy should only be considered as an adjunct, it’s not a primary therapy and equally custom-made orthotics are almost never required for plantar fasciitis and they won’t solve it if you haven’t solved the underlying architectural problem and that’s primarily physiotherapy and stretching.
So moving on to the front of the foot, we don’t have time today unfortunately to talk about the various conditions in the midfoot, I’m going to talk briefly about hallux valgus from bunions. So what is it? Well, it’s an angular deformity of the first metatarsal phalangeal joint that’s your big toe joint at 90 of these are female, at the time of surgery you can see this is a nice significant bunion, the mean age of surgery is 60 but this is getting lower all the time and many people start young and progress. Most people will have bilateral or both sided bunions but with differing magnitudes.
So how do you manage these? Well you can either operate on the shoe to fit the foot by getting a wider shoe or the foot to fit the shoe and usually, it’s a combination of both things. So who gets non-operative management in these well people with a mild deformity mild symptoms normal footwear obviously this isn’t normal footwear so within reason patients who don’t want surgery or they can’t have surgery. We can use spacers in these kind of patients, some patients will come to us with a corrective bunion or bunion directors excuse me, that they’ve used and bought online, please don’t buy these they do not work.
When do I see a surgeon for hallux valgus or bunions? Well if you’ve got pain difficulties with normal shoes this isn’t an operation to allow you to wear 10 stilettos to go to Tesco nor is it reasonable to be going to a wedding wearing Birkenstocks. We’re looking for a patient with reasonable expectations who’s having reasonable problems in normal footwear. Second toe problems, often second toe or hammer toe, the problem is caused by the bunion and the hammer toe is really a secondary symptom of this but it can be seriously debilitating transfer metatarsalgia. Well what is that? That’s pain over your lesser metatarsal heads or overload and you can see there’s a thick velocity at the bottom of this patient’s second foot but the problem here has actually been primarily caused by the bunion and that’s what needs to be treated along with the second toe. Should you get this operation done because you don’t like the appearance of your bunion? The answer to that is categorically not don’t get this done for cosmetics.
So in terms of operative management, well the typical surgery before this is called a scarf osteotomy which is an open osteotomy and it works for most bunions. It’s very stable and strong gives a very powerful correction and you can wear a shoe for six weeks and note that swelling can take at least three to four months to settle down but it’s got a very high satisfaction which the crucial thing about bunions. Before we move on to big joint pain is that while they’re progressive they’re very slow in doing so and not everyone progresses past a certain point so if you’re not bothered and you’re wearing normal footwear to do normal things you do not need your bunion corrected.
So in terms of our final topic, we’re going to talk about big toe joint pain or first metatarsal phalangeal joint pain it’s also called hallux limit us or hallux rigid because we like making latin sounding names in medicine. The vast majority of these are treated conservatively using anti-inflammatories rest modifying your footwear. Orthotics can be of benefit but in very limited circumstances and you can see there the picture here there’s a big bony spur on the top of this toe with a big inflamed toe and this is painful particularly when anybody dorsiflexes or lifts up their big toe.
So what do I recommend in terms of running shoes for forefoot problems? I really like Asic’s glide rods, they’ve got a very nice curved forefoot but your foot actually sits quite straight in these and I find they work really well for patients who like walking or even like jogging and work really well for these because they allow you to move forward without actually raising your big toe up. Hoka runners or Brooks runners are also good but in any running shoe you’re looking for, you need to look for a good solid heel counter, a supportive midfoot and then I like these curved forefoot running shoes, they work very well.
