Dr Gerhard Pienaar | Orthopaedic Surgeon

Commonly known as bunions, this is a very common condition affecting women to a far greater extent than men. The proposed aetiology is shoe wear. Studies done in un-shoed populations in Africa and in the Hong Kong Chinese have shown that the normal shape of the human foot is splayed in the forefoot region. The adaptation where the great toe sits next to the 2nd toe is felt to be due to shoe wear.

Bunions often run in families. It is uncertain as to whether this is a genetic predisposition or an inherited shoe wear tendency.

Often in the initial stages they are painless and symptoms only occur in tight or high heeled shoes. In the later stages the big toe can press on the 2nd toe producing interdigital corns. The big toe may also pass underneath the 2nd toe causing the 2nd MTP joint to dislocate.

In the latter stages a bunion may become arthritic. The pain is often felt medially (on the inside) and is the typical area where the shoe rubs. This can lead to inflammation of the bursa (sac of fluid) occasionally to infection of the bursa and very occasionally to infection of the underlying bone.

Bunions usually are investigated by taking xrays.

Bunionettes

While a bunion is a pronounced bump on the outer edge of the big toe, a bunionette is exactly the opposite. A bunionette is a bump on the outer edge of the little toe.

Pain associated with a bunionette occurs on the outside of the foot, and tight shoes may exacerbate the condition. Shoes with narrow toe boxes are particularly problematic for those with a bunionette. Narrow toe boxes increase friction against the bony protrusion.

People who have mild to medium cases of bunionettes may experience little to no pain. In these cases, one should take the proper precautions to keep the case mild, and not progress any worse. A mild case of a bunionette may be a small bump on the outer edge of the little toe. A severe case may be that your little toe is overlapping your fourth toe.

Hallux rigidus

The most common site of arthritis in the foot is at the base of the big toe. This joint is called the metatarsophalangeal, or MTP joint. It’s important because it has to bend every time you take a step. If the joint starts to stiffen, walking can become painful and difficult.

In the MTP joint, as in any joint, the ends of the bones are covered by a smooth articular cartilage. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe, or hallux rigidus.

Hallux rigidus usually develops in adults between the ages of 30 and 60 years. No one knows why it appears in some people and not others. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint.

Gout

Gout is a disorder that causes sudden attacks of intense pain, swelling, and redness in your joints or soft tissues. In many cases, the first attacks occur in the joints of the big toe, but gout can affect many other joints. It is one type of inflammatory arthritis.

Gout develops when too much uric acid accumulates in your bloodstream. This dissolved uric acid then comes out of the bloodstream and forms microscopic spike-like crystals in joints or soft tissues.

Your body reacts to uric acid crystals as if they were a foreign body or bacteria. White blood cells and other infection fighting cells are sent into the area, which results in inflammation. This reaction can look just like an infection: The affected area will become red, swollen, hot, and very tender.

Acute gout attacks can last from 3 to 10 days. Even without treatment, the attacks slowly get better. With treatment the symptoms improve much more quickly.

What Gout Affects

The tissues that can be affected by gout include:

Gout frequently involves the joint of the big toe. However, it can affect small joints like those in the finger, as well as large joints, such as the knee and hip.
Located throughout the body, these thin, slippery sacs with just a slight amount of fluid in them act as cushions between bones and soft tissues. The bursae most commonly inflamed from gout are the boney tip of the elbow (olecranon bursa) and the front of the kneecap (prepatellar bursa).
Tendon sheaths. These tunnels protect and provide nutrition to tendons in the hands and feet.
High uric acid levels may cause kidney stones and, sometimes, damage the kidneys. About 15 people out of 100 with gout develop kidney stones.

Claw Toe

People often blame the common foot deformity claw toe on wearing shoes that squeeze your toes, such as shoes that are too short or high heels. However, claw toe also is often the result of nerve damage caused by diseases like diabetes or alcoholism, which can weaken the muscles in your foot. Having claw toe means your toes “claw,” digging down into the soles of your shoes and creating painful calluses. Claw toe gets worse without treatment and may become a permanent deformity over time.

