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Think You Have Pes Planus?

July 5, 2017
Overview

Adult Acquired Flat Feet

Fallen arches, or flat feet as they are often referred to, are a structural deformity whereby the arch of the foot lags or collapses. It?s very common, can be painful or not, can lead to a string of other ailments, but it is easily corrected. It is not more common in sports people or people who are overweight, but you knew all that, right?

Causes

Just as there are many different causes of flat feet, there are also many different treatment options. The most important aspect of treatment is determining the exact type or underlying cause of flat feet that you have. Foot and ankle specialists can determine this through thorough clinical examination and special imaging studies (e.g., x-rays, computed tomography, and/or magnetic resonance imaging). Conservative treatment is effective in the vast majority of flat foot cases, and consists of things such as insoles, splints, manipulation, or casting. Surgery is required much less frequently, and is reserved only for some of the severe types of flat foot that do not respond to conservative therapy. You may have noticed that one common element in the conservative treatment of all types of flat feet is orthoses. Many companies now manufacture semi-custom orthotic devices that not only improve comfort, but also seek to control abnormal motion of the foot. These over-the-counter inserts, in the $25 to $50 range, are an economical treatment that may help a majority of people. Unfortunately, these semi-custom devices will not fit everyone perfectly, and those of us who differ too much from the average may respond better to custom orthotic devices. Custom inserts are prescribed by your foot and ankle specialist and are made individually from either a physical or computerized impression of your feet. The only drawback of custom orthoses is their cost, ranging anywhere from $300 to $500. Many physicians recommend trying over-the-counter inserts first (and even keep them in stock) as they may save their patients large sums of money.

Symptoms

The primary symptom of fallen arches is painful or achy feet in the area in which the foot arches or on the heel. This area may become swollen and painful to stand still on. This causes the patient to improperly balance on their feet which in turn will cause other biomechanical injuries such as back, leg and knee pain.

Diagnosis

Runners are often advised to get a gait analysis to determine what type of foot they have and so what kind of running shoe they require. This shouldn?t stop at runners. Anyone that plays sports could benefit from this assessment. Sports shoes such as football boots, astro trainers and squash trainers often have very poor arch support and so for the 60-80% of us who do overpronate or have flat feet they are left unsupported. A change of footwear or the insertion of arch support insoles or orthotics can make a massive difference to your risk of injury, to general aches and pains and even to your performance.

pes cavus

Non Surgical Treatment

Switch activities for a little while. If you?re a super athlete, you don?t want to hear that you need to take a break, but there?s no way around it. You need to lay off the high impact sports like basketball, tennis and running. Don?t panic-there?s no shortage of alternatives. Find a high school track that?s open to the public and try going for a run. Many athletic programs use spongy synthetic materials to pave tracks instead of concrete. This is much easier on all the joints and tendons, not only in your feet but your legs and ankles. You can also try running on dirt trails or stable grassy areas. Take up swimming for a little while. This is actually an ideal activity for your arches. The buoyancy of water takes weight off our feet, but still allows for aerobic activity. Many gyms and activity centers also offer various water sport classes. In no time flat, you?ll be on your way to healthier feet.

Surgical Treatment

Flat Feet

A better approach is to strengthen the weakened ligaments with Prolotherapy, supplemented by an arch support if the condition has existed for several years. Chronic pain is most commonly due to tendon and ligament weakness, or cartilage deterioration. The safest and most effective natural medicine treatment for repairing tendon, ligament and cartilage damage is Prolotherapy. In simple terms, Prolotherapy stimulates the body to repair painful areas. It does so by inducing a mild inflammatory reaction in the weakened ligaments and cartilage. Since the body heals by inflammation, Prolotherapy stimulates healing. Prolotherapy offers the most curative results in treating chronic pain. It effectively eliminates pain because it attacks the source: the fibro-osseous junction, an area rich in sensory nerves. What?s more, the tissue strengthening and pain relief stimulated by Prolotherapy is permanent.

