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Please see foot & ankle anatomy for more information about the subtalar joint.
Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain, and joint deformity.
Subtalar arthritis is when arthritis involves the subtalar joint.
MRI revealing extensive arthritis of the subtalar joint
Any condition that damages the cartilage (joint surface) will cause subtalar arthritis to develop.
The common conditions that cause subtalar arthritis are:
Typical symptoms of subtalar arthritis include:
Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Weight bearing plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they maybe normal. Most people however present when there is some structural damage.
The following are features of arthritis on a plain radiograph:
Radiograph of the foot demonstrating A – normal subtalar joint B – arthritic subtalar joint (note complete loss of joint space posteriorly)
MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
MRI is particularly useful in assessing:
CT images give excellent information on bone structure and is superior to plain radiography in that respect.
CT is particularly useful in the following cases:
Ultrasound is a quick, painless and non invasive method of assessing soft tissue structures.
Ultrasound is particularly good at ascertaining:
Bone scan is a non specific test. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present.
This test is done in special circumstances.
Picture of a bone scan showing increased uptake in the foot
The natural history of arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.
The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe significant pain and functional limitation.
You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:
As the arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.
Grading a disease in medicine is used for the following reasons:
There are a number of grading systems used for arthritis. We use the following grading system based on radiographic (x-ray) features at The London Foot & Ankle Clinic:
Non-operative management for ankle arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.
Wearing above ankle boots that give more support to the ankle and subtalar joint. The use of a shoe with a heel cushion.
Ankle braces give more support and stability to the ankle and subtalar joint and could ease pain particularly when doing sports and exercise. Custom orthotics in the form of an AFO (ankle foot orthosis) coupled with insoles can be successful in easing symptoms.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with subtalar arthritis by reducing inflammation in the joint.
The use of paracetamol and other painkillers to help reduce pain levels.
Physiotherapy works by strengthening muscles around not only the joint but the whole kinetic chain. Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.
The use of a walking stick or cane to reduce the forces going across the damaged joint.
Can relieve the pressure on painful damaged joints.
These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.
Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.
Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.
There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.
Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.
There are a number of treatments that involve an injection or series of injections for the treatment of subtalar arthritis.
This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.
The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.
Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.
We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.
The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.
Injections are not repeated less than 6 monthly intervals.
Please read here for more information regarding injections and possible complications.
Intraoperative x-ray showing correct placement of needle in the subtalar joint (confirmed with radiopaque dye)
Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.
It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.
Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
This is suitable for only a small select group of patients with a small isolated area of damaged joint, loose body or inflamed tissue. Typically patients present with advanced disease and this is therefore not an option. It allows for not only direct visualisation of the joint surfaces (diagnostic) but also treatment as well, such as:
The operation is carried out via keyhole (arthroscopic) surgery or a small incision. It is performed under a short general anaesthetic as a daycase.
This operation has excellent outcomes in terms of pain relief and return to activities of daily living.
It involves removing all remnants of the diseased joint (cartilage) and fusing the two main bones (calcaneum and talus) that form the subtalar joint together. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.
The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active. Please read this blog for more details.
The operation is usually carried out through a small incision on the side of the foot. In some patients the operation maybe performed through keyhole (arthroscopic) surgery. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
The main longterm complication following a subtalar fusion is the development of adjacent arthritic joint disease, particularly talonavicular and calcaneocuboid joints.
The main short term complication is non union (the bones not fusing together). This is reported in numerous studies to be around 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.
Currently subtalar fusion remains the treatment of choice for end stage subtalar arthritis. There is no subtalar joint replacement.
A – Radiograph of the foot in a patient who developed subtalar arthritis after an ankle fusion B – treated successfully by a subtalar fusion
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
All surgical procedures for subtalar arthritis will be carried out under a general anaesthetic.
Following a subtalar arthroscopy +/- open debridement
You will have a small waterproof dressing applied to the front of the ankle to cover the arthroscopy portal sites/wound and a bandage applied. It is advised not to remove this bandage until reviewed by Mr Malik at the 2 week post operative check up. For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.
