Information

• Shoe wear modification (podiatrist review)
• Anti-inflammatory medications
• Activity modification

Early involvement of the big toe with arthritis can cause a painful limitation of movement and surgical removal of spurs can improve this pain and restore movement. This procedure is called a cheilectomy and can be done through a key hole procedure or a very small cut on top of the toe.

Moderate to severe involvement of the joint usually requires a fusion procedure. This procedure can be performed using a minimally invasive approach or through a cut on the top of the big toe.

The joint is then cleaned out and all the arthritic bone is removed to expose fresh bleeding bone for the fusion procedure. The big toe is then fixed in position using screws or a combination of plate and screws. This means, that you now have a stiff painless toe instead of a stiff painful one that you started out with. The metalwork will remain in place unless there is reason to take it out. Click on the link below to view the surgical technique:

• Delayed healing or non-healing of the bone
• Problems with metalwork
• Stiffness of the joints nearby

You are allowed to put full weight on your leg immediately after surgery is a special post-op shoe (DARCO shoe). You have to walk in this shoe for 6 weeks and will not be allowed to drive in this shoe. You must refrain from walking barefooted during this period because of this may put undue stress on the operative site.

• Shoe wear modification (podiatrist review)
• Anti-inflammatory medications
• Activity modification

Surgery involves breaking and realigning the bones of the big toe around the bunion deformity. This can be done through a traditional 5-6 cm skin cut using a SCARF osteotomy or through a minimally invasive/ keyhole approach. Your surgeon will discuss pros and cons of both procedures with you.

• Prolonged swelling
• Under/over correction
• Recurrence
• Arthritis
• Loss of fixation and problems with metalwork
• Delayed bone healing

You are allowed to put full weight on your leg immediately after surgery is a special post-op shoe (DARCO shoe). You have to walk in this shoe for 6 weeks and will not be allowed to drive in this shoe. You must refrain from walking barefooted during this period because of this may put undue stress on the operative site.

There are various spacers and splints that your podiatrist may give you that help alleviate pain and pressure symptoms.

Corrective surgery involves a tendon lengthening procedure and a fusion procedure on the toe. We may use a buried bioabsorbable implant or a wire that protrudes from the tip of the toe (wire covered with a plastic ball so that a sharp edge does not protrude)

• Swelling that may persist for a few months
• Floating toe- slightly extended toe
• You may be unhappy with the shape or direction the toe is pointing in (sometimes these deformities have been present for a very long time and you may never have a perfect toe ever again). Your expectations will be discussed at the time you sign the consent for surgery.

You are allowed to put full weight on your leg immediately after surgery is a special post-op shoe (DARCO shoe). You have to walk in this shoe for 6 weeks and will not be allowed to drive in this shoe. You must refrain from walking barefooted during this period because of this may put undue stress on the operative site.

This is a painful condition of the forefoot that may be due to entrapment of the interdigital nerve where branches supplying the inner and outer side of the foot tend to meet. The most common site of the pain is between the third and fourth toes (although it can also occur between the second and third toes). The pain is usually worse when weight bearing and whilst wearing constrictive footwear.

• Shoe wear modification (podiatrist review) – wide toe – box shoes, metatarsal domes to alleviate pressure
• Anti-inflammatory meds and cortisone injections
• Activity modification

A cut is made on the top of the foot (not the sole – this is usually reserved for revision cases). After careful protection of the blood supply, the nerve is identified. If the nerve is abnormal, it is excised. If found to be normal at the time of surgery, then the overlying ligament is incised and the nerve is preserved.

Most patients will be able to weight bear soon after surgery in a special shoe. Although, it is advisable to limit how much you do until your wound heals completely.

• Numbness in the toes – which will be permanent if the nerve is excised at the time of surgery
• Persistence of nerve type pain in 10-20% of cases

Stretching

Evidence suggests that a specific stretching programme for the plantar fascia and Achilles tendon can give short term relief. A physiotherapist can help design a specific stretching programme for both the plantar fascia and Achilles tendon and demonstrate how to achieve effective stretching. Taping to unload the plantar fascia can help relieve symptoms initially and it can be a useful guide as to whether an orthotic device will be helpful. A physio or podiatrist can apply tape.

