Morton’s neuroma – what’s the best way to treat it?

This is always a tough question to answer in the office because there really is no one universal way that is best to treat a Morton’s neuroma.  Let’s talk a bit about conservative vs surgical care.

It’s surprising how many of my patients do respond to some simple conservative care.  The use of a metatarsal pad or an insert with a metatarsal pad works surprisingly well.  The science behind a met pad is that the met pad tends to stabilize the metatarsal heads so that they no longer pinch the interdigital nerve.  Met pads can be a bit of a challenge to place, but once positioned in the right spot, they really do work wonders.

The next step upthe ladder of conservative care is the use of cortisone or injectable alcohol.  Both have their pros and cons and that conversation is covered in the link above to Morton’s neuroma.

The EDIN procedure is one of several procedure used to treat Morton's neuroma.

Surgical care?  That’s also a tough one.  I used to do a lot of the EDIN procedures for neuromas but found that at least half of the cases had a partial to complete recurrence of the neuroma by 1 year out.  I’m leaning more to doing traditional neurectomies now through a plantar incision for those patients who fail conservative care.

Join us for an in-depth discussion at our pages on Morton’s neuroma.

 

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Foot Surgery – how long will it take to heal, Doc?

One of the most important aspects of my job as a podiatrist is to help guide patients through a decision making process regarding their surgical care.  And one of the most important aspects of that decision is how long we can anticipate it will take for the surgery to heal.  This decision will have an impact on return to work, social activities, family care and a host of other issues specific to that particular patient’s life.  First, let’s take a look at preoperative considerations.

The first consideration is the patient’s general health status.  Is this patient able to go through this surgery successfully?  Do they have the capacity to heal?  Considerations such as age and comorbidities need to be reviewed.  Co-morbities are the conditions that may affect healing and include arterial or venous disease, diabetes, obesity, heart disease, etc.  As comorbidities become more numerous and complex, the chances of a good outcome from foot surgery obviously decrease.  The most important tool to judge the impact of these comorbidities is a good history and physical exam.

Next, does the patient have the support team at home to complete the surgery?  Are they a widow living on their own or are the a member of a family with a spouse and adolescent children?  Does the patient have an infant at home who will need care?  In each scenario, advanced planning is necessary to insure a good outcome from foot surgery.

What is the nature of the surgery?  I find it interesting that some foot surgery has significantly more disability than a total hip or knee replacement!  For instance, a total hip or knee replacement will be ambulatory within the first few days of surgery.  A fusion of the foot or ankle will require 8-12 weeks of non-weight bearing.  That’s a long time to be on crutches.  Pre-op counseling is imperative to be sure that patient’s recognize the degree of disability associated with their surgery.

OK, let’s fast forward to the question at hand; how long is it going to take to heal following foot surgery?  As a general rule, soft tissue surgery (cysts, nerve releases) will heal in a 2-4 week period.  Sutures are typically in for a 14 day period.  Many soft tissue procedures are what we call ambulatory meaning that the patient can walk beginning the day of surgery.  Granted, you may not want to walk very far, but at least you’ll be able to bear weight on the foot.

Bone procedures will take longer to heal.  Most bone procedures will require an 8 week period of healing before they become structurally capable of being able to bear load (body weight).  This time period does vary widely based upon the nature of the procedure and surgeon preferences.  Some bone procedures, such as a bunionectomy can be performed in a manner in which load can be applied to the foot immediately post-op.  But other procedures such as a triple arthrodesis will require 10 weeks non-weight bearing.

Part of the impetus for this post was a patient I saw yesterday (picture at left).  This patient is 10 weeks post dorsiflectory osteotomy of the 1st metatarsal and a wedge osteotomy of the heel called a Dwyer procedure, right foot.  In the picture you can see how the patient’s right foot (surgery foot) is red while the left foot is white.  This is an excellent example of what’s called reflux hyperemia.  Reflux hyperemia is the vascular response of the foot to both the surgery and 8 week period of casting.  The take home point here is that even though we speak of healing being 8-12 weeks for a bony procedure, the body is still attempting to understand how to manage this injury we call surgery.  And yes, we really can describe surgery as a controlled injury. 

So how long does it really take to heal?  I tell my patients that the first 75% of healing takes place within the first 2 months post-op.  The remaining 25% of healing takes upwards of a year.  This last 25% is a reorganization period where post-op scar tissue is reorganized and essentially, your body optimizes the surgical injury so that it can ultimately function at 100%.  And the example above (reflux hyperemia) is just one of the many issues your body manages in that later 25% of healing.

If you have an interest in a specific condition and how that condition will heal following surgery, be sure to check out our knowledge base on Myfootshop.com.  The majority of the conditions in the knowledge base describe how they can be treated surgically and describe an estimated time frame for healing.

Jeffrey Oster, DPM
Medial Director
Myfootshop.com

Fibular sesamoidectomy – pros and cons

Sesamoid fracture

I just got out of surgery after performing a fibular sesamoidectomy.  In this particular case, the sesamoid had been fractured some 15 years ago and had progressively become necrotic secondary to avascular necrosis (AVN).  In this patient’s case, he is an active runner and hasn’t been able to run in the past two years due to sesamoid pain.  I thought it might be timely to address the pros and cons of a procedure known as a fibular sesamoidectomy.

