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FirstHealth of the Carolinas
The foot and ankle By Dick Broom
How many bones do you think there are in the foot and ankle? Ten? Fifteen? Twenty-five?

Try 38. And those bones are all connected by a series of joints and held together by an intricate array of ligaments, tendons and muscles.

Our feet have two basic jobs: to hold us up and to move us around. No matter our size or how much weight we are carrying, it all comes down to our feet. And to get from one place to another without mechanical assistance, we generally rely on our feet.

The architecture of the foot includes three arches that give it stability, supports its weight-bearing function, and allows it to be flexible and mobile. The arches are created by the shape of the bones in the foot and the ligaments that hold the bones in place.

The best-known ligament—because it is the largest and the most susceptible to inflammation—is the plantar fascia, a long, flat ligament that stretches along the bottom of the foot and attaches to the heel. T here are 13 tendons in the ankle—each one attaching a muscle to a bone—that enable the ankle, foot and toes to move the way we want them to.

The largest of the tendons is the Achilles tendon at the back of the ankle, which attaches the calf muscles to the heel bone.

Bunions are the most common problem that people have with their feet. They are so common, in fact, that David Strom, M.D., an orthopaedic surgeon at Pinehurst Surgical, sees several bunion patients every day.


Dr. Strom, who specializes in foot and ankle problems, performs orthopaedic procedures as FirstHealth Moore Regional Hospital and FirstHealth Richmond Memorial Hospital.

“When the big toe deviates from its normal position toward the other toes, that creates a bony prominence on the inside of the foot at the base of the toe joint that we call a bunion,” he says. “It may not be painful, but it usually is. It may not be progressive, but it usually is.”

Bunions are a hereditary trait in some people. Wearing narrow or high-heeled shoes that put pressure on the big toe also can cause bunions.

Surgery to correct the problem usually involves removing or realigning bone and soft tissue around the big toe joint. But less than half of the people who come to Dr. Strom with bunions require surgery. Most can get relief by wearing wider shoes or putting inserts or pads in their shoes to cushion the painful area.

In some cases, injections of antiinflammatory drugs can relieve the pain and swelling of bunions.

“If everything else has been tried and it is still very painful, that’s when we think about surgery,” Dr. Strom says.

Next to bunions, the most common cause of foot pain is plantar fasciitis. The long, flat ligament on the bottom of the foot that attaches to the heel bone—the plantar fascia—can develop small tears that cause inflammation. This can result in sharp heel pain that typically is worse when a person first gets out of bed in the morning.

“It hurts,” Dr. Strom says. “People often think they have heel spurs, but actually those rarely cause pain.”

Activities that stretch the plantar ligament, such as running or jumping, can cause plantar fasciitis. Having a tight Achilles tendon or tight heel cord also can be contributing factors. The condition rarely requires surgery.

David Strom, M.D.

“We have a whole list of conservative measures we use including stretching exercises, physical therapy, heel cups and corticosteroid injections,” says Dr. Strom.

Tendonitis—inflammation of a tendon—in the ankle and lower leg are relatively common conditions. The Achilles tendon at the back of the ankle is particularly susceptible. The posterior tibial tendon, which is on the inside of the ankle, also can become inflamed.

Usually caused by overuse, tendonitis can involve inflammation alone or small tears in the tendon and surrounding tissue that become inflamed.

“There are many different stages of tendonitis,” says Dr. Strom, who is recognized internationally as an expert on the posterior tibial tendon. “Some are easily treated with a little brace or an insert in the shoe, some can be treated with a cortisone injection, and some require surgery.”

People with advanced, poorly controlled diabetes are particularly susceptible to foot problems. Diabetes reduces blood flow to the extremities and affects the ability of nerves to feel pain.

“The nerves that lead to the joints don’t work as well as they used to, so you can have a loss of sensation in the foot that can lead to all kinds of trouble,” Dr. Strom says. “You can have a blister that you don’t feel, and it can turn into a diabetic ulcer. And with the lack of blood supply to the foot, it is hard for anything to heal.”

Karen Fox now stands comfortably while she paints since she had bunion surgery late last year.

Karen Fox
The bunion on the side of Karen Fox’s foot started giving her trouble about five years ago. She tried to ignore it, but it gradually got worse and worse.

“One day I was on the golf course, and I thought, ‘I’ve got to get this fixed, because it hurts too much every time I take a step,’” she recalls. Fox went to David Strom, M.D., an orthopaedic surgeon with Pinehurst Surgical, to have the bunion removed.

Dr. Strom typically advises bunion patients to try other remedies first. He often recommends that they wear wider or specially designed shoes or that they put inserts in their shoes to take pressure off the bunion. But Fox had done all that a few years earlier when she had a bunion on her other foot. She was living in Connecticut at the time.

“I had tried the special shoes and the inserts, and they didn’t work,” she says. “So, rather than going through all that again, I decided to go ahead and deal with the source of the problem,” she says. “I knew I was going to end up having surgery anyway.”

Fox had the operation as an outpatient procedure this past December. She never felt much pain from the surgery, and she had a quick recovery.

“I was wearing regular shoes within six weeks and playing 18 holes of golf at week seven,” she says. “I usually play about three times a week.”

Fox also is an artist, and she stands while she paints. Now 61, she took up oil painting when she retired and moved to Pinehurst in 2002. She had her first single-artist show at the Artist League of the Sandhills in Aberdeen last summer.