Operative Foot Care with Valley Foot Surgeons

As one of the leading Arizona podiatrists for decades, Valley Foot achieves optimal outcomes with its patients time and time again. The goal is to help you get better with the least invasive options available, which would hopefully include avoiding surgery. However, there are times when foot and ankle surgery is necessary as a quality of life decision to reach the best outcome. Valley Foot Surgeons and Dr. Richard Jacoby understand the importance of that decision, and as one of the best podiatrists in the Phoenix, Scottsdale, and Mesa areas, are experts in helping you make the right treatment choices. Here are the operative treatments provided at Valley Foot Surgeons (click on each for more information). Minor office procedures such as Corns are discussed HERE.

What is a bunion?

Bunions are a problem in the feet that most commonly affect women. They may or may not cause symptoms for patients such as foot pain. Typically they affect the inner side of the foot with an irregular bony bump at the joint where the big toe meets the main bones of the feet. This joint is called the metatarsophalangeal (MTP) joint.

Once a bunion occurs, the end of the big toe bends toward the other toes and a crowding effect occurs. As this occurs, the bony bump gets worse as the bone at the base of the toe moves outward. The pain of a bunion comes from resulting inflammation and the bone or the bump is pressing up against the shoe.

The large bump that occurs at the base of the big toe is not simply a misalignment. There is also additional bone formation. The resulting deformity is called in medical terms hallux valgus.

There is also a rare form of a bunion that occurs on the outer part of the foot at the base of the 5th toe. This is much less common than at the base of the big toe and is referred to as a tailor’s bunion.

Why do Bunions occur?

bunnionsBunions occur 10 times more frequently in women than men. They are much more frequent in people who wear shoes then in those going barefoot. There is much we still have to learn about the precise causes of bunions, however, it is known that tight fitting shoes, especially narrow toed and high heel shoes, increase the risk of getting a bunion.

Also, it is widely thought that genetics have an influence on bunion formation, especially when the bunion occurs in a younger individual. Additional reasons thought to contribute to a bunion include rheumatoid arthritis, an abnormality of nerves, a congenital bone issue, or repetitive foot injury. Ballet dancers frequently get bunions and it is thought to have happened from the repetitive injury sustained from putting their feet in extreme positions.

What are the signs and symptoms of a Bunion?

Just because an individual has a bunion does not mean that he or she will have symptoms from it.  A person  may have not symptoms for years despite having a prominent buion. If it does become symptomatic, the most common is foot pain in the area of the bunion during walking. This pain may be intermittent or chronic sort of like having a pebble in your shoe.

bunnionsPatients may have redness, soft tissue swelling, and tenderness around the bunion area. Particular attention should be focused on the area of the bunion as pain in that specific area can come from gout in both men and women and it can appear similar to having a bunion. The treatment for gout is completely different than a bunion.

How is a Bunion diagnosed?

Typically the history that a patient describes along with the physical examination or what is truly needed to diagnose abundant. X-rays of the foot are also necessary to make sure get out is not obvious and also to look specifically at the alignment severity of the bunion. This may help with the type of surgery that needs to be performed if it becomes necessary.

How are bunions treated non-operatively?

Non-operative bunion treatments involve wearing wider shoes that allow enough room for the foot to breathe and not be compressed and so painful. If the bunion is experiencing a painful flare, avoiding extreme walking may help a lot with pain relief as well.

Taking medication such as ibuprofen products or aspirin can help relieve the inflammation from the bunion. This should be taken in accordance with your doctor’s recommendation and the manufacturers recommended dosages. Applying a cold pack over the area of pain on a temporary basis may help too. Ice should not be placed continuously over the area, rather 10 to 20 minutes at a time. It also should not be placed directly on the skin, but rather a thin cloth should be placed over the skin for protection.

Stretching exercises can help a lot to reduce tension on a bunion. Night splinting with a bunion splint can also provide relief. Arch supports, bunion pads, or custom orthotics that are positioned just behind the big toe joint may help redistribute your weight which can take pressure off the big toe while walking. Custom insoles may make it easier to walk.

