The foot is a complex flexible, energy absorbing structure that necessarily must accommodate our body's weight during each step. Five to twenty times our body weight is transmitted through the foot during walking, running and jumping. Because of the location, it is easy to ignore good foot care. Conditions that affect the peripheral nerves and circulation such as diabetes, make the foot particularly susceptible to tissue or bone destructive processes. Several arthritic disorders and diseases can uniquely affect the foot.

The disorders discussed below are by no means a comprehensive summary of the many problems that can occur with feet. Many disease processes and other contributing factors routinely need to be considered. Certainly if one has continued problems with their feet, they should be evaluated by an appropriate physician.

The Developing Foot
Uterine packing can commonly cause the infant foot to have apparent structural abnormalities. A "club foot" typically involves a unique pattern with the foot turned in and unable to be corrected to neutral due to an underlying pathologic process. Serial casting or surgery are the necessary treatments. Hyperflexible flat feet also can be commonly observed in children. Shoes with adequate support and in good repair should be encouraged for the growing foot.

The Aging Foot
Even with hard use every foot does not develop degenerative changes. Certainly genetics and particular disease processes as well as underlying structural issues contribute to aging foot disorders. Persons with rheumatoid arthritis, diabetes, or other peripheral neurologic/vascular diseases should be educated as to appropriate shoe wear, foot care and daily foot inspections. A "collapsing arch" is relatively common especially in rheumatoids and women.

Anatomic Regions

Forefoot Disorders - Great Toe Issues
One of the most common structural concerns in the foot is a bunion deformity. This is a prominence at the inside knuckle of the great toe where the ball of the foot flexes. This disorder is commonly induced in western society by shoe wear (narrow toed and heeled shoes). Modified shoe wear with a wide toe box should be initially utilized. If non-operative intervention fails, various surgeries can be offered for a bunion deformity dependent upon the particular structural issues that need to be addressed.

The great toe is also prone to forming stiffness and arthritis at this primary joint of flexion in the forefoot. This condition, hallux rigidus, (arthritis of the MTP joint) can be addressed with shoe modification, injections, as well as surgically removing an offending spur. This joint is also particularly prone to gout.

Forefoot Disorders - Lesser Toe Issues
Several lesser-toed deformities can commonly occur again for various reasons, including certain types of arthritis and even neurologic disorders. Common lesser-toed deformities include curly toe, hammertoe, claw toe and mallet toe patterns. Beyond a boxed-toed shoe with appropriate toe spacers and foot care, surgical intervention may be warranted to assist in the alignment of these structurally altered digits.

Forefoot Disorders - Interdigital Neuroma (Morton's Neuroma)
As the nerves go between the bones into the toes, the nerves are prone to being pinched by the surrounding tissues and knuckle joints because this area of the foot has increased motion and pressure. This disorder can be addressed with shoe modification, injections, and even surgical intervention.

Forefoot Disorders - Metatarsalgia
This is a common disorder with altered weight bearing mechanics that are transmitted through the mid ball of the foot in an uncomfortable pattern. Various underlying structural issues should be considered. Commonly, there may be a callus formation under one or more of the bones at this location that can be quite sensitive. Once the foot mechanics are addressed, typically this situation should resolve.

Midfoot Disorders
It seems that the midfoot is quite prone to subtle injuries that can easily be overlooked given the difficulties of evaluating the multiple small bones in this area of the foot. Even subtle ligament injuries or hairline fractures can contribute to accelerated arthritis to the midfoot. Certain conditions can also contribute to midfoot collapse with or without associated arthritis. Shoe modification and orthotics are a typical first line of treatment with consideration for focal joint injections. Selective fusions to these involved degenerative midfoot joints also can be quite effective in eliminating pain. A common picture seen with a degenerative collapsing foot is that of midfoot and hindfoot collapse secondary to deterioration of the substantial supportive arch tendon (posterior tibial tendon). This particular degenerative process with subsequent arch collapse is quite common and often subtle over a protracted period of time. The symptoms typically present with achiness to the tendon tissue as it comes around the corner of the inside of the ankle. After midfoot collapse occurs, subsequent hind foot collapse also can occur with associated arthritic changes to the involved joints. If recognized early, orthotic support can be helpful. As this disease advances, consideration for a tendon transfer may be appropriate. Associated degenerative joint changes that can ultimately occur usually would necessitate realigning limited fusions.

