Achilles Tendon Injury

April 12, 2013

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Definition

The Achilles tendon plays an essential role in the day-to-day movement of an individual no matter their level of physical activity.  This tendon connects the muscles of the calf to the heel bone, and helps to raise the heel when standing or flexing the foot away from the body.  It is a very thick band of tissue and can be easily seen and felt along the back of the lower leg, behind the ankle.  Without the Achilles tendon, it would be hard to do simple activities such as walking, running and jumping.

Damage to the Achilles tendon can lead to pain in the back of the lower leg, just above the heel.  Injury usually occurs when there is a sudden increase in stressful force on the tendon.  The three most common types of Achilles injuries are Tendinopathy, Partial Tendon Tear and Complete Tendon Rupture.

 

Achilles Tendonopathy

The term Achilles tendonitis is very commonly used to describe injury to the tendon that has not progressed to partial or complete tear.  The suffix “-itis” is used to describe a state of inflammation, which indicates a very specific sequence of reactions that occur when the body is injured.  Thus, the word “tendonitis” refers to the inflammation of a tendon.  Although tendonitis is often a cause of tendon pain, damage to the Achilles tendon does not always involve inflammation; the disease of the tendon is sometime caused by chronic degeneration.  Therefore, the term “Tendinopathy” which includes all categories of tendon disease, with or without inflammation, will be used in this article to refer to Achilles tendon injuries other than partial or complete tendon tear.

Patients suffering from Achilles tendinopathy will often complain of pain or stiffness just above their heel.

Partial or Complete Rupture

When an intense stress is suddenly placed on the Achilles tendon it can rupture or tear.  The amount of stress needed to tear the tendon can depend on the individual.  Even seemingly small increases in stress, if brought on suddenly, can cause a tendon rupture.  Athletic activities that may result in a tear include sudden pivoting or activities that involve quickly accelerating and decelerating.

Patients who suffer from partial or complete tendon rupture may describe hearing a “pop” followed by sudden pain.  Experiencing sudden pain and a loss or decreased ability to raise the heel increases the probability of a tendon rupture.  It is possible to have a tendon rupture without experiencing pain, so patients complaining of pain in the back of the heel or decreased ability to raise the heel should be evaluated for possible tendon rupture.

Physical Exam

A proper physical exam must assess the patient’s complaints and rule out all other potential diagnoses.  The Achilles tendon should be palpated for any signs of tenderness, thickening/thinning, swelling or other abnormalities.  If pain is present, it is typically felt 2-6 cm above the attachment of the tendon to the heel bone.

In every instance of Achilles injury, it is important to evaluate the tendon for possible rupture.  The tendon should be tested with the patient standing and off weight bearing in order to assess any loss of function.  Specific tests like the Thompson Test (squeezing the patient’s calf while they are relaxed on the exam table with their feet off the table) can be used to check for tendon rupture.

Imaging

X-ray and Ultrasound imaging can be used to evaluate the degree of tendon injury, and may help rule out other possible causes of the patient’s complaints.  If there is a high suspicion of tendon rupture, MRI imaging is frequently used to assess the severity of the tear and to help plan for proper treatment.

Treatment

Achilles tendinopathy can often be treated non-surgically.  Patients should avoid any activities that might cause pain or worsening of symptoms.  Ice can be used whenever symptoms occur, and nonsteroidal anti-inflammatory drugs (Ibuprofen for example) may be recommended.  Shoe wear modifications, inserts or medical orthotics may be used to help prevent continual injury.  Patients may expect to gradually return to normal activity over the course of 6 to 8 weeks.  Stretching, physical therapy, and laser treatment may also be recommended.  If the pain is severe, a CAM boot may be required for several weeks.  If the Tendinopathy does not resolve within 3 months, the patient should be re-evaluated.

Partial or complete tendon rupture may require surgical care.  Ice, pain medication, rest and immobilization of the ankle are used initially until surgical care is deemed necessary.  Once a patient suffers an Achilles tendon rupture there is an increased risk of repeat injury.

Platelet-Rich Plasma Injections

Platelet-Rich Plasma (“PRP”) injection is a relatively new therapy that has been developed to treat various forms of injury.  Concentrating platelets and other growth factors that contribute to the healing process which are naturally found in the blood forms the PRP.  The blood is taken from the patient.  Spinning the blood at high speeds separates the different components of the blood.  Once separated, the portion of the blood rich in platelets and growth factors is extracted and injected into the site of injury.  Studies have shown that PRP injections into acute injuries may increase the speed of recovery, and injections into long-standing (chronic) injuries may cause the body to renew the healing process.

The application of PRP injections are still being investigated, but the treatment has already been used for various forms of injury with positive results.  PRP treatment has been used to help treat Achilles tendon injury, and is typically reserved for patients who fail traditional therapy.  PRP injection therapy may not be for everyone, and treatment must be considered on an individual basis.

Source Material

Achilles Injury

Alfredson, H; Lorentzon, R.  Chronic Achilles tendinosis: recommendations for treatment and prevention.Sports Med. 2000;29(2):135.

Jozsa, L; Kvist, M; Balint, BJ; Reffy, A; Jarvinen, M; Lehto, M; Barzo, M. The role of recreational sport activity in Achilles tendon rupture: A clinical, pathoanatomical and sociological study of 292 cases. Am J Sports Med. 1989; 17(3): 338.

Gravlee, JR; Hatch, RL; Galea, AM.  Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Pract. 2000; 13(5):371.