Symptoms

Your toes are bent upward (extension) from the joints at the ball of the foot.
Your toes are bent downward (flexion) at the middle joints toward the sole of your shoe.
Sometimes your toes also bend downward at the top joints, curling under the foot.
Corns may develop over the top of the toe or under the ball of the foot.

If you have symptoms of a claw toe, see your doctor for evaluation. You may need certain tests to rule out neurological disorders that can weaken your foot muscles, creating imbalances that bend your toes. Trauma and inflammation can also cause claw toe deformity.

Hammer Toe

A hammer toe is a deformity of the second, third or fourth toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.

The forefoot is made up of five toes. Each toe has three joints—except for the first (big) toe, which usually has only two joints.

In hammer toe, the affected toe is bent at the middle joint, which is called the proximal interphalangeal (PIP) joint.

Cause

Hammer toe is the result of a muscle imbalance that puts pressure on the toe tendons and joints. Muscles work in pairs to straighten and bend the toes. If the toe is bent in one position long enough, the muscles and joints tighten and cannot stretch out.

Wearing shoes that do not fit properly is a common cause of this imbalance. Shoes that narrow toward the toe push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. Shoes with a higher heel force the foot down and push the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles can no longer straighten the toe.

Symptoms

A hammer toe is painful, especially when the patient is moving it or wearing shoes. Other symptoms may include:

Swelling or redness
Inability to straighten the toe
Difficulty walking
A corn or callus on the top of the middle joint of the toe or on the tip of the toe

Corns

Every day, the average person spends several hours on their feet and takes several thousand steps. Walking puts pressure on your feet that’s equivalent to 2-3 times your body weight. No wonder your feet hurt!

Actually, most foot problems can be blamed not on walking but on your walking shoes. Corns, for example, are calluses that form on the toes because the bones push up against the shoe and put pressure on the skin. The surface layer of the skin thickens and builds up, irritating the tissues underneath. Hard corns are usually located on the top of the toe or on the side of the small toe. Soft corns resemble open sores and develop between the toes as they rub against each other.

Cause

Shoes that don’t fit properly. If shoes are too tight, they squeeze the foot, increasing pressure. If they are too loose, the foot may slide and rub against the shoe, creating friction.
Toe deformities, such as hammer toe or claw toe.
High heeled shoes because they increase the pressure on the forefoot.
Rubbing against a seam or stitch inside the shoe.
Socks that don’t fit properly.

Metatarsalgia

Metatarsalgia is the pain and inflammation caused by injury to the ball of the foot. Although thought of as a symptom of other conditions rather than a specific disease, it is still considered a common overuse injury.

Metatarsalgia, a forefoot injury, can occur in anyone, though athletes who take part in intense sports that involve running or jumping are at the highest risk. Metatarsalgia occurs when there is strong or unusual pressure on the ball of the foot, creating pain and inflammation.

Metatarsalgia can be caused by injury during sport or physical activity. If there is an abnormal weight distribution or unusual movement, the foot is more susceptible. Metatarsalgia pain generally occurs over time rather than immediately, and can last several months with increasing severity.

Symptoms

Symptoms include irritation and inflammation of the ball of the foot and pain at the end of one or more of the metatarsal bones. The factors that contribute to metatarsalgia can include:

Tight toe muscles
Weak toe muscles
Hypermobile first foot bone (when joints move easily beyond the normal range expected for that particular joint)
Tight Achilles tendon
Loose or tight footwear
High or unusual levels or physical activity
Hammertoe deformity
Excessive side-to-side movements when walking

Also, some medical conditions may predispose individuals to metatarsalgia problems. These can include:

A high arch
Hammertoe deformity
A short first metatarsal bone or a long second metatarsal bone
Pain is usually aggravated when walking or running. Athletes who have inflammatory conditions such as bursitis often also have forefoot pain.

