Conditions & treatments covered

The Foot & Ankle Unit at The Wellington Hospital brings together a group of Orthopaedic Surgeons who work in collaboration to provide patients with access to rapid diagnosis and treatment for a variety of foot and ankle problems. The team includes Mr Nicholas Cullen, Mr Andrew Goldberg, Mr Mark Herron & Mr Simon Moyes. 

To book an appointment with one of our Foot & Ankle Unit consultants, call our Enquiry Helpline team on 020 7483 5148 or click here to book online.

Conditions treated include:

What Is Ankle Arthritis?

Most ankle arthritis is "wear and tear" (or osteo-arthritis) arthritis. Other forms of arthritis exist which can affect the ankle such as inflammatory arthritis, an example of which would be rheumatoid arthritis.

What Symptoms Might I Have?

It is possible that in the early stages or even in the "late" stages of ankle arthritis that one may experience little in the way of symptoms.

Most commonly pain is the presenting symptom and in ankle arthritis this is usually well localised to the level of the ankle joint. It can be felt anywhere circumferentially around the ankle joint but usually it is felt deep within the joint. The intensity and duration of pain from an arthritic ankle varies significantly person to person and at different times. Generally, early symptoms in ankle arthritis are pain and perhaps swelling, after prolonged weight bearing or high impact type activities. If the ankle arthritis progresses then pain can become a more frequent occurrence and provoked by progressively less and less activity. Eventually pain can become present most of the time, even when non-weight bearing or at night in bed.

The Natural History of Ankle Arthritis

There is a great deal of individual variability in the level of symptoms from ankle arthritis and also the rate at which it progresses. Generally, treatment is based upon the level of symptoms that the ankle arthritis is currently giving, as opposed to any extrapolation of how severe the symptoms from ankle arthritis might be in the future.

If I Have Been Diagnosed with Ankle Arthritis How Can I Help My Symptoms?

Methods of relieving symptoms are the same as those used for the relief of arthritic symptoms in any lower limb joints. In other words ensure one is not carrying excess weight, reduce heavy impact activities on the joint, and use occasional non-steroidal anti-inflammatory tablets as required. A lightweight and stiff soled walking boot can also be useful in relieving symptoms of ankle arthritis. The sole itself should be too stiff to flex, and run with a gentle curve from heel through to the toe - a rocker type sole.

Surgery

Ankle Arthroscopy
This is designed to minimise the pain, swelling and stiffness in the arthritic ankle joint. Through two or three small holes, instruments are inserted into the ankle joint to wash debris from it and to remove loose pieces of bone, cartilage, inflamed tissue and bone spurs (lump or outgrowth of the bone, formed when the body tries to repair itself by producing more bone - usually in response to rubbing, pressure or stress over a period of time). You will need to rest and ice your ankle for 48 hours after surgery, and have a short post operative physiotherapy programme. You will normally see 80% good or excellent results.

Ankle Fusion
If simple arthroscopy does not relieve the symptoms, then a more permanent solutions such as an arthroscopically assisted fusion may be required. Ankle fusion involves preparing both sides of the arthritic joint (left) back to healthy and bleeding bone (right). The arthritic joint lining is removed and the ankle joint is placed in a functional position and held there until the bone has grown across the joint and the ankle is thus fused.

The ankle is held in position whilst the fusion is occurring and this is most commonly done with large screws which are buried beneath the skin. Occasionally a large metal rod may need to be inserted through the heel to compress the ankle and sub-talar joints (known as a double fusion).

Ankle Replacement

Ankle replacement involves replacing the two worn out surfaces with replacement highly polished surfaces and adding a high molecular weight polyethylene spacer between the two surfaces. Ankle replacement generally maintains the range of movement which a patient has pre-operatively. It is not suitable for heavy manual or sporting activities and probably has a ten year survivorship in the region of 85%.

The ankle is held together by three main ligaments. The two lateral ligaments stop the ankle sliding forward and rolling from side to side. They are attached to the fibula (the small bone next to the shinbone) and the talus (the anklebone).

When the ankle is violently twisted or forced beyond its normal range of movement, the ligaments can easily become stretched or torn. This is known as a sprain.