After Care

Patients may go home the day of surgery or they may require an overnight hospital stay. The leg will be placed in a splint or cast and should be kept elevated for the first two weeks. At that point, sutures are removed. A new cast or a removable boot is then placed. It is important that patients do not put any weight on the corrected foot for six to eight weeks following the operation. Patients may begin bearing weight at eight weeks and usually progress to full weightbearing by 10 to 12 weeks. For some patients, weightbearing requires additional time. After 12 weeks, patients commonly can transition to wearing a shoe. Inserts and ankle braces are often used. Physical therapy may be recommended. There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications following flatfoot surgery may include wound breakdown or nonunion (incomplete healing of the bones). These complications often can be prevented with proper wound care and rehabilitation. Occasionally, patients may notice some discomfort due to prominent hardware. Removal of hardware can be done at a later time if this is an issue. The overall complication rates for flatfoot surgery are low.

Leg Length Discrepancy Heel Lifts

June 30, 2017
Overview

The bone is lengthened by surgically applying an external fixation device to the leg. The external fixator, a scaffold-like frame, is connected to the bone with wires, pins, or both. A small crack is made in the bone and the frame creates tension when the patient or family member turns its dial. This is done several times each day. The lengthening process begins approximately five to 10 days after surgery. The bone may lengthen 1 millimeter per day, or approximately 1 inch per month. Lengthening may be slower in a bone that was previously injured. It may also be slower if the leg was operated on before. Bones in patients with potential blood vessel abnormalities, such as cigarette smokers, may also need to be lengthened more slowly. The external fixator is worn until the bone is strong enough to support the patient safely. This usually takes about three months for each inch. Factors such as age, health, smoking and participation in rehabilitation can affect the amount of time needed.Leg Length Discrepancy

Causes

Some causes of leg length discrepancy (other than anatomical). Dysfunction of the hip joint itself leading to compensatory alterations by the joint and muscles that impact on the joint. Muscle mass itself, i.e., the vastus lateralis muscle, pushes the iliotibial band laterally, causing femoral compensations to maintain a line of progression during the gait cycle. This is often misdiagnosed as I-T band syndrome and subsequently treated incorrectly. The internal rotators of the lower limb are being chronically short or in a state of contracture. According to Cunningham's Manual of Practical Anatomy these are muscles whose insertion is lateral to the long axis of the femur. The external rotators of the hip joint are evidenced in the hip rotation test. The iliosacral joint displays joint fixations on the superior or inferior transverse, or the sagittal axes. This may result from many causes including joint, muscle, osseous or compensatory considerations. Short hamstring muscles, i.e., the long head of the biceps femoris muscle. In the closed kinetic chain an inability of the fibula to drop inferior will result in sacrotuberous ligament loading failure. The sacroiliac joint dysfunctions along its right or left oblique axis. Failure or incorrect loading of the Back Force Transmission System (the longitudinal-muscle-tendon-fascia sling and the oblique dorsal muscle-fascia-tendon sling). See the proceedings of the first and second Interdisciplinary World Congress on Low Back Pain. Sacral dysfunction (nutation or counternutation) on the respiratory axis. When we consider the above mentioned, and other causes, it should be obvious that unless we look at all of the causes of leg length discrepancy/asymmetry then we will most assuredly reach a diagnosis based on historical dogma or ritual rather than applying the rules of current differential diagnosis.

Symptoms

The patient/athlete may present with an altered gait (such as limping) and/or scoliosis and/or low back pain. Lower extremity disorders are possibly associated with LLD, some of these are increased hip pain and degeneration (especially involving the long leg). Increased risk of: knee injury, ITB syndrome, pronation and plantar fascitis, asymmetrical strength in lower extremity. Increased disc or vertebral degeneration. Symptoms vary between patients, some patients may complain of just headaches.

Diagnosis

There are several orthopedic tests that are used, but they are rudimentary and have some degree of error. Even using a tape measure with specific anatomic landmarks has its errors. Most leg length differences can be seen with a well trained eye, but I always recommend what is called a scanagram, or a x-ray bone length study (see picture above). This test will give a precise measurement in millimeters of the length difference.

