Dr. Gursel operates from the following locations:

Osteoarthritis

Osteoarthritis is an inflammatory degenerative condition affecting the cartilage of the joints. It is primarily caused by wear and tear of the joints and the condition causes pain and stiffness which can make it difficult to walk or perform daily activities. It is one of the most common causes of pain and disability.

In normal joints, articular cartilage provides lubrication at the end of the bones which allows it to glide over each other and minimalize friction during movement. As the cartilage degenerates, the rough surfaces of the bones are exposed and when they come in contact with each other, they rub and produce pain, stiffness, and inflammation.

Osteoarthritis is more common in the elderly as the joints begin the wear and the body cannot keep up with it repairing the damage. However, it may occur at any age and can be brought on by other issues such as trauma or joint deformity.

What is the cause?

Movement of the ankle or foot joints from activities such as walking, running, and jumping cause wear and tear on the joints and joint tissues. As a result, the body is constantly undergoing some kind of repair. Unfortunately, in some people, the repair process begins to falter, and the body cannot keep up with the damage being done to the joints.

As the joints become worn and the cartilage degenerates, the bones of the affected area start to change shape and may develop bony growths such as spurs which cause pain and inflammation to the area. The joints themselves and surrounding tissue can also become inflamed.

Some of the factors that may affect the development of osteoarthritis may include:

Older age
Genetics
Obesity
Previous joint damage or deformities

What are some of the symptoms of osteoarthritis?

Pain in the joints that is made worse by movement and exercise and relieved by resting is the most common symptom of osteoarthritis. In most cases, pain builds up slowly and becomes more severe as the degree of activity increases.

The ankle or foot joints may also develop swelling, warmth, and redness. There is usually tenderness when the joint is pressed upon. Both pain and swelling are usually worse in the morning and stiffness may be worse after resting.

Overall, the condition will cause a marked reduction in ability to function, move, or participate in activities as the pain and swelling usually limits mobility and movement of affected joints.

How is osteoarthritis diagnosed?

A full medical history and physical examination by an orthopaedic specialist surgeon is the best way to diagnose osteoarthritis of the foot and ankle.

An orthopaedic specialist surgeon will ask you about the pain you are experiencing and physically examine your foot and ankle. He/she may ask you perform certain movements such as moving your foot up or down and ask you to stand or walk a short distance. Assessing your gait or walking pattern is especially important to determining the severity and location of osteoarthritis as well as provide details on the strength of your ankles and feet.

You may also have to undergo X-ray imaging (Weight bearing) so the specialist can review the details of your foot and ankle bones.

How can it be treated?

While there is no cure for the condition, management and treatment of osteoarthritis will drastically improve your quality of life in terms of movement and pain.

Exercise can help strengthen muscle around an affected joint and help you maintain movement. In addition to assisting with weight loss and management, exercise can also directly reduce pain and improve joint function.
Weight-loss and management is recommended for people with osteoarthritis as it reduces the load on the joints and helps to reduce pain.
Assistive devices such as specialized footwear or braces can reduce the burden on the joints and should be considered as complimentary treatment.
Drug treatments such as paracetamol and anti-inflammatory creams or ointments are used to alleviate pain in osteoarthritis. It is recommended that you seek medical advice with any drug or medication use as a specialist can monitor their effectiveness and recommend the most effective types.

If these interventions do not relieve your symptoms, then you may need to undergo surgery to clean up the joint by removing loose cartilage, inflamed tissue, and bony growths such as spurs. This is usually done by minimally invasive techniques and instruments (arthroscopy).

Another surgical procedure that may be considered is the fusion of the joint (arthrodesis) where the bones are fused together to eliminate the joint motion causing pain. In this procedure, the bones are fixed together using plates and screws and eventually fuse together over time.

For further information about this procedure, please read our article on Arthroscopic debridement (ankle and foot).