So when should you consider surgery? Well, when non-operative modalities fail achilectomy is the surgery that we would typically use for these and what we do is make an open incision under general anaesthesia of the joint and we take away the impinging bone and soft tissue as you can see in the middle picture and then the lowest picture shows the improved range of motion in the joint. Again, it’s a day case procedure and four to six weeks in a post-operative issue depending on what we see inside there and about 10 to 12 weeks depending on what’s being done and what other problems are on their inside in the joint. Are there replacement options? Yes there are but unfortunately they haven’t been the panacea that we’ve thought they would be, you can get half a replacement put in a joint toe spacer in the middle or even a total joint replacement option and while we’ve tried and looked at these they work in limited numbers of patients and surprisingly enough the most effective treatment for big toe joint arthritis, when it gets too severe, end-stage arthritis is actually this a fusion most patients are horrified of the idea of getting effusion until they actually get it and it works really well in about 94 or 95 percent of patients. You stiffen the joint with a plate and screws and it’s been the gold standard for a very long time at this point it’s very reliable allows patients to wear normal footwear and a heel of about one and a half inches but the toe doesn’t move again and that’s important to note however it’s a really effective operation.
When do I see a surgeon if I’ve got pain in my big toe? Well if you’re having problems with normal footwear and as I said this isn’t an operation to wear very high heels but it’s not unreasonable to want to walk into somewhere like Arnott’s a big department store and say I’d like to buy a nice normal pair of shoes reasonable behaviour for reasonable feet if non-operative modalities fail and if they’re affecting your everyday work or recreational activities.
So, in summary, there are loads of different pathologies around the foot and ankle joints that’s why we like being foot and ankle surgeons it requires a multi-disciplinary approach and predominantly one of physiotherapy intermittent use of orthotics and podiatrist’s new strategies and surgery work really well in conjunction with non-operative modalities and when non-operative interventions are unsuccessful there are multiple operations available in the achilles the ankle joint the ankle ligaments the hind foot and indeed the forefoot and the high patient satisfaction.
There are loads of options for that including non-surgical ones like orthotics injections and some physio to strengthen up the area as well that’s usually our first protocol for those type of things. So it may not actually be time for surgery and in terms of getting checked out it’s very reasonable if you’ve got a lot of foot pain and if you’re up to the point where you’re taking opioids to ratchet your mid foot pain and I think that’s time to get checked out and trying to at least get weaker and views of your foot and ankle and maybe even MRI of the foot and that’d be something to consider getting referred on by your GP.
We don’t take direct referrals in the sports surgery clinic from patients we do take them from physiotherapists and podiatrists and from GP’s but if you’re having ongoing pain that’s to the point where you’re taking opioids, I think you’d be working to chat to your GP and say listen this really isn’t working for me in terms of non-operative modalities are non you know further investigation modalities and I’d like to be referred to somebody to see about getting a scan or maybe the GP could get a scan and further investigate it and I think I would at least be looking at getting some physiotherapy getting the physio to assess your mid foot and see where you’re at with that because really in terms of long-term opioids I’d certainly agree with that I don’t think they’re a solution for anybody’s foot pain in the long term.
It all depends on how you’re getting it done and some people do these arthroscopically I do an open procedure because I think it gives a better fusion rate and it’s a stronger construct with large platen screws at the front of the ankle, so the ankle will be fused with a plate running down the front here like this and then screws go directly across the ankle like that.
My patients and I and they’re two other foot ankle surgeons here in SSC I think we probably all are quite similar with our post-op plans. My patients are non-weight-bearing for, the first six weeks but you can rest your foot in the ground to balance then after that for the next four to six weeks, your weight bearing is tolerated in a boot, you can expect swelling for about four to six months depending on how the ankle goes and it takes about a year for it to fully settle down.
It’s important to note when you’re getting an ankle fusion this is a big operation in a small place, it takes about twice as long to do an ankle fusion as it does to do a hip replacement so it’s a much bigger operation in terms of recovery. Pretty much anyone you go to I would imagine would keep you non-weight-bearing for six weeks post-op.
It’s absolutely not a given and the most commonly injured ligament in the entire body is called your anterior tail fiber dimension, that’s on the outside of your ankle near the skinny bone on the side of your ankle and if you’ve had that reconstructed and there’s no damage to the dome of the tails, here this is your tailless bone, here the ligament in the side of your ankle is running along here called your anterior talofibular ligament that’s the one that’s most likely torn and the one that’s most likely been prepared for you.
