When I talk to you about the causes of your foot pain I have to remember that we speak different languages.  For example, your big toe in podiatry talk is your hallux (hal-ux).  I’ve been calling the big toe a hallux since the beginning of medical school.  I have to speak your language, but sometimes I can slip so let’s go over some common causes of foot pain in both for comparison.

First of all the foot is divided into three areas.  The front part containing your toes and the ball of your foot is called the forefoot.  Your arch is in the middle of your foot and is called the midfoot.  The back part of your foot has the heel, but of course that’s too easy for doctor talk so we refer to the back of the foot as the rearfoot.  Each area has a unique set of problems that can cause foot pain.  Since this is like learning a foreign language I will cover the front of the foot in this article and then the middle and heel next time.

It doesn’t matter if your 2nd toe is longer or shorter than your big toe.  Any toe that is buckled or bent is called a hammertoe.  When a toe is crooked like it can press harder on your shoe causing hard skin to form.  An area of hard skin that develops on a toe from pressure is called a corn or heloma durum.  Your toe can curl so much that it almost sits on the top of your foot.  This causes increased pressure on the bone in the ball of your foot and hard skin can form at this point.  Hard skin forming on the ball of the foot is called a callus or IPK, which stands for intractable plantar keratoma.  Not all hard skin is a corn or callus.  Warts are areas of hard skin with tiny black spots in the center.  This is a virus infection of the skin called verruca.

What about lumps and bumps on the toes and ball of the foot?  A bump at the base of your big toe, remember that’s called the hallux, is a bunion.  In podiatry talk we say the big toe has drifted toward the 2nd toe or hallux valgus.  On the opposite side of your foot at the base of the little toe you can get a bump.  At some point in time this was common in jobs where people sat with their legs criss-crossed or Indian style.  Tailors used to sew sitting in this position so they call this a tailor’s bunion or little bunion, bunionette.  In the center could be due to a broken bone.  Stress fractures are a common cause of swelling, bruising, and pain in the forefoot.

Another cause of pain in the forefoot is a pinched nerve called a neuroma.  You might have a neuroma if the pain is in the ball of your foot and shoots out your toes.  Unfortunately not all foot pain in the ball of your foot is a pinched nerve.  There are tendons and joint capsules in the same area that can become irritated.  When tendon or joint capsule becomes inflamed this is called tendonitis or capsulitis.

That’s a lot of new words so I’ll let you study this for a while then come back with the common terms used in the middle and back of the foot, the midfoot and rearfoot.

Why does your heel hurt, but mine does not?  Why are your first steps out of bed so painful?  Why did my aunt say that wearing cowboy boots is one of the best heel pain treatments?  Why is your right foot heel pain seem so much worse than your left foot?

Enough already, the flight attendant just spilled water on me.  Let’s get technical.

Why do we call it plantar fasciitis?

The plantar fascia is a broad ligament that runs from your heel to the ball of your foot.  If you pull your toes back (up) you can feel your plantar fascia in the arch of your foot.  Because there is this severe pain in the heel of your foot and into the arch it seemed reasonable to the first doctors who described this condition to call it inflammation of the plantar fascia.  They never asked “why?” or “what else could it be?”.  Here’s the technical part.  Inflammation at its’ most basic level is increased blood flow to an area that has been injured.  That’s why you can sometimes feel throbbing like your heart beat in your foot.  The plantar fascia is a ligament.  That means it is a thick, tough band that doesn’t have any space for wimpy, soft, little arteries.  How can you have increased blood flow to something that has no arteries?  Ha, ha you can’t.

We now know that the problem in your heel is the muscles not the plantar fascia.  The small muscles in your foot also run from your heel to your toes.  Bend you toes back and feel the fascia again.  The muscles are right under that, so how can you tell which one hurts by pushing on the heel or arch?  You can’t!  MRI has shown that plantar fasciitis type heel pain is really inflammation in the muscles where they attach to your heel.  Have you heard of a heel spur?  Well the spur actually develops from the muscles pulling away from the heel bone.  The plantar fascia attaches to the heel bone in a different area not at the spot where a heel spur is seen.  A classic heel pain treatment is injecting steroids.  The shot goes in the area where the muscles attach to the bone, not the plantar fascia.

