Ingrowing Toenails

One of the most common foot disorders is an ingrown toe nail. The edge of the nail grows into the skin at the side of the nail, and the area becomes infected. The skin is red and inflamed, and the toe hurts. Pus may form. Major factors which can cause the problem are:
  • Tight shoes
  • Tight socks
  • Cutting the nail too short with rounded edges


Treatment An ingrown toenail can often be effectively treated by antibiotics, surgical removal of a wedge of nail, avoiding tight shoes and tight socks and avoiding improper Post operation cutting of toenail. Post operation a bulky dressing will be applied to the A chronic ingrown toenail with recurrent infections may toe. This should not be removed for 7 days. You will not require surgery. be able to drive yourself. Please make arrangements for transport home in advance.

Surgery Please keep your foot elevated above the level of your heart as much as possible for 72 hours after surgery as With a wedge resection of the nail, the surgeon removes this will reduce swelling and bleeding - both of which a strip of nail at the side and a small part of the nail bed. may increase the risks of local infection. The nail will then grow straight and not grow into the skin. You need to ensure that you have an appointment 7-10 days post-op so that the dressings may be reduced Usually one edge of the nail is removed. In some cases and any sutures removed both left and right edges are removed. To treat severe cases the surgeon may need to remove Complications the whole nail and the complete nail bed.

These include: The surgery is a day-case procedure.
  • It may be Infection
  • Performed under local anaesthetic or general
  • Recurrence of ingrown nails anaesthetic

Hammer Toes and Corn

Complications Complications include: Hammer Toes and Corns
  • Recurrence.
  • Over Correction. Dr. Pradeep Moonot
  • Orthopaedic Surgeon
  • Infection at the site of the wound.
  • Toe stiffness. Specialist in foot, ankle and knee surgery
  • Nerve injury at the time of surgery
What are they? Hammer toe describes one shape the toe may take when the joints are contracted and deformed. The other shapes of deformed toes are claw toes and mallet toes. A corn is the thickened skin that forms where the shoerubsonthetoe. Ahardcornformswherethe skin is dry and a soft corn forms when it is moist, as between the toes.

A Soft Corn What is the cause? Corns are always caused by shoes; shoes may also cause hammer toes. Shoes with high heels and narrow pointed toe boxes bunch up the toes, causing contracted joints and pressure areas in the skin. Some contracted toes are due to muscle weakness, arthritis or congenital problems but most are due to tight shoes. Beneath every corn there is a prominence of the bone. Pressure and friction from the shoe causes the skin to thicken at this point. Corns in the foot are like calluses in the hand - the skin thickens to resist pressure or friction. Unrelieved pressure on the toes can cause complications. With time, a flexible hammer toe deformity becomes a stiff hammer toe, which is more difficult to treat. The second toe may cross over the first and eventually dislocation may occur at the base of the second toe. Corns may eventually lose their ability to protect the toe and breakdown,formingskinulcers. Thismayleadto infection.
What is the treatment? The treatment is to either modify the shoes or modifythetoes. The choice should be simple,but it is not, because fashion, not common sense, dictates the shape of the toe. To eliminate pressure on the toes, the shoes should have a deep toe box that is shaped like the toes and made from soft material. The heel should be low. Sandals or running shoes are the best, but even dress shoes may be found that meet these requirements. Corns that become too large can be shaved down. Sponge pads can be used on tender areas. The object of surgery is to reduce the prominence of the toe where the corn is formed. Part of the bone is removed to allow the toe to lay flat in the shoe.

The Injury

Plantar Fasciitis (heel-spur syndrome) is a common problem.  It starts as a dull intermittent pain in the heel which may progress to a sharp persistent pain.  Classically, it is worse in the morning with the first few steps, after sitting, after standing or walking, and at the beginning of sporting activity. The plantar fascia is a thick fibrous material on the bottom of the foot.  It is attached to the heel bone (calcaneus), fans forward towards the toe, and acts like a bowstring to maintain the arch in the foot.

