Posted on December 18th, 2014


Achilles TendonAchilles tendonitis, also sometimes called Achilles tendinitis, is a painful and often debilitating inflammation of the Achilles tendon (heel cord). The Achilles tendon is the largest and strongest tendon in the body. It is located in the back of the lower leg, attaches to the heel bone (calcaneus), and connects the leg muscles to the foot. The Achilles tendon gives us the ability to rise up on our toes, facilitating the act of walking, and Achilles tendonitis can make walking almost impossible. There are three stages of tendon inflammation, Peritenonitis, Tendinosis, Peritenonitis with tendinosis. Peritenonitis is characterized by localized pain during or following activity. As this condition progresses, pain often develops earlier on during activity, with decreased activity, or while at rest. Tendinosis is a degenerative condition that usually does not produce symptoms (i.e., is asymptomatic). It may cause swelling or a hard knot of tissue (nodule) on the back of the leg. Peritenonitis with tendinosis results in pain and swelling with activity. As this condition progresses, partial or complete tendon rupture may occur. The overall incidence of Achilles tendonitis is unknown. The condition occurs in approximately 6-18% of runners, and also is more common in athletes, especially in sports that involve jumping (e.g., basketball), and in people who do a lot of walking. Achilles tendonitis that occurs as a result of arthritis in the heel is more common in people who are middle aged and older.


The Achilles tendon is a strong band of connective tissue that attaches the calf muscle to the heel bone. When the muscle contracts, the tendon transmits the power of this contraction to the heel, producing movement. The Achilles tendon moves through a protective sheath and is made up of thousands of tiny fibres. It is thought that Achilles tendonitis develops when overuse of the tendon causes the tiny fibres that make up the tendon to tear. This causes inflammation, pain and swelling. As the tendon swells it can begin to rub against the sheath surrounding it, irritating the sheath and causing it too to become inflamed and swollen. It has a poor blood supply, which can make it susceptible to injury and can make recovery from injury slow. Factors that can lead to the development of Achilles tendonitis include, tight or weak calf muscles, rapidly increasing the amount or intensity of exercise. Hill climbing or stair climbing exercises. Changes in footwear, particularly changing from wearing high-heeled shoes to wearing flat shoes. Wearing inadequate or inappropriate shoes for the sporting activity being undertaken. Not adequately warming up and stretching prior to exercise. A sudden sharp movement that causes the calf muscles to contract and the stress on the Achilles tendon to be increased. This can cause the tendon fibres to tear.


Symptoms of Achilles tendonitis include, pain in the back of the heel, difficulty walking, sometimes the pain makes walking impossible, swelling, tenderness and warmth of the Achilles tendon. Achilles tendonitis is graded according to how severe it is, mild - pain in the Achilles tendon during a particular activity (such as running) or shortly after. Moderate - the Achilles tendon may swell. In some cases, a hard lump (nodule) may form in the tendon. Severe - any type of activity that involves weight bearing causes pain of the Achilles tendon. Very occasionally, the Achilles tendon may rupture (tear). When an Achilles tendon ruptures, it is said to feel like a hard whack on the heel.


If you think you might have Achilles tendonitis, check in with your doctor before it gets any worse. Your doc will ask about the activities you've been doing and will examine your leg, foot, ankle, and knee for range of motion. If your pain is more severe, the doctor may also make sure you haven't ruptured (torn) your Achilles tendon. To check this, the doc might have you lie face down and bend your knee while he or she presses on your calf muscles to see if your foot flexes. Any flexing of the foot means the tendon is at least partly intact. It's possible that the doctor might also order an X-ray or MRI scan of your foot and leg to check for fractures, partial tears of the tendon, or signs of a condition that might get worse. Foot and ankle pain also might be a sign of other overuse injuries that can cause foot and heel pain, like plantar fasciitis and Sever's disease. If you also have any problems like these, they also need to be treated.

Nonsurgical Treatment

Nonsurgical methods include rest and stop doing activities that cause stress to the tendon. Ice the area by applying ice to the tendon for 15 minutes after exercising. Compress the tendon by using an athletic wrap or surgical tape. Elevate your injury. You can reduce swelling by lying down and raising your foot at a level that is above your heart. Stretch your ankles and calf muscles. Take anti-inflammatory medication (e.g.: ibuprofen to reduce swelling). Wear orthotics and running shoes. Take part in physical therapy.

