German Centre for Orthopaedics
Hand and Foot Department
The department of hand and foot surgery has an excellent reputation nationally and internationally in the treatment of diseases of the hands, feet and upper ankle.
As a result of their wide range of different functions, the structure of our hands and feet is extremely complex. In diseases caused by wear, injuries, incorrect loading or rheumatism, we will start your treatment by initially conducting precise diagnostic measures.
Then we will do all we can to alleviate your symptoms conservatively or surgically. To this end, our specialists can fall back on many years of experience, whether it be in their choice of conservative treatment options, in standard interventions or in complex operations.
German Centre for Orthopaedics
In our centre, treatment is focused on people who have had accidents, those with diseases of the hand and finger joints related to wear (osteoarthritis), nerve compression syndromes in the wrist and rheumatic changes in the hand. We have compiled the most important information on these diseases for you here.
Osteoarthritis refers to wear of a joint beyond the degree to be expected on the basis of the patient’s age. The causes may be excessive strain, malalignment of the joints, bone diseases or hereditary predisposition.
In the area of the hand, osteoarthritis mainly occurs in three forms:
- as Heberden's nodes in the joints closest to the end of the fingers
- as Bouchard’s nodes on the middle joints of the fingers/li>
- as trapeziometacarpal osteoarthritis at the base of the thumb
Here, swellings occur on the outer or middle joints of the fingers. Patients complain of morning stiffness of the fingers and of pain upon simple movements, such as when opening a bottle. Later, the symptoms can become more severe and also occur when the hand is at rest. They are often accompanied by restricted mobility of the fingers, due to reduced flexion of the joints.
Various conservative measures are available to us for the treatment of osteoarthritis of the wrist and finger joints.
At the onset of the disease, targeted physiotherapeutic exercises or drug therapy may be helpful.
If such steps are not successful, the symptoms persist over a prolonged period, or severe distortions of the finger joints occur, the doctor will suggest a form of surgical therapy.
Possible forms of therapy:
- Joint fusion
- Artificial joints
In the case of nerve compression syndromes, surrounding tissue constricts the supplying nerves, thus damaging them.
The best known of them is carpal tunnel syndrome: The patients suffer from pain, numbness and reduced strength in the hand. Initially, the symptoms only occur sporadically and when the wrist is under strain, later pronounced pain may be experienced at rest.
At the onset of the disease, conservative treatment may be successful, for example it may be helpful to immobilise the arm and wrist in a forearm splint during the night.
If conservative measures do not help and pronounced, prolonged pain occurs, the attending doctor will recommend an operation. This intervention is performed on an outpatient basis in most cases.
Rheumatoid arthritis is the most common inflammatory rheumatic disease: It is characterised by painful swelling of the joints and over its further course leads to joint destruction and increasing restriction of mobility.
Changes in the area of the hand often occur, for example redness, swelling or distortion of the fingers. In many cases, we can improve or at least delay these disturbances of hand function through surgical interventions.
German Centre for Orthopaedics
Foot surgery at the Waldkliniken Eisenberg covers the entire spectrum of foot surgery. We have compiled the most important information on our main areas for you here.
Splayfoot occurs when the transverse stability of the midfoot bones is no longer given. The reasons for this might be a predisposition towards weakness of the muscles and ligaments, but external factors (obesity, unsuitable footwear) also play a role. As a result of the loss of stability, the forefoot splays out – in extreme cases it takes on a triangular shape – and the strain in the area of the central metatarsal heads increases.
For this reason, painful calluses develop in this mechanically overstrained region of the foot (metatarsal heads II, III and IV). Parallel to this development, varying degrees of toe deformity (bunion, claw toe, hammer toe, mallet toe) or painful nerve compression syndromes (Morton’s neuroma) may ensue.
The symptoms of splayfoot can basically be treated by conservative means, for example with individually fitted insoles, which relieve and cushion the painful area. Regular foot care with removal of the calluses can also help to alleviate the symptoms. As a basic rule, it is recommendable to wear shoes with soft soles. Gymnastic exercises to strengthen the muscles of the feet are sensible, although the achievable effect is limited if the feet are already deformed.
If the splayfoot symptoms cannot be sufficiently alleviated by conservative means, surgical measures may be considered. These include operations to correct the position of the metatarsal rays (for example Weil’s osteotomy), in which the heads of the metatarsal bones are raised in order to relieve pressure from the painful calluses.