Protection can be placed between the bunion and the shoes with felt patches or moleskin around these pressure points.

Your foot doctor may administer a local pain management injection such as with cortisone wore a nonsteroidal substance for pain relief. At times the skin may break down over the bunion and an infection may result which could require antibiotics. Most of the time, bunions are effectively able to be treated without surgery.

When these conservative measures fail, a surgical procedure may be indicated to remove the bunion. This is called a bunionectomy and may alleviate pain and fix the deformity. The basic premise of a bunionectomy is to remove the bony overgrowth while fixing the misalignment of the toe.

There are multiple different types of procedures to fix a bunion problem. The specific one selected will depend on the age of the patient, the severity of the bunion, and how the alignment looks on x-rays. Undergoing surgery for a bunion is a quality of life decision. Having a bunion has never been a fatal condition, and if it is not significantly painful for a patient it is not something that has to have surgery.

Having surgery for a bunion simply based on a desire for a better cosmetic result may end up being a poor decision. It is best first and foremost to have the surgery to alleviate pain. Almost a third of those who have surgery for bunions are not completely satisfied with the result even if there is a reduction in pain and the alignment looks good. This may mean that your surgeon does a technically perfect job with the surgery, but the expectation of the result may not be met.

Having surgery for a bunion may end up with an excellent outcome. The doctors at Valley Foot Surgeons are experts in bunion procedures. There is a possibility of a bunion returning in the future despite an excellent initial outcome. Wearing roomier footwear is one of the best things that you can do after bunion surgery.

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Hammer Toes

Overview

A hammer toe is a deformity of the second, third, or fourth toe with bending at the middle joint of the toe. It’s called a “hammer toe” because that’s actually what it resembles. It is the most common deformity problem seen in the small toes.

Initially, as hammer toes develop, they are flexible and may become corrected without surgery. If untreated though, hammer toes may become permanently deformed and need an operation for correction. The tendons and ligaments that tighten cause the joints of the toe to curl in a downward direction.

Individuals dealing with hammer toes often have calluses on the toe’s top middle joint or tip of the toe. The condition may be painful and it can be very difficult to find comfortable shoes.

Why do Hammer Toes occur?

They may occur from improperly fitting shoes. If the shoe becomes too narrow in the toe region, it can push the toes into a bent position. Calluses may form where the toes are rubbing against the shoe. Heels place the foot in a downward position and further compresses the toes against the shoe, which makes the bend worse. There comes a point when people are unable to straighten the toe anymore even without the shoe on due to muscles that can no longer compensate.

Hammer Toes may also occur from a muscle imbalance. Having a straight toe represents a muscular balancing act between those that flex the toe versus those that extend the toe. If imbalance occurs from the toes being bent in one position for too long, certain muscle become too tight and can no longer stretch. The opposing muscles continue to work, however, and a deformity results which in this case is a hammer toe.

There are also inflammatory conditions of the toe joints that may lead to Hammer Toes, such as MTP synovitis or inflammatory arthropathies.

The exact incidence of Hammer Toes is not defined, but there is an association in patients who have second toes longer than the first.

What are the different types of Hammer Toes?

Basically there are two types – flexible and rigid. When a Hammer Toe is flexible, it maintains the ability to move and can be straightened manually. When a Hammer Toe becomes rigid, movement is no longer possible. Any type of movement attempted with a rigid Hammer Toe may be painful. Due to this restricted movement and pain, extra stress may be seen at the ball of the foot, leading to additional pain and calluses.

For those knowledgeable of anatomy terms, there is a flexion deformity of the proximal interphalangeal joint (PIP) with hyperextension of both the metatarsophalangeal (MTP) and distal interphalangeal (DIP) joints.

What symptoms are seen with Hammer Toes?

Patients dealing with Hammer Toes experience calluses or corns on the affected toe(s) and pain in the area. Finding comfortable shoes may be difficult. Patients often have pain on the top of the proximal interphalangeal joint or on the bottom of the affected toe back at the MTP joint.

