Today, I'd like to discuss a common condition known as hammer toe. We'll explore its causes and treatment options and answer some frequently asked questions to provide you with a thorough understanding of this condition.

What is Hammer Toe?

Hammer toe is a deformity that causes one or more of your toe joints to bend upward instead of lying flat.

Hammer toe affects the second, third, or fourth toe results from an imbalance in the muscles, tendons, and ligaments responsible for maintaining toe alignment. If left untreated, the affected toe may progress from being flexible to rigid, leading to increased pain and difficulty walking.

Anatomy of the Toes

The forefoot consists of five toes, each playing a crucial role in balance and movement.

Structurally, four of these toes have three joints: the metatarsophalangeal (MTP) joint at the base, the proximal interphalangeal (PIP) joint in the middle, and the distal interphalangeal (DIP) joint near the tip. However, the first toe, commonly known as the big toe, differs from the others as it has only two joints, the MTP and the interphalangeal (IP) joint.

In cases of hammer toe, the deformity primarily affects the PIP joint, causing it to bend abnormally while the other joints may remain straight or become misaligned over time.

What Is the Main Cause of Hammer Toes?

This condition often results from wearing ill-fitting shoes that force the toes into a bent position over extended periods.

As mentioned, hammer toe is the result of a soft tissue imbalance that puts pressure on the toe muscles, tendons and joints.

High heels or shoes that are too tight can force the foot down and push the toes against the shoe, increasing the pressure and the bend in the toe. If the toe is bent into one position of long enough, the muscles and joints begin to tighten and cannot be stretched out.

Additionally, certain medical conditions like rheumatoid arthritis or diabetes can increase the risk of developing hammer toes due to joint damage or nerve issues.

What are the Symptoms of Hammer Toe?

Hammer toe presents with several noticeable symptoms that can worsen over time.

Initially, you may experience mild discomfort and some hard skin developing on the toes, but as the condition progresses, symptoms can include:

• Toe Deformity: A bend in the middle joint of the affected toe, giving it a hammer-like appearance.
• Pain and Discomfort: Increased pain when wearing shoes, particularly tight or high-heeled footwear.
• Corns and Calluses: Friction from footwear can cause thickened skin to develop over the affected joint.
• Swelling and Redness: Irritation and inflammation around the bent joint.
• Limited Movement: In severe cases, the affected toe may become rigid and difficult to move.

Early recognition of these symptoms will help to ensure effective treatment and prevent longer-term complications.

Diagnosis and Imaging Options

A clinical examination is the first step in diagnosing hammer toe. When you come into the clinic, I will assess your foot’s structure, flexibility, pain levels and mobility.

Imaging studies may be necessary for a more detailed evaluation:

• X-rays: Provide a clear view of bone alignment and joint abnormalities.
• Ultrasound: Assesses soft tissue structures, including tendons and ligaments.
• MRI (Magnetic Resonance Imaging): Helps evaluate severe cases where soft tissue damage or underlying conditions, such as arthritis, may contribute to the deformity.

It is very important to get an accurate and early diagnosis so that we can give you the most appropriate treatment for your specific symptoms and goals.

Can You Correct Hammer Toes?

Yes, hammer toes can be corrected. This can be done surgically or using non-surgical interventions depending on the severity.

Your symptoms and the flexibility of the affected toe play a significant role in determining the best and most effective treatment for you.

In the initial stages, mild hammer toe can be treated with non-surgical interventions when the toe is still flexible.

These may include:

• Footwear Modifications: Switching shoes with a spacious toe box reduces pressure on the toes.
• Orthotic Devices: Custom insoles are used to provide better foot alignment.
• Toe Splints or Caps: Using devices to hold the toe in a corrected position.
• Use Protective Padding: Cushions or pads can prevent friction and reduce discomfort.
• Toe Exercises: Performing specific exercises, with a Physiotherapist or Podiatrist's guidance to strengthen and stretch your toe muscles can help alleviate symptoms.

These methods aim to alleviate symptoms and help prevent further progression of the deformity but are unlikely to correct the condition.

Unfortunately, if the toe has already become rigid then surgical intervention might be necessary to correct the deformity and to give you the best outcome in terms of pain relive, improved mobility and quality of life.

Do Hammer Toe Straighteners Really Work?

Hammer toe straighteners, such as splints or toe caps, can provide relief, especially in the condition's early stages. These devices help in:

• Aligning the Toe: Encouraging the toe to return to its natural position.
• Reducing Discomfort: Minimising friction and pressure from footwear.
• Preventing Further Deformity: Slowing the progression of the condition.

It's important to note that while these devices can alleviate symptoms and provide temporary correction, they may not offer a permanent solution, particularly if the toe has become rigid.

How Do Podiatrists Treat Hammer Toes?

Podiatrists employ a range of treatments based on the severity of the hammer toe. Initial approaches often involve:

• Conservative Measures: Recommending footwear changes, orthotic devices, and specific exercises.
• Medication: Prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and swelling.

Your treatment will depend on an individual assessment and the progression of the deformity.

I work closely with expert podiatrists to provide a holistic and multidisciplinary approach to your treatment and care.

What Are the Surgical Options for Hammer Toes?

Surgical intervention may be necessary for patients with persistent or severe hammer toe.

Each surgical approach aims to relieve pain, improve toe function, and prevent any further complications.

The choice of procedure depends on whether the toe joint remains flexible or has become rigid.

• Tendon Lengthening: If the toe joint is still flexible, lengthening the tendons responsible for the imbalance can help restore normal toe positioning and function. This procedure alleviates tension and allows the toe to straighten without further structural changes.
• Tendon Transfer: Another option for patients with a flexible toe joint is tendon transfer, where tendons from the bottom of the toe are repositioned to the top. This redistribution of tension helps pull the joint into a straighter alignment and prevents future deformity.
• Arthrodesis (Joint Fusion): For patients with a rigid toe joint, tendon lengthening may be combined with arthrodesis. This procedure involves removing a small section of bone from the affected joint to enable full toe extension.

