Chronic Tendinopathy of the Achilles tendon and Plantar Fascia

December 13, 2015

 

Pain on the back or bottom of the heel caused by a condition known as tendinopathy is a common problem among people who are trying to lead an active lifestyle. The Achilles tendon and the plantar fascia are tendon type tissues that each play a key role in maintaining balance while walking and standing and are commonly afflicted with this condition. The pain in these areas often emerges from overuse following repetitive strain or after a recent increase in activity. Most people who have heel pain from tendinopathy will experience relief with the use of stretching, supportive shoes, anti-inflammatory therapy and shoe inserts. However, if the condition is not addressed, the acute inflammatory process continues as the body attempts to repair the damaged tendon. Eventually, this healing process ceases as the tendon becomes riddled with scar tissue.

Chronic tendinopathy in these areas can severely impair your ability to function in your daily life. Often described as tendinosis or fasciosis, this recalcitrant condition may persist for more than 6 months and is not relieved with the use of anti-inflammatory medicine or corticosteroid injection. This chronic, degenerative process manifests as thickened fibrous tissue within the tendon or fascia. Blood flow decreases to the diseased area and the normal healing process is halted. If conservative options fail to alleviate the symptoms of chronic tendinopathy, novel therapy that involves restarting the healing process should be the next option considered. Since healing is a normal response to injury, restarting the healing process in chronic tendinopathy could involve either introducing a controlled injury to the fibrotic/scarred tissue or directly implanting the necessary growth factors. There are several therapies currently available for treating pain due to chronic tendinopathy.

New Approaches to Treating Chronic Tendinopathy

 TENEX FAST – Focused Aspiration of Scar Tissue

The TENEX FAST system provides a novel way of directly accessing the diseased portion of tendon, using ultrasonic energy to break the fibrous tissue within the Achilles tendon or plantar fascia. This minimally invasive approach uses a handheld device with a micro tip. Using ultrasound imaging as a guide, the handheld micro tip is brought to the area of injury through a small incision in the skin. With the use of a foot pedal, ultrasonic energy is emitted through the micro tip to emulsify the scarred portions of tendon. The micro tip is also equipped with a saline delivery system to flush and aspirate/remove the debrided fibrous tissue. This process has been termed phacoemulsification and essentially cleans the scar tissue in a focused manner, leaving behind healthy tendon. (1) Prior to the procedure, local anesthetic is injected near the affected area to control pain during the procedure.

For procedures involving the plantar fascia, one can bear weight on the affected limb with a CAM boot and cane for assistance for 2 weeks. For Achilles, a CAM boot and crutches for guarded weight bearing is used. After the procedure, the doctor will determine when transition out of the CAM boot to supportive shoe gear and careful return to normal activities is appropriate. Any discomfort experienced following the procedure can be controlled with pain medication as prescribed by the doctor.

Platelet-Rich Plasma Injection

Platelet Rich Plasma, or PRP, is an orthobiologic substance that is used to alleviate pain caused by chronic tendinopathy. As mentioned previously, the diseased portion of the tendon has decreased blood flow and is unable to heal. PRP functions by directly stimulating the healing process in this area through the use of growth factors and inflammatory molecules from the patient’s own body. Prior to the procedure, blood is drawn from the patient. It is then spun in a centrifuge to separate the platelet-rich plasma from the rest of the blood. (Because a centrifuge or spinning machine is used in this procedure, PRP is sometime commonly known as, “Blood Spinning”) The platelet rich plasma is then drawn out of the processed vial and injected into the affected area. This procedure has now directly implanted growth factors into the site of injury. These growth factors help recruit other cells from the body which are involved in healing of the injured soft tissue.

During the procedure, ultrasound imaging is used to visually inspect the tendon or fascia and find the specific region of injury. Once the area of injury is located local anesthetic is used to numb the area of interest and the PRP is injected. In order to stimulate the process of healing, many small injections will be peppered into the diseased tissue to introduce a form of micro trauma and encourage the body to recruit inflammatory cells. Doing this essentially restarts the healing process in the previously scarred tendon. Following the injection, anti-inflammatory medications and icing should be avoided in order to allow the inflammatory healing process to work. A short leg-walking CAM boot is worn following the injection. Avoid walking without the boot on the affected limb for 2 week. After 2 weeks, patient can transition to supportive shoe gear.

Amniovo – Amniotic Membrane Injection

Amniovo is a form of dehydrated human amniotic membrane and is another way to introduce growth factors to the site of injury in chronic tendinopathy. Although amniotic membrane tissue is known to possess healing potential, there would be risks involved with direct implantation of untreated, fresh amniotic membrane. In order to avert these risks, the amniotic membrane used in this process is taken from screened and tested donors, it is then purified using the PURION process. This purification process allows for the dehydrated amniotic membrane to be safely implanted to the affected site without the risk of disease transmission and allows for the graft to be stored for up to 5 years. Once purified, the product is in powder form and is suspended in saline solution to use as an injection. Through the direct implantation of growth factors, injection with Amniovo helps the tendon’s diseased tissue heal. In fact, in a study using dehydrated amniotic membrane injection compared to a control injection of local anesthetic and saline the amniotic membrane injection was shown to be more effective at relieving pain from chronic plantar fasciosis. (2)

Once again, ultrasound-imaging guidance is used to identify the diseased portion of tendon or fascia. An anesthetic injection is first used to numb the affected area and Amniovo is then injected.