Plantar Keratosis

Intractable plantar keratosis (IPK) is a focused, painful lesion that commonly takes the form of a discrete, focused callus, usually about 1 cm, on the plantar (bottom) aspect of the forefoot. An IPK is actually a collection of dead skin cells that harden over time and may feel like you are walking with a sharp pebble in your shoe. Typically, IPKs occur beneath one or more lateral metatarsal heads or what we call the “ball of the foot”

Patients may often confuse these lesions with a wart or may think there is a problem with the underlying bone because these lesions can be so painful. As the natural fat pad in this area begins to get thinner with age, you may become more susceptible to these kinds of skin calluses.

Cause

There is an underlying cause of why they form and it really involves abnormal biomechanics of the foot. It can indeed be a bony prominence or arthritis under that particular area. But an often-missed aetiology is an “equinus” of the ankle which leads to more pressure being put on the front of the foot during the gait cycle. When equinus is present, our foot compensates with pronation, or really overpronation. This hypermobility in the forefoot leads to abnormal forces and pressure points and leads to the formation of an IPK.

We often can treat these problems conservatively. We address the equinus by providing splints for stretching and correcting the equinus. Also, a custom orthotic (shoe insert) can prevent that excessive pronation and provide some cushioning to the specific sites that bother you. We will also shave down the lesion and may prescribe you some cream to put on daily. In most patients these can resolve in 1-2 months.

Morton’s Neuroma

Morton’s Neuroma is a thickening of the tissue around nerves leading to the toes. The condition was first described by a chiropodist named Durlacher but is named after Dr. Thomas George Morton.

This condition is relatively common. It can be caused by pressure (from running or use of high heels) or injury.

Morton’s Neuroma may cause a sharp, burning pain or numbness in the ball of the foot or toes, or it can feel like there’s a pebble in your shoe or a fold in your sock.

Treatments include arch supports, footpads, corticosteroid injections, strength exercises, special shoes, and surgery.

Your feet are comprised of many bones, muscles, and soft tissues such as tendons and ligaments. Additionally, they contain many nerves.

A large group of nerves surrounds your toe bones (the metatarsals). Occasionally, the tissues near these nerves thicken and form a growth called a neuroma.

Under different circumstances, neuromas can be cancerous tumors. But orthopaedists stress that Morton’s variety are benign and are not considered tumors.

Morton’s Neuroma is the official name given this condition, also known as Morton’s metatarsalgia. In most cases, this problem occurs between your third and fourth toe bones.

Causes

Researchers believe these abnormal growths are caused by repeated and intense pressure placed upon nerves. Several underlying factors may increase your risk of developing the condition:

If you have been diagnosed with any type of foot problem, most notably issues like hammertoes, bunions, or flat feet, your chances of contracting the condition rise significantly.
People who wear high heel shoes for professional or stylistic purposes. This footwear often places unnecessary strain on the ball of your foot and surrounding toe bones, which can lead to Morton’s Neuroma.
Sports that place added stress on your feet increases your probability of developing neuromas. Of particular concern are activities such as running and rock climbing.
Studies have found that this problem is eight to ten times more likely to occur in women.

Symptoms

There is one common occurrence almost everyone eventually diagnosed with the condition experiences – a feeling that a rock is stuck in the bottom of your shoe or that your sock has a bulge that you cannot seem to straighten. Other notable symptoms include:

A burning sensation in the ball of your foot.
Tingling or numbness around the affected toe bones.
Pain that worsens when wearing tight shoes.
Discomfort that increases during strenuous activities.
Pins and needles.
Reduced sensation of touch.
Lump in the sole of the foot.
Sensation of walking on a marble.

Stress Fractures of the Foot and Ankle

A stress fracture is a small crack in a bone, or severe bruising within a bone. Most stress fractures are caused by overuse and repetitive activity, and are common in runners and athletes who participate in running sports, such as soccer and basketball.

