Unfortunately, a small percentage of people that develop plantar fasciitis will not have success with conservative therapies.  We have an established treatment protocol for heel pain, making us a premier location for the treatment of plantar fasciitis.  The standard of care is six months to a year of conservative therapy before surgical intervention should be considered.  We have multiple surgical modalities available for patients with recalcitrant plantar fasciitis.  These surgical procedures can be performed with mild sedation in our outpatient surgery center that can save you both time and money by not having to go to the hospital or ambulatory surgery centers.  The procedures include:

• gastrocnemius recession
• plantar fasciotomies

A gastrocnemius recession involves lengthening of the muscle in order to reduce the contracture.  A large percentage of people with chronic plantar fascial pain have limited range of motion of the ankle.  This limited range of motion often results in compensation via flattening of the arch, which leads to strain on the plantar fascia.  The post operative course requires a walking boot for about three weeks followed by a transition into proper shoe gear.

The most common procedure for recalcitrant plantar fasciitis is a plantar fasciotomy.  This procedure involves lengthening a section of the fascia.  The idea is to reduce mechanical workload in the fascia thereby providing resolution of symptoms.  This procedure takes about 15 minutes and usually requires a period of non-weightbearing for about three weeks and an additional two to three weeks of protected weightbearing.   

A neuroma is an abnormality of a nerve that has been damaged either by trauma or as a result of an abnormality of foot function. The most common location of neuromas is in the ball of the foot. In this area the nerve can become pinched and inflamed by the abnormal movement of the bones in the ball of the foot.

As the condition progresses the nerve may become permanently damaged and surgical removal of the nerve may be necessary.

The Surgery

The surgical removal of forefoot neuromas is a relatively simple procedure. The surgery can be performed using a local anesthesia in the doctor's office or with intravenous anesthesia (twilight anesthesia) in an outpatient surgery center.

Following administration of anesthesia, a skin incision is made on the top of the foot in the location of the neuroma. This is most commonly in the area between the second and third toes or between the third and fourth toes. An alternative surgical approach is to place the skin incision on the bottom of the foot in the location of the neuroma. Most surgeons perfer to make the skin incision on the top of the foot for several reasons. If the skin incision is placed on the bottom of the foot the patient may be required to use crutches for up to three weeks. Additionally, it takes longer for the skin on the bottom of the foot to heal. In the event that a thicken or irregular scar forms during healing, it may cause pain while walking. When the incision is made on the top of the foot the neuroma is easily found between the long bones (metatarsals) behind the toes. After the nerve is identified it is cut and removed. Once the surgery is completed a gauze dressing is applied. This bandage stays in place until the surgeon sees the patient on their first post-operative visit. On the first post-operative visit the surgical site is inspected and a new dressing is applied. The sutures are removed in 10 to 14 days following the surgery. During this period of time the foot must remain dry to reduce the risk of infection. The patient should limit their activities and keep their foot elevated above the heart as much as possible. A post-operative shoe is worn which allows the patient to do limited walking. The patient should not walk with out the post-operative shoe. Once the sutures have been removed the patient may bath the foot and attempt to wear a roomy stiff-soled walking shoe. It generally takes three weeks from the time of surgery before the walking shoe can be worn comfortably.

Recovery Time

The time required to be off from work will depend upon the type of work being performed and the type of shoe that must be worn. If the patient can work with their foot propped up and elevated with limited walking they may be able to return to work within a week of surgery. It is generally recommended that the patient not return to work until they can wear a normal shoe comfortable. Patients who have jobs that require prolonged standing, walking, kneeling or climbing may be off from work for as long as four to six weeks.

Possible Complications

The surgery has an over all high success rate, however, as with any surgery complications can occur. Possible complications include infection, excessive swelling, and delays in healing or continued pain. Also when a nerve is cut there is a small possibility that the nerve may grow abnormally producing a stump neuroma. If the patient walks on the foot more that what is recommended excessive swelling can cause bleeding or scaring that may result in continued pain and delays in healing.

