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Soft Tissue Injuries and Tumors
Morton's Neuroma | Intermetatarsal Neuroma
WHAT'S THE PROBLEM?A neuroma is a swelling or scarring of a small nerve that connects to two of your toes and provides sensation to these toes. The symptoms can come and go depending on activity, shoe style and even, weather. They consist of pain or numbness, usually affecting the 3rd and 4th toes, counting from the big toe. Any action that shifts the body weight onto the front of the foot, such as wearing high heels, climbing stairs and running, can make a neuroma worse. Some doctors will describe a neuroma as a nerve tumor. However, don't worry because neuromas are not cancer and will not spread to other parts of your body. It is an injury to a nerve, that occurs slowly, over a long period of time.
HOW DOES IT FEEL?
Neuromas frequently start as a numbness or tenderness in the ball of the foot. This is the area just behind the base of the toes. As the swelling increases, pain and strange sensations such as numbness, burning and tingling in the area can radiate out into the toes or back into the foot. The area may be hot or very swollen and, just as mysteriously, the symptoms can disappear and reappear. At first, the pain is only present when weight bearing in tight shoes. As it gets worse, spontaneous shooting pains, often like electric shocks, can be felt even when you're off your feet.
LET'S DO A TEST!
Your doctor will make the diagnosis relying on your history and description of the problem and the physical examination. There is a simple test to find a neuroma. The doctor will squeeze the area between the bases of the toes to see if it is sensitive. If a neuroma is present, the doctor, and sometimes you, will feel a "click", as the soft neuroma mass squishes out between the long metatarsal bones. You may feel the pain shooting out into your toes or back into the foot. This is called a Mulder's Sign, and is the diagnostic sign of the presence of Morton's Neuroma.
Finally, the doctor will do an x-ray to see if there are any other problems present. The nerve and neuroma are soft tissue and don't show on a standard x-ray. However, the doctor can tell if the metatarsals are close together and if the toes are spread apart-both signs of a neuroma. If the diagnosis is at all unclear, a soft tissue imaging technique called an MRI may be done to actually see the neuroma mass.
HOW DID THIS HAPPEN?
To understand why neuromas develop, it is important to know how the nerves connect to the toes. The nerve that carries sensation signals back from the toes starts in the midfoot between the metatarsals. The nerve passes beneath a strong ligament, or soft-tissue band, that holds the metatarsal heads together. Just after it passes this band, it splits in half forming a Y. Each half then connects to the adjacent sides of the two toes.
The neuroma usually develops just under or beyond the tight ligament. Why? Well, imagine that the nerve is the bow of a violin and the tight ligament is the string. The constant pulling of nerve over the ligament irritates the nerve and causes the nerve to thicken and scar. The nerve also can get pinched between the two metatarsal bones that it passes between. A scarred nerve doesn't carry signals well and may send back strange signals to the brain such as burning, pain and tingling. So, instead of beautiful music, we get terrible noise.
Anything that stretches and pulls the nerve will aggravate the condition. For instance, wearing high heels aggravates neuromas in three ways. First, the higher heel will push the toes up from the rest of the foot and cause the nerve to tighten and pull harder against the tight ligament. Second, the tight toebox squeezes the front of the foot together leaving less space between the metatarsal bones for the nerve to rest. Finally, the body weight is put more on the ball of the foot increasing the pressure on the nerve. All 3 are bad news for you and your neuroma.
WHAT CAN I DO FOR IT?
The most significant help that you can give yourself to lessen the pain and allow the injured nerve to heal is to avoid tight, short or pointed shoes. If the metatarsal bones are allowed to splay or spread out naturally, as when you're barefoot, many neuromas will get better on their own. An oral anti-inflammatory medicine like ibuprofen, naproxin sodium or aspirin can help. The application of moist heat can help.
WHAT WILL MY DOCTOR DO FOR IT?
If the home remedies do not relieve your pain or if you have suffered several episodes, see your doctor for care. After the diagnosis is made, the doctor may apply special padding to the foot to take the pressure off the area. An injection of an anti-inflammatory medicine (cortisone) mixed with numbing medicine (xylocaine) may be put into the area surrounding the nerve to calm it down. The doctor may also prescribe a prescription anti-inflammatory medication or begin physical therapy treatments, to help the injured nerve to heal.
