There are several different causes of lumps and bumps on the top of the toes and foot. Working from the toes back these are:

1. Muco-Cutaneious Cyst

Small nodular single mass that can form on the top of the toe is called the Muco-Cutaneious Cyst. These occur most frequently at the joint just behind the toenail. These are caused by a weakening of the joint capsule, which allows a swelling to occur. They are firm and rubbery to the touch. Sometimes as the skin thins due to the stretching pressure of the mass it will appear translucent. When the mass is broken or punctured, a thick clear fluid will leak out. If the mass does break open, the area should be kept clean and free of infection. Once the skin heals the mass will reappear.

2. Treatment of Muco-Cutaneious Cysts

Treatment consists of surgical excision. This can be performed in the doctor's office under a local anesthesia or in an out patient surgery center. The procedure is relatively simple but can pose a problem for the surgeon, as closure of the skin following removal of the mass can be difficult. Often the surgeon will have to create a skin flap to rotate over the hole where the mass was removed. This requires a bit more of an incision than most patients expect. The foot is bandaged in a dry sterile dressing and the sutures remain in place from 7 to 10 days. The area must be kept dry during this period of time and a limitation of activity is advised. Complications associated with the surgery are infection, delays in healing associated with difficulty in surgically closing the wound or excessive activity which can lead to swelling and recurrence of the mass. Draining the mass as a form of treatment is not advised unless the patient is made aware of the likely recurrence. Picking the area open at home or attempting to drain it at home is discouraged. An infection in the area could cause permanent joint damage or bone infection.

3. Hammertoe Deformity

Another prominence on the top of the toes is caused by hammertoe deformity. As the hammertoe forms, the toe cocks up and the joint in the middle of the toe becomes prominent. As the toe rubs on the top of the shoe a callus will form. Treatment consists of padding to reduce pressure or surgical straightening of the toe (See surgical correction of hammertoe).

4. Hallux Limitus

A lump can be found just behind the toe at the joint where the toe attaches to the foot. This is due to a prominence of the head of the metatarsal bone. It indicates that there is an alignment problem with the bones in the ball of the foot. The area may or may not cause a problem. If the lump is behind the big toe joint, it is a sign of a progressive arthritis of the joint. The condition is called Hallux limitus or degenerative arthritis. Treatment consists of orthotics to improve the function of the joint and/or surgical correction. (See surgical correction of hallux limitus).

5. Metatarsal-Cuniform Exostosis, Ganglion

Further up on top of the foot a bony prominence can form. This occurs near the middle of the foot and is due to the formation of bone spurs in the area. Jamming of two bones can over time, cause the spurring. The condition is named after the bones involved and is termed metatarsal –cuniform exostosis. On occasion, as the spurring forms, a weakening of the joint capsule occurs and a ganglion will form. A ganglion is a soft, rubbery mass, which slowly enlarges. Often the ganglion will form without a spur forming first. Treatment consists of padding the area to reduce the pressure from shoes or surgical removal of the bone spur and ganglion if present (See surgical correction of Metatarsal-cuniform exostosis).

6. Other

Yet another area that can demonstrate a lump or bump on the top of the foot is an area just below the ankle on the outside of the foot. Normally there is a small fleshy area. This is the only muscle on the top of the foot called the Extensor digatorum brevis muscle. Some people have a larger muscle than others and the area may appear enlarged. The area may also enlarge if a lipoma or ganglion forms in this area. A MRI is a useful test to determine if a lipoma or ganglion is present. No treatment is recommended if there is no pain associated with the area.

There are a few causes of lumps, bumps or prominence on the outside of the foot. Some of these are just normal anatomy; others are due to abnormal processes. Starting from the fifth toe and working back to the heel:

A common prominence on the fifth toe is due to the formation of a hammertoe. A hammertoe is a structural deformity of the fifth toe causing the joint in the toe to become propionate. Pressure from shoes will cause a thickening of the skin. On occasion, this can become very painful making it difficult to wear a closed shoe. Treatment consists of trimming the thick skin or padding the area to reduce the pressure from the shoe. At times surgical strengthening of the toe is necessary (See hammertoe surgery).

