Usually, Jeff Dorsey doesn't let pain hold him back.
Although he has
rheumatoid arthritis (RA), which causes head-to-toe joint pain and other challenging symptoms, he keeps busy with volunteer work. The 58-year-old Cincinnati resident and former corporate financial manager shares his time and expertise with local nonprofits, and volunteering for events and places like the Krohn Conservatory.
But in 2021, Jeff was unexpectedly sidelined by unbearable foot pain.
“That wasn't the first time I'd had foot problems," he says. “Because of my RA, my toes tend to move up and curl under. That's normal for me. But when I began feeling an extremely sharp, stabbing pain in the ball of my right foot, I knew it was something different. I knew I had to get it checked out."
He called The Christ Hospital Health Network and asked for an appointment with an orthopedic specialist. And that phone call changed everything.
Jeff was referred to
Robert Kulwin, MD, a foot and ankle surgeon with The Christ Hospital Physicians. Not only did Dr. Kulwin pinpoint the cause of Jeff's foot pain, but he also fixed it.
As it turns out, Dr. Kulwin had recently created—and patented—an innovative surgical technique ideal for treating Jeff's condition.
Metatarsalgia: a complex name for a common problem
During his first appointment with Dr. Kulwin, which included an in-office X-ray, Jeff learned important information about foot anatomy:
Our feet contain many joints formed by two bones coming together.
The small bones that make up our toes are called
phalanges. The phalanges connect to five, long foot bones called
metatarsals.
The place where these toe and foot bones meet is called the
metatarsophalangeal joint, or
MTP joint, more commonly called the ball of the foot.
Underneath each MTP joint is a piece of tissue called the
plantar plate. The plantar plate helps bear the force of the body's weight and helps keep the toes in line and in place.
Dr. Kulwin told Jeff that his metatarsalgia (pain in the ball of the foot) caused a torn plantar plate. And as a result of this injury, the second and third toes on that foot were curled downward like claws (claw toe).
“People with metatarsalgia often say it feels like they're walking around with a sharp pebble in their shoe," says Dr. Kulwin. “They usually have a lot of pain and may also have swelling. In some cases, like Jeff's, they also develop toe abnormalities like claw toe or
hammertoe."
Finding a safe, effective solution
There isn't a one-size-fits-all treatment for this type of foot pain. Some patients find relief with nonsurgical options like shoe orthotics or physical therapy. Others eventually need surgery.
“I was afraid to have foot surgery," says Jeff. “In 2015, I had surgery to fix a broken collarbone. But after the procedure, the bones wouldn't fuse back together. My surgeon tried inserting a plate to hold the bones together, but that didn't help. So I worried that with foot surgery, I'd have the same problem with bone healing."
Dr. Kulwin wanted to start with a nonsurgical solution. He gave Jeff an orthotic insert and recommended wearing a specific type of shoe.
At first, Jeff felt better. But after about eight weeks, the pain came back—and it was worse than before.
“I began compensating for the foot pain by walking differently, which started causing additional pain in my hip," says Jeff. “Then, one day at the grocery store, I squatted to grab an item off a low shelf. The pain was so severe I couldn't get back up on my own. And that's when I knew it was time for surgery."
Traditional foot surgery comes with benefits and risks
Surgery to treat metatarsalgia often involves cutting into one of the metatarsals (long foot bones) or one of the joints.
In these cases, the goal is to shorten the metatarsal. The surgery creates room for the toe to relax and straighten. And, if necessary, surgeons can repair a torn plantar plate or the hammertoe at the same time.
But even though surgery can relieve pain, there can be complications.
“Standard techniques for shortening the metatarsal can cause problems later," says Dr. Kulwin. “Patients with cut joints have a higher risk of developing arthritis in that joint, or even bone death. When that happens, there's no reliable way to fix it because there isn't a good joint replacement option for mtp joints.
“To avoid this problem, we can cut the metatarsal bone outside of the joint and then reattach the new ends," adds Dr. Kulwin. “But because the blood supply in this area is not great, the bone may not fuse together properly. We call this a 'nonunion.'"
Fortunately for Jeff, who has a history of nonunion with his collarbone surgery, Dr. Kulwin offers an alternative surgical technique. By using a guide he designed himself—and cutting the metatarsal from a different angle—he avoids harming the joint and reduces the risk of nonunion.
A fresh approach with fewer complications
The traditional procedures described by Dr. Kulwin require many steps that can affect surgical precision.
“We usually screw the ends of the bones to a small, synthetic plate that helps hold them together," explains Dr. Kulwin. “During standard surgery, we have to line up the plate and the screws multiple times, before and after cutting the bone. And when we cut the bone, it's done freehand, without a guide."
Dr. Kulwin improved this process by creating a “cut guide," or template, which he pins to the bone before any cutting occurs.
“The cut guide matches the synthetic plate that will hold the bones together," he says. “It also has a notch that shows where to cut. So, you pin the guide to the bone, make your cuts, remove the guide and then replace it with the plate. Fewer steps means a shorter surgery. And by cutting the bone at a predetermined angle, we may reduce nonunion rates."
Dr. Kulwin uses 3D printing technology to create the cut guides, which he personalizes to each patient. Parts of his technique are patent pending, but Dr. Kulwin receives no royalties or payments for the technique when he or other surgeons perform the surgery.
A successful surgery
On Dec. 14, 2021, Dr. Kulwin performed Jeff's surgery at The Christ Hospital Joint & Spine Center in Mt. Auburn. The procedure took roughly 40 minutes, and Jeff went home the same day.
“My recovery was pretty smooth and seamless," says Jeff. “I was in a surgical boot for two weeks after surgery, then wore a special shoe for about four weeks. After that, I just had to use an orthotic insert in my regular shoe until I was fully healed."
As they hoped, his bones healed perfectly. And although Jeff will always need to manage his RA symptoms, the debilitating foot pain is gone.
“I appreciate that Dr. Kulwin took my medical history seriously and was open about the risks and benefits of the various treatment options," says Jeff. “Even though I didn't want surgery at first, it ended up being the right choice. I started this journey in agony, but thanks to Dr. Kulwin, I found relief."
Ready to find relief from foot or ankle pain? Call The Christ Hospital Physicians - Orthopedics & Sports Medicine at 513-557-4900 or click here to schedule an appointment with a foot and ankle specialist online.