It is then secured with an external K-wire or pin, which holds the bones in place while they fuse together.

Innovative Surgical Treatments for Hammer Toe

Advancements in medical technology have introduced innovative surgical treatments.

Instead of temporarily holding the operated toe in the corrected position with a pin, an internal implant can be used, which does not have to be removed. In certain situations, these implants are very beneficial.

Additionally, minimally invasive surgical techniques have been developed to correct hammer toes with smaller incisions, reducing recovery time and postoperative discomfort.

Is It Worth Getting Hammer Toe Surgery?

Deciding on whether to have surgery depends on several factors:

• Severity of the Deformity: Surgery may be your best option if the hammer toe is rigid and causes significant pain or interferes with daily activities.
• Response to Non-Surgical Treatments: Surgery may be considered if conservative methods haven't relieved your symptoms.
• Overall Health: If you have any underlying health conditions, this may affect the decision to operate.

Surgical correction can offer long-lasting relief, improved toe function and better mobility, but I will always ensure that all the options are discussed, and we will make an informed decision together.

Surgical Patient

Post-operation hammer toe surgery, second toe on the right foot (left side of photo). The mild hammer toe on the other foot is being treated conservatively at present.

Is Hammer Toe Surgery Painful?

Hammer toe surgery is typically performed as a day case, so you are only in the hospital for a few hours and don’t usually stay overnight. The surgery is often performed under local anaesthetic rather than a general anaesthetic, although this will be discussed individually. You will not feel any pain during the procedure.

Postoperative discomfort varies among individuals, but we ensure that you receive the appropriate medication so you do not have pain.

You can weight bear after the operation and do not need crutches, but as hammertoe operations are often associated with after-forefoot operations, you might need to wear a stiff-soled post-op shoe to protect the operated foot.

It’s important that you follow the postoperative care instructions given to you, to ensure a smooth recovery.

How long does it take to recover from hammertoe surgery?

Recovery from hammer toe surgery varies based on the procedure performed. Initial skin healing from the surgery takes approximately 10-14 days.

Here are some guidelines to recovery timeframes:

• First Few Weeks: You are allowed to weight bear but will benefit from using post-op shoes provided by the hospital and reduce the walking and standing to a minimum to give your bones and joints a chance to heal.
• Four to Six Weeks: Most people can resume walking and light activities, though high-impact exercises should still be avoided.
• Three Months and Beyond: Full recovery, including a return to wearing normal (comfortable and well-fitting) footwear and exercise, is typically achieved within this timeframe.

Long-term outcomes are generally positive, and most patients experience significant pain relief and improved toe alignment and mobility.

Conclusion

Hammer toes are a common foot condition that can cause discomfort and affect daily activities. Early recognition and intervention are key to managing symptoms effectively and potentially avoiding surgery.

Whether through lifestyle modifications, non-surgical treatments, or surgical options, I will ensure that you receive a tailored approach to help you restore function and improve your quality of life.

Plantar fasciitis is one of the most common causes of heel pain, affecting people of all activity levels and ages. The condition stems from inflammation or microtears in the plantar fascia; a thick band of connective tissue running along the sole of your foot. While it often resolves with conservative treatment, knowing which healthcare professional to consult can significantly impact recovery time and outcomes.

As an Orthopaedic Foot and Ankle specialist, Plantar fasciitis is a condition that I see very regularly in my clinic, however, I believe that this condition is best managed by a multidisciplinary team of healthcare professionals, including GPs, podiatrists and Physiotherapists.

This blog explores the roles of different healthcare providers to help you decide who to see for plantar fasciitis.

Should I See a GP for Plantar Fasciitis?

General Practitioners (GPs) are often the first point of contact for any health issue, including plantar fasciitis.

A GP can:

• Provide an Initial Diagnosis: GPs are well-versed in common musculoskeletal complaints and can usually diagnose plantar fasciitis based on your symptoms and a physical examination.
• Prescribe Pain Relief: They may recommend over-the-counter painkillers, anti-inflammatory medications, or, in some cases, a short course of stronger prescription drugs to manage acute pain.
• Advise on Initial Treatments: GPs can guide you on first-line treatments like rest, ice application, stretching exercises, and the use of supportive footwear or insoles.
• Refer to Specialists: If your symptoms persist despite initial management, a GP can refer you to a specialist, such as a podiatrist, physiotherapist, or orthopaedic consultant.

A GP is a good starting point, particularly if you are unsure whether your heel pain is due to plantar fasciitis or another condition. However, they may lack the specialist expertise or tools to provide advanced treatment.

What Is the Best Practitioner for Plantar Fasciitis?

The "best" practitioner depends on your specific needs and the severity of your condition. Mild cases often resolve with basic self-care or guidance from a GP. However, more severe cases may require input from specialists such as podiatrists, physiotherapists, or orthopaedic consultants.

In general:

• GPs are ideal for initial evaluation and basic management – but they will often refer you for more specialist input.
• Podiatrists excel in addressing biomechanical issues and advanced therapies.
• Physiotherapists are invaluable for rehabilitation and functional recovery.
• Orthopaedic Consultants are the go-to specialists for more complex or persistent cases.

Who Is Best to Diagnose Plantar Fasciitis?

A proper diagnosis is key to effective treatment. Here’s how each professional approaches diagnosis:

GPs

A GP will have a low-level knowledge of this condition, they will likely make a diagnosis based on history and a physical exam, such as palpating the heel for tenderness and evaluating pain patterns.

Podiatrists

On top of what a GP is able to offer, a Podiatrist can also assess foot positions and biomechanics.

Physiotherapists

Physiotherapists will often look at the body as a whole and as well as focusing on the foot. They will evaluate movement patterns of the whole lower leg, gait (walking and running) and muscle imbalances; strengths and weaknesses that are likely contributing to the condition.

Orthopaedic Consultants

Orthopaedic Consultants perform advanced diagnostic imaging (e.g., MRI) if other conditions like heel spurs or stress fractures are suspected.

