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Chat with a Foot&Ankle Specialist

Online Health Chat with Dr. James Sferra

April 10, 2012

Introduction

Cleveland_Clinic_Host: A normal foot and ankle has 26 bones, 33 joints and more than 100 muscles, tendons and ligaments. The average person will walk the equivalent of four times around the world in his or her lifetime. So it’s hardly surprising that nearly three-quarters of Americans will eventually experience some type of foot problem. Take advantage of this opportunity to discuss common foot and ankle problems, latest treatments and advances and when a patient will need surgery, with a focus on different surgical options that a patient might consider.

Proper foot care is not something most of us think about until problems literally put us out of step. Yet, foot and ankle problems are among the most common health ailments. Virtually everyone will experience some degree of foot and ankle problems during their lifetime. Although some problems are inherited, many stem from a lifetime of accumulated abuse and neglect, such as wearing improper footwear or not seeking early medical attention.

James Sferra, MD, is a foot and ankle orthopaedic surgeon specializing in foot and ankle reconstructive surgery, fractures and sports injuries of the foot and ankle. Dr. Sferra graduated from Medical College of Ohio at Toledo and went on to complete an orthopaedic residency at Cleveland Clinic. He also completed a foot and ankle surgery fellowship at Medical College of Wisconsin in Milwaukee.

Dr. Sferra is an active member of the American Orthopaedic Foot and Ankle Society along with the American Academy of Orthopaedic Surgeons. He has served on AOFAS committees and has given graduate medical education courses on behalf of the AOFAS and AAOS.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist James Sferra, MD. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Possible Solutions for Foot and Ankle Pain

cherry: I often have pain on the tops of my feet, particularly first thing in the morning. What can be done to eliminate that?

Dr__Sferra: When you wake up before you get out of bed, loosen them up with movement prior to getting out of bed.

GroKenHaMMer: What can I do about an off and on numbness in my feet when walking? What helps aching ankles?

Dr__Sferra: On and off numbness, tingling, and burning in the feet usually are signs of neuropathy. In our country (US), the two top reasons are diabetes and alcohol overuse/abuse, but there are many other potential causes for neuropathy. If it is problematic, it is best to have it evaluated by your primary care physician or neurologist. NSAIDs and good supportive shoes can help aching ankles.

JMFeig: I pulled lots of tendons and ligaments in my ankle about 4 years ago. I later found out there was a fracture. I continue to have pain in that ankle, especially when exercising or walking distances. I also have very flat feet and have discomfort with that. Can you please advise what I can do to alleviate any of this pain?

Dr__Sferra: Chip fractures can occur with ligament tears. Inserts or orthotics might help, but it sounds like a more thorough evaluation is needed.

deedee0923: Will a neurostimulator help me with pain at all? Would seeing you or a doctor that you would suggest be a good idea for a second opinion?

Dr__Sferra: Typically, it is impossible to predict if an implanted nerve stimulator would help. A second opinion from a pain management physician would be my recommendation.

gayle1988: I am a 72-year-old male who suffered a severe ankle break 40 years ago that left me with limited motion in my left ankle. Twenty years ago, the pain in the ankle got so bad I had it fused. All of this has put a lot of strain on the joints in my feet as walking uphill caused me to walk on my toes. I now have a lot of pain in my feet and toes. Most of it is in the joints directly behind the toes in both feet and all along the side of my left foot. I had an X-ray by an orthopaedic surgeon. According to him, many of these joints are bone to bone. My question is this: Is there any treatment short of strong pain pills to treat this condition? I am very limited in how far or much I can walk. I would be glad to consider any possibility for relief.

Dr__Sferra: Tough problem. Joints close to a fused joint can sometimes become arthritic prematurely (bone on bone). Custom orthotics, a brace, rocker-bottom soled athletic shoe (running), and NSAIDs can all help decrease the pain. Sometimes, fusion of other joints in the foot can help decrease the pain.