Hindfoot Disorders
Pain at the central weight bearing area of the heel is a common symptom for plantar fasciitis. This is usually treated with stretching, medications, and perhaps a night splint. Rarely surgery is warranted. Achilles tendonitis also is quite common and if this tendon substantially degenerates, it can spontaneously rupture. Certain heel bone shapes can predispose an individual to this problem. Again, surgery is sometimes necessary if conservative measures are ineffective.

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Common Ankle Injuries

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Common Knee Problems

Torn Cartilage
The meniscus is a crescent-shaped piece of cartilage (tough, fibrous tissue) that cushions the spot where bones meet in your knee. Sometimes a meniscus can tear after a sudden twist, or following repeated squatting. The result is pain and swelling, occassionally with painful clicking.

Torn Ligament
A ligament (soft, fibrous tissue that helps support your knee) can tear following a fall, twist, or blow. The result is swelling and a feeling of instability (a "trick" knee).

Patella Problems
Your patella, better known as your kneecap, can suffer damage as a result of aging, overuse, or direct injury. Usually, there is minimal swelling but lots of pain in the front of the knee, especially when using stairs. It is a very common condition.

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Common Hip Problems

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Common Shoulder Problems

Bursitis & Tendonitis
The bursa is a sac filled with fluid that helps cushion your shoulder joint. Close to it are two tendons -- the rotator cuff tendon and the biceps tendon. Through repeated movement involving holding your arm out from your body, bursa and/or tendons are squeezed, and can become inflamed. An inflamed bursa is called bursitis. Inflamed tendons are called tendonitis.

Rotator Cuff Tear
A clicking or popping sound in your shoulder can be a sign of a torn rotator cuff. This is a group of muscles and tendons that provide support and stability in your shoulder. Untreated rotator cuff tears can lead to arthritis.

Arthritis
Arthritis is actually a roughening of any joint, such as your shoulder. A number of diseases or injuries can cause it. In arthritis, the smooth surfaces that are normally present in a joint are replaced by worn cartilage, and sometimes by loose pieces of cartilage and bone. Pain worsens as bone begins to rub on bone.

Dislocation
In dislocation, your arm bone (humerus) has been pulled out of its proper position in your shoulder socket. This can occur if your arm is jerked backward, or pulled sharply. The resulting symptoms may include severe pain, inability to move the arm, numbness, swelling, and bruising. Sometimes this can become a chronic looseness or instability.

Sprains & Separations
A common cause of these injuries is a fall. In a sprain, ligaments are torn. If the tear is large, two bones (the acromion and the clavicle) may separate from each other, causing a bump (the top of the clavicle) to pop up. This is called a separation.

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Common Elbow Problems

Bursitis
If you injure or develop an unexplained swelling on the tip of your elbow, it probably represents what is termed "olecranon bursitis". If this does not resolve quickly, it can be evaluated by x-ray to see whether you have bone spurs on the tip of your elbow. Frequently, the fluid is aspirated with a needle and analyzed. If the fluid indicates an inflammatory, rather than infectious, problem or recent acute bleeding, corticosteroid may be injected. In longstanding problems, the olecranon bursa can thicken to the point it needs to be removed.

Tennis Elbow
Lateral epicondylitis is commonly termed "tennis elbow". This is an inflammation occurring on a bony prominence on the outside of the elbow. This is the point where the muscles on the back of your forearm that power your wrist are attached. This frequently is the result of a strain or sprain of the tendons. It can be treated with rest but, if unsuccessful, it can be treated with a tennis elbow strap, anti-inflammatory agents, or occasionally with corticosteroid injection. In rare longstanding cases, surgery may be indicated.