While GPs, Physios and podiatrists are well-equipped for initial diagnosis, more complex or unclear cases might benefit from imaging studies and specialist orthopaedic consultations and input.

When Should I See an Orthopaedic Consultant for Plantar Fasciitis?

Orthopaedic consultants specialise in surgical and non-surgical treatments for musculoskeletal conditions. You might consider seeing one if:

1.        Conservative Treatments Fail:

Persistent symptoms despite six months of treatments like stretching, orthotics, and shockwave therapy may warrant a specialist review.

2.        Advanced Imaging is Required:

If a precise diagnosis is unclear, orthopaedic consultants can order and interpret imaging like MRIs.

3.        Advanced Treatment is Needed:

An orthopaedic consultant is able to offer interventions such as extracorporeal shockwave therapy (ESWT) or steroid injections.

4.        Complex Foot Issues are Present:

If your plantar fasciitis is part of a broader foot problem, such as severe flat feet or tendon dysfunction, an orthopaedic consultant can provide comprehensive management.

5.        Surgery is Considered:

In rare cases, surgery to release the plantar fascia or remove a heel spur may be necessary.

The Role of Physiotherapists in Plantar Fasciitis Treatment

Physiotherapists play a pivotal role in the diagnosis and recovery process of plantar fasciitis pain, particularly when rehabilitation is required.

They will focus on the following:

·      Stretching and Strengthening Programme:

Targeted exercises for the calf muscles, Achilles tendon, and plantar fascia to alleviate pain and improve function.

·      Manual Therapy:

Techniques such as deep tissue massage and myofascial release can reduce tightness and improve flexibility.

·      Gait and Posture Analysis:

Physiotherapists can identify movement patterns that might be contributing to plantar fasciitis and recommend and facilitate appropriate adjustments.

·      Return-to-Activity Guidance:

They will help you gradually return to normal activities or sports without risking re-injury.

·      Offer Advanced Therapies:

Some Physios provide extracorporeal shockwave therapy (ESWT) or corticosteroid injections to address chronic cases.

Is It Worth Seeing a Podiatrist for Plantar Fasciitis?

Podiatrists are foot and ankle specialists, making them an excellent choice for plantar fasciitis. Their training allows them to:

• Provide a Precise Diagnosis: Podiatrists can identify subtle biomechanical issues contributing to plantar fasciitis, such as flat feet or high arches.
• Recommend Targeted Treatments: They can give advice on footwear and in particular orthotics (shoe inserts) to reduce the stress on the plantar fascia, support and stabilise the foot and to raise but also to cushion the painful heel area. 
• Give Long-Term Advice: They can guide you on footwear choices, activity modifications, and stretching routines to prevent recurrence.

If your symptoms persist despite initial treatments, or if you suspect that poor foot mechanics are making your condition worse, consulting a podiatrist can be highly beneficial.

What Order Should I See Professionals in for Plantar Fasciitis?

The sequence of care often depends on the severity and duration of your symptoms:

1. GP (First Step):

For initial diagnosis and basic treatment advice.

• Podiatrist or Physiotherapist:

If symptoms persist, these specialists can provide targeted treatments and advanced interventions.

• Orthopaedic Consultant:

For chronic or complex cases requiring advanced imaging or assessment and management.

By following this sequence, you ensure timely and appropriate care without jumping straight to invasive treatments.

Collaborative Care for Plantar Fasciitis

Effective management of plantar fasciitis often requires a multidisciplinary approach, as the condition can have multiple contributing factors such as biomechanical abnormalities, muscular imbalances, improper footwear, or overuse injuries. Collaboration between healthcare professionals ensures that all aspects of the condition are addressed, increasing the likelihood of a successful recovery.

The General Practitioner as the Coordinator

The GP typically serves as the first point of contact and acts as a coordinator for your care. They can refer you to the appropriate specialist based on the severity of your symptoms and your progress. For example, if conservative treatment such as rest, pain relief, and basic stretching does not improve your symptoms, the GP may involve a podiatrist or physiotherapist to focus on more specific interventions.

The Podiatrist and Physiotherapist Working Together

A podiatristand physiotherapistoften collaborate to provide comprehensive, holistic care. While the podiatrist focuses on correcting biomechanical issues, such as improper gait or lack of foot arch support, the physiotherapist addresses muscle imbalances and works on functional rehabilitation.

Orthopaedic Consultant for Advanced Cases

An orthopaedic consultant can provide more advanced imaging (such as ultrasound or MRI scan) to confirm the diagnosis and to rule out alternative conditions like painful heel spur, inflammation of the heel fat pad, nerve entrapment, stress fractures of the heel bone or even a rupture of the plantar fascia. 

The orthopaedic foot and ankle specialist works closely together with physiotherapists, podiatrists, and at times radiologists to design a treatment plan.

Conclusion

Plantar fasciitis can be a frustrating condition, but the right healthcare professional can make all the difference. Start with your GP for an initial evaluation and basic treatment. If symptoms persist, seek a podiatrist or physiotherapist for specialised care. Finally, consult an orthopaedic consultant for chronic or complex cases that may require advanced interventions. By taking a stepwise approach, you’ll maximise your chances of a full recovery and a fast return to pain-free activity.

Solving the Mystery of Plantar Fasciitis – By Mr Martin Klinke

Plantar fasciitis is a prevalent and often debilitating condition that affects the bottom of the foot, primarily around the heel and arch of the foot.

As the leading cause of heel pain in the UK, plantar fasciitis impacts a wide demographic, from athletes to individuals with more sedentary lifestyles.

This article delves into the anatomy, causes, symptoms, risk factors, and treatment options for plantar fasciitis, giving some insight and helping those who are suffering from this condition to gain knowledge to be able to beat this common foot condition.

What is Plantar Fasciitis?

Plantar fasciitis is an overuse injury that occurs when the plantar fascia—a thick, fibrous band of tissue connecting the heel bone (calcaneus) to the toes—becomes irritated or inflamed. This tissue acts as a shock absorber, supporting the arch of the foot and playing a critical role in walking and running mechanics.