Following the injection, a walking boot is used for 2 weeks in order to protect the involved site. Two weeks after the injection the patient can transition to supportive shoe gear.

In Conclusion

Chronic tendinopathy is an issue that plagues many people who are attempting to engage in an active lifestyle. Because the condition may not respond to anti-inflammatory therapies, many patients are frustrated, especially if they would like to avoid surgery. Novel therapies that combat this chronic, degenerative process have emerged that help restart the healing process in the diseased tissue. If you have had heel pain from chronic tendinopathy that has stopped you from leading the daily lifestyle you would like to, speak with your doctor to see which therapeutic option would best suit your needs and help you get back on your feet.

References

1) Barnes, D. Ultransonic Energy in Tendon Treatment. Operative Techniques in Orthopaedics. 2013

2) Zelen, C; Poka, A; Andrews, J. Prospective, Randomized, Blinded, Comparative Study of Injectable Micronized Dehydrated Amniotic/Chorionic Membrane Allograft for Plantar Fasciitis—A Feasibility Study. Foot and Ankle International. 2013

 

Venous Leg Ulcers

September 20, 2014

30673534_m

The lower extremity is a common place for wounds to occur. Often times, even with treatment, wounds may not heal and can leave wound care experts perplexed. There are a variety of reasons as to why a wound may not heal, an example of which includes improper functioning of the deep veins in the legs. Venous leg ulcers are becoming more recognized and require treatment that addresses the underlying issue of the disease before the problem becomes worse.

Venous Stasis and Chronic Venous Insufficiency

Venous stasis is a condition characterized by pooling of blood in veins and occurs in the lower extremity. Veins are responsible for collecting blood from tissues and returning it to the heart. Valves within the veins keep blood from flowing backwards in the legs. When these valves are not working properly, gravity keeps blood from returning upward towards the heart. This condition is called Chronic Venous Insufficiency (CVI), which often occurs as a person ages or is not mobile for an extended period of time.

Symptoms of CVI may include swelling of the legs, itching and flaking of stretched skin, leaking of fluid through the skin, and a heavy feeling in the legs. It is useful to think of the legs as balloons in this instance – as the balloons swell with air and stretch, they reach a breaking point and “pop”. Similarly, prolonged swelling causes the outer layers of the skin to break and leads to ulcer formation. This is particularly troubling for diabetics with peripheral neuropathy who have trouble healing wounds. These ulcers often occur near the medial malleolus or the lateral malleolus of the ankle, which is where the major veins from the foot travel.

Many wound experts have trouble healing these wounds because they do not address the underlying issue of why the wound is present. In order for the wound to begin to close, the swelling needs to be corrected. If the wound is not healed in a timely manner, the affected limb may become infected.

Risk Factors

There are many risk factors that can lead to formation of a venous ulcer. Previously having a DVT [https://brucelashleydpm.wordpress.com/2013/10/] is a major risk factor for venous valve insufficiency. Older age and prolonged immobilization can also cause blood to pool in the legs. Oftentimes this manifests as varicose veins, although presence of these superficial veins does not mean they will become a venous ulcer and is largely a cosmetic issue. A prolonged history of obesity and smoking can also lead to CVI. Women are more likely to suffer from this illness, mainly because the anatomy of the female pelvis is different from a male’s, leaving them more likely to suffer from obstruction of the iliac vein in the hip in a condition called May-Thurner syndrome that more commonly affects the left leg, rather than both.

Tests

There are a number of vascular tests that your doctor may want to recommend. Doppler ultrasound is a safe procedure that is used to study blood circulation in the form of sound waves. Your doctor may also want to measure the blood pressure in your leg veins to make sure that increased pressure is not causing too much stress on the valves. These tests can be performed in the office and used to decide what the best course of treatment will be.

Treatment and Education

As the wound progresses in age, it begins to fill with dead tissue that can prevent it from healing. An infection may be present, in which case appropriate antibiotic therapy needs to be implemented. Once any infection is addressed, the wound needs to be cleaned of debris. A dressing is applied to the wound to protect it from the outer environment.

Once this is done, the most important step is to provide compression to the affected limb with a bandage or stockings. This compression will help improve circulation in the legs and allow for blood to be pushed against gravity towards the heart. If a bandage is used, it needs to be applied correctly by a healthcare professional in such a way that provides compression without constricting blood flow through the legs. The dressing and compression will need to be changed every week. Elevation, when combined with compression, will allow for circulation from the lower extremity to the heart to occur and will reduce the swelling. Once this is accomplished, the skin surrounding the open wound is able to close and heal.

Very serious cases of CVI may require surgery from a vascular surgeon. However, this is very rare. Bad habits, such as smoking and excessive drinking, should be discontinued to prevent delay in healing of the wound. Maintain a healthy lifestyle to keep blood flowing well through your legs.

Treating this condition can be a lengthy and arduous process. The compression might feel uncomfortable and will be tempting to remove. If this is the case, your doctor may recommend using an anti-inflammatory medicine to help with the pain. Keep in mind the importance of the compression to help heal your wounds. With proper recognition of this condition, and the right attitude, great improvements can be made to ensure that you are healthy again.

