Specialists in Foot & Ankle Surgery
Mr. Richard R. Brown
MA (Cantab) MB BS FRCS (Tr&Ortho)
Consultant Orthopaedic Surgeon
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Conditions Treated

The Cotswold Foot and Ankle Clinic can see any problem affecting the foot and ankle. The symptoms, diagnosis treatment and possible surgery for the most common conditions are described below.

Conditions

If further information is required Cotswold Foot and Ankle Clinic has approved the information on the patient advice area of the BOFAS website, as well as the American Orthopaedic Foot and Ankle Society (AOFAS) patient education site. We recommend interested patients review their condition only on peer reviewed websites written by experts in our field.


Causes
The Achilles tendon is the connection of the powerful calf muscle to the back of the heel bone. It is essential for pushing up off the floor. Activity causes repeated minor damage. If the body’s healing processes cannot repair this damage persistent pain may occur. Gradually this restricts participation in sport. The skin and tendon behind the heel may thicken, become red and painfully swollen. You might notice a bump on the back of your heel. People often get this by running too much or wearing shoes that rub or cut into the back of the heel.
Pain behind the heel may also be caused by inflammation of an area just in front of where the Achilles tendon inserts into the heel bone (“retrocalcaneal bursitis”).

Diagnosis
The tendon may be tender or swollen either where it attaches to the tendon (“insertional tendinopathy”) or higher up in the main substance of the tendon (“non-insertional tendinopathy”). An ultrasound or MRI scan may demonstrate the severity of the damage. A standing X-ray may help.

Treatment
Initially calf stretches should be performed ideally three times per day. A physiotherapist from our local team of experts can ensure you have the correct stretching technique and whether you have any abnormal foot shape, which may require a specific stretch. The eccentric stretches lowering below a step are the most challenging and most effective. Shoes should not rub on the back of the tendon. An insole to adjust for any biomechanical abnormalities can help. For insertional tendinopathy a heel raise can help by taking the pressure of the tendon. Anti-inflammatory medicines may reduce the inflammation around the tendon, but check with your doctor or pharmacist before taking these as they can have side-effects in some people.
The vast majority of people are much better after three months of stretching. If not imaging may show whether the tendon may benefit from radial extra-corporal shock wave therapy or surgery.

Surgery
Surgery may involve removing an area of damaged tendon (“debriding”) or removing an internal bump of heel bone which is pressing on the inside surface of the tendon. The skin over the tendon is very stretched and may be slow to heal. Thus Achilles tendon surgery is only advised when disabling.

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Causes
The Achilles tendon is the connection of the powerful calf muscle to the back of the heel bone. It is essential for pushing up off the floor. The blood supply in middle age makes it vulnerable to injury. If a complete tear occurs, you would probably feel a sudden pain in your heel or calf. Some people describe it as though someone had kicked, or hit them with a squash racquet on the calf. Usually the heel becomes painful, swollen and bruised, and it becomes difficult to walk.

Diagnosis
It is essential to recognise a new complete rupture quickly.  If in doubt the ankle should be rested in a plaster or a walking boot with the toes pointing down until an expert clarifies the diagnosis and you have chosen a treatment.  There is a choice between treatments with and without surgery.

Treatment
A good outcome can be achieved by treating the torn tendon in a walking boot for eight weeks.  This avoids the risks of wound problems after surgery.  However the tendon may be a little slack and slightly less powerful after surgery.

Surgery
For younger or more active people with a more sporty lifestyle surgical repair is likely to give a better final result. We use a mini-incision technique to minimise the risks of wound problems. Surgery is not an emergency and can be fitted into your busy schedule, within the next ten days.
An accelerated functional rehabilitation programme of early walking and exercises co-ordinated with the local physiotherapists is followed after both treatment methods.
Unfortunately an Achilles tendon tear can sometimes be subtle and making the diagnosis difficult, such that it is not detected until weeks after surgery. In this case with a delay in presentation to the surgeon the tendon must be repaired by surgery, which is a little more complicated requiring a tendon transfer.

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Symptoms
Unsteadiness or recurrent giving way can occur after an ankle ligament sprain. This may also be associated with persistent pain on the outer side of the ankle.  It may limit your ability to play sports or even complete every day activities. There may be swelling or stiffness.  Without thorough and complete rehabilitation, the ligament or surrounding muscles may remain weak, resulting in recurrent instability.

