An overview of the conditions affecting the Foot, each with information on how they develop, on diagnosis and on treatment. These texts do not replace a medical consultation — in the case of symptoms, we will determine the individually appropriate treatment together.
Splayfoot, fallen arches, flatfoot, hallux valgus, heel spur, osteoarthritis of the big toe joint, Achilles tendon problems — pain in the foot is as varied as its causes. Malalignments, overuse or also injuries can be the cause of the complaints. In the great majority of cases, conservative measures are sufficient to relieve or resolve the problems. Insoles or orthoses may be required as support. If conservative measures do not bring the desired success, surgical procedures can be considered.
Condition 02
Ankle Injuries
What is an ankle injury?
An ankle injury — a strain or tear of the capsule-ligament apparatus on the outer side of the upper ankle joint (an outer ligament rupture of the upper ankle joint) — frequently occurs through a so-called supination trauma, that is, a twisting of the foot inwards.
Diagnosis
Initially there is a strong, pressure-sensitive and painful swelling, as well as a bruise (haematoma) in the area of the outer ankle bone. In addition, an instability with increased lateral opening of the joint, as well as an increased forward shift of the talus, may be present. The X-ray image reveals the extent of the injury. If a cartilage injury is suspected, magnetic resonance imaging (MRI) should also be carried out.
Treatment
Initially the affected leg should be elevated and cooled. Treatment is then carried out by means of an ankle brace (orthosis), followed by training of balance, stability and body awareness (proprioception) as well as of the peroneal muscle group. If symptoms and/or the instability of the ankle joint persist (around 10–20%), a surgical reconstruction of the capsule-ligament apparatus is possible.
Condition 03
Osteoarthritis of the Upper Ankle Joint
What is osteoarthritis of the upper ankle joint?
In contrast to osteoarthritis of the hip and knee joints, osteoarthritis of the upper ankle joint occurs primarily after trauma (80%). The remaining cases are usually likewise of secondary origin, due to rheumatic diseases or following infections (post-infectious).
Diagnosis
After the clinical examination, an X-ray of the upper ankle joint in two planes is usually sufficient to make the diagnosis. For specific questions, additional cross-sectional imaging methods (CT or MRI) can be used.
Treatment
Initially, conservative measures are the priority. In addition to physical therapies and local and systemic drug therapies, shoe adjustments in the sense of a so-called rocker sole to ease the rolling-off process, insoles, cushioning heels and — in the case of accompanying instabilities — orthoses are available for osteoarthritis of the upper ankle joint.
If these therapies no longer achieve the desired success, surgery is advised. In the case of surgery, a fusion (arthrodesis) of the upper ankle joint is usually carried out. As an alternative, there remains the possibility of a joint replacement — that is, the implantation of an endoprosthesis. The prostheses in the area of the upper ankle joint do not, however, yet have the durability that we know from prostheses of the hip and knee joints.
Condition 04
Syndesmosis Rupture
What is a syndesmosis rupture?
The syndesmosis is a ligamentous connection between the shin bone (tibia) and the calf bone (fibula). In the area of the lower leg, injuries of the syndesmosis occur above all in football and in contact sports. The injury mechanism consists of a combined movement of dorsiflexion and external rotation, or of inversion and eversion of the foot.
Diagnosis
Isolated injuries of the ligamentous connection in particular are not infrequently overlooked. Clinically, tenderness on pressure in the area of the distal tibiofibular joint, about 4 cm above the joint space of the upper ankle joint, is the main feature. In addition, the so-called Frick test and the squeeze test can support the diagnosis. In addition to conventional X-rays, an MRI can also be helpful.
Treatment
Treatment is carried out surgically, with repositioning of the calf bone by means of positioning screws or special implants (TightRope®). The aftercare consists of a 6-week treatment with a plaster cast, walker or orthosis, with relief of the operated extremity. With screws, removal of the osteosynthesis material after about 6 weeks is advisable in most cases.
Condition 05
Sinus Tarsi Syndrome
What is sinus tarsi syndrome?
Pain on the outer (lateral) edge of the foot, in front of and below the outer ankle bone, which occurs above all on loading and rarely at rest, can point to sinus tarsi syndrome. The term resembles a collective syndrome, behind which various causes lie.
Diagnosis
The diagnosis is made by means of a so-called diagnostic/therapeutic infiltration into the sinus tarsi. In the case of sinus tarsi syndrome, this should lead to a sudden improvement in symptoms. In addition, an X-ray in two planes is carried out.
Treatment
Repeated infiltrations, as well as additional physiotherapy with a focus on gait training and training of the lower-leg musculature, are recommended. Surgery is necessary only in exceptional cases.
Condition 06
Tarsal Tunnel Syndrome
What is tarsal tunnel syndrome?