Charcot Neuroarthropathy

July 12, 2014

CROW_bootCROW BOOT USED TO TREAT CHARCOT FOOT

 

A 60 year old man complains of a red, hot, and swollen foot. He has diabetes and has had peripheral neuropathy for a many of years. He was previously told that he probably has an infection and was prescribed antibiotics. However, xrays show fragmentation of bone in his midfoot that resemble small fractures. What condition could he have? Does he really have an infection?

 What is Charcot Neuroarthropathy?

 People with longstanding high blood sugar from diabetes have a increased chance of developing peripheral neuropathy, a condition in which the feet and possibly hands become numb. Unfortunately, this condition leaves patients susceptible to injury, whether it is wounds under the feet, infection, or trauma. Charcot Neuroarthropathy is a condition that is thought to occur after repeated injury to bones in a neuropathic (Numb) patient. In diabetic patients, the bone breakdown often occurs in the midfoot. Because people with longstanding diabetic peripheral neuropathy may not notice that they have injured themselves, they continue to walk on the injured limb. As the ground forces from walking are applied to the numb foot multiple small fractures continue to develop. This leads to eventual deformity of the foot and possibly infection and amputation. Since this condition is very rare, it is commonly mistaken for an infection and is improperly treated. It is important to quickly recognize the signs of a Charcot foot and treat it appropriately to prevent the disease from progressing.

 Symptoms and signs

A Charcot foot initially presents as a red, hot, and swollen foot. This can be explained as the body’s natural way of attempting to heal the broken fragments of bone. Bone healing occurs with increased blood flow to the affected area, which causes the heat, redness and swelling. In attempting to heal bone, the body sends inflammatory molecules that signal to resorb and remodel the bone. However, long-term diabetics with uncontrolled blood sugar have a decreased ability to heal themselves. The resorption of bone occurs more rapidly then remodeling with new bone and the disease process continues to worsen. As the diabetic patient continues to walk on the limb, the fragmentation increases and the cycle continues. Xrays may or may not show fragmentation of the affected area during early symptoms of Charcot, which makes the condition harder to diagnose.

 After a period of time, healing of the bone fragments occurs and the swelling of the affected foot decreases, xrays may show healing of the bone. Unfortunately, the disease process has not stopped there. The decrease in symptoms can be mistaken as resolution of the disease itself, and as the patient continues to walk, the affected area of the foot begins to cave in and deform, causing what is commonly known as a “rocker bottom” deformity. The dislocated fragments of bone continue to heal in this shape, causing permanent deformity of the foot. This is dangerous for the patient with peripheral neuropathy because deformity increases the chances of developing a diabetic foot ulcer, subsequent infection and possibly amputation of the limb.

 Treatment

An important aspect of treating the Charcot foot is recognizing the condition early and ensuring that the patient does not ambulate further on the affected leg. This method of restricting weight bearing on a limb or part of a limb is called offloading. The total contact cast (TCC) is commonly used to initially offload the foot. The TCC is a below-knee cast that is non removable and, if used appropriately, can halt the disease process cycle. The cast allows forces from the ground to be dispersed when the patient is standing. The TCC is changed every week by the physician and should be used for 4-6 months. Crutches, wheelchair and ankle foot braces can also be used to aid in off loading the foot.

 Once the redness, swelling and heat have decreased in the affected foot, other forms of support can be used to allow the patient to carefully get back to walking.

The Charcot Restraint Orthotic Walker is a boot that is designed specifically to treat the Charcot foot once the swelling has decreased. The outer fiberglass shell provides rigid support for the foot and ankle. The foot bed of this device consists of a custom insole that distributes forces equally across the bottom of the foot. The custom fit of the boot allows the patient to get back to activities of daily living. When the patient starts using the boot, they can walk short distances as instructed by their doctor and can gradually increase as long as the symptoms do not return. An advantage to using this boot is that it can be removed when the patient bathes or sleeps. The patient needs to carefully monitor their foot when using this brace to ensure that the boot is not rubbing causing wounds to develop. Once the doctor deems that the CROW is no longer necessary, the patient can begin using custom diabetic shoes or an Ankle Foot Orthosis (link to AFO blog?)

 Advanced cases of Charcot Neuroarthropathy with severe deformity may require reconstructive surgery. Talk to your doctor about your need for surgery and the options available.

 As is the case with all diabetic foot conditions, patients need to be mindful of their feet and check for new wounds, discoloration, or any other differences daily. Patients with Charcot Neuroarthropathy must recognize the importance of doing this and need to comply with their doctor’s recommendations to help their feet improve.

 

 

 

 

Peripheral Neuropathy and Diabetic Foot Ulcers

April 3, 2014

 

Image

 

What is peripheral neuropathy?

One of the major complications associated with diabetes is peripheral neuropathy. This process of nerve damage gradually takes place after many years of having diabetes and uncontrolled blood sugar. The condition affects the sensory, motor, and autonomic nerves of the body. Muscle strength and balance are diminished with motor neuropathies. While autonomic neuropathies manifest as loss of hair and disfunctioning sweat glands in the lower extremity and can present as erectile dysfunction in very advanced cases. Sensory deficits, which include numbness, tingling or even pain, are often the first symptoms to develop. Many people that are developing the condition may not notice the gradual onset of symptoms. Diabetics may be unaware of of these gradual changes until their doctor informs them that they have the condition. Some may experience shooting pains in their feet that become worse at night, making it difficult to sleep.