If you don’t have any degeneration inside the ankle joint you’re not at any increased risk of getting arthritis in that joint. If you did have degeneration in that at the time of the injury and maybe it needed to be fixed at the time with an arthroscopic procedure then yes you do have an increased chance of arthritis in the future but just for an isolated ankle ligament no there’s no increased risk of degeneration once it’s been stabilized and successfully stabilized.
There are a number of options it really depends on what your activity levels are and what you’re doing on a day-to-day basis could even depend on whether you’re working in an office or you’re going up and down a ladder and standing around all day wearing work beats and the first thing you do non-operative modalities will include injections anti-inflammatories and supported braces and these can go up from just a simple supportive brace to custom-made boots and custom-made footwear.
Moving to the surgical side of things, it really depends on if all the cartilage is gone. Well then they’re down to two options, you either fuse it or you replace it. So there’s two schools of thought on this replacement is the future, I don’t personally think that it’s as good as I would like it to be yet, so I don’t currently offer ankle replacements but I’m hoping to do so within the next couple of years and when better replacement options come out, the long-term results for me just aren’t quite there yet they’re almost there but they’re just not quite there. For the vast majority of my patients, so if I have somebody who is very keen on looking for an ankle replacement I’ll refer them to one of my colleagues, but in terms of my practice where I see patients with severe agile arthritis I would generally offer them a fusion now obviously that depends on age activity and so on as well.
That’s a fantastic result 20 years after severe injuries like that, I’m amazed that you can run. In terms of the injured joints fusing without a triple arthrodesis, they’re very unlikely to fuse spontaneously at this point and we don’t really see that much in post-traumatic patients. We see it sometimes in inflammatory arthritis conditions like rheumatoid arthritis and psoriatic arthritis, patients will spontaneously fuse and over time we can really solve their problems themselves effectively.
In terms of infusing by itself, at this stage, it’s almost guaranteed not to fuse by itself and I got to say it’s very impressive that you’re running and walking and doing this level of activity without any surgical intervention, at this point it’s unlikely to fuse at this stage without any surgery you know.
Well for me plantar fasciitis is a clinical diagnosis it’s very easy to diagnose. Clinically you just press on the bottom of the foot, if you look at the bottom of the foot underneath the arch of your foot, you go on the middle side where your big toe is, if you lift up your big toe you’ll feel a band running along underneath your foot just around about here, everyone thinks it’s a tendon but it’s not it’s your plantar fascia.
Your plantar fascia is just a thick bit of tissue that binds up all of your muscles we have and we have fascia in all of our muscles in our body and for obvious reasons, it’s thickest in your feet and in your hands because that’s where we put our hands and our feet on things.
So if you feel the band here and you work your way back towards the heel and just as you join up to the heel that’s typically where you’ll get the majority of your plantar fascia, it’s called your medial plantar bound and it’s really a clinical diagnosis. We use an MRI to see what it isn’t, we’re trying to see is it something else like a rarer cause of pain around that region, like a stress response in the calcaneus or rare conditional carceral tunnel syndrome and x-rays aren’t really any good for plantar fasciitis, they’re a very good broad view of what’s going on in the footbank give you a good idea of the architecture and I’d always stress when I’m talking to people who are getting an x-ray make sure it’s a weight-bearing x-ray. You need to know what the foot’s doing when you’re standing on it people often get referred to us with a plantar calcaneal spur which is just a little bump just there and the presence are the absence of a calcaneous burn on the bottom of your foot, there’s no resemblance to the presence or absence of plantar fasciitis and it is essentially a useless point.
I have no interest in whether or not somebody has a plantar calcaneal spur because it doesn’t make any difference as to whether or not they have plantar fasciitis. So in summary this is really a clinical diagnosis for me and I think an x-ray is a very useful, a weight-bearing x-ray is a useful way to see if there is anything else globally going on in the foot and if you’re really not sure that’s plantar fasciitis an MRI is a useful way to confirm your diagnosis or to tell you that it isn’t something else.