Achilles Tendon

Surgical Treatment

For paratenonitis, a technique called brisement is an option. Local anesthetic is injected into the space between the tendon and its surrounding sheath to break up scar tissue. This can be beneficial in earlier stages of the problem 30 to 50 percent of the time, but may need to be repeated two to three times. Surgery consists of cutting out the surrounding thickened and scarred sheath. The tendon itself is also explored and any split tears within the tendon are repaired. Motion is started almost immediately to prevent repeat scarring of the tendon to the sheath and overlying soft tissue, and weight-bearing should follow as soon as pain and swelling permit, usually less than one to two weeks. Return to competitive activity takes three to six months. Since tendinosis involves changes in the substance of the tendon, brisement is of no benefit. Surgery consists of cutting out scar tissue and calcification deposits within the tendon. Abnormal tissue is excised until tissue with normal appearance appears. The tendon is then repaired with suture. In older patients or when more than 50 percent of the tendon is removed, one of the other tendons at the back of the ankle is transferred to the heel bone to assist the Achilles tendon with strength as well as provide better blood supply to this area.


Your podiatrist will work with you to decrease your chances of re-developing tendinitis. He or she may create custom orthotics to help control the motion of your feet. He or she may also recommend certain stretches or exercises to increase the tendon's elasticity and strengthen the muscles attached to the tendon. Gradually increasing your activity level with an appropriate training schedule-building up to a 5K run, for instance, instead of simply tackling the whole course the first day-can also help prevent tendinitis.

Posted on March 21st, 2014

Bone spurs and sore feet | SHOES-n-FEET—Solutions for your foot pain

September 11, 2009 - 9:34am | JB says:

Peggy,It sounds like you are having some difficulties that do not sound too much fun.I can give you a few ideas of what to look for in footwear.These are just suggestions since I would need to see your foot to really make a recommendation.

The New Balance 768 is built on a PL/SL 1 semi-curved last (The last is what the shoe is built on).What does that mean?The PL/SL 1 means that it fits narrower and shallower than their other shoes, built on a PL/SL 2 last.With the spur/bump on your joint you want to have enough depth in the shoe so it does not put pressure downward on the big toe.The semi-curved fit is intended for someone who has a high arch with a little bit of pronation (collapsing of the arch inward).

With out knowing what your arch does it makes it difficult to recommend shoes for you.

General shoes characteristics I would think of for someone with your problems are:
1. Wide enough in the toe box
2. Deep enough toe box
3. Stiffer forefoot (where the shoe bends in thefront) having a forefoot rocker might take some pressure off of the ball of the foot, by not allowing the toes to bend as much.

For more specific information about the right shoes for your feet visit one of our Certified Shoe Fitting Specialists at your local SHOES-n-FEET store.

I am wondering if others have additional suggestions for Peggy?

Best regards,

SHOES-n-FEET -San Francisco

Posted on March 20th, 2014

Toe Pain From a Broken Toe - Toe Pain From a Broken or Fractured Toe
A broken toe is usually recognized immediately by severe pain and a cracking or popping sound that is heard as a small bone in the toe fractures. Most broken toes are the result of dropping something heavy on the toe. But a missed step, a stubbed toe or aggravated stress fractures from repeated impact on a hard surface may also result in a fractured toe.
Signs and Symptoms of a Broken ToeWhen a bone in the toes break, pain is immediate and usually quite intense. The affected toe will swell and bruise. And if the break is traumatic, the toe may look crooked or deformed. Typically a broken toe results in the inability to walk normally andpain with walking or putting on shoes.
When To See a Doctor for Toe PainAny traumatic toe injury or crushing toe injury should be seen by a physician. If you have any numbness or tingling, an open wound or bleeding, you should seek medical attention immediately.If you have an obvious deformity, a visit to the doctor for an x-ray will determine if the bone needs any special treatment such as splinting or applying a cast. Most toe fractures are treated with a small splint or "buddy taping," in which the broken toe is taped to the toe next to it in order to keep it stable and aligned as it heals.
Home Treatment for a Broken ToeMost toe fractures can be cared for at home with usual injury treatment that includes rest, ice and elevation.
While the bone heals, it's important to avoid walking or putting excess pressure on the joint. Ice the affected toe several times a day for no more than 20 minutes each time. Keep your foot elevatedto decrease the swelling in the foot.