Stress fractures usually occur when people change their activities — such as by trying a new exercise, suddenly increasing the intensity of their workouts, or changing the workout surface (jogging on a treadmill vs. jogging outdoors). In addition, if osteoporosis or other disease has weakened the bones, just doing everyday activities may result in a stress fracture.

The weight-bearing bones of the foot and lower leg are especially vulnerable to stress fractures because of the repetitive forces they must absorb during activities like walking, running, and jumping.

Refraining from high impact activities for an adequate period of time is key to recovering from a stress fracture in the foot or ankle. Returning to activity too quickly can not only delay the healing process but also increase the risk for a complete fracture. Should a complete fracture occur, it will take far longer to recover and return to activities.

Stress fractures occur most often in the second and third metatarsals in the foot, which are thinner (and often longer) than the adjacent first metatarsal. This is the area of greatest impact on your foot as you push off when you walk or run.

Stress fractures are also common in the calcaneus (heel); fibula (the outer bone of the lower leg and ankle); talus (a small bone in the ankle joint); and the navicular (a bone on the top of the midfoot).

The most common sites for stress fractures in the foot are the metatarsal bones.

Many stress fractures are overuse injuries. They occur over time when repetitive forces result in microscopic damage to the bone. The repetitive force that causes a stress fracture is not great enough to cause an acute fracture — such as a broken ankle caused by a fall. Overuse stress fractures occur when an athletic movement is repeated so often, weight-bearing bones and supporting muscles do not have enough time to heal between exercise sessions.

Cause

The most common cause of stress fractures is a sudden increase in physical activity. This increase can be in the frequency of activity—such as exercising more days per week. It can also be in the duration or intensity of activity—such as running longer distances.

Even for the nonathlete, a sudden increase in activity can cause a stress fracture. For example, if you walk infrequently on a day-to-day basis but end up walking excessively (or on uneven surfaces) while on a vacation, you might experience a stress fracture. A new style of shoes can lessen your foot’s ability to absorb repetitive forces and result in a stress fracture.

Flatfoot

A variety of foot problems can lead to adult acquired flatfoot deformity (AAFD), a condition that results in a fallen arch with the foot pointed outward.

Most people — no matter what the cause of their flatfoot — can be helped with orthotics, braces and physical therapy. In patients who have tried these treatments without any relief, surgery can be a very effective way to help with the pain and deformity.

One of the more common signs of flatfoot is the “too many toes” sign. Even the big toe can be seen from the back of this patient’s foot. In a normal foot, only the fourth and fifth toes should be visible.

Symptoms

Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms below:

Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle.
Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time.
When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain.
Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes.
Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.

Osteoarthritis

Osteoarthritis, also known as “wear and tear” arthritis, occurs when the cartilage that cushions and protects the ends of your bones gradually wears away. This leads to pain and stiffness that worsens over time, making it difficult to do daily activities.

Osteoarthritis is the most common form of arthritis. It develops slowly and most often occurs during middle age.

Although there is no cure for osteoarthritis, there are many treatment options available to help manage pain and keep people staying active.

Cause

With osteoarthritis, the articular cartilage that covers the ends of bones in the joints gradually wears away. Where there was once smooth articular cartilage that allowed the bones to glide easily against each other when the joint bent and straightened, there is now a frayed, rough surface. Joint motion along this exposed surface is painful.

Osteoarthritis usually develops after many years of use. It affects people who are middle-aged or older. Other risk factors for osteoarthritis include obesity, previous injury to the affected joint, and family history of osteoarthritis.

Rheumatoid Arthritis of the Foot and Ankle

Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body. It most often starts in the small joints of the hands and feet, and usually affects the same joints on both sides of the body.

More than 90% of people with rheumatoid arthritis (RA) develop symptoms in the foot and ankle over the course of the disease.

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defences that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.

How It Happens

The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes an overactivity of this lining. It swells and becomes inflamed, destroying the joint, as well as the ligaments and other tissues that support it. Weakened ligaments can cause joint deformities — such as claw toe or hammer toe. Softening of the bone (osteopenia) can result in stress fractures and collapse of bone.