Maffulli, N.  The clinical diagnosis of subcutaneous tear of the Achilles tendon: A prospective study in 174 patients.  Am J Sports Med. 1998; 26(2):266.

Mayer, F; Hirschmuller, A; Muller, S; Schuberth, M; Baur, H.  Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy.  Br J Sports Med. 2007; 41(7):e6.

Khan, RJ, Carey Smith, RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010.

PRP Injections

de Jonge, S; de Vos, RJ; Weir, A; van Schie, HT; Bierma-Zeinstra, SM; Verhaar, JA; Weinans, H; Tol, JL. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011 Aug;39(8):1623-9.

Griffin, LY.  Treating tendinopathy with PRP.  AAOS. 2010 Sept; 7(3). http://www.aaos.org/news/aaosnow/sep10/clinical2.asp .

Mautner, K; Colberg, RE; Malanga, G; Borg-Stein, JP; Harmon, KG; Dharamsi, AS; Chu, S; Homer, P. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review.  PM R. 2013 Mar;5(3):169-75.

Monto, RR. Platelet rich plasma treatment for chronic Achilles tendinosis.  Foot Ankle Int. 2012 May; 33(5):379-85.

Soomekh, D; Yau, SK; Baravarian, B. A Closer Look At Platelet-Rich Plasma For Achilles Tendon Pathology. Podiatry Today. 2011 Nov; 24(11):50.

Storrs, C.  Is Platelet-Rich Plasma an Effective Healing Therapy? Scientific American.  Dec 18, 2009. http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-therapy-dennis-cardone-sports-medicine-injury.

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Nerve Conduction Studies for diagnosing foot conditions

February 2, 2013

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The human nervous system is an amazingly sophisticated network that coordinates all the functions of the body.  In order for the system to relay information, the brain must send a signal to the organ(s) needed to complete the desired function.  This system of communication between the brain and body is made up of two major divisions:  the central nervous system and the peripheral nervous system.

The central nervous system consists of the brain and spinal cord.  The brain is responsible for conscious decisions and controls a majority of the bodily functions.  The spinal cord functions to relay information from the brain to the peripheral nervous system, and is also responsible for many of the body’s inherent reflexes.

The peripheral nervous system is made up of all the nerves extending from the spinal cord to the various organs of the body.   These nerves can have motor, sensory, autonomic, or “mixed” functions.  Motor nerves are fibers intended to control some form of muscle movement.  Sensory nerves are responsible for our sense of pain, temperature, and vibration as well as other forms of the body’s interaction with the environment.  Functions that we are not normally in conscious control of (such as heart rate, digestion, and breathing) are controlled by autonomic nerve fibers.  Nerves with “mixed” functions can contain signals from any combination of these three types.

There are many diseases that can affect the normal functioning of the nervous system.  A nerve conduction velocity test (NCVT) is very useful in the evaluation of various forms of nerve damage and disease.

What do Nerve Conduction Velocity Studies measure?

Communication sent along nerve fibers takes the form of an electrical signal, and travels much like electrical current moving through a wire.  NCVT is used to measure the speed at which the nerve signal travels along a specific nerve fiber.  This technique can be used to study the function and health of both sensory and motor nerves.  Autonomic and “mixed” are not as useful to study in a clinical setting, and so are not examined with this technique.

How is the NCVT performed?

In order to test a nerve, two electrodes are placed over a segment of the nerve and an electrical current is generated that travels between them.  One electrode is responsible for producing the current, and the second electrode detects the electrical impulse as it travels along the nerve.  The nerve conduction velocity is then calculated using the distance between the two electrodes and the time needed for the signal to travel between them.      

Preparation Pain and Risks of the procedure

The day of the procedure you should avoid using any lotion or cream on your feet and legs.

Wear loose fitting pants/cloths that can be rolled up above the knees.

The test should take about 30 minutes and is done in the doctors office.

There are essentially no risks involved in NCVT.  The nerve signals can be measured on the surface of the skin using surface electrode probes.  Testing has been proven to be safe even for patients with pacemakers and other health related electrical implants, especially when being performed on the lower body. 

Why do you have this test?

If your doctor suspects your foot condition may be a result of nerve damage or blockage a NCVT may be needed to make the proper diagnosis. The symptoms in your foot that may indicate such nerve involvement could include numbness, weakness, tingling, burning and or cramps.

Your doctor maybe ruling out such nerve conditions as Tarsal tunnel syndrome, nerve entrapment, diabetic neuropathy, peripheral neuropathy or ridiculopathy.                                                           

 After the test is done you can return immediately to normal activities.

The results are calculated and will be reviewed at your next office visit.

 

 

Source Material

Al-Shekhlee, A; Shapiro, BE; Preston, DC. Iatrogenic complications and risks of nerve conduction studies and needle electromyography. Muscle Nerve. 2003;27(5):517.

Erlanger, J; Gasser, HS. Electrical signs of nervous activity, University of Penn Press, Philadelphia, PA 1937.

Landau, ME; Diaz, MI; Barner, KC; Campbell WW. Optimal distance for segmental nerve conduction studies revisited. Muscle Nerve. 2003;27(3):367.

Liddell, EGT; Sherrington, CS. Recruitment and some other factors of reflex inhibition. Proc R Soc Lond [Biol]. 1925; 97:488.

Nandedkar, SD; Barkhaus, PE. Contribution of reference electrode to the compound muscle action potential.  Muscle Nerve. 2007;36(1):87.