Important: Information is provided for guidance only. Individual circumstances may differ and the best way to approach a condition is by individual medical consultation where a specialist can tailor a treatment plan to suit your needs

Edited by Dr Roderick Kuo
Last updated: 12/11/2019

Lisfranc Injuries | Midfoot Injuries

An injury to the midfoot is called a Lisfranc injury. This type of injury is caused by either fractures of the midfoot bones or damage to the ligaments of the midfoot. If not diagnosed and treated properly, it may lead to long term health effects such as issues walking and arthritis.

The Lisfranc ligament is an important ligament that connects the bones of the foot to the second toe (medial cuneiform to the second metatarsal). The ligament’s main role is to stabilise the second toe and maintain the natural foot arch and furthermore important nerve and blood vessels also run near its position in the foot.

Lisfranc injuries are often mistaken as merely sprains of the foot and the condition maybe overlooked as something that will heal over time with little or no intervention. However, damage to the midfoot is often a severe injury and may involve multiple bones and/or ligaments of the midfoot which may require surgical intervention and prolonged healing time.

What is the cause?

Falling and twisting of the foot or falling over the top of the foot is a common cause of Lisfranc injuries. The low-energy nature of the fall is usually why injuries are often mistaken for a sprain. Tripping over a hole in the ground is a common example of how Lisfranc injuries are caused.

Lisfranc injuries are common in athletic and sporting activities such as football where a player might get kicked at the bottom of the foot or jump and land on a foot that is plantar flexed (like the shape of a high heel shoe). Other sports such as snowboarding and windsurfing that has the foot fixed with bindings over the midfoot as also at risk.

Trauma from heavy objects falling onto the midfoot, motor vehicles accidents, landing on the foot while falling from a significant height, and other types of industrial accidents can also cause Lisfranc injuries.

What are some of the symptoms of Lisfranc injuries?

Severe pain and tenderness in the midfoot area which gets worse when trying to weight bear, stand, or walk is the most common symptom of Lisfranc injuries. If you wrap your hand around the top ankle area of the foot, that is about the midfoot area.

You may experience bruising on both top and bottom of the foot and swelling on the top of the foot. If there is bruising on the bottom of the foot, especially on the inner side (big toe side) it is highly likely you have sustained a Lisfranc injury.

Because of the proximity of important nerve and blood vessels in the midfoot area, you may experience numbness and weakness of movements in the foot that may extend to the leg. If this is the case, it is advised to seek medical attention urgently.

Does Lisfranc injuries get worse?

Lisfranc injuries may be missed and treated as a simple sprain. If first aid interventions of rest, ice, and elevation do not improve pain and swelling, it is advised to seek medical attention as you may have sustained a Lisfranc injury.

Without intervention, untreated Lisfranc injuries may result in long-term disabilities with flatfoot deformity and arthritis.

How are Lisfranc injuries diagnosed?

Diagnosis of Lisfranc injuries are made by a combination of both a medical examination and imaging such as X-Ray, MRI, or CT scan.

At the medical examination, the orthopaedic specialist surgeon will look for signs of bruising, swelling, and then feel for areas of swelling. He/she may have to elicit pain specific to the midfoot by twisting the front of your foot or moving your toes up and down.

You may also need to walk a short distance and stand-up so the specialist can access your posture and gait. Furthermore, you may have to perform a heel lift and try to stand on your tiptoes as this may elicit pain in more subtle injuries.

The orthopaedic specialist surgeon will then order X-ray imaging of your foot. This will show any fractures or displacement of the foot bones. Depending on the cause of your injury, the orthopaedic specialist surgeon may order additional imaging tests such as magnetic resonance imaging (MRI) or computed tomography (CT scan) to determine the extent of the injury.

How are Lisfranc injuries treated? What treatments can be used?

If there is any breakage of bones, completely torn ligaments, or abnormal placement of the foot bones, then surgery is the recommended treatment for Lisfranc injuries.

Surgery for Lisfranc injuries involve internally inserting screws or plates to re-join broken bones or completed damaged ligaments (internal fixation surgery). For more severe injuries where the damage to the midfoot cannot be repaired, the surgery involves fusing the damaged bones together. Unfortunately, this means that the midfoot has a diminished ability to weight bear and the front foot has to compensate. Despite losing some of the midfoot ability, patients who undergo this type of surgery may have retain a relatively normal gait.