If these treatments are not effective at calming the neuroma down, the podiatrist may dispense orthotics to help control the abnormal mechanical structure of your foot. By preventing the arch from dropping, the the nerve will not be stretched as much.
Finally, if these more conservative treatments don't work, then the faulty nerve may need to be removed or destroyed. This is not as bad as it sounds. This is only a sensory nerve that doesn't control any muscles and only provides sensation to a small area between the toes. The nerve is removed through an incision in the top or bottom of the affected area. The nerve is identified and snipped just behind the swollen part and just beyond where it splits in two. Frequently, the tight ligament between the metatarsal bones is also cut to allow more room. It is a relatively minor procedure with possible complications that include infection, swelling and pain.
Rarely, a portion of the remaining nerve may become tender and require additional surgery.
Another procedure involves the destruction of the sensitive nerve through the injection of caustic medications. Either way, the area between the affected toes is likely to remain numb forever. However, this is rarely more than a minor annoyance.
CAN I PREVENT FROM IT HAPPENING AGAIN?
When the nerve is removed, the pain rarely recurs in that spot. However, it is possible to develop another neuroma between two other toes or in the other foot. This is because the underlying conditions that caused the first one to develop are still present. So, you must be careful about what kinds of shoes you are wearing and the amount of pressure you put on the ball of the foot. If your podiatrist dispensed orthotics, then be sure you are wearing them and get them replaced regularly. Finally, if a new neuroma is developing, seek attention sooner rather than later. Early treatment may help you avoid future surgery.
Ganglion and Other Deep Cysts
Synovial Cysts, Ganglionic Cyst and Cutaneous Mucous Cysts
WHAT'S THE PROBLEM?
Synovial cysts, ganglia and cutaneous mucoid cysts are essentially the same thing. All three refer to a fluid filled mass under the skin. The fluid looks a lot like corn syrup or the white of an egg. Most are located under the skin, although occasionally they may be found in tendon or bone. The synovial or ganglionic cysts are connected to a nearby joint or tendon sheath by a small stalk. They therefore may be more resistant to treatment. Mucoid cysts, are not connected to a joint. If the cyst is located near the nail, it may cause the nail to grow funny.
HOW DOES IT FEEL?
Many mucous cysts are painless. Some people are worried about the way it looks, others worry that it may be a serious problem. The cysts are more likely to cause pain or discomfort when they are on the foot, because of pressure created by shoes on them. Occasionally, the cyst encloses or presses on a nerve, causing a shooting, electric type of pain.
LET'S DO A TEST!
Your doctor can identify a mucous cyst by how it feels when he/she touches it. In some cases, the doctor may order an x-ray, ultrasound, MRI, or CT. Rarely, a doctor might order an arthrogram, where dye is injected into the cyst, in an attempt to see if it is connected to a joint or tendon sheath.
HOW DID THIS HAPPEN?
The cysts may form on their own, or may branch out from a joint. Most doctors feel that these cysts form as a result of small injuries that occur repeatedly over a long period of time. Essentially, they can be thought of as bubbles made of a thin layer of specialized cells that produce and surround the fluid.
WHAT CAN I DO FOR IT?
Anytime you notice a lump or mass, you should have it checked out by a doctor as soon as possible, even if it isn't painful. If the cyst isn't painful, it may be best to just watch it to see if it changes over time. If you have a painful ganglion, you can try padding the area around the lump or try changing your shoe gear to relieve the pressure.
WHAT WILL MY DOCTOR DO FOR IT?
Your podiatrist will look at and feel the lump. If it is a ganglion, the doctor will numb the area, then try to pull as much fluid out of the cyst as possible using a syringe. Many doctors will then inject a steroid or hardening agent into the cyst to try to prevent it from filling again. About half of the time, the cyst will fill up again after the treatment. The doctor will then give your the option of having it removed surgically. CAN I PREVENT FROM IT HAPPENING AGAIN?