Why are my first steps out of bed so painful?

That feeling of a hot poker sticking into your heel when you get out of bed is a classic complaint if you’re suffering from plantar fasciitis.  In order to explain this severe pain in the heel of your foot, I need you to keep in mind that the problem lies in the muscles.  Ligaments resist stretch up to a point then they break, like spraining your ankle.  Muscles can stretch.  It takes a very special set of circumstances all occurring at the same time to break a muscle.  When muscles work they are happy.  Lots of fresh blood circulates through bringing oxygen and washing out the used stuff.  If you stretch a happy muscle too far or too fast what happens?  That muscle is not so happy anymore and lets you know it my fighting back, in other words, cramping.  So you’re walking along, doing your own thing.  The muscles in your legs and feet are working so they’re happy.  Eventually you go to sleep and the muscles get what seems like a well deserved rest.  Of course from the muscles point of view it is not working anymore so tightens up a little to try to keep active.  You wake up and step on your foot, stretch the muscles all of a sudden, and they fight back.  Zing, zang, zoom you’re seeing stars and thinking you have a harpoon stuck in your heel.  Gradually the muscles relax with a few more steps and you feel better.  If I place your foot in a night splint that holds your foot muscles stretched slightly while you sleep the muscles stay happy because they are taught so working a little and when you get out of bed there is no harpoon because there is no sudden stretch.  This is no flimsy piece of fabric night splint like in the airline magazines.  I have a night splint in my office that goes along the top of your foot and ankle so it’s more comfortable than other rigid splints and not slippery if you have to get up to go to the bathroom in the middle of the night.

Why do people tell me to wear cowboy boots for my heel pain?

This was a big topic not too long ago when Eli Manning, the quarterback for the New York Giants, was following the advice of his old coach by wearing his cowboy boots for heel pain.  Why the cowboy boots?  Because wearing a slight heel and I’m not talking high heels here, but wearing a 1 1/2 to 2 inch heel relaxes your ankle.  This will decrease the pull of your Achilles tendon just enough to decrease the stretch on the muscles in your arch.

Wearing heels or cowboy boots all the time causes other problems so this is not a long term treatment or prevention.  Remember what I always say, “ you can’t begin to heal until the inflammation is gone”.  Sometimes a patient who has a decent pair of cowboy boots or low heels will ask and I will tell them that wearing these shoes or boots is a good idea for a week or two, but stretching is the real treatment.

Ok, the plane is about to land so let’s wrap this up.  This has been a little more technical than other pieces on this website.  It’s ok to read it over a time or two.  When you think you have it then I want you to ask yourself one more question:

Why can one heel hurt and not the other?

I’ll answer that and other questions in another technical article about the nuts & bolts of how the foot works.

Just this week a resident surgeon diagnosed one of my patients with a “pump” bump.  This is a lump of bone on the back outside “shoulder” of the heel that was thought to be caused by high heeled women’s shoes.  Unfortunately in this case the patient was a man.  How was I going to diagnose the cause of his heel pain without embarrassing my resident or the patient?  We played tic-tac-toe.  I drew a grid around his Achilles tendon attachment to the heel.  Next, I pushed on each square and marked an “X” if he felt pain.  When finished I stepped back and looked at the pattern of X’s.  All of a sudden the true cause of this patient’s heel pain was staring me in the face.

The center square is where the Achilles tendon attaches to your heel bone.  If my X-pattern involves the center row or even sometimes the bottom your problem is with the Achilles tendon insertion.  An X-pattern in the upper squares are a sign of Haglund’s deformity.  This is a lump of bone extending across the top portion of the heel.  The Achilles tendon sits right over this area and is separated from the bone by a fluid filled sack called a bursa.  The tendon, bursa, or both can be involved in this pain pattern.  If my X’s are more along the outside of the heel (right side of the picture) this would be the “pump” bump my resident had suggested.

You can see from the picture that my patient has a problem in the central square.  This is pain at the Achilles tendon attachment to bone.  Fortunately anti-inflammatory medicine, ice, stretching, a lift under his heel, night splints, and physical therapy will usually make this better.  Some times a heel spur can form in this tendon attachment and needs to be removed, other times an arthritic condition such as Rheumatoid arthritis or systemic lupus can inflame the tendon attachments to bone.  This is called enthesopathy and requires medical care with arthritis medications besides the ice, night splints, and physical therapy we just talked about.