If your ankle doesn't heal properly after a sprain, or you sprain your ankle repeatedly, you may end up with chronic ankle instability. The resultant constant swelling in the ankle can cause a reflex in the body that 'switches off' the muscles around the joint, which reduces the stability even more.

If the ankle does not respond to non-surgical treatment (orthotics, supportive footwear, physiotherapy), surgery is recommended.

How does it feel?

There is a sensation that your ankle is going to give way, especially on uneven ground. Your ankle will frequently turn during activity, causing pain, inflammation and swelling. You may have almost constant swelling in the ankle.

What Is An Ankle Sprain?

An ankle sprain (also known as a lateral ankle ligament sprain) is the most commonly occurring injury to the ankle. During weight bearing activity (walking, running or jumping) the ankle and foot move inwards, towards the mid-line of the body, more than the stabilising structures allow, thus resulting in injuries to these structures. Most commonly it is the lateral ankle ligaments and the lateral ankle joint capsule which are torn.

Bleeding into the joints itself is common after this injuries and this can lead to chronic inflammation setting up in the soft tissues within the ankle joint known as synovitis.

What Symptoms Might I Have With An Ankle Sprain?

The symptoms following an ankle sprain are pain, swelling and subsequently bruising which may effect both sides of the joint. Additionally, it is not unusual to find it painful to put weight through the joint and the joint may also feel immediately unstable. Pain on attempted weight bearing after a presumed ankle sprain is something which requires immediate medical review.

Treatment of Ankle Sprain

There are four ways available to manage an ankle ligament sprain/rupture. These are either to do nothing and simply wait for the ankle to settle. Secondly, to immobilise the injured ankle in a plaster cast for a period of 4-6 weeks, walking as comfortable. Thirdly, to use functional rehabilitation to treat the sprained ankle (a graded physiotherapy programme, often combined with a removable ankle brace). The final option is to operatively repair the injured ligaments.

When is an Operation Appropriate After an Ankle Sprain or Ligament Rupture?

Operative intervention is used for two sets of symptoms, which may co-exist. These ongoing symptoms following an ankle sprain are either pain at the level of the ankle or instability from the ankle.

At arthroscopy any areas of loose cartilage or inflamed tissue (synovitis) or scar tissue (arthrofibrosis) can be removed from the joint.

What is Ankle Arthroscopy?

Ankle arthroscopy is minimally invasive surgery of the ankle, also known as keyhole surgery. Ankle arthroscopy involves using very small incisions to gain access to the ankle joint. Each incision is less than 1cm, usually two incisions are required on either side of the ankle.

How is Ankle Arthroscopy Done?

Most ankle arthroscopy is performed under general, or occasionally regional, anaesthesia. Firstly a padded bar is placed behind the thigh.

Next a strap is placed around the ankle and connected to a second bar distant from the first which is attached to the operating table and allows traction to be placed across the ankle. In this way the ankle is stretched open sufficiently to allow a space with sufficient dimensions in which to operate. 

 

What Happens After My Ankle Arthroscopy?

For the first 24 hours:

Pain Relief
When you wake up after the surgery your ankle should feel comfortable. You will have had injections of local anaesthetic both into the joint and into the nerves around the joint whilst asleep. Following surgery you will be given a combination of three pain killers to take regularly for the first 36 hours post-operatively and then only to be used as required.

Mobility
After the ankle arthroscopy, once you are back on the ward the physiotherapist will start mobilising you. You may put as much weight through the ankle as is comfortable. The conditions where this is not the case are with an osteochondral defect and if your arthroscopy has been part of a lateral ligament reconstruction. You will be more comfortable using crutches for a day or two and then these can be discarded.

Your operated leg will need to be elevated when non-weight bearing for the first 24 to 48 hours.

You are encouraged to exercise your ankle within the bandage both by moving it up and down as well as moving it from side to side. This is from as soon as you are able to do this.

Length of Stay After Ankle Arthroscopy
As long as your general medical condition and domestic circumstances permit, most ankle arthroscopy cases can be performed as a day case surgery.