A problem may occur when part of this inflexible fascia is repeatedly placed under tension, as in running.  Tension causes an overload that produces an inflammation usually at the point where the fascia is attached to the heel bone.  The result is pain.  Plantar fascia injury may also occur at midsole or near the toes.  Since it is difficult to rest the foot, the problem gradually becomes worse because the condition is aggravated with every step.  

The inflammatory reaction at the heel bone may produce spike-like projections of new bone called heel-spurs.  They are sometimes shown on X-rays.  The exact relationship between heel spurs and plantar fasciitis is poorly understood.  The heel spurs do not cause the heel pain and they are not the initial cause of the problem.  Indeed some people may have heel spurs found incidentally on X-rays but may be completely pain free.

Treatment :Improvement may take longer than expected, especially if the condition has been present for a long time.  During recovery, loss of excess weight, good shoes and sedentary activities all help the injury to heal. You should return to full activity gradually.  

Rest :  Use pain as your guide.  If your foot is too painful, rest it.

IceIce the sore area for 30-60 minutes several times a day to reduce the inflammation.  Apply a plastic bag of crushed ice over a towel.  You should also ice the sore area for 15 minutes after activity.

MedicationIf your condition has developed recently, anti-inflammatory/ analgesic medication (in tablet form), coupled with heel pads may be all that is necessary to relieve pain and reduce inflammation.  If no pain relief has occurred after two or three months, however, an injection of either cortisone and/ or local anaesthetic directly into the tender area may be considered.

Physiotherapy:  The initial objective of physiotherapy (when needed) is to decrease the inflammation.  Later, the small muscles of the foot can be strengthened to support the weakened plantar fascia.

Heel Pads: A heel pad of felt, sponge or a newer synthetic material can help to spread, equalize and absorb the shock as your heel lands, thus easing the pressure on the planter fascia.

Shoes:  Poorly fitting shoes can cause plantar fasciitis.  The best type of shoe to wear is a good running shoe (jogger/trainer) with excellent support.  The shoe that fits best should be chosen.  Experiment with your athletic shoes to find a pair that is comfortable and gives you fewer symptoms.

Orthoses:  Orthoses are shoe inserts that Dr Pradeep Moonot may prescribe if necessary.

Taping: Taping your foot to maintain the arch may benefit some people as this can take some of the pressure off the plantar fascia.

Night Splints:  These are plastic splints that keep the foot stretched and the ankle at right-angles when you are asleep.  This maintains the tension in the plantar fascia and may help to alleviate some early morning symptoms during the first few steps of the day.

Surgery:  Surgery is rarely required for plantar fasciitis.  It would be considered treatment if the pain is still incapacitating after at least 12 months of treatment.  When needed, surgery involves release of the plantar fascia and release of a small nerve.  

Sports Plantar fascia can be aggravated by all weight bearing sports.  Any sport where the foot lands repeatedly, such as jogging or running can aggravate the problem.  To maintain cardiovascular fitness, weight bearing sports can be temporarily replaced by non weight bearing sports (like swimming, cycling).  Weight training can be used to maintain leg strength.  When recovering from plantar fasciitis, return to sports activities slowly.  If you have a lot of pain either during the activity or the following morning, you are doing too much.

Exercise Stretches:  Stand at arms’ length from a counter or table with your back knee locked and your front knee bent.  Slowly lean towards the table, pressing forward until a moderate stretch is felt in the calf muscles of your straight leg.  Hold 10 seconds.  Keeping both your heels on the floor, bend the knee of your straight leg until a moderate stretch is felt in your Achilles tendon.  (Tendons attach muscles to bones; the Achilles tendon attaches the muscles of the calf to the heel bone).  Hold 10 seconds.  You should feel a moderate pull in your muscles and tendon, but no pain.  Change legs and stretch the other leg. Repeat 10 times, 3 times a day.

The Injury

Plantar Fasciitis (heel-spur syndrome) is a common problem.  It starts as a dull intermittent pain in the heel which may progress to a sharp persistent pain.  Classically, it is worse in the morning with the first few steps, after sitting, after standing or walking, and at the beginning of sporting activity.