Weight bearing status will really depend on how much has been done inside the joint. Most patients are touch weight bearing for 48 hours and then weight bear as tolerate after that with or without the use of crutches. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence ankle range of motion exercises as soon as possible after the operation to prevent stiffness. Activities can be gradually increased as pain allows.
In addition following a subtalar fusion –
You will have a backslab applied post operatively for two weeks. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.
A picture of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for approximately 6 to 8 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high elevation
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection. Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months. If completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
A referral to physiotherapy will be made at this stage. This is the earliest you may return to work.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your foot will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.
Significant improvement in swelling and pain. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.
Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.
If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
Final clinical examination. Discharge if satisfactory.
Following a subtalar fusion
Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
The time given below is only a guide to the actual surgical time.
For a subtalar arthroscopy +/- open debridement
Up to 90 minutes.
For a subtalar fusion
For a subtalar arthroscopy +/- open debridement –
Most patients are able to drive after two weeks. Please see guidance below.
For a subtalar fusion –
Not for at least 3 months post surgery.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
Most patients are able to return to work within 10 to 14 days.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Following a subtalar arthroscopy +/- open debridement –
Excellent pain relief and return to sports by 3 to 6 months. Failure of this outcome warrants further investigation and possible treatment.
Excellent pain relief and return to full activities of daily living.
A plantar fibroma is a benign tumour (growth) of the plantar fascia. It is composed of dense fibrous tissue. It tends to be a solitary lesion and quite superficial. It tends to be slow growing.
Patients with multiple lumps are said to have plantar fibromatosis, also known as Lederhose disease. The lumps are found in deeper layers and can be faster growing. This is also a benign condition.
MRI of the foot in a patient with a plantar fibroma
No one knows the exact underlying cause of plantar fibroma.
Plantar fibromatosis, (Lederhose disease) has an association with Dupuytren contracture of the hand. This is a similar condition affecting the palm of the hand resulting in thickened bands and contractures of the palmer fascia. Plantar fibromatosis, like Dupytrens, is linked with chronic alcoholism, chronic liver disease, epilepsy and repetitive trauma.
A clinical picture of a patients hand demonstrating Dupytren’s disease
Other causes of lumps in the sole of the foot include:
Quite often there are no symptoms. Patients may only notice a firm swelling on the sole of the foot.
Some patients complain of difficulty in standing, walking, or wearing shoes when the nodules or bumps become large enough.
The lump is typically found in the middle of the arch on the sole of the foot.
Clinical picture of the foot demonstrating a large painful plantar fibroma
MRI is useful in detecting plantar fibroma and fibromatosis. An MRI will confirm the diagnosis and allow differentiation of other causes of masses in the foot.
Lumps can get bigger and more painful.
Many patients have lumps that cause no symptoms and therefore can be observed.
Non-operative management aims at relieving pain.
An off-loading insole or pad may relieve painful symptoms.
Well padded shoes.
Stretching tight calf muscles will help reduce the forces going across the forefoot. Plantar fascial stretches.
Carried out through an incision overlying the lump in line with the foot. To ensure low recurrence rates wide margins are recommended. The lump os sent to histology to confirm the diagnosis.
Complications can occur as with any type of surgery. Please see foot and ankle complications for more detailed explanation of post surgical complications.
Almost all surgical procedures for plantar fibroma and plantar fibromatosis will be undertaken as a day case.
You will have a bandage applied similar to this during the operation.
Post operative bandage of the foot
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are mobilising.
Post operative stiff soled shoe
For the first 2 weeks following surgery you will be non weight bearing using two crutches. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period to prevent complications and allow the wound to heal.
High elevation of the foot and ankle
You will be reviewed at the clinic and your dressings removed. Your wound will be checked.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). Depending on the size and healing of the wound you may commence weight bearing. Some patients with large lumps and evidence of delayed healing may require to be non weight bearing for a longer period.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 weeks before any driving is advisable.
Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.
Most patients are able to start wearing normal footwear (swelling permitted) and return to full activities. Final clinical examination. Discharge if satisfactory.
