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Welcome to CITYFOOTCARE.COM! We are group of 7 podiatrists located in Midtown Manhattan.

We offer the best care in Podiatric Medicine and Surgery in NYC.

The doctors at City Footcare are the most compassionate and skilled foot doctors in the New York City Metro area and the country. Our office is conveniently located in Midtown Manhattan near Grand Central Station. We take great pride in providing excellent medical care along with great bedside manner and take the extra time to explain your problems and the treatment options in detail.  Some of our doctors are Board Certified by the American Board of Podiatric Surgery and Medicine (ask about individual certifications).

At City Footcare we treat all problems related to the foot and ankle. We use state of the art diagnostic and therapeutic equipment. When your problem requires surgery, you can rest assured that you are in the hands of a competent and highly trained surgeon. Most of our doctors perform surgery and Dr. Sergi specifically only does foot surgery and not general podiatry (ask about individual providers).

Drs. Sergi and Silverberg have been called the best foot surgeons in NYC and the best bunion surgeons in NYC. The doctors performs all foot and ankle surgery including traditional open surgery, minimally invasive surgery, laser surgery, radio frequency surgery and extra-corporeal shock wave therapy. They are hospital and surgery center affiliated.

To resolve all of your foot and ankle problems, simply look around this site and make an appointment with the doctors at City Footcare today. Your feet will be glad you did!


See our main site:
Blog Posts are Below:

Lapidus Bunionectomy

This patient presented to our office with a large painful bunion of the left foot. During the in office consultation we noted that the 1st metatarsal was also hyper-mobile.  Hyper-mobile means that the first metatarsal moved up and down too easily with minimal pressure. Looking at the x-ray on the left you can see how much the the first metatarsal has shifted away from the second.  This type of deformity does not happen over night, but may take many years to develop. We decided that a proximal osteotomy with internal fixation consisting of both screws and a plate would be the procedure of choice. The surgery was performed and we corrected the deformity utilizing  a Lapidus type bunionectomy.  From the x-ray you can also see that minimal shortening was achieved along the first metatarsal.

If you suffer from large painful bunions call us today.

Recovery after bunion surgery

I’ve written a detailed description of what to expect after bunion surgery on my new site.  This article includes what to expect immediately after bunion surgery and goes up until one year after surgery.

As I’m sure you can imagine, after 15 years of doing foot surgery, I’ve been asked lots and lots of questions about bunion surgery.

I’ve answered the following questions:

What should I expect the day of bunion surgery?
Is bunion surgery painful?
How much pain should I have after bunion surgery?
Do I take pain killers after bunion surgery?
Can I walk after bunion surgery?
What do I wear on my foot after bunion surgery?
Do I wear a surgical shoe after bunion surgery?
Do I wear a brace after bunion surgery?
How long do I have to wear a shoe or brace after bunion surgery?
Do I have a cane or crutches after bunion surgery?
How long do I keep my foot dry after bunion surgery?
How do I keep my foot dry after bunion surgery?
Do I ice my foot after bunion surgery?
Do I elevate my foot after bunion surgery?
How much walking can I do after bunion surgery?
When can I walk after bunion surgery?
How much activity can I do after bunion surgery?
How much can I walk after bunion surgery?
When can I work out after bunion surgery?
When can do the stationary bike after bunion surgery?
When can I run after bunion surgery?
How far can I run after bunion surgery?
When I can wear regular shoes after bunion surgery?
When can I wear high heels after bunion surgery?
How often should I see my doctor after bunion surgery?
When can I go back to work after bunion surgery?
Do I take antibiotics after bunion surgery?
Can I do bunion surgery on both feet at the same time?
How far apart should I do my bunion surgeries on both feet?

To see answers to all these questions click here: Recover after bunion surgery



Second Opinion for Foot Surgery in NYC

Second Opinion

Patients often come in to my office requesting a second opinion for foot surgery after they have seen another podiatrist in New York City. I always welcome my patients to seek second opinions as well.

Many times I agree with the other doctors’ recommendations for surgery. Also, many times I disagree with their recommendations. Often, I disagree because I feel they have chosen the wrong procedure for bunion surgery or hammertoe surgery.

Bunion Surgery

In regards to bunion surgery, many doctors perform distal osteotomies for large bunions that require a more proximal osteotomy. I will explain distal versus proximal osteotomies in a moment, but first let me explained why this happens. Many podiatrists are not trained or experienced in performing more difficult surgical procedures such as proximal osteotomy bunionectomies. Proximal osteotomies are much more challenging, and require much more skill than the distal osteotomies. If you have browsed this blog, you will have seen examples of large bunions that require more proximal osteotomies. This is one of my favorite topics to write about.

Small bunions can be fixed with distal osteotomies. An osteotomy is simply a medical term for a cut in a bone. A distal osteotomy is performed at the far end of the metatarsal bone just behind the toes. Most podiatrists are very experience performing this kind of osteotomy.

Larger bunions require a more proximal osteotomy. Proximal osteotomies are performed at the base of the metatarsal, further back in the foot. There are a few types of these proximal osteotomies. The most common ones are a ‘closing base wedge osteotomy’, an ‘opening base wedge osteotomy’, and a ‘scarf osteotomy’. In previous blog posts I have discussed each of these. Proximal osteotomies are much more difficult than distal osteotomies. The surgeon must be experienced and knowledgeable in order to remove the proper amount of bone, add the appropriate amount of bone graft, fixate the bone cuts properly with screws and plates, and align the bones in three dimensions.

Getting back to second opinions for surgery, I often advised patients to ask their previous doctor about their experience with these more difficult surgeries. It is not my intention to take patients away from their original doctor, but rather to inform them of my opinion on the proper surgical procedures of choice.

Hammertoe Surgery

When it comes to second opinion for hammertoe surgery, I often advised patients to have the small joints of the toes to be fused called an arthrodesis, rather than just remove part of the bone, called an arthroplasty. I perform many arthroplasty procedures but many times a joint fusion is necessary to get a better cosmetic and more permanent correction of hammertoes.