When excessive stress is placed on the plantar fascia, either due to a single event, or more usually, a low level of stress over a prolonged period of time, microtears can develop leading to inflammation, pain, and discomfort.

This condition typically develops gradually over a period of weeks or months, and is not always linked to a specific injury or trauma. Despite its prevalence, many sufferers delay seeking treatment, exacerbating the condition and prolonging recovery.

Anatomy of the Plantar Fascia

The plantar fascia is an important structural component of the foot, running from the heel bone to the base of the toes. It lies just beneath the skin on the sole of the foot and serves several vital functions:

• Arch Support: The plantar fascia provides stability to the foot's arches, ensuring efficient weight distribution during standing and walking.
• Shock Absorption: By stretching and contracting with each step, the plantar fascia absorbs impact forces, reducing stress on other foot structures.
• Propulsion: During walking and running, the plantar fascia aids in forward motion by storing and releasing energy.

Due to its constant involvement in movement and weight-bearing activities, the plantar fascia is highly susceptible to injury.

Causes of Plantar Fasciitis

Plantar fasciitis is a multifactorial condition with no single definitive cause. However, several contributing factors can increase your susceptibility to developing it.

1. Overuse or Overloading

• Repetitive Impact: Activities such as running, dancing, or jumping place repetitive stress on the plantar fascia.
• Prolonged Standing: Occupations requiring extended periods of standing (e.g., teachers, healthcare workers) can strain the fascia.
• Sudden Activity Changes: Starting a new exercise regimen or rapidly increasing high impact exercise, without adequate preparation can overload the tissue.

2. Footwear Choices

• Shoes with inadequate cushioning or poor arch support can exacerbate plantar fascia stress.
• Wearing high heels or flat-soled shoes like flip-flops can alter weight distribution and strain the fascia.

3. Weight Gain

• Excess body weight, whether due to obesity or pregnancy, increases pressure on the plantar fascia, heightening the risk of injury.

4. Biomechanical Factors

• Flat Feet (Pes Planus): Individuals with low arches are prone to overpronation, increasing fascia tension.
• High Arches (Pes Cavus): Conversely, high arches concentrate pressure on the heel and ball of the foot.
• Tight Calf Muscles: Restricted flexibility in the calf or Achilles tendon can limit ankle mobility and increase plantar fascia stress.

5. Age and Tissue Degeneration

• Plantar fasciitis is most common in individuals aged 40-60. As we age, the fascia loses elasticity and resilience, making it more prone to injury.

6. Medical Conditions

• Conditions such as diabetes and arthritis can predispose individuals to plantar fasciitis due to compromised tissue health and healing capacity.

Symptoms of Plantar Fasciitis

The hallmark symptom of plantar fasciitis is a pain on the bottom of the heel, often described as sharp, stabbing, or throbbing. This pain typically worsens when walking or running, especially after a period of rest.

• First Steps in the Morning: Pain is often most intense when taking the first steps after waking up.
• After Inactivity: Prolonged sitting or inactivity can lead to stiffness and pain upon resuming movement.
• During Activity: While the pain may subside during moderate exercise, it often returns or worsens after prolonged activity.

Other symptoms may include:

• Tenderness along the arch of the foot.
• Difficulty raising the toes off the floor.
• Swelling along the arch of the foot.

Diagnosing Plantar Fasciitis

A thorough clinical examination is essential for diagnosing plantar fasciitis.

Key diagnostic steps include:

• Physical Examination: Palpation of the heel and arch to identify pain points and tenderness.
• Assessment of Biomechanics: Evaluating foot structure, gait, and range of motion in the ankle and calf.
• Imaging: Diagnostic ultrasound can confirm the diagnosis by revealing inflammation, thickening, or small tears in the plantar fascia.

Treatment Options for Plantar Fasciitis

Treatment aims to reduce pain, promote healing, and prevent recurrence. Approaches can be categorised into self-care, conservative therapies, advanced interventions, and surgical options.

1. Self-Care Measures

• Rest: Avoid high-impact activities to allow the plantar fascia to recover.
• Ice Therapy: In the earlier stages of this condition when there is acute inflammation, you can apply an ice pack wrapped in a towel to the painful area for 15-20 minutes every 2-3 hours.
• Supportive Footwear: It’s a good idea to wear shoes with cushioned heels and good arch support to alleviate strain. Avoid wearing very flat shoes like sandals, flipflops or ballet pumps.
• Stretching Exercises: Regularly perform gentle stretches targeting the calf muscles and plantar fascia.

For the calf stretch make sure that your heel is down on the floor. Hold for 30-45 seconds and repeat 3 times.

You can use a tennis or golf ball to gently massage and stretch the plantar fascia, along the length of your foot arch.

These can be done 2-3 times a day

2. Pain Management

• Over-the-counter pain relievers, such as paracetamol and ibuprofen, can help manage discomfort.

You should seek professional advice before starting any medication

3. Physiotherapy and Podiatry

A physiotherapist can design a tailored exercise program to improve flexibility and strengthen supporting muscles. Common techniques include:

• Calf and Achilles tendon stretches.
• Soft tissue massage to the plantar fascia and surrounding structures, especially the calves if they are tight.
• Plantar fascia-specific stretches (e.g., rolling a ball under the foot).
• Strengthening exercises for foot and ankle stability.
• Insoles and heel pads can provide additional support and cushioning.

4. Shockwave Therapy

Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment that delivers powerful sound waves to the plantar fascia. Benefits include:

• Stimulating the body’s natural healing process.
• Reducing nerve sensitivity to alleviate pain.
• Promoting tissue repair and regeneration.

Studies show positive outcomes after 3-5 sessions of ESWT.

5. Ultrasound-Guided Injections

For persistent pain, injection therapy may be considered:

• Steroid Injections: A combination of local anaesthetic and corticosteroids can provide rapid pain relief by reducing inflammation.
• Platelet-Rich Plasma (PRP) Injections: PRP promotes healing by stimulating tissue repair and reducing inflammation. It is particularly effective for cases involving tears in the fascia.