In RA, the lining of the joint swells and becomes inflamed. This slowly destroys the joint.

Rheumatoid arthritis is not an isolated disease of the bones and joints. It affects tissues throughout the body, causing damage to the blood vessels, nerves, and tendons. Deformities of the hands and feet are the more obvious signs of RA. In about 20% of patients, foot and ankle symptoms are the first signs of the disease.

Cause

The exact cause of RA is not known. There may be a genetic reason — some people may be more likely to develop the disease because of family heredity. However, doctors suspect that it takes a chemical or environmental “trigger” to activate the disease in people who inherit RA.

Tendonitis

Tendons are tissue cords in your body that attach muscles to bones. When your tendons become damaged and cause irritation or inflammation, it’s called tendonitis. Tendonitis causes acute pain, swelling, and tenderness in the affected area. This can make it painful or difficult for you to move.

Tendonitis most commonly happens after the repeated incorrect use of a part of the body. In the case of foot tendonitis, your Achilles tendon and other tendons that connect your foot to the bones in your lower leg become injured.

Symptoms

Tendonitis foot symptoms include pain, tenderness, and soreness around your ankle joint. It may be difficult and painful to move and painful to the touch. Sometimes the affected joint can swell.

Causes

There are many causes of tendonitis of the foot and ankle. These include, but are not limited to:

Abnormal foot structure
Medical conditions like rheumatoid arthritis or gout
Trauma caused by injury or accident
Improper overuse of the foot and ankle

Lisfranc injuries

Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. The severity of the injury can vary from simple to complex, involving many joints and bones in the midfoot.

A Lisfranc injury is often mistaken for a simple sprain, especially if the injury is a result of a straightforward twist and fall. However, injury to the Lisfranc joint is not a simple sprain that should be simply “walked off.” It is a severe injury that may take many months to heal and may require surgery to treat.

The midfoot is the middle region of the foot, where a cluster of small bones forms an arch on the top of the foot. From this cluster, five long bones (metatarsals) extend to the toes. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.

Lisfranc joint complex

The Lisfranc joint complex includes the bones and ligaments that connect the midfoot and forefoot. Lisfranc injuries include ligament strains and tears, as well as fractures and dislocations of bone (far right).

The midfoot is critical in stabilizing the arch and in walking (gait). During walking, the midfoot transfers the forces generated by the calf muscles to the front of the foot.

The midfoot joint complex is also called the Lisfranc joint. It is named after French surgeon Jacques Lisfranc de St. Martin, who served in the Napoleonic army in the 1800s.

The Lisfranc joint complex has a specialized bony and ligamentous structure, providing stability to this joint.

The midfoot will be affected if the bones are broken (fractured) or the ligaments are torn (ruptured). Injuries can vary, from a simple injury that affects only a single joint to a complex injury that disrupts multiple different joints and includes multiple fractures.

Lisfranc injuries tend to damage the cartilage of the midfoot joints. Cartilage covers the ends of bones in the joints, allowing the joints to move smoothly. If severe midfoot injuries are not treated with surgery, then damage to the cartilage and increased stress at the midfoot joints will result in both collapse of the arch and arthritis, which require complex surgery to correct. Even with successful surgery for the Lisfranc injury, arthritis can still develop in later life.

Cause

These injuries can happen with a simple twist and fall. This is a low-energy injury. It is commonly seen in soccer players. It is often seen when someone stumbles over the top of a foot flexed downwards.

More severe injuries occur from direct trauma, such as a fall from a height. These high-energy injuries can result in multiple fractures and dislocations of the joints.

High Arch (Pes Cavus)

This condition is an abnormally high arch of the foot that results in an excessive amount of body weight being directed to the ball and heel of the foot. Cavus foot can be congenital or acquired, may develop at any age, and can affect one or both feet.

