Overview
In medical terms, a bunion, or hallux valgus, is a bony bump that forms around the joint at the base of your big toe. This joint is one of the most important parts of your foot, bearing most of your body weight. The bony bump is caused by the head of the first metatarsal bone (the long bone) behind the big toe angling out from the foot. This causes the joint to swell, pushing the big toe in towards the adjacent toes. The result is pain on the side of your foot, arch pain, and discomfort throughout the adjacent toes as well.

Causes
Bunions are most often caused by an faulty foot mechanics. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion. Although wearing shoes that crowd the toes won't actually cause bunions in the first place, it sometimes makes the deformity get progressively worse. That means you may experience symptoms sooner.

Symptoms
Symptoms often include pain, swelling, and abnormal position of the first toe. The technical term for bunions is ?hallux valgus? (HV). This refers to the first toe or hallux moving away or abducting from the middle of the foot and then twisting in such a way that the inside edge actually touches the ground and the outside edge turns upward. This term describes the deviation of the toe toward the outside part of the foot. If left untreated, bunions can worsen over time and cause considerable difficulty in walking, discomfort, and skin problems such as corns. In some cases, a small bursa (fluid-filled sac) near the joint becomes inflamed. This condition is known as bursitis and can cause additional redness, swelling, and pain. Less frequently, bunions occur at the base of the fifth toe. When this occurs, it is called a ?tailor?s bunion? or bunionette.

Diagnosis
Orthopaedic surgeons diagnose bunions on the basis of physical examination and weight bearing x-rays. Two angles are assessed, the intermetatarsal angle, that is between the first and second metatarsals (the bones that lead up to the base of the toes). If this angle exceeds 9? (the angle found in the healthy foot) it is abnormal and referred to as metatarsus primus varus. the hallux valgus angle, that is, the angle of the big toe as it drifts toward the small toe. An angle that exceeds 15? is considered to be a sign of pathology.

Non Surgical Treatment
Most of the time, non-surgical (conservative) treatment can control the symptoms of a foot bunion or bunionette. These include. Appropriate Footwear, changing to wide fitting footwear reduces the pressure on the big toe and prevents shoes from rubbing on the bony lump. When possible, go barefoot Toe stretchers are a really simple way to reduce foot bunion pain. Toe Stretchers, wearing toe spaces that fit in-between the toes help to stretch the muscles and ligaments around the toes, improving the alignment and relieving pain. Find out more about how these work in the Toe Stretcher section. Painkillers, your doctor may prescribe or recommend over-the-counter medication to reduce the pain and inflammation. Foot bunion correctors can be worn in your shoe to help realign your foot if you suffer from foot bunions. Orthotics. There are a number of over-the-counter shoe inserts that can help relieve symptoms. Bunion correctors work by realigning the bones in your foot to reduce pressure on the affected toe. There are both day-time and night-time splints on the market, although the evidence of their effectiveness is lacking. Ice. Applying ice packs to the foot can help reduce pain and inflammation. Bunion pads help to reduce any friction on your big toe. Bunion Pads. You can also get protective foot cushions that sit over the skin to prevent the hallux abducto valgus rubbing on your shoes.

Surgical Treatment
Surgery is the only way to correct a bunion. A bunion will usually get worse over time, so if it's left untreated it's likely to get bigger and become more painful. If your bunion is causing a significant amount of pain and affecting your quality of life, your GP may refer you to be assessed for bunion surgery. The aim of surgery is to relieve pain and improve the alignment of your big toe. Surgery isn't usually carried out for cosmetic reasons alone. Even after surgery, there may still be limits to the styles of shoe you can wear. Bunion surgery is often carried out as a day procedure, which means you won't have to stay in hospital overnight. The procedure will either be carried out under a local anaesthetic or a general anaesthetic.

Prevention
There are some steps that may help prevent, or at least slow, the progression of bunions. Avoid shoes with a narrow toe box. If your foot flattens excessively, make sure you wear supportive shoes, and if necessary, get custom orthotics from your podiatrist. See your podiatrist at the first signs or symptoms of a bunion deformity, as early treatment may stop or slow its progression.

Overview
Achilles tendon ruptures commonly occur in athletic individuals in their 30s and 40s while performing activities that require sudden acceleration or changes in direction (ex. basketball, tennis, etc.). Patients usually describe a sharp pain in their heel region almost as if they were ?struck in the back of the leg?. The diagnosis of an acute Achilles tendon rupture is made on clinical examination as x-rays will reveal the ankle bones to be normal. The Achilles is the largest and strongest tendon in the body. It is subject to 2-3 times body weight during normal walking so regaining normal Achilles tendon function is critical. Achilles tendon ruptures can be successfully treated non-operatively, or operatively, but they must be treated. Surgical treatment leads to a faster recovery and a lower rate of re-rupture. However, surgery can be associated with very serious complications such as an infection or wound healing problems. For this reason non-operative treatment may be preferable in many individuals, especially those patients with diabetes, vascular disease, and those who are long-term smokers.