Diagnosis
The stretchiness (‘laxity’) of the ankle ligaments will be determined by the clinical examination as well as evidence of any associated causes of the ankle pain.  It may be necessary to examine the stability of the ankle with your muscles relaxed under an anaesthetic.

Treatment
Usually the initial treatment is to optimise the strength of the muscles around the ankle.

Surgery
If the ankle remains unstable then surgery may be needed. This is often a Bröstrom repair of the ligament itself, but sometimes a tendon must be transferred.  After surgery the ankle is rested in a plaster for four weeks and then an ankle brace for four weeks. The Bröstrom repair is a reliable technique with a high success rate at returning athletes back to their pre-injury level of performance.

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Symptoms
When you sprain your ankle, the connecting tissue (ligament) between the bones is stretched or torn. The most common cause of persistent ankle painful after a sprain is incomplete healing of the ligament. Other causes of persistent pain can be a torn or inflamed tendon, an injury to the nerves that pass over the ankle, arthritis of the ankle joint, a break (fracture) in one of the bones that make up the ankle joint or inflammation of the joint lining (synovium).
Scar tissue may develop within the ankle after a sprain. This scar tissue takes up space in the joint and sometimes “pinches” as the ankle moves.

Diagnosis
As well as X-rays you may also need an additional test such as a magnetic resonance image (MRI), computed tomography (CT) scan, or a bone scan. All these can be arranged at your first visit to the One stop Clinic at Linton House, so that the follow up appointment is conveniently later that afternoon.

Treatment
Your treatment will depend on the precise cause of the pain and will be personalised to your individual needs. Both conservative (non-operative) and surgical treatment methods may be used. Conservative treatments include: anti-inflammatory medications such as aspirin or Ibuprofen to reduce swelling; physiotherapy exercises to strengthen the muscles, restore range of motion, and to increase your perception of joint position; an ankle brace or other support; an injection of a steroid medication; or in the case of a fracture, immobilisation to allow the bone to heal.

Surgery
Surgical treatments are usually arthroscopic (“keyhole”) and options include removing (excising) loose fragments, cleaning (debriding) the joint or joint surface or repairing the ligaments perhaps with a transfer of a tendon. Many surgical procedures can be done as a day case procedure, but rehabilitation may take 6 to 10 weeks to ensure proper healing.

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Causes
Arthritis commonly affects the ankle joint. Osteoarthritis is the most common cause and is usually after a previous injury, but may occur out of the blue. An inflammatory condition such as rheumatoid arthritis can affect the ankle. The treatment will aim to reduce the inflammation around the joint, prevent further damage and alleviate the effects of any deformity. The precise treatment will depend on the precise location and the severity.

Diagnosis
Standing X-rays and essential and some blood tests may be needed to check for rheumatoid arthritis.  However advanced imaging is usually the key, especially computed tomography (CT) scans, or magnetic resonance imaging (MRI) or a bone scan.  In complex cases the precise injection of steroids under image guidance can give temporary relief and confirm the site of the damage. This will suggest the effectiveness of any permanent surgical treatment.

Treatment
The full benefit of non-operative treatments such as insoles, pads, shoes, physiotherapy and medicines will need to be assessed before embarking on surgery. An injection of steroids into the worn ankle joint can often provide excellent pain relief for some months.

Surgery
In early ankle arthritis, a catching pain, restricted movement or intermittent locking may be helped by minimally invasive technique of arthroscopic surgery. The gold standard technique has been fusion of the ankle (the two bones grow into one) where the painful grinding movements are eradicated. This is also performed using a minimally invasive technique.
Some patients may benefit from a total ankle replacement.
More information is available from the arthritisresearchuk.org

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Causes
Arthritis can affect any of the many joints in the foot region.  Osteoarthritis often involves the mid-foot usually after a previous injury or the collapse of the inside arch of the foot, but an inflammatory condition such as rheumatoid arthritis may be the cause. The treatment will aim to reduce the inflammation around the joint, prevent further damage and alleviate the effects of any deformity. The precise treatment will depend on the precise location and the severity.