Non Surgical Treatment

Internal heel lifts: Putting a simple heel lift inside the shoe or onto a foot orthotic has the advantage of being transferable to many pairs of shoes. It is also aesthetically more pleasing as the lift remains hidden from view. However, there is a limit as to how high the lift can be before affecting shoe fit. Dress shoes will usually only accommodate small lifts (1/8"1/4") before the heel starts to piston out of the shoe. Sneakers and workboots may allow higher lifts, e.g., up to 1/2", before heel slippage problems arise. External heel lifts: If a lift of greater than 1/2" is required, you should consider adding to the outsole of the shoe. In this way, the shoe fit remains good. Although some patients may worry about the cosmetics of the shoe, it does ensure better overall function. Nowadays with the development of synthetic foams and crepes, such lifts do not have to be as heavy as the cork buildups of the past. External buildups are not transferable and they will wear down over time, so the patient will need to be vigilant in having them repaired. On ladies' high-heel shoes, it may be possible to lower one heel and thereby correct the imbalance.

Leg Length Discrepancy Insoles

height increase exercises

Surgical Treatment

In growing children, legs can be made equal or nearly equal in length with a relatively simple surgical procedure. This procedure slows down the growth of the longer leg at one or two growth sites. Your physician can tell you how much equalization can be gained by this procedure. The procedure is performed under X-ray control through very small incisions in the knee area. This procedure will not cause an immediate correction in length. Instead, the limb length discrepancy will gradually decrease as the opposite extremity continues to grow and "catch up." Timing of the procedure is critical. The goal is to reach equal leg length by the time growth normally ends. This is usually in the mid-to-late teenage years. Disadvantages of this option include the possibility of slight over-correction or under-correction of the limb length discrepancy. In addition, the patient's adult height will be less than if the shorter leg had been lengthened. Correction of significant limb length discrepancy by this method may make a patient's body look slightly disproportionate because of the shorter leg. In some cases the longer leg can be shortened, but a major shortening may weaken the muscles of the leg. In the thighbone (femur), a maximum of 3 inches can be shortened. In the shinbone, a maximum of 2 inches can be shortened.

What Can Cause Heel Painfulness

June 29, 2017
Overview

Pain At The Heel

The most common form of heel pain, is pain on the bottom of the heel. It tends to occur for no apparent reason and is often worse when first placing weight on the foot. Patients often complain of pain the first thing in the morning or after getting up to stand after sitting. The pain can be a sharp, searing pain or present as a tearing feeling in the bottom of the heel. As the condition progresses there may be a throbbing pain after getting off your feet or there may be soreness that radiates up the back of the leg. Pain may also radiate into the arch of the foot.

Causes

There is no one cause of heel pain. Whole text books have been written on Disorders of the Heel. Some of the types of problems that can be seen in the heel include Heel spurs, these are small bony spurs that often develop on the bottom of the heel. They do not really cause any problems. It is only mentioned here as it is a common myth that they are a problem - almost always the pain associated with heel spurs is really plantar fasciitis. Plantar fasciitis is the most common cause of heel pain and is due to a strain of the long ligament along the bottom of the foot. The most symptom is pain when getting out of bed first thing in the morning ('post-static dyskinesia') A number of disease processes can uncommonly cause heel pain, such as rheumatoid arthritis, ankylosing spondylitis and gout. Stress fractures, which is an abnormal reaction of bone to stress can occur in those that are very active (eg athletes) or have weaker bones (eg osteoporosis) Pain at the back of the heel could be due to a number of problems, there could be a bursitis at the back of the heel bone (sometimes called 'Haglund's) there could be problems with the insertion of the achilles tendon, such as tendonitis or calcification. A 'stone' bruise is sometimes considered to be a cause of heel pain, its is simply a bruise of the bone. Another cause of heel pain is problems in the calf muscles that refer pain to the heel (myofascial trigger points) or pain referred from the lower back via the nerves from the back to the heel. Heel pain in children is usually due to severs disease or calcaneal apophysitis.

Symptoms

The primary symptom is pain in the heel area that varies in severity and location. The pain is commonly intense when getting out of bed or a chair. The pain often lessens when walking.

Diagnosis

A podiatrist (doctor who specializes in the evaluation and treatment of foot diseases) will carry out a physical examination, and ask pertinent questions about the pain. The doctor will also ask the patient how much walking and standing the patient does, what type of footwear is worn, and details of the his/her medical history. Often this is enough to make a diagnosis. Sometimes further diagnostic tests are needed, such as blood tests and imaging scans.