Night splints

There is fair evidence that the use of night splints can relieve the discomfort of plantar fasciitis. In unresponsive case, a resting boot or walking cast may be a treatment option.

Orthotics

There is fair evidence to support the short-term use of orthotics in the short-term relief of plantar fasciitis. A soft, flexible orthotic with a deep heel cup and plenty of soft cushioning under the affected area is the most suitable. An ‘off the shelf’ orthotic can be used initially and if relief is obtained, then a custom made orthotic may be appropriate. Shoes are important for providing support and cushioning. A podiatrist can be helpful in suggesting shoes that may be appropriate.

Anti-inflammatory medication

Anti-inflammatory medication appears to only be helpful in relieving pain from plantar fasciitis in the 1^stmonth of treatment.

Corticosteroid injection

Limited evidence to support the short-term effectiveness of corticosteroid injection (4-6 weeks). The risk of fascial rupture or fat pad atrophy outweighs the use of repeated corticosteroid injection. Cortisone delivered by iontophoresis may provide a safer alternative.

PRP- Platelet rich plasma injection

This treatment with platelets obtained from your blood sample that is spun down to a concentrate (full of growth factors) seems to be showing promising results in the literature.

The injection is painful, but worth trying if you want to avoid having surgery.

Extra-corporeal shock wave treatment

There is conflicting evidence supporting the use of extra-corporeal shock wave treatment for plantar fasciitis.

Plantar fascia PRE-STRETCHING:

Many people with HPS and PF have what is referred to as “start-up” pain. This means that when they first start to walk after lying in bed, or sitting they experience moderate to severe discomfort with the first few steps. This phenomenon is caused by tension suddenly developing in the inflamed fascia as it is initially stretched with weight bearing and push off. Pre-stretching the fascia prior to standing after prolonged immobility will reduce start up pain.

Pre-Stretch 1:

• Step 1: In the sitting position fully extend your knee (i.e. straight out) and place both hands on your knees.
• Step 2: Point you toes towards your head bending your foot upwards at the ankle. (Fig. 1) The more effort you put into this motion the better the stretch.
• Step 3: Hold this position as long as possible (Minimum 30 seconds)

Fig 1

Pre-Stretch 2 (Alternative to #1):

• Step 1:Place the ball of your foot on the edge of a stool while seated with knee flexed. (Fig. 2)
• Step 2: Exert downward pressure on the knee with your hands. Hold this position for 30 seconds to a minute. Repeat as necessary.
  

  Fig. 2

Plantar fascia STRETCHING

The following program is designed to stretch the plantar fascia most effectively utilizing a mechanical principle known as creep. Creep is a phenomenon that occurs when a sustained stress is applied to a deformable material. If creep takes place the material (or tissue) does not return to its original length when the force is removed, but rather has undergone some permanent deformation. In the case of the plantar fascia an increase in length. Therefore, these plantar fascia stretches should be sustained for the recommended times to allow creep to occur.

Stretch 1:

• Step 1: Position yourself with the ball of your foot on the edge of a stair (Fig. 3)
• Step 2: Holding the rails for balance allow your heels to sink downwards. You should be relaxed and no active muscle contraction in your legs should be necessary.
• Step 3: Hold this position for 4 to 5 minutes

Fig. 3

Stretch 2:

• Step 1: Roll a towel tightly so that its diameter is 1 to 1-11/2 inches.
• Step 2: With your toes of the leg to be stretched approximately 1-1/2 feet away from a table, or a wall, place the towel under your toes but allow the ball of your foot rest on the ground (Fig. 4)
• Step 3: Place your opposite leg straight back for balance.
• Step 4: Keep your heel on the ground, now force your knee towards the wall.
• Step 5: This position is difficult to maintain for long periods of time, but the longer you can do it the better. Minimum time for each stretch should be 30 seconds. Total stretching time of 2 to 3 minutes should suffice.