Diagnosis
Standing X-rays and essential and some blood tests may be needed to check for rheumatoid arthritis. However advanced imaging is usually the key, especially computed tomography (CT) scans, or magnetic resonance imaging (MRI) or a bone scan.  In complex cases the precise  injection of steroids under image guidance can give temporary relief and confirm the site of the damage. This will suggest the effectiveness of any permanent surgical treatment.

Treatment
The full benefit of non-operative treatments such as insoles, pads, shoes, physiotherapy and medicines will need to be assessed before embarking on surgery.

Surgery
Where the damage is limited to just a few joints, a mid-foot fusion (the two bones grow into one) can reduce the painful grinding movements.
More information is available from the arthritisresearchuk.org

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Symptoms
When arthritis affects the main joint of the big toe it is called hallux rigidus. The main feature is stiffness ("rigidus") of the big toe ("hallux"). An important difference is whether the whole joint is worn out or just sometimes only the upper part of the joint is affected with extra bone around the edges. Of the whole body, the big toe joint is the second most commonly affected joint involved with arthritis. This is because it is under tremendous stress in walking.
Pain is felt in the big toe around the joint. In some people the pain is present whenever they walk or even at rest, but in others it only occurs when they turn the big toe up as far as it will go.
Painful stiffness of the big toe, may be worse when walking up slopes. A bony bump ("osteophyte" or "dorsal bunion") may develop on top of the joint, which may rub on shoes. This is your body's natural response to the worn joint. Some people tend to walk on the outside of the foot. This may produce pain in the ball of the foot or down its outside border.

Causes
A few people may recall a specific injury or perhaps a preference to use one foot in a lifetime of sport.  For others gout, rheumatoid arthritis or an infection may have damaged  the joint.

Treatment
If the arthritis is at an early stage, the pain is improved by weight control, simple painkillers, comfortable wide shoes often with stiffer soles and an insole. Recently rocker soled shoes such as MBTs and Fit-flops have become fashionable.  If the toe remains very painful, it may be worth injecting a low dose of steroid mixed with local anaesthetic into the small joint.
This is either an outpatient procedure but may be done in the operating theatre if the diagnosis is uncertain.

Surgery
There are two main operations for hallux rigidus. Firstly joint preservation where the extra bone around the joint is removed (“cheilectomy”) possibly with an alteration of the shape of the bones around the joint. At this time a small bare area may be microfractured to attempt to cover it with scar tissue. The arthritic process will slowly continue and years later another operation may be required. A few select patients may benefit from an arthroscopic treatment.
Secondly a fusion of the joint would be recommended if the cartilage of the central joint is gone. This removes the painful joint and stiffens it completely. 95% of people will get rid of their pain. However, the choice of shoes will be more limited.
Replacement of the whole big toe joint has not been reliably successful over the years. But recently promising results have suggested an option to keep some movement at this joint and thus shoes with a wider range of heel height may be worn. This involves resurfacing just one side of the joint. The Cotswold Foot and Ankle Clinic does not recommend a Keller's procedure except for elderly patients who walk very little and rarely leave their home.

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The term bunion refers to a swelling on the side of the big toe joint. It is usually associated with the big toe slowly drifting to point towards the outside.

Symptoms
Bunions are very common indeed but frequently do not cause pain. If the swelling is prominent, it will become inflamed and painful, often rubbing on your shoes. For some the pain is over the swelling while for others pain develops under the ball of the foot or at the second toe, which may change shape into a hammer toe. This can limit your choice of shoes, ability to play sport or even simply walk.

Causes
There is a strong genetic tendency to forming a bunion, especially if it commences in the adolescent years. Bunions can occur in people who have always worn sensible shoes, but footwear with narrow toe-boxes and high heels can speed up the development of a bunion. They can also occur after injury, inflammatory arthritis and in muscle weakness.

Diagnosis
Clinical examination and an X-ray are required by the surgeon to check the severity and confirm which type of surgery is required. However whether surgery is needed, is determined by the severity of the pain, limitation of footwear, expectations of the patient and the speed of deterioration.