There are five metatarsal bones in each foot. These bones are the long bones behind each toe. The metatarsal bone behind the big toe is called the first metatarsal. The metatarsal bone behind the little toe is called the fifth metatarsal. The most common metatarsal surgery is preformed on the first metatarsal for the correction of bunion deformity. The second most common metatarsal surgery is on the fifth metatarsal for the correction of tailor's bunion deformity. This article will address metatarsal surgery of the other metatarsals.

Surgery on the remaining metatarsal bones is performed infrequently. When surgery is performed on the second, third, or fourth metatarsal bones, it is generally for the treatment of painful callouses on the bottom of the foot or for the treatment of non-healing ulcerations on the ball of the foot. Patients with rheumatoid arthritis may require surgery of the metatarsals, which is discussed in another section. Also surgery of the metatarsals may be necessary in instances of trauma of the foot where the metatarsal bones may have been fractured. This article will discuss elective metatarsal surgery.

Painful callouses on the ball of the foot are due to an abnormal alignment of the metatarsal bones. If a metatarsal bone is lower than the others, excessive weight is placed on this area of the foot, and a painful callous may form. In people with diabetes, these areas of excessive pressure may break down and form open sores or ulcerations. Initial treatment generally consist of using a functional or accommodative orthotic to reduce the pressure to these areas. If this is not successful, metatarsal surgery may be considered.

The Surgery

The surgery consists of cutting the metatarsal bone just behind the toe. Generally, the bone is cut all the way through, and then manually elevated and held in its corrected position with a metal pin or screw. Following the surgery, the patient may be placed in a cast, or may be required to use crutches for several weeks. If a pin is used to hold the bone in place, it is generally removed in three to four weeks. Removal of the pin can be done in the doctor's office without the need for anesthesia. While the pin is in place, the patient should keep the foot dry to prevent infection. Generally it takes a total of six to eight weeks, or longer, for the bone to heal. During this healing period, the foot should be protected from excessive weight bearing. Walking prematurely on the foot can cause the bone to shift and heal in an incorrect position. This is the most common cause of failure with this surgery. Some studies indicate a failure rate as great as 60%. If the bone shifts downward, or is not elevated enough at the time of surgery, the painful callous may return. If the bone is elevated too much, a painful callous may form under the metatarsal next to the one which was operated on.

Some surgeons will also cut out the painful callous on the bottom of the foot when they perform the metatarsal surgery. Rarely will a foot surgeon remove the painful callous without also performing the metatarsal surgery. Without correcting the metatarsal alignment, the painful callous is almost certain to return.

Most surgeons prefer to do the surgery in an outpatient surgery center or hospital. In this setting, intra-venous sedation or general anesthesia can be used for the patient’s comfort.

At the conclusion of the surgery, the surgeon places a gauze bandage on the foot. Generally, the bandage stays in place until the patient’s first follow up visit with the doctor. The skin stitches are removed in ten to fourteen days. If there are stitches in the bottom of the foot, they may remain in place for three weeks. The foot should be kept dry while the stitches and/or pin are in place to help prevent infection. May surgeons will have the patients wear a below the knee cast and/or use crutches for six to eight weeks. Other surgeons will allow the patient to wear a stiff-sole post-operative shoe, and allow limited walking on the foot.

Recovery Time

The time required to be off work will vary with the demands of the person’s job. A minimum of one week off work would be advisable with the patient staying at home with the foot elevated above the heart.

Possible Complications

Complications associated with this surgery are: infection, failure of the bone to heal in its correct position resulting in the return of the painful callous or transfer of the callous to a new location, delays or failure of bone healing, stress fractures of adjacent metatarsals, or excessive swelling. A common occurrence following the surgery is elevation of the toe associated with the elevated metatarsal bone that was operated on.

Metatarsal Surgery to Treat Diabetic Ulcerations

Diabetic patients with non-healing ulcerations on the ball of the foot may undergo a different type of metatarsal surgery. In this instance, the section of the metatarsal bone associated with the excessive pressure, called the metatarsal head, may be removed entirely. This is a relatively common and successful surgery that aids in the healing of the ulceration on the bottom of the foot. Possible complications with this surgery include infection, failure of the procedure to heal the ulceration, or the development of new ulcerations in adjacent areas on the ball of the foot. If the patient has poor circulation, further complications may be failure of the surgical sight to heal, or gangrene with partial loss of the foot or leg.