Hallux valgus (bunion) is the most common deformity of the big toe: The big toe bends to varying degrees towards the other toes and the ball of the big toe juts out sideways. When wearing shoes, increased friction occurs on the inside of the ball and additional pressure is exerted on the soft tissues. This can continue up to the formation of painful bursal sacs.
Depending on the degree of deformity, the big toe can butt up against the neighbouring second toe, leading to painful calluses here. The small toe may also be displaced upwards, which promotes the development of claw or mallet toes.
The causes of bunions are diverse and include congenital changes, a hereditary predisposition and muscle-ligament weakness. Many years of wearing unsuitable footwear (high heels, tight shoe tips) also contributes to the development of a bunion.
There is no causally orientated conservative treatment for bunions. To alleviate the symptoms over the painful ball of the toe, sufficiently broad shoes or shoes open in the forefoot area are recommendable. Toe spreaders may be helpful if painful contact between the big toe and the adjacent toe is the main problem. In adulthood, bandages or postural splints can no longer achieve any positional correction.
A permanent correction of the position of the big toe can only be achieved by means of an operation. Depending on the degree of the deformity, the patient’s age, functional demands and possible accompanying disorders, various different methods are available. The basis for bunion surgery is axial correction of the first metatarsal ray, which is supplemented by appropriate soft-tissue measures on the metatarsophalangeal joint.
The use of modern surgical techniques and stable fixation methods makes it possible to put weight back on the foot in special shoes immediately after the operation. Plaster casts are thus a thing of the past. Consistent elevation of the foot, movement exercises and physical therapy measures (cold applications, lymph drainage) reduce the swelling of the forefoot and shorten the healing process.
Hallux rigidus (stiff big toe) describes joint wear on the metatarsophalangeal joint. As a result of the reduced mobility of the big toe, recurrent pain occurs here when walking.
Large bone spurs often form on the extension side, which cause additional pressure pain in the shoe. The cause of the disease is multifaceted: congenital anomalies of the first metatarsal bone, prior cartilage damage (sports injuries) or metabolic disorders (gout).
Depending on the stage of the disease, conservative treatment consists of targeted physiotherapeutic measures, injections into the joint and the options offered by orthopaedic footwear technology (sole stiffeners and ball rockers).
The surgical measures are dependent on the extent of the disease and the remaining joint mobility available. While joint-sparing interventions that improve the range of movement of the joint are possible at an early stage, joint stiffening (arthrodesis) or resection arthroplasty (operation according to Valenti) are indicated in the later stages.
The decision on which surgical method is to be applied depends on the patient’s functional requirements, their age and the cause of the disease.
Deformities of the small toes can occur as a result of muscular imbalance, due to a genetically-related excessive length of the small toe, an accompanying bunion deformity and unsuitable footwear.
Most common is a flexion malalignment in the middle joint (claw toe), which is accompanied by a painful callus over the joint. If the base joint is additionally in an overextended position, a mallet toe is present. Patients primarily complain of pain under the affected metatarsal head.
The hammer toe is a rare deformity and describes an isolated flexion malalignment in the distal phalanx, so that pressure pain at the tip of the toe with deformation of the toenail may occur under strain.
The conservative therapy of small toe deformities consists of a local cushioning of the painful areas, wearing of sufficiently broad or open shoes as well as individually fitted insoles and regular foot care.
The range of surgical measures is wide and is dependent on the degree of malalignment and the accompanying forefoot deformities. The aim of surgery is to restore a straight small toe that has sufficient contact with the floor when standing.
While soft-tissue interventions on the tendons and joint capsules may be sufficient in the early stage, arthrodesis in the medial or distal joint often has to be performed in advanced stages. In mallet toe deformities with an overextension of the toe in the base joint, it may even be necessary to shorten the metatarsal bones, in order to eliminate midfoot pain.
The term skewed flat foot refers to a deformity in which the heel axis is skewed outwards in relation to the lower leg axis under weight-bearing (skewed foot). At the same time, the arch of the foot flattens to a varying degree (fallen arches, flat feet).
Adults who have developed skewed flat feet initially have pain behind the inner ankle and the inner edge of the foot. The reason for this is damage to or failure of the tendon of the rear shin muscle (musculus tibialis posterior). This makes it difficult or possibly even impossible for them to stand on their toes. Later, the shape of the foot changes. Painful bone spurs can develop and pain increasingly occurs on the outside edge of the foot.