The other areas of heel pain in this part of the foot are lumps and bumps.  If the pain is across the top squares, a Haglund’s deformity, or along the outside squares, a pump bump, I will recommend starting with the relief of inflammation like I always do and add a change in shoes that won’t push on this painful area of the heel.  If your pain does not go away with stretching, night splints, ice, anti-inflammatory medicine, changing shoes, and physical therapy that pretty leaves us with only one option, surgery.

Even though there are 3 causes of heel pain in this area surgery always involves the Achilles tendon because either the tendon is the cause or it lies just over the problem area.  For this reason no matter which diagnosis you have the recovery from Achilles heel surgery is the same.  Your game plan for recovery will include 2 months completely off that foot using crutches or a knee walker.  I will begin your physical therapy at 2 weeks.  Your first steps will be in a cast boot with the help of a physical therapist around the 8 week mark.  From there I’ll teach you how to gradually return to shoes.  Your total time out of shoes will be about 3 months.

I don’t think my resident will ever forget how to diagnose Achilles heel pain after this.  Using a simple child’s game to make a complex diagnosis is just one of the things I love about my job.

The bottom of the heel:

Plantar fasciitis:
The most common diagnosis given to heel pain.  The problem is inflammation of the small muscles in the foot where they attach to the heel.  This is caused by an unstable foot and is most often described as deep sharp pain when you get out of bed in the morning or after sitting for a prolonged period of time.  It can extend into the arch and will get worse if left untreated.

Heel spur:
A growth of bone on the bottom of the heel along the attachment of the small muscles in the foot.  This is the same problem as plantar fasciitis.  The best way to think of this is your muscles are pulling away from the bone because your foot is unstable.  The spur forms when the bone tries to hold onto the muscles to keep them from pulling away.  The spur does not cause the pain, it is the plantar fasciitis that is causing your pain.

Systemic arthritis:
Yes, that’s right your heel spur might not be related to plantar fasciitis at all.  Systemic arthritis such as Systemic Lupus, Reiter’s Syndrome, or Psoriatic arthritis cause inflammation along the attachment points of tendons.  This is called enthesopathy.  The heel is a common spot for this to occur, but the spur is different.  With enthesopathy the spur is not crisp at the margins.  We call this “whispering”.  If you have pain in other joints or your low back, your heel pain might not be plantar fasciitis.

Nerve entrapment:
Heel pain that is described as electrical or shooting is more likely to be from nerves.  There are nerves in the heel that can become entrapped or pinched as they cross muscles and fascia.  This pain can mimic plantar fasciitis, but when I press along the side of your heel  and run my finger over the nerve you will have the pain.  The low back is a common area to have pinched nerves that send pain to the heel.  If you tell me you also have pain in your low back I will test your spine to see if the heel pain occurs with stress.

The back of the heel:

Achilles tendonitis:
The Achilles tendon runs from the muscles in your calf to the back of the heel.  This is one of the strongest tendons in the body.  Inflammation of the tendon occurs either around the tendon or within the tendon.  With inflammation around the tendon there is sharp and stabbing pains with activity, but this might be improved in heels.  Inflammation within the tendon is worse, but hurts less.  You will notice swelling of the tendon.  If left untreated the tendon will weaken.  Everyone has heard of a friend of family member who was playing sport and suddenly without warning ruptured (broke) their Achilles tendon.

Pump Bump or Haglund’s deformity:
The heel bone can form a lump on the back side usually the outside edge of the Achilles tendon area.  This area is a pressure point in shoes, especially women’s shoes, therefore was given the name of pump bump.  Avoiding shoes that apply pressure to that area is the easiest treatment of all, but many people need to wear dress shoes for work.  Prominent bone can only be removed by surgery.

Bursitis:
The Achilles tendon attaches to the back of your heel bone, but not at the top edge.  As the tendon passes the top edge working its way to the attachment in the center of the bone there is a fluid filled sack called a bursa.  This allows the tendon to slide over the top edge of the bone as you walk.  This fluid filled sack can become irritated causing pain and swelling.  Relieving the inflammation and stretching your Achilles tendon usually make this problem go away completely.