Foot and Ankle Surgery

charliebabe: I have a fractured left ankle that is now arthritic and sometimes painful. Do they replace ankles like knees and hips?

Dr__Sferra: Yes.

Linguini: What is your opinion of the success rate in current ankle replacement technology?

Dr__Sferra: Total ankle replacements are getting better all of the time. On average, they last about 10 years compared to 20 years for hips & knees.

Linguini: How limiting to a person’s mobility is ankle fusion and what are the time limits for how long a person can remain active with fused ankles?

Dr__Sferra: Most people have a normal gait after an ankle fusion. There is definitely some loss of up/down motion of the ankle, but it is not usually as much as you would think. There are usually no activities that are limited after an ankle fusion except to discourage from performing repetitive impact aerobic activities (like running).

gayle1988: Is it possible to replace and ankle that has already been fused?

Dr__Sferra: It is possible but very rare and would require extenuating circumstances.

deedee0923: Is it too late for me? To sum up a long process I’ve had my right foot/ankle fused, twice. In total, I've had 4 major and 5 minor surgeries and I’m still in excruciating pain...can’t walk, drive, enjoy life in 2 years. My podiatrist said that he can’t do anything more for me and I am now about to have a neurostimulator implanted. Is there hope if this stimulator doesn’t work? I still question why I had to have 2 surgeries for fusion. Is this normal practice? My podiatrist all along has told me I am an extraordinary case that he has made many speeches and received many accolades from the work he has done on me. I just really wonder if I should get a second opinion or if it’s senseless because there would be nothing that could be done. I know I’m all over the board with my questions but this has depleted my life at the age of 45. I went in for surgery to get rid of pain and 2 years later I am now stuck with even worse pain and even more problems!

Dr__Sferra: This is a complex problem. It sounds as if you may have chronic regional pain syndrome. Unfortunately, sometime people have persistent pain despite appropriate surgical intervention. It can be a very frustrating problem for the patient and the physician. It sounds as if you are under the care of a pain management specialist and that is the appropriate doctor to see for this problem. Typically, after 9 surgeries on your foot, the 10th one is not very beneficial.

windycity: I have mid-foot collapse that has become filled with osteoporosis. I understand the only surgery that can be performed is fusing the bones, and that will not be good for the rest of the foot. Do you agree? What is the latest treatment for this type of foot problem? Also, how do you feel about steroid shots in the arthritic foot? I have been told that the foot can get infected and that this will be worse for the foot.

Dr__Sferra: Cortisone injections can be very helpful for arthritic joints in the foot, but there are three potential complications: 1- infection, 2- fat atrophy at the site, and 3- blanching (whitening) of the skin at the site, like a tattoo. All three are very rare. Fusion of the bones in a collapsed arch can provide excellent pain relief, and typically does not lead to other problems.

WEB22YZP: The cartilage in both of my ankles is worn out. I have tried cortisone injections, clean up surgery, and ankle braces. The doctor claims that I need either ankle replacement or ankle fusion. Which do you think is the best or do you think that there is another way to go? I am 71 years old.

Dr__Sferra: It sounds like your physician is correct in that you have tried all the appropriate treatment options. The only thing is either an ankle fusion or ankle replacement.


Medications for Foot and Ankle Pain

GroKenHaMMer: What can I do for an off and on slight numbness in the bottom of my feet when walking?

Dr__Sferra: It is most likely neuropathy, and can be from diabetes, alcohol consumption, or vitamin B deficiency. It should be tested and confirmed, and the underlying disorder treated. If there is no clear cause, there are several medicines that can be tried, but they have several side-effects.

WEB22YZP: Is there any proof that any of the herbal supplements bought over the counter can help severe arthritis in the ankles?

Dr__Sferra: Not that I am aware of.