In most instances of metatarsal surgery, the patient should use an orthoticin their shoe after the surgery has healed. This is especially important for the diabetic patient. The orthotic will reduce the risk of reoccurrence or the development of new areas of callous formation or tissue break down.

Heel pain is caused by the excessive pull of a ligament in the arch of the foot called the plantar fascia. Generally the pain can be treated successfully without the need for surgery. However there are instances where non-surgical treatment of heel pain may fail and surgery may be necessary. Very often, the patient with heel pain will demonstrate a heel spur on an x-ray. In the past, many of the surgeries that were performed to relieve heel pain were designed to remove the bone spur. An incision was made on the side of the heel or the bottom of the heel, the spur identified and removed. Unfortunately, the healing time was very protracted and continued pain following the surgery was not uncommon. Now that the cause of heel pain is better-understood (See heel pain) the surgery is much more successful and the recovery time greatly diminished.

The Surgery

Most surgical procedures are aimed at detaching the plantar fascial ligament from its attachment into the heel bone. This may be accomplished with a small incision on the bottom of the heel or on the side of the heel. The procedure is performed by "feel". The surgeon inserted the scalpel blade and felt for the plantar fascia. Once they were confident that they had identified the plantar fascia they would cut the ligament free from the heel bone.

In the mid 1990's a new procedure was developed called the "Endoscopic Plantar Fascial Release". This procedure developed by Dr. Steven Barrett DPM and Dr. Steven Day DPM of Houston, Texas uses technology similar to that used in arthroscopic surgery. A small incision is place on the side of the heel where a small cannula is placed allowing the insertion of an arthroscopic camera. The plantar fascial ligament is visualized and then cut using a small surgical blade. This allows the surgeon greater control during the surgery. The surgeon can control where and how much of the ligament is freed from the heel bone. Some surgeons still perfer to remove the spur at the time of surgery. This is the surgeon's choice and based upon their training and experience.

The surgery is generally performed in an outpatient surgical center or hospital operating room. It can be performed under a local anesthesia, twilight anesthesia or a general anesthesia. At the completion of surgery a gauze dressing is applied and the patient placed in a post operative shoe or cast.

Recovery Period

Most patients are allowed to walk on the foot immediately but they are encouraged to limit their activities. The first week it is recommended that they stay off their feet except to use the restroom or have something to eat. After the first 3 to 7 days the bandage is removed and Band-Aids placed over the incision site. At this point the patient may attempt to wear a good supportive walking shoe if allowed to by their surgeon. Some surgeons perfer to protect the foot with a cast or have the patient use crutches. In 10 to 14 days the sutures are removed and the patient is allowed to bath the foot. It generally takes a minimum of three weeks before the patient is able to walk normally, with minimal discomfort. The patient should return to wearing their orthotics as soon as they are comfortable to wear in their shoes. Because the surgery does not address the cause of the heel pain (See heel pain) it is a good idea to wear orthotics following the surgery to reduce reoccurrence of the heel pain or other foot problems that might arise from excessive pronation of the foot.

The amount of time needed to be off from work depends upon the demands of the job and the type of shoes that must be worn. If a limited amount of walking is required for the job and the patient is able to return to work wearing a cast the patient may be able to return to work in one week. If the job requires a lot of time standing, walking climbing or kneeling the patient may be required to be off work for three weeks or longer. These are general guidelines and it is important that the patient follow their doctor's instructions and guidance. Each surgeon has their own set of criteria to guide the patient through their surgery based upon their experience.

