Deciding to have bunion surgery can be one of the most difficult health decisions to make. 'Bunions' are a cause of distress to many thousands of people -mostly women -worldwide. Last year, I wrote about bunions and my opinion was and still is – "avoid bunion surgery if at possible, unless it is ruining your life and crippling you with pain".
The 'bunion' referred to here is the bony deformity characterized by a big toe that deviates towards the rest of the toes, possibly accompanied by a second toe which is bent and overlies it.
When any surgical intervention is considered, be it the podiatrist enucleating a corn, removing part of a toe-nail or the orthopaedic surgeon realigning the foot in bunion surgery, all of us strive to do our best to achieve a satisfactory outcome, by exercising our skills to the utmost.
So you can imagine my concern to have two patients recently complaining bitterly about their unhappiness with the result of their bunion surgery. Add to this my surprise at the 'twenty-something' who wants surgery because she doesn't like the look of her feet and her bunion (this one is the small thickening of the metatarsal bone with no deformity), prevents her from wearing the high fashion shoes she needs for work.
What can you say to a middle-aged, active woman who decided to have her bunion (deformed type) corrected, but after three months can only wear trainers with the toe cut out, has a swollen foot, pain and discomfort, difficulty driving, plus all the associated emotional stress? Or how do you respond to a similar woman who is now in constant pain and has had altered her walking style because the foot is rigid at the big toe joint?
To the best of my knowledge the procedures were technically successful and there is no deformity anymore. In addition we all react differently to a surgical "assault" and time does allow better healing. Also, there are numerous variations of operations and techniques available for bunion correction surgery.
Firstly – go back to the surgeon and discuss your options.
Secondly – see if a podiatrist can assist with biomechanical correction or alignment and footwear advice.
With my 2 patients, one has had orthotics made and the other I referred to the surgeon, who has recommended further physiotherapy, with the possibility of another operation to remove the steel plate that is in the foot.
I will still refer patients who meet my criteria outlined above for consideration for surgery, because the final decision to undergo sugery is always taken by the patient. Unfortunately, there can be no absolute guarantees since the structure of each foot is so complicated.
So what to do about 'bunions'? Is there an underlying systemic disease such as rheumatoid arthritis?
We must consider the patient's age. Is the patient overweight? What is the biomechanical structure and function, not only of the feet but lower limbs and body? Have all possible conservative measures such as night splints, orthotics, insoles, appropriate footwear, been exhausted?
Be guided by the severity of loss of function, pain, discomfort and limitation of daily activities. Will the patient be able to adhere to all the post-operative requirements, expected by the surgeon?
Eventually, all these factors (plus others), must be seriously thought about before undergoing bunion surgery.
Are you 'foot fit' for voting? On Wednesday of this week South Africans go to the polls to elect a new government. Foot fitness could be important since the process can involve many hours of extra standing or walking.
Here are a few tips to help you through the day!
Try to get a lift to the polling station – this reduces the walking you have to do.
Take a folding chair or sit on the ground if your feet start to ache.
Wear comfortable shoes with thicker soles – trainers or lace ups are best, because they can be loosened if your feet and ankles start to swell.
Don't stand in one position for too long – move from foot to foot, wriggle your ankles up and down to keep the circulation going.
Bend gently from the knees up and down a few times.
If you have diabetes and reduced sensation take extra care that you don't rub a blister from your shoes.
Start talking to the people around you – it helps to pass the time!
(Try to avoid talking politics!).
Have something to eat before you go to vote. (Voting on an empty stomach is as risky as shopping on an empty stomach!).
Sometime it's a good idea to go later to the polling station, since everyone wants to get there early!
Above all do vote. Remember that it is a Public Holiday, so rush home and put your feet up.
I have just seen the 8 year old child with Traction Apophysitis featured in previous posts. Since January 26, when I first saw him, he has followed a strict programme of reduced activity.
He has been fantastic in wearing trainers at school – remember that all the other children are barefoot – and severely limiting or stopping any activity that caused pain. Although, about a month ago we did let him start swinging a golf club at the driving range!
His mother reports that he no longer sits on the side of the bed in the morning rubbing his painful feet. Has no pain after school, even though he has recently started playing some soccer at break time and he is completely pain-free.
Today's X-rays show a normal appearance of the calcaneal epiphysis (the growth area/point at the back of the heel), and improved bone density.
The plan now is to slowly start activity again and that will be rugby.(He plays barefoot). The trainers must still be worn as often as possible. Follow up will be in 6 months.
The diagnosis of Traction Apophysitis is usually based on the presenting clinical symptoms, as the X-ray findings are often inconclusive. Nevertheless we must never ignore the younger child with painful heels and always consider Traction Apophysitis.
Management is clearly "rest", by reducing or avoiding those activities that cause pain. A supportive but soft/cushioning trainer is the best footwear. There is a place for short term anti-inflammatories followed preferably by topical gels and plasters.
Whatever we try, there is always the question of 'what would have happened if we had done nothing?" I believe that that decision can only be made with the individual patient in front of you, so that you can respond with clinical judgement and personal empathy. However there is no doubt that for many children it is a transient condition.
My apologies for not getting the case history on the site as promised.
THE COMPLETE CASE HISTORY WILL BE ON THE WEBSITE SOON.
Never ignore foot pain. A recent case of tibialis posterior tendon rupture is a case in point.
A 76 year old lady was brought to me by her daughter because she could barely walk and was in constant pain. She had been prescribed anti-inflammatories and sleeping tablets for 'the arthritis.'
At her only previous visit to me in 2003, I had diagnosd the potential for flat foot related problems and made orthotics. The lady never kept any follow up appointments.
This time, the lady described her symptoms as "the left foot is giving me hell. Over the past year, it's been getting gradually worse and now I can't wear my shoes."
When I asked about the previous treatment, she informed me that she gave up with orthotics because they didn't fit easily into her shoes.
When I examined the foot, it was completely flat and rolled over and the arch was non-existent. The lady was unable to stand for more than a few seconds and she couldn't manage more than two steps across the room. In addition she was unable to raise up onto tiptoe.
As I traced a path along the inside of the foot up behind her ankle to the lower part of her calf she experienced significant pain. This is the path of the Posterior Tibial Tendon, the main tendon to help form and hold the arch of the foot.
Posterior Tibial Tendon
I immediately sent the lady for X-rays and an Ultrasound scan. The scan revealed a rupture of the Posterior Tibial Tendon.
Referral for surgery has been completed and now we wait for the outcome, except that she has developed a problem with her eyes that needs treating before any surgery can take place.
The moral of this story? Follow up is vital from both sides of the medical equation. Ignoring foot pain can have serious consequences, so managing it is a team effort.
READ THE FULL CASE HISTORY IN Case Histories