What treatment exists for Hammer Toes?

The initial treatment for painful Hammer Toes is changing the type of footwear. The toe box area should be high and broad, sufficient to accommodate the hammer toes. This will minimize toe friction and reduce pain. It is not a good idea to continue wearing high heels while suffering from symptomatic hammer toes. Your shoes should be at least one-half inch longer than the longest toe. There are stretching and strengthening exercises that can be performed daily that may help as well (almost like an easy home physical therapy program).

There are also some forefoot products that may help substantially, such as (we would insert the type of products you have at the office here).

Surgery for Hammer Toes may become necessary if conservative treatments fail. There are multiple surgical options available, and will depend on your specific type of deformity. Surgical options have included fusing bones, transferring tendons or lengthening them, metatarsal shortening, or a joint resection.

If a patient is having correction of a bunion deformity, it is a good idea to fix associated Hammer Toes at the same time, even if it is not very painful. Otherwise, the surgery should only be performed for pain relief, as it is not intended to be a cosmetic surgery.

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Achilles Tendon Tear Repair

The Achilles tendon is a large fibrous tissue structure connecting the calf muscles to the heel bone and one of the largest and strongest tendons in the body. It may partially tear or rupture, especially in middle aged individuals participating in recreational sports as “weekend warriors.” When the tendon ruptures, one may feel a snap or even hear a pop, with subsequent immediate sharp pain in the back of the lower leg and difficult walking. A person may actually have no symptoms, but that would be unusual. Typically along with the pain there is swelling with difficulty “pushing off” with the foot while walking. With a complete rupture, the person will also not be able to stand up on the toes of the injured leg.

As a person ages, the blood flow to the Achilles tendon slowly decreases. Because of this, it becomes more prone to rupturing at an area between 2 and 3 inches from the heel bone. A typical scenario is a rupture from a fall or stepping into a hole, and the common “weekend warrior” rupture due to a sudden increased intensity in sports participation.

There are some patients who are at increased risk of rupturing the Achilles, and the age range of 30 to 40 is the peak. Men are five times more likely to tear the Achilles than women. An additional risk factor is being on antibiotics called fluoroquinolones (Cipro or Levaquin) or having received steroid injections nearby, which may weaken the tendon.

When being evaluated for an Achilles injury, the doctor will perform some physical exam tests looking at the extent of injury. Sometimes it’s so obvious an MRI is not necessary. But if it appears to be only partially torn, an MRI can show the tear and whether or not it’s complete with retraction of the tendon up into the calf muscle area.

Surgery is not mandatory for an Achilles tear, but it is often the chosen treatment for younger individuals. There are studies showing equal effectiveness for operative versus nonoperative treatment. However, there are also studies showing a significantly longer healing time for conservatively treated tears and a higher re-rupture rate.

When a tear is treated nonoperatively, the patient is placed into a cast or walking boot with the heel elevated attempting to approximate the torn tendon edges for healing. The risks of surgery are avoided, but the re-rupture rate has been shown to be higher.

Achilles tendon rupture operative repair is very common. The surgeon makes as small an incision as possible to then stitch the tendon back together, or it may be necessary to reinforce the repair with additional tendon tissue. There are standard risks of surgery involved such as infection.

After the procedure, a rehab program with physical therapy will be necessary and most individuals are back to full activity within 4 to 6 months.

Valley Foot Surgeons has been supplementing selected Achilles Tendon repairs with stem cell rich injections and noticing accelerated wound healing compared to what is typically seen. The potential for this is better wound healing with quicker recovery!

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Peripheral Neuropathy and Diabetic Neuropathy
(Dellon Procedure)

Peripheral neuropathy involves damage to the peripheral nervous system, and there are multiple different types. Diabetic neuropathy is one of those types, and similar to other causes of peripheral neuropathy may lead to severe burning pain along with pins and needles in the feet and legs.