Possible Complications

Overall this surgery has a very high success rate, but as with any surgical procedure there are possible complications. If the patient walks excessively on the foot during the healing period following the surgery, it may damage the weakened soft tissues in the area of the heel. This can lead to continued pain in the heel or in other areas of the foot, particularly on the top and outside of the foot. This is due to jamming of a joint in the area. Infection is another possible complication. The risk of infection will increase if the surgical site gets wet while the sutures are in place. In some instances a continuation of the pain may occur. This can be due to the ligament not being cut all the way through at the time of surgery. Another cause of continued pain might be the presence on a pinched or damaged nerve called a calcaneal neuroma. A calcaneal neuroma is relatively rare and not easily identified and may only be recognized with the failure of the initial surgery. Some instances of failure of the surgery cannot be identified. In these cases the initial cause of the heel pain maybe due to something other than abnormal foot mechanics. Unfortunately, there are no tests for identifying these other causes of heel pain. They are generally diagnosed as a matter of exclusion, rather than with direct diagnostic testing.

Hallux valgus or bunion deformities have may different surgical techniques for their correction. One group of procedures that your surgeon may use is the shaft osteotomies. These osteotomies are different from the head osteotomies and also the procedures performed at the base of the metatarsal or at the metatarsocuneiform joint, because they are performed in the middle of the first metatarsal.

The shaft osteotomies were designed to use internal fixation (screws) and to correct larger deformities. In most of these cases, your surgeon will use 2 screws to fixate the osteotomy. The osteotomy is longer than the head procedures and has more inherent stability because of more bone contact. Also these procedures can correct larger deformities then the head procedures and about the same deformities as the base procedures.

There are two basic shaft osteotomy procedures that your doctor may talk to about: The Z bunionectomy or the offset V bunionectomy. These osteotomies are very similar and are used interchangeably, based on different patient characteristics, by most surgeons that perform these procedures. The decision to use these procedures over other procedures is typically surgeon preference. In most cases, these procedures are used for patient with mild to severe structural bunions without hypermobility. In old patients with poor bone stock, the surgeon may opt for other procedures.

What is the post-operative course?

Typically, the patient is allowed to bear weight immediately after surgery in the a surgical shoe. Some doctors may have you use crutches for one to two weeks or use a slipper cast. This is surgeon's preference. It is not unusual for the front part of your foot to look bruised after the surgery. So at the first dressing change, do not be surprised if your toes and the top of your foot are bruised. This will dissipate in 3-6 weeks. At two weeks after surgery, the sutures are typically removed and at three weeks most patients are advanced into a surgical shoe. After the first or second week, your surgeon may have you start range of motion of your big toe joint. It is important that you follow your doctor's instructions on all range of motion exercises to help return motion to the operative foot. As with all surgery on the foot and ankle, the limiting factor to advance into different shoe gear is swelling. This swelling can last up from 6 months to one year after surgery. Typically most patients returned to pre-operative dress shoes in 6 to 8 weeks after surgery.

With any surgery, complications are possible. Every procedure has unique complications and your surgeon will discuss these with you before surgery. Make sure that you ask any questions that you have about the surgery with your surgeon.

The surgical correction of bunions is dependent upon the severity of the deformity, the patient's over-all health and activity level.

There are several different approaches to the surgical correction of bunions. Most commonly, the surgery is performed in the area of the big toe joint. The bony prominence is removed and the bone is surgically fractured to allow realignment of the joint and straightening of the big toe joint. This surgery is designed so that the patient can walk on the foot almost immediately following the procedure; however, activity must be significantly curtailed for several weeks following the surgery. Typically, the patient is instructed to remain home from work for at least one week with the foot propped up and elevated above the heart throughout the day. If the patient's job requires much standing or walking, they may be required to stay home from work for as much as six weeks. Often the patient may return to work sooner if they are placed in a removable below-the-knee walking cast. There are no short cuts to the healing time. Healing time is based upon basic physiological principles that are common to all human beings. Certain vitamins and nutrients may help with the healing process. Laser surgery does not alter the healing time and provides no significant advantage to the performance of the surgery.

Surgical Correction of Severe Bunion Deformity

If the bunion is more severe in nature, surgery is performed further back on the bone in order to straighten the big toe. When surgery is performed in this area of the bone, there is greater instability of the bone after it is cut and moved into a corrected position.

The overall success rate and satisfaction of patients who have had bunion surgery is quite high. The most common complaint of patients is the healing time. This is particularly true if the patient is not adequately prepared or informed as to what to expect. Most patients experience minimal pain following the procedure and this pain is easily controlled with pain medication prescribed by the surgeon.