Non Surgical Treatment

The proper treatment for your heel pain depends entirely on the specific cause(s) of your symptoms. Therefore, it is critical to understand the cause(s) of your symptoms before beginning any treatment program and if you are unsure, then seeking medical advice is essential to develop the proper treatment program for your condition. Some common treatments are listed and can be performed at home. Keep in mind that not all of these treatments are appropriate for every condition, but they usually a good place to start. Rest, reducing activities for a few days can help to reduce the most severe pain. Ice, applying ice to the heel for 10 minutes several times a day will help to reduce inflammation. Stretching exercises, to lengthen the muscles in the back of the leg, including the hamstrings, will help to ease pain, reduce focal pressures to your feet and assist in recovery. For plantar fasciitis, this may be the best treatment of all. Avoid going barefoot, when without shoes excessive stress and strain is placed on the plantar fascia. Proper shoe gear, supportive shoes that fit and are not too worn along with good arch support help to reduce the stress and strain on the plantar fascia over time. Medications, non-steroidal anti-inflammatory medication, such as Motrin (ibuprofen), may help to reduce inflammation. If the pain persists or worsens after a couple of days, an appointment may be necessary where Dr. Talarico may add one or more of these additional modalities to your treatment program. Orthotic b, whether pre-fabricated or custom orthotic is used, these devices can help reduce the underlying structural abnormalities of the foot which have lead to the development of plantar fasciitis. These are often used to limit the recurrence of plantar fasciitis pain. Strapping, a special taping technique to help reduce the strain on the fascia. Injection therapy, in some instances injections are used to reduce the inflammation and reduce pain. Night Splint, this allows you to maintain an extended stretch on the plantar fascia while sleeping. Over time, this has shown to reduce the morning pain which some people experience. Removable Walking Cast, in some case of severe heel pain this may be used to keep your foot immobile for a few weeks allowing it to rest and heal. Physical Therapy may be recommended to aid in pain relief. At The Foot & Ankle Center, PC, Dr Talarico will often utilize two additional in-office modalities, EPAT and MLS Laser Therapy, which are very effective in treating most inflammatory conditions of the foot and ankle, including plantar fasciitis.

Surgical Treatment

Surgery to correct heel pain is generally only recommended if orthotic treatment has failed. There are some exceptions to this course of treatment and it is up to you and your doctor to determine the most appropriate course of treatment. Following surgical treatment to correct heel pain the patient will generally have to continue the use of orthotics. The surgery does not correct the cause of the heel pain. The surgery will eliminate the pain but the process that caused the pain will continue without the use of orthotics. If orthotics have been prescribed prior to surgery they generally do not have to be remade.

heel spur shoes

Prevention

Heel Pain

Maintaining flexible and strong muscles in your calves, ankles, and feet can help prevent some types of heel pain. Always stretch and warm-up before exercising. Wear comfortable, properly fitting shoes with good arch support and cushioning. Make sure there is enough room for your toes.

Mortons Neuroma Remedies

June 1, 2017
Overview

MortonMorton's neuroma is a swollen or thickened nerve in the ball of your foot. When your toes are squeezed together too often and for too long, the nerve that runs between your toes can swell and get thicker. This swelling can make it painful when you walk on that foot. High-heeled, tight, or narrow shoes can make pain worse. Sometimes, changing to shoes that give your toes more room can help.

Causes

Anything that causes compression or irritation of the nerve can lead to the development of a neuroma. One of the most common causes comes from wearing shoes that have a tapered toe box, or high-heeled shoes that cause the toes to be forced into the toe box and overload pressure onto the forefoot. An injury or trauma to the forefoot may also lead to a neuroma. People at a higher risk of developing a Neuroma include people with certain foot deformities, such as bunions or hammertoes. Certain foot types, such as flat feet (Pronation) More flexible feet, and woman after pregnancy.

Symptoms

Symptoms associated with a neuroma include a dull burning sensation radiating towards the toes, a cramping feeling, or even a stinging, tingling sensation that can be described as being similar to an electric shock. It is often worse when wearing shoes with most people finding the pain disappears when removing their shoes.

Diagnosis

Plain x-rays of the foot may demonstrate that one or more of the metatarsals are long (Figure #5). Not uncommonly, the second and/or third metatarsal may be long relative to the third or fourth. This can create a situation where excessive load is occurring in and around the vicinity of the interdigital nerve.

