Boyd W. Haynes III, MD
As an Orthopaedic physician, I see folks everyday who come in for a consultation regarding a limp in their gait. They may have pain associated with this limp in a certain part of their body, and there could be obvious reasons for the limp, such as a recent injury or an onset of illness, with conspicuous swelling, bruising or maybe even a lump or abscess right in front of me on examination. Occasionally, things aren’t always what they seem, and I must play detective and dig a little deeper for the reason behind the limp. So, put on your Sherlock Holmes tweed hat and get out your magnifying glass as we discuss how I go through the process of elimination to determine what exactly is causing that limp and how to best treat the problem.
Before we get started, a bit of a disclaimer…I’m not going to discuss the rare disorders and maladies causing limps that affect a small percentage of the population in this article. So, if you have Charcot Marie Tooth or Ledderhose Disease, please don’t send me an angry email saying I forgot you. I didn’t – but your conditions are not run of the mill and deserve special attention.
Do doctors sometimes seem a bit nosy? Why do we ask so many questions and ask you fill out so much paperwork? Well, it may seem intrusive, but that is the starting point for me in my investigation of why you are limping. When did the problem start? Was it due to an injury and if so, what happened? What body part was hurt? How long ago? When is the pain better or worse? What treatments have you tried? Does anything help?
Based on your answers, I’ll order x-rays of the body part that you tell us is hurting, or was injured. It isn’t always the culprit, but at least it is another place to start looking for clues. So, the really obvious place to start looking is anywhere on the leg, so let’s start at the bottom and work our way up, shall we?
Toe – Whether you jammed your toe into the door and suffered a bruise, strain, sprain, or fracture, have a hammer or claw toe, are developing a bunion, have arthritis or gout in the toe, develop a corn or callus on the toe, or have nerve pain (Morton’s Neuroma), any of these issues can cause you to limp when walking. Most of these are going to be discernable by me after x-rays, a physical exam and lots of questioning about the problem.
Treatment will vary based on the issue, but typically we’ll start conservatively, with anti-inflammatories, Physical Therapy, rest, activity modification, bracing or splinting. You may need a steroid injection to help calm inflammation. Corns or calluses may need to be excised in the office. Nerve issues may require special medication to help calm agitated nerves and we also have electric cell signaling therapy to reduce painful nerve irritation.
For the issues that don’t resolve, we may need to order a MR scan or further testing for nerves issues, such as an EMG to determine if there is nerve damage. Some structural issues, like bunions, hammer, mallet and claw toes may need surgical intervention. For persistent nerve issues, I’ll refer you to my partners in Pain Management for further interventional treatments.
Foot – The foot is a complex piece of anatomy, with many bones, muscles, ligaments, and tendons, which bears all our weight, so it is prone to injury and pain which can cause a limp. Any of the aforementioned bones can be fractured and soft tissues can be injured – tendon and ligament tears are common. Some of the more common ailments I see are plantar fasciitis, metatarsalgia, heel spurs, plantar warts, Achilles tendonitis, calluses and corns, fallen arches, flat feet, over pronation or supination. Neuropathy is also a big issue and can be caused by diabetes, chemotherapy, toxins, substance abuse or even for unknown reasons.
As with the toes, treatment will start out conservatively, unless there is an acute severe injury, such as Achilles tendon tear or complex fracture(s) that requires immediate surgical intervention. Because our feet are so necessary for walking, I tend to use lots of braces, splints, and orthotics to keep my patients ambulatory, while at the same time, addressing the issue that is causing the painful limp. I also will tend to use steroids, whether oral or injected to quickly try to reduce inflammation and pain. I will refer to Physical Therapy as well, because they have specific modalities to help with swelling and soreness, while at the same time helping to improve range of motion and flexibility.
Nerve issues (neuropathy) will more than likely be referred for an EMG and to our Pain Management team as they specialize in working with this disorder.
I also will address the issue of footwear, which is often overlooked. Well-fitted, supportive footwear can make a world of difference for many foot issues and can help correct pronation, supination and provide arch support for flat feet or for those with fallen arches. Poorly fitting shoes cause corns, calluses, and blisters and squeeze the toes together irritating nerves and, overtime, cause Morton’s Neuroma.
In Part II, we’ll continue our journey up the leg, to visit the ankle, calf and knee to see how these body parts can contribute to making us limp.