The best that we can do to avoid forming these cysts is to wear loose fitting comfortable shoes which don't injure the feet. It is especially important to avoid wearing shoes which are tight over the bony top of the foot or instep, where many of these cysts form.
Foreign Body
Penetration Wound WHAT'S THE PROBLEM?
A foreign body is an object that has become imbedded in your foot. Usually this is a small sharp piece of metal or glass that has been stepped on. It may also be a needle or nail. In extreme situations, an impalement injury has resulted from a nail gun or an object such as a spike or stick penetrating the foot.
HOW DOES IT FEEL?
Pain, bleeding, and a noticeable entry site are all common signs of a foreign body injury.
LET'S DO A TEST!
Depending on the particular foreign body, an x-ray may help to show the location. Metal and some types of glass are seen on x-rays, while plastic and wood, are less well seen.
HOW DID THIS HAPPEN?
Most foreign body injuries are a consequence of stepping on the object and having the foreign body break off in the foot. This kind of injury is far more dangerous for people with diabetes or other conditions that cause numbness in their feet. They often don't realize that they have the foreign body in their foot until a dangerous infection results.
WHAT CAN I DO FOR IT?
If the foreign body is buried and no part of it is visible, specialized medical care is necessary. Self-care should be limited to applying an antibiotic ointment or cream and applying a clean dressing.
WHAT WILL MY DOCTOR DO FOR IT?
After numbing the area, the object will be located and removed. The site will be cleaned out and any debris, dirt, or damaged tissue will be removed. The site may be packed open and dressed. An antibiotic may or may not be given, depending on your doctor's judgment concerning the possibility for infection. It is important to realize that many factors such as age of injury, depth, associated contaminates, and other health factors play a role in this decision and an infection may result even if antibiotics ARE used. This treatment may be done in your doctor's clinic or may require a trip to the hospital outpatient department or surgery center. Facilities such as these often have a machine known as an Image Intensifier or Flouroscan, which can help the doctor to locate and remove the foreign body with as little tissue injury as possible.
CAN I PREVENT FROM IT HAPPENING AGAIN?
Always wear shoes when walking outside and especially if you have numbness in your feet. Always be aware of your surroundings and any debris in the area where you are walking.
Corns and Calluses
WHAT'S THE PROBLEM?
A corn is simply an area of hard, thickened skin that can occur on the top, between, or on the tip of the toes. A callus is similar in nature, but is larger and usually occurs across the ball of the foot, on the heel, or on the outer side of the great toe. Corns and calluses are often mistakenly considered a "skin" condition. They are actually the visible sign of an underlying "bone" problem.
HOW DOES IT FEEL?
Everyone knows that "big oaks from little acorns grow", but few realize that "big aches from little toe corns grow". Calluses and corns quite often have painful nerves and bursal sacs (fluid-filled balloons that act as shock absorbers) beneath them, causing symptoms ranging from sharp, shooting pain to dull, aching soreness.
LET'S DO A TEST!
First, your doctor will conduct a thorough inspection of these areas. He/she may gently trim some of the thickened skin away, in order to rule out a wart (caused by a viral infection of the skin) as the culprit. X-rays will often be taken to identify the specific bone problem that is causing the corn or callus. The doctor may place a small marker on the corn before taking the x-ray, to make it's location visible on the x-ray. The finished x-ray will then show the location of the corn and the bone spur underneath that caused it.
HOW DID THIS HAPPEN?
Corns and calluses form due to repeated friction and pressure, as the shoe (or ground) rubs against a bony prominence (bone spur) on the toe or foot. The skin thickens in response to this pressure, in order to keep you from getting an open sore or blister. Small amounts of friction or pressure over long periods of time cause a corn or callus. Large amounts of friction or pressure over shorter periods of time cause blisters or open sores. Corns can be due to a buckled or contracted toe position called a hammer toe. Often toes curl under the neighboring toe (especially the smallest toe) causing corns to form. Calluses develop under a metatarsal head (the long bone that forms the ball of the foot) that is carrying more than its fair share of the body weight, usually due to it being dropped down or due to its longer length. Many of these bone conditions are inherited. A poor choice of shoes can aggravate corns and calluses, but often it is not the "sole" cause. (No pun intended.)
