Orthopädie am Rhy

Basel, Rheinfelden, Liestal

Your specialists for feet and ankles

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Foot pain? Do your favourite shoes no longer fit? Has your foot become so deformed that you are embarrassed? Acute injuries?
The foot, that little body part which has to support everything, is made up of twenty-six bones. This corresponds to about ¼ of all bones in the human skeleton! It also consists of several joints, muscles and ligaments which connect them. The foot is divided into three segments, namely the forefoot (phalanges), the midfoot (metatarsal bones) and the hindfoot (navicular and cuneiform bones).

The forefoot and midfoot are separated by the Lisfranc joint. The hindfoot includes the calcaneus (heel bone) and the talus (ankle bone). The midfoot and hindfoot are separated by the Chopart joint. The plantar fascia is a firm tendon plate running from the calcaneus to the base of the metatarsals. It supports the arch of the foot when walking. The Achilles tendon traverses the ankle, connecting the calf muscles to the heel bone.

The ankle is made up of three bones, two joints, and the muscles, tendons, and ligaments which connect them. The three bones are the tibia (shinbone), the fibula (fibula) and the talus (a heel bone). The ankle joint is a hinge joint formed by the tibia and fibula, which fork around the tarsal bone. The articular surfaces of the ankle are covered with articular cartilage, which protects the end of the bone. The loss of this cartilage is called osteoarthritis and is usually caused by wear and tear. The ankle is supported by numerous ligaments that connect the individual bones and help stabilise them. If these ligaments are injured (torn ligament), the bones are separated.

Damage to the foot can occur either through injury or age-related wear and tear (degeneration). In young people, the main cause is usually trauma. Dislocations (distortions) can lead to fractures of the metatarsal bones or to torn ligaments. People who have to walk a lot in everyday life are particularly susceptible to foot damage. The risk of foot injury is increased for endurance athletes such as runners or people who sports that require sudden changes of direction, such as basketball or tennis.
In most cases, an imbalance in the foot results in an imbalance in the entire body. One of the reasons for this is that the sensors in the foot and ankle are directly linked to our sense of balance. It is all the more important to treat diseases and injuries of the foot quickly and in a targeted manner.
To this end, knowledge of the conservative, non-surgical treatment options is just as important as knowledge and skills of the surgical therapeutic options. Most problems in the foot and ankle area can also be treated conservatively or at least significantly improved.

Our range of treatments includes the following foot complaints:
- toe deformities: Hallux valgus, Hallux rigidus
- flatfoot complaints
- ankle pain
- Achilles tendon rupture
- heel pain 

Foot and ankle – an overview of our treatments

Hallux valgus is a widespread misalignment of the foot skeleton whereby there is a deformity in the ball of the big toe. There is usually a predisposition, which is then often exacerbated by high-heeled, tight shoes. Women are predominantly affected. Typically, there is pain, tingling, and numbness in the big toe.

Hallux rigidus is a fairly common disease. "Hallux rigidus" means "wear and tear or osteoarthritis of the metatarsophalangeal joint". Due to increasing wear and tear on the joint surfaces, the metatarsophalangeal joint of the big toe hurts becomes increasingly painful while running, and also at rest as the process progresses. An operation is then usually inevitable.

The following treatment options are available for toe deformities,
depending on the symptoms and age:
- Night splint, shoe insoles
- Operative axis correction
- Forefoot correction
- Joint arthrodesis
- Artificial joint 

If an operation is not yet necessary, conservative, non-surgical measures can alleviate pain or prevent the deformity from progressing. A definitive correction of the hallux valgus can only be achieved through an operation. The main conservative methods which help in our experience include:

- Wearing sufficiently wide and soft shoes
- Physiotherapy to strengthen the foot muscles.
- Shoe insoles to stabilise the longitudinal arch of the foot
- Sensorimotor insoles to strengthen the foot muscles.
- Hallux valgus splints as day splints with a joint and as night splints without a joint 

In the case of a slight misalignment, a chevron osteotomy is usually performed:

The end of the metatarsal bone is rotated (adjustment osteotomy) and usually fixed with a small titanium screw. The screw does not necessarily have to be removed again. In addition, the bone can be straightened to correct the big toe, whereby the protruding ball is removed (this is an Akin osteotomy). The foot can usually immediately carry weight after the operation by wearing a special shoe.
© Arthrex GmbH

In the case of a more pronounced deformity, an additional correction is carried out close to the base (e.g. Lapidus). 