 

Lack of sensation in the lower extremity can be very dangerous because it increases the risk of developing sores, open wounds and ulcers on the feet. If the wound becomes infected, there is a likelihood that the infection can spread and amputation of the affected limb may be necessary if it is not treated soon enough. Losing a limb becomes a large burden for patients in their daily activities and adds additional costs to their medical care. Because of this, it is recommended that a comprehensive foot exam be performed annually in all diabetics.

 

Muscle weakening associated with motor neuropathy acts as an added detriment because it can lead to development of foot deformities, such as hammertoes, bunions or limitation of motion in joints of the lower extremity. These defomities may rub on shoe gear and cause skin breakdown. Coupled with a numb foot, these deformities increase the patient’s risk of developing foot wounds.

 

Foot exam

The physical exam involves a thorough review of the skin health, blood supply, nerves and muscle strength of the lower extremity. The skin is assessed for hair growth, any discoloration and wounds. Diabetics have an increased risk of developing poor blood supply also known as peripheral vascular disease. This in turn greatly increases their risk of acquiring a dangerous infection and non-heeling wounds of the feet. The neurological portion of the exam involves measuring the patient’s ability to feel a small flexible fiber under their feet with their eyes closed. Additional testing evaluates their ability to detect vibratory sensation. Patients that develop peripheral neuropathy may not be able to tell the doctor when the bottom of their feet is touched with a monofilament. These patients are at an increased risk of developing unnoticed foot wounds.

 

Diabetic foot wounds – how are they treated?

Repetitive trauma to the foot leads to development of a hard callus, which increases pressure on the foot when the patient walks. The person with a numb foot continues to exert pressure on the callus, which forms a deeper wound that can subsequently lead to infection. An ulcer develops when a break of the skin occurs. The depth of the wound plays a large role in how serious the infection can be and how it can be managed. A rim of callus usually surrounds the wound. Once the wound becomes infected, the foot may become red, leak fluid, and may have a foul smell. As the infection progresses, thick yellow fluid can leak from the wound. It is important that callus and any wound is medically evaluated and appropriate medical treatment is started as soon as possible. Initial treatment involves debriding the wound to remove any dead tissue covering in order to expose the underlying healthy tissue in the wound. Any callus that surrounds the wound is also removed. A culture is obtained to find out which bacteria are involved with the infection so that appropriate medical therapy with antibiotics can be initiated. Negative pressure wound therapy a small vacuum placed over the wound can be used in some cases to quicken the healing process. Some of these infected ulcers may require intervenous antibiotics and hospitalization.

In addition to antibiotics and debridement pressure from the shoe and the ground must be reduced or eliminated to allow the wound to heal. Offloading pressure from the wound sight is accomplished in many ways. Sometimes a wheelchair or crutches are needed to completely remove weight from the foot. An orthotic or shoe insert with cutout areas under the wound can reduce pressure from causing additional damage. There are also many other ankle-foot braces and cast that remove pressure from the foot. One of these braces is the Bledso Boot. This boot has a layer of auto-molding foam in the foot bed, which reduces pressure on the wound. It also prevents movement at the ankle therefore reducing friction that can cause tissue breakdown. Another type of device made to eliminate pressure from the bottom of the foot is called the Toad Brace. This apparatus is molded to fit and grip around the top of the lower leg and the knee. This construct floats the foot off the ground and completely offloads the bottom of the foot. After the wound heals it will be necessary to use an offloading orthotic and a shoe designed to fit this inner sole.

If you have peripheral neuropathy, it is important to check your feet daily for wounds. Areas of your feet that receive high pressure may develop calluses, which increase the risk of a wound forming in that area. Seek help early from your doctor so that a proper treatment regimen can be started. A wound that is deep and does not heal leads to further complications, such as bone or systemic infection. Disregard for the condition of your feet, especially if you are diabetic, can lead to loss of a limb.

 

Ankle Foot Orthoses (AFO) – Richie brace and Arizona Gauntlet

February 16, 2014

Ankle Foot Orthoses, or AFOs, are devices used to support the lower extremity. They usually cover the bottom of the foot and extend up the ankle. The size of the brace is custom fitted to the patient and varies based on the patient’s needs. Some cover the entire ankle up to just below the knee, while others barely extend past the ankle. They are usually prescribed to patients in order to help reduce pain while walking or while healing from injury. An AFO may also be used to assist with walking in people with neurological disorders, such as Charcot-Marie-Tooth syndrome or cerebral palsy. Diabetics who have lost sensation in their feet may also benefit from the use of an AFO to prevent injury.

One condition that is frequently treated with the use of an AFO is posterior tibial tendon disorder (PTTD), also known as adult acquired flatfoot. The posterior tibial tendon courses from the calf around the inside and behind the ankle and attaches underneath the midfoot on the side of the arch. The action of this muscle/tendon when functioning properly is to provid stable support for the arch of the foot. An important function of the posterior tibial tendon is to twist the foot inward while walking therefore creating a foot that is stable and able to propel the body forward. When there is decreased muscle strength in the posterior tibial tendon the foot no longer functions, as it should. With prolonged overuse, the posterior tibial tendon can lose its ability to create an adaquit arch, causing the foot to flatten. If this progressive condition is left unsupported the tendon can rupture and may need surgery.