The plantar fascia is a thick fibrous material on the bottom of the foot.  It is attached to the heel bone (calcaneus), fans forward towards the toe, and acts like a bowstring to maintain the arch in the foot.

A problem may occur when part of this inflexible fascia is repeatedly placed under tension, as in running.  Tension causes an overload that produces an inflammation usually at the point where the fascia is attached to the heel bone.  The result is pain. Plantar fascia injury may also occur at midsole or near the toes.  Since it is difficult to rest the foot, the problem gradually becomes worse because the condition is aggravated with every step.  

The inflammatory reaction at the heel bone may produce spike-like projections of new bone called heel-spurs.  They are sometimes shown on X-rays.  The exact relationship between heel spurs and plantar fasciitis is poorly understood.  The heel spurs do not cause the heel pain and they are not the initial cause of the problem.  Indeed some people may have heel spurs found incidentally on X-rays but may be completely pain free.


Treatment

Improvement may take longer than expected, especially if the condition has been present for a long time. During recovery, loss of excess weight, good shoes and sedentary activities all help the injury to heal.  You should return to full activity gradually.  


Rest:  Use pain as your guide.  If your foot is too painful, rest it.

Ice: Ice the sore area for 30-60 minutes several times a day to reduce the inflammation.  Apply a plastic bag of crushed ice over a towel.  You should also ice the sore area for 15 minutes after activity.

Medication:  If your condition has developed recently, anti-inflammatory/ analgesic medication (in tablet form), coupled with heel pads may be all that is necessary to relieve pain and reduce inflammation.  If no pain relief has occurred after two or three months, however, an injection of either cortisone and/ or local anaesthetic directly into the tender area may be considered.


Physiotherapy:  The initial objective of physiotherapy (when needed) is to decrease the inflammation.  Later, the small muscles of the foot can be strengthened to support the weakened plantar fascia.


Heel Pads: A heel pad of felt, sponge or a newer synthetic material can help to spread, equalize and absorb the shock as your heel lands, thus easing the pressure on the planter fascia.

Shoes:  Poorly fitting shoes can cause plantar fasciitis.  The best type of shoe to wear is a good running shoe (jogger/trainer) with excellent support.  The shoe that fits best should be chosen.  Experiment with your athletic shoes to find a pair that is comfortable and gives you fewer symptoms.


Orthoses:  Orthoses are shoe inserts that Dr Pradeep Moonot may prescribe if necessary.

Taping: Taping your foot to maintain the arch may benefit some people as this can take some of the pressure off the plantar fascia.




Night Splints:  These are plastic splints that keep the foot stretched and the ankle at right-angles when you are asleep.  This maintains the tension in the plantar fascia and may help to alleviate some early morning symptoms during the first few steps of the day.


Surgery:  Surgery is rarely required for plantar fasciitis.  It would be considered treatment if the pain is still incapacitating after at least 12 months of treatment.  When needed, surgery involves release of the plantar fascia and release of a small nerve.  


Sports Plantar fascia can be aggravated by all weight bearing sports.  Any sport where the foot lands repeatedly, such as jogging or running can aggravate the problem.  To maintain cardiovascular fitness, weight bearing sports can be temporarily replaced by non weight bearing sports (like swimming, cycling).  Weight training can be used to maintain leg strength.  When recovering from plantar fasciitis, return to sports activities slowly.  If you have a lot of pain either during the activity or the following morning, you are doing too much.


Exercise Stretches:  Stand at arms’ length from a counter or table with your back knee locked and your front knee bent. Slowly lean towards the table, pressing forward until a moderate stretch is felt in the calf muscles of your straight leg.  Hold 10 seconds.  Keeping both your heels on the floor, bend the knee of your straight leg until a moderate stretch is felt in your Achilles tendon.  (Tendons attach muscles to bones; the Achilles tendon attaches the muscles of the calf to the heel bone).  Hold 10 seconds. You should feel a moderate pull in your muscles and tendon, but no pain.  Change legs and stretch the other leg.


Repeat 10 times, 3 times a day.
Tendonitis is a term which means inflammation or swelling, and it occurs often in and around the Achilles.