Non Surgical Treatment

Once a diagnosis is obtained, it is essential to begin treatment immediately. Your podiatric physician will advise you on the most effective means. If caught early enough, good foot care, shoes that fit properly, and/or orthoses may eliminate the need for any further intervention. Other conservative measures might include oral non-steroidal anti-inflammatory medication (NSAIDS), physical therapy, ultrasound or other non-invasive measures. If that doesn?t work, your podiatric physician might use injectable steroids, and/or a local anesthetic around the neuroma to reduce inflammation and pain. Many patients report relief after these measures are taken.plantar neuroma

Surgical Treatment

If other therapies have not worked it may be necessary to perform surgery. As surgery may result in permanent numbness in the affected toe, doctors ten to use this procedure as a last resort. However, in most cases surgery is extremely effective. The patient usually receives a local anesthetic. Surgery involves either removing the nerve, or removing the pressure on the nerve. Two surgical approaches are possible. The dorsal approach, the surgeon makes an incision on the top of the foot, allowing the patient to walk soon after surgery, because the stitches are not on the weight-bearing side of the foot. The plantar approach, the surgeon makes an incision on the sole of the foot. In most cases the patient will be in crutches for about three weeks. The resulting scar may make walking uncomfortable. However, with this approach the neuroma can be reached easily and resected without cutting any structures. There is a small risk of infection around the toes after surgery.

Hammer Toe Pain

August 15, 2015
Hammer ToeOverview

A Hammer toe is a deformity of the second, third or fourth toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery. People with hammer toe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.

Causes

Risk factors for hammertoe include heredity, a second toe that is longer than the first (Morton foot), high arches or flat feet, injury in which the toe was jammed, rheumatoid arthritis, and, in diabetics, abnormal foot mechanics resulting from muscle and nerve damage. Hammertoe may be precipitated by advancing age, weakness of small muscles in the foot (foot intrinsic muscles), and the wearing of shoes that crowd the toes (too tight, too short, or with heels that are too high). The condition is more common in females than in males.

HammertoeSymptoms

The most common symptoms of hammertoes include. The toe is bent upward at the middle toe joint, so that the top of this joint rubs against the top of the shoe. The remainder of the toe is bent downward. Pain upon pressure at the top of the bent toe from footwear. The formation of corns on the top of the joint. Redness and swelling at the joint contracture. Restricted or painful motion of the toe joint. Pain in the ball of the foot at the base of the affected toe. This occurs because the contracted digit puts pressure on the metatarsal head creating callouse and pressure on the ball of the foot.

Diagnosis

Most health care professionals can diagnose hammertoe simply by examining your toes and feet. X-rays of the feet are not needed to diagnose hammertoe, but they may be useful to look for signs of some types of arthritis (such as rheumatoid arthritis) or other disorders that can cause hammertoe. If the deformed toe is very painful, your doctor may recommend that you have a fluid sample withdrawn from the joint with a needle so the fluid can be checked for signs of infection or gout (arthritis from crystal deposits).

Non Surgical Treatment

Podiatric Care may include using anti-inflammatory oral medications or an injection of medication and local anesthetic to reduce this swelling. When you go to your doctor, x-rays are usually required to evaluate the structure of your foot, check for fractures and determine the cause. The podiatrist may see you to take care of any corns that develop due to the bone deformities. They may advise you on different shoewear or prescribe a custom made orthotic to try and control the foot structure. Padding techniques may be used to straighten the toe if the deformity is flexible, or pads may be used to lessen the pressure on the area of the corn or ulcer. Your podiatric physician may also recommend a surgical procedure to actually hammertoes fix the structural problem of your foot.

Surgical Treatment

Laser surgery is popular for cosmetic procedures, however, for hammer toe surgery it does not offer any advantage to traditional methods. Laser is useful for soft tissues (not bone), and because hammer toe surgery involves bone procedures, it is not effective. For cosmetic hammer toe surgery, patients should look for surgeons experienced in aesthetic foot surgery.

HammertoePrevention

Most cases of hammertoe can be prevented by wearing shoes that fit properly and give the toes plenty of room. Some recommended guidelines include avoid shoes with pointed or narrow toes. Avoid shoes that are too tight or short. Avoid high-heeled shoes, which can force the toes forward. If the shoes hurt, don't wear them. Choose shoes with wide or boxy toes. Choose shoes that are a half-inch longer than your longest toe.

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