RichieThe Richie brace is an AFO, commonly used to treat mild to moderate stages of PTTD. The brace is comprised of a custom foot orthotic and two hinged upright supports on both sides of the ankle. The brace supports the foot arch, rebalances the muscle strength in the foot and controls the position of the bones and joints of the foot and ankle. When used for PTTD, its purpose is to stop the posterior tibial tendon from over-working to maintain the foot’s arch, thereby reducing the chance of damage to the tendon. This low profile style device can usually be worn with many commonly available shoes. Most of the time, it may be necessary to use a shoe that is one size bigger than normally worn may be preferred for comfort.

 

Another AFO that is commonly used is the Arizona gauntlet AFO. This style of device is also worn with shoes and Arizonaimmobilizes motion at the ankle. It is effective in treating degenerative joint disease or ankle and foot arthritis. Arthritis can occur because of previous traumatic injury, such as an ankle fracture or sprain, or can happen as a process of aging. As these conditions progress, it becomes increasingly painful to move the foot and ankle. Using the Arizona brace restricts motion and can eliminate pain while walking. The brace is two-layered with a firm, durable outside and soft, leather inside. It is equipped with laces, which is convenient for those who may need to make minor adjustments to the size of the brace if the foot and ankle swells. This type of brace may also require that patients wear a bigger or extradepth shoe to accommodate the foot and brace. The Arizona gauntlet can also be used for PTTD.

If an AFO is the correct form of treatment for your condition, your doctor will recommend the appropriate type of brace for you.  The next step in the process for making your AFO is that a plaster or fiberglass casting of your foot and ankle will be taken. This model will then be sent to the orthotic lab to custom manufacture the device for your foot and ankle. When the lab returns the finished device to the doctor’s office the AFO will be checked to insure that it fits properly. After a brief break-in period the brace should be comfortable and must be worn as directed by your doctor.

If you are have pain when walking and are looking for a way to get back to being active, talk to your doctor about your options, possibly an AFO may be right for you.

Treatment of Hallux Limitus

December 29, 2013

Image

This is an example of an orthotic with a Kinetic Wedge

When a patient presents with symptoms of hallux limitus, it is important to take into account the severity of their deformity as well as the level of pain and how the pain limits daily activities in order to determine what treatment would be most appropriate. A variety of treatment options can be considered, including both conservative and surgical procedures.

Early stages or minimal discomfort from hallux limitus are often approached using conservative treatments. One popular method of conservative pain control is to take oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil or Motrin. Keep in mind that taking this medication does not cure the condition causing the pain. This method of treatment can be used to treat acute flair-ups of pain and swelling.

Foot orthotics are another conservative option to treat hallux limitus and have been shown to relieve pain better than the use of oral anti-inflamatories alone (1). Examples of custom modifications of orthotics used to treat this condition include the Kinetic Wedge and Morton’s extensions. These specialized foot orthotics can help alleviate pain in the 1st MTPJ. By providing functional correction of deformities with the proper orthotic, 1st MTPJ discomfort can be improved. Foot orthotics are inserted into shoes and can be moved from shoe to shoe.

Physical therapy is also another conservative option that may be of some benefit in early stages of the condition.

Steroid injections can be administered in the doctor’s office. A steroid or cortisone shot is given into and around the joint this may help to relieve pain.  The reduction in swelling and pain from this type of injection may not last long. The injection can be repeated, however since over use of steroid can breakdown tissue there is a limit to the number of injects patients can receive.

If the conservative therapy that has been reviewed does not reduce pain, then surgical intervention may be necessary. The major goals of surgery are to reduce pain and improve daily function. Depending on the nature of the patient’s foot and the degree of joint destruction, other goals could include improving joint motion, recreating a joint space in the 1st MTPJ and reducing deformities of bone.

Operations that are able to preserve the joint involve removing any abnormal bone formations around the joint in order to improve mobility. However, there are instances in later stages of hallux limitus and hallux rigidus where preservation of the joint is not possible. In this case, the joint articulations or cartilage may be removed and replaced by an artificial joint or the joint may require to be permanently locked together also known as joint fusion.

If you believe you are feeling symptoms of hallux limitus or hallux rigidus, it is important to address the pain with your doctor as early as possible. May people that have pain in this area assume that they have a “bunion”.  An earlier and accurate diagnosis opens the possibility of a variety of noninvasive, conservative treatments that can help reduce pain while walking.

References:

1. Shurnas PS. Hallux limitus: etiology, biomechanics and nonoperative treatment. Foot Ankle Clin. 2009 Mar; 14(1):1-8.

Hallux Limitus/Rigidus Part 1

December 16, 2013

Image

 

Hallux Limitus/Rigidus Part 1

A 55-year-old male comes into his podiatrist office complaining of pain in the area of his big toe after he finishes his morning walks. He noticed that there is swelling and he has trouble bending his toe because of the pain. He recently noticed a bump at the base of the toe in the area where the big toe bends.  Because of the size of the bump he is starting to have difficulty wearing his running shoes. What could be the cause of his pain?