Causes
Ruptured Achilles tendons may result from falling from a height or down a hole. Increasing training intensity abruptly, boosting distance, frequency or duration by more than 10% a week. Failing to stretch before and after exercise. Repetitive training, especially uphill running. Deyhydration, which causes cramping and tightness in the calves. Taking antibiotics. Improper footwear. Explosive movements in competitive sports like basketball, soccer or track & field.

Symptoms
Many people say that a ruptured Achilles feels like ?being shot in the heel?, if you can imagine how enjoyable that feels. You may hear a snap sound or feel a sudden sharp pain when the tendon tears. After a few moments, the pain settles and the back of the lower leg aches. You can walk and bear weight, but you may find it difficult to point the foot downward or push off the ground on the affected side. You will be unable to stand on tiptoe. Bruising and swelling are likely, and persistent pain will be present. Similar symptoms may be caused by an inflamed Achilles tendon (Achilles tendonitis), a torn calf muscle, arthritis of the ankle, or deep vein thrombosis in the calf, so an MRI or ultrasound scan will likely be used to diagnose your condition.

Diagnosis
Laboratory studies usually are not necessary in evaluating and diagnosing an Achilles tendon rupture or injury, although evaluation may help to rule out some of the other possibilities in the differential diagnosis. Plain radiography. Radiographs are more useful for ruling out other injuries than for ruling in Achilles tendon ruptures. Ultrasonography of the leg and thigh can help to evaluate the possibility of deep venous thrombosis and also can be used to rule out a Baker cyst, in experienced hands, ultrasonography can identify a ruptured Achilles tendon or the signs of tendinosis. Magnetic resonance imaging (MRI). MRI can facilitate definitive diagnosis of a disrupted tendon and can be used to distinguish between paratenonitis, tendinosis, and bursitis.

Non Surgical Treatment
If you suspect a total rupture of the achilles tendon then apply cold therapy and compression and seek medical attention as soon as possible. In most cases surgery is required and the sooner this takes place the higher the chances of success. If the injury is left longer than two days then the chances of a successful outcome decrease. Cold and compression can also be applied throughout the rehabilitation phase as swelling is likely to be an issue with such a serious injury.

Surgical Treatment
A completely ruptured Achilles tendon requires surgery and up to 12 weeks in a cast. Partial tears are sometimes are treated with surgery following by a cast. Because the tendon shortens as it heals, a heel lift is used for 6 months or more after the cast comes off. Physical therapy to regain flexibility and then strength are begun as soon as the cast is off.

Overview
Posterior tibial tendon dysfunction is one of several terms to describe a painful, progressive flatfoot deformity in adults. Other terms include posterior tibial tendon insufficiency and adult acquired flatfoot. The term adult acquired flatfoot is more appropriate because it allows a broader recognition of causative factors, not only limited to the posterior tibial tendon, an event where the posterior tibial tendon looses strength and function. The adult acquired flatfoot is a progressive, symptomatic (painful) deformity resulting from gradual stretch (attenuation) of the tibialis posterior tendon as well as the ligaments that support the arch of the foot.

Causes
There are multiple factors contributing to the development of this problem. Damage to the nerves, ligaments, and/or tendons of the foot can cause subluxation (partial dislocation) of the subtalar or talonavicular joints. Bone fracture is a possible cause. The resulting joint deformity from any of these problems can lead to adult-acquired flatfoot deformity. Dysfunction of the posterior tibial tendon has always been linked with adult-acquired flatfoot deformity (AAFD). The loss of active and passive pull of the tendon alters the normal biomechanics of the foot and ankle. The reasons for this can be many and varied as well. Diabetes, high blood pressure, and prolonged use of steroids are some of the more common causes of adult-acquired flatfoot deformity (AAFD) brought on by impairment of the posterior tibialis tendon. Overstretching or rupture of the tendon results in tendon and muscle imbalance in the foot leading to adult-acquired flatfoot deformity (AAFD). Rheumatoid arthritis is one of the more common causes. About half of all adults with this type of arthritis will develop adult flatfoot deformity over time. In such cases, the condition is gradual and progressive. Obesity has been linked with this condition. Loss of blood supply for any reason in the area of the posterior tibialis tendon is another factor. Other possible causes include bone fracture or dislocation, a torn or stretched tendon, or a neurologic condition causing weakness.

Symptoms
Symptoms shift around a bit, depending on what stage of PTTD you?re in. For instance, you?re likely to start off with tendonitis, or inflammation of the posterior tibial tendon. This will make the area around the inside of your ankle and possibly into your arch swollen, reddened, warm to the touch, and painful. Inflammation may actually last throughout the stages of PTTD. The ankle will also begin to roll towards the inside of the foot (pronate), your heel may tilt, and you may experience some pain in your leg (e.g. shin splints). As the condition progresses, the toes and foot begin to turn outward, so that when you look at your foot from the back (or have a friend look for you, because-hey-that can be kind of a difficult maneuver to pull off) more toes than usual will be visible on the outside (i.e. the side with the pinky toe). At this stage, the foot?s still going to be flexible, although it will likely have flattened somewhat due to the lack of support from the posterior tibial tendon. You may also find it difficult to stand on your toes. Finally, you may reach a stage in which your feet are inflexibly flat. At this point, you may experience pain below your ankle on the outside of your foot, and you might even develop arthritis in the ankle.