Bandaging After Ankle Arthroscopy
Following an ankle arthroscopy you will have three layers of covering. Closest to the wounds are two small adhesive coverings and these should be kept on for two weeks. Overlying this is a layer of sterile wool and overlying this is a crepe bandage. The dressings should be left intact for the first week. The wounds themselves should be kept dry for two weeks. At one week following the surgery you may remove the outer crepe bandage and the underlying wool. The adhesive dressings over the two arthroscopic portals should be left intact. If these should become loose or dislodged, replace them (without touching the wound) with a good sized adhesive plaster. These can be replaced as often as required, it is important that the wound itself is kept untouched and dry.

Driving After Ankle Arthroscopy
Generally you should be comfortable and safe to drive at one week following your ankle arthroscopy as long as you are permitted to weight bear.

Return to Sport
After ankle arthroscopy you will be back to walking at 1-2 days following your ankle arthroscopy. This will be without use of a crutch. Any sporting activity is best left for at least two weeks following the procedure. Realistically, things can be built up from two weeks post-operatively but will probably take in excess of four weeks before more vigorous sporting activity will be possible.

Ankle replacement involves replacing the two worn out surfaces with replacement highly polished surfaces and adding a high molecular weight polyethylene spacer between the two surfaces. Ankle replacement generally maintains the range of movement which a patient has pre-operatively. It is not suitable for heavy manual or sporting activities and probably has a ten year survivorship in the region of 85%.

What is an Ankle Fusion?

An ankle fusion is a permanent joining together of the main bones of the ankle joint. The two main bones which require to be joined for an ankle fusion are the tibia and the talus. Depending upon the technique, occasionally the fibula is also included into the fusion site.

How long does it take for an ankle to fuse?

The time to fusion can vary considerably between different conditions, different operative techniques and different patient related factors. Generally, under the optimum circumstances an ankle should be well on the way to uniting by six weeks and be united by 12-14 weeks. Just as after a fracture, the bone will continue to strengthen beyond this time.

How will I walk after an Ankle Fusion?

After an ankle fusion it is likely that a patient’s gait will be normal or much improved. This is possible because there are other joints close to the ankle which, if non-arthritic and mobile will compensate to an extent for the loss of ankle movement.

What will I be able to do after an Ankle Fusion?

You are likely to be able to return to most activities following isolated ankle fusion, assuming the neighbouring joints are arthritis free. This would certainly include returning to heavy manual duties, being able to walk distance and the use of ladders. You would generally be able to break into a short light jog but the ability to run following an ankle fusion is unusual though not unheard of.

Why consider an Ankle Replacement?

Very few things in life (including surgical procedures) come "free". In case of ankle fusion the "payback” is that the joints which have "taken over" the ankle function do so at their own expense, often suffering degenerative change themselves eventually. There is a probability that between ten and twenty years following an ankle fusion the main joint beneath the ankle (sub-talar joint) will be come arthritic. It is however unusual for this joint to require secondary surgery as a result of the ankle fusion.

How does it feel?

Generally pain will be felt when the ankle bears weight but can also be painful at rest. It may often result from a sprained ankle which has failed to settle, creating long term pain and instability. Osteochondral defects(OCD) are very localised areas of joint damage. Unlike arthritis the damage exhibits as joint surface softening, rather than arthritic hardening.

Treatment

These conditions usually occur on the talus and are a region where the cartilage and underlying bone have been disrupted, usually after injury. The degree of disruption can range from 'bruising' to a crater or deep defect on the surface of the joint, lacking the underlying bone as well as cartilage.

An OCD may or may not progress to osteoarthritis and a decision to have treatment will depend upon just how persistent and painful your symptoms may be.

What is an OsteoChondral Defect?

An osteo chondral defect is a very localised area of joint damage. This involves both the underlying bone (osteo) as well as the overlying cartilage (chondral). In the ankle an osteo chondral defect usually occurs on the talus. The characteristic areas are either antero-medial (on the inner side of the ankle and to the front) or postero-lateral (to the outer side of the ankle and to the back)

What Symptoms Might I Expect From an Osteo Chondral Defect

Generally pain is the main symptom. This is usually on weight bearing and usually, though not always, is localised to the side of the joint on which the osteo chondral defect exists. It is also not uncommon to have feelings of instability from the joint, despite the fact that there may be no actual laxity of the normal restraints. This is known as functional instability.