6. Surgical Interventions

Surgery is very rare and reserved for severe, refractory cases. Options include:

• Gastrocnemius Release: Lengthening the calf muscles to reduce plantar fascia stress.
• Plantar Fascia Release: Making a small cut in the fascia to relieve tension.

Preventing Plantar Fasciitis

Preventive strategies are crucial to reduce the likelihood of developing plantar fasciitis or experiencing a recurrence:

• Gradually increase your exercise levels, both frequency and intensity to avoid overloading the fascia.
• Maintain a healthy weight to reduce stress on the feet.
• Wear supportive footwear, especially during prolonged standing or physical activity.
• Incorporate regular lower leg stretching and strengthening exercises into your routine.

When to Seek Professional Help

While self-care measures are often relatively effective, certain situations warrant medical attention:

• Severe or worsening pain that impedes your daily activities and quality of life.
• Symptoms persisting for more than a few weeks despite home treatment.
• If your sleep is being disrupted
• Tingling, numbness, or loss of sensation in the foot.
• Foot pain in individuals with diabetes, as it can indicate more serious complications.

Plantar fasciitis can significantly impact your quality of life, but with timely intervention and proper management, most individuals experience substantial improvement.

If you’re struggling with the relentless heel pain and discomfort of plantar fasciitis, I’m here to help you take the first steps toward relief.

As a dual-trained foot and ankle surgeon with a degree in sports medicine, I bring a unique perspective to your care. I don’t just look at your foot in isolation—I consider how your entire body moves and functions, particularly if you’re active or trying to get back to the sports and activities you love.

My goal is to help you recover fully, regain your mobility, and leave heel pain behind. I also have a team of Physiotherapists and Podiatrists who I work closely with, and can therefore ensure a holistic approach to your treatment.

Together, we’ll create a tailored approach to get you back on your feet and thriving!

Presentation

A 32-year-old avid runner presented in my clinic with a longstanding Morton’s neuroma, diagnosis (diagnosed by her GP and Physiotherapist) that had significantly impacted her ability to train and participate in endurance events. Her symptoms had initially been managed with conservative treatment, including changing her footwear, physiotherapy and reducing her running, but these interventions ultimately failed to provide long-term relief. Her frustration with persistent pain led her to seek further consultation.

History and Conservative Treatments

This lady initially managed her neuroma symptoms with wider-fit footwear, avoiding doing up her laces too tightly on the running shoes, and reducing her training, all of which seemed to give mild reduction in her symptoms, but did not resolve them.

She went on to have some Physiotherapy, which focused on reducing tightness in her calf muscles, working on her balance and proprioception, and looking at her walking and running technique. She also tried some off the shelf insoles which only seemed to exacerbate her symptoms.

Minimally Invasive Treatment

In our first consultation we explored all her options to manage her symptoms.

Together we decided to initially try a corticosteroid injection, which is a very safe and common treatment option for Moreton’s neuroma. This initially brought significant pain relief, and the patient was able to get back to her normal life and running training. However, as is often the case, the symptoms returned within a few months, leaving her frustrated and still unable to enjoy running or even walking without discomfort.

Decision for Surgical Intervention

After exhausting conservative treatments and given her clinical history, and the fact that her life and mental wellbeing was being so negatively affected, we had an open discussion about surgery.

While the idea of an operation can be daunting, this lady felt ready for a solution that could offer a long-term return to her active lifestyle. We decided that a neurectomy (a procedure to remove the thickened nerve), would give her the best chance at lasting relief.

The patient opted for surgery which was covered through her private health insurance.

Surgical Approach

The procedure was done as a day case surgery, was performed under general anaesthetic. The Morton’s neuroma was excised along with a significant portion of the nerve, extending to the mid-arch region. This extended excision approach helps prevent the formation of a “stump neuroma,” which could reintroduce symptoms if the nerve were only partially removed. Post-operatively, she was given a surgical sandal and crutches and instructed on pain management, including avoiding opioids if possible.

Postoperative Recovery and Rehabilitation

The surgery went smoothly, and within days the patient noticed a marked difference. The usual pain was gone, replaced by mild, manageable post-operative soreness.

During the early recovery phase, I emphasised the importance of elevating the foot to reduce swelling. The patient’s partner provided extensive support, handling daily tasks to allow for an easier recovery time.

By two weeks, she returned for a follow-up; while healing was progressing well, she still had some residual nerve sensitivity and shooting pain when attempting to walk in clinic, a common response as the nerve heals. At this stage I referred her to Physiotherapy for post operative rehabilitation.

Her recovery was then managed through progressive physiotherapy, focusing initially on reducing nerve sensitivity and restoring functional gait. Physiotherapy interventions included gait training with one crutch, controlled load-bearing activities, and gradual strengthening exercises specific to her biomechanics.

Key to her recovery was a gradual reintroduction to impact-based activities, such as walking and low-impact gym exercises, leading to more advanced exercises like stationary cycling and rowing.

At approximately eight weeks post-operation, she began a carefully monitored return-to-run program. This consisted of brief run-walk intervals on grass to minimise impact. Her progress was monitored weekly, with steady improvements observed in foot strength, gait alignment, and endurance.

Outcome and Long-term Prognosis – Back to an Active Lifestyle

A few months post-surgery, the patient was back on her feet in every sense of the word. She returned to running and hiking and was finally free from the nagging nerve pain that had disrupted her daily life.

She completed a 25K trail race 10 months after the surgery which included challenging terrain, with no neuroma-related pain during or after the event.

The patient remains highly satisfied with her surgical outcome, experiencing minimal discomfort and demonstrating an encouraging return to long-distance running. She anticipates training for future marathons and remains mindful of incorporating gradual progression to avoid flare-ups.

Conclusion

This case underscores the potential of surgery as an excellent option for treating Morton’s neuroma when conservative measures are no longer effective.

When managed appropriately, surgery can offer a durable long-term solution; and with careful postoperative management and guidance from a sports-focused physiotherapist, patients can successfully return to high-impact activities.