WHAT CAN I DO FOR IT?
Trimming of this thick skin can relieve the pressure for a short time. You should never consider doing this yourself if you are diabetic or have poor circulation. If you cut yourself, you may cause an infection. Corn pads and callus removers often have harsh acids that peel this excess skin away after repeated application, but they can cause a severe chemical burn, which might lead to infection and greater pain than the original foot condition....so be careful with self-care. You can begin by soaking your feet in warm soapy water and gently rubbing away any dead skin that loosens. A pumice stone, buff bar or emery board is then use to "file" this thickened skin. This should be done gradually, a bit a a time, ideally after each shower or bath. Attempting to file off the entire thickness of a corn or callus can result in a burn or abrasion. Applying a good moisturizer such as Vitamin E oil, cocoa butter, or lanolin to the hardened areas should keep them softer and relieve pain. Non-medicated corn pads or moleskin (a thin fuzzy sheet of fabric with an adhesive back) can be purchased to protect corns and calluses, but should be removed carefully, so you do not tear the skin, and should only be worn for a day at a time.
WHAT WILL MY DOCTOR DO FOR IT?
After an initial history and physical exam of your feet, x-rays will be needed to tell the whole story and determine why corns and calluses are developing. Your doctor is the expert in trimming down these areas of thick skin and will often apply comfortable padding to these painful corns and calluses. Special padding devices and materials may be available only from your doctor for your use at home. Medication for inflammation may be utilized to treat the underlying injury and sometimes a cortisone injection into the underlying bursal sac will be recommended to rapidly reduce pain and swelling.
Changes in shoewear may be recommended. A prescription custom-made device called an orthotic might be made to wear inside your shoes, to redistribute pressure more evenly across the ball of your foot. A pad placed in your shoes (called a metatarsal pad) may help reduce your contracted hammer toes and relieve pressure on the ball of the foot as well. Often corns and calluses will have to be trimmed on a regular basis to prevent them from hurting. Eventually, you may desire corrective foot surgery by your podiatrist to straighten curled or contracted toes for corns or elevate and shorten metatarsals for calluses. Often such surgery represents a short term inconvenience to your lifestyle, but will not require any lengthy period of rest or inactivity. Many satisfied patients have remarked that surgery to remove the bone beneath the corn hurts less the very next day than on a painful day walking in their shoes with the corn present.
CAN I PREVENT FROM IT HAPPENING AGAIN?
Often changing your style or size of shoes may help. Carefully review the shoes in your closet. Check their fit and discard any that have seams and stitching over painful corns or have worn out innersoles that offer too little protection for calluses on the ball and heel of your foot.
Make sure shoes are wide enough for your feet and have enough depth in the toe area to allow minimal pressure on the toes. To demonstrate whether your shoes are of adequate size and shape, place your foot on a blank sheet of paper and trace the shape of your foot. Then, place the shoe in question on top of your foot tracing. You may be surprised, as are many people, that your shoes are actually smaller and narrower than your feet. Try to imagine the forces present in that shoe when you squeeze your foot into it and then walk at any speed. Ouch!
Review the socks in your drawer. If they have thick seams at the toes or holes, it's time to go shopping. Try to choose natural materials such as cotton and wool. Several types of socks (such as Thor-lo brand) have a double thickness in the toes and heels to protect these areas. Nylon hose can be purchased that have a woven cotton sole on the bottom of the foot to offer less friction and more padding.
Tendonitis
WHAT'S THE PROBLEM?
Tendonitis is inflammation of a tendon, the structure that connects a muscle to its bone. There are several tendons in the foot and ankle that are commonly affected. The inflammation can occur after trauma, from overuse, or as a result of another medical problem such as arthritis or collagen vascular diseases. The inflammation puts pressure on the surrounding nerves, causing pain, and releases certain chemicals that damage the tendon, causing further pain and sometimes altering the structure of the tendon.
HOW DOES IT FEEL?