The way I fuse hammertoes is also superior in my opinion to the older methods of joint fusions. Most podiatrists use a wire that sticks out from the end of the toe in order to hold the bones together while they heal, and fuse. I prefer to use a screw that is totally within the toe and does not stick out. There are many advantages to this method. The most important in my opinion, is that the screw creates compression between the 2 bones pushing them together and achieves the goal of fusing the 2 bones together almost all the time. Using a pin in the toes simply holds the bones in one direction and does not push them together. The bones are free to move longitudinally in the direction of the pin as well as rotate on the pin. The screw prevents this. Additionally, the screw is buried within the toe does not stick out which allows the patient to get the foot wet in the shower after just 12 days, rather than keeping it dry for 4 weeks while the pin sticks out from the end of the toe.

I have tried many of the new implants that have been designed for hammertoe fusion. These are very extensive pieces of metal that go inside the toe in order to avoid the need for the pin to stick out from the end of the toe for 4 weeks. Unfortunately, I have not been satisfied with any of them. They all fail to have one importance quality that the screw has. Only the screw pushes the two bones together called compression. These new implants hold the bone in 2 directions. They stopped the bones from rotating and moving up and down, but all fail to push the bones together in that third longitudinal direction that I think is necessary in order to increase the chances that the bone will heal together.

A Story about Second Opinion for Foot Surgery

Now that I have discussed second opinions for bunion surgery and second opinion for hammertoe surgery, let me tell you a story about second opinions for surgery.

Unfortunately, there are some unethical doctors that consider monetary gain as a reason to do surgery on patients. In the past few weeks, I have seen three patients that came to me for second opinions for foot surgery that I told not to have surgery. It is unfortunate and disturbing that these doctors recommended surgery when it was not necessary or recommended the wrong procedure.

Interestingly, two of the patients came from the same unethical doctor. This doctor recommended surgery for a 15-year-old patient with plantar fasciitis without performing any conservative care. First of all, the patient was only 15 years old and not done growing completely. Secondly, I would estimate 98% of patients with plantar fasciitis do not need surgery, and get better with conservative treatment. There are many treatments for plantar fasciitis that do not involve invasive surgery. In fact, there are at least 10 different treatments that are regularly done before surgery is recommended. This doctor only recommended one treatment, custom molded orthotics. I speculate that this treatment was recommended because orthotics can be profitable for the doctor. Orthotics alone are not the recommended treatment for plantar fasciitis. They are a good long-term solution to prevent it from returning as well as helping other acute treatments. I told this 15-year-old patient and his parents that he should not have surgery until all conservative measures are exhausted.

The next patient that came to me for a second opinion for surgery from the same unethical doctor that they saw previously had a soft tissue mass on the top of her foot. The mass had been there for only a few weeks. The patient had no associated pain and it was very small, and not a cosmetic concern. The previous doctor did an ultrasound in his office on the first visit and told the patient that he did not like the looks of the lesion and scared her that it may be cancerous. He recommended surgery as soon as possible to remove the soft tissue mass. She came to me for a second opinion for foot surgery to remove the soft tissue mass. I also did an ultrasound in my office that showed the mass was a simple fluid-filled ganglion along one of the tendons. Treatment for a ganglion involves aspiration of the fluid out of it and injection of steroid to prevent it from coming back. I would only recommend surgery if, and only if, this treatment failed two to three times to get rid of it, and it was also symptomatic/painful or a major cosmetic concern. Additionally, if I had suspected anything more than a simple benign lesion I would order an MRI to evaluate it prior to surgery.

The next patient that came to me for a second opinion involved her toenails. Her doctor had removed 9 of her toenails in order to treat nail fungus. When the nails grew back exactly the same as they were, he recommended repeating the procedure. She came to me for a second opinion on nail removal. When I examined her I concluded that the discoloration and thickening of her toenails was not due to fungus. It was due to repetitive trauma from tight shoes that damaged the nail roots. To be sure, I sent a sample of the nail to the laboratory for biopsy for a pathologist to look under the microscope for fungal elements. As I suspected, the biopsy came back negative. Had the biopsy been positive, treatment would still not have been surgical removal of the nails. Fungal nails are much better treated with laser or oral medication, as removal of the nails rarely works. It is sometimes painful and can sometimes cause damage to the nails that is permanent. When there is damage to the nail root surgical removal of the nail rarely works also to resolve the discoloration and thickening. Most of the time, the nail grows back exactly the same or can be worse. Sometimes I will remove nails but I informed patient that there is a greater chance that they will grow back the same. If it is one or two nails, I am more likely to perform this procedure than when many more are affected.

Besides these unethical behaviors most patients come in for second opinions when surgery is indicated. I give my honest opinion as to what procedures I recommend and inform the patient of risks, complications and postoperative expectations. I do not ask the patient who the previous doctor was until the end of the visit and reserve any judgment about the doctor as that is ethical behavior.

So, if you require a second opinion for foot surgery, please call and schedule a consultation.

Bunion Surgery Done the Right Way

Case of the day:

Bunion surgery for a large bunion

Four weeks ago I performed bunion surgery on a patient with a very large bunion. She came in today for her four week follow-up visit.

She had a large bunion with constant pain in her great toe joint.

Bunion surgery for a large bunion, before and after pictures.

Large bunion surgery before and after pictures p01Large bunion surgery before and after pictures p02

Before and after large bunion surgery x-rays


I performed two procedures:

Scarf bunionectomy

A scarf bunionectomy cuts the metatarsal bone down the center allowing me to rotate half of the metatarsal toward the other toes to straighten the angles.

Akin bunionectomy

An akin bunionectomy cuts the first toe bone and removes a wedge allowing me to move the big toe back the other way, away from the other toes in order to straighten it.

For large bunions you can’t just do a ‘distal osteotomy’ as most doctors do.

If you suffer from a large bunion, contact my office to schedule a surgical consultation.

Dr. Silverberg

Case Study: A large bunion with overlapping second toe

Today I would like to share with you a surgery that I performed six months ago. This patient came in today for her 6 month follow up visit. She said she was doing great, running, yoga and wearing high heeled shoes at times.