Heel pain is very common and as you can see there are many reasons your heel can hurt.  Think about where the pain is and when it hurts.  You might not be suffering from plantar fasciitis.

Bunion:

A lump behind your big toe caused by the big toe going one way, towards the 2nd toe, and the bone that supports the big toe, metatarsal, going the opposite way.  The lump is the metatarsal.  Pain can be divided in two:  on the lump is usually sharp pain with pressure from shoes, redness, and sometimes swelling, while the other pain is deep in the joint described as aching or throbbing that gets worse when you walk.

Bunionette or Tailor’s Bunion:

Similar to a bunion, but at the little toe.  This is where the 5th toe moves toward the 4th and the bone supporting the toe, 5th metatarsal, moves the opposite way making a lump on the outside of your foot.  Pain can be described just like it can for a bunion.

Corns: 

Hard skin on any side of a toe that usually causes sharp pain to pressure or shoes.  You might notice that the toe has changed position or shape.

Calluses:

Hard skin on any surface of the foot other than the toe, usually causing sharp pain while walking.  Why is a corn on the toe and callus on the foot?  I have no idea.

Exostosis:

This is an abnormal growth of bone.  Places where you might be able to see this are on a toe, top of the 1st metatarsal, or on the top of your arch.  These cause sharp pain when pressure is applied, but are caused by arthritis in the nearby joint.  Arthritis pain is deep aching, throbbing and yes it does get worse with the weather.

Hammertoe:

A toe that is buckled, curled, or bent any way other than straight.  Pain from the toe is usually related to a corn, but the joints can cause deep aching pain when walking.

Hallux limitus or hallux rigidus:

The hallux is the big toe and these conditions describe the joint at the base of the big toe.  The motion in this joint can be limited or completely gone, rigid.  These are forms of arthritis commonly described as deep aching, throbbing, or even sharp.  Anything that makes the toe move aggravates the pain such as walking especially in heels or up hill.

Metatarsalgia:

This is a general term for inflammation of a metatarsal.  It has fallen out of favor recently since it is not very descriptive.  Now-a-days this would be inflammation of the joint in the ball of your foot called capsulitis.  This is deep aching or throbbing pain when the joint moves, such as when walking, but usually better in supportive shoes and worse in heels or on stairs.

Metatarsal stress fracture:

A stress fracture is true inflammation of the bone that weakens the structure of the bone and can become a real break.  This is deep aching and throbbing with swelling of the foot in the area of the break.  Usually you have increased your activity or changed shoes before this started.

Neuroma:

A pinched nerve in the ball of the foot.  This causes sharp shooting pains that might travel out the end of your toes, most commonly the 3rd and 4th toes.  Some people can describe a clicking feeling in the ball of their foot when they walk.

Peripheral neuropathy:

The sensations of burning, tingling, or insects crawling on your skin worse when you have no other distractions like when you lay in bed.  These usually follow nerve patterns and can travel up and down the foot or leg.  This can get worse leaving you with loss of feeling.  You would think that loss of feeling has no way to be described, but since you had feeling then lost it patients are able to describe this lack of sensation.

Plantar fasciitis:

Arch pain in the muscles that is often described as cramping, aching, pulling, or even sharp when you walk.  This pain is usually worse with the first steps in the morning or after a period of sitting.  The plantar fascia is a big strong ligament running from the heel to the toes, but it is actually the muscles that sit just beneath the fascia that are inflamed.  The heel is usually involved in the pain as well.

Sesamoiditis:

The sesamoids are like knee caps for your big toe.  They sit in the ball of your foot behind the big toe and help the tendons hold your big toe on the ground.  These can be injured directly or by forceful upward motion of the big toe.  Aching in the ball of the foot at the base of the big toe with or without swelling is usually described by patients.

Tendonitis:

The muscles in your leg travel to your foot by tendons.  Any of these tendons can become irritated, injured, or inflamed.  The pain is usually along the line of the tendon and is commonly described as sharp, stabbing, aching, or throbbing depending on your activity.