Just behind the fifth toe, at the joint where the toe connects to the foot, a prominence can develop. This is called a Tailors bunion. It is caused by the abnormal function of the foot and can be slowly progressive. Some people naturally have an enlargement in this area. Shoe pressure can make the area painful and at times cause a bursa to form. A bursa is a sack of inflamed tissue that occurs over a bony prominence in response to excessive pressure or friction. The bursa is spongy to the touch and can be very painful. The bursa can be treated with cortisone injections to reduce the swelling and inflammation. Padding the area is also useful to reduce the pressure from the shoes. Selecting the correct shoe can also be helpful (See selecting the appropriate shoe). Surgical correction of the tailor's bunion is a common procedure to reduce the prominence and the pain associated with it (See Tailors bunion surgery). A rare occurrence of gout can also occur in this area. This condition usually presents with a sudden onset of pain and swelling in the area.

Further down, along the side of the foot another bony prominence can observed. This area is the base of the long bone (metatarsal bone) behind the fifth toe called the styloid process of the fifth metatarsal. In children this area has the growth plate to the bone. Injury to the area can cause the area to become enlarged. X-rays will show an open growth plate until the age of 12 - 14. If there has been an injury to this area in a child with an open growth plate, caution must be taken because of the possibility of injury to the growth plate. A very powerful tendon also attaches into this area of the bone. In the event of an ankle sprain this area can become injured as a result of the tendon attempting to prevent the foot from twisting. Pain to the touch at this site indicates either tendon or bone injury, and an x-ray should be taken. A fracture can occur in this area, and if it is displaced or out of alignment then surgery may be required to repair the bone. If the fracture is in good alignment or if the area is just sprained, then a below the knee cast should be applied. It may take six weeks for this injury to heal.

Some people have a natural enlargement of this area. When painful, padding the area to reduce shoe pressure is useful and selecting the correct shoe is also helpful. Rare instances of gout can also occur in this area.

Just behind the area of the styloid and a bit over to the top of the foot there is a spongy, soft area of the foot. This area represents the extensor digatorum muscle. This is the only muscle present on the top of the foot. In some people it can be quite large. Fatty deposits can also occur about the muscle making the area appear larger. On occasion, a ganglion may form. In this instance, the area may enlarge and then shirk and then enlarge again. A MRI is the most useful test to determine if a ganglion is present. If the area is not painful, no treatment is required. If the area is painful and a ganglion has been identified, then treatment might consist of draining the fluid from the ganglion with a needle or surgically removing the ganglion.

Small, soft lumps can be observed around the fat pad of the heel when a person stands. These small, soft bumps are usually found in groups. They are called Piezogenic papules and represent herniations of fat from the heel fat pad. They are rarely painful and no treatment is necessary. Removal of the pziogenic papules should be discouraged. There is no adequate treatment for their removal, and surgery to the area will only make the condition worse.

Another lump seen on the side of the heel is called an inclusion cyst. This lump appears as an elevated, soft mass which is often callused on is surface. These are caused by minor puncture wounds or from prolonged pressure or friction to the area by shoe gear. Surgical excision is often recommended. Padding the area to reduce friction may be of some temporary benefit in painful situations.

Other less common lumps and bumps that can appear on the outside of the foot are lipomas, fibromas, and giant cell tumors. These are non-cancerous tumors that tend to slowly enlarge and have a spongy like consistency. They only present a medical problem if they interfere with the function of a tendon, press excessively on a nearby nerve or cause pain secondary to shoe pressure. Malignant tumors of the foot are exceedingly rare.

There are many different causes of lumps and bumps on the inside of the foot. Starting from the big toe and working back to the heel:

A swelling along the margin of the big toenail is likely to be due to the formation of an ingrown toenail. At times this swelling can produce open, weeping flesh. Treatment consists of removing the ingrown toenail (See treatment for ingrown toenails).

A swelling often associated with a hard, callused area may form on the side of the big toe. This is due to an enlargement of the bone in this area. It is usually associated with a deviation at the joint in the big toe. Treatment consists of using a functional foot orthotic to redirect the pressure from the area. Surgical removal of the underlying bony prominence or surgical straightening of the toe may be recommended. People who have diabetes must watch this area because over time the excessive pressure to the area from walking can cause the skin beneath the callused area to break down forming an ulceration that can become infected. Left untreated, the bone can become infected and in severe cases amputation of the toe may be necessary.