Fig. 4

Stretch 3 Alternative:

• Step 1: Sit with leg crossed, hold toes until tight band is felt.
• Step 2: Hold for a count of 10 and repeat 10 times at least once daily.

Surgery is offered to patients who have exhausted non operative treatment.

The surgery is performed through a keyhole (endoscopic) technique demonstrated in the video link below:

Recovery Times:

You will be advised to keep your foot off the ground for 7-10 days until your wounds heal. You may then begin progressively weight bearing on your heel. It is expected that you will have some soreness in your heel because of the deep cut to the plantar fascia, but this will settle in 3-4 weeks. It is recommended that you wear a sneaker and some silicon heel cushions to minimise any discomfort around your heel.

Success Rates:

The success rate if this operation is around 70-80%.

• Prolonged wound healing
• Numbness in the sole of the foot
• Ongoing pain

If you have tight calves and have not had any surgery to lengthen your calf muscle or undergone an adequate calf stretching program, your symptoms might persist or recur.

Sometimes the bones can be only mildly displaced and immobilisation in a boot may be suggested. Most of these injuries are managed surgically except in the elderly population with minimally displaced stable injuries.

Depending on the complexity of the injury surgery is done through one or two incisions on top of the foot. The nerve and vessel that run on top of your foot are protected throughout surgery.

The Lisfranc interval between the long bone of the second toe and the midfoot medial cuneiform bone is reduced and diamond shaped plate is usually applied. This plate has to be taken out in 4-6 months.

• A period of immobilisation in a boot of 6 weeks is usually recommended.
• Gradual weight bearing in the boot is allowed after 6 weeks and progresses to full weight bearing over the next few weeks.
• Return to sport usually after 4-6 months.
• Followed by minor surgery to remove all metalwork.

• Shoe wear modification (podiatrist review)
• Arch supports
• Anti-inflammatory meds
• Activity modification

Surgery offered to a patient with flat feet will depend on the stage of the disease. Early stages are amenable to tendon repair and or reconstruction with or without bony realignment of the heel. Later stages require reconstruction of the spring ligament with bony realignment of the heel. Advanced stages usually require a fusion/ arthrodesis procedure of some sort with lengthening of the Achilles tendon.

The links below are some of the procedures that we may perform to help correct your flatfoot deformity:

First tarsometatarsal fusion:

Flatfoot-Spring ligament augmentation with Arthrex internal brace:

This will be dependent entirely on the combination of procedures the surgeon undertakes for your flat foot. Each patient is likely to present with different problems and hence the prescription for surgery will vary. Usually a period of non-weight bearing of 6-8 weeks in a boot is required during the post-operative period.

The more complex the surgery the longer the period of immobilisation.

This is reserved for patients that are not suitable for surgery.

• Plaster cast for a period of 6-8 weeks or longer followed by a boot

Ankle fractures generally need to be fixed with surgery. Surgery involves cuts to the sides of the ankle with you lying on your back or alternatively, surgery can be performed via a single cut to the back of the calf. Your surgeon will discuss the best approach to fixing these fractures when they sign the consent form for surgery with you.

High Ankle Sprains – please view the surgical technique via the video below:

• Delayed wound healing
• Numbness
• Removal of metalwork
• Need for surgery to be carried out in stages if the leg is too swollen

• Usually a period of immobilisation of 6 weeks in a boot and then progressive weight bearing with a crutch or walking stick for support until you are able to walk independently.
• Early ROM exercises (range of motion exercises whilst not walking) are encouraged to get the best outcome.
• Outcomes depend on the severity of the original injury.

• Anti-inflammatory medications
• Injections into the ankle joint
• Ankle braces and various other ankle foot orthoses may help
• Rocker bottom shoes and offloading wedges may be prescribed

Currently we offer joint sparing procedures like supramalleolar osteotomies that involving breaking the tibia bone of the leg to realign the weight bearing forces through the ankle joint.