Ulcer:

An ulcer is a break in the skin.  Obviously this would hurt, but most patients with ulcerations on their feet are lacking the ability to feel pain.  This can be hidden under callus or develop from a blister next to a callus.

These are the most common causes of “foot pain”.  I hope this will help when you need to explain the pain.  My heart can only handle so many complaints of “foot pain” in a day.

I asked about his recovery from the race.  I heard about the celebration that night soaking in a hot tub with friends drinking and eating whatever was there.  His wife had scheduled him for a massage the day after the race.  Paul said it hurt more than it felt good and had no lasting effect.  Stretching was impossible because of the pain and stiffness.  The tight muscles made it nearly impossible to run the few times he had tried.  When I asked if he was following any schedule or program he reminded me of his pre-race training program, but had nothing to follow for recovery.  Do you know what Paul did wrong?

What you do immediately after the race is as important as what you did to get there.  You know that running 26 miles is serious business, that’s why you were so careful in your training program.  After the race you will be exhausted mentally and physically.  Your recovery plan has to be set before you race so you won’t have to think about it.  Your muscles have worked hard for 26 miles and all nutrients in your body have been used.  When your body works hard for a long time you get inflammation.  Treat your body right and this will go away quickly so you’ll be running again in no time.  Ignore the inflammation and you’ll suffer.  I’m sure you’ve heard stories about people who ran a marathon and were never able to run again.  If you ask them about their post-race recovery I bet you’ll get a blank stare.

As soon as you finish the race:

You’re exhausted and legs feel weak, but this is the time you need to keep walking.  Don’t stop and get a chair massage, don’t chat at the booths.  Get your packet, medal, snack pack, and drink water as you walk around.  Make a mental note of what hurts.  I don’t mean big areas like your entire leg.  I mean specific areas like your calf muscle, front of your thigh, back of the thigh, front of your leg, arch, heel, toe.  Pay attention to any pains so that you can address these after a thorough cool down.

Your kidneys have been fighting to balance your hydration and electrolytes.  All the waist products coming from all that muscle action of running 26 miles is filtered by your kidneys.  They have worked overtime and need to recover.  Anti-inflammatory medications stress your kidney more.  This is not the time to take anti-inflammatory medications like Ibuprofen or Naproxen.  Refuel by drinking water, electrolyte drinks are OK, but water has to continue even if you’re drinking electrolytes.  Eat like you did while you were training.  Protein helps repair muscles and carbohydrates help with fuel. 

I don’t know how to describe it, but there’s an excited feeling in your legs, some people tell me a throbbing, others say it’s like their legs are just revved up.  Don’t stretch until that feeling in your legs goes away.  You can ice the sore spots and gently stretch.  When you get home take a cool bath.  Use a foam roller or gently massage sore muscles.  If possible schedule a massage in the evening, at least 4 hours after the race.

Things to avoid:

1. Sitting for more than 10-20 minutes
2. Soaking in warm water or hot tub
3. Sauna
4. Anti-inflammatory medications

The first week:

Inflammation can last 24-72 hours.  You will have to pay close attention to your body. If you treat the inflammation right you’ll be running again after a few days.  Ignore the inflammation and it can become a repeating cycle that is difficult to break even with my treatment.  Have more massages, practice yoga, swim or bike.  Don’t be aggressive, your goal is to stay loose.

If you have no aches and pains by day 3 you can begin gentle-paced, low mileage runs.  Do not exceed the mileage you did the week before the marathon.  Begin every three days with light resistance training on off days.  Any aches and pains need to be addressed.  Don’t wait to see me for any pains that remain.  The sooner these are addressed the easier they are to treat.

The 2nd week and forward:

If you’ve made it this far without needing me you’re doing well.  Gradually increase run frequency and distance back to your training levels as tolerated.  You might find that you are more easily fatigued, but that is normal for the first month.  Anything more than that and you should seek medical attention.  Don’t forget to have your running shoes checked.  During this return to training period you will need to have new shoes.  At Desert Foot Surgeons we offer video gait analysis to see what the naked eye cannot.  Come have your gait analyzed in or out of shoes.