Large Bunion

This patient is a 65 year old professional. She came into my office with a complaint of pain in her great toe joint and second digit hammertoe. She had pain with exercise and could not wear feminine shoes. She said that she would like to be able to wear high heels with her business suits as she works at a big NYC bank and needs to look good for work. She also wanted to be able to exercise without pain.

Her preoperative photos and x-rays are below:

You can see that she has a large, dramatic bunion with the second toe overlapping the great toe.

Large bunion with overlapping second toe p01Large bunion with overlapping second toe p02

Large bunion with overlapping second toe p03

Large bunion with overlapping second toe p04

Large bunion with overlapping second toe p05

I performed four procedures to correct for her bunion, hammertoe and dorsally dislocated second toe joint.

1) I performed a scarf osteotomy of the first metatarsal. I love the scarf osteotomy. It allows me to get a huge correction of the first metatarsal while allowing the patient to partially bear weight immediately postoperatively. I often do ‘opening base wedge osteotomies’ and ‘closing base wedge osteotomies’ but they require the patient to be on crutches for 10-12 weeks. The scarf osteotomy is one of the most challenging procedures to perform but I do a lot of them and have mastered this difficult procedure. The base wedge osteotomies allow for more correction than the scarf so some patients with large bunions will still need to use crutches when I do them.

2) I next performed an ‘akin osteotomy’ of the great toe, proximal phalanx. If you can imagine that the toe is connected to the metatarsal bone when the metatarsal is moved toward the second toe, the great toe goes with it. I then move the great toe back the other direction by adjusting the soft tissue holding it. When I cannot get the great toe to be parallel to the second and it still leans toward the second toe, I then cut the great toe bone and take out a small wedge to move it away from the second toe.

3) I next performed a lengthening procedure of the tendon and other soft tissues holding the second toe upwards.

4) I next performed a fusion of the bones in the second toe to keep it straight forever. I like to fuse toes with screws rather than pins or other fusion implants. I find that the screw holds the toe straightest and I am able to compress the two bones together. This allows for the highest success rate of getting those two bones to heal together. Another advantage of using screws over pins is that the pin needs to stick out through the skin. This allows for a higher chance of getting an infection and the patient needs to keep their foot dry for four weeks versus 12 days with the screws. I then take the screw out with a small surgical procedure under local anesthesia anywhere from 6 weeks to 6 months after it is put in depending on the patient. This is one of the only times I remove screws postoperatively.

The below x-ray was taken three months postoperatively. You can see healing of the bones, especially the fusion of the second toe bones next to and around the screw.

Large bunion with overlapping second toe p06

Large bunion with overlapping second toe p07

Below are before and after pictures of this surgery for a large bunion with overlapping second toe.

Please note also that these after surgery pictures were taken at only six months. It takes up to a full year for the scar tissue to go down and the foot to look less ‘fat’, and for the scars to mature completely. I’ll post pictures again in an additional six months.

Large bunion with overlapping second toe before and after pictures p08Large bunion with overlapping second toe before and after pictures p09

Large bunion with overlapping second toe before and after pictures p10

Large bunion with overlapping second toe before and after pictures p11

Large bunion with overlapping second toe before and after pictures p12

Large bunion with overlapping second toe before and after pictures p14Large bunion with overlapping second toe before and after pictures p15

Large bunion with overlapping second toe before and after pictures p16Large bunion with overlapping second toe before and after pictures p17

I enjoy treating the most challenging problems but also enjoy the more ‘regular’ surgeries.

I hope you enjoyed reading about this challenging bunion surgery as much as I enjoyed writing about it and presenting it you.

If you are considering bunion surgery or any other foot surgery, please call my office to schedule a consultation with me.

Lawrence Silverberg, DPM

Pain in the big toe joint. Hallux Limitus Surgery including before and after pictures. Arthritis of big toe joint.

Hallux Limitus Surgery

This pain can be caused by many things. I’ve already written blog articles on bunions and gout which are two very common causes of great toe joint pain. Click these links for those articles. Gout. Bunions.

Pain in great toe joint Hallux Limitus p01The medical term for the big toe joint is the “first metatarsal phalangeal joint”. This is because the two bones that make up the joint are the “first metatarsal bone” and the “first proximal phalanx bone”. (Click any picture to enlarge). Doctors often refer to the big toe joint (“First Metatarsal Phalangeal Joint”) as the “First MPJ” or just “MPJ”.

Pain in the big toe joint is one of the most common complaints I hear in my podiatric surgery practice.

I really enjoy doing surgery for MPJ pain caused by arthritis in this joint because the surgery works so well. Arthritis is a general term for pain and inflammation of a joint and can be used to refer to any joint in the body.

Arthritis of the big toe joint can be caused by many things: bunions, gout, inflammatory arthropathy such as rheumatoid arthritis and other autoimmune diseases, trauma, infection, bad shoes, overuse such as athletes, congenital malformation, congenital anomalies such as longer or shorter bones than normal, higher or lower bones than normal, misshaped bones or cartilage, functional anomalies like flat feet or curvature of bones of the leg, and some other that I’m sure I left out of this list.

Most of the above lead to the slow progression of arthritis in the form of loss of cartilage of the joint. Cartilage is the smooth semi-hard substance between bones that allows bones to glide smoothly together in a joint and not grind or scrape each other. Once the cartilage is gone, bones grind on one another and cause pain and decreased range of motions.

Pain in great toe joint Hallux Limitus p02Additional sequelae of arthritis is formation of bone spurs. Bone spurs usually grow due to small micro-trauma to the bone that heals by producing more bone. Each time the bone heals the tiny breaks, it produces more and more bone until finally you have a piece of bone sticking out where it should not be. Bone spurs can cause joint to not move by blocking the normal range of motion.

Once a joint doesn’t move, your body compensates by trying to move other joints to make up for the lack of motion. This, in turn, causes those other joints to have abnormal forces and range of motion and they get overused and injured leading to arthritis.