Treatment for peripheral neuropathy is not a one size fits all, and the surgeons at Valley Foot have a broad range of operative and nonoperative options depending on the type of neuropathy and severity. The expertise is so deep that the Scottsdale Neuropathy Institute was created to specifically focus on comprehensive treatment for all types of peripheral neuropathy.

Nonoperative treatments for peripheral neuropathy at the Scottsdale Neuropathy Institute (SNI) include

  • pain medications
  • Neurologic modulating medications
  • Stem Cell Rich Injections
  • Laser Treatments
  • L-Arginine Amino Acid
  • Regional Nerve Blocks
  • B-Complex Vitamins
  • Light Emitting Diode Therapy (Anodyne)
  • Tricyclic Therapy
  • Nutritional Supplements

A lot of doctors believe that neuropathy symptoms can only be masked and not cured.

The Dellon Decompression Procedure was developed in response to this theory, and has been a revolution in the treatment of peripheral neuropathy. The procedure was pioneered by Dr. Lee Dellon, a plastic surgeon at Johns Hopkins University. The surgery involves freeing up the pressure areas in the legs, ankles, and feet, similar to a carpal tunnel procedure. caption – The Dellon Procedure can relieve peripheral neuropathy pain

Dr. Richard Jacoby, a Four Time Phoenix Magazine Top Doc Winner as a leading Scottsdale Podiatrist, has performed thousands of successful Dellon Procedures for peripheral neuropathy, most commonly in diabetic neuropathy patients. In indicated patients, studies have shown the procedure maintains an 80% effectiveness with good to excellent relief of neuropathic pain or numbness.

In addition, the results at SNI have shown that no patients have needed to go on to subsequent diabetic amputations.* Peripheral neuropathy is not an easy diagnosis to treat, and SNI has been successfully combining its comprehensive options for years to the benefit of patients dealing with a painful, disabling disease. *Results cannot be guaranteed.

Watch The Real Bears show you the Truth About Soda and Diabetes:

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Tarsal Tunnel Release

Tarsal tunnel syndrome is compression of the tibial nerve as it passes through the tarsal tunnel. It is a painful compression neuropathy also known as posterior tibial neuralgia. The tarsal tunnel itself is found on the inside of the foot and ankle just behind the bony bump.

There are multiple structures that pass through the tarsal tunnel, including the tibial nerve, posterior tibial artery, and multiple tendons. While in the tunnel, the tibial nerve splits into 3 different paths. One goes to the heel (calcaneal nerve), while the other two (medial and lateral plantar nerves) continue on the bottom of the foot.

The tarsal tunnel itself is bordered by bone on the inside, and a soft tissue structure on the outside called the flexor retinaculum. Where patients complain of pain depends on where the compression is occurring. If it is occurring high in the tunnel, the entire foot may feel pain, burning, electrical sensations, and some tingling. More commonly, compression occurs lower in the tarsal tunnel and patients complain of numbness in the foot which affects the big toe and the first 3 toes.

If the compression is high in the tunnel, along with the symptoms above patients may have ankle pain and swelling.

Here is a broader description of potential patient symptoms from Tarsal Tunnel Syndrome:

  • Pain and tingling in and around ankles and sometimes the toes
  • Swelling of the feet
  • Painful burning, tingling, or numb sensations in the lower legs. Pain worsens and spreads after standing for long periods; pain is worse with activity and is relieved by rest.
  • Electric shock sensations
  • Pain radiating up into the leg, and down into the arch, heel, and toes
  • Hot and cold sensations in the feet
  • A feeling as though the feet do not have enough padding
  • Pain while operating automobiles
  • Pain along the Posterior Tibial nerve path
  • Burning sensation on the bottom of foot that radiates upward reaching the knee
  • “Pins and needles”-type feeling and increased sensation on the feet

The diagnosis of tarsal tunnel syndrome is often made by patient history alone. The doctor will tap over the area of the tarsal tunnel, and if that causes a tingling electrical shock sensation that is called a positive Tinel’s sign. The workup may include x-rays, an MRI, and quite possibly a nerve conduction study to test for severity. In actuality though, a nerve conduction study may be completely negative, even if the tarsal tunnel syndrome is very significant.

tarsal tunnel

You can see in this photo as the tarsal tunnel is being released that the tibial nerve is swollen and being significantly pinched as it sits under the tarsal tunnel tissue. This patient did very well after the nerve got some relief!