Possible Complications

Potential complications associated with the surgery are infection, over or under-correction of the bunion, joint stiffness, delays in healing or non healing of the bone, or healing of the bone in the wrong position. Most of these complications can be avoided by following the surgeon's instructions. Walking on the foot without the protection of a post-operative shoe or cast, or against the surgeons advice can lead to a dislocation of the bone where it has been cut. This results in delays in healing, non-healing of the bone or healing of the bone in the wrong position. Allowing the bandage to get wet increases the risk of infection. The most critical time for an infection to occur is within the first three days following surgery. Infection can also occur following this period of time but is less common.

Joint stiffness following bunion surgery is common, but generally improves with time. Postoperative physical therapy is useful to improve the movement of the joint but is not always necessary.

Place of Service and Anesthesia Considerations

Most often the bunion surgery is preformed in an outpatient surgery center or hospital. However, at our office we are fully equiped with our own on-site surgical facilty. We are able to perfrom many procedures at our office. Because of our surgery center we save patients money, time and the frustrations associated with outpatient procedures. 

Anesthesia for the surgery can range from a straight local anesthesia, given by injection into the area of surgery, to a general anesthesia with the administration of an anesthetic gas. A very common form of anesthesia is a combination of a local anesthesia and medicine given intra-venous to make the patient drowsy. This is commonly called twilight anesthesia.

Generally there is very little blood loss during surgery. Most often the surgeon will use some form of tourniquet to stop bleeding during surgery. Because the surgery can be performed in a relatively short period of time the use of a tourniquet is very safe. Technically, the tourniquet can be left in place for as long as 90 minutes safely in most cases. The potential for the need for a blood transfusion with bunion surgery is nearly non-existent.

Can My Bunion Come Back?

It is important to understand that bunion surgery does not correct the cause of the bunion. Therefore there is the possibility that the bunion can reoccur. How quickly a reoccurrence will occur is difficult to predict. It may take several years or just a matter of months for the bunion to begin to come back. Bunions are caused by abnormal movement of a set of joints below the ankle joint in the foot called the subtalar joints. To help prevent the bunion from reoccurring the patient should be prescribed a functional orthotic. These are custom-made shoe inserts that correct the abnormal function of the foot. Generally they will fit in normal shoes without requiring the use of larger shoes.

Bunions and tailor's bunions can be painful foot conditions that interfere with a patients ability to stay active and healthy. Bunions, also called metatarsus primus varus and tailor's bunions, also called a bunionettes can be treated conservatively or with surgery.  The causes of bunions are attributed to genetics, activity level, trauma and or shoe gear.

A recent patient had visited the office with pain resulting from bunions. The paitent suffered from both a bunion and Tailor's bunion. Here are the preoperative x rays.

 

 

 

 

 

 

 

 

 

 

 

 

 

The patient had a bunionectomy and tailor's bunion surgery corrected at our certified surgery center.  The patient was able to avoid the hassle and expense of a hospital, but with all the same comforts.  The patient required only intravenous sedation and was walking within one week after surgery.  The postoperative x rays can be appreciated below. 

 

• The dramatic reduction of forefoot width can be appreciated on the x ray. 

 

 

 

 

 

 

 

 

 

First metatarsal neck osteotomies are known by various names based on the individual who first described the procedure (e.g. Austin, Reverdin-Green, Kalish-Austin). Regardless of the procedure, the goal of all these procedures is the same, to remove the bump and realign the joint. The first part of all bunion procedures involves removing the bump of bone from the side of the 1st metatarsal head. This is performed in a manner so as not to damage the viable part of the joint and not to leave any irregularities of bone that can cause future irritation in shoes. Once this is completed, the podiatric surgeon will create an osteotomy (bone cut) through the first metatarsal that will allow shifting the bone and realigning the joint. Depending on the type of osteotomy, the actual shape of the bone cut can vary. In the case of the Austin bunionectomy, the bone cut is V-shaped with the "V" sitting on its side and the tip of the "V" pointing toward the joint. When this cut is completed, the head of the metatarsal and joint is shifted toward the 2nd toe. In this way the bone and joint are repositioned in a more normal position. The Reverdin-Green osteotomy is made in a similar location but is trapezoidal in shape rather than V-shaped. Both these procedures are stable bone cuts and provide good correction of mild to moderate deformities. The Kalish-Austin bunionectomy is a modification of the Austin bunionectomy. It also is a V-shaped bone cut but is typically used for greater degrees of bunion deformities.

