Answers for Foot & Ankle Pain
March 25, 2014
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. It is likely that the majority of people will experience some degree of foot and ankle problems during their lifetime.
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. In athletes, these problems are even more common.
Some of the more common foot problems involve ingrown toenails, bunions or warts. Medical conditions such as diabetes and arthritis typically affect the foot and ankle. More complex problems of the foot and ankle may involve diabetic ulcers, infections and conditions such as tendinitis or flat feet, which require surgery. Inherited foot and ankle problems include club foot and hammer toe among others. Add to this the numerous injuries that occur regularly, including sprains and fractures, and it is clear that we rely heavily on the health of our two feet and ankles.
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. Proper assessment and treatment of problems are critical to foot and ankle health.
About the Speakers
Mark Berkowitz, MD, is a board certified orthopaedic surgeon, specializing in foot and ankle reconstructive surgery, arthritis, fractures and sports injuries of the foot and ankle, at Cleveland Clinic. Dr. Berkowitz completed a foot, ankle, and lower extremities trauma fellowship at Florida Orthopaedic Institute, in Tampa, Fla., following his residency in orthopaedic surgery at Tripler Army Medical Center, in Honolulu. He graduated from medical school at Case Western Reserve University School of Medicine, in Cleveland. Dr. Berkowitz sees patients at Cleveland Clinic main campus.
Arjun Srinath, MD is a foot and ankle orthopaedic surgeon, specializing in total ankle replacement surgery, rheumatoid foot disorders, fractures, and sports injuries of the foot and ankle. Dr. Srinath completed his foot and ankle fellowship at the Institute for Foot and Ankle Reconstruction/Mercy Hospital in Baltimore, Md, after completing his orthopedic surgery residency at the University of Kentucky School of Medicine, in Lexington, Ky. Dr. Srinath is a graduate of the State University of New York College of Medicine, in Syracuse, NY. He sees patients at Cleveland Clinic Florida, in Weston, Fla.
Let’s Chat About Answers for Foot and Ankle Pain
Foot Arthritis Diagnosis
barbararita: I have been diagnosed with arthritis in my feet, which is very painful —especially on the top of the feet. My doctor ordered regular X-rays, and I have had blood work to rule out rheumatoid arthritis (which came back negative). Are there any other imaging studies that would help me with my diagnosis? My left foot feels like there is a broken bone—especially when I get out of the car and start to walk. I had a Jones fracture in my right foot years ago and this feels the same.
Arjun_Srinath,_MD: If it is just arthritis, an X-ray is fine. However, an MRI may be helpful to look at the soft tissue structures, and to rule out a stress fracture if your pain is severe.
pilatesgirl: What are your thoughts about bunions? Are they genetic as well as caused by the type of shoe?
Mark_Berkowitz,_MD: Bunions are related to both genetics and choice of footwear. Sometimes one or the other predominates. In a teenager, the cause is usually genetics. In a 50-year-old woman, it is usually shoes. In both cases, the initial treatment is nonsurgical in the form of wider shoes. Surgical treatment can be considered if symptoms persist.
Flat Feet Progression of Symptoms
jpaque: I have flat feet and teach fitness classes. I jump most of the time, and I often experience shin splints. Can flat feet create more problems throughout your body?
Mark_Berkowitz,_MD: Shin splints are associated with flat feet. It is important to really stretch your calves out before doing high-impact activities like jumping.
Fractures of the Foot and Ankle
dashone: How long should one expect the healing process to be for a high malleolus fracture of the fibula and dislocation of the left ankle? I am a female, who is 45 years old with multiple sclerosis (MS). I had to take steroids due to involuntary muscle twitching caused by stress and later developed pneumonia. I fell in January of this year and I am still not allowed to put any weight on it. The swelling is still diminishing.