A shoe with a stiff sole is usually recommended in order to prevent any movement of the joint while walking.

You may also want to talk with your doctor about using an over-the-counter pain medication.

Broken Toe ComplicationsThe most common complication of a broken toe is trauma to the toenail of the affected toe. Toenails may become discolored, turn black and blue and even fall out. The toenail will usually regrow normally, but it may be wise to see a podiatrist as you heal. A podiatrist can help you avoid ingrown toenails or any infection in the nail bed as your toe heals. If blood collects under the nail, a podiatrist may need tomake a small hole in the nail to allow the blood to escape.
Broken Toe Healing TimesAfter the splint or buddy taping is removed, it's important to begingentle stretching and range of motion exercises for the broken toe. The goal of the exercise is to obtain the same range of motion as the same toe on the opposite foot.
Most broken toes will heal within four to six weeks. Some people are more prone to chronic pain or stiffness in the affected joint, and in some cases, may develop arthritis in the future.

What Causes a Toe Stress FractureStress fractures in the bones of the feet or toes are usually caused by overtraining or overuse. They can also be caused by repeated pounding or impact on a hard surface, such as running of concrete. Increasing the time, type or intensity of exercise too rapidly is another cause of stress fractures to the feet, as is wearing improper footwear.
Any foot pain that continues for more than one week should be seen by a doctor for a thorough evaluation and diagnosis.


Robert L. Hatch, M.D., M.P.H, and Scott Hacking, M.D.,Evaluation and Management of Toe Fractures. The American Academy of Family Physicians, December 15, 2003.

Posted on March 18th, 2014

Foot Conditions | Bunionette (Tailor's Bunion) | Houston Methodist Orthopedics & Sports Medicine in the Greater Houston Area, TX


A Patient's Guide to Bunionette (Tailor's Bunion)
A Patient's Guide to Bunionette (Tailor's Bunion)
A bunionette is similar to a bunion, but it develops on the outside of the foot. It is sometimes referred to as a tailor's bunion because tailors once sat cross-legged all day with the outside edge of their feet rubbing on the ground. This produced a pressure area and callus at the bottom of the fifth toe.

This guide will help you understand
where a bunionette develops why a bunionette causes problems what can be done to treat a bunionette
Where does a bunionette develop?

A bunionette occurs over the area of the foot where the small toe connects to the foot. This area is called the metatarsophalangeal joint, or MTP joint. The metatarsals are the long bones of the foot. The phalanges are the small bones in each toe. The big toe has two phalanges, and the other toes have three phalanges each.

Related Document: A Patient's Guide to Foot Anatomy

How does a bunionette develop?

Today a bunionette is most likely caused by an abnormal bump over the end of the fifth metatarsal (the metatarsal head) rubbing on shoes that are too narrow. Some people's feet widen as they grow older, until the foot splays. This can cause a bunion on one side of the foot and a bunionette on the other if they continue to wear shoes that are too narrow. The constant pressure produces a callus and a thickening of the tissues over the bump, leading to a painful knob on the outside of the foot.

Related Document: A Patient's Guide to Bunions

Many problems that occur in the feet are the result of abnormal pressure or rubbing. One way of understanding what happens in the foot as a result of abnormal pressure is to view the foot simply. Essentially a foot is made up of hard bone covered by soft tissue that we then put a shoe on top of. Most of the symptoms that develop over time are because the skin and soft tissue are caught between the hard bone on the inside and the hard shoe on the outside.

Any prominence, or bump, in the bone will make the situation even worse over the bump. Skin responds to constant rubbing and pressure by forming a callus. The soft tissues underneath the skin respond to the constant pressure and rubbing by growing thicker. Both the thick callus and the thick soft tissues under it are irritated and painful. The answer to decreasing the pain is to remove the pressure. The pressure can be reduced from the outside by changing the pressure from the shoes. The pressure can be reduced from the inside by surgically removing any bony prominence.