This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a well cushioned shoe while your foot continues to heal.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 4 to 8 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief. Ability to participate in sports by 2 to 3 months. Sometimes up to a year before the foot feels “normal” and fully healed.
A Morton’s neuroma is thickening of the tissue around the interdigital nerve that runs between the metatarsal bones down to the toes.
Despite the name, it is not a true neuroma (tumour of the nerve). Instead there is thickening and scarring (fibrosis) around the nerve.
The incidence of Morton’s neuroma is roughly 9 times greater in women than men. It is more common in middle age. It almost never occurs between the 1st and 2nd or 4th and 5th metatarsals. The most frequent site of a Morton’s neuroma is between the 3rd and 4th metatarsal heads.
Illustration of A – normal interdigital nerves B – a Morton’s neuroma between the 3rd and 4th metatarsal bones
The exact cause and mechanism of injury is still not clearly understood. Amongst surgeons it is felt to be due to repetitive microtrauma, irritation and excessive pressure around the nerve.
The anatomy of the foot may also predispose to the development of Morton’s neuroma. The space between the metatarsal heads 2 & 3, and 3 & 4 is quite narrow.
Radiograph (x-ray) of the foot demonstrating the narrow space between 2nd and 3rd as well as 3rd and 4th metatarsal heads
Anything that causes increased pressure and irritation of the nerve may lead to the development of Morton’s neuroma such as:
Occasionally, problems in adjacent structures can result in local inflammation which irritates the interdigital nerve and reproduces symptoms similar to a Morton’s neuroma. It is extremely important to rule out any other pathology as treating the Morton’s neuroma (including surgery) may fail to alleviate symptoms as the real underlying problem has not been treated.
Local problems that can mimic Morton’s neuroma include:
Pain is the commonest symptom of Morton’s neuroma.
The pain can be present in many different forms for example it may be:
There may also be tingling or numbness of the toes.
Some patients also describe “clicking” in the foot which may or may not be painful.
Symptoms are worse wearing tight fitting shoes and high heels. Symptoms are relieved by taking off shoes and massaging the foot.
On examination there will be tenderness on palpation of the webspace (positive web space compression test). Sometimes it is possible to “feel” the neuroma (Mulder’s click). There may be numbness or altered sensation in the toes.
Examination will also look to see how tight the calf muscles are, and whether there are signs of callosities and any other foot problem that may be the cause of the symptoms.
Plain radiographs are a quick and effective way of ruling out any other foot condition that may be causing symptoms similar to Morton’s neuroma.
Plain radiographs (x-rays) may demonstrate the following conditions that can cause forefoot pain:
Ultrasound is requested in almost all cases. It is quick, effective and safe. It helps to confirm the diagnosis of Morton’s neuroma and also treat the condition by undertaking an image guided injection of local anaesthetic. All patients are recommended to undergo this before considering surgery.
An ultrasound scan will also pick up other pathologies that are not visible on an x-ray such as:
MRI is a useful investigation when x-rays and an ultrasound scan appear normal. It is also useful in patients who have recurrent symptoms post surgery. It provides excellent high definition static images.
An MRI of the foot demonstrating inflammation (synovitis) in the 2nd MTP joint
An MRI in combination with a small injection can help confirm any injury to the plantar plate (if there is a tear, fluid leaks out of the 2nd MTP joint, see image below), it can also confirm any stress lesions in the bone itself. If the underlying diagnosis is not clear an MRI can be a useful investigation.
MRI of the foot demonstrating leaking out of dye injected into the 2nd MTP joint indicating that there is a likely tear in the plantar plate and capsule
Morton’s neuroma are sometimes seen as an incidental finding on ultrasound scans when treating another foot condition. Therefore not all Morton’s neuromas are painful. Of those patients that have a painful neuroma, a significant proportion will respond well to non operative measures (see below).
Having said that, Morton’s neuroma is a condition that can become chronic and fail to respond to non operative treatment. Surgery is reserved for this group of patients.
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports that involve lots of turning, twisting and bending of the toes such as running, dancing, basket ball etc.
An insole with a metatarsal dome pad just proximal to the neuroma
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can sometimes decrease discomfort.