Signs and symptoms of big toe joint arthritis.

Arthritis of the big toe joint presents with pain in the joint that usually starts off minor and intermittent and slowly progresses to happen more often and with more intense pain. Activities or certain shoes that didn’t hurt in the past, start to hurt more often and more intensely. Women often tell me that they progressively can wear their high heel shoes for less time or less distances before the pain starts. They say that they have to wear lower heels than previously. Patients report they cannot exercise as much as they used to before having pain. Arthritis is a problem that slowly progresses as the cartilage wears away.

Sometimes people have arthritis but do not know it. I wrote an article not too long about about people who have bunions but no pain associated with them. One of the only times I tell people to have bunion surgery when they are not in pain is when they have signs of arthritis on x-ray but no associated arthritic pain. See the article here: When to have bunion surgery when you do not have pain.

One of the main reasons people come in to see me for big toe joint pain is for something called Hallux Limitus. This Latin term comes from the word Hallux which is the medical term for the big toe and Limitus, which means limited range of motion of a joint.

Pain in great toe joint Hallux Limitus p03Hallux Limitus can be broken down into two major categories but both describe lack of range of motion of the big toe joint. The first kind is called Structural Hallux Limitus. This describes a joint that cannot move enough due to changes in the structure of the joint. This can be due to lack of cartilage between the bones, bone spurs that block the motion and sometimes bone growth that actually fuses the bones together. When the bones fuse together two bones actually become one piece without any space between them.

The second kind of hallux limitus is called Functional Hallux Limitus. This describes a condition in which the bones don’t move enough due to abnormal forces on the bones of the foot. Most commonly people who have arches that collapse or flat feet have functional hallux limitus. When the arch collapses the first metatarsal bone gets pushed up and out of the way by the ground forces. When the first metatarsal is elevated, the phalanx bone cannot move up enough to make it over the metatarsal and flex upwards to bend the toe joint.

Functional hallux limitus leads to arthritis and bunions. In my article and video about bunions I describe how functional hallux limitus causes the bunion. See those articles and videos by clicking the links at the end of this paragraph. This blog will focus on hallux limitus and joint arthritis. Video describing bunions. Article describing bunion formation.

As I stated above, functional hallux limitus often leads to big toe joint arthritis by causing abnormal forces on the joint and wearing away of cartilage which in turn leads to structural hallux limitus with loss of cartilage and bone spurs that block motion.

Okay, we’ve now discussed what causes hallux limitus and arthritis as well as signs and symptoms of big toe joint arthritis. Next we will discuss treatment and surgery of them.

When a patient comes into my office with a complaint of big toe joint pain, I first do a thorough history and physical exam. I ask them all about the pain including what it feels like, where they get it, how long have they had it, what was the onset like, fast or slow progression, what activities cause pain, what shoe types cause pain, and what treatments have they tried and which worked or did not work.

Once I’ve established that detailed history I start my exam. I check the entire foot starting with the circulation, the nerves, and the range of motion of all the joints including the big toe joint. I check the muscle strength and tendons. I have the patient stand up to see how the foot looks weight bearing.

The next part of the examination is the x-rays. The x-rays tell a big part of the story. I look for the length and position of the bones. I look at the amount of cartilage of the joints. I look for bone spurs or bone cysts. I look at the overall bone structure of the foot.

Once I’ve completed my history and exam with x-rays I am able to determine the extent of the problem and the cause(s) of it. I then explain to my patients in layman’s terms all of this info.

The next and most important step is the treatment of big to joint pain and arthritis. Most often the treatment is surgical but there are a few non-surgical treatments that can be done.

I take great pride in my ethics and the ethical treatment of my patients that trust me to take care of them. I will try to keep this tangent as short as possible but I’m very passionate about the subject. I have a tremendous respect for my patients. I feel privilege to be a doctor and take care of patients. Strangers come to me for help and expect me to do the right thing, tell them the whole truth, and act in their best interest, not my own. I often think about other circumstances in life where this happens and I, unfortunately, cannot think of many or any for that matter. It seems that all businesses out there are out for profit and not for altruism.

I make most of my profits by performing surgeries but I would never tell a patient that they need surgery when I can help them with a less invasive, less risky, less painful alternative non-surgical treatment. Unfortunately, in my career I have come across many doctors that do not practice this way and do make decisions based on profit to some extent at the cost of their patients but I will not expand on this further here.

Okay, sorry about that divergence, back to treatment of big toe joint pain. I was about to tell you about the non-surgical treatment of big toe joint pain. When the arthritis is not too severe non-surgical treatment works better than once the arthritis has progressed more. When there is functional hallux limitus and not structural hallux limitus, as described above, non-surgical treatment works better.

Non-surgical treatment includes two things. The first is what we call palliative care. This means treating the symptoms of the problem, not the cause of the problem. The symptoms are pain and inflammation. We treat pain and inflammation with anti-inflammatory medications, or pain killers; pills and injections. Pills are often non-steroidal anti-inflammatories such as aspirin, Motrin, Aleve, Celebrex and many over-the-counter and prescription medications. Sometimes we use steroid pills as well for more severe inflammation. We also treat inflammatory symptoms with icing, rest, compression and physical therapy modalities.

The second kind of non-surgical treatment addresses the lack of motion of the joint. We can increase range of motion with physical therapy and custom foot orthotics. Again, these work better for functional hallux limitus and not structural. Structural hallux limitus almost always requires surgery.

As stated earlier, I like performing surgery for hallux limitus. The reason I like it is because by the time people need surgery they are usually in a great deal of pain and it affects their lifestyle, and it is such a big relief for them when I correct the problem.

After I evaluate the cause and extent of the problem I decide on which surgical procedure to perform. There are a few different procedures to choose from. I’ll list them here and then describe each one. These procedures include: Cheilectomy, decompressional metatarsal osteotomy, Keller procedure of the proximal phalanx, joint implant arthroplasty, and joint fusion.

Cheilectomy procedure for hallux limitus.