Phongsamart, G; Wertsch, JJ; Ferdjallah, M; King, JC; Foster, DT. Effect of reference electrode position on the compound muscle action potential (CMAP) onset latency. Muscle Nerve. 2002;25(6):816.

Schoeck, AP; Mellion, ML; Gilchrist, JM; Christian, FV. Safety of nerve conduction studies in patients with implanted cardiac devices. Muscle Nerve. 2007;35(4):521

Posterior Tibial Tendon Dysfunction (PTTD)

November 29, 2012

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The posterior tibial tendon (PTT) is a vital structure in proper foot function.  Failure of the PTT to properly function can occur due to disease in the tendon or from excessive stress to the tendon.  Regardless of the cause, once the PTT no longer functions as it should, it often causes a great deal of discomfort and limitation of normal foot function.

Anatomy

The PTT begins in the calf and extends down the leg and around the base of the inner ankle to attach to the underside of almost every bone in the middle of the foot.  The primary attachment is on the bones supporting the arch of the foot. It is an essential structure that maintains the bones in their proper position.  The PTT is different than the other muscles and tendons that are in the same region because the portion of the tendon below the ankle receives very little blood supply.

Symptoms

Dysfunction of this tendon can produce pain and swelling if the tendon is damaged through sudden increased activity, direct injury, or as the result of a medical condition.  The condition can include swelling and warmth around the inner-middle foot or ankle. These symptoms can last from weeks to months.

Dysfunction that develops over a long period of time may not result in significant pain and swelling.  The only indication of impaired function may be changes in the appearance of the foot.  As this tendon provides support to the arch of the foot, PTTD can present as a decrease or loss of the arch.  This will cause the foot to flatten out and even appear to be rotated inwards.  Long periods of exercise or standing may cause discomfort and exhaustion.  

Causes

Most of the causes of PTTD are from long-term degeneration and injury of the tendon.  Diseases like rheumatoid arthritis can cause constant inflammation of the tendon over a long period of time.  This can lead to weakening of the tendon and can eventually result in tearing of the tendon.  Uncontrolled infections such as tuberculosis or gonorrhea can cause inflammation of the tendon leading to PTTD as well.

As mentioned earlier, the PTT has an area with limited blood supply.  Previous steroid use, obesity, chronic high blood pressure, diabetes, and old age can all cause a decrease in the amount of blood flow to the tendon. If the tendon’s blood supply becomes to low it will no longer receive enough nutrients and oxygen, the tendon then begins to degenerate and weaken.  Weakening of the PTT from lack of proper blood supply will lead to dysfunction.

Simple overuse of the PTT can also lead to tendon dysfunction.  Individuals who are extremely overweight or have a low arch in their foot can exert a large amount of stress on the tendon.  Sudden tearing of the tendon from overuse is very rare.  However, overuse can cause inflammation of the tendon and eventually lead to a tendon tear, which in turn will cause improper tendon function.      

Direct cuts and puncture wounds (something piercing through the skin) to the inner ankle can cause injury of the tendon, but surprisingly tearing of the tendon occurs more often with ankle sprains and fractures.  Injury of the lower back, resulting in nerve damage, can also cause PTTD.

Physical Exam

When a foot is being evaluated for PTTD both the appearance and function of the foot must be taken into account.  Appearance of the foot should be assessed with the patient both sitting and standing.  If PTTD is present, the arch of the foot will be decreased or absent while the patient is standing.  In early PTTD, a normal arch might be observed while the patient is not placing weight on the problematic foot.  The foot may present with more deformities when the tendon dysfunction has been present for a long time.

“Too many toes” sign is linked to PTTD and loss of the normal appearance of the foot.  When viewing a normal foot from directly behind the patient, only the fifth toe and a portion of the fourth toe should be visible.  In patients with tendon dysfunction the foot will tend to turn out as the arch collapses inwards, causing more toes to be visible from behind.

The motion of the ankle and joints of the foot can also be affected.  Over time arthritis can develop in the joints of the foot due to abnormal function with PTTD.   Arthritic changes in the joints can lead to decreased or painful motion in the foot.

While the patient is seated, the strength of the PTT is gaged by having the patient hold their foot with the toes pointing toward the floor and the foot turned inward.  The physician will then place force against the foot, attempting to move it back to a resting position.  Decreased ability to hold the foot’s position is a sign of PTTD.

A Single Heel Raise Test can also be used to evaluate PTTD.  The patient is first asked to stand and then rise on their toes.  Normally the heels should rotate slightly inward as the patient rises to their toes.  The patient may also be asked to stand on one leg and rise to their toes.  This should exaggerate the slight inward rotation of the heel.  If the patient shows decreased heel rotation, or is unable to rise to their toes it is a sign of PTTD.

Diagnostic Studies:

X-rays are used to assess any boney changes, adaptations, or variations that may have aggravated or resulted from the PTTD.  These x-rays are taken with the patient weight bearing and include several views of the affected foot.  An MRI is used to view the tendon and associated non-boney structures of the foot in order to assess the severity of the inflammation and destructive changes.

Non-Surgical Treatment

Symptoms can be relieved through limiting or stopping activities that produce pain and icing the painful region. Orthopedic shoes, orthotic shoe inserts, padding, footwear changes, and bracing may be used to help patients who have limited PTTD.  Over-the-counter (OTC) anti-inflammatory medications, such as Ibuprofen, can be used to help reduce pain and swelling.