What are Hallux Limitus and Hallux Rigidus?

The hallux, or big toe, plays an important role in our ability to walk normally. The motion of this toe provides us with pushoff force necessary to lift our foot off of the ground while walking. In order to accomplish this, the hallux normally bends upward (or dorsiflexes) You can see this occur if you lift your heel up while keeping the front of your foot on the ground. In a healthy foot there is a smooth gliding, around 60 degrees of upward motion at the joint where the 1st metatarsal and the big toe bone meets.

Hallux limitus is a condition that describes limited motion of the big toe joint. This limitation in motion is caused by jamming of the big toe into the 1st metatarsal bone, thereby inhibiting the ability to bend the big toe without pain. This condition occurs at the 1st metatarsal-phalangeal joint (1st MTPJ), which is the joint between the hallux and 1st metatarsal. As the hallux and metatarsal move in an abnormal relationship they do not glide they now scrape against each other with uneven and excessive forces.  When this occurs extra bone formations develope, called spurs or osteophytes. These appear in order to disperse the force generated from the friction. Unfortunately, this extra bone leads to more pain and further limitation to the joint motion. The condition can eventually progress to a degenerative arthritic disease called hallux rigidus. At this stage, the motion at the joint approches zero degrees. In a final stage fusion or bone bridging across the joint occurs. Further advancment of this condition can lead to pain in other parts of the lower extremity. This may occur because other muscles, bones and joints will be forced to compensate or function abnormally to make up for the lack of motion of the big toe.

What causes it?

This condition can be caused by a number of factors. Some people have biomechanical abnormalities, such as flat feet, that can lead to imbalances that cause jamming and rubbing of the hallux against the metatarsal. Traumatic events like turf toe injuries or simply accidental injury of the big toe can lead to this condition as well. Wearing shoegear such as high heels can increase the risk of occurrence. Hereditary arthritic conditions, such as rheumatoid arthritis, can also be the inciting factor. Inflammatory joint conditions such as gout can lead to deformity at this joint as well.

Clinical Presentation

Symptoms that generally appear early in the course of hallux limitus are a throbbing, achy pain when moving the big toe and inflammation or swelling at the location of the 1st MTPJ. Cold weather can exacerbate the symptoms. As the disease progresses, the pain may become constant and will be present even when not wearing shoes. A hard ridge of bone may develop on the top of the 1st MTPJ.  A grinding sensation may be felt when the toe is moved up and down this is known as crepitus. It is a sign that the joint cartilage is warning out and now raw bone on one side of the joint is rubbing against the raw bone on the other side.

As this condition progresses the hallux is no longer able to function properly while walking, other structures in the foot and lower extremity are forced to change the way they normally function. This can lead to pain in other joints of the foot or ankle; eventually knee, hip or lower back pain may develop.

Diagnosis

If a patient presents with the symptoms described above, x-ray studies are performed to confirm the diagnosis. These images usually reveal abnormalities in the 1st MTPJ space. There is usually an uneven loss of the joint space compared to the other joints of the same foot.

Small pieces of bone called osteophytes or spurs may also be seen in the joint space, along with thickening of the margins (sclerosis) of the involved bones, both of which are indicative of this arthritic process.

Look for our next installment Hallux limitus/rigidus Part 2: Treatment

Metatarsal Stress Fractures

November 9, 2013

Image

Metatarsal Stress Fractures

A teenage girl presents complaining of pain in her forefoot. The pain first started 2 weeks ago and has gradually worsened. She noticed swelling over the top of her foot a couple days ago. She recently started long distance running and started training for a half-marathon. She states that her pain worsens the longer she runs and gets somewhat better when she is off her feet. What could be the cause of her pain?

What is a Stress Fracture?

Our bones undergo stresses everyday. Every time we take a step, stress is applied to the bones in our feet. The human body has developed ways to lessen these forces by using muscles in the foot that help decrease the load applied to the bones. Additionally, the ability of the bone to repair itself when minor damage occurs prevents the development of a full fracture. A stress fracture is an injury that occurs because of repeated low-grade stress that is applied to the bone over a prolonged period of time, which overpowers this ability for the bone to repair itself. The slow, progressive nature of this injury causes symptoms to occur gradually and worsen with continued exertion.

Our feet endure stresses when we walk, jump or even stand. A change in normal routine or increased level of activity introduces new stresses to the bones of the foot and can result in a stress fracture. An area commonly affected by these types of injuries is the metatarsals, which are the long bones of the forefoot.

Metatarsal Stress Fractures

Stress fractures affecting the metatarsals are a common occurrence, especially in sports that involve running such as track and field and basketball, especially when played on a hard floor [1].

There are five metatarsals in each foot. It is important to note the function of the individual metatarsals in order to understand which bones are likely to be affected. The first and fifth metatarsals are unique in that they have their own independent range of motion apart from the other middle three metatarsals. This means that they have the liberty to move upward when forces from the ground are applied to them. This helps prevent injury to these two bones, making stress fractures of the first and fifth metatarsals relatively rare.