I would encourage any patient considering surgery to discuss expectations and timelines thoroughly, as recovery varies depending on each individual.

If you’re struggling with this painful condition and conservative treatments aren’t providing relief, it is worth exploring surgical options. Life is too short to be held back by pain, especially for those who thrive on an active lifestyle.

If you have a hard, bony bump on the outside of your big toe, you likely have a bunion. A bunion—also known as hallux valgus—develops when your bones shift out of place, creating a noticeable protrusion when your big toe is pulled in the direction of your smaller toes.

They are not only a cosmetic concern for people, they can also cause a great deal of pain and discomfort.

Bunions can form on one or both feet. Unfortunately, they grow bigger over time. The bigger the bunion, the more uncomfortable it may be to wear shoes and the more impact it will have on your activity level and quality of life.

What Are Bunions, and Who Gets Them?

Bunions are a progressive condition, meaning that without intervention it will get worse and more painful over time.

The bony deformity is caused when the big toe bone (metatarsal) gets pushed inwards towards the second toe, while the base of the big toe deviates outward. This shift causes a bony prominence on the inside of the foot (the ‘bunion’). Contrary to popular belief, it is not a new or extra bone growth.

As the position of the big toe shifts further, it often also causes overlapping the other toes, which can cause further pain and discomfort.

While adolescents can sometimes develop bunions, these foot deformities are more common among adults. They are particularly prevalent among older women, including women who wear shoes that crowd their toes (high heels or pointed-toe shoes, for example). Women are also more susceptible to developing bunions on account of their foot anatomy; they have lower arches, narrower feet, and a more flexible foot structure.

What Causes Them?

There are a number of causes and risk factors to developing bunions, including:

• Age – As we age, this conditions becomes more common.
• Gender – more prevalent in women
• Genetics and family history
• Foot wear (high heels, narrow toe box)
• Inflammatory joint disorders (e.g. rheumatoid arthritis).
• Foot conditions such as flat feet and lax ligaments.

While most bunions take years to develop, it’s important to be aware of their presence and take note of any pain or other unpleasant symptoms that they cause you to experience so you can decide if bunion surgery is right for you.

What Are the Symptoms of Bunions?

Your big toe joint is responsible for bearing a significant portion of your body weight when you are standing and walking or running. Most commonly pain is experienced around the bunion when wearing shoes, which increases when doing any weightbearing activity.

Common symptoms include:

• Pain
• Swelling
• Redness
• Joint stiffness in the big toe – this is a less common symptom

Pain may also be experienced under the balls of the toes (metatarsalgia) joint, and you may also experience secondary foot issues, including the formation of hammertoes, corns, and calluses.

A bunion can alter the biomechanics of your forefoot and affect the way that you walk or run. This can cause issues with other parts of your body such as your knees, hips and back.

Bunion surgery may be the only way to remove a bunion and completely correct the problem.

What is Bunion Surgery and When is it Indicated?

Though bunions aren’t considered a serious medical condition, as they grow that can become very troublesome, painful and unsightly.

Bunion surgery is indicated when conservative treatments such as custom orthotics, bunion shields, and anti-inflammatory medications have not been effective in alleviating your pain and the discomfort associated with the bunion. 

Surgical intervention should be considered if:

• Your ongoing big toe pain continues to worsen
• If your walking or running is being affected
• If the bulging bump on the outside of your toe continues to grow bigger
• If you have stiffness and decreased movement in your big toe or your foot
• If you are becoming increasingly frustrated with how difficult it is to find footwear that fits well
• If your activity level is decreasing and you are low in mood due to your condition.

It is important not to delay surgery for too long, as ignoring your symptoms will just lead to secondary complications, poor mobility and reduced quality of life. It also often means that a more invasive procedure will be required to correct the deformity.

Some patients with bunions have no symptoms at all, in which case there is no indication for surgery. Surgery should not be performed for cosmetic reasons alone.

What Does Bunion Surgery Involve?   

The surgery that is required will depend on the severity of your condition. In most cases it is performed as a minimally invasive procedure which only a very small excision.

For mild cases, the surgery required is quite minimal. However, in general more severe deformities will require your bunion surgeon to perform a procedure to break the bone, realign it and reset it with 2 or 3 small screws to fix it into the desired position.

Sometimes severe deformities or patients with arthritis may require a fusion of the big toe joint. This provides excellent pain relief and stability of the joint.

Bunion Surgery is performed as a Day Case procedure, under a local anaesthetic ankle block. You can be awake, sedated or have a general anaesthetic during surgery, which takes about 45 minutes.

Most patients do not experience significant pain after surgery, although you will need to take some pain relief for a couple of weeks following your operation.

Post op you will be required to wear a stiff-soled shoe for up to six weeks post-surgery, and you will likely need to have some Physiotherapy rehabilitation to help you regain your strength and mobility.

How Does Bunion Surgery Provide Relief from Pain? 

Bunion surgery provides relief from pain by realigning the bones in your big toe joint. Once those bones are returned to their proper position and the bunion is removed, you should no longer experience pain or discomfort, and you can go back to all your normal activities.

Bunion surgery also works well to reduce sore and inflamed tissues that surround your big toe. Since inflammation is closely related to pain, a reduction in inflammation will also help to provide reduced pain

Following successful bunion surgery, your foot will function as normal, your movement and stiffness will improve, and you will be able to mobilise pain free.

When your foot posture and movement is back to functioning normally, you will put less strain/pressure on the big toe joint, and your lower limb biomechanics will improve. This leads to better movement and function of your other joints and will improve/prevent you from developing pain in other parts of your body.

Bunion surgery is considered a safe and effective procedure for alleviating pain and improving your overall foot function.

If you have any questions about bunions, your bunion surgery or your post op recovery, please get in touch with Mr Klinke - we are here to help you on every step of your journey and ensure that you have a smooth and stress free recovery.

Have you recently found out you need bunion surgery in London? Do you suspect you have bunions but don’t know what to do about them?

