BIPEDAL

In this episode of BIPEDAL, we explore one of the most common deformities of the forefoot—hammertoes. These toe deformities affect millions of people and often develop gradually due to biomechanical imbalance in the foot. A hammertoe occurs when one of the lesser toes—most commonly the second, third, or fourth toe—becomes bent at the middle joint, creating a characteristic hammer-like appearance. Early in the condition the toe may remain flexible, but over time the deformity can become rigid and painful. We discuss the different types of digital deformities, including: Hammertoe, where the proximal interphalangeal (PIP) joint bends upward Mallet toe, which involves bending at the distal joint near the tip of the toe Claw toe, where multiple joints bend and the toe curls more dramatically The episode explains how these deformities develop, focusing on the role of muscle imbalance between the intrinsic and extrinsic muscles of the foot, as well as contributing biomechanical factors such as long second toes, joint instability, structural foot types, and restrictive footwear. Common symptoms include: Pain or irritation in shoes Corns and calluses from pressure points Difficulty finding comfortable footwear Progressive deformity of the toe We also review treatment options, beginning with conservative approaches such as footwear modifications, padding, orthotics, and activity changes. These strategies aim to relieve pressure and slow progression of the deformity. When symptoms persist or the deformity becomes rigid, surgical correction may be considered. Surgical procedures typically focus on realigning the toe, releasing tight tendons, or stabilizing the joint to restore function and relieve pain. Finally, we discuss recovery and patient expectations following hammertoe surgery. Most patients are able to walk immediately in a protective surgical shoe, with gradual return to normal footwear over several weeks. Swelling can persist for a few months, but long-term outcomes are generally very favorable when the deformity is appropriately corrected. This episode provides a clear overview of hammertoes—from how they develop to the treatments available—helping listeners better understand a condition that affects a large portion of the population. Key Takeaways Hammertoes are a common deformity affecting the lesser toes. They often develop due to muscle imbalance and biomechanical factors. Early treatment focuses on pressure relief and supportive footwear. Surgery may be recommended when deformities become rigid or painful. Recovery typically allows early walking with gradual return to activity. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Beginning with early primates more than 50 million years ago, the episode examines how primitive feet functioned primarily as grasping tools for arboreal life, featuring a divergent big toe, long toes, and a flexible midfoot. As environmental changes pushed early hominins toward life on the ground, the foot gradually adapted to support bipedal locomotion. Key fossil discoveries—including Ardipithecus, Australopithecus, and the famous 3.6-million-year-old Laetoli footprints—provide critical evidence of how early humans began walking upright. Later species such as Homo erectus show the emergence of many modern features of the human foot, including shorter toes, a larger heel bone, and the development of the longitudinal arch. The episode also explores the biomechanics that make the human foot so efficient, including the windlass mechanism, elastic energy storage within the arch and plantar fascia, and the role of the big toe in propulsion. Together, these adaptations transformed the foot into a structure capable of supporting long-distance walking and endurance running. Finally, the discussion connects evolutionary design to modern foot pathology, highlighting how conditions such as plantar fasciitis, bunions, and arch dysfunction may represent trade-offs of our specialized bipedal anatomy. I named the podcast 'Bipedal' since the story of structure origin is fundamental to understanding what can structurally go wrong. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

In this episode of BIPEDAL, we take a comprehensive look at arthritis of the foot and ankle, a common condition that can significantly affect mobility and quality of life. Foot arthritis is actually quite common, particularly in adults over the age of 50, while ankle arthritis is less frequent but often more debilitating when it occurs. Osteoarthritis is the most common joint disease worldwide, affecting hundreds of millions of people. In the foot alone, imaging studies suggest that roughly one in five adults over 50 show signs of arthritis, although not all cases produce symptoms. Ankle arthritis affects approximately 1% of the population, and unlike hip or knee arthritis, the majority of ankle arthritis cases are post-traumatic, meaning they develop after an injury such as an ankle fracture or severe sprain. Arthritis typically begins with breakdown of the protective cartilage inside the joint, which normally allows smooth, pain-free movement. As cartilage deteriorates, the joint space narrows and the bones begin to experience increased mechanical stress. Over time this can lead to bone spurs, stiffness, loss of motion, and chronic pain. There are different causes of arthritis, including: Primary osteoarthritis, related to age and long-term wear Post-traumatic arthritis, often following fractures or ligament injuries Inflammatory arthritis, such as rheumatoid arthritis or psoriatic arthritis Biomechanical causes, including deformities or abnormal foot structure Common symptoms of foot and ankle arthritis