In the early stage, conservative treatment consists of individually fitted stable insoles and targeted physiotherapeutic measures. However, these measures are not suitable for correcting a deformity that is already present or for halting the progression of the disease. Therefore, it is important to have an orthopaedic check-up at least every three months, so that a progression of the deformity can be identified at an early stage.
A positional correction of the foot with corresponding alleviation of the symptoms can only be achieved by surgical measures. At an early stage, the diseased tendon can be replaced (tendon transfer). In adults, this intervention is always combined with a positional correction of the heel bone.
In advanced stages, the malaligned joints of the hindfoot must be returned to their original position and stiffened in this condition. After the operation, the foot is immobilised for between six and ten weeks in a plaster cast or special shoe. During this period, the foot must be treated with care, and the patient should use crutches.
Thereafter, physiotherapists will help the patient in becoming accustomed to increased weight-bearing on the foot. Additional orthopaedic measures such as bedding insoles or custom-made orthopaedic shoes support the recovery process.
A high arch or pes cavus is characterised by an excessively elevated longitudinal arch. It is usually caused by a muscle or nerve disease (e.g. hereditary sensorimotor neuropathy).
Whereas high arches can be successfully compensated in childhood and adolescence, strain-dependent pain in the hindfoot or pain below the metatarsal heads is experienced in adulthood, depending on the type of deformity.
DConservative therapy consists of an individually adapted bedding of the foot. Orthopaedic footwear is often necessary for this purpose.
Surgical measures depend on the type and extent of the deformity. The aim of treatment is to straighten the heel in relation to the lower leg and to flatten the excessively elevated arch of the foot. Beside soft-tissue interventions (tendon transfer), this generally requires surgery on bones (positional correction) and joints (stiffening).
After the operation, a plaster cast is imperative for a number of weeks (between six and ten weeks).
Osteoarthritis (cartilage wear) on the joints of the talus or of the hindfoot usually develops as a result of prior injuries (broken bones, torn ligaments) or changes in the form of the foot (skewed flat foot).
Typically, patients complain of strain-dependent pain in the foot when walking and standing, while they are often no longer able to walk barefoot at all. In their efforts to avoid pain, those affected often develop an unphysiological gait pattern, which can lead to pain in the entire leg and the pelvic region.
Conservative treatment may consist of targeted injections into the joint. In addition, the painful joint can be relieved by means of special shoes (sole stiffeners and rocker soles).
As a general rule, surgical therapy consists of stiffening of the affected joint. Up until the bone has healed, the foot has to be immobilised for six to ten weeks in a lower leg cast or in a special shoe.
The upper ankle is a joint that bears a high degree of strain, having to cope with forces many times the bodyweight during walking and sporting activities. Injuries to the joint, for example repeated sprains, are the reason for the later development of wear-related cartilage changes. Inflammatory joint changes (e.g. rheumatoid arthritis) or metabolic disorders can also lead to joint wear.
Joint wear (osteoarthritis) often develops gradually over a period of several years: Occasional pain when going upstairs or walking on uneven ground develops into persistent pain, with restriction of mobility. It may also cause impairment when driving.
In the early stage, conservative treatment consists of targeted physiotherapy applications, joint injections and changes to footwear (shoes with soft soles, sole stiffening with a midfoot rocker). If these measures do not lead to the desired alleviation of symptoms, various different surgical treatment options come into question, depending on the stage of the disease.
If it is a question of circumscribed cartilage damage, it is possible to stimulate the formation of replacement cartilage by means of an arthroscopic joint intervention. The grafting of cartilage-bone segments or the transplantation of patient-specific cultivated cartilage cells is also possible.
If the cause of the joint wear is an axial malalignment of the lower leg or of the hindfoot (usually after bone fractures), a positional correction can be performed in suitable cases, so that the ankle bears the bodyweight along the correct axis again.
In advanced stages, the joint can no longer be salvaged, due to the extent of cartilage wear. The options available here are either replacement with an artificial joint or stiffening of the upper ankle. Both methods have their own particular advantages and disadvantages, so that the decision on which of the two procedures to choose has to be discussed with the patient.
In the case of stiffening, the lower leg is connected to the hindfoot, which means that heel-to-ball movement of the foot when walking is then impaired. However, the adjacent joints take over this function in part, so that the gait pattern is not obviously changed. After the operation, the foot must be immobilised for six to eight weeks in a lower leg cast or in a special shoe. Thereafter, the sole of the custom-made shoe is altered to improve the gait pattern.
