Foot & Ankle Services

The Achilles tendon connects the calf muscle to the heel bone. The calf muscle is actually two muscles, the gastrocnemius muscle and the soleus muscle. The soleus lies underneath the gastrocnemius.

The Achilles tendon is the largest tendon in the body. It allows you to rise up on your toes and push off while walking or running.

The two main injuries are:

• Achilles tendinopathy. This refers to tiny tears (microtears) in the tissue in and around the tendon. These tears are caused by overuse. This is often called Achilles tendinitis.
• Achilles tendon tear or rupture. An Achilles tendon also can partly tear or completely tear (rupture). A partial tear may cause mild or no symptoms. But a complete rupture causes pain and sudden loss of strength and movement.

Treatment
Rehabilitation (rehab) and/or physical therapy are the usual treatment for an Achilles tendon injury. For Achilles tendinopathy, physical therapy can decrease your pain. It can allow you to gradually return to your normal activities. For an Achilles tendon rupture, you can try a rehab program after surgery to repair the rupture. Rehab can strengthen the tendon and help the tendon heal. A rehab program typically includes physical therapy.

Surgery is the most common treatment for Achilles tendon rupture. It reattaches the torn ends of the tendon. It can be done with one large incision (open surgery) or many smaller incisions (percutaneous surgery). In open surgery, the surgeon makes a single large incision in the back of the leg. In percutaneous surgery, the surgeon makes several small incisions rather than one large one.

In both types of surgery, the surgeon sews the tendon back together through the incision(s). Surgery may be delayed for about a week after the rupture. This delay lets the swelling go down.

Nonsurgical treatment starts with immobilizing your leg. This prevents you from moving the lower leg and ankle so that the ends of the Achilles tendon can reattach and heal. A cast, splint, brace, walking boot, or other device may be used to do this.

Both immobilization and surgery are often successful. They both help the tendon to heal. Another rupture is less likely after surgery than after immobilization, but immobilization has fewer other risks.

A bunion is an enlargement of bone or tissue around the joint at the base of the big toe. The big toe may turn toward the second toe. The tissues around the joint may be swollen and tender.

What causes a bunion?
You may get bunions if:

• The way your foot is shaped puts too much pressure on your big toe joint. Because bunions can run in families, some experts believe that the inherited shape of the foot makes some people more likely to get them.
• Your foot rolls inward too much when you walk. A moderate amount of inward roll, or pronation, is normal. But damage can happen with too much pronation.
• You have flat feet.
• You often wear shoes that squeeze the toes together or that shift weight to the toes (such as high-heeled shoes).

How is it treated?
Bunions are treated to help with pain and walking. Treatment starts with wearing shoes that are wide enough. It may include pads or splints to take pressure off the toe. Applying ice and taking some over-the-counter medicines can also help. Surgery is an option only if home treatment doesn't help.

Bunion surgery most often involves an incision in the top or side of the big toe joint and the removal or realignment of soft tissue and bone. This is done to relieve pain and restore normal alignment to the joint. Small wires, screws, or plates may be used to hold the bones in place.

A hammer toe bends down toward the floor at the middle toe joint. This causes the middle toe joint to rise up. It usually affects the second toe. Hammer toes often occur with bunions.

What causes hammer toe?
Tight shoes are the most common cause. Wearing tight shoes can cause the toe muscles to get out of balance. 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 can't straighten the toe, even when you aren't wearing shoes.

It can take years for a hammer toe to form. Women are affected more often than men because they are more likely to wear shoes with narrow toes or high heels.

Less often, these toe problems are linked with other conditions, such as diabetes, rheumatoid arthritis, stroke, or an injury to the foot or ankle.

What are the symptoms?
Your toe may be painful and it might be difficult to find shoes that fit or are comfortable to wear. The toe may rub against your footwear and cause calluses or corns. In more severe cases, these toe problems may affect your balance and make it hard to walk.