For further information, please read our article on Lisfranc injuries surgery.

Edited by Dr Roderick Kuo
Last updated: 12/11/2019

Ankle Sprains

The ankle is the point where the two long bones (tibia and fibula) of the leg meet the top of the ankle joint (talus). The bones are held in their proper position with strong ligaments that provide support and stability to ankle. Although they have a high tolerance to stretch and flex, ligaments can become damage or injured by partial or complete overstretch or tearing.

When an ankle sprain is sustained, the bones in the ankle become forced into unnatural positions and results in pain and swelling. In most cases, spraining an ankle will affect but not take away the ability to walk. Only if there is a bone fracture involved will the ability to walk be lost.

Thankfully, most ankle sprains can be treated at home with ice, rest, compression, and elevating the limb. However, if you experience more severe symptoms such as inability to weight bear, severe pain, and are unable to walk, it is recommended you seek medical advice.

Ankle sprains weaken the ankle joint and makes it more likely the ankle injuries will happen again. Multiple ankle injuries, especially without rehabilitation and treatment, may cause may result in long-term health effects such as arthritis, instability, and chronic pain.

What is the cause?

Ankle sprains are usually caused by the foot being twisted inwards (on the side of the little toe with the foot soles pointed inwards) or an ‘inversion injury’. Often this may be referred to as “rolled ankle”.

Some common causes and risks of ankle sprains include:

Falling or tripping over; especially on uneven surfaces
Sporting or athletic activities that requires the rolling or twisting manoeuvres of the foot such as basketball or football
Past ankle injuries and poor ankle joint condition

What are the symptoms of ankle sprains?

Pain is the most common first symptom of an ankle sprain. This is followed by redness, swelling, and tenderness of the ankle. You may still be able to bear some weight on the foot but may be walking with a limp.

In cases of severe ankle sprains, you may hear a ‘pop’ sound when sustaining the injury and you may be unable to weight bear at all. In cases like this, you should seek medical attention and evaluation.

Do ankle sprains get worse?

Unfortunately, ankle sprains weaken the ankle joint. It reduces the ability of the ligaments to hold the bones securely in place and after sustaining an ankle injury, you may notice that your ankle becomes ‘loose’ and more susceptible to rolling or ‘giving way’.

You may be able to determine a loose ankle by having someone move your ankle from side to side to test the resistance and strength of the ligaments. Compare this to your other foot (that hasn’t been sprained). Of course, this won’t be possible if you have sprained both ankles. In which case, seek professional evaluation.

How are ankle sprains diagnosed?

If not severe, an ankle sprain should start to recover within a few days of applying ice, rest, compression, and elevation. Being able to weight bear and walk (even with a limp) usually means the sprain isn’t severe.

If you experience symptoms such as being unable to bear weight, severe pain and swelling that doesn’t seem to be getting better, then an orthopaedic specialist surgeon will perform a medical examination on your ankle to assess the severity of the sprain.

This includes examination of the ankle and surrounding structures for signs of ligament damage and palpating the ankle to feel where the injuries may have occurred.

The orthopaedic specialist surgeon may also move your foot in different directions to test movement ability and ask you to undergo imaging such as X-ray, MRI, or ultrasound if severe damage is suspected.

What treatments can be used?

The most useful treatment for ankle sprains is the RICE approach.

R - Rest

I - Ice

C - Compression

E - Elevation of the limb

Within a few days, symptoms should improve. You should also consult with a physiotherapist to start ankle strengthening exercises so you can prevent recurrent injuries.

If symptoms persist and you feel that they are not improving after a few months, then you may need to have further investigations done. The most common surgical investigation is an arthroscopy where a specialist will use minimally invasive keyhole instruments to examine the internals of the ankle. From there, you may opt to have ankle ligament reconstruction surgery to repair any ligament damage or stabilize a loose ankle.

For more information, please read our article one Ankle Ligament Surgery.