Mark_Berkowitz,_MD: Generally, it will take three months for bones to heal, so things are going as expected. I would expect that at three months weight bearing will be allowed, and therapy will be initiated. However, the steroids do slow things down.
pilatesgirl: I had a foot fracture when I was 32 years old related to a jump and landing. In 1987, a lot less was known about bone density issues. My calcareous bone split in half and the talus got jammed between. My surgery was successful and I have good daily function despite fusion. In 1999 I discovered I had undiagnosed celiac disease causing bone density compromise. I believe this along with valgus (flat) feet created this "perfect storm" for this fracture to be so severe. When I was a child I once felt like my bones clanged together painfully when I jumped. I wonder if that was an early warning sign of some malfunctioning cartilage or positioning in that joint. All these years later I have wondered. Do you have any thoughts about this with the greater knowledge in your profession now?
Mark_Berkowitz,_MD: Honestly, I think your injury was an isolated traumatic event unrelated to the other issues. It sounds like a high energy injury which produces bad fractures regardless of bone quality. Poor bone quality is more likely to cause fractures from low energy events such as walking.
Nerve Pain and Post-herpetic Neuralgia
johnnnita: One night, while sitting at my computer, I started feeling a strange vibrating on the bottom of my right foot. This continued intermittently, but somewhat every minute or two until I went to bed. While this was happening, I searched the internet and discovered many people experience this. The next morning my foot was fine. I haven't felt anything like that since. What was that all about?
Mark_Berkowitz,_MD: It sounds like your foot fell asleep. If a nerve is compressed from sitting in an unusual position, it will cause tingling sensations like the one you had.
chambiges: I have post-herpetic neuralgia as a result of shingles that damaged the nerves in my right foot five years ago. I was 50 years old when I had shingles. I received a shingles vaccination one year after I that episode. I suffer constant burning and shooting pain in my right foot. Also, the toes on my right foot are paralyzed as a result of the shingles. They also have burning pain and hypersensitivity. I have tried the standard-of-care medicines, including Neurotin® (gabapentin), nortriptyline hydrochloride, and Lyrica® (pregabalin), but none of them helped ease my relentless pain. I am very discouraged. Is there any method of treatment for post-herpetic neuralgia that can successfully treat my pain? I would gladly join a clinical trial if there is some new promising treatment being offered somewhere.
Mark_Berkowitz,_MD: Unfortunately, there are no surgical treatments that I am aware of. I would recommend evaluation by a neurologist and/or pain management specialist to determine what the latest and greatest treatment options are.
xdwl: I have intermittent pain in my left big toe (in the joint of the big toe) that began three months ago with no clear cause. It happens suddenly every time. It is an intense pain—like a cutting pain. It usually lasts for a few seconds. Gentle massage can relieve the pain sometimes. The skin is normal. My uric acid level and X-ray are normal. My doctor does not think I have gout, but may have tarsal tunnel syndrome. I tried to avoid placing my foot in an over-pronated position. It reduced the pain frequency for the first a few weeks, but the pain is recurrent again now. I searched an internet patients' forum and discovered that many people suffer from the same problem. But nobody knows what the cause is and how to treat it. I would like to get your advice on what may be the problem? Is there any treatment that could help?
Mark_Berkowitz,_MD: This is an unclear situation. A meticulous physical exam and a review of your X-rays would be necessary to rule out structural causes such as arthritis. It does not sound like tarsal tunnel syndrome. Whatever the cause, it sounds subtle and will require a thorough hands-on evaluation.
Emergency Care of the Foot
Alucard: I had a piece of glass stuck in my foot, but I got it out. I took all the steps to treat it, but now something is happening with it. What should I do?
Mark_Berkowitz,_MD: You should have it reevaluated. It is common for small pieces to be retained. An MRI can often provide useful information about what else might be happening.
Orthotics and Foot Wear
pilatesgirl: Do you have any thoughts on full or partial foot lifts with short leg situations related to surgical changes? Do you find one works better than the other?