Because bone is cut and repositioned, it is often preferred to fixate or hold the bone in place with some external device. In the case of the Austin and Reverdin-Green osteotomies, this is most often accomplished by the use of a stainless steel pin across the bone cut. This prevents accidental displacement and loss of correction. Over the past 5 years, it has become increasing more advantageous to use small stainless steel or titanium screws to provide compression of the bone and to hold the bone in position. This is the main advantage of the Kalish-Austin bunionectomy. By using the screws, bone will heal faster and will allow for earlier ambulation. The screws are typically left in permanently unless they cause irritation of the soft tissues while the pins are generally removed in the office setting in three to four weeks following the day of surgery. The surgery is generally preformed as an outpatient in a hospital or out patient surgery center. Anesthesia is the choice of the surgeon made in consultation with the patient and anesthesiologist. Anesthesia may be a general anesthesia, twilight anesthesia or a local anesthesia.

Post Operative Care

The postoperative course and rehabilitation following bunion surgery depends on the procedure and can vary amongst podiatric surgeons. Patients have varying levels of postoperative pain but quite often the pain is significantly less than what the patient anticipates. A period of total non-weight bearing with crutches may be recommended in the first 3 to 5 days. In many instances, the surgeon may allow the patient to bear full weight in a postoperative surgical shoe. In all cases patients are instructed to limit their activities and to elevate their feet above their heart during the first 3 to 5 days. After this, a resumption of gradual weight bearing with a special surgical shoe is begun. Walking without the postoperative shoe is strictly prohibited. In cases where a pin is used, return to full weight bearing with a stiff soled walking shoe is allowed after the pin has been removed, generally in 3 to 4 weeks following the bunion surgery. Screws provide increased stability when used to fixate bone cuts and most patients can return to full weight bearing and regular shoes in 3-4 weeks following the surgery. The postoperative and rehabilitative course is improved by the use of ice and elevation of the extremity as much as possible. One of the most important aspects of the postoperative treatment is early motion of the joint to prevent joint stiffness. In most cases, range of motion exercises are begun almost immediately following surgery. No matter what the form of bone fixation is used, pins or screws; bone healing will take 6 to 8 weeks or longer. During this period of time it is important that the patient not walk without shoes or in thin-soled shoes or sandals. Should the patient risk walking without an adequately supportive shoe, they risk re-fracturing the bone and increase the duration of healing.

Possible Complications

Complications following bunion surgery are uncommon but may include infection, suture reaction, delayed or nonunion of the osteotomy, irritation from the pin or screws, stiff joint or recurrence of the deformity. Recurrence of the deformity can be halted or slowed with the use of functional foot orthotics. It is important to realize that surgery does not correct the cause of the bunion deformity. Functional foot orthotics however do address the cause of the deformity and their use are strongly encouraged following bunion surgery. A rare complication is the over correction of the bunion deformity. This condition, called Hallux Varus, may require additional surgery for its correction

This article should serve as a guideline for patients who are contemplating bunion surgery. The most commonly performed procedures for treatment of bunions have been discussed here. Procedures are selected based on surgeon's experience and preference. Patients are encouraged to discuss the surgery, the postoperative course and possible complications with their podiatric surgeon openly before consenting to surgical intervention.