Another area on the big toe, which can demonstrate a lump or bump, is the top outside portion of the toe at the level of the joint in the toe. This is usually seen in association with a contracture of the big toe making the joint more prominent. This prominence can become irritated due to shoe pressure. The condition is called a Hallux hammertoe. The word Hallux is the medical term for the big toe. If the deformity is flexible and the toe can be manually straightened, the condition can be corrected by a simple surgery that releases the tendon in the bottom of the toe. If the condition is rigid and the toe cannot be manually straightened, then a fusion of the joint may be necessary (See surgical correction of hallux hammertoe). Treatment should also include determining what caused the condition. Quite often it is due to some underlying functional problem in the foot and treatment of this condition with a functional foot orthotic should be considered. Other causes of a hallux hammertoe are previous surgery in the area, nerve damage or a neurological condition.

A painful lump may also be found on the bottom of the big toe. This condition often presents as a hard callused area. Sometimes a hard lump may be felt beneath the callused area. The most common cause of this condition is a limitation of movement at the big toe joint while walking. If there is limitation of movement at this joint, then the big toe cannot bend upward as the heel comes off the ground while walking. As a consequence, there is excessive force placed on the bottom of the big toe and an enlargement of the bone in this area will occur secondary to the pressure. Another cause is the presence of an extra bone or piece of cartilage in the area. However, it is the limitation of movement in the big toe joint that causes the area to become enlarged and painful. People who have diabetes must watch these areas closely. Over time, the excessive pressure can cause this area to break down and ulcerate. As in the previous condition this can lead to infection and possible amputation. One way to check to see if there is a limitation of movement of the big toe joint is to perform the following test. While standing on a flat surface have another person try to bend the big toe upward. The joint that must move is the joint where the toe attaches to the foot. There is a joint in the middle of the big toe and this is not the one you are checking. If the big toe joint cannot be bent upward then a limitation of motion exists. Testing the movement at the joint without putting weight on the foot will give a false impression as to the available movement at the joint while you are walking. The limitation of movement of the big toe while walking can, over time create an arthritic condition in the joint. A bony mass may then form on the top of this joint as a result of jamming in the joint. This condition is called hallux limitus or hallux rigidus. Treatment for the painful lesion in the bottom of the big toe joint consists of using functional foot orthosis to correct the functional limitation of the big toe joint motion or may consist of surgical correction of the hallux limitus. Rarely is surgery to remove only the lesion on the bottom of the toe alone successful, because the cause of the initial problem still exists.

Yet another area of bony prominence about the big toe joint is on the outside of the joint. The most common cause of this condition is called hallux abductovalgus or bunion. This is a common condition associated with deviation of the big toe towards the second toe. Treatment consists of padding the area to reduce shoe pressure, bigger shoes, orthotics and surgery (See surgical correction of bunion deformity). A sudden onset of pain in the area with or without a bunion may be due to gout. Gout is a metabolic condition that results in an elevation of the uric acid in the blood stream. Once the uric acid level reaches a certain point it will crystallize and leave the blood stream and deposit itself in a joint or other soft tissue location. Gout rarely occurs in women until after menopause or if they have had a hysterectomy. A sudden onset of pain in this area in women is usually associated with the formation of a bursa secondary to wearing a tight shoe. Treatment consists of wearing looser fitting shoes and taking an oral anti-inflammatory medication. Occasionally, a cortisone injection may be advised.

