Posterior Impingement of the Ankle

Posterior impingement of the ankle, also known as impingement of the ankle, is when tissue damage at the back of the ankle joint occurs due to compression of the tissue during maximal ankle plantar flexion which is movement of the foot that flexes the foot or toes downward toward the sole.

Symptoms are generally felt in the Achilles area or the back of the ankle and may include a dull ache or sharp pain which increases when touched firmly. Other areas may be the calf or foot.

Activities that can cause ankle impingement include:

  • pushing off the wall during lap swimming
  • kneeling
  • walking/running downhill
  • ballet positions such as en pointe

This fairly unique foot and ankle condition generally found in gymnasts, foot ballers and ballet dancers. Ballet dancers may experience this condition which can be caused by the en pointe position. To learn more visit orthopedic surgeon and foot ankle specialist Sean Peden, MD’s blog post – The Fragile Feet: A Ballerina Story


Achilles Tendinitis

The Achilles tendon is the largest tendon in the human body. It is located at the back of the ankle joint and attaches the calf muscles to the heel bone. The Achilles tendon is used to walk, run, jump or push up on the toes. Achilles tendinitis is the inflammation of the tendon and is most often caused by overuse, or is a result of a strain injury.

Aging and sports activities that involve a lot of calf muscle like basketball and tennis have a higher incidence of injury to the Achilles tendon. The injury is also associated with a sudden increase of intensity or frequency of an exercise.

Symptoms of Achilles Tendinitis

  • A dull ache or pain during activity
  • Tenderness, particularly in the morning, above the heel bone
  • Stiffness that improves as the tendon warms up
  • Mild swelling or a bump

A sudden pain or swelling above the heel and difficulty walking or moving the foot up and down may indicate a rupture of the tendon. As with any injury to the Achilles tendon, it is important to be seen by an orthopedist to determine if it is due to tendinitis or more serious conditions such as a partial tendon tear, heel bursitis or a rupture.

Treatment of Achilles Tendinitis

When treated properly, Achilles tendinitis is usually resolved quickly. When left untreated, it may lead to a more serious condition or tear. Some or all of the following may be used to treat the condition depending on its severity:

  • Rest
  • Nonsteroidal anti-inflammatory medication
  • Orthotics or shoe inserts that help support the muscle and relieve stress on the tendon
  • Bandaging to restrict motion
  • Physical therapy that includes stretching, massage, ultrasound and strengthening exercises

If friction between the tendon and its covering sheath causes the sheath to become thick and fibrous and conservative treatments are not effective, surgery may be an option. A surgeon can remove the fibrous tissue and repair any tears. A temporary cast may be worn during recovery and a rehabilitation program is usually recommended.

Prevention of Achilles tendinitis

  • Choose a running shoe that provides cushion to the heel.
  • Walk and stretch to warm up gradually before exercising.
  • Stretch and strengthen the muscles in the calf.
  • Increase running distance and speed gradually.
  • Avoid unaccustomed strenuous sprinting and hill running.
  • Cool down gradually after exercise.

Arthritis of the Foot & Ankle

Osteoarthritis, or arthritis of the foot, as with other joints in the body, develops with aging and may also be a result of wear-and-tear on the joint. The cartilage on the ends of bones that cushions the joints as they move, becomes worn over time. Eventually, joints may become damaged to the point where they are swollen, inflamed and painful.

Sometimes, if a joint has been injured, even if treated properly, osteoarthritis may develop in the future. A severe sprain, torn ligament or broken bone may all contribute to the development of arthritis, long after the initial injury.

Arthritis Symptoms

The most common symptoms of arthritis in the foot include pain and stiffness, swelling and a loss of mobility. Walking may become difficult due to soreness. X-rays of the foot may reveal changes in the spacing between bones. An MRI may show varying degrees of damage to the cartilage.


Medications are used to treat arthritis symptoms but cannot restore joint cartilage or reverse damage. Anti-inflammatory medications are commonly used to reduce pain and swelling. If anti-inflammatory medications do not control pain, steroidal injections into the joint may be used. Sometimes, physicians prescribe the use of orthotics; special pads, arch supports or other inserts for the shoe.

A physical therapy or home exercise program may also be effective. For patients who are overweight, weight loss can be very beneficial. Painful feet will be less sensitive if they have less weight to bear.

If conservative treatments are unsuccessful and the patient has great difficulty with simple activities such as walking or climbing stairs, surgery may be considered. The type of surgery depends on the type and location of the arthritis. Possible surgeries include:


The most common cause of serious foot pain is a bunion or hallux valgus, the swelling or enlargement of the joint where the big toe connects to the foot. A bunion can become especially painful when it reaches the point when the joint begins to rotate outward, causing it to bulge from the inside of the foot.

Bunions may be an inherited condition. They may develop with no recognizable cause or can be brought on by wearing poorly fitting shoes.

Bunion Treatment

Treatment for bunions varies depending on their severity. The single most important treatment for bunions is wearing shoes that conform to the shape of the foot and do not create pressure areas. This alone often alleviates the pain. High-heeled, pointed-toe shoes should be avoided as they put pressure on the front of the foot and create an unnatural position for the foot and toes.

Other non-surgical treatments include prescribed orthotic devices; lifts and inserts to change the shoe’s pressure points.

Bunion Surgery

If a bunion is not addressed early, it can become very painful and even affect the quality of life. In severe cases, the pain from bunions can be disabling and surgery may then be the best solution. Surgery is usually done to relieve pain and should not be done simply to improve the appearance of the foot.