Most patients feel an aching pain in the area of the inflammation. There may also be swelling and/or weakness of the involved tendon. The pain usually increases with an increase in activity levels.
LET'S DO A TEST!
Your doctor will examine your foot, moving it through various motions to evaluate more specifically where the pain is originating. He/she will look for areas of swelling and feel for lumps or gaps in the tendons. You may be asked to stand or walk so your doctor can determine if your foot structure or walking pattern are affected by or causing the problem. If tendon damage is suspected, you may be sent for a special test such as an X-ray, MRI, or ultrasound. If there is a suspicion of an underlying medical condition, you may be asked to have your blood checked for certain products.
HOW DID THIS HAPPEN?
There are a number of ways that tendonitis may develop. A common cause is overuse, usually occurring after an increase in your activity level, or from improper or inadequate stretching before a work out. There are several tendons in the foot that act as a pulley when they round the ankle joint. Improper or excess motion in the tendon around the joint it may create tiny tears in the tendon, which triggers the inflammation that causes the pain. Tendonitis may follow trauma, such as ankle sprains, or may be the result of a medical problem such as arthritis.
WHAT CAN I DO FOR IT?
In most cases, applying ice and taking Tylenol, or non-steroidal anti-inflammatory medication will relieve the pain. Keeping the foot elevated, decreasing your activity level for a couple of days, and wearing a compressive dressing such as an ace wrap will also help a great deal.
WHAT WILL MY DOCTOR DO FOR IT?
If the pain continues, your doctor may send you for physical therapy, such as contrast bathes, ultrasound, massage, electrical stimulation, and/or stretching and strengthening exercises. Your may need to start wearing orthotics. If the problem is being caused by an underlying medical condition, your doctor may send you to a
general practitioner or other medical specialist for treatment of that condition. In more severe cases, the tendon may need to be surgically repaired.
CAN I PREVENT IT FROM HAPPENING AGAIN?
The best way to prevent tendonitis is to stretch properly before any work out or athletic event. Wear high quality, supportive shoes that are made for your specific foot type. If you have been prescribed orthotics, wear them as directed. If you have an underlying medical problem that may cause tendonitis, follow the treatment plan for that condition. Finally, keep in good communication with your doctor so that if a problem arises, it can be treated quickly and accurately.
Posterior Tibial Tendon Dysfunction
Tendonitis in the foot is a common problem because we use our feet continuously. It is a common example of an overuse injury. One of the most frequently affected tendons is the posterior tibial tendon, a structure that is normally hard at work, helping to hold the arch up and prevent over-pronation or rolling in of the foot.
ANATOMY
The posterior tibial tendon runs behind the inside bump on the ankle (the medial malleolus), across the instep, and attaches to the bottom of the foot.
WHAT'S THE PROBLEM?
Posterior tibial tendon dysfunction actually runs the gamut from initial strain and minor degeneration of the posterior tibial tendon to frank rupture. It is now known that the problem is caused by a degenerative tendinosis rather than inflammation. Inflammation when it does occur is secondary.
HOW DOES IT FEEL?
The symptoms of tendonitis of the posterior tibial tendon include pain in the instep area of the foot and swelling along the course of the tendon. The patient may also experience pain and swelling right behind the inner ankle bone. There is pain upon palpation along the course of the posterior tibial tendon behind the inner ankle. There may also be burning, shooting, tingling, stabbing pain, because the nerve is inflamed inside the tarsal tunnel. Patients experience significant pain when walking, steadily worsening toward the end of the day. There is significant pain when the patient inverts his/her foot, as well as pain upon passive stretching of the posterior tibial tendon, and on eversion or flattening of the foot. In some cases the tendon may actually rupture or tear, due to weakening of the tendon by the inflammatory process. Rupture of the tendon leads to a fairly pronounced flatfoot deformity that is easily recognizable.
LET'S DO A TEST!
1. The patient is viewed standing from behind. The amount of heel valgus on the affected side is noted. The patient is then asked to stand on his toes. The heel should invert upon standing in the normal foot without posterior tibial tendon dysfunction.
