Injection therapy,
short courses of treatment

Joint pain

Painful stiff joints that give sharp and shooting pains or that ache in the cold or after activity can be a result of damage and early wear and tear arthritis.

Before surgery is required in many cases a short course of injections (3 over a 3 week period) can reduce chronic joint pain and stiffness. Ostenil® is a solution containing hyaluronic acid, a naturally occurring substance.

Please view this website for the management of wear and tear arthritis (osteo-arthritis).

Steroid injections

For localized reduction of pain inflammation. Corticosteroids can be injected locally for a concentrated anti-inflammatory effect and may be indicated for the treatment of plantar fasciitis (heel pain) or Morton's neuroma (an inflamed trapped or thickened nerve in the forefoot). In some types of joint inflammation they are injected intra-articularly to relieve pain, and improve function.

Chilblains

Serial low dosage injections of a local anaesthesia prior to the onset of the worst of the winter weather can, in most cases, delay or even in some cases, prevent the onset of chronic chilblains. Treatment can alleviate some of the worst symptoms and aid recovery from persistent chilblains.

Lesser metatarsal surgery for forefoot pain

Metatarsalgia (pain in and around the metatarsal bones) has multiple causes.

The pain experienced may be due to inter-metatarsal bursitis (inflammation of the soft tissues) / persistent corns, callus or ulceration on the sole of the foot.

Many patients suffer with long term painful corns or callus under the ball of the foot, often requiring frequent palliative visits to the local chiropodist.

This type of problem can be cured.

It is possible to adjust the loading where the pressure is abnormally high in one area by surgically altering the bones in the forefoot returning normal function and a more normal foot loading pressure.

These types of procedure can be very effective in selected cases preventing the growth of recurrent painful corns and reducing the overloading that can lead to arthritic change or soft tissue ulceration.

The exact point of pressure under the foot affected in combination with weight-bearing radiographs (X-rays) give a clear indication of the most appropriate procedure to correct the problem. It is also essential to identify when in the gait cycle the excessive forces are causing the problem.

This type of foot condition and especially inter-metatarsal bursitis can often be helped and made more comfortable with the use of a biomechanically designed functional orthosis (orthotic / insole that improves the stability and function of the foot) worn in well-fitting footwear. No surgery would be considered without prior consideration of biomechanical stabilization.

Please consider my biomechanics page.

Neuroma / neuroamas / nerve entrapment

• Forefoot (Morton's neuroma / plantar digital neuroma)
• Ankle (tarsal tunnel syndrome)

Morton's neuroma describes a trapped digital (toe) nerve that swells and becomes chronically painful between the third (middle) and fourth toes. The same condition in the other inter-metatarsal spaces revels in the name of plantar digital neuroma.

Multiple neuromas are less common but not rare. The patient is often limited to flat roomy footwear and may complain of a burning or shooting/electric shock like pain with numbness in the lesser toes. The level of treatment is usually symptom led.

A neuroma can occur in other areas of the foot (ie the heel) as a result of trauma to the nerve.

Steroid therapy may resolve the problem if in its early development. However long term symptoms or patients resistant to steroid therapy usually require surgery.

Morton's Neuroma – surgical excision

Tarsal Tunnel Syndrome is a complex condition that requires in-depth investigation and consultation. This complex condition requires nerve conduction studies and MRI as part of the diagnosis and treatment planning. The complexities of the condition require an individual response.

Verruca surgery

Verrucae are considered a nuisance by most medics as you will not die from it and the multiple treatments required are time consuming, can be very painful and therefore ultimately very costly.

However if you ask the patient, they can be painful if on weight bearing areas, they are a potential source of infection to nearest and dearest and are prone to spread on the patient.

They are unsightly and often a source of embarrassment to the patient.

Many self-resolve over time, but Mr Cozens has had patients who report verrucae present for 30 years (so how patient do you have to be?).

If you have tried multiple conservative (over the counter preparations) and even cryotherapy (freezing) and they persist then you may consider surgical management.

Mr Cozens favours an electro-surgery technique under local anaesthesia that removes the virally infected warty tissue and cauterises the vascular base of the verruca.

However a verruca prone patient will be susceptible to re-infection if contaminated by their old shoes or returning to a less than hygienic changing / locker room.

Stiff painful joints

As mentioned above, in the early stages of the condition injection therapy can defer the need for surgery by years.