The use of comfortable and wide fitting shoes with a small or no heel.
Stretching tight calf muscles will help reduce the forces going across the forefoot. This can help reduce pain from a Morton’s neuroma.
There are a number of treatments that involve an injection or series of injections for the treatment of Morton’s neuroma. At The London Foot And Clinic we only use local anaesthetic and steroid.
We carry out all injections only after ultrasound confirmation that there is indeed a Morton’s neuroma present. Most injections are performed under ultrasound image guidance to make sure the needle is in the correct spot. A mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is then injected around the Morton’s neuroma. Undertaking the injection in this manner ensures the best outcome clinically as there is no doubt about the placement of the needle and subsequent injection.
Injections are not repeated less than 6 monthly intervals. Repeating injections can also weaken local tissue and cause complications such as:
Please ensure someone is available to drive you home after the injection as the foot may hurt for a few days after the injection.
We do not use alcohol or sclerosants at The London Foot and Ankle Clinic.
It has been suggested that injecting these substances in and around the nerve will damage the nerve sufficiently to eliminate symptoms. Our experience and concern is that the alcohol will cause excessive scarring and if anything make symptoms worse and any open surgery more complicated.
For the very same reasons we do not use crysosurgery. This involves destroying the nerve by freezing it. While some patients may claim to get better using these techniques the complication and failure rates are unacceptably high in our opinion.
Surgery involves an incision over the top of the foot between the metatarsal bones. Some surgeons carry out the operation through the sole of the foot however in our experience this results in a painful and thickened scar and quite a lot of discomfort in the immediate post-operative period while the wound heals.
Traditionally surgery for Morton’s neuroma involves identifying the nerve and cutting (resecting) it proximal to the point where it is irritated/injured (the neuroma).
This should result in relief of pain, but does leave permanent numbness along the distribution of the nerve. This does not usually cause any problems.
Illustration of a foot – resecting the Morton’s neuroma will leave numbness between the toes (red)
Some surgeons advocate releasing a ligament (intermetatarsal) over the Morton’s neuroma and freeing the nerve of local scar tissue. This may be suitable for certain patients and can discussed with your surgeon Mr Malik.
The operation is carried out under a general anaesthetic and is usually done as a daycase procedure which means you will not have to stay in the hospital overnight.
The success of surgery is variable. Around 75% of patients feel happy with the outcome and have a pain free foot.
It is important to make sure that the underlying diagnosis is correct and that the pain is not from another pathology but actually from Morton’s neuroma.
If the pain is truly arising from the irritated nerve (Morton’s neuroma) then surgery will probably be successful. However a variety of conditions cause forefoot pain (metatarsalgia) and this needs to investigated carefully and treated.
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.
For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and redressed if necessary.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Commence range of motion exercises of the lesser toes immediately after surgery and continue for 6 weeks. After two weeks start intrinsic foot muscle strengthening exercises.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
Typical appearance of Morton’s neuroma excision wound at 6 weeks post surgery
You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.
This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.
Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Please see foot & ankle anatomy for more information about the midfoot joint.
Midfoot arthritis is when arthritis involves the midfoot joint.
Plain radiograph (x-ray) of both feet showing a normal right foot and and an arthritic left foot involving the left 2nd and 3rd TMT joints. Note the decreased joint space indicating loss of normal cartilage in the joint
Any condition that damages the cartilage (joint surface) will cause midfoot arthritis to develop.
The common conditions that cause midfoot arthritis are:
Typical symptoms of midfoot arthritis include:
Plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they maybe normal. Most people however present when there is some structural damage.
Plain radiograph (x-ray) of both feet which shows arthritis in the left big toe (1st MTP) joint and 2nd & 3rd TMT joints – note the complete loss of joint space in the 2nd & 3rd TMT joints
The natural history of midfoot arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.
As the midfoot arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.
Non-operative management for midfoot arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
Wearing above ankle boots that give more support to the midfoot joints. The use of a shoe with a rocker bottom sole can also help as it helps spread the load away from the midfoot.