Orthotics

martincito: Orthotics have helped me, I have been wearing them for many years because I have high arches. My question: Someone I know, who has very healthy feet, was told by his chiropractor he should get orthotics because he has one leg shorter than the other leg, by 1/4 inch. Would orthotics help this person? Would using orthotics alleviate joint aches and pain? There is absolutely nothing wrong with the person's feet.

Dr__Sferra: Orthotics can be used to equalize a leg length discrepancy (one leg longer than the other.) Usually, you correct a 1/4 inch discrepancy with an 1/8 inch lift.

Linguini: I have a very high arch in my feet and my Dr. says that is why I am prone to osteo arthritis onset. He also says that he would need to surgically lower my arch before an ankle replacement could be done. Is this true?

Dr__Sferra: High arches tend to cause more foot problems than flat feet. However, most of the time, high arches can be addressed with orthotics or inserts alone. It is unusual to require surgery for high arches unless there are additional problems present. Consider a second opinion.

carverp: What's the best type of OTC insert for a high arch and narrow foot?

Dr__Sferra: This is called supination of the foot. If you go to a shoe store such as New Balance, they carry inserts for supinators and pronators (flat arch.) They even make running shoes for these foot types as well.

Lenv: About 10 years ago I had a very painful situation with plantar fasciitis on the left foot. I had cortisone shots but did not help much. Then I wore orthotics (rubber attachments to the sole of the shoe) on both shoes. Apparently, this was enough because the pain went away for good. Now I am experiencing symptoms on the same foot that remind me of the plantar fasciitis pain. It has not reached the extreme paid I had before, but I am afraid that it will develop. The slight burning sensation is there. After 10 years, is there any orthotic product that I can wear inside the shoe? How do I select it? Should I wear it in both shoes? I do not want to ruin my dress shoes by attaching the rubber devices, if I can help it.

Dr__Sferra: I prefer orthotics in both feet for most foot problems. Plantar fasciitis does recur at times, and the mainstay of treatment remains: Wearing shoes at all times, Achilles stretching, heel cushions or over the counter orthotics, ice application daily, and a night splint to dorsiflex the foot while sleeping in bed at night.

carverp: I have been hiking a lot lately and this past week I was fitted for backpacking boots. Because I have a very narrow foot and a high arch, it was recommended that I get inserts made for my feet. My mother had her arches collapse in her 30’s when she was a skinny aerobics instructor. What should I do?

Dr__Sferra: It's a good idea to start with over-the-counter inserts for high arches, or supination of the feet. High arches rarely collapse, but can cause more foot problems than fallen arches, or pronated flat feet. If OTC inserts don't help, then custom inserts should be prescribed.


Plantar Fasciitis

cleclifan: I believe I've had plantar fasciitis since last July and that it was caused by daily flip- flop wear and a very long walk. Since then, I've tried taping the foot, only wearing sneakers with Dr. Scholl’s® inserts, and doing stretching exercises. Sometimes it seems to get a tiny bit better, other times it's back to all-day pain, not just on getting up from bed. Also sometimes the bone(s) along the outside of the foot on the edge hurt. What can I do? (I'm trying to avoid x-rays etc.) Thanks.

Dr__Sferra: It sounds like you may not be doing the full regimen for plantar fasciitis as described earlier. This needs to be done for at least 9 months. Custom orthotics may be your best bet.

sorefeet: In Sept. 2011, after X-rays were taken of my feet and lower legs, a podiatrist told me I had plantar fasciitis. He taped the perimeter of my feet and I continued with new tapings for a week. I discontinued the tapings because the tape caused the skin on my feet to blister. He also gave me some supports to put in my shoes (not custom orthotics). I wear the supports all the time but still have foot pain plus a burning sensation of my lower legs and feet at night. Voltaren Gel 1% offers enough relief so I can get back to sleep. I cannot take Diclofenac orally, as recommended by the podiatrist, because it bothers my stomach. After 6 months of pain, will this problem ever go away completely? Can you suggest any other treatments? I have not been back to the podiatrist.

