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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

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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.

 

 

 

 

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

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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

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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

Ankle Sprains and Ruptures

March 12, 2011

Anatomy of the Ankle

Ankle sprains, if not treated early, can create chronic ankle instability; (weak ankle) which leads to difficulty in sports activities and frequent recurrent ankle sprains. The ankle is composed of the joint, formed by three bones called the tibia (lower leg bone) and the talus as well as the fibula and ligaments that surround the joint.  The ankle ligaments support the joint and prevent excessive motion that may cause instability. There are two sets of ligaments in the ankle joint, the deltoid ligaments (found on the inside of the ankle joint on the same side as the big toe) and the lateral collateral ligaments (found on the outside of the ankle joint on the same side of the little toe).  The weakest of the fore mentioned and most commonly injured ankle ligaments are the lateral collateral ligaments. It is commonly injured by “rolling the ankle” or turning the foot inward, which stretches the ligament and results in tearing or rupturing of the ligament.

Causes of Ankle Sprains

Stretching the ankle ligaments beyond their maximum ability causes ankle sprains. This results in tearing or rupturing. Stretching of the ankle ligaments can occur when missing a step on a curb or physical activity that results in turning the foot inward or outward. Certain factors can increase the likelihood that ankle sprains occur.  Skeletal deformities of the foot where the heel is turned inward places the foot in a position that encourages the ankle to roll. Increased laxity and flimsiness of the ligaments will create a situation in some people where the supporting ligaments cannot stop the twisting motion, which leads to the ankle injury.  Impaired proprioception, a condition where the body has difficulty sensing the position of the ankle and impaired muscular control of the ankle joint, can also lead to more frequent sprains. Additionally, the incidence of ankle sprains can also increase if there are loose bone fragments found in the ankle joint associated with arthritis.

Symptoms of Ankle Sprains

Ankle ligament injures are classified by grades from grade I to grade III. Each grade is treated differently and the classification enables the podiatrist to provide the best treatment for the patient. Grade I ankle ligament injuries do not involve ligament rupture and only have minor swelling and tenderness. Grade II injuries have partial rupture of the ligaments, with moderate tenderness, swelling and loss of motion. Grade III injuries include a complete rupture of the ligament, severe bruising, swelling, pain, and major loss of function and motion of the ankle joint. Patients with ankle instability complain of persistent pain, recurrent sprains, and repeated instances of the ankle giving way.

Diagnosing Ankle Sprains:

When visiting a podiatrist for evaluation of an ankle sprain, the doctor will ask if the patient can recall the position the foot was in when the injury occurred. This will allow the podiatrist to determine which ligament was most likely injured. Additionally, the podiatrist will perform a physical exam. The exam will include pushing along both sides of the ankle where the ligaments attach, as well as distracting and moving the ankle to determine which ligaments have been injured. The podiatrist will perform X-rays of the foot and ankle in order to determine if the ankle sprain is accompanied by a fracture.  This may occur when the ligament has pulled off a bone fragment from the ankle and/or foot. Diagnostic ultrasound may be done to visualize the extent of the soft tissue injury.

Non-surgical Treatment for Ankle Sprains

Simple sprains can be treated non-surgically with: resting the foot and ankle, ice, compression, and elevation— especially during the first few days. Early weight bearing without crutches is encouraged if possible to prevent stiffness of the ankle joint.  It is usually recommended to start range-of-motion exercises of the ankle followed by coordination training with balance boards and trampoline, as well as strengthening exercises. An external ankle brace or ankle taping may be used to control the motion of the joint to reduce symptoms of the sprain and to prevent additional injury during the healing phase. With more severe ligament injuries, treatment can consist of cast immobilization, rehabilitation and possible surgical repair.

Platelet Rich Plasma Treatment:

Also known as PRP, is another treatment method that can be used to treat this condition. The procedure can be performed in the office and takes about 45 minutes. This is performed by taking a small sample of blood from the patient. This blood is then processed and a concentrated smaller amount of blood is produced with a very high quantity of platelets. Then, using ultrasound to guide the needle to the exact location of the injury the platelet-rich compound is injected. When the platelets are placed at the injured area they release a growth factor that attracts the patients stem cells. These stem cells then infiltrate the area and form new tissue to aid in healing the injured tissue.