Moving back towards the heel, another area of a common lump or bump is just in front of the weight-bearing portion of the heel. This prominence is usually a hard bony mass that protrudes outward. It is due to a bony enlargement of the Navicular bone. Some people have a natural enlargement in this area while other people have an extra bone in this area. This condition is often referred to as Os Navicularis. This condition is often associated with a flat foot deformity. A very powerful tendon from a muscle in the leg called the posterior tibial tendon partially attaches into this area. If the navicular bone is naturally enlarged or there is a second bone present then the tendon dose not function properly and cannot support the arch of the foot adequately. Over time, this will cause a weakening of the tendon causing an entire collapse of the arch of the foot. This condition called Posterior Tibial Tendon Dysfunction is a very serious condition that should be treated promptly and aggressively. The bony prominence of the navicular bone may cause secondary pressure in shoes resulting in pain. Treatment of the prominence of the navicular bone consists of padding to reduce shoe pressure, functional foot orthosis to treat the associated flat foot deformity and the possible onset of posterior tibial tendon dysfunction, or surgery. Following any surgical intervention in this area, the patient should be placed in a functional foot orthosis. The surgical removal of the bony prominence does not correct a flat foot or prevent the occurrence of posterior tibial tendon dysfunction.

There are a number of different causes of lumps and bumps on the bottom of the foot. Working from the toes to the heel:

1. Lumps and Bumps on the Bottom of the Big Toe

A painful lump may be found on the bottom of the big toe. This condition often presents itself as a hard callused area. Sometimes a hard lump may be felt beneath the callused area. The most common cause of this condition is a limitation of movement of the big toe joint while walking. If there is limitation of movement at this joint, then the big toe cannot bend upward as the heel comes off the ground while walking. As a consequence, there is excessive force placed on the bottom of the big toe and an enlargement of the bone in this area will occur secondary to the pressure. Another cause is the presence of an extra bone or piece of cartilage in the area. However, it is the limitation of movement in the big toe joint that causes the area to become enlarged and painful.

People who have diabetes must watch these areas closely. Over time, the excessive pressure can cause this area to break down and ulcerate. One way to check to see if there is a limitation of movement of the big toe joint is to perform the following test. While standing on a flat surface, have another person try to bend the big toe upward. The joint that must move is the joint where the toe attaches to the foot. There is a joint in the middle of the big toe and this is not the one you are checking. If the big toe joint cannot be bent upward then a limitation of motion exists. Testing the movement at the joint without putting weight on the foot will give a false impression as to the available movement at the joint while you are walking. This limitation of movement of the big toe while walking can, over, time create an arthritic condition in the joint. A bony mass may then form on the top of this joint as a result of jamming in the joint. This condition is called hallux limitus or hallux rigidus. Treatment for the painful lesion in the bottom of the big toe joint consists of using functional foot orthosis to correct the functional limitation of the big toe joint motion or may consist of surgical correction of the hallux limitus. Rarely is surgery to remove only the lesion on the bottom of the toe alone, successful, because the cause of the initial problem still exists.

2. Lumps and Bumps in the Ball of the Foot

Painful lumps in the ball of the foot are usually but not always associated with a thickening of the skin or callus. These areas are due to a prominence of the long bone behind the toe called the metatarsal bone. When there is a mal-alignment of these bones, one or more of them may become propionate. When this occurs, the weight-bearing force across the bottom of the foot is disturbed. Weight is not evenly distributed across the ball of the foot, and these areas absorb greater pressure. The excessive pressure often forms a callus or thickening of the skin. People who have diabetes should watch these areas carefully. Over time, they can ulcerate the skin and can become infected. Treatment consists of removing the pressure with pads or using a molded insole or orthotic in the shoes.

Other skin lesions that frequently occur on the bottom of the foot are plantar warts, porokeratoses, and inclusion cysts.

3. Lumps and Bumps in the Arch of the Foot- Plantar Fibromas

Within the arch of the foot, firm, nodular masses may form. These can occur as a single mass or in clusters. They are called plantar fibromas and are a non-cancerous tumor that forms within a ligament in the arch of the foot called the plantar fascia. Frequently, they will slowly enlarge causing pain while walking. Their cause cannot always be determined. Damage to the tendon will cause their occurrence and there is an association with taking the drug Dilantin. In 10% of the cases, patients will also demonstrate similar lumps in the palms of the hands called Dupuytren's Contracture. Treatment consists of padding the area to reduce pressure. Functional foot orthotics will take the strain off of the plantar fascia ligament and sometimes cause the fibromas to shrink in size. Cortisone injections are of little value and may even stimulate the mass to enlarge or spread. Surgical excision of the mass requires removal of most of the plantar fascia. Simple excision of the mass without removal of the entire ligament generally results in recurrence of the mass. Whenever surgery is contemplated, the patient should wear a functional foot orthotic following the surgery. The orthotic helps to accommodate for the loss of the plantar fascia and its effect on foot function (See surgical excision of plantar fibromas).