The least destructive to the joint is called the Cheilectomy. A cheilectomy involves simply cleaning up the joint. I remove bone spurs and loose extra bones in order to allow the joint to move more freely and more normally. When I choose this procedure the cartilage has to be mostly intact as it does not address the lack of space between the bones, but only the extra bones that block motion.

Below are before and after pictures of Cheilectomy procedure. Click to enlarge.

Pain in great toe joint Hallux Limitus p04Pain in great toe joint Hallux Limitus p05

Decompressional  Osteotomy, Youngswick procedure for hallux limitus.

One of the most common procedures I do is the decompressional  metatarsal osteotomy procedure. One of these is called the Youngswick procedure named after the doctor that first described it. This involves cutting the metatarsal bone and moving it down and back in order to create more space between the metatarsal and the proximal phalanx. This is used to address a long or high metatarsal or a functional hallux limitus. Again, this procedure often requires there to be some cartilage left on the bones. Recently, I have been modifying this procedure in my own unique way in order to treat more advance loss of cartilage and I’m having excellent outcomes.

Below are before and after pictures of a decompressional osteotomy. Click to enlarge.

Pain in great toe joint Hallux Limitus p06

Keller Procedure for Hallux Limitus:

The next procedure is called the Keller procedure. This procedure is called more joint destructive because it involves removing part of the joint. I remove the base of the proximal phalanx bone in order to create a space between the bones. The trick here is to maintain that space for years after the surgery as it has a natural tendency for the bones to move back together over time. There are many ways doctors try to maintain this space including using metal pins to hold the bones while they heal, implanting cadaver soft tissue grafts and skin components between the bones and various other ways. I feel my way is the best and I have seen patients follow-up long term with preservation of the space. I modify the joint capsule around the joint and use it as a spacer between the bones. This is the most challenging and difficult part of the procedure but I have discovered a way to make it work.

Below are before and after pictures of a Keller Procedure. Click to enlarge.

Pain in great toe joint Hallux Limitus p07

Implant Arthroplasty for Hallux Limitus:

The next procedure is the great toe implant arthroplasty or great toe joint implant procedure. I have performed many of these procedures in the past but often prefer other procedures over them. They work very well to reduce the painful arthritis but they often get stiff over time. This procedure involves removing either the head of the metatarsal or the base of the proximal phalanx and replacing it with a metallic joint implant. The advantages are that it maintains the length of the toe cosmetically. The disadvantage is that I find they get stiff over time. I have not done one of these procedures in a while because many patients reported stiffness postoperatively.

Below is a picture of after a joint implant Procedure. Click to enlarge.

Pain in great toe joint Hallux Limitus p08

Joint fusion or metatarsal phalangeal joint arthrodesis for hallux limitus.

The last procedure is called the joint fusion. This involves permanently fusing the metatarsal and phalanx bone together. The theory here is that if there is no motion, there is no pain, and that theory almost always works. The disadvantage is that you never can move your big toe joint again. This means that women can never wear a high heel again. Also, it can slow a patient down because as we walk faster or run, we need the big toe joint to move up more and the fusion blocks that. I reserve the fusion for patients that are more sedentary. I often perform fusions for people that have major angular deformity of the bone as well. When there is contracture of the soft tissues that misaligns the big toe joint or when the bones have been previously altered in other surgeries, I will perform a fusion.

In the below example, I felt there was just no way that any less invasive procedure would realign this joint and give satisfaction to the patient. She had previous bunion surgery by another surgeon that had a bad outcome. In the end I fused her joint and her pain completely went away. She fit into shoes that she had not previously. She was an older patient that did not need to the mobility of a younger patient. She was extremely happy with the result and was pain free last I spoke to her over a year after surgery.

Below are before and after pictures of a joint fusion Procedure. Click to enlarge.

Pain in great toe joint Hallux Limitus p09

As you can see I am passionate about big toe joint pain and consider myself an expert in it. I hope you enjoyed reading this article as much as I enjoyed writing it. As with most of my articles I expect thousands of views from people around the world. I always love comments and emails about my articles and encourage them. I wish I had enough time to write back to everyone but it has gotten a bit overwhelming to do so. I will try to write back to some of you time permitting.

Dr. Silverberg quoted for NBC’s Today Show on: Pregnancy Foot Problems.

I’m pleased to announce I was asked to contribute to a story on NBC’s Today Show (Moms Section image) on High Heels and Pregnancy.

Pregnancy Foot Problems

I was asked about foot problems women face during pregnancy and my opinion on wearing high heels during pregnancy.

Click the below picture to go to the article.


Bunion Surgery Including before and after pictures of bunion surgery.


Updated 2013 03-03
Originally posted 2010 11-18
Bunion surgery is the most common foot surgery I do. Before I tell you about the actual surgery, I will describe what a bunion is and how a patient gets one. Below is a picture of a severe bunion deformity and a moderate to minor bunion.  See further below for before and after bunion surgery pictures. (Click any picture to enlarge)


Bunion Surgery Before and Afer Bunion Surgery Before and Afer

Bunions are also called “hallux abducto-valgus” in medical terms. Hallux refers to the great toe. Abducto-valgus refers to position of the great toe such that it points towards the other, lesser toes and is rotated. The bunion deformity consists of the movement of two bones at the great toe joint. The further back bone, called the first metatarsal, moves toward the midline of the body and the toe bone, called the proximal phalanx, moves in the opposite direction toward the other toes.

Bunions are mostly genetic. Very rarely, people are born with a bunion deformity called a juvenile bunion, but almost all bunions occur later in life due to forces on the foot. People who have arches that collapse or feet that flatten out get bunions. In that sense, people are born with the genetic predisposition to get bunions later in life rather than being born with a large bump sticking out of the side of the foot.

People who get bunions have many different foot types. Some people have no arch when they’re standing or sitting. Other people have a normal arch that collapses to a flat arch. Even people with high arches that collapse to a more normal arch can get bunions.