Surgery for hallux limitus / rigidus

Osteo-arthritis of the big toe joint is so common it has its own names - hallux limitus with reduced range of joint mobility which worsens to become hallux rigidus where all normal functional joint motion is lost. Usually it is be treated surgically by cutting the excess bone away at an angle (Cheilectomy or a modified Valenti procedure) or shortening the first metatarsal (decompression osteotomy) or by permanently fusing the joint (arthrodesis) or by a total joint replacement (multiple joint types / brands available).

However there is now also a Cartiva implant to add to the previously existing choices. The Cartiva is an implant which is embedded into the worn (osteo-arthritic) joint surface which returns the stiffening joint back into a functioning joint. The Cartiva implant functions as a durable cartilage replacement keeping the worn bone ends from rubbing together and giving pain.

Again this condition is complex in its treatment Clearly with such diverse choices a patient must take individual advice with the surgeon while reviewing the radiographs of the foot.

The same condition can occur at the lesser metatarso-phalangeal joints as a result of multiple conditions such as an old freibergs osteochondritis or an intra-articular fracture as well as osteoarthritis with the same multiple treatment options and considerations.

Soft lumps and bumps – cysts / ganglion / foreign bodies

There are multiple types and causes of soft tissue (flesh not bone) enlargement and or deformity. Of those that do not repair or self resolve surgical removal is an option.

“Having worked along side some very talented plastic surgeons I have picked up some very useful tips and techniques which I apply to all of my tissue handling in surgery.” – David R Cozens

Heel bump surgery – Haglund’s

Also called “pump-bump” this is a thickening of bone at the posterolateral (back outside) aspect of the Achilles tendon insertion into the heel. Often presents as a footwear problem with persistent rubbing and blistering in all forms of footwear (especially all new shoes).

This is usually a sign of an underlying biomechanical problem with other bone and joint involvement. Simply removing the hypertrophic (enlargement) of bone is only a short term measure and therefore is not advised as the sole treatment.

Without biomechanical correction of the instability the problem is most likely to return over time.

Please consider my biomechanics page.

Arthritic (rheumatoid / erosive arthropathies)

Active rheumatoid and erosive arthropathies are medically managed conditions; unlike osteoarthritis (wear and tear) which is currently believed to be just a mechanical condition.

Early surgical intervention is less common and is more in the form of symptom relief when the condition has settled. Chronic arthritic changes can be managed surgically while not in “flare up” (active stage). Soft tissue correction such as tendon repair or lengthening may significantly improve function especially in the toes. Irregular joint edges and pointy bits of bone can lead to persistent ulceration or footwear problems and can be remodelled with surgery.

As with diabetes, it requires appropriate professional care and an initial consultation to discuss your options.

Please consider my biomechanics page.

Sub-ungual exostectomies

Exostoses (bone spurs) usually form in the foot as a result of chronic repetitive relatively minor trauma or a localised single acute injury. They can occur under the nail, deforming its normal appearance, and are often misdiagnosed as an ingrown toenail. The lesions can also be present under the nail bed area projecting forward or sideways protruding the flesh with no disturbance to the nail plate itself.

Plain film X-ray may not clearly indicate the full volume of the exostosis as they have a cartilage cap that does not show on standard films.

These deformities can often be operated upon to both remove the pain and also return the toe to a more normal cosmetically pleasing appearance.

Bunion or hallux abducto-valgus

Bunions: unfortunately a common deformity of the foot that can lead to a lifetime of joint pain and difficulty fitting shoes. Often an inherited family trait, the bunion deformity can indicate a more deep seated structural instability of the foot bones that can adversely involve the hips, knees and low-back.

Please consider my biomechanics page.

Bunion surgery aims to correct the structural deformity and improve joint function. This is a complex condition that requires individual guidance following the review of the weight-bearing radiographs (x-ray views).

There are numerous surgical variations to correct this type of complex deformity. The subsequent choice of surgery and advice on biomechanical stabilization post operatively requires individual consultation and explanation and discussion with your podiatric surgeon.

For more information on one of the techniques, see the patient information sheet on the Scarf Akin bunion procedure from The College of Podiatry (UK).

Hammer toes / mallet toes

Lesser hammer toes / mallet toes / painful toes / overlapping / rotated / burrowing toes or fixed flexion deformity are terms used to describe a series of symptoms and joint changes seen in the lesser toes and the metatarso-phalangeal joints (knuckle joints in the ball of the foot). They may occur singularly or as part of a group in which all of the lesser digits display abnormality and are often associated with persistent painful corns and calluses or even ulceration.