Surgical Treatment for Ankle Sprains

When nonsurgical treatment does not resolve the ankle sprain, surgical treatment is the next option. There are three main types of surgical repair of ankle ligaments:

1. Tendon reconstruction: uses tendons to function similarly to the ligaments and since the long-term outcome is not as successful as other procedures, it is commonly used as secondary procedures in repairing ankle injuries.

2. Anatomic repair of the ligaments: restores the original ligament attachment and length by shortening and stitching the rupture ligaments.

3. Anatomic reconstruction: uses tissue flaps and grafts to reinforce and strengthen the ankle ligaments. This type of procedure is commonly used if anatomic repair of the ligament cannot be performed due to weakness and damage to the ends of the original ligament, failure from previous repair, increased ligament slack, or longstanding ankle stability of greater than 10 years.

After surgery, it is usually expected that the patient will be in a weight-bearing cast for about 6 weeks, followed by physical therapy and range-of-motion exercises.

Alleviating Foot Pain

December 20, 2010

Pain can interfere with normal daily activity and can prevent us from enjoying life fully. However, pain is the body’s alarm system to alert us when something is wrong, and it is a normal response produced by the body.

How does pain work?
There are four major stages with which pain will begin in our body. The first is the actual stimulus, which starts the pain information pathway to the brain. The stimulus is usually negative and results in tissue damage. The damage can be a cut of the skin, a broken bone or a tear or crush of soft tissue.
During the transmission stage, this negative stimulus is converted by the nerves to an electrical signal. This information is then carried by nerves toward the brain.
Before the electrical information finally enters the brain, the body has a third step in the pain route, called modulation. The modulation step works like a gate, where the brain sorts out the various stimuli that the body receives and determines whether or not the signal is strong enough to be recognized.
Once the brain accepts the electrical signal and final process begins, which is the awareness of pain in the body.

What are the goals of treating pain?
The two main goals that a podiatrist wants to achieve in treating pain are to eliminate the source of the problem and also to treat the symptoms caused by the problem. In order to do so, the podiatrist will need to investigate the cause of the pain by first asking the patient a series of questions regarding the problem. Below is a series of questions that podiatrists commonly ask in order to find the source of the pain and how to better treat it. Patients should think about some of the answers to the following questions before and during the appointment in order to better assist the podiatrist in finding the source of the problem.

1. Where is the pain located?

2. How would you describe the pain?
There are different types of pain in the body. If the pain is tingling or burning, the problem is most probably associated with the nerve. Most likely, achy, dull, throbbing, or sharp pain, more often indicates more of a muscle or bone problem.

3. On a scale of 1-10, 10 being the most painful, what is your pain level?
Knowing the level intensity of the pain can help determine what type of medication to alleviate the pain. Stronger pain intensity may mean that a stronger strength of pain medication may be needed.

4. How long has the pain been occurring?
The duration of the pain can help the podiatrist determine whether the pain is acute, lasting for a few days to weeks, or chronic, which lasts for a period longer than 3 months. If the pain is acute, it may signify that there was trauma that occurred to the area. Chronic pain may indicate arthritic changes or overuse injuries of the foot.

5. Did you injure your foot or was there anything different that occurred before the pain?
Knowing the incidences before the occurrence of pain can help determine what structures in the foot are injured.

6. What makes the pain worse or better?

7. What treatments have you done to alleviate the pain?
Knowing what type of treatment a patient has tried helps the podiatrist know how to better treat the patient, especially in avoiding treatments that have already been tried. Additionally, if there may be two causes to the pain, it can help a podiatrist eliminate one of the two sources of the pain.

What are the common treatments for pain?
Aside from treating the source of the problem, the podiatrist may offer treatment that can alleviate pain.