Diagnosis
It is of great importance to have a full evaluation, by a foot and ankle specialist with expertise in addressing complex flatfoot deformities. No two flat feet are alike; therefore, "Universal" treatment plans do not exist for the Adult Flatfoot. It is important to have a custom treatment plan that is tailored to your specific foot. That starts by first understanding all the intricacies of your foot, through an extensive evaluation. X-rays of the foot and ankle are standard, and MRI may be used to better assess the quality of the PT Tendon.

Non surgical Treatment
Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities.

Surgical Treatment
Until recently, operative treatment was indicated for most patients with stage 2 deformities. However, with the use of potentially effective nonoperative management , operative treatment is now indicated for those patients that have failed nonoperative management. The principles of operative treatment of stage 2 deformities include transferring another tendon to help serve the role of the dysfunctional posterior tibial tendon (usually the flexor hallucis longus is transferred). Restoring the shape and alignment of the foot. This moves the weight bearing axis back to the center of the ankle. Changing the shape of the foot can be achieved by one or more of the following procedures. Cutting the heel bone and shifting it to the inside (Medializing calcaneal osteotomy). Lateral column lengthening restores the arch and overall alignment of the foot. Medial column stabilization. This stiffens the ray of the big toe to better support the arch. Lengthening of the Achilles tendon or Gastrocnemius. This will allow the ankle to move adequately once the alignment of the foot is corrected. Stage 3 acquired adult flatfoot deformity is treated operatively with a hindfoot fusion (arthrodesis). This is done with either a double or triple arthrodesis - fusion of two or three of the joints in hindfoot through which the deformity occurs. It is important when a hindfoot arthrodesis is performed that it be done in such a way that the underlying foot deformity is corrected first. Simply fusing the hindfoot joints in place is no longer acceptable.

Overview
Chronic posterior tibial tendon insufficiency can result in acquired adult flatfoot deformity. This is a chronic foot condition where the soft-tissues (including the posterior tibial tendon, deltoid and spring ligaments) on the inside aspect of the ankle are subject to repetitive load during walking and standing. Over time these structures may become painful and swollen ultimately failing. When these supporting structures fail the result is a change in the alignment of the foot. This condition is typically associated with a progressive flatfoot deformity. This type of deformity leads to increased strain on the supporting structures on the inside of the ankle and loading through the outer aspect of the ankle and hind-foot. Both the inside and outside of the ankle can become painful resulting significant disability. This condition can often be treated without surgery by strengthening the involved muscles and tendons and by bracing the ankle. When non-operative treatment fails, surgery can improve the alignment replace the injured tendon. Alignment and function can be restored, however, the time to maximal improvement is typically six months but, can take up to a year.

Causes
Flat feet causes greater pressure on the posterior tibial tendon than normal. As the person with flat feet ages, the muscles, tendons and ligaments weaken. Blood supplies diminish as arteries narrow. These conditions are magnified for obese patients because of their increased weight and atherosclerosis. Finally, the tendon gives out or tears. Most of the time, this is a slow process. Once the posterior tibial tendon and ligaments stretch, body weight causes the bones of the arch to move out of position. The foot rotates inward (pronation), the heel bone is tilted to the inside, and the arch appears collapsed. In some cases, the deformity progresses until the foot dislocates outward from the ankle joint.

Symptoms
Most people will notice mild to extreme pain in their feet. Below outlines some signs and symptoms of AAFD. Trouble walking or standing for any duration. Pain and swelling on the inside of the ankle. Bump on the bottom of the foot. Ulcer or wound developing on the outer aspects of foot.

Diagnosis
Examination by your foot and ankle specialist can confirm the diagnosis for most patients. An ultrasound exam performed in the office setting can evaluate the status of the posterior tibial tendon, the tendon which is primarily responsible for supporting the arch structure of the foot.

Non surgical Treatment
Footwear has an important role, and patients should be encouraged to wear flat lace-up shoes, or even lace-up boots, which accommodate orthoses. Stage I patients may be able to manage with an off the shelf orthosis (such as an Orthaheel or Formthotics). They can try a laced canvas ankle brace before moving to a casted orthosis. The various casted, semirigid orthoses support the medial longitudinal arch of the foot and either hold the heel in a neutral alignment (stage I) or correct the outward bent heel to a neutral alignment (stage II). This approach is meant to serve several functions: to alleviate stress on the tibialis posterior; to make gait more efficient by holding the hindfoot fixed; and thirdly, to prevent progression of deformity. Devices available to do this are the orthosis of the University of California Biomechanics Laboratory, an ankle foot orthosis, or a removable boot. When this approach has been used, two thirds of patients have good to excellent results.

Surgical Treatment
If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath, tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease. Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression of disease to later stages of dysfunction.