While the foot might not be the prettiest part of the body, it is critical for maintaining function, balance and coordination when walking. Conditions such as bunions and flatfeet can be extremely cumbersome and painful if not treated correctly, and may compromise mobility. Because of this, non-surgical and surgical approaches to treating bunions and flatfeet were presented today at the 73rd Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) at McCormick Place.
Battling bunions
Bunions are malalignments of the big toe that appear as “bumps.” Consisting of soft tissue and bone, bunions cause the big toe to protrude, and when rubbed against shoes can grow larger and become red and painful. According to Judith F. Baumhauer, MD, professor of orthopaedic surgery and chief of the division of foot and ankle surgery at the University of Rochester Medical Center, in Rochester, N.Y., “The two main causes of bunions are family genetics and narrow, ill-fitting shoes. Bunions most commonly occur in women because of footwear issues.”
A person can usually compensate for a bunion by using arch supports, stretching the shoe or simply wearing shoes that aren’t too narrow, high or pointy and fit the foot comfortably. Not all bunions are painful; however, if a person feels pain or the bunion grows too large to wear any shoe comfortably, surgery may be required.
“There is no data to show at what rate a bunion will worsen or become symptomatic,” said Dr. Baumhauer. “Because of this, surgery is only performed when the bunion becomes a painful problem that is not accommodated with shoes or inserts. It’s not performed for cosmetic reasons.”
Currently, there are several types of bunions and approximately 135 different types of bunion operations. In general, bunion surgery consists of shaving off the bony prominence, cutting the bone to improve alignment (osteotomy) and releasing tight, contracted soft tissues to rebalance the big toe joint. The type of surgery is dependent upon the presence of arthritis in the big toe joint, stiffness, the size of the deformity and the age of the patient.
According to George H. Thompson, MD, professor of orthopaedics and pediatrics at Case Western Reserve University and director of pediatric orthopaedics at Rainbow Babies & Children’s Hospital, both in Cleveland, the main difference between adolescent and adult bunions is “in children, most bunions are congenital in origin, while adult bunions can be degenerative or a continuation of an adolescent bunion and may worsen over time.”
“Surgery to remove bunions in an adolescent is not recommended unless there is persistent pain following non-operative management,” stressed Dr. Thompson. “If adolescents have bunion surgery – particularly before they are full grown – there is an increased possibility the bunion will reoccur.”
Fixing Flatfeet
Adult-acquired flatfoot is common and one of the most under-recognized foot conditions. It occurs when the ankle’s posterior tibial tendon – which supports the foot’s arch and provides stability when walking – weakens or ruptures, resulting in a progressive collapse of the arch. Causes include age – the posterior tibial tendon undergoes degenerative wear as a person gets older – traumatic injuries and systematic diseases, such as rheumatoid arthritis. In many adults, a foot that starts to flatten is painless. If the condition progresses, however, individuals can develop pain on the outside of the ankle, pain on the inside of the knee, and/or lower back pain. People with a flatfoot may also experience difficulty walking, climbing stairs or wearing shoes.
“If adults let flatfoot linger, the deformity gradually worsens,” said Steven L. Haddad, MD, associate professor of orthopaedic surgery at Northwestern University in Chicago, Ill., and attending orthopaedic surgeon at the Illinois Bone and Joint Institute in Glenview, Ill. “The longer this condition is ignored, the more complicated the surgery becomes, so it is extremely important to recognize its onset early.”
The first line of defense in patients with posterior tibial tendon insufficiency is physical therapy, paired with wearing comfortable shoes with arch supports to relieve tension from the inflamed or damaged tendon. A lace-up brace or walking boot may also be required. If these non-surgical treatments do not work, then surgery becomes a consideration.
Similar to bunion surgery, Dr. Haddad pointed out, “Adult-acquired flatfoot surgery is not conducted for cosmetic purposes, but as a form of pain management.”
The type of surgery performed depends on the severity of the condition and location of the symptoms. Flatfoot surgery may consist of a tendon transfer, which replaces the damaged posterior tibial tendon with an adjacent flexor tendon. In addition to replacing the damaged posterior tibial tendon, supplementary procedures – such as arthrodesis (fusion) of the collapsed joints or joint-sparing procedures, like a calcaneal osteotomy, which realigns the hindfoot by shifting the heel bone – may be required. Post-surgery, rehabilitation and physical therapy will be necessary.
According to Dr. Thompson, “Flatfeet in children are very common and rarely abnormal.” Children up to six years of age tend to have the appearance of a flatfoot due to fatty tissue filling the arch. Flatfeet in children are asymptomatic and rarely require treatment; most have an increased laxity of ligaments and soft tissue. While corrective shoes, physical therapy and shoe inserts have little impact on younger children, adolescents and older children with painful flatfeet should seek orthopaedic care.
“It is important people of all ages take care of their feet, as foot problems can adversely affect the entire body,” explained Dr. Haddad.
An orthopaedic surgeon is a physician with extensive training in the diagnosis and non-surgical as well as surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.
With more than 29,000 members, the American Academy of Orthopaedic Surgeons (www.aaos.org) or (www.orthoinfo.org) is the premier not-for-profit organization that provides education programs for orthopaedic surgeons and allied health professionals, champions the interests of patients and advances the highest quality musculoskeletal health. Orthopaedic surgeons and the Academy are the authoritative sources of information for patients and the general public on musculoskeletal conditions, treatments and related issues. An advocate for improved patient care, the Academy is participating in the Bone and Joint Decade (www.usbjd.org) – the global initiative in the years 2002-2011 – to raise awareness of musculoskeletal health, stimulate research and improve people’s quality of life.