The Lis Franc,s joint is a combination of joints in the middle of the foot. At the point where the long bones behind the toes, called metatarsals, connect with a grouping of small cube shaped bones, called cuniform bones, there are several joints the move together in an interlocking fashion. This grouping of interlocking joints is referred to as the Lis Franc's joint. The Lis Franc’s joint are bound together by a series of transverse ligaments on the top and bottom of the joint, as well as an intermetatarsal ligament. This grouping of joints is clinically called the tarsometatarsal joints. Fracture-dislocations of the tarsometatarsal joint are named for Lis Franc who was a field surgeon in the Napoleonic army. Fracture-dislocations of the tarsometatarsal joint (Lis Franc's) is extremely significant in that it is a commonly missed diagnoses with a great potential for long term disability.

Lis Franc's fracture-dislocations can occur in many different ways. It can be caused by both a direct crushing type injury or a force applied to the metatarsal heads (ball of the foot) which both can result in displacement of the Lis Franc's joint or fractures that in involve the joint. Common causes are motor vehicle accidents, falls from heights, severe foot and ankle sprains, crushing force to the top of the foot. These injuries can occur during strenuous and competitive athletic activities. The athlete who complains of sudden onset of pain, in the middle of the foot during the course of an athletic event should be carefully evaluated for a possible Lis Franc's injury.

Diagnosis

Diagnosis is extremely important following the injury. Early diagnosis and treatment can prevent long-term chronic pain and other sequalae. Diagnosis is made by both clinical and X-ray modalities. On physical examination there is marked tenderness across the tarsometatarsal joint usually with pinpoint tenderness at the articulation of the second metatarsal base and the medial and intermediate cuneiforms. Global forefoot and midfoot swelling is commonly seen from several minutes to several hours following injury. In severe dislocations it is very easy to visualize a change in shape of the foot as compared to the other foot. X-rays may reveal either a partial or total dislocation at the tarsometatarsal joint. The difficult cases to diagnosis are those when the joint dislocates and then relocates on it’s own. When this occurs there may be little evidence of the injury on an x-ray. If there are no X-ray changes and clinical diagnosis makes the doctor suspicious of injury they may order stress X-ray, bone scan, CT scan or MRI. In all acute injuries circulation must be monitored to assess the possibility of compartment syndrome (increase in pressures within the foot which can shut off circulation). This could result in loss of oxygen to the tissues, which might result in loss of the foot.

Treatment

Closed reduction should always be attempted in an acute fracture-dislocation. Treatment involves general anesthesia to relax the patient and an attempted reduction of the second metatarsal base into its anatomic position is attempted. If the second metatarsal can be reduced then metatarsals two through five may reduce without much manipulation. If closed reduction is successful then reduction of the first metatarsal cuneiform joint is performed and pins are inserted to allow for stability during healing. If closed reduction fails it is usually due to one of the foot tendons, which may be caught in the dislocated joint. If closed reduction fails in an acute injury or the injury is old then open reduction must be performed to reduce long-term problems. If vascular compromise is evident this also constitutes a need for immediate surgery. There are usually two to three incisions placed on the top of the foot to allow for adequate visualization and manipulation of the bones. Once the foot has been placed back into anatomic position the tarsometatarsal joint is stabilized with either pins or screws to allow for stability during the healing process. If pins are used they are usually removed in six to eight weeks. Whether pins or screws are used doesn’t really matter as the patient is non-weight bearing for six weeks and is usually casted for at least eight to twelve weeks. Following bony healing and return to ambulation the patient will need a good functional foot orthotic to provide support and relieve stress from the tarsometatarsal joints and assist in pain free ambulation. Long-term prognosis for this injury is guarded. When any injury involves a joint the likelihood of an on-going arthritic process is likely. In sever cases fusion of the joints may be necessary. In the athlete this injury can be devastating. Rehabilitation to return to the same level of performance can takes several months or longer.