Treatment
Patients with mild bearable bunion pain can be helped by adjustment of footwear or an orthotic, given after a biomechanical assessment. A qualified podiatrist can prescribe an orthotic, which is a device inserted into the shoe to prevent the condition from worsening. These can be ready made or customised. The Cotswold Foot and Ankle Clinic works closely with a local team of expert podiatrists.

Surgery
The aim of bunion surgery is to rebalance the forefoot and straighten the hallux valgus. At the same time any lesser toe deformity can be corrected. Our reliable modern techniques provide comfort by stable fixation of the small bones of the foot. This is a big advantage over historical operations, which were traditionally very painful. The headless metal screws are very small and remain within the bone. They very rarely need to be removed.
In addition every patient will have an ankle nerve block to numb the nerves for 8 to 24 hours, giving time for the pain relieving effect of tablets to be at full strength. This will be performed by either the Anaesthetist or the Surgeon.
In the last fifteen years we have learnt which procedures are best suited to the different types of hallux valgus. The choice of operation will be tailored to your needs. The Scarf osteotomy is the most commonly performed bunion procedure by the Cotswold Foot and Ankle Clinic.
For the first two weeks patients must ideally rest to allow the wound to heal without trouble. Each patient will be given a sloped shoe for six weeks to help avoid weight passing through their tender forefoot. After this you will be taught toe exercises and may require physiotherapy.
All forefoot surgery is associated with toe stiffness and swelling for three months, but complications can also occur such as recurrence, toe numbness and infection. However overall in our hands most patients will have an excellent outcome at one year. Our Audit and Results at one year showed a Mean AOFAS score 82.3 % (excellent >80%).
The Consultant Orthopaedic Surgeon at the Cotswold Foot and Ankle Clinic has been trained in the new minimally invasive techniques for bunion surgery. Although as a principle we use minimally invasive techniques in all our surgery, the keyhole bunion operations have not yet been adopted as routine practice until good reliable evidence shows that they are better than the tried and tested gold standard methods.

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Many former procedures for the correction of a painful bunion and hallux valgus have now been shown to have a high recurrence rate. These techniques are no longer practiced by specialist Consultant Orthopaedic Foot and Ankle Surgeons. However the Cotswold Foot and Ankle Clinic has developed an interest in further surgery to correct these complicated recurrent deformities.
However the Cotswold Foot and Ankle Clinic has developed an interest in further surgery to correct these complicated recurrent deformities.

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Symptoms
Metatarsalgia is a forefoot pain in the ball of the foot. It is usually felt in the sole of the foot and sometimes feels like "walking with a stone in the shoe". It can be in one point or a more diffuse vague pain, ache or burning sensation. It may involve numbness.

Causes
It is often worse if overweight, wearing high heel shoes or with a lesser toe deformity. A tight calf muscle or an unusual foot shapes, such as a high-arched ("cavus") foot, severe bunion pain or having a long metatarsals. Both a stress fracture of a metatarsal or a trapped nerve (“Morton’s neuroma”) can cause metatarsalgia. Arthritis, gout or inflammation of the small metatarsal phalangeal joints can also produce this forefoot pain.

Treatment
Initial treatments should involve rest with your feet up after periods of standing or walking, wear comfortable shoes with a small heel and plenty of room for your feet, exercise your ankle and stretch your Achilles tendon, a metatarsal insole or pad can be bought in a local chemist and it is worth taking simple painkillers such as paracetamol or if you can tolerate them anti-inflammatory tablets.
You may wish to directly contact a local podiatrist for a biomechanical review and perhaps a customised insole. In Gloucestershire we have many excellent podiatrists of which some are mentioned on the local team of experts page.
Blood tests for inflammatory arthritis, diabetes or gout may be useful. Standing X- rays of your foot may show a problem in the bones or joints.

Diagnosis
Depending on the Consultant’s examination findings you may require further investigations such as a magnetic resonance (MRI) scan, or rarely a bone scan. If a nerve entrapment is suspected or joint damage an ultrasound will be performed with the Radiologist and Surgeon. Occasionally foot pressure measurements or nerve tests may be required. Sometimes these tests may reassure us that no major damage or disease is present, but a precise diagnosis may not be possible.
After diagnosis a further visit to the podiatrist to obtain an insole (“orthotic”) may be all that is required. An insole shares the weight more evenly about your foot. A clinically or an ultrasound guided injection of steroid into an inflamed joint or around an irritated nerve may reduce inflammation and pain.