Cubital Tunnel Syndrome
This condition is the entrapment of the ulnar nerve near the "funny bone", or the medial inside portion of your elbow. Entrapment will result in numbness in the little finger and a portion of the ring finger. Occasionally it will result in significant weakness of the fine motor control of your hand. Numbness can occur with pressure on the nerve, such as leaning on your elbow while talking on the phone for a long period of time. Laying your elbow on a hard surface while using a computer mouse can also cause numbness. If the symptoms are not relieved with rest, electrodiagnostic studies can be performed. These test the function of the nerve. Initial treatment is conservative and involves anti-inflammatory agents and protection of the medial aspect of the elbow. If this is unsuccessful, the ulnar nerve may need surgical decompression by moving it out of the cubital tunnel more toward the anterior aspect of the elbow.

Biceps Tendon Rupture
The biceps tendon attaches to the radius at the elbow. It flexes the arm and it can be ruptured. If so, there is significant loss of strength for flexing the elbow up and also in moving the forearm into the "palm up" position. This injury should be dealt with promptly and will require surgical repair.

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Common Wrist Problems

Sprains
A sprained wrist can occur from a fall on an outstretched hand. A sprain may be very minor and resolve in a few days to a few weeks, or it may be so severe the carpal bones in the wrist are dislocated. If your symptoms are quite severe or you have marked swelling, x-rays should be obtained promptly. Treatment may consist of rest and immobilization. If there is significant injury to the ligaments holding the small bones of the wrist, surgical repair may be indicated. Occasionally there may be occult or "hidden" fractures, which will be missed, if x-rays and follow-up are not obtained.

Fractures
Fractures at the wrist can involve the distal forearm bones, either the radius or ulna. They also may involve the small wrist bones, called "carpal bones". The scaphoid is the carpal bone nearest to your thumb and it can be injured in a fall. Because of its blood supply, it may not heal without prompt immobilization, and it may require surgery. Scaphoid fracture can be easily misinterpreted as a sprain, but they can cause later arthritic problems if not corrected.

Carpal Tunnel Syndrome
This condition is characterized by numbness primarily in the thumb, index, and middle finger, and occasionally on the middle-finger-side of the ring finger. It can be accompanied by pain in the hand with radiation up the forearm. It also can result in night pain, which can awaken you. It can be caused by tendonitis, which occurs with repetitive movements, and in early stages can be treated with immobilization and anti-inflammatory agents. If symptoms seem persistent, electrodiagnostic studies should be obtained. These will provide a quantitative evaluation of the function of the median nerve. If these tests are significantly abnormal, surgical treatment is usually required to decompress the carpal tunnel and free the median nerve from overlying pressure, which has restricted blood supply to the nerve. If appropriate treatment is not obtained, the median nerve can be permanently damaged.

Ganglion Cyst
Ganglion cysts are fluid-filled sacs. They can occur either on the back or front of the wrist and occasionally at the base of the fingers. These can be thought of as "balloons filled with joint fluid", as the fluid comes from the joints of the wrist. They can be treated nonsurgically with aspiration, although there is a high recurrence rate If these are unsightly or cause pain, they can be surgically removed with a much lower recurrence rate. Sometimes cysts represent underlying abnormalities within the joint itself.

DeQuervain's Tendonitis
This condition occurs on the thumb side of the wrist and is the result of tendon inflammation. The tendons go to the thumb and pass under a tight band on the thumb side of the wrist. You will have pain when picking up objects and/or deviating the wrist away from the thumb. Discomfort can be treated with rest and anti-inflammatory agents. If rest is unsuccessful, the tendonitis usually can be alleviated with corticosteroid injection. If the problem recurs, surgical release of the constricting sheath over the tendons can be performed.

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Common Hand Problems

Dupuytren's Disease
This condition runs in families and usually occurs in people of Northern European descent. It can result in fibrous cords or nodules forming in the palm of the hand, eventually extending to the fingers, causing contractures, which draw the fingers down into the palm. This problem is more easily treated in the early stage by removing the diseased fascia (fibrous tissue under the skin), which has caused the fibrotic cords.