Professor Gavriil Abramovich Ilizarov graduated from medical school in the Soviet Union in 1943, near the end of World War II. After graduation, he was assigned to practice in Kurgan, a small town in western Siberia. He was the only physician within hundreds of miles and had little in the way of supplies and medicine. Faced with numerous cases of bone deformities and trauma victims due to the war, Professor Ilizarov used the equipment at hand to treat his patients. Through trial and error, with handmade equipment, this self-taught orthopedic surgeon created the magical combination that would cause the bones to grow again, similar to the adolescent growth state. Thus the Ilizarov technique was created.

For almost 45 years, Ilizarov and his co-workers have been perfecting their apparatus and helping individuals with severe orthopedic abnormalities. Reports of dwarfs made taller, and birth defects corrected were first observed in Italy, and then presented in the United States where Professor Ilizarov's technique met initial skepticism.

Today, Professor Ilizarov's methods are an acceptable means of correction of severe orthopedic deformities. Limb correction is a gradual process, which lengthens and straightens bone and soft tissue so a limb can function as normally as possible. There are many reasons why a person may be a candidate for limb correction. For many patients, the procedure is used to straighten or lengthen a bone. Others have a need because of a trauma, which has caused highly fragmented breaks, bone loss, or to encourage a bone which isn't healing.

How the Procedure Works

This method takes advantage of the body's remarkable ability to grow new bone tissue. It involves the surgical application of a circular metal frame called the Ilizarov fixator. Fixator rings are attached to each segment of the original bone through pins and wires, which hold each bone segment in place while new tissue is growing and maturing.

There are two main phases to the correction process: correction/lengthening and consolidation. The lengthening phase is the time needed to gradually achieve the desired correction/length of the limb. The consolidation phase is needed for the new bone tissue to harden and mature. Each individual's body is different, but the total time of wearing the fixator is typically 4-12 months.

Lengthening refers to the period of time it takes to "grow the bone." The lengthening phase begins after the surgeon cuts the bone and attaches the fixator. During this time the patient will be working with the physician and the physical therapist to make gradual adjustments to the fixator which increase the gap between the bone segments, adding "length" to the total limb. Over a period of months, new bone tissue will grow in the gap, ultimately hardening the area between the segment of the original bone.

When the physician is satisfied with the length and position of the new bone, the consolidation phase begins. During this phase, the bone tissue matures and becomes solid. The patient still wears the fixator, but no adjustments are made. The consolidation phase is the longest part of the Ilizarov process. It takes twice as long for bone to harden as to does to lengthen it, so the consolidation phase typically doubles the time spent in the lengthening phase.

Post Operative Course

During the lengthening phase, the patient will be seen by the physician every few weeks to monitor the progression of correction of the deformity. On each visit, X-rays are taken to monitor the progress of the lengthening and to assess the quality of the new bone. Office visits may range from thirty minutes to two hours, depending on what work needs to be done.

If a limb lengthening procedure is being performed, the patient will be required to assist in the process by making fixator adjustments at home. This is usually done every six hours. The physician will make sure that the patient is fully trained and understands how to make adjustments if need.

At times, some patients experience some failure of the mechanics of the fixator. The patient may have broken wires, bent rods, or be unable to turn one of the "clickers". Through proper education of the physician and the patient, these problems can be solved without permanent sequela.

 

Other Uses of the Ilizarov Technique

Limb lengthening are not the only procedures that can be used with the Ilizarov frame. Ankle fusions, triple arthrodesis, midfoot fusions, etc. can be performed without prolonged cast immobilization and non-weight bearing. In most cases, partial to full weight bearing is suggested to encourage functional capabilities and healing.

Charcot reconstruction of the ankle or rearfoot is a prime example in which a fusion procedure can be performed with the patient full weight bearing on the involved extremity almost immediately. This diminishes the stress that is placed on the opposite extremity, which is prone to trauma due to increased stress of the uninvolved side.

Conclusion

The patient attitude throughout the Ilizarov process is very important to its success. The patient will have to find ways to cope with discomfort, pain, and frustration, plus the natural ups and downs of emotions during this long process. Knowledge of the process prior to surgery ensures proper patient compliance and minimal pain. Each individual experiences pain differently, so it is difficult to talk about norms when performing this type of surgery.