Another method which we carry out with great expertise at our clinic is displacement of the metatarsal head ("Weil operation"). The elevation of the head of the metatarsal allows plantar callous build-up to recede. The combined shortening also allows the affected toe to relax.

In the case of a severe misalignment with abnormal mobility in the joint, it may be necessary to render the joint rigid ("Lapidus arthrodesis"). Screws and a special titanium plate are used to affix the bones to each other. The metal is usually removed after about a year. The foot must be immobilised for about 8-12 weeks after this operation.

If the joint can no longer be preserved, it may be necessary to immobilise the joint (arthrodesis), or, if the disease has not progressed quite that far, replace it with an artificial one. The best long-term results are currently being described in studies on hemiprostheses to replace the articular surface of the big toe (Anatomic Hemiprosthesis for Hallux rigidus). We thus use this procedure as standard! A great advantage in this case is preservation of joint mobility.

Come for a consultation so we can give you detailed expert advice about which procedure is necessary for you or which would be the most suitable for you personally. 

The term 'flat foot' only describes the external appearance of the foot. In many cases, a foot which looks flat from the outside does not cause any discomfort. Children often have flat feet for a period during their foot development, which is perfectly normal. If the deformity is very pronounced, onset is recent, if it has worsened, or if symptoms occur it is time for further examinations. Pain often occurs on the inner edge of the foot and towards the sole of the foot. Every now and then, pain occurs in the calves, knees, thighs, hips and lower back.

Treatment options which prove useful for this symptom are:
- Shoe insoles, strengthening of the muscles
- Surgery to displace the tendons, straightening operations, axis correction 

Slight forms of flat feet can be treated well with insoles that directly support the longitudinal arch and activate supporting foot muscles. At the same time, the lower leg and foot muscles should also be strengthened.

Surgical correction of the flat foot is complex and should be individually tailored to the symptoms and the degree of the deformity. It always requires great expertise on the part of the surgeon!
On the one hand, the lowering of the arch of the foot must be corrected; on the other hand, the goal is to restore the tendons to normal function. This is usually done by relocating one of the many tendons which flex the toes. The misalignment of the bones is corrected by correcting the position in the heel bone (PICTURES).

Additional surgical steps such as a correction of the position to straighten the metatarsus may be necessary on an individual basis.

The ankle joint can be damaged as a result of injury, repeated use, or wear and tear with age. In young athletic people, injury is the main cause of damage. Rotation injuries (e.g. in soccer) can lead to ligament tears. People who climb, squat or bend over a lot in their work are also particularly prone to suffer from ankle pain. The risk of ankle injury is increased for endurance athletes such as runners or people who sports that require sudden changes of direction, such as basketball, tennis or volleyball jumps. Ankle pain in old age is often due to signs of wear and tear (osteoarthritis) and is usually associated with restricted mobility, which reduces the quality of life. In the advanced stage of osteoarthritis, the patient usually notices joint swelling and heat in the affected area. Having suffered a broken ankle in the past is a risk factor for the premature development of osteoarthritis.

The following treatment options are used depending on the symptoms:
- Syringe therapy / infiltration
- Arthrodesis
- Operative axis correction
- Surgical joint replacement 

At the beginning of the disease, it is recommended to inject the cartilage’s own substances (hyaluronic acid) into the joint. This can improve the metabolic situation in the joint and the damaged cartilage can 'regenerate'. Physiotherapy and topical ointment application are complementary treatment options. If there is so-called 'activated osteoarthritis', in which there is inflammation in the joint, infiltration therapy with a narcotic (local anaesthetic) and an anti-inflammatory substance (corticosteroid additive) can effectively treat the inflammation and improve the pain situation. Furthermore, special orthopaedic shoes with brace support and a buffer heel stabilise and relieve the joint.