Mark_Berkowitz,_MD: I usually have the patient go to an orthotist to either put a lift in the shoe for small deficits or build up the outer part of the shoe for bigger discrepancies. In general, smaller discrepancies are easier to tolerate than larger ones.
dashone: Are there places that will help a person select the right shoes for given conditions?
Mark_Berkowitz,_MD: You want to look for a good quality shoe store. This will vary by region. A podiatrist or orthopaedic surgeon in the area will likely be able to recommend a good store. Some chains specialize in good shoes such as Foot Solutions or the Walking Store. These are good places to start.
pilatesgirl: What do you think about high-heeled shoes for women?
Mark_Berkowitz,_MD: If they feel OK, go for it. But if they cause pain, then look for something more comfortable. Listen to your body.
lightning#: I have been diagnosed with Ehlers-Danlos syndrome, hypermobility type 3. I have foot pain more or less all of the time. I have used custom orthotics and soft orthotics (which work well) with some success, but I have had to stop walking—which I enjoyed. The best shoes for me are the SAS brand. But it is very troublesome to wear lace-up shoes even though I need more support. Consequently, I am in sandals year around. Do you have any suggestions? It's not easy to find a doctor who understands this situation.
Mark_Berkowitz,_MD: I would look for supportive sandals if those feel the best. Brands, such as Keen, Merrell, and Chaco, all make supportive sandals that might fit your needs. It is a trial-and-error situation, so you will have to experiment. I recommend using Zappos free shipping and free return policy to your advantage.
Achilles Tendonitis Treatment
boopthenight: I have several painful chronic conditions that have kept me from doing what I love to do—gardening, walking, and being outside. I have had severe Achilles tendonitis for over ten years. A chiropractor recently tried to help by suggesting a certain technique that was to break up the scar tissue and with stretches was supposed to directly line up the scar tissue. After eight very painful treatments and taking Lortab® (hydrocodone bitartrate/acetaminophen) that did not take all of the pain away, I told the doctor that I could not take the inflammation and pain. It was much worse than before the treatments. I have huge lumps in both heels. I have paid twice for custom-made orthotics at $400 each. I have had MRIs and X-rays. I have worn several different splints to bed. I wear a brace or a support piece on my left foot and ankle, which is the worst ankle. I know this is now chronic. The chiropractor mentioned that Levaquin® (levofloxacin) may have caused this. I have taken this medication three times in the last ten years. Can you help me?
Mark_Berkowitz,_MD:It sounds like you have insertional Achilles tendon degeneration. Unfortunately, this is often a condition that persists despite nonsurgical treatment. I think it is time to see a surgeon for an evaluation that will likely start with an MRI and then a discussion of surgical treatment options. Levaquin® is associated with tendon rupture, but this is likely a chronic condition you have.
Ankle Arthritis Treatment
sinaihospital: I have had arthritis in my right ankle since 1999. I have tried medicine, injections, therapy, and braces for it, but it didn’t work or help me. Can surgery help me fix my ankle arthritis in this case? Who does this surgery? Is it an outpatient or inpatient surgery?
Mark_Berkowitz,_MD: There are surgeries for ankle arthritis—generally either joint replacement or fusion. Both are performed by orthopaedic surgeons, usually with an overnight stay in the hospital. Recovery is three months to heal and followed by three to six months of rehabilitation.
Hallux Rigidus (Toe Arthritis) Treatment
dashone: Can you discuss hallux rigidus? I have been diagnosed with stage 3 hallux rigidus. Sometimes even at rest I experience stabbing pains. I would be interested in treatment options and considerations.
Arjun_Srinath,_MD: Hallux rigidus is arthritis of the great toe. Nonsurgical treatment consists of cortisone injections, stiff shoes, and nonsteroidal anti-inflammatory drugs (NSAIDs). However, if you have pain at rest and are at stage 3, you may consider surgery. The most reliable procedure is a fusion of the great toe. It takes away pain, but you will lose motion of the toe—something to consider depending on your activity level.