Edited by Dr Roderick Kuo
Last updated: 12/11/2019

Bunions | Hallux Valgus

A bunion is a painful or sore bump that occurs on the inside of the big toe. This abnormality of the foot is often called Hallux Valgus meaning big toe turning outwards in Latin and occurs slowly as pressure is placed on the big toe turning it outwards and eventually pressing against or overlapping the second toe.

Due to continual pressing of the big toe outwards, the shape of the bones in the foot changes and the resulting deformities are responsible for the pain experienced while walking or running.

Bunions occurs at the largest joint of the big toe where the first long bone of the foot meet the first long bone of the toe. This joint is also called the metatarsophalangeal joint (MTP joint) and is responsible for the bump appearance of a bunion affected toe as the misalignment of the connecting bones cause the joint to become inflamed and swollen.

While bunions more commonly affect women, they can occur in any person and develop in one or both feet.

What is the cause?

There may be no specific cause to developing a bunion. Tight shoes and high heels shoes may increase risks of developing bunions as the tight, squeezing fit of these types of footwear may pressure the shape of the foot.

Other causes may include having family history of someone with bunions or foot deformities and inflammatory conditions such as osteoarthritis or rheumatoid arthritis.

What are some symptoms of bunions?

Pain, inflammation, tenderness, and swelling on the big toe are the most common symptoms of bunions. Pain is usually worse when walking and running and may occur when wearing shoes.

Thickening of the skin of the big toe together with redness and pain is also a common symptom.

Cosmetically, the big toe will progressively turn outwards towards the little toe. As the condition slowly advances, the big toe may push under the second or third toe causing them to bend upwards.

Do bunions get worse?

Bunions develop slowly over time and you may not feel significant discomforts until the condition advances considerably. Unfortunately, this means that many people do not seek medical help with bunions until there is significant pain or cosmetic issues with the foot.

It is better to seek medical advice on bunions early as there will be more treatment options available and less chances of complications such as big toe arthritis.

How are bunions diagnosed?

A medical examination of the foot together with weight-bearing X-ray imaging is the most common way to diagnose bunions.

An orthopaedic specialist surgeon will be able to perform an examination of the foot including thorough inspection and palpation of the joints. The orthopaedic specialist surgeon may also ask you to perform specific movements such standing-up to assess your posture or asking you to walk a short distance to assess your gait.

Discussing your symptoms such is an important part of the examination and it will allow the orthopaedic specialist surgeon to determine which treatments may be suitable.

X-RAY imaging of the foot will allow the orthopaedic specialist surgeon to determine the bone structure of your foot and assess for any signs of complications such as arthritis.

What treatments can be used?

Bunions can be treated with surgical and non-surgical interventions depending on the progress of the condition.

Non-surgical interventions may include toe-spacers, re-alignment splits, proper footwear together with anti-inflammatory medication or painkillers to manage discomforts. Surgery may be needed if these interventions fail to relieve pain or if the condition is severe.

Bunion surgery is a treatment option that physically realign the toes and changes the shape of the foot. Depending on the methods used, the bones of the big toe may be shortened or re-aligned then held together in a new position with pins and screws.

The recovery process may be lengthy and keep you off your feet for a few weeks. Therefore, it is recommended that bunion surgery is done one foot at a time, so you keep some mobility while recovering.

For more information about the surgery procedure, please read our article on Bunion Surgery.

Edited by Dr Roderick Kuo
Last updated: 12/11/2019

Flatfoot | Pes Planus | Flatfeet

Most people have feet in an arch shape allowing the foot to support the weight of the body while standing in an erect posture. The space below the arch of the foot varies between different people but in most cases should be raised off the ground and only the heel and ball of the foot bearing the weight.

Flatfoot in both feet can occur naturally in some people and never cause any issues. Infants and children usually have flat feet as the foot arch is a result of normal bone, tendon, ligament, and muscle development from ages 3 to 5.

However, if you are experiencing pain, discomforts, or have noticed that a single foot has gradually lost its shape, then treatment may be necessary. A loss of the arch of the foot may involve issues with tendons or bones in the foot and problems will continue to worsen without intervention.

What is the cause?

Flat foot can be caused by a number of different conditions affecting the tendons, muscle, ligaments or bones of the foot. Most cases of flat foot are presented in a single foot although cases where both feet are affected are not uncommon.