Injection of platelet rich plasma is an emerging technology which is also used to treat the involved tendon.

Surgical Treatment

Surgery may be required if the PTTD discomfort and related disability cannot be relieved with non-surgical treatment.  The goal of surgery is to relieve pain and/or re-establish stability in the arch of the foot and provide better function.  The degree of PTTD is assessed by combining all of the findings from the physical exam and diagnostic studies to determine the condition of the tendon and the state of the associated bone structures.  The level and type of surgery needed is then determined by the amount of flexibility in the foot, and damage to the boney structures and the PTT.

Tears in the PTT may be repaired directly.  Direct tendon repair can involve cleaning out the inflamed tissue or reinforcing the PTT with another tendon from the same region.  The bones may be cut and shifted to correct any changes or damage that has occurred from improper movement and to restore the arch.  If the deformity is severe, it may be necessary to unite or fuse some of the joints in the foot.  Although fusion can limit mobility, it will decrease the pain experienced when walking and halt the deformity from causing more damage. 

 

Source Material

Mahan, Kieran T; Flanigan, Paul K. Tibialis Posterior Tendon Dysfunction. In: Banks, A., Downey, M., Martin, D., Miller, S., eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Pa: Lippincott Williams and Wilkins; 2001: 862-899

Pomeroy, Gregory C; Pike, R. Howard; Beals, Timothy C; Manoli, Arthur.  Current Concepts Review: Acquired Flatfoot in Adults Due to Dysfunction of the Posterior Tibial Tendon.  JBJS 1999, 81-A(8), 1173 – 1182

 

Posterior Tibial Tendon Dysfunction (PTTD)

The posterior tibial tendon (PTT) is a vital structure in proper foot function.  Failure of the PTT to properly function can occur due to disease in the tendon or from excessive stress to the tendon.  Regardless of the cause, once the PTT no longer functions as it should, it often causes a great deal of discomfort and limitation of normal foot function.

Anatomy

The PTT begins in the calf and extends down the leg and around the base of the inner ankle to attach to the underside of almost every bone in the middle of the foot.  The primary attachment is on the bones supporting the arch of the foot. It is an essential structure that maintains the bones in their proper position.  The PTT is different than the other muscles and tendons that are in the same region because the portion of the tendon below the ankle receives very little blood supply.

Symptoms

Dysfunction of this tendon can produce pain and swelling if the tendon is damaged through sudden increased activity, direct injury, or as the result of a medical condition.  The condition can include swelling and warmth around the inner-middle foot or ankle. These symptoms can last from weeks to months.

Dysfunction that develops over a long period of time may not result in significant pain and swelling.  The only indication of impaired function may be changes in the appearance of the foot.  As this tendon provides support to the arch of the foot, PTTD can present as a decrease or loss of the arch.  This will cause the foot to flatten out and even appear to be rotated inwards.  Long periods of exercise or standing may cause discomfort and exhaustion.  

Causes

Most of the causes of PTTD are from long-term degeneration and injury of the tendon.  Diseases like rheumatoid arthritis can cause constant inflammation of the tendon over a long period of time.  This can lead to weakening of the tendon and can eventually result in tearing of the tendon.  Uncontrolled infections such as tuberculosis or gonorrhea can cause inflammation of the tendon leading to PTTD as well.

As mentioned earlier, the PTT has an area with limited blood supply.  Previous steroid use, obesity, chronic high blood pressure, diabetes, and old age can all cause a decrease in the amount of blood flow to the tendon. If the tendon’s blood supply becomes to low it will no longer receive enough nutrients and oxygen, the tendon then begins to degenerate and weaken.  Weakening of the PTT from lack of proper blood supply will lead to dysfunction.

Simple overuse of the PTT can also lead to tendon dysfunction.  Individuals who are extremely overweight or have a low arch in their foot can exert a large amount of stress on the tendon.  Sudden tearing of the tendon from overuse is very rare.  However, overuse can cause inflammation of the tendon and eventually lead to a tendon tear, which in turn will cause improper tendon function.      

Direct cuts and puncture wounds (something piercing through the skin) to the inner ankle can cause injury of the tendon, but surprisingly tearing of the tendon occurs more often with ankle sprains and fractures.  Injury of the lower back, resulting in nerve damage, can also cause PTTD.

Physical Exam

When a foot is being evaluated for PTTD both the appearance and function of the foot must be taken into account.  Appearance of the foot should be assessed with the patient both sitting and standing.  If PTTD is present, the arch of the foot will be decreased or absent while the patient is standing.  In early PTTD, a normal arch might be observed while the patient is not placing weight on the problematic foot.  The foot may present with more deformities when the tendon dysfunction has been present for a long time.

“Too many toes” sign is linked to PTTD and loss of the normal appearance of the foot.  When viewing a normal foot from directly behind the patient, only the fifth toe and a portion of the fourth toe should be visible.  In patients with tendon dysfunction the foot will tend to turn out as the arch collapses inwards, causing more toes to be visible from behind.

The motion of the ankle and joints of the foot can also be affected.  Over time arthritis can develop in the joints of the foot due to abnormal function with PTTD.   Arthritic changes in the joints can lead to decreased or painful motion in the foot.

While the patient is seated, the strength of the PTT is gaged by having the patient hold their foot with the toes pointing toward the floor and the foot turned inward.  The physician will then place force against the foot, attempting to move it back to a resting position.  Decreased ability to hold the foot’s position is a sign of PTTD.