Surgery
Only a minority will require an operation. Removal of an irritated nerve is performed as a day case under general anaesthetic, so that a tourniquet can be used to allow the Surgeon to see the nerve clearly. Other procedures may alter the shape or length of a metatarsal or straighten out a deformed lesser toe.

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The inside edge of the foot is usually arched and in part held up by the shape of the joints and the strength of the main tendon, tibialis posterior. In adult life this arch may slowly collapse if this tendon becomes inflamed, over-stretched or torn.

Symptoms
Pain perhaps with swelling usually starts on the inside of the ankle. The arch falls and weakness leads to deterioration in the ability to stand up on tip toes. Later pain may develop on the outer side of the ankle or foot.

Diagnosis
The surgeon will ask you to stand on your bare feet facing away from him to view how your foot functions. While the condition progresses, the front of the affected foot will start to turn to the outside. From behind, it will look as though you have "too many toes" showing. You will be requested to stand on the toes of the painful foot. Standing X-rays will be arranged to check the joints have not yet become damaged. An ultrasound or a magnetic resonance image (MRI) is frequently arranged.

Treatment
The treatment you require will depend on how far the condition has progressed. In the early stages, damage to this posterior tibial tendon can be treated with rest, non-steroidal anti-inflammatory drugs such as Aspirin or Ibuprofen, or immobilisation of the foot for six to eight weeks in a walker boot to prevent overuse. After the cast is removed, shoe inserts with an arch support may be helpful. Most patients do not need surgery. Some patients may have an injection of a small amount of steroids beside the tendon to help reduce the inflammation along with immobilisation.

Surgery
A minority require surgery if these conservative treatments are unsuccessful. If the joints are not damaged, then the effect of the tendon can be replaced by transferring a tendon along with correcting the alignment of the back of the heel. Additional procedures may be performed, but the recovery usually involves six weeks in a plaster and then six weeks in a removable walker boot, in which patients can start to walk.
If the joint below the ankle is damaged then the shape of the hind foot needs to be corrected by fusing the two bones together.

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Any of the twenty eight bones of the foot can be fractured (‘broken’). They each require different treatments and sometimes surgery.
The Cotswold Foot and Ankle Clinic always uses the most modern and least restricting techniques in order for the athlete to return safely to sport as promptly as possible.
Mr Brown has looked after local elite Athletes from the Cheltenham Racecourse, Gloucester Rugby Football Club and Cheltenham Town Football Club, as well as amateur sportsmen and women from all over the area.

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Causes
Your foot is a tremendously strong structure that can withstand great loads during activity. The arch of the foot is maintained by the bones, muscles and ligaments. A vital structure is the fibrous band of tough tissue, the plantar fascia, which connects the heel to the base of the toes. If this becomes damaged it may become inflamed and painful. Without treatment eventually it becomes tight and vulnerable to further injury and inflammation. The first few steps out of bed in the morning usually cause severe pain in the heel of the foot.
People with very flat feet or very high arches are more prone to plantar fasciitis as to are women, the overweight or those in a job that requires a lot of walking or standing on a hard surface. An acute tear of this structure can occur as a sports injury, especially if your calf muscles are tight, which restrict how far you can stretch up your ankles.

Diagnosis
The diagnosis is usually made by examining the foot. The role of the surgeon is to exclude other unusual causes of heel pain, fat pad incompetence, acute tear, chronic thickening of the plantar fascia or a calf contracture, or to establish if there is an underlying biomechanical reason. If the heel pain is failing to settle then an x ray may help exclude some of the other causes such as a stress fracture of the calcaneum. For a resistant or atypical case more advanced imaging with a MRI scan may be required.