When the arch of the foot collapses, the force of the foot on the ground causes the great toe to decrease in its range of motion. This is called “functional hallux limitus”. This simply means that the great toe cannot move through its normal range of motion as you push off the ground. Obviously when you push off, the toe needs to move somewhere. When the great toe cannot move straight up, the foot turns more to the side and you roll off the inside of the foot and great toe. This creates a force pushing the toe toward the other toes. Slowly over time the great toe gets pushed toward the other toes which in turn, pushes the metatarsal in the opposite direction.


Symptoms of bunions: Some people can live with bunions for their entire life without having any pain. Many people experience pain with pressure from shoes due to the metatarsal bone sticking out. Other people experience severe pain in the joint with any range of motion. Many people report that they cannot find shoes to fit. Often people also report that their exercise and activity is limited due to the pain.

Below is a picture of an x-ray of a foot with a bunion inside of  a shoe.  It clearly shows how a foot with a bunion fits in a shoe.  This is a male patient.  As you can imagine, Men’s shoes are much more forgiving than womens’.  Notice how the shoe is the proper size / length but the foot is too wide for the shoe. Not only does it put pressure on the great toe joint but also on the other side of the foot at the 5th toe.


Cosmetics: Often people come into my office and report that aesthetics alone are the reason that they seek treatment for bunions. Many request that I perform cosmetic foot surgery for bunions. I often perform bunion surgery for cosmetic reasons alone, however, as an ethical physician, I have a lengthy discussion about this with patients: I describe to my patients that when a person comes in with a painful bunion and says they have a 6 or a 7/10 pain scale for example, I can do bunion surgery to make the foot look very nice and they may end up with a pain that is a 0 to 1/10. These people are very happy as their pain is significantly reduced and the foot looks much better. When a person comes in with a cosmetic complaint only about the bunion and a 0/10 on a pain scale, I warn them that they may have an occasional minor 1/10 pain after surgery. While there is a small chance of this, this is a concern. Due to the unique function of the foot in weight bearing, it is different than other cosmetic surgeries. In my experience, about fifty percent of these people proceed with the bunion surgery and fifty percent thank me for being honest and put it off for the future if and when they have pain.

Conservative treatment of bunions: Unfortunately, there are not many options for conservative treatment for bunions. If caught early, orthotics (insoles in your shoes) can alleviate some of the forces that cause the bunions. While this will not remove the bump on the foot, it will slow down or stop the progression of the bunion due to the forces I described above. Other conservative treatment for bunions address the pain due to the deformity. This includes changing shoes in order to accommodate for the large bump, anti-inflammatories, icing, padding and shielding, cortisone-type injections into the joint, and occasionally physical therapy.

Surgical treatment of bunions: I advised the patient that surgical treatment for bunions is necessary when the patient has pain that limits their ambulation, activity level and if they cannot wear the shoes they would like to wear. Surgery for bunions is elective. The patient chooses if and when they do it. Note: elective surgery is not the same as cosmetic surgery. Elective surgery is covered by insurance, cosmetic surgery is not.

The bunion surgery is done as outpatient surgery meaning that patients do not stay overnight. The surgery is done either in a hospital or an outpatient surgery facility. An anesthesia doctor (anesthesiologist) Will give the patient an IV. The procedure is done under sedation. This means that patients will be asleep, however, they will be breathing on their own. This is not general anesthesia which requires a tube down the throat to assist in breathing. Patients are required to have an adult pick them up from the surgery to ensure they get home safely after the anesthesia.

The type of bunion procedure I choose depends on how severe the bunion is. It ranges from simply shaving off a bump of bone, to cutting and moving bones, removing pieces of bone, joint implants, and occasionally joint fusions. The procedure normally takes me approximately 45 minutes to one hour to do. I make an incision on the side of the foot so that the scar is not visible. Some doctors put the scar on top of the foot; however, I feel there is no need to have a visible scar. Once inside, I access the bone and remove a small piece. I then make a cut in the bone and move the bone back where it belongs. I usually use a small titanium screw to hold the bone in place for healing. I then do any soft tissue rebalancing of the joint that is necessary. I also perform skin-plasty procedures to remove the excess skin that has formed over the bunion over time. This is a cosmetic addition to fixing bunions. The goal is improving the feel and aesthetics of the foot. I then close the skin with a plastic surgery type stitch that is underneath the skin surface so that it scars less. Having trained with plastic surgeons during my residency, I perform a more cosmetic bunion surgery than almost all other surgeons. (For more information about this see my procedures page of my website by clicking here!)

What to expect after bunion surgery: I almost always perform bunion surgery on Fridays. This allows the weekend for resting. I instruct patients that they must remain at home for Friday, Saturday and Sunday. (Walking to the bathroom and kitchen only). People that have desk jobs may do the surgery on a Friday and return to work on Monday, however, if they can take one week off of work I recommended it. People that have jobs that require them to be on their feet all of the time, I advised to take three to four weeks off of work. After the surgery patients will wear a surgical shoe or fracture brace for four weeks. Some patient have no pain at all and some patients have a lot of pain. Most people have moderate pain that is well controlled with the pain medicine that I prescribe. Note: there are surgical techniques that I employ that reduce the amount of postoperative pain. I also prescribe five days of antibiotics after the surgery to prevent infection. Patients must keep the foot dry for 10 days. I dispense a shower bag before the surgery. I will see patients once a week after the surgery until I feel that they are stable to start skipping weeks. I usually do the first visit on the Wednesday after the Friday of surgery. At this time I inspect the foot to make sure there are no problems. I will take an x-ray and usually wrap the foot in a soft cast. They return the following Wednesday, 10 days after surgery. At this time I usually let them get their feet wet and rewrap the foot themselves.

After spending four weeks in the surgical shoe or the fracture brace I allow patients to start wearing loose-fitting shoes or open shoes in the warmer weather. At this time they may start to increase their walking a bit. I advise them that they will most likely not be doing exercise until six to eight weeks after surgery. Initial exercise includes walking and using a stationary bike. After eight to ten weeks they may start to do an elliptical machine or more weight bearing exercises. At eight weeks, I advise them that they may start using any shoe that they fit into.

Below are just a couple of examples of before and after pictures of bunion surgery.