Similarly to meralgia paraesthetica and carpal tunnel syndrome, tarsal tunnel syndrome is a so-called nerve compression syndrome of the foot. In it, a mechanical irritation of the tibial nerve (the posterior tibial nerve) occurs. Injuries (trauma) and footwear that is too tight, as well as possible foot malalignments, are the most common causes of this syndrome.
Diagnosis
Clinically, pain and abnormal sensations such as tingling and numbness on the inner edge of the foot are the main features. The pain can occur more intensely at night and radiate into the sole of the foot. To support the diagnosis, electroneurographic examinations (nerve conduction studies and EMG) can be considered. For imaging, it is advisable to use plain X-rays, followed by sonography and MRI.
Treatment
Conservative therapy with injections of local anaesthetics and steroids, as well as the wearing of comfortable, wide shoes and insoles to relieve the arch of the foot, is the treatment of first choice. If the symptoms persist despite this treatment, a surgical decompression is carried out by exposing the nerve beneath the flexor retinaculum.
Condition 07
Splayfoot
What is a splayfoot?
In a splayfoot (pes transverso-planus), the transverse arch of the foot sinks down unnaturally far. The causes are external factors such as being overweight or incorrect footwear (a weakly developed or absent footbed).
Diagnosis
Due to the sinking of the transverse arch, the metatarsal heads are heavily loaded. The result is pain and possibly also calluses, up to the formation of corns. Through the change in the direction of pull of the tendons in the foot, crooked big toes (hallux valgus) or small toes can develop.
Treatment
In early childhood, a strengthening of the foot musculature is aimed for by means of foot exercises. This should also be encouraged in adults, alongside insoles with transverse arch supports intended to relieve the metatarsal heads. Insoles alone bring about a purely passive correction and therefore no lasting effect. If these conservative therapies do not lead to the desired pressure relief, various surgical procedures (metatarsal osteotomies) are available. After surgery, patients usually receive special shoes, which are mostly worn for 6 weeks.
Condition 08
Flatfoot / Fallen Arches
What is a flatfoot or fallen arches?
With a flexible flatfoot (pes planovalgus), a distinction must be made between the harmless, physiological foot deformation in small children and the pathological form in adolescents or adults. Through muscle weakness, being overweight, a knock-knee position of the knee joint, and insufficient support from the ligaments, the apparent poor posture can, with increasing age, develop into a genuine deformity.
Diagnosis
Children and adolescents usually complain of foot pain only rarely at first. In adults, complaints usually occur on the inner side of the foot along the posterior tibial tendon. The examination is carried out while walking, standing and lying down. If the changes have progressed to the point where a passive or active correction is no longer possible, this is referred to as a rigid flatfoot.
Treatment
The flatfoot in children generally has a very good prognosis. Insoles can be prescribed as support, although the considerably more important pillar of treatment is active foot exercises. In adults, insoles can likewise be prescribed, whereby appropriate instruction and foot exercises should also be carried out here. Surgical therapies in children are necessary only very rarely. In adults, in the case of symptoms and flexible forms, a tenolysis/tenosynovectomy of the posterior tibial tendon can be carried out as the condition progresses, and — with advanced degeneration — a tendon transfer as well.
Condition 09
Hammer Toes and Claw Toes
What are hammer toes?
If there is a fixed flexion of the toe end joint with the base joint extended, this is referred to as a hammer toe. The claw toe, by contrast, has an over-extension at the base joint with the middle and end joints bent, and with a normal step has no contact with the ground.
Diagnosis
The diagnosis is usually made purely clinically. These malalignments frequently occur in combination with other malalignments, such as a fallen-arch splayfoot. In addition, X-rays in two planes are usually taken while standing.
Treatment
In addition to local treatments of the calluses and the malalignment, hammer and claw toes are usually treated surgically. Hammer toes are usually treated by means of a so-called resection arthroplasty according to Hohmann. With claw toes, the malalignment at the base of the toe must additionally be corrected. The aftercare is carried out by means of a strapping bandage and a special shoe, usually for 2–4 weeks.
In hallux valgus, an increased lateral deviation of the big toe outwards occurs. This malalignment usually appears in combination with an inwardly directed first metatarsal bone. Genetic factors, incorrect footwear, an existing fallen-arch splayfoot and being overweight promote this malalignment. As a result, a so-called shoe conflict, with pressure points and inflammation of the bursa over the joint, frequently occurs.
Diagnosis
The diagnosis is made first clinically. To determine the extent of the malalignment, standing forefoot X-rays are also taken in the lateral and dorsoplantar beam path.