A Single Heel Raise Test can also be used to evaluate PTTD.  The patient is first asked to stand and then rise on their toes.  Normally the heels should rotate slightly inward as the patient rises to their toes.  The patient may also be asked to stand on one leg and rise to their toes.  This should exaggerate the slight inward rotation of the heel.  If the patient shows decreased heel rotation, or is unable to rise to their toes it is a sign of PTTD.

Diagnostic Studies:

X-rays are used to assess any boney changes, adaptations, or variations that may have aggravated or resulted from the PTTD.  These x-rays are taken with the patient weight bearing and include several views of the affected foot.  An MRI is used to view the tendon and associated non-boney structures of the foot in order to assess the severity of the inflammation and destructive changes.

Non-Surgical Treatment

Symptoms can be relieved through limiting or stopping activities that produce pain and icing the painful region. Orthopedic shoes, orthotic shoe inserts, padding, footwear changes, and bracing may be used to help patients who have limited PTTD.  Over-the-counter (OTC) anti-inflammatory medications, such as Ibuprofen, can be used to help reduce pain and swelling.

Injection of platelet rich plasma is an emerging technology which is also used to treat the involved tendon.

Surgical Treatment

Surgery may be required if the PTTD discomfort and related disability cannot be relieved with non-surgical treatment.  The goal of surgery is to relieve pain and/or re-establish stability in the arch of the foot and provide better function.  The degree of PTTD is assessed by combining all of the findings from the physical exam and diagnostic studies to determine the condition of the tendon and the state of the associated bone structures.  The level and type of surgery needed is then determined by the amount of flexibility in the foot, and damage to the boney structures and the PTT.

Tears in the PTT may be repaired directly.  Direct tendon repair can involve cleaning out the inflamed tissue or reinforcing the PTT with another tendon from the same region.  The bones may be cut and shifted to correct any changes or damage that has occurred from improper movement and to restore the arch.  If the deformity is severe, it may be necessary to unite or fuse some of the joints in the foot.  Although fusion can limit mobility, it will decrease the pain experienced when walking and halt the deformity from causing more damage. 

 

Source Material

Mahan, Kieran T; Flanigan, Paul K. Tibialis Posterior Tendon Dysfunction. In: Banks, A., Downey, M., Martin, D., Miller, S., eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Pa: Lippincott Williams and Wilkins; 2001: 862-899

Pomeroy, Gregory C; Pike, R. Howard; Beals, Timothy C; Manoli, Arthur.  Current Concepts Review: Acquired Flatfoot in Adults Due to Dysfunction of the Posterior Tibial Tendon.  JBJS 1999, 81-A(8), 1173 – 1182

 

 

 

 

 

HAMMER TOE

October 16, 2012

Hammer Toes
Definition:
Hammertoe deformities can cause all types of problems with daily life. This deformity can cause pain and discomfort especially when wearing shoes. These conditions are troubling and are the most the most common deformity of the forefoot.

Anatomy:
A hammertoe is a deformed toe. (See the illustration below) The bone distal to the 1st toe joint is bent toward the floor. Other less common deformities include claw toe which is when both the 1st and 2nd toe joint is bent toward the floor and mallet toe when only 2nd toe joint bent toward the floor, with all other joints normal.
If the bend in the toe does not straighten, regardless if observed in weight bearing or non-weight bearing, position it is know as a rigid deformity. If the deformity is elastic, it will straighten when weight-bearing and return to the hammered (bent) position when the foot is non-weight bearing this is called a flexible deformity.

Figure 1:

The toe to the right of the big toe is a hammertoe.

Note that the 1st Toe Joint, seen here with a circular corn, is bent downward, toward the floor

Symptoms:
Hammertoes can be painful and sometimes there may be no pain or discomfort. When there is pain, it can originate from a variety of areas. The pain and discomfort is usually caused by the patient’s shoe wear. As the deformed toe rubs against the inside of the shoe, this causes pain along the top of the digit. Although people of all ages can develop hammer toes, patients typically do not experience pain or discomfort until early adulthood or later.
Causes:
Hammer toe syndrome can be caused by various factors. The deformity could develop from hereditary factors or as a part of a medical condition such as arthritis. Hammertoes usually occur due to a breakdown or failure in the normal function of the foot. Flat feet, high arch feet, lack of flexibility (especially in the calf), and weakened muscles of the leg and foot can all lead to deformities of the toes. To properly evaluate this condition, it is important to seek a foot and ankle specialist when considering treatment.
Physical Exam:
A complete foot evaluation is needed when evaluating a patient for hammertoe deformities. The foot should be examined in both weight bearing (with the patient standing upright) and non-weight bearing positions to determine if the deformity is flexible. When a deformity is found to be rigid on physical exam, it most likely involves changes in the bone structure. These types of deformities may require more aggressive medical or surgical care.
Diagnostic Studies:
X-rays are used to confirm and assess the deformity. X-rays are best taken with the patient weight bearing and usually include 3 different views. Patients who have been suffering from the deformity for a long period of time may have developed arthritis, and the severity of the arthritis can also be viewed on X-ray. Commonly related deformities of the foot, such as bunions may also be seen when examining an X-ray. These deformities may need to be taken into account when planning the course of treatment.
Non-Surgical Treatment:
The use of padding, taping, footwear changes, and removal of callouses or steroid injections may all be used to help relieve symptoms. Padding can help to reduce abnormal pressures caused by the deformity. Taping techniques or the use of a splint can be used to reduce the a flexible deformity. Changing the patient’s footwear can also help to reduce discomfort. These shoe changes can include a wider or higher toe box to better accommodate the toes. Removal of built-up callouses often associated with hammer toes can help minimize discomfort. Occasionally, steroid injections may be used to temporarily reduce the pain and swelling within the toe joints.
Surgical Treatment:
The goal of hammertoe surgery is to correct the deformity in order to relieve pain and/or restore function to the digit. The degree of surgical intervention will depend on the severity of the deformity. Flexible deformities often require less aggressive surgery. Surgery that decreases the pull of the muscles responsible for the deformity may be used alone or in combination with other procedures at the joint to correct the position of the toes. If the deformity is only partially flexible, or completely rigid, then surgery on the bone structures as well as muscles and joints may be necessary.
Following surgery, full weight bearing with the aid of a specialized shoe/brace is required. However, the time before a patient is able to return to normal footwear and activity will depend on the level of treatment required to correct the deformity.

