When your feet hurt, you hurt all over. In many cases, ailments of the foot and ankle can be treated conservatively. This means by methods which do not require surgery. Commonly seen conditions which typically resolve with non-invasive treatment can include tendinitis, plantar fasciitis, capsulitis, neuromas and warts. Unfortunately there are instances where surgery is recommended and even some instances where it is required.

What is capsulitis?
This is a condition in which there is pain and inflammation to the ligament surrounding a joint. This is commonly seen in the big toe joint, but can affect any joint in the foot. Some individuals experience this condition in the ankle as well. What is important to realize is that capsulitis is a very generic term. An individual can experience capsulitis as the result of a variety of causes. It can simply be due to an instance of overuse of a particular area of the foot, but it can also be due to a deformity in the foot – think bunions and hammertoes. Capsulitis is often treated by use of some form or protection or support which puts the affected area in a position that it can rest in, which allows your body to recover and heal. To speed the process, anti-inflammatories and icing are often recommended. If the condition improves with these simple first methods, the goals of treatment are re-directed to prevention of the recurrence of pain. When this condition does not improve, advanced imaging offers further diagnostic information which can at times reveal a need for advanced immobilization or more aggressive treatments. Capsulitis can be the initial diagnosis from your doctor, but it can be associated with a tear of a ligament depending upon the chronicity (or length of time the condition has been present) and tears require longer periods of immobilization.

What is tendinitis?
Tendinitis is when there is pain and inflammation of a tendon. This can occur to any tendon and at times tendinitis can be a secondary diagnosis when another condition leads to compensation and overuse of tendons. Similarly to capsulitis, initial methods of treatment are aimed to reduce strain of the tendon to allow your body the opportunity to heal. Anti-inflammatories and icing again help to improve this condition faster. Just as with the ligaments around joints, if inflammation and overuse of a tendon is chronic it can lead to tears within the tendon. This is due to deposition of collagen within the tendon that may not have the opportunity to remodel into a functional and resilient tissue while activity continues.

What is plantar fasciitis?
Plantar fasciitis is an incredibly common condition where there is inflammation of the ligament on the bottom of the foot called the plantar fascia. You may now be appreciating a pattern with these conditions. The suffix ‘-itis’ is used to describe inflammation. The plantar fascia in the foot is a large ligament which runs from the heel all the way to the ball of the foot. Pain from plantar fasciitis can be in the arch of the foot itself, but most often occurs on the inner aspect of the heel where this ligament tends to experience most of its strain. The plantar fascia can become overstretched and inflamed with increased time on feet, a change or reduction in the support of shoes that is within the foot or even compensation due to another condition in the foot. Plantar fasciitis treatment protocols consist of support for the arch to decrease daily strain and wear-and-tear in the form of an arch strapping. Anti-inflammatories are also useful to decrease healing time and exercises and devices to stretch the achilles tendon, calf muscle and plantar fascia are necessary to reduce tightness which is commonly associated with this condition. The plantar fascia can also become torn – sometimes by trauma but most often by chronic overuse.

What are neuromas?
Neuromas are localized areas of swelling and/or scar tissue that develops at particular areas along a sensory nerve in the foot. The suffix ‘-oma’ means tumor and this is a generic term for any mass of tissue, not necessarily dangerous or cancerous. Neuromas tend to develop from pressure and friction along a nerve in the foot which causes inflammation and scarring to develop. These are most commonly seen between the third and fourth toes in the foot. People often describe the symptoms of a neuroma as walking on a pebble and will also notice tingling, burning or numbness into one or two nerves. Neuromas develop most often in a foot structure whereby the bones in the forefoot are closer together, but can develop as the result of wearing shoes that are tight in the forefoot area and/or put more than usual pressure on the ball of the foot (think high heels and pointy shoes). Neuromas often improve with the use of anti-inflammatories, a pad worn on the foot to reduce pressure to the affected area, and physical therapy to decrease inflammation and loosen up the forefoot area.

What are warts?
warts are the skin presentation of the human papilloma virus. Many people have this virus, but not all will develop warts on the skin and the reason for this is not clear. Warts are most common in children, but it is not unheard of for adults or even the elderly developing plantar warts. There are many over the counter treatments available for warts, though due to the thickness of the skin on the bottom of the foot these treatments rarely resolve the condition. Treatment at our office involves a biweekly application of a compounded acid and home treatments with a higher concentration salicylic acid. This treatment essentially causes an immune response to the areas where the warts are present and the body then starts an inflammatory reaction which eventually pushes the wart from the deeper layers of skin.

So when and why would I need surgery?
When capsulitis becomes recurrent and difficult to manage with conservative measures, surgery may be needed. If capsulitis has lead to a tear in a ligament that does not resolve with immobilization, surgery may be required to repair the tear in this area. When capsulitis is recurrent due to a deformity in the foot and begins limiting your daily activities, surgery may be recommended to correct the deformity which solves the reason for which the capsulitis continues to be present. Bunions are a very common foot deformity and some people will never have pain – regardless of the severity of the deformity, while other people will have pain from a very small bunion. The reasons for this are not always known, but the key to determining the need for any elective surgery is to evaluate the effect that the condition is having on your life and whether conservative measures have been exhausted.  This is efforts to reduce overall risk and optimize the outcome of surgery. Surgery may by some people be thought of as the ‘fix’ for a given condition, but this doesn’t mean that surgery is perfect or that your outcome will make your foot feel as though you had never had a foot problem. On the contrary, surgery requires recovery time and initially causes more pain than what you have experienced from your condition. This is why if a person does not have pain due to their foot deformity, surgery may not be the appropriate treatment.

If tendonitis leads to a tear which is either severe or does not improve with conservative measures, repair of the tendon may be necessary. There are also some condition in the feet whereby tendonitis is due to a foot deformity and in these cases there is occasionally a need to correct this deformity in efforts to not experience recurrent bouts of pain.

Plantar fasciitis can also lead to a need for surgery if conservative measures fail to provide appropriate improvement in symptoms. Surgery in these cases in aimed to remove scar tissue that has developed and to loosen the plantar fascia ligament (sometimes by releasing some of this ligament).

Neuromas that do not resolve with conservative treatment may require surgery. This is a last resort, as the procedure recommended involves removal of the swollen and scarred portion of the nerve and this often leads to localized numbness in the foot.

Plantar warts can even (in rare cases) lead to a need for surgery. If these lesions do not resolve, they may need to be surgically excised and the blood supply which has developed to the wart needs to be cauterized. Again, this is a last resort, as there is potential for scarring that can develop in the area of the treated warts which may be painful.

When is surgery NOT necessarily elective?
When it comes to foot surgery, there are instances where surgery is necessary. The most common scenario is if there is a severe infection in the foot. Infections in the foot can lead to septicemia (or a blood infection) which can make a person very ill. When there are abscesses in the foot, these do not resolve with antibiotics and require drainage to resolve the infection. There are instances, most often seen in patients with diabetes and neuropathy, where an infection has reached and affected the underlying bone. In these cases the most definitive treatment is to remove any infected bone. Infections can also occur in joints, these cases also do not respond well with antibiotics alone so surgically washing out the joint is necessary to reduce the risk of worsening infection.

The decision to have surgery should never be taken lightly. Your surgeon will carefully weigh the benefits and risks against each other, but in elective cases (those which are not life threatening) a patient's input is ultimately what determines whether surgery should or should not be performed. As always, if you have foot concerns or are unsure if surgery is right for you, our doctors are here to help. We strive to help you understand the medical side of your foot condition which helps you to make the most educated decision about whether surgery is right for you!