Approximately 14 million people in the UK deal with bunions.

If you’re one of them (or think you might be), this guide is for you. It breaks down everything you need to know about diagnosing and treating bunions.

What Are Bunions?

Bunions are bony bumps on the joint that connects the base of the big toe to the foot. Some people also develop “bunionettes” — more minor bumps on the joint at the bottom of the little toe.

What Are Bunions Made of?

Bunions occur when bones in the foot shift out of place. When the bones move, the tip of the big toe gets pulled in toward the other toes. As a result, the joint below the big toe sticks out.

Symptoms of Bunions

A bump on the side of the foot is the most common symptom of bunions. However, you might experience other symptoms, including these:

• Pain and stiffness in/around the big toe joint
• Swelling of the big toe joint
• Difficulty walking 

You might also develop corns or calluses between the first and second toes due to them rubbing together.

What Causes Bunions?

Several issues can contribute to bunion development. The following are some of the most well-known causes:

• Genetics: If your family has a history of bunions, you’re more likely to develop them as well
• Medical conditions: Conditions like gout, osteoarthritis, and rheumatoid arthritis can increase your risk of experiencing bunions
• Poorly fitting shoes: If you frequently wear shoes that compress your toes (such as high heels with pointy toes), you’re more likely to deal with bunions
• Foot type: Those with low arches or flat feet are more prone to bunions

Foot injuries or birth deformities can also increase your risk of developing bunions.

How to Treat Bunions

Not everyone with bunions needs surgery — at least not right away. Here are some treatment options you can consider if you’re experiencing bunions:

Bunion Pads

Bunion pads are small cushions that create a soft barrier between your foot and your shoe. Adding extra cushioning can provide some relief and reduce pain while standing or walking.

Shoe Inserts

You can also purchase shoe inserts for additional comfort while standing or walking. Shoe inserts allow for more even pressure distribution when you move, which helps to prevent bunions from getting worse.

You may find over-the-counter inserts that work for your symptoms, or you may need to talk to a specialist about prescription inserts.

Changing Shoes

Whether you choose bunion pads or shoe inserts, you’ll likely find that certain types of shoes are no longer ideal for you.

If you frequently wear narrow shoes or shoes that compress the toes, it’s time to invest in some more comfortable and supportive alternatives. Otherwise, you’ll end up worsening your bunion symptoms.

Ice

Applying ice to your bunions — especially after standing or walking for extended periods — can reduce inflammation, swelling, and soreness. However, those with circulation issues or reduced feeling in their feet should consult a physician before trying this technique.

Medication

Many people find relief from the pain, inflammation, and soreness associated with bunions by taking over-the-counter medications like paracetamol or ibuprofen.

Injections

If over-the-counter painkillers alone aren’t sufficient for reducing bunion pain, you may also want to consider steroid injections. These injections reduce swelling and are particularly helpful for those who also struggle with osteoarthritis or rheumatoid arthritis.

Surgery

Surgery may be your best option for long-term bunion relief, particularly if the above treatments don't work.

Bunion surgery involves the following:

• Cutting bones to realign them in the correct position and fix them with small screws
• Removing prominent bone that causes pain
• Releasing some soft tissue and tightening other parts of the joint
• Cutting out swollen tissue from around the big toe joint

Most physicians recommend bunion surgery to those who experience pain caused by the bony prominence of the bunion.

Surgery might also be helpful when the pain is getting worse or you can’t find properly fitting shoes. Surgery is necessary when your second toe is starting to hurt or changes alignment eg starts to look like a hammer toe.

Schedule Bunion Surgery in London Today

If you suspect you’re dealing with bunions, meet with a foot specialist as soon as possible. They can diagnose your condition and help you develop a comprehensive treatment plan.

Dr Klinke is one of the leading foot specialists in London. If you’re considering bunion surgery in London or just want to know your options, book an appointment today.

Martin Klinke is a world-renowned foot specialist who has been practising in London for over 20 years. He has dedicated his career to helping people with foot problems and has helped patients regain mobility and quality of life. Mr Klinke is one of the leading foot specialists in London with qualifications in orthopaedics and sports medicine.

He can help you with everything from bunions to Achilles tendinopathies and much more. He's a consultant at the London Foot and Ankle Centre and London Bridge Orthopaedics, and he offers a wide range of services designed to meet your needs. So, if you're looking for a "foot specialist near me," be sure to give Martin Klinke a call.

Martin Klinke Excellence in Foot and Ankle Care

Total Ankle Replacement Focus

Martin Klinke is one of only a handful of surgeons in the United Kingdom with a focus on total ankle replacement. This means he can provide you with this cutting-edge procedure if you have end-stage arthritis or other conditions that haven't responded to conservative treatment. Total ankle replacement can relieve pain, improve function, and restore quality of life for many patients.

If you're looking for an ankle replacement surgeon in London, look no further than Martin Klinke. He has the experience and expertise to get you back on your feet and enjoying life again.

Biologic Foot and Ankle Treatment

Martin Klinke is also a pioneer in the use of biologic treatments for foot and ankle conditions. Biologics are substances derived from living organisms and can be used to promote healing and reduce inflammation.

Some of the biologic treatments that Mr Klinke offers include platelet-rich plasma injections which may help to stimulate your healing process. These cutting-edge treatments can help you heal faster and get back to your normal activities sooner.

Managing Surgical Pain with Less Medication

Martin Klinke is committed to helping his patients manage their pain with less medication. He offers a variety of options for postoperative pain management, including local anaesthesia, nerve blocks and various physical therapies. These techniques can help you stay comfortable during your recovery and get back to your normal activities sooner. The thing is, when you're in pain, it's tough to stay positive and motivated.

That's why Martin Klinke also offers psychological support to his patients. He understands the importance of a positive outlook during recovery and will work with you to ensure that you have the support you need to heal properly.

Moving Foot and Ankle Care Forward

Martin Klinke is always looking for ways to improve the care he provides to his patients. He is constantly researching new treatments and procedures and is always up-to-date on the latest advances in foot and ankle care. This means that you can be confident you're getting the best possible care when you see Mr Klinke. He is committed to providing his patients with the best possible outcomes and the highest quality of life.