Bunion Surgery Before and After

The first example of before and after pictures of bunion surgery are of a severe bunion. The after picture is at only three months.

Bunion Surgery Before and After Bunion Surgery Before and After

This patient’s x-rays are show below before and after bunion surgery.

Bunion Surgery Before and After

Below: Another bunion surgery before and after pictures.  The after pictures are 4 years after surgery. This patient had both of her feet done.

Left: (Below)

Bunion Surgery Before and After Bunion Surgery Before and After

Right: (below)

Bunion Surgery Before and After Bunion Surgery Before and After

The next patient had bunion and tailor’s bunion surgery. Fifth metatarsal osteotomy and first metatarsal osteotomy procedures. The after picture is immediate, still on the operating table. Note: the discoloration of the foot is due to the Iodine and the fact that the tourniquet is still inflated. I use a tourniquet (like a blood pressure cuff around the ankle) to stop the bleeding so I can see better while operating. (Below)

Bunion Surgery Before and After Bunion Surgery Before and After

I hope you found my post on bunion surgery informative. If you have any questions please feel free to post a comment or email me, Dr. Silverberg. Please also see www.cityfootcare/procedures


© Copyright 2010
Best Podiatrist NYC
Lawrence Silverberg, DPM
City Footcare, PC
20 E 46th Street
New York, NY 10017
Specializing in foot surgery, bunion surgery, hammertoe surgery, cosmetic foot surgery, general podiatric surgery.

A metaphor of how insurance companies and doctors interact. A great explanation for the layperson.

I did not write the article below in this blog post. I read this article from 2009 and was so impressed I decided to repost it here. I loved how it explains what physicians go through with insurance companies.

A great explanation about insurance companies for the layperson.

Physicians are really interested in provided excellent health care while covering our very high overhead for business and making some profit at the same time. Everyone goes to work to make money, including doctors. Speaking for myself, and I’m sure most of my colleagues, we feel as though we should be compensated well for providing such a necessary service, taking care of illness and injury, our years of higher education and post-graduate training, and the high cost of malpractice insurance with the added risk of being sued by malpractice attorneys.

The insurance companies, on the other hand, are only about making profits for their shareholders and officers. Their share price does not reflect the health care provided to their customers, only how much profit they can report.

In my 13 years of practice I’ve seen the situation get worse and worse with insurance companies paying less and less, and patients out of pocket expenses going up more and more. Add that to the annual increase in insurance premiums paid by patients and their employers and it creates negative emotions. I hear all the time from patients complaining that their insurance premiums have gone up and their responsibilities to pay the doctors have also gone up.

I have had to hire additional employees just to try to get paid from insurance companies because they deny more and more claims all the time. My accounts receivable is the biggest it has every been. We are constantly fighting to get paid. Patients get seen and we often do not get reimbursed from the insurance companies, only partially reimbursed, or paid months after the service was provided. Patients do not appreciate getting billed at all for services when they pay so much money for insurance, and also don’t understand why we bill them many months later after we are done fighting with the insurances and the claims were denied.

The below article is a great metaphor of how this third party payer system works from the providers point of view. Enjoy…

How do doctors get paid?

Imagine going to your favorite restaurant.  You are greeted at the door by the hostess, who seats you and takes your drink order.  You order through your favorite waiter, Andrew, who recommends the special of the day: prime rib with a dinner salad and a chocolate torte for dessert. Soon after, the food is brought out and it is delicious!  You have time to enjoy your food.  You then receive the bill and pay for your meal, returning to your home satisfied, all your dining needs met.  Let’s say, for simplicity’s sake, you paid $75 for this meal: $50 for the steak, $10 for the salad and $15 for the dessert.

A change then occurs in the restaurant industry.  A new form of eating out has been adopted.  Your favorite restaurant has now contracted with over 30 different ”restaurant insurance companies.”

Anticipating another pleasant dining experience, your return to the restaurant with your new “subscribers card.” You pay your $5 “copay.” You sit in the foyer of the restaurant. You wait an hour, even though you made reservations.  A harried Andrew greets you and quickly takes your order after you briefly glance at the menu.  The food arrives at your table.  As you take your second bite, Andrew informs you that “your time is up” and the table is reserved for another party.  You are escorted outside with your hastily boxed left-overs.

What has happened to the restaurant?  Behind the scenes, the restaurant owner has learned some tough realities of the “new system.”  During the first month of taking insurance, the owner sends a form to the insurance company requesting payment for the $75 steak dinner: $50 for the steak, $10 for the salad and $15 for the torte.  The contract with the insurance company already states that they will only pay $45 for the $50 steak, but the owner decides that the extra customers brought to the restaurant by contracting with this insurance company will more than off-set this small loss.

The first attempt at collecting the $75 dollars for the full meal is returned unpaid with the note that it was rejected due to a “coding error.”  The forms for payment from the insurance company require the owner to list the parts of the meal, not by name, but by the numerical codes. The owner had listed the salad by the wrong numerical code.  No suggestions for the correct code are offered, so the restaurant owner purchases a series of books, at a cost of $500, to learn how to assign the correct code to the different parts of the meals.  These books will need to be bought annually due to the constant changing of the code numbers. After 30 minutes of study, the owner realizes the dinner salad should be coded as a 723.13, not the723.1 the owner originally put on the form.  The salad, it turns out, needed to have two digits after the decimal point, indicating that it was a dinner salad, and not a “main course” salad.  The owner mails the corrected form.

In response to the second request for payment, the insurance company does not send a check, but a detailed questionnaire:  Was garlic used in seasoning the steak?  Was it necessary to use garlic for this particular recipe?  Did the restaurant ask for permission to use garlic from the insurance company before serving the steak? Why was salt, a less expensive alternative, not used instead? The owner submits the answers, emphasizing that the garlic is part of a secret family recipe that made the restaurant famous.

The owner waits another week (it has now been 3 weeks since the dinner was served).  The check arrives three and a half weeks after the meal was served.  The check is for $20 and states that it is specifically for the steak.  The check also comes with a letter stating that no billing of the patron may occur for the salad, but no other explanation is enclosed.  No mention is made of the $15 dessert.