Bone Spur Treatment
Lacey: What can be done to relieve spur pain?
Mark_Berkowitz,_MD: It depends on the location. In general, padding is the key—particularly if it is on the bottom of the foot. Commercial gel pads really help and are relatively easy to find.
robtoby: I have a bunion that flares up perhaps once a year. Is there any preventative things that I can do to perhaps prevent these flare ups? I do wear very supportive shoes with a large toe box.
Mark_Berkowitz,_MD: Sounds like you are already wearing sensible shoes, but pads can also be worn to decrease the pressure. If it is only happening once per year, you are probably already doing something right.
JonCas: I have a bunion on my left foot, my toes are shifted to the left, and now I am developing a hammer toe on my second toe. What can I do to prevent this from progressing further? I am also developing a bunion on my right foot. I always wear supportive shoes and have no history of wearing pointy or tight shoes. The bottom pads of my feet also hurt a lot now. Does being in my 70s have something to do with all this?
Arjun_Srinath,_MD: You are on the right track with supportive wide shoes. You can try to use a spacer to limit pressure from the bunion, but this is not always successful. A gel pad may help the bottom of your feet. As we get older we can lose the fat pad on the bottom of our foot.
eileena: Can you speak about the treatment for severe bunions? If one is not a candidate for surgery, are there other treatments? If you elect surgery what should one expect in terms of recovery time, recurrence, or unexpected consequences?
Arjun_Srinath,_MD: With most bunions, nonsurgical treatment involves finding wide shoes that do not put any pressure in the area. After surgery for severe bunion—which is usually a fusion procedure, you would need to stay off the foot for six weeks, then start walking in a boot and start physical therapy. Risks after severe bunion correction include a small chance of recurrence, delays in healing, and swelling.
eileena: Could you please talk about new techniques for treating severe bursitis? If the patient is not a good candidate for surgery, are there any treatments that can help?
Mark_Berkowitz,_MD: It all depends on the location of the bursitis. Bursae are fluid-filled sacs that are present in many locations in the body. In the foot the most common symptomatic location is the back of the heel where the Achilles tendon attaches. Standard nonsurgical treatment for bursitis usually involves brief immobilization, anti-inflammatory medication, rest, stretching and footwear (shoe) modification. These interventions usually help. If these treatments are not sufficient, the next step is usually an MRI to determine if surgery is an option.
Flat Feet Treatment
jpaque: I have flat feet and now one of my foot is experiencing pain when I walk? What problems can flat feet lead to over time?
Mark_Berkowitz,_MD: Most flat feet are well tolerated. If they do become painful, the first line of treatment involves arch supports and supportive shoes along with weight loss and low impact aerobic exercises.
spurbes: I have extremely flat feet which makes balance in yoga very difficult and daily workouts sometimes painful. Do you suggest a certain shoe or insole? Is there an exercise to help with the balance issue?
Mark_Berkowitz,_MD: It is good that you are already doing yoga. This is a great exercise for the foot in general and for flatfeet in particular. I would recommend continuing with the yoga, but modifying the pad you are using. You probably need a much thicker pad. The best pad available is the Manduka brand. I would consider purchasing this pad, and then stacking it on top of a thick workout mat or multiple yoga mats until your feet feel comfortable. If you are still uncomfortable, you can still do yoga with a padded sandal on and still get the benefits.
spurbes: Could my tight hip flexors be a result of running and training with flat feet?
Mark_Berkowitz,_MD: Tight hip flexors are endemic to runners and people who sit a lot at work. I don't think it is related to your flat feet. I would recommend an aggressive stretching program such as yoga, which really helps open up the hips and is good for the feet as well.
jpaque: Do you recommend to have surgery for flat feet? What would be the process?