1. Icing and compression. Increased swelling and inflammation to the foot caused by trauma can make the pain worse. Accordingly, icing and compression of the foot may be recommended.

2. Topical Anti-inflamatories: Botanical anti-inflammatories can also be used to reduce swelling and therefore reduce pain. Arnica is one of these topical plant products that can help. It comes from the Arnica Montana plant. It was discovered and used my native Americans before the arrival of Columbus and is still used successfully today

3. Non-steroidal anti-inflammatory drugs (“NSAIDS”). NSAIDS are commonly prescribed to control inflammation and swelling. They are often recommended for mild or moderate pain level intensities. Caution must be taken when using “NSAIDS”. If the patient has a history of stomach ulcers this class of drugs can increase the chance of a gastric bleed. It is important for everyone taking this class of medicine to take the pill with food. If stomach discomfort occurs, it is best to change the medication.

4. Opioids. Opioids do not decrease inflammation. However, they do decrease the amounts of chemicals that need to be released to start the electrical signal for pain. This prevents pain signals from entering into the brain. Opioids are often recommended at higher pain level intensities. When using, opioids caution must be taken to avoid drug abuse.

5. Capsaicin. This is a topical cream or solution that is applied to the skin and recommended more for chronic pain. Capsaicin has chemicals that are made from chili peppers. It decreases the chemicals that are needed for the nerves to transmit pain signals to the brain. Caution must be taken to avoid eyes, mouth, and genital areas when using this medication because it causes a severe burning sensation.

6. Local anesthetics injections. This type of treatment directly affects the nerves and prevents the nerves from sending signals to the brain. Local injections, however, only produce temporary relief.

7. Steroid injections. This type of injection is given in combination with local anesthetics and is another form of treatment to decrease inflammation. Depending on the problem, this type of injection can alleviate pain anywhere from a few weeks to a few months.

Treatment of Sinus Tarsi Syndrome

September 18, 2010

Where and what is the sinus tarsi:

The word “sinus” refers to a cavity, most often in bone. The cavity known as the sinus tarsi is located on the outside of the foot in front of and below the outside anklebone. The cavity is formed at the junction between the heel bone and the bone that sits over the heel bone called the Talus.  The heel bone forms the floor of the cavity and the talus creates the roof.

Within the cavity there are blood vessels, nerves and ligaments.  The ligaments function to hold the two bones together.

Symptoms:

“Sinus Tarsi Syndrome” refers to a painful condition located in this cavity in the rear portion of the foot. The pain is made worse with weight bearing. The pain can become much more intense when walking, running or hiking on uneven surfaces.

Causes of Sinus Tarsi Syndrome:

The most common cause of sinus tarsi syndrome is an inversion injury to the foot. This occurs when the foot rolls inward and stretches the soft tissue in the cavity.  When the foot is stressed by this inward motion a tear or strain occurs to the ligaments. The injury to these ligaments results in inflammation, swelling and thickening.

The other causes of this condition are structural as apposed to the injury noted above. One of these structural abnormalities that can occur is growths or masses of soft tissue.  Over growth of nerve or fat tissues in the cavity can cause increased pressure and result in pain. The pain in this area can also be caused by deviations in the bone structure. For example, bone spurs; arthritis and bone bridges can be responsible for the development of sinus tarsi syndrome.

Another helpful procedure to determine the exact location of the pain is to inject the sinus tarsi with a small amount of local anesthesia. If upon examination after the injection the pain is gone the diagnosis is confirmed. If however, the pain is still present following the injection the injury may be in another location in the foot.

Non-Surgical Treatment:

Research has shown that a majority of the people with sinus tarsi syndrome will respond favorably to conservative management. Rest, ice and compression are suggested to reduce the inflammation. Oral anti-inflammatory medications can be prescribed to further decrease the pain and swelling.

Another treatment option is to tape the foot to attempt to limit the motion at the subtalar joint. If the taping successfully reduces the pain long term treatment with a custom orthotic can be used to control the motion of the rear foot. In most cases foot orthotics are sufficient to treat this condition, however in some cases an ankle foot orthotic may be necessary to fully control the motion.