After the implantation of an artificial joint, movement exercises are started immediately after the operation. Once wound healing has been completed (after around 14 days), the foot can be placed under full weight-bearing in a special shoe. Only after four to six weeks is the patient switched to custom-made footwear.
One of the best-known nerve compression syndromes of the foot is tarsal tunnel syndrome. Patients suffer from pain or discomfort on the inner ankle, which may radiate into the sole of the foot and toes. Typically, the symptoms are particularly strong after getting out of bed in the morning. The diagnosis can only be rendered in cooperation with a specialist for neurology.
Conservative treatment may be successful in the early stage. Insoles to correct a hindfoot malalignment, physical measures or injections are suitable measures. If these therapies do not achieve the desired success, the nerve can be exposed surgically.
Morton’s neuralgia is a typical symptom of splayfoot. Strain-dependent burning or piercing pain in the area of the forefoot is typical. Patients also often complain of a foreign-body feeling or discomfort in the toes.
The diagnosis is rendered by means of a clinical examination, whereby the doctor carries out a test anaesthesia of the nerve to obtain final confirmation.
After confirmation of the diagnosis, conservative measures (insoles, injections) can be performed. If the desired alleviation of symptoms is not achieved by these measures, surgery can be performed to expose the nerve (neurolysis) or sever it (neurotomy). This can be done from the back of the foot or the sole.
After the completion of wound healing, weight-bearing can be gradually increased in custom-made footwear.
In principle, all joints can be affected by rheumatic disease. However, patients very often suffer from a rheumatic deformity of the forefoot, which causes painful impairment when walking and standing.
Painful calluses form under the metatarsal heads, the small toes no longer have contact to the ground (mallet toes) and the big toe often displays an advanced bunion deformity.
Conservative treatment consists of the fitting of customised insoles, which cushion the painful areas and provide a soft bedding. Orthopaedic footwear is often indispensable.
If, despite these measures, an alleviation of the symptoms is not achieved or open sores develop, surgical therapy should be considered. Due to the particular way in which patients with rheumatic disease are affected, this can be performed on both sides.
In the early stages, surgical therapy consists of the removal of rheumatic tissue from the joints (synovectomy) and axial correction of the big toe and the small toes.
In advanced stages, the metatarsal heads are resected via a surgical incision in the sole of the foot and at the same time the calluses are removed. Additional soft-tissue measures make it possible to straighten the small toes again. On the big toe, a stiffening of the metatarsophalangeal joint is performed.
If the upper ankle is affected by the rheumatic disease, in the early stage a removal of the joint’s synovial membrane (arthroscopic synovectomy) can be performed, with subsequent radiosynoviorthesis. In later stages, either a stiffening of the upper ankle or the implantation of an artificial joint may be necessary.
Before and after the operation, we work closely with specialised doctors from the department of internal medicine, physiotherapists and ergotherapists as well as orthopaedic technicians. This enables us to achieve a high quality of care and patient safety.
In the area of the foot, the Achilles tendon is most commonly affected by injury and disease. A rupture of the Achilles tendon is a sudden occurrence, which the patient experiences as a severe pain (pop, crack of a whip). As a result of the pain, walking and standing is subsequently considerably impaired.
Once the diagnosis of an Achilles tendon rupture has been confirmed, the doctors discuss the further procedure (conservative or surgical) with the patient. A conservative treatment with special splints and dressings (foot in pointed toe position) is possible, depending on the type of rupture and the ultrasound findings, and takes around eight to twelve weeks. In this case, a regular check-up with the attending orthopaedic specialist or trauma surgeon is absolutely essential.
The surgical therapy of a fresh Achilles tendon rupture is generally performed minimally invasively today, via an incision measuring just a few centimetres. Postoperatively, the foot is immobilised in a special shoe, whereby full weight-bearing is possible once the wound has healed. Again, a rehabilitation of eight to twelve weeks is to be reckoned with here.
Diseases of the Achilles tendon at the bony attachment to the heel bone (Haglund’s exostosis) or in the area of the Achilles tendon are primarily a domain of conservative treatment. After analgesic treatment in the acute phase, physical treatments and regular eccentric training of the calf muscles are generally suitable for achieving an alleviation of symptoms. However, a duration of treatment of several weeks is to be reckoned with.
In rare cases, surgical therapy can also be performed if conservative treatment has not been successful. Thickening in the Achilles tendon (achillodynia) as well as bony formations at the attachment of the Achilles tendon can be removed. Here, too, a special shoe must be worn for six to eight weeks postoperatively to relieve the Achilles tendon.