It may be very difficult to determine the specific cause for the problem. Anything that creates pressure in the tarsal tunnel may compress on the tibial nerve. The syndrome is common in athletes, and various causes include inflammation, bone spurs, swelling from a sprained ankle, or a ganglion cyst.

Treatment for tarsal tunnel syndrome includes rest,ice, strengthening, anti-inflammatories, low dose narcotics, a walker boot, corticosteroid injections, along with various types of wraps and medications like Lyrica or Neurontin. Laser treatment may help decrease inflammation as well, and physical therapy may alleviate symptoms too.

If conservative treatments fail, a tarsal tunnel release surgery may provide substantial relief.

Here is an example of a tarsal tunnel release. Patient is a runner who had been having chronic symptoms of tarsal tunnel syndrome which failed conservative treatment.

During surgery, the tarsal tunnel was approached. You can see in this surgery picture that you would not know from looking at the tissue on the outside of the tarsal tunnel that there was anything wrong underneath.

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Foot and Ankle Fracture Treatment

Valley Foot Surgeons has significant expertise in treating foot and ankle fractures. Fractures are evaluated to determine the stability of the injury along with how separated the bony fragments are. In addition, it is important to determine the extent of the soft tissue injuries as well. Ankle fractures for instance will often involve ligament injuries which can affect the stability, even if the broken ankle looks not too bad on x-rays. Fractures treated at Valley Foot Surgeons include:

  • Ankle Fractures
  • Toe Fractures
  • Talus Fractures
  • Calcaneus (Heel) Fractures
  • Stress Fractures

These fractures may simply require a cast or brace without surgery, or may need a pin or two placed to ensure proper bony alignment during healing. More severe fractures may need what is called an open reduction and internal fixation (ORIF) to ensure the best chance of healing properly.

Here is an example of an ankle fracture.

It is just as important to consider the soft tissue injury as the bony injury, and Valley Foot Surgeons knows this. The soft tissues around the fracture are treated with respect and utmost care during surgery.

If you have a foot and ankle injury with a suspected fracture, Valley Foot Surgeons is here to help. These Scottsdale podiatrists use the most modern methods of treating fractures, and often enhance healing with added Laser treatments and regenerative injections. Call Today.

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Crush Injury Treatment

A crush injury may be very difficult to heal and involves a significant high energy force coming down on your foot. This may be an industrial machine, an animal, or injury from an auto or motorcycle accident. The soft tissue injuries in this case are just as important to handle properly as the bony injury.

Valley Foot Surgeons maintains significant expertise in handling crush injury treatment from both the bony and soft tissue injury aspects. Viable tissue is preserved, while tissue that is dead will be removed to lower the chances of subsequent infection.

Valley Foot often supplements treatment with laser treatments and stem cell rich injections, both have shown substantial promise in improving both the chances of success while reducing the time necessary for recovery.

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Ankle Ligament Reconstruction

Ankle instability occurs when ligaments are stretched or torn and most commonly affects the outer ankle ligaments including the anterior talofibular ligament (ATFL). If these ligaments remain unstable patients will develop chronic ankle instability.

Phoenix podiatrist

Ligaments repaired with Brostrom procedure

For those individuals dealing with continued instability issues and pain in the ankle, an ankle ligament reconstruction procedure known as the Brostrom procedure may work well. It has been shown to restore full ankle function in over 90% of patients along with relieving pain.

As the premier Phoenix and Scottsdale podiatry doctors in the Southwest, Valley Foot Surgeons has been performing the Brostom procedure with excellent results for many years. The procedure restores stability to the ankle and reduces the incidence of ankle sprains in the future.