2. A very popular test for posterior tibial tendon dysfunction is the single heel rise. The patient is asked to stand on his toes standing on one foot. They will not be able to perform this maneuver and if they are, there will be significant pain upon single heel rise. If the patient is able to do the test, they are asked to repeat it and will soon start feeling intense pain if a tendonitis is present.
3. In some difficult cases, an MRI scan may be useful to determine whether the tendon has ruptured.
HOW DID THIS HAPPEN?
Behind the medial malleolus, the ankle bone on the side of the ankle facing the other foot, there is a concavity which is called the medial retromalleolar sulcus. Within this groove runs the tendon of the posterior tibial muscle. The groove and the fibrous covering which envelopes it, is known as the Tarsal Tunnel. The section of the tendon where it passes through the tunnel is a relatively hypovascular area, where this tendon becomes strained and degeneration develops. If activity and injury continues, the problem increases and the tendon begins to degenerate.
Problems with the posterior tibial tendon seem to occur in stages. Initially, irritation of the outer covering of the tendon called the paratenon causes a paratendonitis. This simply indicates that there is inflammation around the tendon as it runs through the tarsal tunnel. As we age, the tendon is subject to degeneration within the substance of the tendon. This creates a situation where the tendon becomes thickened, sometimes to the extent that a nodule forms within the tendon. The normal arrangement of the fibers of the tendon (similar to a nylon rope) becomes jumbled, and the tendon loses strength. This condition is called tendonosis. In many cases, the two conditions are present simultaneously. The weakened, degenerative tendon sets the stage for the possibility of actual rupture (above, left) of the posterior tibial tendon. Flat foot types, with equinus influences (tight heel cords, pronation during late stance, too low a heel and inadequate support in footwear are factors which can lead to Posterior Tibial Tendon Dysfunction. Walking up and down hills (golf course) hyperpronating and supinating activities (golf swing) can bring on symptoms.
WHAT CAN I DO FOR IT?
When the foot is acutely painful, rest, ice, nonsteroidal anti-inflammatory drugs like Advil are recommended, and a compressive dressing may be applied.
WHAT WILL MY DOCTOR DO FOR IT?
Cast immobilization holding the foot in slight inversion and plantar flexion for 4-6 weeks may be started. After the acute period, a custom orthosis or brace may be fitted. An air stirrup brace or lace-up ankle support is beneficial during the rehabilitation period. Your foot doctor may prescribe special shoes with external additions to the medial side (.i.e., medial heel wedge), to support the foot and prevent arch collapse. The doctor may prescribe a custom foot orthotic based on the flexibility of the foot. The orthosis may be constructed of leather or plastic. Medial posting may be placed along the hindfoot. A UCBL orthosis with a rearfoot varus post is sometimes used for posterior tibial dysfunction as the foot begins to change shape and flatten. If the foot becomes both flat and rigid, an Ankle-foot orthosis may become necessary.
If the condition becomes severe and chronic, the doctor may suggest surgical intervention, which consists of tendon transfers and osteotomies to improve function, and parts of the thickened tendon may be removed, to decrease symptoms.
If the tendon has ruptured, surgery may be required to either repair the ruptured tendon - or to replace it with a tendon graft. Most tears will not simply be repairable, unless they only recently occurred. Usually, another tendon in the foot, such as the tendon that flexes the four lesser toes (bends them down) is used as a tendon graft to replace the function of the posterior tibial tendon.
Finally, in cases which have been neglected, and a fixed flatfoot deformity is present, a fusion (or arthrodesis) of the foot may be required. A fusion is an operation where a joint between two bones is removed and the two bones on either side of the joint are allowed to grow together - or fuse. This type of operation is used to stop pain from joints that are worn out and can be used to realign the bones when the normal mechanisms for maintaining normal alignment are deficient - such as when the tendons and ligaments no longer work properly. Usually, several joints must be fused to control the flatfoot deformity occurring after posterior tibial tendon rupture.
Following surgery, you will most likely be placed in some sort of brace or cast if the tendon has been repaired or grafted. You will probably be in a cast for 6-8 weeks if a fusion has been performed.
Information prepared and provided for you by Dr. Craig H. Thomajan, D.P.M.