What Treatments are Available For Osteo Chondral Defects?

The treatments available are either non-operative, debridement and drilling of the defect or cartilage transplantation.

Non-operative management involves restricting activities not weight bearing. This may require the use of a plaster cast or an Aircast walking boot and may need to be worn for up to four months. This type of management is really only appropriate for very minimal cartilage and bone changes and only really if they have been detected early. In such early cases the chance of success is in the region of 40-50%.

Arthroscopic Debridement and Micro Fracture of Osteo Chondral Defects

This is the first line of treatment for most osteo chondral defects. Once the defect has been diagnosed with an MRI scan it is important to know that following this operative treatment you will be non-weight bearing on the affected ankle for six weeks and will be restricted in terms of sporting activity for five months.

Using a standard ankle arthroscopy, performed as a day case surgery, the defect is better assessed. Very occasionally a fragment of bone and cartilage exists as a single well defined piece which can be fixed back into place with an absorbable pin. More commonly this technique is not technically possible and there are many loose fragments in the base of the defect with a detached piece of cartilage and possibly some bone. Any loose fragments of bone and any other material within the defect are best removed arthroscopically and then the base of the defect drilled arthroscopically with fine wires or micro fractured.

Osteoarthritis in the foot is usually the result of some previous injury, such as breaking the toe. It can also be the result of overuse - repetitive bending and stooping, for example. It tends to affect people over 50, but can occur in those as young as 20. Osteoarthritis can cause the big toe to become stiffened, swollen and painful, making walking difficult. The most commonly performed surgery to correct this is debridement, cheilectomy or fusion.

How does it feel?

Pain in and around your big toe joint can be present all the time, or just when you walk. You will also feel pain when you pull your big toe up towards you. The big toe may become so stiff that you cannot pull your big toe up at all.

Diagnosis

The surgeon will examine your feet and manipulate the big toe to determine its range of motion. X-rays will determine how much arthritis is present and evaluate any bone spurs or other abnormalities that may have formed.

Surgery

Debridement

During arthroscopic surgery, the area around the diseased bone will be cleaned and any bone spurs and deformities will be removed.

Cheilectomy

This is a minor operation to remove the bony bump (an osteophyte or dorsal bunion) which develops as a result of the body’s attempt to heal the arthritis. This bony bump or spur is carefully burred away to restore the bone to its normal shape. This would normally resolve some 60% to 70% of the pain and stiffness.

Fusion

The two joint surfaces which generated the pain are removed, and the cut edges placed next to each other in a position that allows the fused joint to rock, rather than flex as it normally does.

After debridement and cheilectomy, you can be walking almost immediately. With fusion, however, it may be four weeks before you can put weight on the foot.

If there is too much pressure on the inside of the foot at the base of the big toe, the big toe is forced towards the other toes. A hard, bony lump forms on the joint, causing pain, inflammation and swelling.

Most commonly performed surgery:

bunion is a deformity of the big toe. The toe tilts towards the smaller toes and a bony lump appears on the inside of the foot - at the end of the 'knuckle bone' of the big toe. Sometimes a soft fluid swelling develops over the bony lump. The first metatarsal bone that runs along the foot to the big toe can also be pushed out of alignment, causing instability and difficulty walking.

Bunions are more common in women than in men. They can be the result of wearing too-tight shoes. Also, women's ligaments are looser and less likely to keep the big toe properly aligned. The condition is also hereditary.

If bunions develop later in life, there is a possibility that the bone deformity is caused by arthritis.

How does it feel?

Swelling and pain on the bunion itself and along the inside of the foot. The bigger the bunion gets, the more it hurts to walk.

Diagnosis

A physical examination will determine the presence of a bunion. Range of motion of the big tow will be tested. An x-ray will show the extent of the deformity, and help the surgeon decide if surgery is necessary.

Surgery

Bunionectomy/First Metatarsal Oseotomy
At surgery, the bony lump is removed. The abnormality of the first metatarsal bone is corrected and loose ligaments tightened to correct the leaning over of the big toe. In very severe cases, some further surgery is carried out at the base of the big toe.