How is it diagnosed?
Your doctor will ask questions about your symptoms and past health and do a physical exam. Your doctor will want to know:

• When the problem began, what activities or shoes make them worse, and if other parts of the foot are painful.
• What kind of shoes you wear and how much time you spend standing or walking every day.
• Any previous foot problems you have had.
• Any medical conditions you have that could be related, such as arthritis, diabetes, or poor blood flow (circulation).

During the physical exam, your doctor will look at your foot to see if the toe joint is fixed or flexible. A joint that has some movement can sometimes be straightened without surgery. A fixed joint often requires surgery. You may need surgery if other treatments don't control your pain, if your toe limits activity, or if you can't move the toe joint (fixed toe problem). In general, surgery is used only for severe toe problems.

A metatarsal osteotomy is surgery to treat foot deformities, including hammer toe and bunions. During metatarsal surgery, the surgeon will cut the big toe’s metatarsal bone and realign the bone to correct the deformity.

Osteotomy ("bone cutting") is a procedure in which a surgeon removes, or sometimes adds, a wedge of bone near a damaged joint. This shifts weight from an area where there is damaged cartilage to an area where there is more or healthier cartilage.

In osteoarthritis, cartilage breakdown in the knee often is much greater in the inner part of the knee joint, often resulting in a bowlegged appearance. Surgery to shift the weight away from the inner knee is one of the most common uses of osteotomy for osteoarthritis.

Osteotomy may be effective for hip and knee joints. Doctors often do an osteotomy to correct certain knee deformities such as bowleg (varus) and knock-knee (valgus) deformities of the knees. Hip osteotomy involves removing bone from the upper thighbone (femur). Osteotomy may allow an active person to postpone a total joint replacement for a few years and is usually reserved for younger people.

It can also be used to correct bunions. The surgeon will make small cuts in the bones (osteotomy) and move the bones into a more normal position.

Plantar fasciitis causes heel pain, which often becomes chronic. It can happen when the long, flat ligament on the bottom of the foot (plantar fascia) becomes strained and starts to get small tears. These can cause the ligament to become weak, swollen, and irritated.

The most common symptom of plantar fasciitis is heel pain when you take your first steps after getting out of bed or after sitting for a long time.

Plantar fasciitis is often caused by:

• Problems with the way you walk, such as walking with an inward twist or roll of the foot (pronation).
• Having high arches, flat feet, or tight Achilles tendons.
• Doing repetitive activities, being overweight, or wearing bad shoes. These can make plantar fasciitis worse.

Treatment
There are nonsurgical treatments for plantar fasciitis. Most people who have plantar fasciitis are able to relieve heel pain without surgery.

Plantar fascia release surgery involves cutting part of the plantar fascia ligament to release tension and relieve inflammation of the ligament (plantar fasciitis). Your doctor can use medicine that numbs the area (local anesthetic) for the procedure. Plantar fascia release can be done by cutting the area (open surgery) or by inserting instruments through small incisions (endoscopic surgery).

Your doctor may advise you to have surgery if:

• You've tried other treatments for at least 6 months and it has not helped.
• Heel pain is affecting your ability to work or to do moderate exercise.

The plantar plate is a ligament in the ball of the foot that supports the joints where the toes connect to the foot. When the plantar plate tears, the toe can begin to move out of alignment. This is most commonly seen in the second toe.

Symptoms

• pain under the toe
• a knot or swelling under the toe
• second toe might start to move towards the big toe or even overlap
• toe is raised
• hammer toe
• difficulty fitting into shoes

Non-surgical Treatment

• rest
• ice
• taping/bandaging the toe
• pain medication
• wear stiff-soled shoes like hiking boots
• use orthotic inserts

Surgical Treatment
Plantar plate repair is done either through an incision on the top of your toe or through an incision under the ball of your foot. The procedure might require the cutting of the metatarsal bone to correct the alignment to relieve the pressure on the ball of the foot.