Congratulations, you did it!!

screw and absorbable pin

So your toe is bent to the point where your shoes rub on the top of your to causing pain.  The skin is always red and sore.  The bending has gotten worse over the past year and at times you have pain in the ball of your foot.  What if I told you I could fix the bend in your toe so that the pain goes away?  Take it one step further, I can fix the bend in your toe so that the pain goes away, but there will be a pin sticking out the end of your toe for 4-6 weeks.  For a lot of people that’s a deal breaker.  They want the toe fixed, are willing to deal with the pain and recovery of hammertoe surgery, but don’t want to see that pin sticking out the end of their toe.

This is a big problem and as your surgeon I have to address your concerns.  I recognized this early in my training and began using absorbable pins that did not stick out of the toe while I was a resident.  Smaller screws became available that could be used in toes and more recently special little devices made of space-age material were introduced just for toe surgery.

I’ve already talked about the difference in hammertoe surgery between the 2nd and 3rd toes as compared to the 4th and 5th.  Here I’m talking about the 2nd and 3rd toes only.  When I fix the bend in your toe I need to make a stiff, straight toe.  I remove the crooked joint and force the bone to heal together straight.  That’s why I need to use a pin, screw, or special little device to get the bones to heal together, or in other words fuse.  The only question to ask for this part of your surgery is how strong is your bone?  That changes my options.  Stronger bone means I can use just about anything, but weaker bone limits my options.

Why do some people still have hammertoe surgery with the pin sticking out of the end of the their toe?  The most common reason is weak bone.  Some things that have been around a long time are still used today because they work in almost every case.  Even if your bone is weak a pin can be used to hold it straight until healed.  The other reason is the joint at the base of our toe where your foot begins.  Many people have toes so badly bent that the joint in the ball of their foot is also bent.  More recent advances have shown that breaking the bone in the ball of your foot to straighten this joint is better than the older method of cutting tendons and ligaments.  When we used to cut the tendons and ligaments in this area the best way to hold the toe straight was using a long wire.  Now we use screws to hold the bone in the ball of your foot without having to use a pin across that joint.

smart toe

New techniques and new technology are sometimes slow to catch on.  Hammertoe surgery without the pin sticking out of your toe is not new.  As I said in the beginning, I started doing this when I was in residency.  I’ve been training residents for about ten years and even the very first resident I taught learned how to fix a hammertoe without a pin sticking out the end of the toe.  When I discuss toe surgery with you I will talk about the options and what I think is best for you.  I want to hear your opinion and make sure I’m addressing your goals.  It is very important that we are on the same page when it comes to fixing your toe.

Hammertoe toe surgery might be in your future.  If you are scared about having a pin sticking out the end of your toe come and talk to me.  More often than not I can straighten your toe without having to leave a pin sticking out the end.

Recently three people came to see me for the most common running injuries.  Even though these people had different pain, were different ages, lived in different cities, and had different lifestyles, they all had similar stories about training for a marathon.  All three had not run for exercise consistently in more than 5 years.  A friend had convinced each one to train for the marathon.  Not one of the 3 had a training program made specifically for them, but all were using a group training schedule from either a magazine, the internet, or joining a training group.

The first patient complained of heel pain that was worse with the first steps out of bed then again in the evenings especially after running.  I diagnosed this patient with plantar fasciitis and relieved her pain by teaching her how to stretch and ice, gave her foot orthotics to support her sudden increase in activity, and plantar fascia night splint for the morning pain and stiffness.  Plantar fasciitis is a common overuse injury.  The muscles in your arch stretch beyond their limits when you walk or run.  A sudden increase in activity, change in shoes, or an injury is usually related to the start of pain, but very few people realize this until I point it out.  In this case the patient had a new activity, running.  She also had new shoes that she bought for this training.  Had I seen her before she started training I could have watched her walk on slow motion video and analyzed how her foot might be effected by running.  Stretching could have been started before training began and help individualizing her training program could have been arranged.  Her heel pain and time away from training could have been avoided, but she will be able to run the marathon.