You will wear a compressive dressing after the surgery and can walk immediately with lightweight over-shoes. These are worn for two weeks after which you switch over to loose sandals or trainers, getting back to normal shoes at six weeks.

Hallux Rigidus refers to osteoarthritis of the big toe. The pain and inflammation caused by osteoarthritis gradually over time restricts the movement of the big toe.

This condition is more common in middle aged men and will often present in both big toes.

A bunion may also be present at the same time as hallux rigidus. Treatment is therefore decided by which the more prevalent problem is.

How does it feel?

The big toe will feel stiff and gradually the pain can become quite severe and persistent, especially after standing or walking for any length of time. Symptoms are usually triggered in the ‘push off’ phase of walking which relies on the forefoot and big toe region and puts the toe in a maximally extended position.

However the presentation of hallux rgidus like most arthritic conditions can be unpredictable.

Diagnosis

A physical examination will determine the presence of Hallux Rigidus. Range of motion of the big toe will be very restricted and there maybe an appearance of bony growths on the top aspect of the big toe. An x-ray will show the extent of the deformity, and help the surgeon decide if surgery is necessary.

Diagnosis

A physical examination will determine the presence of Hallux Rigidus. Range of motion of the big toe will be very restricted and there maybe an appearance of bony growths on the top aspect of the big toe. An x-ray will show the extent of the deformity, and help the surgeon decide if surgery is necessary.

Treatment

A combination of the level of pain, radiographic stage of degeneration, the presence of deformity and the chance of success versus the degree of restriction following treatment helps to reach an informed decision as to which of the many therapies will be most appropriate.

Non Surgical (Orthotics):

The principle with orthotic management is to offload the big toe during walking. During normal walking the front part of the foot acts as a rocker, this requires the big toe joint to both extend and take weight. By modifying a normal shoe to add a subtle rocker to the sole at the location of the joint, as well as stiffening the sole here so it doesn't bend, the foot can progress forwards normally with reduced big toe movement and thus reduced pressure through it. The shoe "takes the strain".

 

Surgical:

Injection/manipulation:

This may be useful in the early stages of arthritis, however the effects are often temporary.

Arthroscopic debridement:

A minimally invasive technique, generally for patients with moderately severe symptoms but lesser degrees of x-ray changes.

Open debridement:

Debridement either by arthroscopic ‘keyhole’ surgery or by the standard ‘open’ procedure involves removal of any loose cartilage within the joint and fine drilling into small areas lacking cartilage. This allows new, though poor quality cartilage, to form in drilled areas. In addition the excess arthritic bone (osteophytes) which form on the top edge of the joint are removed. This should allow an increased range of extension (upwards movement) post-operatively.

Debridement is performed as a day case and a rigid bandage is applied afterwards. A physiotherapist will ensure you are able to mobilise with crutches and generally you are allowed to weight-bear as much as is comfortable. You will return to see the consultant 2 weeks post surgery and you will be instructed on exercises to minimise stiffness. Gradual return to full function will occur.

 

Kellers/Hamiltons arthroplasty:

A good option in the less mobile, more elderly patient. This involves removal of one side of the painful joint. This stops the pain of the arthritic joint but the big toe sometimes becomes floppy.

Fusion:

The two joint surfaces which are generating the pain due to osteoarthritis are removed and the remaining joint fuses as part of the normal healing process following surgery. The joints are fixated together utilizing screws.

Similar to an ankle fusion, the joints either side from the fused joint can take over some of the original function of the affected joint.

You will need to keep your foot elevated for the first 48 hours. You will be given crutches and generally will be able to weight bear as comfortable (check with your surgeon first). All bandaging will be removed after 2 weeks, however it normally takes 6 weeks before you are able to wear your normal shoes. It will take approximately 6 to 12 weeks for the bones to fuse fully and then there are no restrictions on activity, although you may find due to restricted movement you are limited on the height of heel that you can wear.

Replacement:

Replacement of the big toe has a long though not yet satisfactory history, certainly twenty five years. No previous/established implants have succeeded in being able to maintain movement whilst preserving good mechanical forefoot function and being predictably long lived. However there are still some presentations of hallux rigidus where a replacement may be worth considering. This needs to be fully discussed with your surgeon.