Custom orthotics that stiffen the mid portion of the foot can ease symptoms.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with midfoot arthritis by reducing inflammation in the joint.
Physiotherapy works by strengthening muscles around not only the midfoot joints but the whole kinetic chain. Calf stretches can also help reduce loads and forces going across the midfoot.
Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.
The use of a walking stick or cane to reduce the forces going across the damaged joints.
There are a number of treatments that involve an injection or series of injections for the treatment of midfoot arthritis.
Radiographic images of arthritis in the left midfoot TMT 1 – 5 joints, treated with an image guided injection under x-ray control – note the dye in the lower image indicating correct placement of needle
It involves removing all remnants of the diseased joint (cartilage) and fusing the the bones so that no joint exists. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.
The operation is usually carried out through one or more incisions on the top (dorsum) of the foot.
Right Midfoot Arthritis treated with 2nd & 3rd TMT joint fusion, wound appearance at 3 months post surgery
The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
The main complication is non union (the bones not fusing together). This is reported in numerous studies to be around 5%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.
Currently midfoot fusion remains the treatment of choice for end stage midfoot arthritis. There is no midfoot joint replacement.
Radiograph of the foot A – before and B – after 2nd & 3rd TMT joint fusion (blue arrows indicate the arthritic joints)
You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling.
You will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.
A midfoot fusion takes up to 90 minutes to complete.
Depends on the side operated on and whether you drive an automatic car. If the car is manual then regardless of the side operated on it will be roughly 3 months post surgery. If you drive an automatic and the left foot has been operated on then it will be roughly 4 weeks before you can drive short distances.
To enable me to walk pain free.
I was concerned the operation may not work.
My right foot, the first to be operated on, took me far longer to recover from than the left. I had an overnight stay and took pain relief for longer the first time round and I felt generally very tired for a few weeks. The second time (several months later), the left foot, I came home the same day and was able to manage without the pain relief after the first week. I also had much more energy.
The most challenging part of the recovery was the time of non weight bearing, adjusting to a wheel chair, walking frame and relying on others help.
I was wrongly diagnosed about 12 years ago and told to ‘ walk through the pain ‘ the doctors could find nothing wrong with my foot ! I therefore did as I was told and suffered the pain for all these years especially when out walking and exercising. It was when the pain started in my other foot that I decided to try just once more to see if anything could be done. Fortunately I was recommended to see Mr Ahmad Malik. he knew immediately the cause of my pain – I was in shock ! There was a reason and it could be repaired. The decision to have the operation was an easy one and the sooner the better before the condition worsened.
My main concern before the operation was not the actual procedure but the long recovery time ie being non weight bearing on one foot and not driving for 3 months.
The operation went well and I felt no pain as I was given painkillers. After an over night stay in hospital I was given a lesson in hopping with crutches – I quickly discovered that it had to be a zimmer frame ! the first 2 weeks in bed went quite quickly as i had organised a trolley by my bed with books, ipad, and knitting etc to keep me occupied. A partner or good friend is needed to provide food and drinks as there is little you can do on one foot. We hired a folding wheel chair to put in the car which was great once you can venture outside. Once you are in the plastic boot it is easy to walk on crutches. However getting dressed takes practice as the boot is cumbersome. When the boot comes off you have to learn to walk again ! Hydro therapy and physiotherapy are essential to build up your muscles and have the confidence to walk on two feet again.
The most challenging part of having the operation for me was not the boredom ( I watched Sky box sets ) it was sheer frustration and lack of independence. Not being able to carry a drink or move something to another location without having to rely on someone else is very difficult. I also worried a great deal when I was learning to walk again that I might damage the bone fusion. I know that was silly my brain had learnt to protect my operated foot.
The best advice I can give future patients is PREPARATION both mentally and practically. Accept that the recovery period is a long one but you will be pain free in the end. Make sure you have hobbies, books or tv by your bed especially for the first 2 weeks and ask your partner or friend to take you out on trips – even to the local supermarket (Waitrose have the best wheelchairs you can borrow) I enjoyed the sheer freedom of just going round the aisles on my own. Accept help from people and find a good physiotherapist to get you back on your feet again.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