Pes cavus foot type describes a highly arched foot whereby the longitudinal arch does not flatten on weightbearing. It’s much less commonly seen in comparison to pes planus (flat or pronated foot type). Generally speaking the pes cavus foot type tends to be stiff with poor shock absorbing capacity. It can also present in a wide variety of a neurological disorders.

With this foot type it is fairly common to see retracted/ hammered digits, prominent forefoot/ ball of foot and callosities on the 1st and 5th metatarsal heads. The rearfoot may sit at an inclined angle or supinated position and this foot type tends to be pre-disposed to lateral ankle sprains, peroneal tendinopathy, stress fractures and plantar fasciitis.

Treatment options vary depending on if the deformity is flexible or rigid and if there is any paralysis from a neurological condition.

If the deformity is flexible or partially reducible a corrective orthotic may be used with lateral posting to increase pronatory motion. If the foot type is rigid, then an accommodative type orthotic may be useful to contact the foot and help distribute weight bearing more evenly and offload and provide cushioning to the ball of the foot.

If there is paralysis involved an Ankle Foot Orthosis (AFO) may be required to address the deformity and lack of ankle dorsiflexion. In very severe cases a caliper that is attached to the sole of the shoe can be used.

Hindfoot

Arthritis

The hindfoot is the section of the foot that begins immediately below the ankle joint and ends at the level of the Chopart joint.

The ankle bone (talus) and the heel bone (calcaneum) make up the hindfoot. These are connected to each other and to the midfoot area at the Chopart joint.

Causes

There are several different reasons for developing arthritis in the hindfoot. These include:

Post-traumatic – Bone fracture, even if successfully treated many years before, can lead to arthritis
Rheumatoid arthritis – Patients with rheumatoid or other forms of inflammatory arthritis can develop arthritis in their hindfoot
Osteoarthritis – Even without an injury, unexplained arthritis can develop in the hindfoot
Tibialis posterior tendon dysfunction – If this tendon in the foot develops problems then the arch can flatten and cause midfoot or hindfoot arthritis

Symptoms

People often live with hindfoot arthritis for many years before seeking medical help and the problem will usually become worse, with increased pain and stiffness. This can make walking and weight-bearing exercise difficult. Symptoms include:

Aching in the middle or back of the foot when walking
Loss of flexibility in the foot, especially on uneven surfaces
Swelling around the ankle area and side of the foot
Changes in the shape of the foot, becoming flatter with loss of the natural arch; the heel bone can begin to point outwards
Rubbing of shoes on the skin on the inside of the foot; shoes may be uncomfortable and wear out more quickly

Achilles Tendinitis

Achilles tendinitis is a common condition that occurs when the large tendon that runs down the back of your lower leg becomes irritated and inflamed.

The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, climb stairs, jump, and stand on your tip toes. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.

Achilles tendinitis pain can occur within the tendon itself or at the point where it attaches to the heel bone, called the Achilles tendon insertion.

Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body’s natural response to injury or disease, and often causes swelling, pain, or irritation.

There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed.

Noninsertional Achilles tendinitis – Fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken. Tendinitis of the middle portion of the tendon more commonly affects younger, active people.
Insertional Achilles Tendinitis – Involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.

In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.

Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active. More often than not, however, it comes from years of overuse (long distance runners, sprinters).

Cause

Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including:

Sudden increase in the amount or intensity of exercise activity—for example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance
Tight calf muscles—Having tight calf muscles and suddenly starting an aggressive exercise program can put extra stress on the Achilles tendon
Bone spur—Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain

Symptoms

Common symptoms of Achilles tendinitis include:

Pain and stiffness along the Achilles tendon in the morning
Pain along the tendon or back of the heel that worsens with activity
Severe pain the day after exercising
Thickening of the tendon
Bone spur (insertional tendinitis)
Swelling that is present all the time and gets worse throughout the day with activity
If you have experienced a sudden “pop” in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.

Plantar Fasciitis

Plantar fasciitis is the most common cause of pain on the bottom of the heel. Approximately 2 million patients are treated for this condition every year.