We are currently involved in a multi-centre trial of a new big toe joint replacement.

As you walk, a strong ligament the foot (the metatarsal ligament) pushes downwards, while the ground effectively pushes back up. The digital nerve is compressed between the two, and if it is even slightly enlarged, it will cause pain.

The enlargement or swelling of the nerve can be caused by irritation to the nerve, which might be the result of flat feet, wearing too tight shoes or high heels, or a result of an injury or trauma to the foot.

How does it feel?

Persistent burning pain the ball of the foot - feeling as though you are 'walking on a marble'. The pain may radiate into the toes, occasionally causing numbness in the toes. It mostly occurs between the third and fourth toes. It's generally felt when you're moving about, especially when wearing high-heeled or tight shoes.

Diagnosis

There will be a distinct pain between the bones of the affected toes, which sometimes 'click' when manipulated.

A thorough examination of the foot will determine if the pain is caused by something other than Mortons Neuroma, such as stress fractures in the bones, or by calluses or bunions. An MRI scan will ascertain that there is no tumour in the foot. Tests on the way your foot moves can rule out arthritis or joint inflammations as the cause of pain.

Treatment

It is possible to treat Mortons Neuroma with simple, non-surgical procedures such as the following:

  • Wearing wider shoes with lower heels, which allows the toes to spread out and reduces pressure on the digital nerve, enabling it to heal.
  • Orthotics - tailor-made inserts for your shoes which lift and separate the bones, and reduce pressure on the nerve.
  • Injecting corticosteroid can reduce the inflammation and bring relief from pain.

Surgery

If Mortons Neuroma does not respond to the above procedures, minor surgery is usually recommended.

The Dorsal Approach

An incision is made in the top of the foot, which means that the patient will be able to walk soon after surgery - because the stitches are not on the underside of the foot.

The surgical instruments have to be carefully manoeuvred through all of the complex structures of the foot, and the surgeon will cut deep into the metatarsal ligament, which will reduce the compression of the nerve.

The most obvious deformity with a flat foot occurs on the inner side of the foot and arch. However this side of the foot does not exist in isolation and if the arch on the inner side flattens this may result in the following:

  • Heel moves outwards(valgus)
  • Front part of the foot 'sqews' outwards at the midfoot
  • The Achilles tendon may also become tight as a result of the heel position
  • The forefoot may need to rotate inwards to balance the heel position

The correct medical term is a plano-valgus foot. 'Plano' refers to the flattened arch, valgus to the heel position away from the midline of the body.

Treatment

The following refers to the two commonest scenarios which comprise the bulk of operative cases. These are:

1. A flat foot due to Tibialis posterior dysfunction which an orthotic has failed to treat.

2. The rigid and painful adult flat foot.

The most common cause of heel pain is plantar fasciitis, typified by the presence of a heel spur (a plantar fasciitis) on the front and bottom of their heel. The heel spur does not actually cause pain but is a clear indication on an x-ray of long term inflammation which caused calcium deposits at the point where the plantar fascia inserts into the heel. Pain invariably derives from either inadequate flexibility in the calf muscles, lack of arch support, being overweight, suddenly increasing activity, and spending too much time on the feet.

How does it feel?

Symptoms include a dull persistent ache with episodes of a sharp pain in the centre of the heel or on the inside margin of the heel. Pain is often most severe on first putting weight on the heel in the morning and after rest and is aggravated by prolonged weight bearing and thin soled shoes.

The condition may result from or be aggravated by obesity, weight increase during pregnancy, sudden rise in walking or sporting activity or excessive flattening of the arch on weight bearing, possibly associated with walking abnormalities. Arthritis can also cause heel pain.

Treatment is best achieved with arch support - see Orthotics.

A toenail can be described as 'ingrowing' when the side of the nail cuts into its neighbouring toe, causing pain and bleeding, possibly leading to infection and inflammation. The big toe is commonly affected, as a result of trauma to the nail, improper toenail cutting, tight shoes or hosiery, or an abnormally thick or shaped nail plate.