include: Pain during walking or standing Stiffness in the affected joint Swelling and inflammation Loss of joint motion Progressive deformity in advanced cases Treatment generally begins with conservative management aimed at reducing pain and improving function. These strategies may include activity modification, supportive footwear, custom orthotics, bracing, anti-inflammatory medications, and occasionally injections to reduce inflammation. When symptoms become severe or conservative treatments fail, surgical options may be considered. These procedures can include joint debridement, realignment procedures, joint fusion, or in certain cases joint replacement, particularly for the ankle. The episode emphasizes that treatment decisions are individualized and depend on the severity of arthritis, the joints involved, and the patient’s activity level and goals. Key Takeaways The foot contains 33 joints, making arthritis a common source of foot pain. Approximately 20% of adults over 50 show signs of foot arthritis on imaging. Around 70–80% of ankle arthritis develops after trauma, such as fractures or severe sprains. Symptoms typically include pain, stiffness, swelling, and decreased mobility. Conservative treatments often provide relief, but surgical options exist for advanced cases. This episode provides listeners with a clear overview of how arthritis develops in the foot and ankle and the wide range of treatment options available to maintain mobility and quality of life. For more discussions about foot and ankle health, stay tuned to BIPEDAL. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Approximately 10% of all fractures in the human body occur in the foot and ankle. It is a load bearing, highly stressed region of the body whereby forces are continuously being applied. Move the foot suddenly in the wrong direction, and these forces can overwhelm the ability of the bones to stay intact. However, all injuries resulting in fractures do not have to be the result of sudden movement or significant force. Repeated cyclic stress such as when training or carrying heavy loads may result in a type of fracture pattern as well. Understanding the mechanism of injury is crucial in fracture evaluation and management. Because fractures follow patterns, skilled clinical evaluation can determine whether straightforward conservative management is appropriate, or more intensive surgical repair is required. Factors such as patient age, activity level, biologic capacity for healing, and even adequate blood flow all become part of a clinical picture that dictates methods of treatment. I am taking a broad look at this type of injury in Season 1 to lay the foundation for future discussions. Next season we will begin to explore more in depth surgical topics including specific fracture scenarios that we treat. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

The great toe joint is just that - it's great! Until it's not. Stiffness and immobility are very common conditions. Some studies show that over 60% of people will develop arthritis in this joint at some point in their life. Patients will report initially with occasional pain with bending, or when performing certain activities such as jumping or stooping. As the condition progresses, limitation of motion becomes more pronounced, and bone spurs will become evident. In later stages, even walking may be painful. Because arthritis is progressive degeneration, there is no easy "fix." We manage symptoms using shoe modifications and orthotic therapy, occasionally supplemented by medications and physical therapy. When these modalities fail, surgery may be indicated. The good news is that this is a slow process, often taking years for symptoms to rise to this level of care. Surgery also has options. In early stages, joint salvage is preferred over joint destruction. This may include a simple clean up of the spurs and removal of loose cartilage. As the cartilage wear patterns continue and joint space narrows, decompression through osteotomy (cutting of the bone) may extend the life of the natural joint. In later stages of degeneration the joint may no longer be salvageable. At this stage we consider either replacement or fusion depending on activity level, radiographic parameters, and patient preference. Joint fusion remains the mainstay for end stage arthritis. So there is always a definitive procedure for alleviating pain in this joint, but we work through many methods before choosing this option. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Gout is a term we use to describe the intense inflammatory episode that occurs when elevated uric acid levels in the blood - a condition called hyperuricemia - cause crystal deposition in the joints. Very often this occurs in the foot since this is a cooler area of the body. Patients will remark that even the sheets touching the joint elicits intense pain. Clinically, we often see the great toe joint involved. This is probably due to several factors, including that underlying arthritis is often present before a gout episode occurs. Additionally this is a relatively large joint in a cool area of the body. Diet may play a role. Specifically, foods high in purines will contribute to hyperuricemia. Shellfish, dark flesh fish such as salmon and tuna, red meat and derivative products such as gravy, even beans and peas may elevate systemic uric acid levels. Additionally, dehydration may compound the elevated uric acid levels, such as with consumption of alcohol or when taking diuretic medication. With blood tests we can determine the levels of uric acid and consider either diet modification for transient or slightly elevated uric acid or long term medication for very high levels. These medications will lower the uric acid and thus indirectly reduce or eliminate gout attacks. Gout as an inflammatory condition is manageable, but clinical evaluation is essential. Each attack is not without consequence and multiple attacks over time can lead to severe debilitation, sometimes requiring surgical management. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Ankle sprains are very common orthopedic injuries. A sprain is stretching or tearing of ligaments. Since there are multiple ligaments holding the ankle complex together, there is a myriad of injury patterns that can result from "rolling" your ankle. On the outside of the ankle there is a ligament complex called the lateral collateral ligaments. These are the most commonly injured in a typical ankle sprain. On the inside of the ankle lies the deltoid ligament, and triangular shaped ligament complex that can secondarily become injured during a lateral sprain or primarily injured, such as when stepping in a hole and the foot is turned outwards. And in between the leg bones, the tibia and fibula, is a strong ligament complex called the syndesmosis that can also become torn in high ankle sprain patterns. When I examine patients, I am taking inventory of the integrity of all of these structures, as well as the bones that they connect to. I pay special attention to the ability of the ligament to restrain motion. This can clue us in to whether a ligament has been simply stretched, partially, or fully torn. An unstable ankle as a result of torn ligaments can be especially problematic long term. This is due to the aberrant motion allowed when ligaments are stretched or unstable. The result is premature wear of the cartilage lining the joint which can lead to early arthritis. Thus the reason we take even 'simple' sprains very seriously both in initial approach and with rehabilitation. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Flat feet are common. And not all of them are painful. Some people are born with a flexible flatfoot and have no issues with common activities, while others were born with a normal arch but develop a flat foot over time. This is more likely related to posterior tibial tendon dysfunction, or PTTD. This condition can happen as a result of poor biomechanics, repetitive stress, age, weight, certain medical conditions or even medications you might take. The posterior tibial tendon rarely weakens or fails all at once. It is a progressive degeneration, like we saw with the Achilles tendon in Episode 6. Repetitive stress on a weakened tendon creates a cycle that ultimately results in tendon tearing and failure, leading to collapse of the arch. At first this is a tendon only problem. Later this becomes a multi-joint failure with degeneration and adaptive changes in other structures of the foot and ankle. Early intervention may prevent progression to the arthritic process of joint degeneration. Orthotics, physical therapy, activity and shoe gear modification are used early on. Later stages may require more aggressive treatment including surgery. Occasionally, we use surgery as a tool earlier in the process before the late stage events occur. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

The Achilles tendon is the combination of the gastrocnemius and soleus muscles as they course down the leg and attach to the calcaneus. This large tendon is a powerful plantar flexor of the foot. The tendon is under a resting tension, ready to propel the foot forward when the brain sends it a signal. It is this resting tension that may become problematic. For example, part or a flatfoot condition involves the heel cord contracting, a condition we call "equinus." If the resting tension is excessive, even small escalations of use may cause pain to develop, a signal that the tendon is being overworked. When tension exceeds the elasticity of the tendon small tears may develop. Small tears can scar in, but this tissue is weaker than the original tendon fibers. consequently a cycle can develop of micro tearing and repairing. Eventually, enough of the tendon is compromised and a nodule or lump may appear in the tendon. This is an indication that things have degenerated quite a bit. Stretching and warming up the tendon before activity is the mainstay of prevention and treatment of early Achilles tendonitis. This is performed with bands, towels, or just gravity, to eccentrically load the tendon and get it ready for engagement. Unfortunately, tendonopathy (as it is more appropriately termed) is not a quick fix; it involves weeks and sometimes months to work through before returning to normal activity. When stretching and resting do not alleviate the pain and tightness of the Achilles tendon we may resort to surgical methods. This can vary from high energy sound waves directed at the tendon, radiofrequency ablation of the scarred tissue, up to open debridement, tendon lengthening and even tendon transfers. It is helpful to know that 80% or more patients will not escalate to this level. The vast majority will respond well to appropriate treatment and addressing underlying biomechanical issues. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Orthotics are a mainstay of treatment for many foot and ankle conditions. This is because so many conditions are a result of poor biomechanics. Pronation, a normal foot motion required for efficient gait, can be excessive in some individuals, leading to a variety of downstream problems. For example, excessive pronation leads to hypermobility, hypermobility leads to foot deformity such as bunion and hammertoe formation. Thus control of excessive pronation is a way to prevent or slow the progression of these conditions. Orthotics do just that - control abnormal motion. Orthotics are also a way to compensate for arthritic joints, failing or weakened tendons, inflamed nerves, arch fatigue, or excessive forefoot stress. Depending on the materials used and the modifications of the device, many foot conditions can be adequately treated using these powerful tools. If you are considering purchasing shoe inserts because of a painful foot condition wait! Listen to the episode before you spend considerable money on devices that may not work! In the long run, you may be better off evaluated by a professional to determine if these will work for you at all, and which type of device you require. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Many patients present to my clinic complaining of bunion pain. These patients range in age from adolescents all the way to my geriatric population. There is no predilection for age, gender, body weight, race, or any other factor - yet they can be painful and are quite often progressive. The major factor playing a role in development is genetics. When coupled with biomechanics, bunion formation is inevitable in most patients. Consequently, their formation is not necessarily preventable. Progressive conditions are dynamic. In this case, the formation of a bunion is just the start of a process of deviation of bones from their original position into a buckled one. This means when a patient notices the bump near their great toe, almost always that bump does not stay the same size forever. It will grow, the great toe will shift position over time, and symptoms may eventually emerge as a painful sore great toe that becomes bothersome even without shoes on. Understanding what a bunion is, why it progresses, and what the symptoms are can be revealing. Who will get a bunion? Why do they get worse with time? What you can do to slow that progression? We will get into all of that and more. There are varied treatments for bunions, from conservative to surgical. In this episode we will stick with a broad overview of the deformity and touch on conservative methods of management. I will dive deeper into surgical treatments in subsequent podcast episodes for patients or clinicians who want to understand more about corrective measures. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Pronation is a complex triplanar motion: eversion of the heel, abduction of the foot, and dorsiflexion of the ankle. Supination is the reverse motions: inversion of the heel, adduction of the foot, and plantarflexion of the ankle. These motions occur at specific phases of gait, the cycle of taking a step. Pronation is critical for proper shock absorption and adaptation to uneven terrain. Supination is the process of reversing the foot from a mobile adapter to a rigid lever to allow efficient propulsion. When either motion is excessive, prolonged, or unrestricted, specific pathological conditions may follow. Often a condition seemingly unrelated to foot motion can be traced back to an excess of either motion. For example, stress fractures occur more commonly in a supinated foot. These motions are dynamic, and required for efficient gait. When evaluating a foot type, the static position is one part of the equation. The foot as it functions dynamically is the other. A pronated foot may supinate excessively, slightly, or not at all. Likewise for the supinated foot. It is this complex series of movements that we study when evaluating foot pathology. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Plantar Fasciitis is one of the most common conditions I see in my clinic. Roughly 1 in 10 people will experience this in their lifetime, making it extraordinarily prevalent. There can be confusion as to how the condition evolves, but I will say it mainly has to do with form and function. By that I mean our feet were not designed for the surfaces we walk on each day. This can be corroborated by the fact that a majority of sufferers spend inordinate amount of time on hard surfaces. Think teachers, warehouse workers, nurses. Not to mention the runners and athletes who can be sidelined when the condition develops. The majority of patients I see have tried resting, over the counter pain medications, changing their shoes and possibly some stretching. I have to assume a great deal of patients have success with this. However many do not, causing them to come limping into the office seeking professional help. We begin with evaluating precipitating events, avoiding these activities and modifying shoe gear appropriately. NSAIDs, a rigorous stretching routine, and occasionally corticosteroid injections are used initially. Shoe inserts that are appropriate for a patients foot type and activity are also instituted. The majority of patients will obtain relief with these techniques. For stubborn cases a physical therapist is brought on to aid in pain reduction and reversal of the factors that led to fasciitis developing. In more refractory cases surgery may be required. Surgical methods vary among practitioners but most have very high success rates. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Dr. Weinstein discusses the impetus for creation of a podcast that discusses all aspects of medical and surgical treatment of foot and ankle disorders. Dr. Weinstein has been practicing foot and ankle surgery for over 20 years. In this time new formats for public education have emerged. No single source exists where a comprehensive discussion of common pathologies and treatment algorithms are explained in short format audio or video. The hope is to change that in this series. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.