The Comprehensive Services He Offers

Martin Klinke treats a wide spectrum of foot-related conditions and is passionate about helping his patients achieve their goals and live their best lives. He will work with you to develop a treatment plan tailored to your specific needs. Whether you're looking for relief from pain or you want to improve your function, he can help.

Why Choose Martin Klinke, Foot Specialist London?

There are many reasons to choose Martin Klinke as your foot and ankle specialist. Here are just a few:

• He is a leading expert in his field
• He has a wealth of experience
• He offers comprehensive services
• He uses cutting-edge treatments
• He is committed to helping his patients achieve their goals
• He has a passion for his work
• He is dedicated to his patients

Why You Should Seek the Services of Martin Klinke for Your Foot and Ankle Needs

These and many more reasons are why you should entrust your foot and ankle care to Martin Klinke. He is dedicated to providing you with the best possible care and treatment and will work tirelessly to help you achieve your goals. Contact Martin Kinke's office today to learn more about what he can do for you.

While a great deal of us have heard of the condition known as Plantar Fasciitis, far fewer may know exactly what it is, how it affects us and how exactly it is treated. Despite its rather exotic name, it is quite a common condition, one which can cause a great deal of pain on the underside of the foot, typically under the heel but also along the arch of the foot causing tenderness to the touch. It is a condition that can be particularly bad after periods of non-weight bearing, for example getting up in the morning or after long periods seated. It can also cause pain after long periods on your feet, yet you might be fine while you are active. Typically the pain subsides at some stage, and the condition itself can also be temporary, lasting anywhere up to around a fortnight. For some, however, it can be a longer term problem requiring professional advice and medical intervention.

Causes

Plantar Fasciitis develops when the tissues running between the heel area up to the foot’s arch become inflamed. This area acts as the body’s natural shock absorber but can easily become damaged from repetitive daily wear and tear, sudden impacts or just something as simple as a barefoot walk across hard ground. There are links between the onset of Plantar Fasciitis and a sudden increase in activity levels, placing those who might have started jogging, joined the gym or taken up other physical activities at more risk. There are also strong links between the condition and obesity as well as those with flat feet.

Diagnosis

Generally, if the condition hasn’t improved within a fortnight, it may be a longer term issue and making an appointment with your local GP should be considered. Typically your doctor will explore the history of your condition and undertake a physical examination to rule out other potential causes of the pain. This may involve touching the heel to see if it causes pain and asking you to flex your toes upwards to tighten that area between heel and arch (the fascia) to examine it under tension.

Ultrasound might also be an option to help ascertain the fascia’s thickness. A thickness greater than 4mm is generally indicative of the condition and a diagnosis can be made.

Easing the pain

There are several things you can undertake yourself to help alleviate the pain caused by Plantar Fasciitis. The most common (and one of the most effective) is comfortable, supportive footwear with particular focus on the heel and the arch of your foot, making trainers and sports shoes ideal. The comfortable shoes should raise your heel a little bit and support your arch. Stretching your calf muscles three times a day for a few minutes is also very effective. Rolling your foot over a small soft ball such as a golf or tennis ball is also effective for stimulating and helping to stretch your foot. Some people also find pain relief from the application of ice packs or packs of frozen peas wrapped in a towel every few hours. For those still looking to keep fit and active, swimming or cycling is an ideal form of non-weight bearing exercise.

Important things to try and avoid are long periods on your feet, walking barefoot (particularly on hard surfaces) and any footwear that is backless such as flip-flops or sandals. Whether Plantar Fasciitis is a condition you’re able to successfully manage and treat at home or whether you need the advice and support of an orthopaedic foot and ankle specialist, effective treatment is nearly always a combination of understanding and managing the mechanics of your foot and treating the problem area. In persistent painful cases a steroid injection or extra-corporeal shockwave treatment might be needed to help combat inflammation. Extra-corporeal shockwave treatment is a well recognised, successful and safe treatment option which stimulates the soft tissue to heal within a short period of time. 

Sufferers generally make a full recovery but it is important to remember that often there is a specific reason why people develop Plantar Fasciitis in the first place. This is the key reason why seeking the help of a medical professional is a good idea, to help ascertain the root cause of the problem and prevent it from recurring further down the road.

Lesser toe deformities are a common problem and often associated with big toe deformities. The lesser toes are linked to the foot by multiple soft tissue structures, the strongest one is on the sole of the foot and is called the plantar plate.

With forefoot overload, this structure can rupture and until recently this problem was very difficult to treat. Detecting this pathology with the help of thorough clinical examination and an MRI scan can lead to a successful repair of this important stabiliser of the toe joints. Special techniques and dedicated instruments now allow to repair the plantar plate. This means that the plantar plate is re-attached to the toe, therefore, the function of the toe is preserved.

This makes extensive and “debilitating” forefoot surgery unnecessary.

Are you suffering from pain or problems with your feet, contact me today.

Pain in the big toe joint can be caused by inappropriate footwear, big toe deformity, inflammation in the joint or some wear and tear in the joint. Once cartilage is damaged it does not grow back. This can lead to arthritis in the big toe joint called hallux rigidus. When conservative treatment has failed, surgery becomes an option. In milder forms of degeneration, one can perform a cheilectomy which removes prominent bone and any inflammation in the joint. In the more severe cases, a fusion of the big toe joint becomes necessary. This means the joint is made stiff and does not move.

For a few years now a new implant has become available that provides another successful treatment option. The so-called Cartiva implant “resurfaces” part of the joint, it helps to reduce the pain further and preserves the range of motion. This implant is a synthetic substance similar to the one used in contact lenses. Implanting the device does not need a lot of bone resection but is rather a “resurfacing” of the joint. So far, short and midterm results have been very good, reducing the need for a fusion substantially. The Cartiva implant is associated with very high patient satisfaction rate.

If you are suffering from pain in the big toe joint, contact me today.