Treatment
First, the underlying splayfoot should be treated by means of insoles. Special hallux valgus night-positioning splints can have a corrective effect for as long as they are worn, although this effect is as a rule not lasting. If the symptoms are severely pronounced, surgery is therefore advisable. For surgical treatment, various procedures are available depending on the extent of the big toe malalignment. The greater the extent of the malalignment, the more proximal — that is, closer to the body — the bony correction must be carried out. The aftercare depends on the site of the correction.
Hallux rigidus describes osteoarthritis of the big toe joint. As causes, in addition to injuries and overuse, rheumatism and gout in particular come into question. In the initial stage, in which the rolling-off process is impeded primarily by bony attachments on the extensor side, the term hallux limitus is occasionally also used.
Diagnosis
The diagnosis is made primarily clinically. The big toe joint is often thickened and occasionally also reddened. Those affected usually develop a characteristic protective gait. In addition, standing X-rays of the forefoot in two planes are taken in order to determine the extent of the osteoarthritis.
Treatment
In the initial stage, conservative measures are sufficient. These include locally decongesting measures, pain-relieving and anti-inflammatory medication and physiotherapy/manual therapy. Initially, shoe insoles or a so-called rigidus spring can ease the rolling-off process. Only if all these measures do not lead to the desired success should surgery be considered. In the early stage, a so-called cheilectomy is carried out. In the case of more severe wear, three surgical procedures are available: resection arthroplasty according to Keller-Brandes, joint fusion (arthrodesis) or an artificial joint. The most frequently applied method is the fusion of the big toe joint.
Haglund's deformity describes a hump-like elevation and broadening of the heel bone immediately in front of the insertion of the Achilles tendon.
Diagnosis
Clinically, the heel usually appears thickened and tender on pressure. Due to the thickening, a shoe conflict usually also occurs in addition, which can have a further negative influence on the painful process.
Treatment
Initially, conservative therapy with anti-inflammatory measures and appropriate footwear to relieve pressure is advisable. Raising the heel with a gel cushion or a cushioning insole can reduce the pressure of the hump on the Achilles tendon. In addition, the use of physical measures and shock-wave therapy can be considered. In the case of persistent symptoms, a removal of the bony prominence can be considered.
Condition 13
Heel Spur (Plantar Fasciitis)
What is a heel spur?
A heel spur (plantar fasciitis) is a bony spur of the heel bone located towards the sole of the foot. As a cause, overuse and irritation of the plantar fascia through traction lead to the formation of a so-called traction osteophyte. The bony spur is therefore only the result of the tendon inflammation and not its cause. Contributing factors are being overweight, footwear that is too hard, overuse, a flattening of the longitudinal arch of the foot and a shortening of the calf musculature.
Diagnosis
Typical symptoms are strong pain after loading, whereby initially above all the first steps after prolonged standing or sitting are painful. The clinical examination shows tenderness on pressure of the sole of the foot in the area of the heel. The diagnosis is ultimately confirmed by X-ray. The extent of the symptoms does not correlate with the size of the heel spur.
Treatment
Treatment should only be carried out if symptoms are present. It is important to design the therapy as causally as possible. In the case of accompanying malalignments, passive measures such as insoles can be prescribed in addition to strengthening the musculature. Furthermore, for local therapy, infiltrations and physical therapies can be carried out. Manual therapy — in particular fascial techniques — can also be very helpful. A further treatment option is extracorporeal shock-wave therapy. A surgical removal of the heel spur is indicated only in treatment-resistant cases.
Condition 14
Achilles Tendon Rupture
What is an Achilles tendon rupture?
The Achilles tendon is one of the strongest tendons of the human body. It is the tendinous connection between the calf musculature and the heel bone. The most common site of rupture lies about 4–6 centimetres above its insertion on the heel bone. As a cause, ruptures occur above all with sprinting and jumping loads (so-called stop-and-go sports). In most cases there is pre-existing damage or degenerative changes in the Achilles tendon. A healthy tendon almost never tears.
Symptoms and diagnosis
Initially, patients usually report a bang-like sound, frequently described as a “snap”. Active standing on tiptoe is, with a complete rupture, as a rule no longer possible. The clinical examination also shows a palpable dent. In terms of imaging, ultrasound (sonography) is the method of choice. Before any surgery, it is also advisable to carry out an MRI.
Treatment
Fresh ruptures should be treated surgically as quickly as possible after the initial swelling has subsided. If surgery is not possible, conservative therapy by means of a plaster cast can also be considered. As surgical techniques, the open end-to-end tendon suture technique or minimally invasive percutaneous suture techniques are available.
After surgery, a lower-leg plaster cast is applied in a 20–30-degree “equinus position” until secure wound healing. As recovery progresses, the equinus position can be gradually reduced. The duration of immobilisation is usually 6–8 weeks. Regular sporting activity should begin at the earliest from the fourth month, and “stop and go” sports at the earliest after 6, usually only after 9 months.