What do bunionettes feel like?

The symptoms of a bunionette include pain and difficulty buying shoes that will not cause pain around the deformity. The swelling in the area causes a visible bump that some people find unsightly.

How do doctors identify a bunionette?

The diagnosis of a bunionette is usually obvious on physical examination. X-rays may help to see if the foot has splayed and will help decide what needs to be done if surgery is necessary later.

What can be done for a bunionette?

Nonsurgical Treatment
Treatment initially is directed at obtaining proper shoes that will accommodate the width of the forefoot. Pads over the area of the bunionette may help relieve some of the pressure and reduce pain. These pads are usually sold in drug and grocery stores. They are small and round with a hole in the middle, like a small doughnut.

If all else fails, surgery may be recommended to reduce the deformity. Surgery usually involves removing the prominence of bone underneath the bunion to relieve pressure. Surgery may also be done to realign the fifth metatarsal if the foot has splayed.
Bunionette Removal
To remove the prominence, the surgeon makes a small incision in the skin over the bump. The bump is then removed with a small chisel, and the bone edges are smoothed. Once enough bone has been removed, the skin is closed with small stitches.
 Distal Osteotomy
If your doctor decides that the angle of the metatarsal is too great, the fifth metatarsal bone may be cut and realigned. This is called an osteotomy. Once the surgeon has performed the osteotomy, the bones are realigned and held in position with metal pins. The metal pins remain in place while the bones heal.

What should I expect after treatment?

Nonsurgical Rehabilitation
Patients with a painful bunionette may benefit from four to six physical therapy treatments. Your therapist can offer ideas of shoes that have a wide forefoot, or toe box. The added space in this part of the shoe keeps the metatarsals from getting squeezed inside the shoe. A special pad can also be placed over the bunionette.

These simple changes to your footwear may allow you to resume normal walking immediately, but you should probably cut back on more vigorous activities for several weeks to allow the inflammation and pain to subside.

Treatments directed to the painful area help control pain and swelling. Examples include ultrasound, moist heat, and soft-tissue massage. Therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can't tolerate injections.

After Surgery
Patients are usually fitted with a post-op shoe. This shoe has a stiff, wooden sole that protects the toes by keeping the foot from bending. Any pins are usually removed after the bone begins to mend (usually three or four weeks). You will probably need crutches briefly after surgery, and a therapist may be consulted to help you use your crutches.

You will probably wear a bandage or dressing for about a week following the procedure.The stitches are generally removed in 10 to 14 days. However, if your surgeon chose to use sutures that dissolve, you won't need to have the stitches taken out.

During your follow-up visits, X-rays will probably be taken so that the surgeon can follow the healing of the bones and determine how much correction has been achieved.
*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.All content provided by eORTHOPOD(R) is a registered trademark of Medical Multimedia Group, L.L.C..Content is the sole property of Medical Multimedia Group, LLC and used herein by permission. PRINTABLE BOOKLET

Meet our Foot and Ankle Specialists
Texas Medical Center
Pedro Cosculluela, M.D.*
Kevin E. Varner, M.D.*

Sugar Land
David Braunreiter, M.D. (primary care)
Kenneth M. Renney, M.D. (primary care)
Christopher K. Smith, M.D.
Ray R. Valdez, M.D.*

Travis Hanson, M.D.*

Pedro Cosculluela, M.D.*

West Houston/Katy
Pedro Cosculluela, M.D.*

Physicians marked with an asterisk (*) are fellowship-trained in the field of foot and ankle surgery.

To schedule an appointment with one of our foot or ankle specialists, visit the Request an Appointment page or contact us.

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Our SpecialtiesJoint Replacement (Arthroplasty) Sports Medicine Spine Surgery Hand & Wrist Surgery Foot & Ankle Surgery Physical Therapy
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Posted on March 16th, 2014

Bunions, bunion pain, foot surgery, big toe joint
What Is a Bunion?