Kohler's Disease is a spontaneous loss of blood supply to a bone in the foot called the Navicular bone. Dr. Kohler described it in 1908. The spontaneous loss of blood supply to a bone is called osteochondrosis. In later years Dr. Kohler was also associated with another osteochondrosis of the foot known as Freiberg's disease. Some texts refer to this condition as Kohler's II.

Clinical features and Treatment

Clinically, the presentation of Kohler's disease may be an incidental x-ray finding. Often, however, localized pain or a painful gait is noted. Occasionally mild swelling is seen. It is seen most commonly in males and most cases only affect one foot. Biopsy of the bone to make the diagnosis is not necessary.

Complete recovery is almost always the rule; therefore, treatment efforts should be conservative. Cast immobilization provides satisfactory results. Reduced activities and foot orthotics (inserts for the shoes) have also proved effective. Most cases respond within 8 months. Follow-up studies after 30 years have shown no residual degenerative changes in spite of severe fragmentation and flattening of the navicular bone. It is interesting to note that Kohler's disease has been reported to be associated with "Tarsal Coalition" in this area. So it is important that proper follow-up be done.

This article was adapted from the text book Foot and Ankle Disorders in Children edited by Dr. Steven DeValentine.

Our Issaquah clinic is kid friendly! We see a large number of children from the Seattle area and beyond. There are a variety of problems that can affect their feet.

Arch Problems and Walking Problems

Many children start life off with low arches. We all start out life with quite a bit of "baby fat." It's surprising, but this is even in the foot and especially the instep. This makes it difficult to tell if the young child has a normal arch or not. The problem is, that sometimes they don't have a normal arch. Even in these cases, sometimes the parents are told that they will outgrow this low arch or flatfoot. However, many children do not outgrow these problems and they become lifelong challenges. We evaluate and treat a number of these different arch and walking concerns.

Heel Pain

Many of our pediatric patients have pain in their heels. This makes it difficult to do the sports they like. We have developed treatments that can eliminate this heel pain rapidly. A common cause of this heel pain is irritation to the growth plate in the heel bone (calcaneal apophysitisor Sever's Disease). Other possible causes include Achilles tendonitis and plantar fasciitis.

Growing Pains

Children may complain of pain in their legs during or after activity or sports. Often, this is not really growing pains but rather leg muscle pain and fatigue. These muscles support and control foot function. In adults these can be part of the shinsplint syndrome. Children can get a variation of this. Our clinic has very effective treatments for this condition.

Children's Sports Injuries

We also see and treat foot and ankle injuries. So many kids are doing multiple sports. This is great exercise, but it does put an extra work load on the legs and feet. This can cause problems and injuries ranging from a simple sprain or tendonitis to a fracture that is either a typical fracture or a growth plate type of injury to the bone. Each sport seems to require slightly different treatment considerations. Some of these different sports include soccer, football, basketball, lacrosse, baseball, gymnastics, dance and ballet, track and field, martial arts and volleyball.

Plantar Warts

These are warts on the bottom of the feet. Compared to adults, children are often barefoot, which makes them more vulnerable to these plantar warts. The virus that causes these warts only live in human skin and they can be contagious. These warts can be painful and often are much deeper than expected. What you see on the skin is often just "the tip of the iceberg." Many medical clinics treat all warts with a liquid nitrogen freezing technique; this is often very painful and causes many children to be apprehensive about treatment for plantar warts. However, we have found a number of treatments that are very effective and often do not have any associated pain. Our office has become a treatment center for resistant plantar warts. We work with many of the local pediatricians and family practice clinics to treat these problems.

Ingrown Toenails

Adolescent boys in particular get ingrown toenails. They are growing so fast that their shoes can become snug fitting before they get replaced. This shoe pressure is often a causative factor in ingrown toenails.

For children, we use a combination of topical anesthetic -- ethyl chloride (cold spray), and gentle electrical stimulation. The patient controls electrical stimulation themselves to help keep the nerves "busy." Then, the local anesthetic injection is administered. Our younger patients benefit from this special technique. They are often very apprehensive about an injection, but with our techniques, the patient and their parents are usually pleasantly surprised at how well they do.