The central three metatarsals (referred to as #2, #3, #4), on the other hand, are more rigid. This is important because their immobility provides stability to the forefoot. However, this anatomical configuration makes the central metatarsals more likely to develop stress fractures. The second metatarsal is particularly susceptible because it is the longest of the five metatarsals. The term “March” fracture has been applied to stress fractures of the second and third metatarsals because of their increased incidence in military personnel. In fact, metatarsal stress fractures were first described in Prussian soldiers in 1855 [2].

Clinical Presentation

Metatarsal stress fractures typically present as pain in the forefoot that increases with weight bearing activity. The pain can be generalized in the front part of the foot or localized to a certain area in advanced cases.  The pain usually subsides when the inciting activity is ceased. Over time, however, if left untreated the pain can remain even when at rest. Since the pain usually slowly worsens, the patient may not be able to indicate a specific time when an injury took place. Swelling over the site of injury is very common.

What are the Risk Factors?

The patient should be asked if they recently changed their level of physical activity. Stress fractures commonly occur when people abruptly increase their level of activity.

Biomechanical abnormalities in the foot can also lead to development of a fracture.

Other risk factors include corticosteroid use, smoking and disorders of Vitamin D (rickets, osteomalacia).  Also, smoking can affect bone healing .

Physical Examination

Visual examination of the patient may reveal swelling in the forefoot. The affected metatarsal can be identified by pushing the metatarsal heads to elicit pain over the site of the fracture. Placing a vibrating tuning fork over the suspected metatarsal may also elicit pain.

Imaging

X-ray imaging is always obtained.  However, they may not reveal a visible fracture line early in the course of metatarsal stress fractures. Usually, the diagnosis of stress fracture is made based on the clinical history, even when the radiographs look normal.

MRI scans are useful to visualize a stress fracture, but are not always required especially if the fracture is clearly seen on the x-ray film.  These scans can rule out other suspected causes of pain because of the level of detail it reveals. Bone scanning is another method that can be used and involves injection of technetium-99 isotope to visualize uptake of the agent in the area of injury.

Treatment of Metatarsal Stress Fracture

Metatarsal stress fractures can usually be treated non-surgically, especially if the symptoms are addressed early in the course of the disease. The activity that caused the injury must be discontinued until the fracture is healed. The patient should also elevate the injured limb.  Crutches may be needed for ambulation to relieve stress. The affected limb may require immobilization with a CAM walker. NSAIDs such as ibuprofen (Motrin) can be used as needed to alleviate pain. When someone chooses to ignore symptoms of a stress fracture and refuses to rest, the injury can progress to a full fracture that could require surgical intervention. Surgery may also be necessary if the injury fails to heal properly or heals in a poor position. Once the patient feels comfortable and the fracture appears healed on imaging physical activity can be resumed. After healing the fracture, return to activity should start off slowly and modified to reduce chances of recurring injury.

Source Material

1. Iwamoto and Takeda. Stress fractures in athletes: Review of 196 cases. J Orthop Sci 2003; 8: 273 – 275.

2. Gehrmann and Renard. Current Concepts Review: Stress fractures of the foot. Foot and Ankle Int 2006; 27:250

Why do I Have Calf Pain? Could be……… Deep Vein Thrombosis

October 19, 2013

Image

A young woman presents to her podiatrist office with pain and swelling in her calf.  She was seen two weeks prior and was found to have a fractured bone in her foot. To treat this condition, she was given a CAM boot (walking cast) to stabilize the fracture. Current medications she is taking include oral contraceptives (birth control pills). What is the cause of her pain?

Definition of Deep Vein Thrombosis (DVT)

The ability of blood to clot plays a major role in healing. Upon injury that causes bleeding, platelets and fibrin clump together to form a durable barricade to blood flow.  This prevents loss of blood from the body and facilitates the healing process. However, this process can occur at times that are unnecessary, resulting in an unwanted blockage of blood flow in blood vessels. A common site for blood clotting gone awry is the deep vein of the calf. Deep vein thrombosis, or DVT, occurs when a blood clot forms in the deep vein of the calf. You may have heard about episodes of DVT caused by sitting or lying down for a long period of time, such as on an airplane or in a hospital bed. A long period of immobility slows down blood flow through the veins, which is a major risk factor for clot formation. DVT can also occur after surgery due to damage to the venous vessel wall. Hypercoagulability of blood is another reason why DVT can arise. Hypercoagulability is a state of excessive clotting in the blood, and could possibly be the reason why the patient in the above example presents to the clinic today. Supplemental estrogen from contraceptive use can increase the coagulability of blood. Notice also that the patient arrived in a CAM walker, which rendered her immobile for a considerable period of time and furthered her risk of developing DVT. Other risk factors include pregnancy, smoking, or genetic conditions like thrombophilia.

Clinical Presentation

A patient with DVT can present with pain in one leg that gets better when the leg is elevated. Redness, swelling and tenderness are other symptoms to take into account. It should be noted, however, that a patient with DVT might not experience symptoms at all.