These deformities are readily treated surgically to give a straight flat toe that does not rub in normal shoes or poke up in sandals. Paediatric patients developing these conditions can be treated with simple pain-free non-surgical methods such as corrective silicone digital splints.

Hammer toe surgery explained

Nail surgery – different types (incisional / phenolisation)

If neglected an ingrowing toe nail (onychocryptosis) is a source of infection that can impact poorly on your health (a motorway into your body for bacteria), also the condition can become chronic with fibrosis and scar tissue deforming the toe.

Rarely is it necessary to remove the whole toe nail. Great care is taken to preserve the best most cosmetically acceptable nail plate for the patient regardless of age or sex. Nail surgery should be cosmetically pleasing as well as resolving the pain and/or infection usually associated with the condition. There are basically two methods of surgically correcting a deformed nail plate that is painful or prone to recurrent or persistent infections. These are usually performed under a local anaesthetic.

Phenolisation Partial, where a sliver of nail is removed from the side of the nail plate and the nail root and bed is chemically prevented from growing again. (Typically the size of the sliver of nail is much larger than the hole it leaves.) Total, where the whole of the nail plate is removed and prevented from growing again.

Incisional techniques which allow for the removal of part or all of the nail plate with additional removal of hypertrophied (thickened or overlapping) flesh or scar tissue.

Recovery rates differ significantly and the merits of each procedure should be discussed thoroughly before deciding.

There is an incidence of re-growth of the removed portion of nail with both procedures, the treatment of which is to repeat or alternate the procedure.

Forefoot reconstruction

This is flexible group of procedures that can be performed at the same time to address complex foot deformities that cause difficulty in all normal footwear and normal function. Combinations of surgical procedures are explained and applied to correct the foot function to achieve a return to pain-free function with the shortest recovery time possible. For example: multiple lesser metatarsal osteotomies with internal screw fixation and hammer toe corrections with tendon lengthening and joint realignment to correct the forefoot overloading and a combination of osteotomies with internal screw fixation to correct the hallux abducto-valgus (bunion joint).

As you will note this is a significant amount of surgery on one foot at a time, but is an approach that would be considered on an appropriate patient.

On a less medically appropriate patient the combination of procedures would be considered as staggered smaller combinations of procedures to safely correct the patient.

Following surgical correction it may be prudent to review the biomechanics and take preventative management steps to avoid further deformity development or deterioration.

Please consider my biomechanics page.

Adult / paediatric acquired flat foot

Surgical option for adults only

Please consider my biomechanics page.

This is a complex biomechanical condition that gives multiple structure problems (miserable malalignment syndrome) link up the length of the body.

This surgical option is only considered at present following adherence to the pre-operative protocol and the satisfactory use of biomechanical measures (orthotic and, if required, a Richie brace). While use of orthotics is now commonplace and clearly beneficial to the appropriate patients, some patients may wish to consider a surgical intervention that would render the use of such measures redundant. At present Mr Cozens favours the Hypocure stent artheroerresis procedure for the surgical management of this condition.

Plantar fasciitis / heel spur surgery

Plantar fasciitis is characterised by early morning pain shooting up into the heel the moment you weight bear and then minutes later settling into a deep seated ache in and under the heel.

Heel surgery for this condition is not common as most patients will respond to appropriate orthotic management and extracorporeal shockwave therapy (ESWT).

Other soft tissue pathology in the heel can be misdiagnosed as plantar fasciitis with resulting difficulty in treating the condition. A thorough knowledge of the condition is required to differentiate from the often misdiagnosed tendon injuries.

Please consider my biomechanics page.

Heel spurs (again often misdiagnosed) are a common finding on radiographs of the foot, evenly found in patients with and without heel pain, they are rarely the cause of heel pain. The exception being when the pitch of the shoe (high heels) angles the spur down toward the plantar surface.

Diabetic

Diabetes can give multiple and often complex problems which can commonly manifest particularly in the feet. This is because they are the structures furthest from the heart and brain and therefore can often show the earliest signs of neurological and vascular changes in the body. Also they are regularly traumatised in day-to-day activity.

Whilst diabetic patients can have all of the usual foot problems non-diabetic patients present with, their management and care offers more complex challenges and requires appropriate planning and management.

As with rheumatoid arthritis and erosive arthropathies, it requires appropriate professional care and an initial consultation to discuss your options.

Please consider my biomechanics page.