The second patient came to me with the complaint of pain and swelling in the top of his foot.  He was training for a marathon and noticed the pain increasing gradually as his distance increased.  Pain was present all day long, worse in shoes, and swelling increased the more he walked.  Running had stopped because of the pain.  X-rays showed a stress fracture of his 2nd metatarsal.  This is the bone behind your second toe and is commonly the bone involved in stress fractures of the foot.  Stress fractures are broken bones that happen gradually when you have a sudden increase in activity.  The sudden increased pressure on the bone causes inflammation that weakens the bone, but you’re still not aware of it so you keep on training.  When the weak area of the bone breaks you get the big ouch.  Treating the fracture early is easiest.  A removable cast and anti-inflammatory pills relieve the pressure and inflammation allowing the fracture to heal.  Once you heal the real treatment begins.  There is a reason the fractured bone has more pressure than the others and it’s my job to find out.  Detailed exam of your foot structure including video gait analysis will be done so that custom foot orthoses can be made.  This will correct the pressure problems in your foot and prevent further fractures.  Unfortunately in this case the patient came to me once his bone had broken.  His goal of completing a marathon will have to be postponed until later in the year.

The third patient wasn’t far along in her marathon training when she developed pain in her lower legs.  This pain was very bad when running and improved with rest.  She wanted to run the marathon so bad that she trained until until her leg started to swell.  By the time I saw her my major concern was a stress fracture of her tibia, the main bone in the lower leg.  The beginning of her story was more like shin splints, but I had to make sure so a few tests were done to prove this was not a stress fracture and she improved with treatment for shin splints.  Medial tibial stress syndrome is the newer term used in sports medicine for shin splints.  The cause is always related to pronation, see my article “Are You a Pronator”.  Most foot problems can be related to pronation, but medial tibial stress syndrome occurs in the leg.  To make a long story short, it’s the rotation of your lower leg when you run that causes this pain.  Custom foot orthoses are the only way to make this go away and stay away.  I had to modify this patient’s training program and get her help to strengthen her thigh muscles, but she will be running in the marathon.

Running is good for you!  No one will argue that point, but getting started is the hard part.  Buying a running shoe from a specialty store is a good idea, but now a lot of stores are using pressure mapping to tell you how your foot works.  First of all, you cannot tell how the foot works by standing still on a pressure plate.  At Desert Foot Surgeons I use video gait analysis to see exactly how your foot works while you run or walk barefoot and in shoes.  Second the study of foot motion is called biomechanics.  This takes years of study to master and is only provided in podiatry schools.  I have many friends in the running shoe business and have learned a lot about shoes from them.  Likewise I have taught my friends a lot about biomechanics.  I won’t pretend to know more about shoes than these professional salespeople and all of my friends will not pretend to know more about the function of the foot than I do.

Come see me before you start running.  I can help you with more than just shoes and orthotics.  I can get you personalized training or even physical therapy.  If you have shoes already video gait analysis will show if they are working for you.  Preventing injuries is much easier than treating injuries.  Running is good for you, just do it smart!

With that said, recovering from hammertoe surgery is usually not that hard.  You should do a few thins to make sure that your healing experience is the most pleasant possible.  Before your surgery is the most important time.  The more you can do for yourself before surgery, the happier you will be after.  Simple things like preparing meals before hand, practicing walking in your special shoe or boot, and planning for time spent resting your foot.

What room in your home worries me most?

Believe it or not it’s your kitchen.  Those kitchen cabinets have that little ledge at the bottom.  Be careful not to hit your toes against this edge.  The shoe or boot you will be wearing is higher than regular shoes and has grabbed hold of more than one of my patients’ bandages.  That’s a good reason to prepare meals before your surgery, but the real reason is you are recovering from surgery.  You shouldn’t have to cook for yourself.  Give yourself at least a little few meals off to rest and stay off your foot.

Since we’re talking about hammertoe surgery most of you will be allowed to walk, but in a special shoe or boot.  You might not think this is going to be hard, but if you’re weak this can be a challenge.  I can send you to physical therapy before the surgery to be sure you can handle the shoe or boot.  This way you and I know exactly what to expect after surgery.  I can even prescribe a strengthening program for you through physical therapy if you need.