Common causes may include:

Foot or ankle injury
Arthritis or rheumatoid arthritis
Nervous system or muscle diseases (muscular dystrophy or cerebral palsy)
Posterior tibial tendon dysfunction
Obesity
Pregnancy

If you have noticed that your foot or feet is changing shape, losing its arch, or feels like they are collapsing inwards then you should consult medical advice.

What is Posterior Tibial Tendon Dysfunction?

One of the major support tendons of foot arch is called the posterior tibial tendon or tibialis posterior tendon. This large tendon connects the calf muscles to a bone in the foot arch called the navicular.

Dysfunction or rupture of this tendon is a common cause of flat foot in adults and typically occurs in one foot. In addition to flattening of the foot arch, you may experience pain, tenderness, and swelling on the inside of the shin, ankle, or foot. Damage or dysfunction of the tendon may be a result of sporting injuries, falls, or overuse (such as high impact sports, running, stair-climbing). Dysfunction of the tendon can also occur gradually, and symptoms may only be noticed slowly. Unfortunately, this condition will also gradually get worse especially if it is not detected and treated early.

You can test your tibial tendon function by performing a heel raise. If you are unable to raise your heel and stand on your tiptoes, it may indicate that there is an issue with the posterior tibial tendon.

What are some of the symptoms of flat foot?

Pain or discomfort in the foot is the most common complaint of acquired flat foot. You may experience pain while walking or running on the inside border of the foot and ankle. Pain is usually worse with weight-bearing activities but can also be experienced if you are standing up for long periods of time.

Flattening of the foot will result in both the loss of space under the foot arch and change the shape of the foot with the toes beginning to turn outwards while the ankle rolls inwards. You may notice a change in posture as other parts of the body frame compensate for the foot’s weight bearing ability.

Because the structure of the foot and weight-bearing ability of the body is affected with flat foot, you may also experience pain in other areas such as the lower back, hips, knee, calf, or lower legs.

Sensations of tingling or an electric-like sensation may also be felt in the ankle and foot as the muscles and tendons may be impinging on the nerves in the foot.

Other symptoms may include swelling of the ankle, foot or shin. Swelling usually follows the course of the posterior tibial tendon which runs from about the midpoint of the foot arch, back towards to the inside knob of the ankle (medial malleolus) and to the back of the leg. However, swelling and tenderness may be felt in other weight bearing areas of the body such as the lower back.

Does flat foot get worse?

Many causes of flat feet are progressive and unfortunately, this means that the longer that flat feet that remains untreated the worse it becomes over time.

Some complications of untreated flat feet may include arthritis and inflammation of the joints as well as stiffness of the foot and increasing difficulty in treatment.

How is flat foot diagnosed?

The initial step of diagnosing flat foot is a medical examination by an orthopaedic specialist surgeon. This includes a very thorough Look, Feel, Move approach of the affected foot.

The orthopaedic specialist surgeon will examine the foot, feel and palpate relevant areas such as the ankle and toes then ask you to perform specific movements such as standing-up, performing a heel lift, walking a short distance, or moving your foot in a certain direction.

Imaging of the affect foot is then performed by plain film X-RAY (Weight Bearing) which allows the orthopaedic specialist surgeon to view the overall shape of the foot and check for misalignments of bones or other abnormalities such as arthritis.

The orthopaedic specialist surgeon may also order magnetic resonance imaging (MRI) to check the status of the tendons.

What treatments can be used?

Depending on the presentation of flat foot, there are a range of methods that can be used for treatment. These can as easy as getting simple insoles for your shoes and physiotherapy exercise to strengthen different parts of the foot.

However, if these treatment options fail to bring relief to pain and discomfort then surgical intervention is recommended.

The most commonly used type of flatfoot surgery is called flatfoot reconstruction surgery where an orthopaedic specialist surgeon can repair bones or tendons that may be causing pain and deformities of the foot. For further information about this procedure, please read our article on Flatfoot Reconstruction Surgery.

Edited by Dr Roderick Kuo
Last updated: 12/11/2019