Bunion surgery is performed to realign the bones, ligaments and tendons to bring the big toe back into its correct position. In the last ten years, new techniques, materials and an emphasis on maintaining mobility throughout the healing process have made bunion surgery extremely successful and less painful than in the past. Rarely are casts applied, and patients normally use crutches for only a week to 10 days. With anti-inflammatory medications and physical therapy, most patients only miss a week or so of work. Complete healing takes between two and four months.

Recommendations for Healthy Feet

  • Don’t buy shoes that are uncomfortable or too tight.
  • Don’t assume you know your shoe size. Feet can continue to grow well after age 40.
  • Don’t assume you wear the same size in all shoes. Size consistency varies by manufacture and style.
  • If a shoe feels tight, buy the next size larger and use pads to adjust the fit if necessary.
  • If a shoe doesn’t fit properly, take it to an orthotics fitter to see if any adjustments can be made.

Video and News Segments
What’s Ailing You: Michael Clain, MD on Bunionectomy News 12
What’s Ailing You: Ankle Foot Pain Connecticut News 12

Hammer Toes

Hammertoes is a condition in which the middle toe joint is contracted and has a permanent sideways bend. Tight fitting shoes can aggravate the deformity creating pain over the prominent bony areas on the top and end of the toe.

Treatment usually involves wearing a shoe that accommodates the bend in the toe. Shoe inserts or pads also may help. If pain and discomfort persist, surgery to straighten the toe or remove the prominent area of bone may be an option.

Illustration reproduced with permission from Fischer S, (interim ed): Your Orthopaedic Connection. Rosemont, IL, American Academy of Orthopaedic Surgeons. Available at

Morton’s Neuroma

Morton’s neuroma is a thickening of the tissue that surrounds the nerve leading to the toes. This thickening, or neuroma, causes the nerve to be pinched which may create a burning pain that radiates between the third and fourth toes.

Sometimes a neuroma is a result of wearing tight shoes that squeeze the foot bones together. Wearing high-heeled shoes that are tight or fit poorly can compress the toe bones and pinch the nerve. High impact athletes, such as runners, may also be prone to Morton

Plantar Fasciitis

Plantar fasciitis is characterized by a stabbing or burning pain in the heel that is particularly acute upon getting up in the morning. The plantar fascia serves as a shock-absorbing bow that supports the arch in the foot. If there is too much tension on that bow, small tears can occur and the fascia may become irritated or inflamed.
In addition to pain in the morning, symptoms may include pain that occurs after standing for long periods, pain after getting up from being seated, heel pain following exercise, and mild swelling in the heel.

Causes of planter fasciitis

  • Overuse
  • Arthritis
  • Diabetes
  • Poorly fitting shoes
  • Obesity

If left untreated, plantar fasciitis may become a chronic condition and can lead to other foot, knee, hip and back problems due to the way pain impacts normal walking patterns.


Resting the foot is the first course of treatment for plantar fasciitis. Ice may be applied to relieve symptoms. Nonsteroidal anti-inflammatory medications along with a home exercise program to stretch the Achilles tendon and plantar fascia are the most common early treatments.

Most people see significant improvement in their condition after two months of treatment. Patients are often advised to wear shoes with very cushioned soles or with an orthotic device like a rubber heel pad.

If the condition does not respond after a few months of conservative treatment, the physician may recommend a injection of a steroidal anti-inflammatory medication. A walking cast or a positional splint for sleeping hours may be required if the symptoms do not improve. In a few cases, surgery may be needed to release the ligament.

Reproduced with permission from Fischer S, (interim ed): Your Orthopaedic Connection. Rosemont, IL, American Academy of Orthopaedic Surgeons. Available at

Stress Fractures of the Foot & Ankle

Stress fractures are a type of overuse injury characterized by tiny cracks in the bone. When muscles are fatigued and cannot absorb repeated impact, the shock is transferred to the bones. Weak bones caused by Osteoporosis may also be more vulnerable to stress fractures. These fractures can occur from normal daily use or from sports activities.

Stress fractures most often occur in the bones of the foot and lower leg. The second or third long bones between the toes and the mid-foot are the most often effected. Stress fractures sometimes appear in the heel, the outer bone of the lower leg and the navicular, on the top of the foot.

One of the most common occurrences of stress fractures happens in runners who have been confined indoors during an off season and then, return to running without proper conditioning.

Improper foot gear is another reason that athletes get stress fractures. An old and well-worn shoe can alter the dynamics of the foot and contribute to stress fractures. Athletes that change surfaces, like going from a grass tennis court to a hard court, or from an outdoor running track to an indoor track, can increase their risk for stress fractures. Other conditions, such as flatfoot or bunions, can alter the mechanics of the foot making it more susceptible to stress fractures.

Symptoms of Stress Fractures

  • Pain that develops gradually and is relieved with rest
  • Tenderness
  • Swelling on top of the foot or outside the ankle
  • Possible bruising

Treating stress fractures

Most stress fractures will heal if activity level is reduced and protective footwear is worn for two to four weeks. A stiff-soled shoe, or sandal, or a removable leg brace shoe may be needed to provide support. Athletes are usually advised to switch to a sport that puts less stress on the foot and leg while the bone heals, such as swimming and bicycle riding.

For stress fractures in the outer side of the foot or in the navicular or talus bones that take longer to heal, a cast may be applied to the foot or the use of crutches may be recommended until the bone heals. In some cases, surgery may be necessary. The orthopedist may insert a screw into the bone to ensure proper healing.