Plantar fasciitis occurs when the strong band of tissue that supports the arch of your foot becomes irritated and inflamed.

The plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot, and supports the arch of your foot.

The plantar fascia is a ligament that lies beneath the skin on the bottom of your foot.

Cause

The plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body’s natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis.

Symptoms

The most common symptoms of plantar fasciitis include:

Pain on the bottom of the foot near the heel
Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
Greater pain after (not during) exercise or activity

Calcaneal Fractures/Malunion

A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. This type of fracture commonly occurs during a high-energy event—such as a car crash or a fall from a ladder—when the heel is crushed under the weight of the body. When this occurs, the heel can widen, shorten, and become deformed.

Calcaneus fractures can be quite severe. Treatment often involves surgery to reconstruct the normal anatomy of the heel and restore mobility so that patients can return to normal activity. But even with appropriate treatment, some fractures may result in long-term complications, such as pain, swelling, loss of motion, and arthritis.

The bones of the feet are commonly divided into three parts: the hindfoot, midfoot, and forefoot. Seven bones — called tarsals — make up the hindfoot and midfoot. The calcaneus (heel bone) is the largest of the tarsal bones in the foot. It lies at the back of the foot (hindfoot) below the three bones that make up the ankle joint. These three bones are the:

Tibia — shinbone

Fibula—smaller bone in the lower leg

Talus—small foot bone that works as a hinge between the tibia and the fibula

Together, the calcaneus and the talus form the subtalar joint. The subtalar joint allows side-to-side movement of the hindfoot and is especially important for balance on uneven surfaces.

Calcaneus fractures are uncommon. Fractures of the tarsal bones account for only about 2% of all adult fractures and only half of tarsal fractures are calcaneus fractures.

A fracture may cause the heel bone to widen and shorten. In some cases, a fracture may also enter the subtalar joint in the foot. When this occurs, damage to the articular cartilage covering the joint may cause long-term complications such as chronic pain, arthritis, and loss of motion.

The severity of a calcaneus injury depends on several factors, including:

The number of fractures
The amount and size of the broken bone fragments
The amount each piece is out of place (displaced) — In some cases, the broken ends of bones line up almost correctly; in more severe fractures, there may be a large gap between the broken pieces, or the fragments may overlap each other
The injury to the cartilage surfaces in the subtalar joint
The injury to surrounding soft tissues, such as muscle, tendons, and skin
When the bone breaks and fragments stick out through the skin or if a wound penetrates down to the bone, the fracture is called an “open” fracture. An open fracture often causes more damage to the surrounding muscles, tendons, and ligaments and takes a longer time to heal. Open fractures have a higher risk for infection in both the wound and the bone. Immediate treatment to clean the wound is required to prevent infection.

Cause

The calcaneus is most often fractured during a:

Fall from a height
Twisting injury to the ankle
Motor vehicle collision

The severity of a fracture can vary. For example, a simple twist of the ankle may result in a single crack in the bone. The force of a head-on car collision, however, may result in the bone being shattered (comminuted fracture).

Similar fractures can result from different mechanisms. For example, if you land on your feet from a fall, your body’s weight is directed downward. This drives the talus bone directly into the calcaneus. In a motor vehicle crash, the calcaneus is driven up against the talus if the heel is crushed against the floorboard. In both cases, the fracture patterns are similar. As a rule, the greater the impact, the more the calcaneus is damaged.

In a high-energy fracture, other injuries, such as fractures of the spine, hip, or other heel, can occur.

Symptoms

Patients with calcaneus fractures usually experience:

Pain
Bruising
Swelling
Heel deformity
Inability to put weight on the heel or walk

With some minor calcaneus fractures, the pain may not be enough to prevent you from walking — but you may limp. This is because your Achilles tendon acts through the calcaneus to support your body weight. If, however, your calcaneus is deformed by the injury, your muscle and tendon cannot generate enough power to support your weight. Your foot and ankle will feel unstable, and you will walk differently.