Nerve pain under the heel bone stabbing like electric shock sounds much more like plantar fasciitis there are rarely those baxter’s nerves, rare nerves you get rare neuropathies around the heel and you can get in you can get nerve pain true nerve pain in the heel much more likely it is plantar fasciitis as I said briefly answering the last question and you can get a thing called tarsal tunnel syndrome that can give you pain around the heel but by far the most common cause of pain in this region is plantar fasciitis and the other thing would be that you can get a stress response or stress fracture even with the calcaneus that gives you that severe sharp pain.
Plantar fasciitis it’s really important that it gets no credit, this drives people absolutely insanely, it’s extremely debilitating and the problem with it is if you’re sitting behind a desk for hours all day you get up out of your desk with plantar fasciitis you’re living but if someone sees you 15 minutes later in Tesco you look like a fraud because you’re walking around without a problem because plantar fasciitis settles down very quickly after you get moving and then as you move for longer during the day as anyone with plantar fasciitis will tell you their pain becomes more prominent as your inflammation rises later on and say an hour of walking. Around the heel, it’s much more likely to be plantar fasciitis, if you think it’s nerve pain it would need to be diagnosed by somebody and usually, that would be diagnosed by a thing called a nerve conduction study and which would be rare that would be in the heel.
Yeah absolutely metatarsalgia is something we treat quite commonly, so by metatarsalgia these are these bones here are metatarsals and the bones at the bottom of the feet is really where you get metatarsalgia. So you’ve got bones underneath your big toe, you’ve actually got two small bones here called sesamoids we won’t get into that that’s a little bit more complicated but the most common place you get metatarsalgia is in your lesser metatarsal heads and the most common place you get it is in your second and third and what this is typically actually caused by and you saw in my talk, posterior kinetic chain tightness again if you think of your foot here and you think your gluteal is way up at the top of your backside if they’re tight your hamstrings are tight the muscles in your calf are tight and then this causes a pull on the heel and that drives the foot into the floor.
Now there are some other conditions you can have with the shape of your foot that can lead you to have metatarsalgia but that’s the most common cause of tightness and that can be alleviated by physiotherapy. One of the other things that can be done for metatarsalgia is to get a metatarsal pad or bar and this should be fitted by a physio, it doesn’t need a custom-made orthotic, almost never needs a custom-made orthotic, you can get one done but you should start with non-custom orthotics because a lot of the time you just get a simple basic off-the-shelf orthotic and add a little pad and the crucial thing for it is not to put the pad where the pain is. That’s the most common mistake that we all make because it’s sore but actually if you think about it you just focus the pressure on the area that was under pressure.
So what you should do is move the pad behind okay so that’s your physio to stretch that out the posterior kinetic chain to offload it with a pad, if it’s very painful you should get a plain film x-ray to see if there is any arthritis or anything in that and you can check as well because another thing that can give you pain in this is a thing called a Morton’s neuroma and that’s most commonly operating between the third and fourth toes and it gives you kind of burning stinging pain and it can also be described as a known pain which you know sounds quite counter-intuitive but the reason you’ve got that is because you’ve got damage to a nerve there, so the information going back to your head is garbled, so you get this horrible sensation of I’ve got this burning pain but it’s there but it’s not there and it’s really hurting in the bottom of my foot but when I go to press on it it’s kind of not there and that’s actually a great explanation of nerve pain.
So metatarsalgia can be caused by pressure or it can be caused by nerve or degeneration in the area there. So what I would do is if you’ve got metatarsalgia, my first protocol would be to see a physio and see what can be done from that point of view, if that’s not working the next step would be to get a plane film x-ray and maybe go see somebody from a foot manipur point of view and you may need an MRI scan.
Prior to getting anything done but there are lots of surgical treatments that can be done for that such as shortening the bones and ejecting them. From a non-operative point of view and even if it’s very arthritic you can replace the lesser metatarsalgial joints and they’re very reliable because they don’t take a lot of load through them and replacements work really well if you have to do that in that region. So there’s lots of treatments both non-operative and operative for metatarsology.