Pain or discomfort in the great toe joint is a common occurrence amongst people seeking podiatric treatment. There are numerous reasons why people may experience pain or discomfort in this region. Pain in this area may be due to a restriction of motion, a condition referred to as hallux limitus or rigidus. This condition can lead to jamming of the joint and potential degenerative joint disease or arthritis. Ironically, this will lead to even further stiffening of the joint and pain with walking. Bunions or hallux abductovalgus deformities can also cause pain in the great toe joint. After years of this abnormal alignment of the joint arthritic changes can occur causing even more pain. Prior injury to the joint can lead to the development of traumatic arthritis. This is another potential cause of pain in the great toe joint. Patients with diabetes may develop an altogether different problem related to this lack of motion. In the presence of peripheral neuropathy (lack of painful sensation), these patients can develop skin breakdown and ulceration.

As you can see there are numerous causes for a painful joint. There are also numerous options, conservative and surgical, to treat these conditions. A Keller Arthroplasty is a surgical procedure designed to eliminate pain and discomfort in this joint. It is typically reserved for cases of severe arthritis, previous failed surgeries, diabetic ulcerations or certain types of bunion deformities.

Indications For Surgery

As with all surgical procedures there are certain criteria that are followed in choosing one procedure over another for any individual patient. In the case of the Keller arthroplasty, it is most commonly reserved for patients over the age of 55 with limited athletic activity. These patients are best able to tolerate the alteration in toe function created by this procedure. There should also be a moderate to severe amount of pain on movement of the joint, either passively or with walking that is not relieved by shoe gear, orthotics or other non-surgical means. X-rays are helpful to evaluate the condition of the bone and joint. These may show joint space narrowing, bone spurs or joint deterioration. As with any surgery, it is important that the patient have a clear understanding of all available options. They should also be aware of what to expect after surgery.

The Surgical Procedure

The procedure itself is fairly straightforward. An incision is made over the great toe joint. Once the joint is exposed, a small portion of bone is removed from the base of the proximal phalanx. This allows for an increase in motion in the joint and a reduction in pain. The defect created by the removal of the bone will fill in with soft tissue, creating a “false joint”. Some surgeons may choose to place a pin across the joint to maintain the position of the toe and to allow for scarring. The pin is usually left in place for 3-4 weeks. The soft tissue structures are then re-attached and the wound is closed. The patient is then placed in a surgical shoe. Casting is not necessary and limited ambulation is usually allowed following this procedure.

What to Expect after Surgery

The postoperative recuperation usually involves use of the surgical shoe for 2-3 weeks. Limited ambulation may be allowed. If a pin was inserted, this is usually removed after 3-4 weeks. Because the pin exits out the tip of the great toe, it can usually be removed in the office. It does not require a second surgical procedure. Once the pin is removed, the patient can get the foot wet, increase their weightbearing activities, begin range of motion exercises and gradually advance to sneakers. Most people can return to their usual shoe gear and activity at 6 weeks.

The most common postoperative concerns are prolonged swelling. It is not unusual for some degree of swelling to persist beyond 3 months. This will typically resolve on its own. Occasionally, the use of a compression sock will expedite resolution of the swelling. Also, an orthotic device may be helpful to allow for more efficient transfer of weight during ambulation and more even distribution of weightbearing forces. All in all, when the preoperative criteria are met, this procedure can provide a significant degree of relief from a painful great toe joint.

Kaposi's Sarcoma lesions occur most commonly on the soles of the feet They are irregular in shape and have a purplish, reddish or bluish black appearance. They tend to spread and form large plaques or become nodular. The nodular lesions have a firm rubbery appearance. The appearance of these lesions is an ominous sign. In the late 1970's and early 1980's an outbreak of Kaposi's sarcoma occurred in San Francisco, California. It was later learned that the disease was associated with AIDS infection. It can occur without the concurrent AIDS infection but this is very rare.

Chronic athlete's foot can cause an increased pigmentation to the bottom of the foot. It is associated with dry scaling skin and may have a reddish appearance.