In the case of advanced arthrosis of the upper ankle joint, in some cases freedom from pain can only be achieved through surgical joint stiffening (arthrodesis).

The be-all and end-all: a straight and stable ankle joint!

An ankle joint endoprosthesis is only stable if the ankle joint is straight. For the prosthesis to be durable, it is important to correct misalignments and ligament damage that would otherwise prevent the ankle prosthesis from becoming incorporated stably. A good, experienced surgeon for ankle prostheses must therefore always be able to assess and correct the position of the hindfoot, heel bone and misalignments of the foot. In many cases, an endoprosthetic implant or arthrodesis can be averted by a procedure to correct the axis. Our top priority is always to achieve the best possible result! We have a wealth of experience in the correction and analysis of ankle misalignment. 

An alternative that is being used more and more frequently today is the implantation of an ankle joint endoprosthesis. The decisive advantage of this prosthesis is that it preserves joint mobility. In modern ankle joint prostheses, the talus is covered with a metal cap and the tibial joint surface is protected with a metal plate. The third component of the prosthesis is a freely movable polyethylene sliding core that provides the necessary movement between the two parts of a joint.

A rupture of the Achilles tendon usually occurs when the calf muscles are suddenly tensed during sporting activities. This is often accompanied by a really audible snapping sound! Incidentally, the Achilles tendon is the strongest tendon in the human body. Active men between the ages of 30 and 50 are most commonly affected. Straight after a rupture occurs, the patient can feel a painful gap with their finger, usually a few centimetres above the attachment point on the heel bone. After a while, the area will become swollen. It is no longer possible to walk on tiptoe.

Depending on the symptoms, the following treatment options are used:
- Special shoe, physical therapy
- Healing using the body's own growth factors (ACP)
- Surgical Achilles tendon suture 

If the Achilles tendon ruptures, conservative therapy may be successful. This is particularly suitable for a partial tear of the Achilles tendon and for older, less active people. Essentially, the patient is immobilised in special shoes and other physical measures are taken. For young athletic patients who want to regain good resilience, surgery is usually advisable.

In the case of partial ruptures, therapy with hyaluronic acid and the body's own growth factors (PRP) can be considered. The body's own growth factors contained in the blood are used to stimulate healing and generation processes in the torn tendon. To do this, we take blood from a vein in the arm. The blood components which have regenerative effects (growth factors) are extracted from the blood tube by means of a special separation process (centrifugation). The endogenous solution obtained in this way is then injected locally into the rupture site: endogenous substances thus contribute to faster healing!

In the case of a ruptured Achilles tendon, surgical treatment consists of sewing the torn ends of the Achilles tendon back together. The surgeon makes an incision a few centimetres long over the Achilles tendon and opens the tendon tube, which has an important nutritional function for the tendon. Depending on the findings, he can also braid the tendon with special suture materials to enhance the mechanical strength of the repair measure.These will then be broken down by the body in time. After the operation, the foot must be immobilised in a cast for a few days. Subsequently, a functional treatment can be used, i.e. normal weight load without plaster of Paris, in order to restore permanent and robust resilience as quickly as possible.

Achillodynia" refers to pain in the Achilles tendon, which is caused either by wear and tear of the tendon tissue or by inflammation of the surrounding structures. The cause of this is usually a chronic overload of the tendon, for example from an extended long-distance running. It can also occur as a result of degenerative changes to the ankle.

Treatment options are shoe insoles and various kinds of physical therapy. 

Therapy is usually conservative. Physical measures plus the use of special shoe insoles lead to an improvement in most cases. If necessary, anti-inflammatory drugs can also be taken.

Your foot and ankle specialist in our practice

Dr Caspar Steiner

Specialist in orthopaedic surgery and traumatology of the musculoskeletal system FMH

Main focus: Foot, Ankle joint

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