You may benefit from a specialist lower limb centre when:

• You want a second opinion about your diagnosis and treatment plan
  
• You want to be sure of all treatment options available.
  
• You have multiple medical problems and are at high risk for any medical or surgical treatment
  
• Surgery has been recommended
  
• A second surgery is necessary to correct the results of a previous operation.

The Brisbane Orthopaedic and Sports Medicine Centre consists of a team of orthopaedic physicians who manage the full spectrum of lower limb disorders – from the common to the complex.

Common Diagnoses

• Hammertoes - Hammertoes syndrome is a general term used to describe a series of symptoms and joint changes involving the lesser toes of the foot. Hammertoes most frequently involve the second toe, however, multiple digits can be involved. Hammertoes can be congenital (from birth), but usually are acquired and may be precipitated by improperly fitted shoes and/or hosiery, pressure or deforming force from adjacent digits, i.e. bunion, trauma, arthritis, neuromuscular disorder to name a few more common causes. Hammertoes usually become painful when a corn or callus forms secondarily, making it difficult to ambulate in shoes comfortably. Appropriate shoe wear, toe pads, and custom orthotics are usually the first treatment modality. Surgery becomes indicated when adequate pain relief and an acceptable level of comfort is not attained through non-surgical means. A hammertoe, specifically, is a toe deformity that occurs in the sagittal plane when the metatarsophalangeal joint (MTPJ) is extended; the proximal interphalangeal joint (PIPJ) is flexed; and the distal interphalangeal joint (DIPJ) is neutral or hyperextended. Among the three toe deformities described, hammertoes is the most common condition encountered.

• Mallet Toes - Mallet toes occur in the sagittal plane, with the distal interphalangeal joint flexed and the proximal interphalangeal joint and metatarsophalangeal joints unaffected. A build-up of tissue or corn formation is most common on the tip of the toe, or dorsal part of the digit. Appropriate shoe wear, toe pads, and custom orthotics are usually the first treatment modality. If one’s symptoms persist, surgical intervention may be necessary to provide pain relief.
  
  
• Diabetic Foot Problems - Diabetes can be the cause of many foot related problems. In general there are two major causes for these complications: Nerve Damage – which causes loss of feeling in the feet and legs or Vascular Insufficiency – which delays or inhibits the diabetic’s ability to heal wounds. In general there are several things that you can do to protect your feet:
  • Inspect your feet on a daily basis and look for blisters, cuts, scratches and nail problems.
  • Check your shoes for foreign objects or rough spots which could cause sores.
  • Wash your feet daily with a mild soap. Dry well between your toes.
  • Use a moisturizer on your feet to avoid dry cracking skin..
  • Make sure your shoes and socks fit well.
  • Don’t walk barefoot, use hot soaks or heating pads on your feet, cut into the corners of your nails when trimming your nails, or use chemicals or sharp instruments to remove corns or calluses.
  • Prevention of diabetic foot complications is essential. Preventing problems from occurring is much easier than treating them after they arise.
  
  
• Tendonitis - Tendons are the part of the body that attach the muscle to the bone. It is through tendons that our muscles of the foot and ankle act to allow us to perform the different motions necessary for walking. Injuries to tendons usually start with an inflammation of the lining of the tendon (paratendonitis) that lead to inflammation within the tendon (tendonitis). Both of these conditions commonly are initiated by overuse secondary to over activity or increased stress on the tendon. If left untreated, tendonitis can lead to a tear within the tendon or a complete rupture of the tendon. If properly treated early with rest, activity modifications, direct physiotherapy and proper medication, the problem can be resolved completely. If untreated, in addition to pain, long term structural abnormalities such as flat foot can result. Occasionally, surgery may be necessary in order to regain the normal pain free function of the foot and ankle.
  
  
• Corns - Corns are a build up of hard skin near a bony prominence of a toe or between the toes. Some use the terms “corns” and “calluses” interchangeably. Corns may be very diffuse or very discrete, both of which can be very painful, particularly from external pressure of shoe gear.

  Corns, basically, result when pressure from shoes rub against the toes or cause friction between the toes, causing a build up of hard tissue resulting in a painful corn. Corns may occur on the top of the toes, the side of the toes or between the toes, depending upon where friction builds up and the body’s reaction to the friction resulting in the build up of the corn.