References:
McGlamry, E., Jimenez, A., Green, G. Lesser ray deformities. In: Banks, A., Downey, M., Martin, D., Miller, S., eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, Pa: Lippincott Williams and Wilkins; 2001: 253-371
Schuberth, John M. Preferred Practice Guidelines: Hammer Toe Syndrome. Journal of Foot & Ankle Surgery, 38(2), 166-178.
Shirzad, Khalid; Kiesau, Carter D; DeOrio, James K; Parekh, Selene G. Lesser Toe Deformities. J Am Acad Orthop Surg 2011; 19: 505-514.
Thomas, James L et al. Clinical Practice Guidelines: Diagnosis and Treatment of Forefoot Disorders. Section 1: Digital Deformities. Journal of Foot & Ankle Surgery, 48(2), 230-238.

Living with Peripheral Arterial Disease

March 8, 2012

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Definition of Peripheral Arterial Disease

Peripheral arterial disease (PAD) can be a debilitating disease. It is caused by fatty deposits that accumulate on the inner walls of arteries.  These deposits in the arteries of the lower extremity will result in poor blood flow to the legs and feet. If arteries are clogged and narrowed, blood will not be able reach its destination to supply muscles and organs with oxygen and nutrients. Decreased oxygen and nutrients to muscles can result in severe cramping in the legs, especially with increased workload such as walking. Patients with diabetes, high blood pressure, high cholesterol and smokers can be at increased risk of developing PAD. It is also important to note that persons, who have PAD, are also at increase risk of having fatty deposits in the arteries of the heart, which can result in a heart attack or stroke.

 

Symptoms of PAD

Most people with PAD are non-symptomatic.  However, if symptomatic, the most common complaint from patients with PAD is they get severe cramping or burning in the calf muscles when walking. Typically the cramping begins after one or two blocks of walking and will subside after a few minutes of rest. The cramping results from a build up of a waste product produced by exerting muscles called “lactate”. This is produced when there is not enough oxygen getting to the muscles. The cramping can significantly alter a patient’s lifestyle and prevent the patient from enjoying normal daily activities.  Aside from physical limitations, severe PAD can lead to non-healing wounds on the leg and foot and black/gangrene in the toes.  Some of these patients with PAD may require an amputation of the foot or leg.

 

Physical Examination for PAD

When a podiatrist evaluates a patient for PAD, there are key signs that are presented on the feet. Patients with PAD tend to have diminished or absent digital hair growth and nails that are brittle and thickened as well as decreased temperature in the feet. The podiatrist may ask the patient to hang their legs over the side of the exam chair, in patients with PAD the legs begin to display a deep purplish color. Patients with PAD will have a white, pale discoloration to the feet if the legs are elevated above the heart for one minute. The podiatrist will also feel the pulses in the feet. If the pulses are weak, it may indicate that there is poor blood flow to the feet. These are important signs that lead to a high suspicion of PAD.

 

Testing for PAD

The most common and least expensive office test for PAD is called an ankle-brachial index. This is done by taking the blood pressure of the arm (brachial) and comparing that number to the blood pressure in the ankle. This test requires a blood pressure cuff and Doppler ultrasound to hear the pulse.  The blood pressure cuff is inflated on both the arm and the leg. Next, the cuff is slowly deflated; the first sound heard in sync with the blood pressure number is recorded and compared by ratio. The normal ankle-brachial index is 1, in other words the arm and the ankle should ideally have the same pressure. Patients with an ankle-brachial index of 0.4-0.9 are considered to have PAD.  There are also additional tests that can determine poor blood flow. PAD can also be visualized with an MRI/MRA or angiogram, which requires injecting a dye through the blood vessels and using an imaging system to follow the dye through the arteries in order to visualize artery narrowing.

 

Conservative Treatment of Peripheral Arterial Disease

The most important goal in treating PAD in the lower extremity is to reduce the risk of amputation. Treatment is usually administered by the primary care or vascular physician. Drugs that thin the blood, such as aspirin, are often prescribed to patients with PAD to prevent the risk of clotting.  Smoking cessation programs and good control of cholesterol, blood pressure, and blood sugar levels are also strongly advocated. Foot care is also important in managing peripheral arterial disease to prevent ulceration to the feet. In treating cramping sensations from PAD, exercise therapy has been scientifically shown to increase maximal walking distance because it promotes small vessel formation around the area of the clot.