There are two areas of the Achilles prone to this problem: in the middle of the tendon (mid-substance Achilles tendonitis) and at its insertion into the heel bone (Insertional Achilles tendonitis). Patients with tendonitis within the heel and Achilles, may be seen in our Heel Pain Clinic where they can normally have an assessment, imaging, decision and first treatment within a single, first clinic visit.

Where is the Achilles tendon? The Achilles tendon is the large, strong tendon that connects the calf muscles, specifically the gastrocnemius and soleus muscles to the heel bone or calcaneum. It allows you to point your foot downwards and push off the ground when you are walking or running.     What causes Achilles tendon pain?
  • In many patients no definite cause is found.
  • The Achilles tendon can withstand huge forces even in people who are recurrently stressing it, such as in long distance running however despite good conditioning, pain can ensue.
  • Rapid increases or changes in training regimes can precipitate the symptoms.
  • Inappropriate shoe-wear that can alter the mechanics of your foot when you hit the ground whilst running can increase symptoms.
  • Patients with more general symptoms such as that associated with different types of arthritis/inflammatory disorders can develop Achilles pain. 
Why does it get painful?
The tendon is made up of strong fibres made of collagen. Over time this substance can “degenerate” and become weaker and less flexible. As this occurs then tiny microscopic tears can develop in the tendon, leading to weakness, pain and eventually swelling. The tendon swelling often develops in the middle of the tendon because this area has a less well-developed blood supply hence unable to heal itself effectively.

What are the symptoms?
  • Pain and stiffness along the Achilles tendon in the morning
  • Pain along the tendon or back of the heel that worsens with activity
  • Swelling that is present all the time and can get worse throughout the day with activity
  • Severe pain the day after exercising
  • Thickening of the tendon


Achilles tendinopathy (non-insertional) When pain, weakness and loss of function is associated with a swelling in the main portion of the tendon and not down at the bottom by the heel bone, it is referred to as Achilles tendinopathy. “Tendinopathy” is used to describe the typical microscopic findings in this condition and means tissue degeneration in the tendon fibres.

Achilles tendinopathy (insertional) When pain, weakness and loss of function is associated with a swelling down at the bottom of the tendon by the heel bone, it is referred to as insertional Achilles tendinopathy. This is because the tendon “inserts” onto the heel bone. Sometimes the heel bone can be quite prominent here and very painful. This can be because of a combination of problems here including: 
  • Achilles tendon degeneration
  • Bone spurs at the tendon insertion
Inflammation of a small bursa (fluid filled sac behind tendon) – bursitis


How is the condition diagnosed? The clinical features usually diagnose the problem. An X-Ray can be done to look for tissue swelling or bone spurs. A more helpful test is an ultrasound which can easily be done to look at the tendon quality or an MRI.
Can the problem get worse? People often “live” with the symptoms for quite a while, or alter their activity profile. The symptoms can, unfortunately, progress with a potential even for rupture of the tendon. It is advisable getting assessed by a foot and ankle surgeon or physiotherapist when possible.
How do you treat Achilles tendinopathy? Both insertional and non-insertional tendinopathy can be treated in a similar fashion.

The treatment is operative or non-operative.
The vast majority of patients require no surgery. Activity modification and rest coupled with suitable anti-inflammatories or pain-killers can really make a difference. Early rest in a boot may be needed in the short-term. A small heel raise (silicone insert) can help in the shoe. It is important to get introduced to a correct physiotherapy regime as they can prove hugely successful IF FOLLOWED AS INSTRUCTED. If physiotherapy is not fully successful then shock wave therapy can be used which has good results.

Operative treatment can be performed if other measures fail. Surgery usually involves exploration of the painful tendon area and removal of the degenerate/inflamed tissue or painful bony bumps on the heel. If the tendon is detached from the bone during surgery or a large amount of the tendon is removed then using another tendon in the foot to support the damaged Achilles tendon may be needed. This is not usually needed

Medical Team

DR. PRADEEP MONOOT

MBBS (Bom), MS (Ortho)(Bom), DNB (Orth), MRCS (UK), FRCS (Ortho) (UK)

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