Treatment
Stretching is the best treatment for plantar fasciitis. It may help to try to keep weight off your foot until the initial inflammation goes away. You can also apply ice to the sore area for twenty minutes three or four times a day to relieve your symptoms. Often your GP will prescribe a non-steroidal anti-inflammatory medication such as ibuprofen or naproxen. A program of home exercises to stretch your Achilles tendon and plantar fascia are the mainstay of treating the condition and lessening the chance of recurrence.
About 90% of people with plantar fasciitis improve significantly after three months of stretching.
If you do not treat plantar fasciitis, it may become a chronic condition. You may not be able to keep up your level of activity and you may also develop symptoms of foot, knee, hip and back problems because of the way plantar fasciitis changes the way you walk. Explanation of the stretching techniques for the calf and plantar fascia can be explained by a local physiotherapist from our local team of experts or read from www.aofas.org/footcaremd/conditions/ailments-of-the-heel/Pages/Plantar-Fasciitis.aspx.
A shock-absorbing insole, such as a rubber heel pad may help especially if there is also damage to the normal pad of fat under the skin of the heel.
If the early morning pain is severe you may benefit from wearing a splint at night. We may discus an injection of steroids into the most tender area.
Recent evidence has supported the use of extra-corporal shock wave therapy to speed up a recovery, which is rather prolonged and slow. The Cotswold Foot and Ankle Clinic offer this treatment.

Surgery
Rarely surgery may be indicated to release a very tight chronically contracted plantar fascia, or to correct an underlying abnormality.

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Causes
This common disorder is due to trimming your toenails too short. The sides of the nail curl down and dig into your skin. An ingrown toenail may also happen if you wear shoes that are too tight or too short. Any of your toenails can get ingrown, but it is most likely to affect your big toes. When you first have an ingrown toenail, it may be hard, swollen and tender. Finally, your skin may start to grow over the ingrown toenail. Sometimes it may get red and infected, and feel very sore. You may see pus drain from it.

Treatment
To treat an infected ingrown toenail, soak your foot in warm, soapy water several times each day. You may need to gently lift the edge of the ingrown toenail from its embedded position and insert some cotton or waxed dental floss between the nail and your skin. Change this packing every day. If your infection is severe, your doctor may prescribe a course of antibiotics. Learn how to trim your toenails properly. Wear clean socks and open-toed shoes, such as sandals.

Surgery
If you are in a lot of pain and/or the infection keeps coming back, your GP, podiatrist or surgeon may remove part of your ingrown toenail under a local anaesthetic. The choice is between only the removal of part of the nail (partial nail plate avulsion), removal of the ingrown edge and part of the tissue, which grows new nail (wedge resection), or removal of the entire nail and all the growth potential (Zadic procedure). Ingrown toenails often recur after the lesser procedures.

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The lesser toes can become bent at any of the small joints, rubbing on shoes. A hammer toe is bent at the near joint while a mallet toe is bent at the far joint. Initially you will be able to stretch out the toe but later it will become fixed in the bent position.

Causes
The hammer toe is due to an imbalance of the small muscles that hold a toe in position. It may start initially after an injury or be associated with tight shoes or inflammatory arthropathy. Eventually the toe is pulled out of joint (“a claw toe”) which can cause pain under the metatarsal head.

Treatment
Shoes need to be wide and spacious around the toes. Shoes should be one 1cm longer than your longest toe. You should try your own toe stretches. Local pharmacists or an orthotist may provide a choice of straps, cushions or pads to relieve the symptoms.

Surgery
Hammer toe can be corrected by day case surgery. The actual procedure will depend on the type and extent of the deformity. The traditional treatment involves a metal wire protruding through the tip of the toe for six weeks. This must be kept clean every day. However the Cotswold Foot and Ankle Clinic now offers an easier option for the patient using an absorbable pin which is entirely within the toe. Our results at one year show this is as good at correcting the toe as the traditional technique.

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Inflammatory arthritis often commences in the forefoot, but it can damage any area from the ankles to the toes. Rheumatoid arthritis (RA) is a systemic disease that attacks multiple joints throughout the body. About 90% of people with rheumatoid arthritis eventually develop symptoms related to the foot or ankle. Usually symptoms appear in the toes or forefeet first, then in the hind feet and finally in the ankles.
Mr Brown has a special interest in RA and has a regular combined clinic with the Rheumatology Consultants.

Causes
The exact cause of rheumatoid arthritis (RA) is unknown, but there are several theories. Some people may be more likely to develop RA because of their genes. However, it usually takes a chemical or environmental "trigger" to activate the disease. In RA, the immune system of the body turns against itself. Instead of protecting the joints, the body produces substances that attack and inflame the joints.