Easier Hammertoe Recovery

Other things that can make your recovery from hammertoe surgery easier include getting your house set.  Firsts of all, do you have stairs?  If walking on flat floors is hard in the shoe or boot, stairs might be impossible.  You might want to sleep downstairs the first few days.  You will need to clear a path to the bathroom.  Think about removing area rugs that can slip and slide out from under foot.  Small tables and chairs can have legs that stick out, which could bump your toe.  Think about the ways you can set up your house to help you recover.  My staff has many more ideas that they will be glad to share with you.

Before surgery we developed a plan to help you heal as fast as possible.  After your surgery you need to stick to the plan.  The game plan we designed together before surgery will be given to you in writing.  Obviously there will be a special shoe or boot and pain medication that you should have before you get to the hospital.  That leaves swelling and pain to discuss.  A toe is small and there is not much room for swelling.  The more your foot is down, the more it will swell.  Since there is so little space in the toe this swelling can hurt.  Both of us want your surgery to be as free of pain as possible.  You will need to rest with your foot up.  That means lie flat on the couch or bed and put your feet on pillows.  Make sure your knees are bent a little so this is more comfortable.  Ice can go behind your knee or at the inside of your ankle to prevent swelling.  The ice should be on 20 minutes and then off for 40 minutes.  This can be repeated as often as needed, but usually no less than 3 times per day for the first 3 days.

I like to prepare before surgery as much as possible.  I tell my residents to review a surgery in their mind 5 times before they even step into the operating room.  If your surgeon prepares before surgery shouldn’t you?  I hope this information shows you how Desert Foot Surgeons helps you heal after hammertoe surgery.  Remember, feet are like snowflakes, no 2 are alike.  Choosing your foot surgeon is very important.  Your surgeon needs to have the training and artistic talent to fix your toe.  Equally as important is your ability to communicate with your surgeon.  Ask questions and prepare before your surgery.  You’ll be glad you did.

Let’s start with your 4th and 5th toes.  Unfortunately shoes press the hardest on your 4th and 5th toes.  Because of this constant pressure I can’t make these toes stiff or you would never wear shoes again without pain.  In fact, your 4th and 5th toes are fixed by removing the crooked joint and leaving the toe flexible.  Removing the joint will fix the bend, but does nothing to fix the twisting so I have to use a carefully planned skin incision to un-twist your toe and bring the nail back on top.  The bandages will help to hold your toe in this position since there are no screws or pins, so it is very important that you do not remove your bandages.  To prevent the tendons from pulling on your toe you must wear a special shoe or boot.  You will be allowed to walk after the surgery as long as you wear this shoe or boot, but remember that the more time you spend walking around on your foot after surgery the worse the swelling and pain will be.  Stitches are removed after 10 days and you will wear a loose fitting tennis shoe before you return to tighter shoes.  I expect swelling to last 3-6 weeks, but a lot of that depends on your body.

Your 2nd and 3rd toes are more complicated to fix than the 4th and 5th because they buckle for a different reason.  Because of this difference I have to treat these toes using another approach.  Your 2nd and 3rd toes must be made stiff so that the muscles won’t cause the toe to buckle again after it has been fixed by surgery.  That means that after the surgery your 2nd and 3rd toes will not bend at the toe joint.  You will have a screw or pin in your toe to hold the bones straight.  The screw or pin can be removed in the office at a later date if needed.  No doubt you have heard stories about people having pins sticking out of their toes after hammertoe surgery.  I use newer technology when I can so that you won’t have anything sticking out of your toe.  It is still important that you not change the first set of bandages after surgery.  In straightening your 2nd and 3rd toes I am removing the crooked joint and making the bone ends heal together.  You will be able to walk using special cast boot, but again the amount you walk determines how much swelling and pain you get.  The bone takes about 1 month to heal.  Tennis shoes are easier to wear at first and as swelling and pain subside you can progress to the shoes you want, within reason.

That’s the scoop on the most common hammertoe surgeries.  I’ve told you how fixing your 4th and 5th toes are different from your 2nd and 3rd.  You have an idea of what to expect after surgery.  I have not told you about the more complex toe problems, but will in future posts.  For now remember what I always say, “feet are like snowflakes, no two are alike”.  The surgical approach from one foot to another has to be different, that’s the art of surgery and is one of the main things separating me from other foot surgeons you might meet.