Potential complications

A major concern for development of DVT is the potential for portions of the clot to break off, forming an embolus. An embolus flows through the blood and can lodge itself in a downstream location. A pulmonary embolism is a dangerous complication that occurs when a portion of the clot breaks and gets stuck in an artery in the lungs. Symptoms of pulmonary embolism include a sudden shortness of breath and cough. Patients experiencing these symptoms should immediately visit the emergency department.  This condition can be life threatening! Physical Exam When a podiatrist suspects a DVT, there are certain simple physical test that can be performed as screening tools. Some patients may exhibit pain when their foot is extended towards the ankle, eliciting a positive Homan’s sign. A positive Bancroft’s sign is observed when the patient experiences pain when the doctor squeezes their calf from the front and back. Neither of these tests can absolutely confirm that a DVT is present, but can certainly aid in diagnosis when combined with patient history and further diagnostic testing.

Diagnostic test

Use of a duplex ultrasound is a sure-fire way to confirm diagnosis of DVT. This noninvasive procedure measures the blood vessels in the patient’s calf for irregularities in flow. A thrombus is present when blockage of flow is observed. A d-dimer test can also be used. D-dimer is a fragment of fibrin, one of the molecules involved with building a robust clot in blood vessels. Blood is drawn from the patient and the level of d-dimer is measured. If measured level is high, indicating a positive test, then further testing can be done to confirm DVT. This test is usually used when there is a low probability that the patient has DVT because a negative test rules it out.

Treatment

The importance of treating DVT, even if it is asymptomatic, is to prevent the occurrence of more lethal complications such as a pulmonary embolism. Anticoagulants can be prescribed for the purpose of achieving this goal by dissolving the clot or preventing it from growing larger. These medications include injections of Low Molecular Weight Heparins (LMWH) or oral Coumadin. Prophylactic measures can also be taken in patients that are at risk of developing DVT. Compression stockings can be used on patients who are bed-bound for a long period of time. Anticoagulants can also be used prophylactically. It is important to advise patients who have had previous episodes or are at risk of clotting to not stay seated for too long when flying long distances since this can cause development of DVT. If you are reading this because you think that this might be what is causing your calf pain….call 911 or go quickly to the nearest emergency room!

Laser for Treatment of Pain-Low Level Light Therapy (LLLT)

May 30, 2013

 

Image

The fact that biological systems react to light is no mystery.  When light strikes the leaves of a tree it initiates a biochemical reaction which generates energy for the plant to use.  In a similar fashion the human body also responds to light exposure.  The sense of sight is possible through a biochemical reaction that takes place when light contacts the eyes.  The skin also reacts to natural light through a number of biochemical processes; these processes are responsible for darkening of the skin (“getting a tan”) and the body’s production of vitamin D.

LLLT, also known as “photobiomodulation,” takes advantage of the body’s reactions to different spectrums of light in order to improve healing, decrease inflammation and even reduce pain.  The spectrum of light used in LLLT is in the far-red to infrared region of the spectrum.  Light in this range does not cause heating of the area being treated and has been proven to stimulate the body’s natural processes. 

Experimental data has shown that LLLT stimulates cellular mitochondria.  Mitochondria are the cell’s natural “power house” and provide the energy needed for proper cellular functioning.  Acceleration of cellular and tissue repair have also been observed in experimental models.  When used in clinical studies LLLT has proven to be useful in reducing inflammation in pediatric bone marrow transplant patients, and provided pain relief for patients suffering from joint and muscle pain.  LLLT offers an advantage over other therapies due to its non-invasive nature and lack of significant side effects.  Although it is a relatively new form of therapy, the potential applications of LLLT treatment are widespread.

Nexus 10W Laser

The Nexus 10W laser is a state-of-the-art class IV laser capable of providing the benefits of LLLT.  These benefits include improved healing time, pain reduction, increased circulation and decreased swelling.  LLLT can aid in the treatment of many types of patient complains.  Some treatable conditions of the lower leg and foot include (but are not limited to) heel pain, sprains, tendonitis, and bursitis.  Laser treatments only require a short amount of time and are capable of providing drug free pain relief.  The duration and frequency of treatment may differ depending on the condition/injury, and should be determined by the physician.

 

Source Material:

Brosseau, L et. al. Low level laser therapy (Classes I, II and III) for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002049.

Chow, RT; Johnson, MI; Lopes-Martins, RA; Bjordal, JM. Effcacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomized placebo or active-treatment controlled trials. Lancet. 2009 Dec 5;374(9705):1897-908.

Desmet, KD et al.  Clinical and Experimental Applications of NIR-LED photobiomodulation.  Photomed Laser Surg. 2006 Apr; 24(2):121-8.

Low Level Light Therapy. American Society for Laser Medicine & Surgery. (Updated June 3, 2010). http://www.aslms.org/public/LowLevelLight.shtml .

Nexus 10 Overview. USA Laser. http://www.usalaser.us/nexus10.php.

Oz, S; Gokcen-Rohlig, B; Saruhanoglu, A; Tuncer, EB.  Management of myofascial pain: low-level laser therapy versus occlusal splints. J Craniofac Surg. 2010 Nov;21(6):1722-8.

Poyton, RO; Ball, KA. Therapeutic Photobiomodulation: Nitric Oxide and a Novel Function of Mitochondrial Cytochrome C Oxidase. Discovery Medicine. 2013 Feb; (81).

Venezian, GC; da Silva, MA; Mazzetto, RG; Mazzetto, MO. Low level laser effects on pain to palpation and electromyographic activity in TMD patients: a double-blind, randomized, placebo-controlled study. Cranio. 2010 Apr;28(2):84-91.