Symptoms
The most common symptoms of rheumatoid arthritis (RA) in the foot are pain, swelling, and stiffness. Symptoms usually appear in several joints on both feet. You may feel pain deep in the joints, in the sole or under the ball of your foot. The joint may be warm and the way you walk may be affected. You may develop corns or bunions, and your toes can begin to curl and stiffen in positions called claw toe or hammer toe.
If your hindfoot (back of the foot) and ankle are affected, the bones may shift position. This can cause the long arch on the bottom of your foot to collapse (flatfoot), resulting in pain and difficulty walking.

Diagnosis
The Consultant Orthopaedic Surgeon may be the first to suggest the diagnosis before referral to see a Consultant Rheumatologist in Cheltenham or Cirencester Hospitals. They will ask you about your medical history, other joint pains, early morning stiffness, as well as your occupation and recreational activities. The appearance of symptoms in several joints is an indication that RA might be involved. Blood tests will show whether you are anemic or have an antibody called the rheumatoid factor, which is often present with RA.

Treatment
Many people with rheumatoid arthritis (RA) can control their pain and the disease with medication and exercise. Some medications, such as aspirin or ibuprofen, help control pain. Others, including methotrexate, prednisone, sulfasalazine, and gold compounds, help slow the spread of the disease itself. In some cases, an injection of a steroid medication into the joint can help relieve swelling and inflammation.
Disease modifying drugs such as anti-TNF alpha agents, (eg Enbrel) have dramatically controlled this condition in the 21st century, so much so that we rarely see the dramatic foot deformities of before.
A podiatrist or orthotist may provide special shoes or a soft arch support with a rigid heel. Keeping active is very important in the treatment of RA and you may see a physiotherapist for special stretches and range of motion exercises.

Surgery
Surgery can correct several isolated common forefoot conditions, such as bunions or hammer toes. With more severe damage it may be better to stabilize the entire forefoot by fusion the big toe and operating on the lesser toes.
Midfoot deformities or a damaged ankle may benefit from a fusion procedure. In this procedure, the joint cartilage is removed; in some cases, some of the adjacent bone is also removed. The bones are held in place with screws, plates and screws or a rod through the bone. After several months in a plaster the bones unite, creating one solid bone. There is loss of motion, but the foot and ankle remain functional and generally pain-free. A total ankle replacement is a reasonable choice for a painful ankle in rheumatoid arthritis.
As in all surgeries, there is some risk. Infection and failure of the wound to heal is a real concern and you may be asked to stop any strong medication until the wound is safely healed. Any internal metal device may loosen, requiring repeat surgery.
More information is available from the arthritisresearchuk.org

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The commonest sports injuries affecting the foot and ankle are described in the following sections.

  • Ankle Instability
  • Ankle Pain after a Sprain
  • Fractures
  • Achilles tendon rupture
  • Achilles tendon pain
  • Stress fractures
  • Heel pain (plantar fasciitis)

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Causes
Any bone of the foot or ankle may break (“fracture”) after repeated loading. Initially the bone will become tender in a tress response and if the force continues and the bone is unable to repair itself fast enough, a fracture may occur. The metatarsal bones of the foot (the five long bones between the toes and the mid-foot) are especially vulnerable. A normal strength bone can break if a force is repeatedly applied for long enough. A softer bone such as in osteoporosis or a metabolic bone disease will be at higher risk.

Diagnosis
There will be a very focused area of bony tenderness. X-rays may be normal if taken in the first two weeks of symptoms. After this time a faint fracture line or new bone formation can usually be seen. An MRI scan can be obtained to demonstrate either a stress reaction or a indeed a stress fracture. A bone scan may be requested.

Treatment
To allow the bone to repair the loading forces need to be offloaded and shared around the foot. This is achieved by immobilisation in a removable walker boot or plaster. When healing is confirmed to be progressing, the weight through the foot and then the specific bone can gradually be increased. This may involve progress to wearing only an orthotic in a rigid soled shoe.
An underlying medical cause needs to be identified, as too should any at risk activities. For example an excessive training programme may need modification.

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