Dr__Sferra: Again, plantar fasciitis treatment involves no bare feet, Achilles stretching exercises 5-6 times per day, ice application and a boot in bed at night. It sounds like you have a tape allergy and should avoid tape on the skin. Custom orthotics may be the answer. We usually try this for 9 months. A study done at Cleveland Clinic illustrated that after 9 months of this 95% people found relief.

SKBURMAN: I am 50 and have been exercising regularly, including running on a treadmill. For past few weeks, I have been feeling pain in my right heel. The pain is centered towards the lower side of the heel and I feel only when I run on the treadmill. I don’t feel any discomfort when I walk around. This started suddenly. Do you have any pointers?

Dr__Sferra: It sure sounds like plantar fasciitis. I prefer orthotics in both feet for most foot problems. Plantar fasciitis does recur at times, and the mainstay of treatment remains as follows: wearing shoes at all times, Achilles stretching, heel cushions or over-the-counter orthotics, ice application daily, and a splint to dorsiflex the foot while sleeping in bed at night.

Panther: Once plantar fasciitis symptoms have stopped, are the symptoms likely to return if you stop using the orthotics or go barefoot? In other words, is this a condition that is ever "cured" or is it necessary to continue all precautions indefinitely?

Dr__Sferra: DO NOT go barefoot! Barefoot is always bad news for plantar fasciitis. Yes – plantar fasciitis can be resolved.


Achilles Tendonitis

glarocca: I have been having heel problems for close to two years. The general consensus between family doctor, foot doctor and a sports medicine doctor is that it is Achilles tendonitis (although some have mentioned Achilles tendonosis, but this is not conclusive). I have had steroid treatment, cortisone shots, physical therapy and prolotherapy with no meaningful improvement. Although the pain is not debilitating, it is chronic and limits physical activity to the point where it has caused other problems such as high blood pressure, weight gain and high cholesterol. Recently I have tried to exercise on an elliptical 2-3 times a week with resistance at lowest setting. It has not seemed to make the problem any worse. My questions are 1) Am I risking further damage with moderate exercise and 2) are there any other treatment options?

Dr__Sferra: Initial conservative treatment for Achilles tendonitis is similar to plantar fasciitis, as outlined above. There are additional modalities to try, such as shockwave treatment, night splints, and the mainstay - Achilles stretching. If you are not having an increase in pain after exercise, then you are not making it worse.


Morton’s Neuroma

Panther: Please address Morton's neuroma and how (or whether) a person may recover the ability to walk long distances (at least several miles) after this diagnosis. What can be done if cortisone shots are not returning your foot to "normal"?

Dr__Sferra: Morton's neuroma usually happens between the 2nd & 3rd toe OR 3rd &4th toe on one foot or the other. Classically, you can relieve the symptoms by removing your shoe, which stops the pain. The cortisone should at least work temporarily or this may be an incorrect diagnosis. Surgery is the final solution for a Morton's neuroma. It involves cutting the nerve and implanting it into a non-weight bearing surface of the foot. It is usually a very successful surgery.

astridava01: If a person is diagnosed with having a Morton's neuroma, can it be corrected and treated entirely?

Dr__Sferra: Yes.

Panther: If cortisone injections don't help Morton's neuroma, and alcohol injections are suggested, what are the possible side effects of that? Would that be a good course of action to be able to return to long walking again without pain?

Dr__Sferra: The alcohol injections are designed to stop the nerve pain by deadening the nerve so that surgery may be avoidable. It is not something I perform.


Additional Questions Regarding Foot and Ankle Pain

ASC123: Questions about bunions: How long do you have to be off your feet when you have bunion surgery? Do you keep your feet on ice afterward? Is the surgery painful? Do they come back? Can you wear high heels afterward? If yes, how long do you have to wait? For people who do not have their bunions removed, do their toes eventually start to point at an angle or become deformed?