Source: https://www.footcaremd.org/conditions-treatments/toes/plantar-plate-tear

The posterior tibialis tendon is in your leg. It attaches the posterior tibialis muscle on the back of your calf to the bones on the inside of your foot. When you walk, it helps support your foot and arch. This tendon can tear or become inflamed, which can cause the arch of your foot to slowly fall. This can cause pain and swelling in the foot and ankle.

Treatment
Non-surgical treatments include:

• rest
• ice
• pain medicines
• a brace
• steroid injections
• physical therapy

Posterior tibialis tendon surgery may be recommended if the non-surgical methods brought no relief or complete healing.

There are several types of surgery, depending on location in the leg and how much the tendon is damaged.

• Gastrocnemius recession (lengthening of the Achilles tendon). The surgical lengthening of the calf muscles. Recommended for patients who have limited ability to move the ankle up.
• Tenosynovectomy. Recommended when there is mild disease, the foot shape hasn’t changed, and there is pain and swelling over the tendon.
• Tendon transfer. The damaged portion of the tendon is replaced with another tendon from the foot.
• Osteotomy (cutting and shifting bones). This utilizes bone cuts to change the shape of a flexible flatfoot to recreate a more "normal" arch shape.
• Fusion. This removes the cartilage in the joint. It realigns the foot and removes any arthritis.

Source:

• https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/posterior-tibialis-tendon-surgery
• https://orthoinfo.aaos.org/en/diseases--conditions/posterior-tibial-tendon-dysfunction

In some situations, like complicated diabetic foot problems, people need major reconstructive foot surgery. Our foot and ankle surgeons team with expert vascular surgeons, podiatrists, and orthopedic trauma surgeons when needed to help restore maximum function. With the level of experience and expertise that can only be found in a Level I trauma surgery center like ours, the most grave limb salvage cases from across Northern Connecticut are sent to our foot and ankle specialists.

The subtalar joint is just below the ankle joint, located between the talus bone and the calcaneus (heel) bone. The subtalar joint is what allows the foot and ankle to move side to side, which helps when you walk, especially on uneven surfaces.

Subtalar fusion surgery is done either to correct rigid and/or painful deformities or instability of the subtalar joint, or to remove arthritis. The surgery, which removes the subtalar joint, locks together the bones to alleviate pain and restore function.

Symptoms

• pain along the outer side of the foot just below the ankle
• frequent limp
• swelling in the area
• difficulty and pain while walking on uneven surfaces
• stiffness in the foot

Source: https://www.footcaremd.org/conditions-treatments/ankle/subtalar-fusion

The ankle joint is called the tibiotalar joint. It is where your shinbone, called the tibia, rests on top of a bone of your foot called the talus. As you age, the cartilage on the surface of these bones can wear away. Osteoarthritis or rheumatoid arthritis can also play a factor. It can result in pain, inflammation and swelling.

For people with osteoarthritis or rheumatoid arthritis who have been suffering with ankle pain and a lack of mobility, ankle replacement surgery (or ankle arthroplasty) is sometimes the answer. Some patients have already had an ankle fusion (arthrodesis), but then the ankle can’t move normally. Total ankle replacement surgery removes arthritic areas in the ankle joint and replaces them with implants. There are a number of these FDA-approved ankle replacement implants available, and our specialists are trained in all of them. We are experts who can help you decide whether a total ankle replacement can relieve your ankle pain, restore your range of motion, and return you to walking more normally.

If you have chronic ankle pain and swelling that is not relieved by non-invasive methods such as pain medication, special footwear, physical therapy, or corticosteroid injections, your doctor may recommend a total ankle replacement. Total ankle replacement surgery removes arthritic areas in the ankle joint and replaces them with implants. There are a number of these FDA-approved ankle replacement implants available, and our specialists are trained in all of them.

Source: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/ankle-replacement-surgery