Treatment

If caught early, regular soaking and softening of the skin around the affected nail for a few weeks, combined with gently guiding the growing nail over rather than into the skin, can limit or cure the problem. If the nailfold becomes infected, antibiotics may be prescribed. For persistent ingrown toenails, part of the nail may need to be removed under local anaesthetic, with regrowth of the problem nail edge prevented by application of a small amount of acid to the nail bed.

Toes that are bent into an odd position at one or more the joints tend to develop calluses, sores and bony lumps and are often inflamed, swollen and painful. Lesser toe deformities can cause problems walking or participating in sports. If they are not treated soon enough, the deformities become fixed and surgery is necessary to straighten them out.

Tight shoes are the most common cause of this problem. Two muscles work together to straighten and bend the toes. If a shoe forces a toe to stay in a bent position for too long, the muscles tighten and the tendons shorten or contract. This makes it harder to straighten the toe. Over time, the toe muscles cannot straighten the toe, even if you are not wearing shoes.

Other common causes for lesser toe deformities are: diabetes, poor blood supply to the foot; brain, spinal cord or nerve injury; arthritis.

The most common lesser toe deformities are:

Hammer toe
all three bones in the toe should form a straight line. With hammer toe, the first bone of the toe is slightly raised, the second bone is tilted downwards and the bone at the tip is almost flat. It is the result of one of the tendons in the foot contracting.

Claw toe
all three bones in the toe should form a straight line. With claw toe, the first bone in the toe is raised, the second two bones are pointing downwards. It is the result of one of the tendons in the foot contracting.

Mallet toe
all three bones in the toe should form a straight line. With mallet toe, the first two bones of the toe are in line, but slightly raised. The bone at the tip is pointing downwards. It is the result of one of the tendons in the foot contracting.

How does it feel?

Any pressure on the deformed toe is painful. Walking is painful and you may cause other problems with your foot as you adjust your gait to avoid the pain. You may have redness and inflammation on the affected toe.

Diagnosis

Physical examination and tests are used to diagnose toe deformities. The surgeon measures flexibility, stability, and sensation in the toe and checks for redness (erythema), swelling, and calluses. X-rays will show the precise nature of the deformity.

Surgery

Arthroplasty:
this is used to treat claw, mallet and hammer toes. The surgeon performs a number of minor procedures including releasing trapped or pinched soft tissue, and tendon lengthening to allow the toes to straighten.

Arthrodesis:
if the deformity has been present for so long that the joint can no longer function properly, the joint may need to be fused. This is done by removing the cartilage from the end of the toe bones in the middle joint, exposing the bone. The two cut ends of bone are held in place with a removable pin so that the bones can fuse together.

Orthotic treatment may be effective in repositioning a mobile flat foot and then to hold it in a corrected position.

The effect is only present when the orthotic is worn in the shoe and ceases if it is not worn. Whatever the cause of the flat foot, the techniques used will be essentially the same. These are to resupport the arch with a rigid plastic arch , and to reposition the heel by placing a "wedge" under its inner side to tilt it and a heel cup to hold it. Whether orthotic treatment prevents the progression of a deformity is not definitively known, but from basic principles there is no reason why it should not.

In the flexible flat foot, orthotics are usually the recommended first line of treatment. In a rigid and arthritic flat foot orthotics cannot correct the foot position but they may be able to improve symptoms.

Stress fractures or trauma fractures can cause displacement of the bones in the foot. This can result in pain, swelling and poor foot function.

Most commonly performed surgery:
re-setting bones using pins.

The Wellington Foot & Ankle Unit

The Wellington Foot & Ankle Unit is one of the world's leading private clinics in treating conditions of the foot and ankle.

When considering treatments for the foot or ankle, it's essential that you receive effective and accurate diagnosis of your problem, major or minor.

When considering treatments for the foot or ankle, it's essential that you receive effective and accurate diagnosis of your problem, major or minor.

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Barefoot marathon running - just a fad or a brilliant way forward?

Mr Andrew Goldberg, Consultant Orthopaedic Surgeon within the Foot & Ankle Unit at The Wellington Hospital, discusses how whether you are an advocate or a sceptic, the subject is hard to ignore. 

Find out more ...