Dr__Sferra: Bottom line - there are literally 100 different bunion procedures that can be performed. The type of procedure determines the length of time for immobilization and non-weight bearing. Many factors go into the consideration of which procedure is performed for the individual person. This is a true question for consultation.

b1cott: My son had a stress fracture in the 4th metatarsal on his right foot. An MRI indicated that it has healed but it is still sore. Should he continue now with playing baseball? Any specific suggestions?

Dr__Sferra: This can be more complex than the question sounds. A thin slice CT scan through the fracture would be a better test to evaluate whether or not it is completely healed. It is not unusual to have some discomfort in an area of a stress fracture even if it has healed.

Panther: What helps cramping feet when swimming?

Dr__Sferra: Stretching and hydration. Cramping may be for a number of different reasons. Also, ask the coach for suggestions.

Johnmcintyre: I was in a car accident several years ago. My foot was crushed under a car. Reparative surgery placed temporary pins and I wore a walking cast for 6 weeks. After that the pins were removed. The upper instep of my foot was left in some discomfort. Over the years it has worsened. The doctor at the time said that foot would be more prone to arthritis. About 5 years ago I had a staph infection that "settled" in that joint on the top of my foot across the instep. The fluid/infection was drained out with a syringe but ever since then the pain and discomfort has worsened. I actually seem to walk on the outer part of my foot to a degree which then makes my ankle unstable. Any suggestions?

Dr__Sferra: You may have post-traumatic arthritis in the foot, on top of an infection in the foot - which may make it even worse. Anti-inflammatories, orthotics and potentially surgery may be necessary.

Rebecca: Within the last six months I have developed what seems to be a higher mass of bone on one foot. I have also developed considerable pain walking. The foot doctor didn't seem concerned about the way the bone has developed and didn't have any answers for the pain. He did say the arthritis was pretty bad. What gives?

Dr__Sferra: I am not sure of the description of a “higher mass.” This needs to be evaluated - consider a second opinion.

glarocca: What is PRP therapy? Does it have a good success rate?

Dr__Sferra: It seems to work best in young, active individuals for very specific problems. It is definitely not the first line of treatment and usually not covered by insurance.

Lakeside22: I have a large, hard "bump" on the top of my foot that has been there for about two years. There is no pain associated with it.

Dr__Sferra: Most likely it is a ganglion cyst but should be evaluated by your PCP initially.

charliebabe: I am 64 and have what appears to be a "wart" like growth between my little toe and the one next to it -- my doctor said might be fungal and prescribed fungus cream which seems to work -- should I see a podiatrist or a dermatologist to have it removed?

Dr__Sferra: Either would be beneficial - and it could be either of the things you describe.

b1cott: Is there a typical period for the discomfort after a foot stress fracture heals?

Dr__Sferra: Maybe an additional 6 weeks would be the standard - but it should be improving all the time.

mnr98: The nail on one pinky toe has gotten thicker and thicker over the years. It is now pretty thick. It is not discolored or seem to have any kind of fungus or something of that nature. It does not hurt. Is this something I should be worried about? Why would it thicken like this and how can I stop it from getting worse?

Dr__Sferra: It sounds like it may be a fungal nail problem. I would suggest seeing a podiatrist.

Panther: How does a lay person know whether and when to use an orthopedic MD versus a podiatrist?

Dr__Sferra: Orthopaedic foot & ankle surgeons are sparse. Many routine foot & ankle problems can be handled by a general orthopaedist or a podiatrist.

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. James Sferra is now over. Thank you for taking the time to answer our questions today about foot and ankle problems.

Dr__Sferra: These were great questions - thank you!

Panther: Thank you Dr. Sferra and Cleveland Clinic! This was my first time for a chat, and it was very helpful.


More Information

To make an appointment with Dr. Sferra or any of the other specialists in our Foot and Ankle Center at Cleveland Clinic, please call 866.275.7496. You can also visit us online at clevelandclinic.org/ortho

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