Arjun_Srinath,_MD: It depends on the amount of pain and severity of the deformity. You always want to try inserts, braces, and so on as your first choice. If there is no pain, usually we do not recommend surgery. If it is painful, surgery consists of realigning the foot with bone cuts and moving tendons or fusing the bones in a better position.
Hammer Toe Treatment
jpaque: What are the best and effective options to treat a hammer toe? I have a friend that has hammer toes in both feet!
Arjun_Srinath,_MD: If the hammer toe is not painful, then I recommend leaving it alone. If it is painful, the first thing to try is an over-the-counter toe straightener or gel sleeve to make it more comfortable. Surgically, the toe can be straightened with a fusion or by cutting the bone and creating space at the joint. Both are effective procedures depending on surgeon preference.
Peroneal Tendon Treatment
sadiegrey: I have Marfan syndrome and connective tissue disease. In 2009, I was just walking fast and my ankle barely turned on me. It kept hurting and so I couldn't bear any weight on it. I was in bed for weeks, and then an MRI showed a split peroneous brevis tendon. Due to atrial fibrillation and many other medical problems, as well as my age (72 years old), my orthopaedic doctor treated me with phonophoresis with steroids three times per week for six weeks. I got somewhat better, but if walk too much my ankle becomes swollen and hurts acutely.
I have now had five platelet-rich plasma (PRP) injections in my foot, which seems to help about 25 percent. (I had PRP injections in my knee joints for loss of cartilage, which really helped me and I was very happy with those results.) My ankle has gotten much worse. I had an MRI in 2013. I had two more PRP injections with the orthopaedic doctor and pain management, but have doubts will heal this torn tendon. I have nerve damage and neuropathy in both feet, but I am not diabetic. I use a wheelchair for going distances. What is your opinion on the healing of the tendon with the platelet-rich plasma injections? Do you have any other suggestions?
Mark_Berkowitz,_MD: Peroneal tendons have poor healing capacity. Most treatments are rather designed to decrease symptoms. Thus, if your symptoms are not improved, surgical treatment can be reevaluated. Unfortunately, you do seem to have some significant comorbidities. This will have to be assessed as well.
Plantar Fasciitis Treatment
robtoby: What are the best treatments for plantar fasciitis?
Mark_Berkowitz,_MD: There is one best treatment. Plantar fascia specific stretching of the bottom of the foot is 90 percent successful when paired with avoidance of barefoot walking, use of gel heel pads, weight loss, low impact aerobic activity (such as swimming), and use of good shoes. However it does take about 90 days to see improvement.
Posterior Tibial Tendon Dysfunction (PTTD) Treatment
Ladysmithfair: How much movement will there be after surgery to correct stage 3 posterior tibial tendon dysfunction (PTTD)?
Mark_Berkowitz,_MD: After a triple fusion, hind foot motion is largely eliminated. However, up and down motion from the ankle is preserved.
Ladysmithfair: I had total knee replacement recently. I also have posterior tibial tendon dysfunction (PTTD), which seems to be twisting my knee. Do you have any suggestions to correct this besides surgery? I wear Arizona AFO™ boot which helps, but still allows twisting.
Mark_Berkowitz,_MD: If the deformity (twist) is severe, it may not be able to be controlled by a brace such as the Arizona AFO™. There are other AFOs (ankle-foot orthosis) that may be tried as an alternative. Surgery is always a last resort based on the persistence of symptoms if the braces don't help enough.
Subtalar Fusion Surgery
pilatesgirl: I have a subtalar fusion that was created in 1978. I am doing well after all these years with no arthritis or pain. Do you have experience with fusion surgery and post-surgical outcome? Is this surgery still performed? Are artificial joints ever put into place? Do you have any updated advice for me as I look forward to aging? I have an active walking life. I can run if needed, but do not do that as a sport. I do yoga with some challenges in standing poses, related to my lack of subtalar motion. I would love to do my best to keep excellent functioning levels and health. I still have two long screws and a staple in my foot.
