Did you spend the summer and early autumn in sandals? Do you prefer to be barefoot? You wouldn’t be alone if you had. There are some conditions we see in podiatry that feel better if your feet get more room. So, depending on the sandal, your foot structure and your activity level, you may actually find yourself MORE comfortable without a confined shoe.
One condition that patients find to sometimes feel more comfortable in sandals or mules (open in the back) is called a Haglund’s deformity. This condition relates to a bony prominence in the back of the heel. The prominence itself looks like a bump behind your heel bone or your calcaneus. This is the shape of the calcaneus as it occurs in some foot structures. Another condition which might feel better with an open back shoe or a sandal is a posterior calcaneal spur. This means that there is a bone spur behind the heel bone which is due to stress and strain of the achilles tendon where it attaches to the heel bone in the back.
So how do you know if you have a Haglund’s or a posterior calcaneal spur? Well, an x-ray is the simple answer here. I do even see patients who have BOTH a haglund’s deformity as well as a calcaneal spur. An x-ray will demonstrate the shape of the heel bone when we take a sagittal (or side) view of the foot. We can also see heel spurs on these views.
The reason that a calcaneal spur or Haglund’s deformity is more comfortable out of a shoe is because many shoes will place pressure on this prominence. This causes inflammation of the overlying tendon (the Achilles tendon) as well as the bursae in these areas. The nerves in the skin experience pressure between the shoe and the bone and can start to cause hot, burning, tingling, stabbing pain in the area.
So if pain in your foot is caused by irritation from bone or a spur, will the pain ever go away if the bone stays that way? Do I have to have the bone removed to get relief? These are very common concerns when it comes to pain in the back of the heel. The answer is: not always. How can this be? Well, there are some shoes which have a heel contour that doesn’t match that of your foot and may therefore cause irritation. On the flip side, some shoes will have accommodation or just be fit better to your foot so that they don’t hit directly on that tender area. Custom orthotics also help to position the heel in a way that often reduces the irritation within shoes.
However, sometimes no matter what shoe or insert you wear, the pain may persist. If this occurs, surgical removal of bone spurs or haglund’s deformities may be recommended. If you are a surgical candidate for this procedure, know that the recovery is often more than you might think to just “remove some bone.” The anatomy in the back of the heel dictates that to even get to that heel spur or that Haglund’s deformity, the achilles tendon itself needs to be partially resected (or removed) from the bone. After this, your surgeon has access to reduce the prominent bone, remodel and smooth it down and then the achilles tendon has to be repaired and secured back to the heel bone, often with use of surgical anchors. In many cases, having had a spur or Haglund’s on your heel will have caused damage and scarring to the achilles tendon, so your surgeon will likely need to clean the damaged tissue away and repair the achilles tendon itself.
These anchors help to provide good contact between the bone and the tendon, but then your body will need to incorporate the tendon back to the bone with scar tissue. This process takes around 6-10 weeks, so in order to not compromise your surgical site, there is a period of rest, protection and immobilization. After all of this, physical therapy helps to get you back on your feet, back into your regular activities and eventually back into sports or running.
Sometimes these Haglund’s deformities and posterior calcaneal spurs hurt even if you take your shoe off. Now we may have a different issue to address. Aside from shoe gear irritation, pain in the back of the heel in presence of Haglund’s deformity or posterior calcaneal spur is associated with issues of the Achilles tendon. With extra bone back on the heel and the up and down motion of your ankle with activity, shearing occurs to the tendon. Over time, the tendon can fray and scar repeatedly and this results in a thickened and painful achilles tendon. As the tendon continually scars, tears can develop within it and they have difficulty healing if you are not adequately immobilized.
If your pain is only in part due to shoes, the Achilles tendon needs to be addressed with proper immobilization, stretching, support and physical therapy. As the condition improves or resolves, a slow return to activity can be performed.
A few other conditions that may have you wanting to kick off your shoes are hallux limitus, hallux rigidus or hallux valgus. Hallux is the latin term referring to your big toe. In hallux limitus or rigidus, the motion of the big toe at the big toe joint is limited or completely restricted – respectively. There is some amount of bone spurring that occurs on the top of the big toe joint, resulting in difficulty finding shoes with enough room to accommodate this. In hallux valgus, the great toe leans into the smaller toes and is typically associated with a prominence to the inside aspect of the big toe joint.
As with Haglund’s and posterior calcaneal spurs, sometimes it is simply a matter of finding the right shoes. Finding shoes that have a wider toebox helps. Also, finding shoes that have a softer upper material so that it can accommodate for any prominences.
Similarly to Haglund’s or posterior calcaneal spurs, if the pain in your big toe joint from shoes isn’t effectively treated conservatively, surgical intervention may be recommended. In the case of hallux valgus, a repositioning of the bone that has become prominent is required. Depending on the severity of the bunion (hallux valgus), this may be performed at the joint which is loose near the arch – and a fusion of this joint (near the arch) may be recommended. In some instances, a planned cut (osteotomy) can be performed of the bone behind the big toe joint and is then secured with surgical screws and allowed to fully heal.
When it comes to hallux limitus or hallux rigidus, any surgical approach is again considered depending on each individuals case. Some patients have bone spurring without any noted concern of the position of the foot bones (though this is rare) and can simply have the spurs removed. A surgery like this requires little down time but is best accompanied by physical therapy. In cases where position of the bone behind the big toe is part of the problem, the bone spurs can be removed, but then the bone would be repositioned to reduce the likelihood of bone spurs returning later. If a patient has end stage hallux rigidus, whereby they already have either no motion remaining in the joint or very little, a fusion of the joint after removal of the bone spurs may be required. As much as some worry if this will affect their overall function, I always remind them in these cases that they are already functioning with accommodations and have likely already adapted to not using full motion of the great toe. Therefore, after fusion, pain is resolved and patient’s function typically improves.
If you are finding yourself not wanting to wear shoes and it isn’t just because you like to be on the beach, call our office for an appointment today. An evaluation and initial treatment discussion helps to provide you with the tools to feel better and get back to what you love. In understanding your condition in detail, you can also be assured that you are prepared for what is recommended in the future.