  The formation of corns is generally lessened or eliminated by wearing properly fitted shoes which avoid pressure and compression of the toes. Patients are advised to avoid very high heeled, narrow shoes that push the toes forward, causing them to rub against the shoe, as well as against each other. Properly fitted shoes need to have enough toe area length, as well as a deep enough toe area in order to accommodate the patient’s foot, preventing rubbing between the shoe and the toe. People who suffer from corns are able to find some relief from use of cushion pads which help to dissipate friction and pressure over bony prominences, thus alleviating the pain of a corn.

  Corns may be treated by wearing shoes that have increased height or width in the toe area, thus alleviating the friction that originally causes the corns in the first place. Cushion padding can also be helpful in eliminating a pressure point over toes leading to painful corn conditions. Medicated creams and lotions may also be recommended in order to help soften the corns and help in gentle debridement. If conservative therapy has not been helpful in alleviating the pain of a corn, surgery may be recommended. This surgery generally involves removal of the pressure by removing a small piece of underlying bone or changing the position of the toe in order to prevent continued pressure and friction while in shoe gear. Most important to all treatment for corns is the appropriate fitting of good, supportive shoes.
  
  

• Mycotic Nails - Mycotic nails are nails that are infected with a fungus. The nail may be discolored, yellowish-brown or opaque, thick, brittle and separated from the nail bed. In some cases the nail actually may be crumbly.

  Mycotic infections of nails are caused by a fungal organism that is found in the atmosphere. This organism likes the dark, moist, warm environment of shoes, which promotes fungal growth. Prior injury to the nail may predispose the nail to developing a fungal infection.

  Preventing mycotic infection of nails is difficult. The fungal organisms that cause these infections are ubiquitous and difficult to control. Patients are urged to maintain good pedal hygiene by alternating shoes, changing hose on a daily basis and treating any injuries to the nails or toes promptly. Wearing properly fitted shoes and avoiding tight constrictive shoes may also be helpful in preventing injury to the nail and nail plate which may predispose the nails to mycotic infections. Appropriate regular care to the toenails may also be helpful in avoiding fungal infections.

  Mycotic nail infections are difficult to treat. If patients notice any infected nail they should not try to remove that part of the nail, since this may predispose the spreading of the fungal infection. Topical medications are available, but are helpful in only a small number of fungal nail problems. Oral medications may be prescribed to eradicate the fungal infection. Conservative treatment for fungal infections in the nails may include periodic removal of the damaged portion of the nail and thinning out of the thickened nails to prevent pain to the patient.
  

• Clawtoes - Clawtoes occur in the sagittal plane with the metatarsophalangeal joint extended upward (dorsiflexed), and the proximal interphalangeal joint and dorsal interphalangeal joint extended downward (plantarflexed). Clawtoes most often affect the lesser toes, although the great toe, too, may be involved. This condition is often associated with a high arched (cavus) foot type, which may be a component of a neuromuscular disease. Appropriate shoe wear, toe pads, and custom orthotics are usually the first treatment modality. If one’s symptoms persist, surgical intervention may be necessary to provide pain relief.
  
  
• Neuromas - A neuroma is an irritative process of a nerve branch. A neuroma in the foot usually occurs as the nerve courses between the metatarsal bones and into the toes. An inflamed, irritated nerve that supplies sensation to the third and fourth toes is called a Morton’s neuroma and is the most common neuroma. Numbness and burning are generally consistent findings. Pain may vary from mild to severe and is frequently precipitated by tight fitting shoe gear or hosiery or by trauma. Treatment frequently involves removing the irritating process, i.e. removing the narrow or high heeled shoes. Metatarsal pads, non-steroidal anti-inflammatories and cortisone injections are often treatment modalities. Surgical intervention is reserved for the recalcitrant cases, but can provide excellent symptom relief in properly selected individuals.
  
  
• Fractures - A fracture is a broken bone. If not treated properly, a fracture can lead to long term disability. The bone may fail to heal (non-union) or it may heal in a poor alignment (mal-union). If a non-union or mal-union occurs, often times a surgical reconstruction is necessary.

  The complex anatomical relationships of the multiple bones of the foot and ankle allow for pain free walking, running, jumping, etc. When a fracture of one of these 30 bones of the foot and ankle occurs it is essential to obtain a prompt evaluation for proper diagnosis and treatment. Techniques employed may be non-operative with casting and early foot and ankle physical therapy or surgical reconstruction of the broken bone(s) followed by a foot and ankle rehabilitation program. With early diagnosis, proper treatment, and correct rehabilitation, the goal of a healed fracture leading to a foot and ankle that functions without pain can be obtained.
  