 

Surgical Treatment of Peripheral Arterial Disease

If the symptoms of PAD are severe, inhibiting lifestyle or resulting in non-healing wound or gangrene on the feet, surgical treatment may be required by the vascular physician. The goal of surgery is to increase blood flow to the legs and feet.  Surgical treatment may include bypassing the area of clot with a vessel graft or vein or opening the artery with a balloon and placing a stent to increase the diameter the artery and attempt to keep it open.

 

The Dilemma with Wearing High Heeled Shoes

September 24, 2011

History of High Heeled Shoes

High heeled shoes have been historically apart of human culture. It was first documented on ancient Egyptian murals showing both men and women of royalty wearing heels for religious ceremonies and Egyptian butchers wearing them to walk above the blood of butchered animals. In Greece and Rome, heels were worn in theatrical plays to indicate social status. Regardless of its purpose, heels have been perpetually apart of daily life since ancient civilization.

Effects of High Heeled Shoes on the Body

High heels are unique compared to other footgear due to the shoes anatomy.   The structure of heels changes the positioning of bone orientation in the foot and ankle, resulting in postural changes of the body.

1. Narrow toe box

The shoe covering over the toes is called a toe box.  In the design of most high heels, the toe box tends to be narrow, decreasing the space inside the shoe and increasing friction between the foot and shoe. This results in increased risk of blisters and corns forming on the foot. Additionally, a narrow or pointed toe box squeezes the ball of the foot causing bones in this area to be forced closer together. This pressure increases the likelihood of irritating the nerves that run in close proximity to the bones. Constant use of heels can exacerbate nerve irritation leading to inflammation of the nerve called a neuroma. This condition is associated with a numbing or throbbing sensation at the ball of the foot and may radiate to the toes.  A narrow toe box in can also aggravate bunions and hammertoe deformities.

2. Heel Cup

The covering around the heel is called a heel cup and is often very hard and rigid in high heeled shoes. Additionally, the heel cup protrudes forward into the heel resulting in friction between the back of the wearer’s heel and the shoe. This increases the pressure on the back of the heel and overtime can create a bony protrusion in the area known as a “pump bump” or Haglund’s deformity, which can be painful when walking in shoes.

3. High Heel

The increased heel height places the ball of the foot lower than the heel. This position of the foot and ankle is called plantarflexion. As plantarflexion increases, the foot loses its shock absorbing ability and creates increased shock applied to the foot when the shoe hits the ground. This shock wave is transmitted through joints in the foot, knee, and hip causing leg and back pain when wearing heels.

Increased plantarflexion of the foot and ankle also shortens the calf muscle.  This shortening decreases the ability of the calf muscle to help lift the foot off the ground. Overtime, a shorten calf muscle can create a tight Achilles tendon, which strains the tendon and causes pain to the area when transitioning back to normal shoe gear. Additionally, heels change body posture by increasing pressure on the ball of the foot and decreasing pressure on the heel.  This results in increased pressure in the knee joint and strains the knee joint tendons, leading to arthritis of the knee. Studies have shown that even moderate heel heights of 1.5 inches can significantly increase strain to the knee. By distributing body weight unevenly and causing the wearer to lean forward, heels can increase the risk of falls.

Preventing Adverse Effects of High Heeled Shoes on the Body

Statistics has shown that 35-65% of women wear heels. However, there are preventive treatments that can alleviate pain and decrease adverse effects associated with wearing heels.

1. Custom Inserts

Custom made inserts that are placed inside heels can reduce the impact force the body experiences when wearing heels. Custom inserts support the arch and heel of the foot by increasing the area of foot contact to the shoe and distributing body weight to the middle of the foot. This can relieve some of the pressure from the heel and ball of the foot. Research studies have shown that custom inserts have been clinically proven to improve comfort.

2. Stretching

As mentioned above, higher heels tend to shorten and contract muscles in the foot and shorten the Achilles tendon and calf musculature, which results in increased workload on these muscles and tendons. Therefore, stretching these areas can relieve pain and aid in more comfortable transitioning between heels to flat shoe gear. Wrapping a towel around the ball of the foot and pulling the towel towards the body stretches the bottom of the foot. It is usually recommended to hold the stretch for 30 seconds and alternating between each foot 3-4 times.  A runner’s stretch is often recommended to stretch the Achilles tendon. This stretch entails pushing against a wall while one foot is forward and bent and the other foot placed back and straight. The foot placed back is stretching the muscles and tendons in the back of the lower leg. This stretch again is held for 30 seconds and is alternated with the other foot 3-4 times.

3. Rotating types of shoes

Alternating between supportive athletic shoes, flats and heels can decrease the potential problems associated with wearing high-heeled shoes.

Tarsal Tunnel Syndrome and Treatment

March 20, 2011


Symptoms of Tarsal Tunnel Syndrome

Tarsal tunnel syndrome refers to the irritation and/or compression of a nerve called the posterior tibial nerve. This nerve is found behind the anklebone on the inner side of the foot.  (Same side as the big toe) As the nerve travels in this area it runs through small canal called the Tarsal Tunnel.

Symptoms of tarsal tunnel include:

1. Radiation, burning, or shooting pain on the bottom of the foot, along the arch and/or up into the leg

2. “Pins and needles” sensation to the bottom of the foot and into the toes

3. Disturbances in the perception of temperature (feelings of coldness)

4. Feeling like there is a tight band around the foot

5. Loss of sensation to the sole of the foot and/or heel

6. Pain getting worse with prolonged standing or walking

7. Rest and leg elevation can relieve symptoms

Causes of Tarsal Tunnel Syndrome

The main culprit of tarsal tunnel syndrome is the decrease in space in the tarsal tunnel, which results in compression of the posterior tibial nerve. There are multiple reasons that can cause narrowing of the tarsal tunnel.