There is a limited role for ankle arthroscopy and debridement for very early arthritis with synovitis.

The joint is sacrificed if the arthritis is extensive and this is performed via a fusion procedure. Most fusions are performed utilising keyhole / arthroscopic techniques. We do not offer ankle replacements at our centre.

• Numbness around the keyhole wounds
• Delayed healing/ non healing of the fusion site which may need further surgery in the future
• Irritation from metalwork/ screws

You will be immobilised in a plaster cast for a period of 6-8 weeks and then change over to a boot to begin weight bearing. Initial weight bearing will be with the support of a single crutch or a walking stick with gradual progression to walking normally.

Usually it takes 3-4 months to begin walking normally again.

Non operative functional treatment is usually the norm the first time you sprain your ankle. Rest, ice, elevation and pain relief is the mainstay of initial treatment. You will usually be placed in a boot and be advised to begin ROM exercises as soon as tolerated. It is advisable to rest with the foot elevated for 48-72 hours and then begin to put weight on the leg in a boot.

You will then be advised to begin a dedicated rehabilitation program with our physiotherapists. Return to sport is usually possible with some form of taping or bracing at the 2-3 months following injury. Strict adherence to our program is essential to prevent chronic ankle instability.

Unfortunately, some patients assume that their injury has healed and fail to follow through with the program.

Chronic ankle instability involves recurrent ankle sprains with loss of confidence in the stability of the ankle. The condition, may or may not be associated with pain and swelling.

After an MRI scan is performed to accurately document all injuries, a plan for surgery is usually made. Our technique involves firstly a keyhole examination of the ankle, followed by a mini-open cut to retention the ligament. This is usually augmented with an internal brace as documented in the video below.

Please view the surgical technique used for Ankle sprains below:

• Stiffness of the ankle
• Numbness or nerve pain around the cuts for the key hole technique
• Prolonged swelling

You will be immobilised in a half plaster for a week until wound review in our rooms. You will then change over to a moon boot and be allowed to weight bear as tolerated with a crutch for support. If there has been damage to the cartilage within the ankle from repeated ankle sprains and your surgeon required to perform additional surgery within the ankle, you may be required to keep off the foot for a further 3-4 weeks. Your surgeon will discuss this with you after your surgery.

Gradual progression to independent weight bearing and gentle foot and ankle ROM (range of motion exercises) will follow. Our physiotherapists will guide you through a dedicated rehabilitation program over the next few weeks.

You are able to return to sport around 3-4 months after surgery.

• Eccentric stretching program for non-insertional tendinitis
• Shoe wear modification (podiatrist review)- heel raises, orthotics
• Anti-inflammatory meds
• Activity modification to reduce pain symptoms. Weight loss also helps relieve symptoms.
• Extracorporeal shock wave therapy- stimulates blood flow to the area, relieving pain.

Surgery is more commonly performed for insertional Achilles tendinosis that has failed to resolve with non-operative management. An incision is made on the back of the heel down to the tendon. The tendon is split and debrided, followed by removal of bony spurs and Haglund’s deformity. The tendon is reinserted into the heel with the help of strong suture tape and bioabsorbable screws. This is a very robust construct. We usually combine this surgery with a keyhole calf lengthening procedure for better results.

Please click on the videos below to view the following surgical techniques:

Surgery for Achilles tendonitis:

Surgery for Endoscopic Gastrocnemius Recession (Calf lengthening for tight calves):

• Delayed wound healing
• Deep vein thrombosis – higher risk than most other foot and ankle conditions. Hence, you will routinely be placed on blood thinning medication unless you are at high risk of bleeding.

General

• You will be immobilised in a plaster back slab for 1 week until your wounds are reviewed. This is to remain intact and kept clean and dry at all times.
• Please ensure you elevate your foot as much as possible.
• Wounds need to be kept dry by whatever means possible until complete wound healing. This usually takes 3 weeks but may take longer if your body takes longer to heal.