  

• Calluses - Calluses are a build-up of hard skin and generally found beneath the weight bearing surfaces on the bottom of the foot. Calluses may occur on any surface of the foot, but are more commonly found on the bottom of the forefoot. It should be noted that some degree of callus formation on the sole of the foot of an active person is normal and generally does not cause any problems for a patient. Callus formation can also form around the periphery of the heels, which can lead to fissuring of the callus, which can become quite painful.

  Calluses are generally felt to be caused by an uneven distribution of weight, generally on the bottom of the forefoot or heel that leads to a build-up of hard skin. Calluses can be caused by wearing improperly fitted shoes and, in rare instances, an abnormality of the skin causing a build-up of callus tissue.

  Calluses can be prevented by paying attention to the type of shoes that are being worn. Properly fitted, supportive shoes with good shock absorbing soles can help to alleviate pressures on the bottom of the foot which can eventually lead to the build-up of callus. People who have problems with calluses should definitely avoid hard soled or leather soled shoes that do not cushion the bottom of the foot. The use of over-the-counter cushion pads or insoles can also be helpful to eliminate pressure points that can lead to a painful callus. Patients who are used to walking barefoot should also limit the amount of time that they walk barefoot, since walking barefoot can also cause a build-up of calluses.

  Calluses are generally treated conservatively by debridement of the build-up of hard tissue and some attempt to try to distribute weight bearing forces away from the callused area. It is not recommended that patients use sharp objects, such as razor blades or knives to cut calluses on the feet since injuries can occur and are particularly dangerous in patients suffering with diabetes. The use of cushion pads or insoles can be very helpful in redistributing weight bearing forces, as well as, providing cushion to a calloused area. Certain medicated creams and lotions are also helpful in breaking down callus tissue and keep the skin soft and pliable. When conservative treatment for calluses is not successful, special inserts are sometime prescribed for the patient in order to better even out weight bearing forces on the bottom of the foot to prevent abnormal callusing. In rare instances, surgical procedures may also be performed in order to move a piece of bone or change the position of the bone so that callusing does not continue to form.
  
  

• Ingrown Nails - Ingrown nails most commonly involve the big toe, but can involve any of the toenails. The nail becomes ingrown when one or both sides grow into the skin of the toe. The skin then becomes red and swollen and causes pain. Sometimes the nail actually breaks the skin and causes a localized infection which may become more acutely painful and cause drainage from the side of the toe. They can become quite debilitating. Ingrown toenails are most commonly caused by shoe pressure, although some people may be born with a tendency to develop ingrown toenails. They inherit this directly from one or both parents who may suffer from the same problem. Other causes for ingrown toenails may be improperly trimmed nails, crowding of the toes within shoes, repeated trauma to the toes from abnormal activities, such as running, walking or certain sports.
  
  Ingrown toenails can be prevented by cutting the toenails after bathing, when they are soft and making sure to cut the nails straight across, only slightly rounding the edges of the nails. Patients are not recommended to cut down into the borders of the nails, which often leads to infection along the side of the toe. After properly trimming the nails, the edge of the nails should be lightly smoothed with a file or emery board. Patients are also advised to wear well fitted shoes that are not restrictive in the toe area.
  
  Patients who suffer from discomfort of ingrown toenails are advised to soak their feet in a solution of lukewarm water and soap, followed by applying an antiseptic or topical antibiotic and covering with a bandage. If this treatment is not successful in alleviating the patient’s discomfort the patient may need to seek a doctor’s care. Ingrown toenails that are infected usually require some minor surgery in order to remove the portion of nail causing the infection, followed by prescribing soaks and appropriate topical antibiotics to resolve the localized infection. Patients are advised to continue to properly care for their nails and wear properly fitted shoes in order to prevent more chronic problems with ingrown nails. Chronically ingrown toenails may be corrected with surgery by removing part of the toenail and the growth matrix to prevent the regrowth of the problem side of the nail. Patients who suffer from diabetes are particularly cautioned against cutting their nails improperly, since these individuals are prone to serious infections which often require a doctor’s care.

Patient Services - More on Lower Limb

* Source: The Cleveland Clinic; Diagrams: Australian Orthopaedic Association