The now frustrated restaurant owner calls the provider service number listed in the contract. After five separate phone calls to five different numbers (The harried voice behind phone call number four explains that the insurance company has merged with another insurance company and the phone numbers had all changed last week, sorry for the inconvenience…), the owner gets to ask why, when the contract says the steak will be paid at $45, has the check only been written for $20?  And what happened to the payment for the $10 salad and the $15 dessert?

As it turns out, this particular patron’s insurance contract only pays $45 when the patron has reached their deductible, which this patron has not at this time.  The remaining portion of payment for the steak must now be billed by the restaurant to the patron directly.

The $10 for the salad would have been paid if the patron had ordered it on a different day, but, per page 35 in the contract, because it was billed on the same day as the steak, it is considered to be part of the payment for the steak and no extra money can be collected from the patron or the insurance company.

The dessert, the owner learns, should have had a “modifier” number put with its particular billing code when billed with the steak and the salad.

Realizing that the insurance billing is quite a bit harder than anticipated, the restaurant owner hires a company, who is paid 5% of any money collected to specifically make sure these coding errors do not occur again and follow up on payment rejections.  For an additional $99 per month, the billing company will “scrub” the forms submitted for payment to make sure specific clerical errors will not cause future delays in payment.

The owner now must lay off the hostess and the bus boy to pay the billing company, so these duties are now added to the waiter’s other responsibilities.

In the meantime, the restaurant owner has also had the waiter take on the job of answering the phones due to the now high volume of phone calls from patrons questioning why they are receiving bills for meals they ate over two months ago, and why did their insurance company not pay for this portion of the meal?  This extra work is now resulting in longer times patrons must wait to be seated, and grumblings from the waiters who “were not hired or trained to do this kind of work.”

The owner now realizes that, although the dinner originally cost $75 to make, only $25 has been paid. The remaining $30 billed to the patron is now in its third mailing, with the first two requests for payment going unanswered by the patron.  The restaurant owner realizes a collection agency must be employed in order to have any hope of receiving any portion of payment from the patron.

Each meal served now costs at least an additional $20 due to the added overhead of the billing company, coding books, and the collection agency.  These added expenses have nothing to do with cooking food or providing any direct service to the restaurant’s customers.

Service to the restaurant’s patrons has been compromised with these changes as well. The owner has now over-extended the waiter, who was an excellent waiter, but is now taking on the roles of host, phone answering and table bussing.

In order to even meet the costs of providing fine dining, the restaurant owner now must seat twice as many patrons in the same amount of time.

What was once an outstanding business that focused on fine dining and customer service has now been turned into a business in the business of trying to get paid.

Alas, I wish this were a fictional tale, but it is not.  The only fictional portion is that this is not your favorite restaurant, but your favorite doctor’s office, which is responsible not for meeting your dining needs, but those of your health.

Megan Lewis, M.D.

A family physician in rural Colorado.

Practice Focus:

Effective January 1, 2013, I have changed the focus of my practice. I have explained it completely in the below letter I wrote.

Summary: I will still see new patients but I will focus on Podiatric Surgery. When new patients do not require surgery they will follow up with my partner doctors after I have diagnosed them and made a preliminary treatment plan. I will continue to oversee their care when necessary.

To my valued patients:

As 2012 comes to an end, I am humbled and proud to acknowledge, and share with you, that my first twelve and a half years in practice have been successful beyond my predictions! After finishing residency, I moved to New York City in 2000 with a job only one half of one day per week. I quickly made valuable connections and filled my week with office hours and patients in four New York City Boroughs and Westchester County. Within two years I had opened my own practice part time. In 2003, I left my former employers to devote my full attention to my own practice and started my current group, City Footcare, PC.

‘Fast forward’ ten years to 2013 and I have developed and grown a thriving, successful group practice with four associate doctors under my supervision and guidance. I would not have been so successful without the support of you, my patients. In light of this success, I have chosen to change the focus of my practice going forward from general podiatry mixed with podiatric surgery, to predominantly podiatric surgery.

Focus on Podiatric Surgery:

It has always been my passion and goal to focus primarily on podiatric surgery. It takes many years to build a reputation as a great surgeon. I feel comfortable saying that I have already achieved this reputation at this point in my career. Right now, I am excited that this is the opportune time to act upon this success. Going forward I will be focusing my practice on podiatric surgery.

Practice Focus

I Will Continue to Accept New Patients for all Podiatric Problems:

I will not completely stop doing, general, non-surgical podiatry related care. I have formulated a way to spend a majority of my time performing surgery, including the preoperative and postoperative care related to surgery, while also practicing general podiatry some of the time.

I have assembled a team of excellent podiatrists in my City Footcare Group. I have hand-picked talented physicians who I have had the opportunity to work with for many years, and even train during their residencies. They have all spent time working with me in my office and observing my unique way of practicing podiatric medicine which has made my practice so successful.

Our physician group will work as a team to share in the care of our patients. I will help to oversee the care of patients who visit our practice. I will continue to see new patients a few days per week. During the initial visit, I will perform a detailed new patient visit including the patient’s history and physical examination. I will perform, order, and interpret the appropriate diagnostic tests. I will derive the diagnosis and start with appropriate treatments on the initial visit when indicated. When the treatments required are surgical, I will continue the care of the patients including preoperative consultation, performing surgery and all postoperative care.

When the treatment indicated is not surgical, I will direct the patients to follow-up with my partner doctors who will continue the necessary care. I will maintain communication with my partner doctors and provide any necessary input going forward.

To all of my existing patients, I would like to thank you for my success. It is because of you that I am where I am today. I know, and appreciate, that many of you will want to continue to see me, but I assure you that you are under the care of qualified physicians with my partner doctors. I will still be around to say hello or to provide any necessary input into your care.

I ask that you please respect my decision to make this change as it has been my career, and lifelong dream, to have a surgically oriented practice.


Lawrence Silverberg, DPM

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