Glossary of Terms
Bunion	Bump on the side of the foot at the base of the great toe
Bursitis	An inflammation of a fluid sac often found overlying a bunion
Fixation	Act of holding bones together, commonly require external devices such as pins, screws or plates
Hallux abductovalgus (HAV)	Medical term describing the deviation of the great toe toward the 2nd toe; common component of bunions
Metatarsal	A long bone of the foot that forms the ball of the foot
Orthoses	Devices made from a mold of the foot used to control abnormal motion of the foot; may be prescribed to prevent progression of bunion deformity or reoccurance following bunion surgery
Osteotomy	Surgical procedure that creates a cut in a bone to achieve realignment; a "surgical fracture"
Pronation	Motion of the foot which when excessive results in flattening of the arch; one possible cause of bunion formation
Toe box	Part of the shoe that covers the toes

About the Authors:
Kenneth W. Oglesby, D.P.M., Second-year podiatric surgical resident, Beth Israel Deaconess Medical Center, Boston, Mass.
John M. Giurini, D.P.M., Chief, Division of Podiatry, Beth Israel Deaconess Medical Center, Boston, Mass., Assistant Clinical Professor of surgery, Harvard Medical School, Boston, Mass.

Bone spurs of the toes most commonly occur on the fifth toe. They occur less frequently on the other toes. The areas of the fifth toe that can form bone spurs are the outside of the toe next to the toenail, the inside of the toe near the tip of the toe where the toe presses up against the fourth toe, and on the inside of the base of the fifth toe. When the spur is at the base of the fifth toe, it is often associated with a soft corn between the fourth and fifth toes (See surgical correction of soft corns). Bone spurs can also occur on the side of any toe. Bone spurs in the toes are associated with excessive pressure of the toes pressing on one another while wearing shoes.

Surgical Procedure

Surgical correction consists of making a small incision near the spur and smoothing the bone with a rasp or power burr. Quite often, this can be accomplished thru an incision small enough to require a single stitch. When the spur is adjacent to the toenail, a small section of the toenail may also be removed. On occasion, the spurring on the fifth toe may be associated with a mild, flexible contracture or curving of the toe. When this is the case, an additional incision may be required to release the tendon in the bottom of the fifth toe.

If the spur is at the base of the fifth toe and associated with a soft corn, a different surgical procedure is performed (See surgical correction of soft corns). A small bandage is placed over the surgical site. Sometimes a Band-Aid may be used. Quite often, the patient will be given a post-operative shoe to wear until they can comfortably get into a normal shoe. The stitches stay in place for seven to ten days. During this time, the area should be kept dry to help prevent infection. Frequently, the surgeon will allow the patients to change their own bandage on a daily basis. The day of surgery, the patient should significantly limit their activity to reduce the risk of bleeding.

What to Expect Following the Surgery

It usually takes a few weeks for the surgical site to completely heal, and activities should be limited or kept within normal reason during this period of time. "If the activity hurts, don't do it." The time required to be off from work will depend upon the demands of the job and the type of shoe that must be worn at work. If the patient's work is relatively sedentary, and they can return to work in a post-operative shoe, then they can generally return to work the day following surgery. If work requires standing or walking long hours, or requires work boots or sung fitting dress shoes, time off from work may be ten to fourteen days or more.

Possible Complications

Relatively few complications are associated with this type of surgery. Infection or reoccurrence of the bone spur can occur. If the patient is too active during the healing period, delays in healing can occur.

New treatment for plantar fasciitis: Dry needling combined with a cortisone injection, guided ultrasound imaging-the alternative to plantar fasciitis surgery. Researchers state that this approach has a 95% success rate. They also state that the ultrasound guidance makes the procedure very safe. They recommend the procedure combined with orthotic treatment and advised that 42/44 of their study patients were cured of their symptoms within 2-3 weeks of treatment. The dry needling technique allows for increased blood flow to the symptomatic plantar fascia region. This helps it heal faster. Traditionally structures like the plantar fascia, tendons and ligaments do not have a lot of blood flow, so they tend to heal slowly. The premise behind this is quite similar to the APC percutaneous growth factor procedure that we also utilize. One difference is that this new procedure is much less costly and can be done right in our exam rooms with local anesthetic.

Our doctors have been safely performing ultrasound-guided cortisone injections for plantar fasciitis for several years. This approach has been successful when combined with other types of treatment such as prescription orthotics. We now offer this new technique at our clinic with the dry needling technique combined with a cortisone injection and we further recommend that the foot be in a protective medical boot for 3 weeks following the procedure.