Arjun_Srinath,_MD: Yes, we still do the subtalar fusion quite often. There is no artificial joint for this. It is a reliable procedure with good outcomes as you have experienced. A subtalar fusion puts you at a higher risk of developing arthritis in other joints in the foot, so staying with low-impact exercises as you are doing is the way to go.
Tarsal Tunnel Syndrome (TTS) Treatment
johnnnita: About a year ago, after discovering I had a foot infection from a bad case of athlete's foot (including a toenail infection) and being treated successfully with prescription Lamisil® (terbinafine hydrochloride), I had a tingling sensation that would not go away in my left foot. My dermatologist referred me to a podiatrist, who diagnosed tarsal tunnel syndrome (TTS) by tapping until he caused a reaction, perhaps caused by a "compression". After wearing both support hose and shoe inserts, the tingling sensation receded and then disappeared for about ten months. I've stopped wearing the support hose for several months, but I do wear the shoe inserts on occasion. That said, the tingling has not returned. I was under the impression that this TTS was permanent. Is it possible for it to not return or return?
Mark_Berkowitz,_MD: TTS is an unusual diagnosis, so it is hard to confirm that it was actually present. If compression is relieved from a nerve by wearing better shoes, arch supports, etc., then the symptoms can go away permanently. Likewise, the symptoms can recur if these measures are not utilized.
Toe Positioning Treatment
Trykkergirl: Short of surgery, what can be done to keep the second toe from going under the big toe?
Mark_Berkowitz,_MD: Short of surgery, there are straps and braces to hold the great toe and second toe in a correct position.
Trykkergirl: Where can I buy braces or straps to hold my second toe to the great toe?
Mark_Berkowitz,_MD: Look for websites such as www.footsmart.com. These online stores will have a variety of braces to choose from.
Athlete’s Foot Prevention
johnnnita: Now that I don't have the tingling sensation in my left foot nor athlete's foot infection, what else can I do to avoid what has happened before? What should I not do as well?
Mark_Berkowitz,_MD: Avoiding athlete’s foot involves keep the foot clean and dry with regular preventative use of Tinactin® (tolnaftate) and frequent changing of socks. This should keep you out of trouble.
robtoby: I have gout that flares up once every few years (maybe every three years). My uric acid levels are fine. I try to stay away from shellfish and don't drink alcohol. I rarely— if ever—eat red meat. Is there anything else I can do to prevent these flare ups?
Mark_Berkowitz,_MD: You need to be evaluated by a rheumatologist to determine if you need a medicine to chronically lower your uric acid levels. This would help decrease flare-ups.
Acupuncture for Ankle Arthritis
PERTY 1929: I have a painful arthritic ankle. I use a cane, limp, and my balance is not good. I am 85 years old. When my pain gets bad, my doctor gives me a cortisone shot which helps for only a short period of time. My wife and I would like to know if acupuncture might relieve the pain, soreness, and help in a significant way. Is it worth a try?
Mark_Berkowitz,_MD: Acupuncture may be worth a try as it will likely not worsen the problem and may help. Braces and aquatic therapy are also critical parts of nonsurgical treatment.
Moderator: I'm sorry to say that our time with Dr. Mark Berkowitz and Dr. Arjun Srinath now over. Thank you both for taking the time to answer questions today.
Arjun_Srinath,_MD: Thank you for all of the great questions.
Mark_Berkowitz,_MD: Thank you for chatting and for all of your great questions today!
To make an appointment with Dr. Berkowitz or any of the other specialists in our Department of Orthopaedic Surgery at Cleveland Clinic, please call toll-free 866.275.7496, you can also visit us online at clevelandclinic.org/ortho.
To make an appointment with Dr. Srinath or any of the other specialists in our Department of Orthopaedic Surgery at Cleveland Clinic Florida, please call toll-free 877.463.2010, you can also visit us online at clevelandclinicflorida.org.
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