A small incision is made on the outsie part of the ankle and the ligaments are evaluated and repaired where injured. An intra-substance tear can be sutured and if the ligament has torn off the bone an anchor may be placed into the bone with sutures attached.

The overlying band of fibrous tissue over these ligaments is tightened to supplement the reconstruction. The combination of direct repair plus the overlying supplementation (of the extensor retinaculum) provides for a tight repair and substantial ankle stability along with reduced pain.

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Peroneal tendon repair

Scottsdale podiatrist

Surgical repair of peroneal tendons

There are two peroneal tendons on the outer side of the ankle. They help with lateral movement of the ankle and stability. They may tear after a previous ankle sprain or from chronic looseness of the ankle.

With pain and ankle instability, a physical examination may display gliding peroneal tendons. An MRI or ultrasound may be necessary to confirm the injury.

Tendon tears may be directly repaired, and proper tension may be placed to ensure adequate strength and enhanced stability. If the tendon is subluxing out of its regular position, the normal groove where it’s supposed to be positioned may be deepened. Then the overlying fibrous tissue may be tightened to ensure the peroneal tendons stay where they are supposed to be. Valley Foot Surgeons has performed this procedure hundreds of times successfully in patients, and are experts in the procedure.

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Foot and Ankle Arthritis Treatment

Patients develop arthritis in the foot and ankle for a number of reasons including degeneration from normal wear and tear, post-traumatic, or an inflammatory condition such as rheumatoid arthritis.

At times these may be treated effectively nonsurgically with medication, bracing, physical therapy, laser treatments, or injections with either steroid or regenerative stem cell rich substances.

If these happen to fail, as a quality of life decision surgery may be undertaken to improve a patient’s function and decrease associated pain.

The award winning team of Scottsdale and Phoenix podiatry doctors at Valley Foot Surgeons offers multiple surgical approaches to arthritis in the ankle joint or toe joints. One of these conditions is hallux rigidus (arthritis of the great toe MTP joint).

The first type of surgery is a bony fusion, which involves removing the joint’s cartilage and welding the bones together. This will decrease pain of the arthritic joint and typically increase function. Valley Foot Surgeons has performed thousands of successful ankle, foot, and toe fusions over the past three decades.

The second type of surgery is revolutionary in the field of foot and ankle surgery. Valley Foot Surgeons has been treating foot and ankle arthritis that is severe with an operative procedure involving cartilage drilling and stem cell rich injections. This procedure has been showing anecdotal success with significant improvements, allowing individuals to avoid the risks of a fusion and to maintain range of motion in the affected joint.

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The FAST Tendonitis Procedure

Dr. Richard Jacoby is now offering the FAST procedure for patients with foot and ankle tendonitis. The FAST procedure is a minimally invasive procedure designed to remove the scarred, damaged, and inflamed tissue that is the the source of tendonitis pain. The procedure leaves the surrounding healthy tendon tissue alone.

It is called FAST which stands for Focused Aspiration of Scar Tissue, and involves using a toothpick sized instrument delivering ultrasonic energy  to break up and safely remove damaged tissue. The incision is so small a Band-Aid covers it up nicely.

It works well for Achilles tendonitis, peroneal tendonitis, plantar fasciitis, and more! Open procedures for these conditions often have significant wound healing problems, and the FAST procedure does not entail large incisions. So the wound healing problems are largely avoided.

FAST procedure

The procedure achieves the goal of open surgery, with the benefit of only needing local anesthesia in a nonsurgical setting. Normal activities can often be started again within one to two months.

For more information on the FAST Procedure, call (480) 994-5977 and visit the FAQ Page on the FAST HERE.

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Testimonials

I was facing an ankle fusion or replacement and needed crutches all the time. Dr. Jacoby performed a cartilage drilling on my ankle with a stem cell injection. I don’t need surgery or crutches anymore. Thanks!

-Tom P, Scottsdale