What to expect
At Issaquah Foot and Ankle Specialists, we have developed a treatment protocol and have fine tuned the technique for dry needling for plantar fasciitis. In addition, we have developed adjunctive treatments that help further ensure that chronic plantar fasciitis is resolved. Dr. Young has personally communicated with Dr. Lucia Sconfienza by e-mail soon after the results were first presented. He discussed details of the procedure to make certain that we were able to provide our patients with the best possible treatment and outcome.

 

Who is a candidate for dry needling
Those individuals who have already tried other means of treatment for plantar fasciitis including but not limited to prescription orthotics, excellent shoes, a night splint, cortisone injections, taping and bracing.

Diagnostic ultrasound imaging typically will show enlargement of the plantar fascia in those individuals with severe plantar fasciitis. The typical thickness of the plantar fascia at the heel is anywhere from 3 to 4 mm thick maximum.  Those individuals with chronic plantar fasciitis typically will be anywhere from 20% to even 100% thicker than normal. This means that the fascia can be 5 mm to 8 mm thick (even up to 10 mm in some severe cases). If an individual does not have significant swelling (edema) of the plantar fascia, then the prognosis for improvement with dry needling and many of the other traditional plantar fasciitis treatments tend to be less effective. In general, it is a severe case without swelling of the fascia and there are other significant causes of the heel pain instead of plantar fasciitis. 

 

Dry needling description

First, we utilize our electrical stimulation in conjunction with the local anesthetic to help minimize discomfort.  After the local anesthetic has fully taken effect, the procedure is done with no discomfort whatsoever.

High-resolution ultrasound guidance is used to direct the procedure, which allows for the precise finding of the exact location. A needle and syringe is used to repeatedly probe the fascia throughout the thickest portion at the calcaneal attachment site.  This probing can go all the way down to the attachment and periosteum (outer layer bone). Once this has been done for the prescribed time frame, then we typically utilize a combination of Kenalog and dexamethasone phosphate at the interface between the plantar fascia in the plantar fat pad. This is another example of where the ultrasound guidance is essential. Using this technique, we can make certain that the cortisone is not injected into the plantar fascia itself or the plantar fat pad. Injecting into the plantar fascia would raise the risk of a partial tear or rupture of the plantar fascia. In addition, injecting into the plantar fat pad can cause long-term thinning (atrophy) of the fat pad.

 

New treatment variations on this technique 
This is where instead of using cortisone, we use autogenous platelet rich plasma with growth factor. It is also possible to do this procedure without using any cortisone.

 

Frequently ask questions
Is it safe?
Yes, dry needling is very safe.  There are few risks associated with the procedure and these risks are minimal compared to surgical risks.  A patient may experience an allergic reaction from the anesthesia and they do run a small risk of post-injection infection.  Some patients may have pain for a few days following the procedure as well. 

Is there any pain with the procedure?
No, a patient shouldn't experience any pain during the procedure.  We use a local anesthetic to numb the foot as well as electrical stimulation with our TENS unit to make sure the procedure is pain-free. 

How long have you been doing dry needling? 
Our clinic started providing the service in December of 2008. Our clinic has been providing high-resolution ultrasound guided injections for over 5 years.

Does my insurance cover this procedure? 
We accept many different insurance plans at our office.  This is something that our billing staff can help you with.

 

Post-procedure treatment protocol essentials:

• Avoid anti-inflammatory medication and icing
• Use a cast boot.  This is done to protect the soft tissue in the heel as it now starts the healing process.
• Allow for bruising and inflammation.  When you tear or sprain a tendon or ligaments, there is deep internal swelling or bruising that occurs due to the need to protect the tissue which allows for soft tissue healing phases to occur. The same should occur with this procedure.

 

What else can be done to help make sure this is effective:

• Use a night splint every night for the first 2-3 months.
• Prescription orthotics that are specific to your problem and to plantar fasciitis. You want to treat the mechanics that caused the problem to begin with.
• Electrical stimulation may be beneficial to the post-procedure healing time frame.

 

Contact us today for an appointment or to learn more.