A bunion is an enlargement of the joint at the base of the big toe--the metatarsophalangeal (MTP) joint--that forms when the bone or tissue at the big toe joint moves out of place. This forces the toe to bend toward the others, causing an often painful lump of bone on the foot. Since this joint carries a lot of the body's weight while walking, bunions can cause extreme pain if left untreated. The MTP joint itself may become stiff and sore, making even the wearing of shoes difficult or impossible. A bunion--from the Latin "bunio," meaning enlargement--can also occur on the outside of the foot along the little toe, where it is called a "bunionette" or "tailor's bunion."

Development of a firm bump on the outside edge of the foot, at the base of the big toe.Redness, swelling, or pain at or near the MTP joint.Corns or other irritations caused by the overlap of the first and second toes.Restricted or painful motion of the big toe.
How Do You Get a Bunion?

Bunions form when the normal balance of forces that is exerted on the joints and tendons of the foot becomes disrupted. This can lead to instability in the joint and cause the deformity. They are brought about by years of abnormal motion and pressure over the MTP joint. They are, therefore, a symptom of faulty foot development and are usually caused by the way we walk, and our inherited foot type, our shoes, or other sources.

Although bunions tend to run in families, it is the foot type that is passed down--not the bunion. Parents who suffer from poor foot mechanics can pass their problematic foot type on to their children, who in turn are prone to developing bunions. The abnormal functioning caused by this faulty foot development can lead to pressure being exerted on and within the foot, often resulting in bone and joint deformities such as bunions and hammertoes.

Other causes of bunions are foot injuries, neuromuscular disorders, or congenital deformities. People who suffer from flat feet or low arches are also prone to developing these problems, as are arthritic patients and those with inflammatory joint disease. Occupations that place undue stress on the feet are also a factor; ballet dancers, for instance, often develop the condition.

Wearing shoes that are too tight or cause the toes to be squeezed together is also a common factor, one that explains the high prevalence of the disorder among women.

What Can You Do For Relief?
Apply a commercial, nonmedicated bunion pad around the bony prominence.Wear shoes with a wide and deep toe box.If your bunion becomes inflamed and painful, apply ice packs several times a day to reduce swelling.Avoid high-heeled shoes over two inches tall.See your podiatric physician if pain persists.
Conservative Treatment For Bunion Pain

Treatment options vary with the type and severity of each bunion, although identifying the deformity early in its development is important in avoiding surgery. Podiatric medical attention should be sought at the first indication of pain or discomfort because, left untreated, bunions tend to get larger and more painful, making nonsurgical treatment less of an option.

The primary goal of most early treatment options is to relieve pressure on the bunion and halt the progression of the joint deformity. A podiatric physician may recommend these treatments:
Padding & Taping
Often the first step in a treatment plan, padding the bunion minimizes pain and allows the patient to continue a normal, active life. Taping helps keep the foot in a normal position, thus reducing stress and pain.Medication
Anti-inflammatory drugs and cortisone injections are often prescribed to ease the acute pain and inflammations caused by joint deformities.Physical Therapy
Often used to provide relief of the inflammation and from bunion pain. Ultrasound therapy is a popular technique for treating bunions and their associated soft tissue involvement.Orthotics
Shoe inserts may be useful in controlling foot function and may reduce symptoms and prevent worsening of the deformity.
Surgical Options

When early treatments fail or the bunion progresses past the threshold for such options, podiatric surgery may become necessary to relieve pressure and repair the toe joint. Several surgical procedures are available to the podiatric physician. The surgery will remove the bony enlargement, restore the normal alignment of the toe joint, and relieve pain.

A simple bunionectomy, in which only the bony prominence is removed, may be used for the less severe deformity. Severe bunions may require a more involved procedure, which includes cutting the bone and realigning the joint.

Recuperation takes time, and swelling and some discomfort are common for several weeks following surgery. Pain, however, is easily managed with medications prescribed by your podiatric physician.

Bunion Tips
Wear comfortable shoes that conform to the shape of your foot.Wear shoes with a wide and deep toe box.Always fit the larger foot and have your feet sized each time you purchase shoes.Apply a commercial, nonmedicated bunion pad around the bony prominence.If your bunion becomes inflamed and painful, apply ice packs several times a day to reduce swelling.Avoid high-heeled shoes over two inches tall.Seek professional podiatric evaluation and assistance with uncomfortable or noticeable bunions.
Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.

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