The fibular sesamoid is one of two sesamoid bones found on the bottom or plantar aspect of the great toe joint (first metatarsal phalangeal joint).  A good way to describe the two sesamoid bones is to compare them to the knee cap (patella).  Each of the sesamoids are used to facilitate the transfer of force (pulling force called traction) generated by a muscle and tendon.  And this transfer of force is around a corner.  In the case of the knee, the quadriceps muscle and patellar tendon use the patella to change direction at the level of the knee.  The same holds true for the sesamoids.  The extensor hallucis brevis (EHB) tendon originates on the bottom of the heel.  The distal tendons (2) of the EHB inset into the base of the proximal phalanx of the great toe.  As the great toe bends, the sesamoids are used to facilitate the transfer of load beneath the great toe joint.

The two most common injuries of the sesamoids are fractures and AVN.  The literature varies in regards to the success of conservative care for sesamoid fractures.  The literature is consistent in the success rate of treating sesamoid AVN noting that the success rate is poor.

The outcome of sesamoid fractures varies due to a number of contributing factors.  Those factors include the patient’s general health and ability to heal, activities to which the patient wishes to return to, the extent of the fracture and the patient’s age.  Many sesamoid fractures will go on to form a fibrous union that is not truly bone, but is structurally sufficient to support load applied to the fracture site.  And in a small percentage of patient, the fracture results in degenerative change of the dorsal articular surface of the sesamoid.  This degenerative change in the cartilage is called chondromalacia and result in pain with weight bearing.

Excision of the fibular sesamoid is typically a reliable procedure reserved for folks who fail to respond to conservative post fracture.  Once healed, the balance of the three tendons that pull on the plantar aspect of the great toe is weakened subsequent to the excision of the fibular sesamoid.  But in the great majority of cases, the balance is sufficient to maintain a stable great toe joint.

Granted, no one wants to be faced with the decision to have a fibular sesamoidectomy, but out goal with my patient today is to have him non-weight bearing for 3 weeks.  This is customary during the first few weeks of healing with a plantar incision.  Pedestrian activities will follow for 3 weeks and hopefully we’ll see this patient back and running at about 8 weeks post-op.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Shin Splints – anterior and posterior. Are they the same?

There are two types of shin splints called anterior and posterior.  The most common shin splint is anterior marked in the image to the left in blue.  Anterior shin splints in runners are often due to over striding or training at a pace that doesn’t allow for healing of the tibialis anterior muscle.

Posterior shin splints (also called posterior tibial tendonitis) are a less common condition that is often due to pronation (flattening of the arch).

For more information on shin splints please follow this link to the Myfootshop.com Knowledge Base or join us in the sports medicine thread in The Foot Talk Forum.

Jeffrey Oster, DPM
Medical Director
Myfootshop.com

Metatarsal pads – how are they used?

felt metatarsal pad

Metatarsal pads (also called met pads) are used for a host of forefoot conditions to include bursitis, capsulitis, Morton’s neuroma and metatarsal deformities.   The idea behind a met pad is really quite simple.  The met pad increases the load bearing surface area under the forefoot, subsequently decreasing load to the problem spot.

Metatarsal pads are one of the top selling products we offer at Myfootshop.  So I thought it would be important to talk a bit about their use and how to use them.

In practice, I prefer the use of a firmer met pad like a felt met pad or a firm rubber met pad.  The firmness may be a bit noticeable at first, but the support will last much longer than a softer foam met pad.

Application of a met pad can be a bit counter-intuitive at first.  Most folks would tend to think that a pad should be placed directly under the metatarsal heads.  But met pads are designed to be used just proximal to the load bearing surface of the forefoot (see image above).  One other trick that is helpful is to try to place the met pad on the bottom of the shoe insert.  By placing the met pad on the bottom, you will receive the same degree of support but you won’t feel the firmness of the pad.

A unique form of metatarsal pad is called a dancer’s pad.  A dancer’s pad is used to specifically off load the great toe joint for conditions like sesamoiditis or sesamoid fractures.  Dancer’s pads are also great for hallux limitus.

Metatarsal pads can also be placed on OTC orthotics.  The one advantage of this method is that once the arch support is placed into the shoe, the met pad ought to be positioned in exactly the right spot….that makes livn’ easy.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Metatarsal stress fractures…why me?

metatarsal stress fracture

One of the common questions I get asked in practice is this; “I didn’t do anything like fall or twist my foot.  So why did I sustain a metatarsal stress fracture?”

Metatarsal stress fractures are a common injury that often seem to appear at odd times.  I think what’s interesting is that many met stress fractures are actually on opportunity for the metatarsals to correct differences in load bearing.  You see, each of the 5 metatarsal bones are designed to carry a percentage of forefoot load that occurs with each step.  When one metatarsal is forced to carry more, two things can happen.  First is that the metatarsal rises to the occasion and gets bigger and stronger.  The second alternative is that the metatarsal undergoes physical change….a stress fracture.

Follow this link for additional information on metatarsal stress fractures.

Jeff Oster, DPM
Medical Director
Myfootshop.com