Basilar Joint Arthritis
This problem occurs primarily in women, but it can occur in men following an injury. The base of the thumb becomes quite painful. There is joint wear primarily because of instability, and deformity and pain result with the passage of time. You will have pain in the thumb with most activities. In early stages, splinting and anti-inflammatory agents are successful. Sometimes corticosteroid injections will provide long-term relief but, ultimately, most cases progress to surgery. The surgery can consist of a reconstructive procedure using one's own tissues to accomplish an arthroplasty (replacement) of the basilar joint. The other alternative is arthrodesis (fusion) of the metacarpal of the thumb to the trapezium at the base of the thumb. This procedure also alleviates the pain. Trigger Finger: This condition occurs after repetitive activities and sometimes after an injury. Generally there is no known cause. It results in "catching or locking" of the finger in flexion, and pain with pressure over the base of the finger in the palm. It can be treated with rest but, if rest does not alleviate the problem, anti-inflammatory agents, injections of corticosteroid, or surgical release of the constricted area around the tendon should resolve the problem.

Tendon Lacerations
The tendons that flex your fingers are called "flexor tendons" and the tendons on the back of your hand that extend your fingers are called "extensor tendons". If these are lacerated or cut, you will lose the function of your finger. Such an injury should be promptly treated. Any fairly deep laceration to the fingers or palm should be evaluated, as partial division of the tendon can occur. Such division could result subsequently in rupture and loss of function of the finger.

Mucous Cysts
These cysts occur on top of the fingers at the last joint just back from the nail bed. They are the result of arthritic spurs causing fluid in the joint to be released. They can cause discomfort and thinning of the skin. They also can put pressure on the nail growth causing grooves in the nail. The cyst and the offending spurs can be surgically removed.

Mallet Finger
This problem occurs when you "jam" your finger and results in inability to fully straighten the finger at the last joint. If treated initially, splinting and immobilization are used to hold the joint in position. Surgical intervention may be required if the injury is not immediately addressed.

FOR MORE DETAILED DESCRIPTIONS OF THESE CONDITIONS

Visit the following sites:

American Society For Surgery of the Hand
American Academy of Orthopedic Surgeons

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Total Joint Replacement

When the cap of cartilage (the smooth bearing surface) on the end of the long bones forming the joint wears out, pain occurs because of bone to bone contact. This is a common occurrence from wear and tear arthritis (osteoarthritis) or after prior trauma (post traumatic arthritis). Several other arthritic conditions are known to cause accelerated deterioration of the joints (rheumatoid, psoriasis, and certain genetic patterns). The weight bearing joints are particularly vulnerable. When a joint becomes sufficiently symptomatic from advanced arthritis, it will commonly effect the individual's routine daily activities. If conservative measures (medications, injections, etc.) are unsuccessful, a joint replacement surgery may be indicated.

A joint replacement surgery typically involves replacing the surfaces on both sides of the joint with a metal and/or plastic prosthesis. A plastic bearing surface between the two bones is the most common style of joint replacement. The metal portion of the prosthesis is normally made of cobalt-chromium or titanium. These are very special metallurgical materials proven for compatibility within the body. The plastic is high density polyethylene and again has the best proven function for these prosthetic joints. The prosthesis either can be bonded to the bone by design and direct contact for bone ingrowth, or secured with a "bone cement" forming a grout between the prosthesis and the bone. Again, this bone cement is a proven material for these purposes (polymethylmethacrylate).

What are some of the problems that might occur with a joint replacement surgery?
Joint replacement surgery has become a very common procedure in the United States with over half a million prostheses implanted each year. With improved skills and technologies, these surgeries have become quite safe and relatively predictable. However, potential problems cannot be totally eliminated. The risks include blood clot formation, infection, prosthesis failure, prosthesis bone interface loosening, joint instability, nerve injury, or blood loss. Again, with modern techniques, all of these risks can be significantly reduced by implementing care in the technique of the operation, the use of antibiotics, and the use of blood thinners.

What can I expect from a joint replacement surgery?
A joint replacement surgery in an appropriate candidate will typically improve the symptomatic joint by eliminating the arthritic pain and commonly improving the joint motion. This combination has several beneficial effects. The patient commonly can have better function in their routine daily activities. If the replaced joint is a weight bearing joint, the patient typically will increase their activity level which enhances heart function, lung function, muscle and bone function/strength, and even helps many of the other organ systems function better. Furthermore, replacement of effected weight bearing joints will commonly reduce back and spine symptoms that are manifested by an altered gait pattern. Studies have shown that indicated weight bearing joint replacement surgery (hips and knees) will commonly add many years of independent living to an effected individual.