Finally, a steroid injection into the sinus tarsi may be effective at relieving the pain.

Surgery:

In conservative measures have not helped to relieve the pain surgery may be needed.  A common surgical procedure to threat this condition is decompression or removing the abnormal tissues from the cavity. If the MRI scans shows a soft tissue mass present in the sinus tarsi surgical removal of the mass will be needed.

After the surgery, protected weight bearing in a post-operative shoe or walking boot will be required for a period of approximately 2-4 weeks.

If this surgery fails or the patient has severe arthritis the bone in the rear foot may need to be fused.

Treatment and Cause of Ganglion Cyst

August 23, 2010

What is a ganglion cyst?

It is a single or multi-chambered soft tissue mass with thin walls that is filled with high-protein fluid. The fluid color ranges from amber to clear and located beneath the skin and can be attached to muscle tendons, joint capsules or nerves.

What causes a ganglion cyst?

The causes of ganglion cysts are still unknown. However, it is suggested that they are caused by repetitive trauma or joint fluid projecting out of its contained area. In the case of repetitive trauma, ganglion cysts may form if there is friction or excessive rubbing between a bone and/or shoe against a tendon.

What are the symptoms of a ganglion cyst?

Ganglion cysts can be found all over body. Most commonly, on the hand and wrist, then followed by the foot. In the case of the foot, ganglion cysts are the most common soft tissue masses found in the foot and ankle; in addition most are located on top of the foot. When a ganglion cyst becomes large, it may appear frightening and worrisome because patients may believe they have developed a cancerous growth. Fortunately, ganglion cysts tend to be harmless and painless and may even resolve on it’s own.  However, if the ganglion cysts become large enough, it can begin to cause pain. This is because the enlargement produces increased pressure on the surrounding tissues such as skin and nerve.  Additionally, large ganglion cysts can interfere with shoe gear.

How do you diagnose a ganglion cyst?

Ganglion cysts are usually diagnosed clinically. The podiatrist will test if the soft tissue mass has characteristics of ganglion cysts. These characteristics are that the mass is movable and soft.

X-ray studies are occasionally used in examining a ganglion cyst. The cysts are soft tissue and do not appear on x-ray, however, x-rays can rule out other diagnostic possibilities, such as calcified masses or bone invading tumors.

Diagnostic ultrasound is inexpensive and very effective at diagnosing and revealing the nature of the ganglion cyst.  By studying the cyst with the ultrasound, the doctor can see the size, shape and the number of chambers in the mass.

MRIs may also be requested usually to determine the size and the degree of how much soft tissue is involved with the ganglion cyst. This is an expensive test and is most often used for surgical planning.

How do you treat a ganglion cyst?

Non-surgical treatment:

It is often difficult to treat ganglion cysts without surgery. However, non-surgical treatment can help relieve pain and symptoms from the ganglion cysts. Padding may be placed around the ganglion to decrease pressure and irritation to the area. Change in footwear may also be suggested to reduce friction and pressure to the area as well.

Aspiration of a Ganglion Cyst:

This is done by first numbing the area with local anesthesia.  Next, the site of aspiration is cleansed with antiseptic skin cleaner. Then, using an empty syringe and needle the fluid is pulled out of the ganglion cyst. After aspiration of the ganglion cyst, a syringe with steroid maybe injected. Also, it must be noted that there is a high risk of recurrence of the ganglion cyst after aspiration.

Surgical treatment:

Surgery as a treatment for ganglion cysts is only considered if conservative treatment failed, the ganglion is recurring, or there is significant pain. Surgical removal of a ganglion cyst consists of removing the entire ganglion wall and surrounding soft tissue that is associated with the ganglion cyst. Since surrounding soft tissue needs to be removed, the incision site will need to be longer then ganglion cyst. Pain, swelling, numbness, or tingling may occur after the surgery. As with aspiration procedure noted above, it must be noted that there is risk of recurrence of the ganglion cyst after surgery as well.