Weight bearing status and exercises

• NON weight bearing until your first follow up visit.
• Your surgeon will then decide how long you need to continue to non-weight bearing depending on the status of your wound. Most wounds heal in 2-3 weeks.
• If your wound is healing well, you will be changed into a boot with 2 heel raises and allowed to weight bear with a frame or a stick (The added support ensures you do not put too much of strain on your healing tendon).

Moon boot

• To be kept on at all times whilst mobilising (whether non weight bearing or weight bearing).
• To be kept on at night until 3-4 weeks post-surgery.
• To be kept on whilst showering until wound is healed – this may take as long as 3 weeks in your case (or longer). Use a garbage bag with tape at the top end to keep things dry.

Walking aids

• Knee Walker: You may attempt to use a knee walker prior to surgery to see if you will be able to manage to use it after surgery. If you rent/hire/purchase a knee walker, please take it with you to hospital. Our physiotherapists will help you in your pre-operative assessment.
• Crutches: Physiotherapists at the hospital will help you further at the time of your discharge.
• Frame: If you are struggling with all the above, the physiotherapists may suggest using a frame.

Movement

If wound healing is progressing well, you may be allowed to begin gentle movement of the foot and ankle to aid with swelling minimisation and to maintain flexibility of your joints.

Timeline:

• 3 Weeks: Review of weight bearing in boot with 2 wedges
• 8 Weeks: Remove 1 wedge every 2 weeks. Then progress to walking flat in boot for more 2 more weeks before transitioning to shoes
• 3 Months: Normal shoe wear – gradually increase walking, light exercise. Sport specific training and increase dynamic weight bearing exercises. Begin physiotherapy

Physiotherapy

You will be allowed to move your ankle and foot around when you are at rest. Specific physiotherapy should not commence prior to 3 months after the surgery.

DVT (Deep Venous Thrombosis or blood clots) prophylaxis

• 300mg aspirin daily for 6 weeks.

Return to Sports:

• Jogging at 4-6 months under supervision of physiotherapist.
• Sport specific training may commence at 3 months.
• Gradual progressive return to light sports/low impact activities may begin at 6 months.
• Return to high impact activities e.g. soccer, football may be considered after 9 months if you can perform a single heel raise.

Follow up

• 1 week: Rooms for wound review. You will have dissolvable sutures that do not require removal. Only knots at either end will need to be trimmed at the 3 week visit. Boot with 2-3 heel wedges inside.
• 3 weeks: Review integrity of repair and trim sutures.
• 8 weeks: Examine the integrity of the repair. Advise on heel wedge removal.
• 12 weeks: progress review

This has to be instituted immediately after injury, otherwise the gapping between the tendon ends may be difficult to reduce/heal. Persistent calf weakness and higher re-rupture rates are likely.

• Shoe wear modification – Moon boot/ CAM boot with heel wedges/raises removed sequentially as per our strict protocol.
• Activity modification- strength training to begin at 3 months after transitioning to a good shoe without a heel raise.

The latest percutaneous and minimally invasive technique has fewer complications especially with wound healing. The PARS (Device technologies/ Arthrex) utilises multiple strong sutures to grasp the tendon through a very small incision overlying the ruptured tendon. Click on the links below to view surgical technique.

Click on the videos below to view surgical technique:

• Small risk of nerve injury resulting in numbness along the lateral border of the calf.
• Small risk of tendon re-rupture
• Deep vein thrombosis- higher risk than most other foot and ankle conditions. Hence, you will routinely be placed on blood thinning medication unless you are at high risk of bleeding.

• PARS (Arthrex) Achilles repair (minimally invasive technique)
• Week 1: Weight Bearing as tolerated in boot, active Range of Motion (ROM)
• Week 2: Progressive plantar flexion (toes pointing down, resisted exercises)
• Week 4: Early cycling but care to avoid forced dorsiflexion (toes pointing up- this position should be avoided)
• Week 6: Out of boot for Weight Bearing rehabilitation
• Week 12: Eccentric loading, power and sports specific training