Total Knee Replacement
The knee is the most common joint to be replaced in the United States with approximately 300,000 replacements performed each year. The knee has two joint portions which can become arthritic. The more common arthritic area is the portion between the thigh bone and the lower leg bone (femoral/tibial arthritis). The other portion that can become arthritic and painful is the joint between the knee cap and the thigh bone (patellofemoral joint). When either of these joints is sufficiently arthritic, a joint replacement surgery may be warranted. The surgery typically lasts between 1 to 1 ½ hours and is performed through a longitudinal incision over the front of the knee. The three bones involved (femur, tibia, and patella) are addressed by removing the damaged joint surface as needed and placing an appropriately sized cap on each of the surfaces typically with an interposed plastic bearing. The patient routinely is in the hospital approximately three to four days and will need additional physical therapy as an out-patient to regain enhanced knee motion.

Total Hip Replacement
The hip joint is the second most common joint to be replaced with approximately 250,000 hip replacements in the United States each year. This operation typically lasts 1 to 2 hours with a routine hospital stay of three to four days. The joint replacement surgery involves removing the ball portion and the bad joint surface of the cup. A new ball that is attached to a stem secured into the top part of the thigh bone (femur) and a new cup typically with a plastic liner are secured to the respective bone. The cup is typically metal backed with a plastic liner to serve as the bearing surface. The prostheses can be cemented to the bone or designed for bone ingrowth. This surgery is accomplished through an incision on the side of the hip joint. The patient will need physical therapy after surgery. Typically, motion comes easier for a hip replacement than a knee replacement. Because of anatomic geometry, the hip joint is prone to being more unstable than the knee with the chance of a dislocation being normally less than 4%.

Shoulder Replacement
This surgery involves an incision over the front of the shoulder joint to acquire access to the joint surfaces which are replaced. Many times only the ball portion of the shoulder will be replaced if the cup surface is in reasonable shape. The prosthesis can be secured to the bone either by bone ingrowth or with bone cement. The patient is typically in the hospital for two to three days and will need many weeks of therapy to realize their maximum motion.

Other Joints
Other joints that can be considered for joint replacement surgery include the elbow, wrist, knuckles and perhaps the ankle. Severe rheumatoid arthritics are typically the candidates for these particular joint replacements. Many joints that become arthritic are better served with fusions. A fusion is an intentional stiffening of the joint by creating a bony bridge to eliminate the pain of the arthritis.

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Common Diagnostic Tests

Arthrogram
An x-ray that is taken in conjunction with dye; enhances/highlights ligaments and cartilage in joints.

Arthroscopy
Surgical examiniation of the interior of a joint through small puncture sites. The joint is examined with an arthroscope, an optic device capable of providing an external view of the joint area. With the arthroscope and various instruments it is possible to do many procedures through the small insertion areas, thus not requiring to open up the joint.

Bone Scan
A nuclear medicine study which demonstrates where bone is actively being produced or destroyed (in comparison to an x-ray which shows only where bone is present). This study is helpful in the detection of infection, fractures, and metastatic lesions.

CT/CAT Scan
A computer generates a two-dimensional, cross-sectioned image which shows bones and some soft tissues. The CT scan shows a sharp, detailed image.

EMG/Electromyography
An electrodiagnostic test which is conducted on the nerves and muscles for evaluation of their responsiveness.

MRI/Magnetic Resonance Imaging
A radiographic technique in which the patient is exposed to a magnetic field to create an image. MRI is useful for diagnosing injuries to ligaments, tumors, meniscal tears, and infection.

NCS/Nerve Conduction Study
Often performed with the EMG, this tests the integrity of peripheral nerves. This test is useful in the diagnosis of nerve entrapment syndrome and polyneuropathies.

X-Ray
A radiologic picture of your bones. A physician uses an x-ray to diagnose a crack or fracture (broken bone). They may also use an x-ray to evaluate joint problems.