1. As the tibial nerve travels behind the anklebone, it goes through the tarsal tunnel, which is a narrow canal bordered by a sheath of tissue and the heel bone.  As the tibial nerve goes through the tarsal tunnel, it usually splits into two nerves, the medial and lateral plantar nerves. If the tibial nerve splits into two nerves before entering the tarsal tunnel, it increases the number of structures going through the tarsal tunnel. This results in a relative decrease of space in the tunnel and compression of the nerve.

2. Several tendons and veins course through the tarsal tunnel with the tibial nerve. If these structures are enlarged or swollen the tibial nerve can be compressed.

3. Compression of the tibial nerve can also occur from bony prominences, spurs or fragments of bone in the tarsal tunnel.

4. Abnormal heel position with the heel positioned more inward or outward can stretch the tibial nerve or narrow tube of the tarsal tunnel again resulting in excessive pressure on the nerve.

Physical Examination in Tarsal Tunnel Syndrome

Tarsal tunnel syndrome can mirror other foot conditions, such as heel pain, arch pain, or neuropathy therefore, the podiatrist may need to utilize various examination techniques, imaging modalities and electro diagnostic studies to diagnosis tarsal tunnel and syndrome. The podiatrist will tap along the course of tibial nerve to reproduce the shooting sensation often associated with tarsal tunnel syndrome. The podiatrist will also examine if there is any swelling along the tarsal tunnel and the medial arch because this may indicate a mass that may be in the tunnel. The podiatrist may also try to increase the pressure on the tibial nerve by turning the foot outward and up and holding this position for 5-10 seconds. This exam produces a narrowing the space of the tarsal tunnel and can recreate the patient’s symptoms. Heel and foot position may also be examined to determine if that may be the cause of tarsal tunnel compression. In order to determine which nerve branches are involved, a pin prick test may be applied to the sole of the foot to determine which areas of the foot has decreased sensation.

Diagnostic Studies in Tarsal Tunnel Syndrome

If a bony prominence is suspected as the cause of tarsal tunnel syndrome, the podiatrist may request X-ray imaging of the foot and ankle. For soft tissue masses or increase tendon size/swelling, MRIs may be requested as well. Ultrasound may also be utilized to determine the tibial nerve split or tendon pathology. If vein enlargement is suspected, the podiatrist may use a tourniquet wrapped above the tarsal tunnel to increase fluid accumulation in the veins.  Other studies that may be ordered to study the function of the tibial nerve are nerve conduction studies or electromyography.

Non-Surgical Treatment of Tarsal Tunnel Syndrome

The podiatrist may recommend taping, bracing, orthotics, or shoe modifications to provide support to the feet and correct the heel position.  Correcting the abnormal foot movement that may cause stretching and pressure in the tarsal tunnel may prove to relieve the symptoms of Tarsal Tunnel Syndrome. Icing and oral anti-inflammatory may be suggested to decrease swelling in the area.

Surgical Treatment of Tarsal Tunnel Syndrome

The main purpose of tarsal tunnel surgery is to release structures that may be putting pressure on the posterior tibial nerve or removing bone or soft tissue masses that may cause narrowing in the tarsal tunnel. The incision is made behind the anklebone and in front of the Achilles tendon. During surgery, blunt surgical instruments are utilized in order to avoid damage to the nerves. The sheath of the tarsal tunnel is opened and the course of the tibial nerve and its branches are followed in order to remove any thickened structures and release any tight structures around the nerves. Following surgery, a bulky dressing is applied to the foot in order to decrease swelling. One week after surgery, simple motions of the ankle for 10-20 minutes twice a day may be recommended to prevent adhesions. After 2-3 weeks, sutures are removed and ambulation with tennis shoe may be allowed.  The average time for most patients to begin exercise and full activity is 2-3 months after surgery.  It is also important to note that tingling and pain may increase after surgery, and the pain and numbness may take up to one year or more to resolve

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.

Understanding the Workings of X-rays

November 2, 2010

X-rays are used in podiatry for many reasons. For example, X-ray can be used to monitor the healing progress of a surgical procedure, confirm a suspected fracture or to confirm a bone infection. In other words, X-ray images are tools to assist and improve patient care. There are, however, potential harmful effects of X-ray radiation. Therefore, the process of taking X-rays and common precautions must be understood.  With an understanding of the mechanism and nature of X-ray concerns, potential negative effects can be lessened.

Properties of X-rays:

The nature of X-rays can be perplexing because it is a form of energy similar to light. However, unlike light, there is nothing directly or physically seen. A main component in creating X-ray images is radiation, which is the transmission of energy as waves or particles akin to light. There are different types of radiation, ranging from lower energy radiation like radio, television, microwaves, and visible light to higher energy radiation like X-rays. Unlike low energy waves, X-ray radiation can change the properties of particles of an object that are exposed to the high-energy emission.

Categorizing X-ray Radiation:

There are three categories of radiation that are found where X-ray radiation is used.

The strongest is called the primary beam. This is the radiation that is made inside the X-ray tube which is located in the X-ray machine. The tube is made of glass that is lined with lead. This is meant to contain the X-ray waves and prevent X-ray overexposure to the patient and personnel that are near the machine. The primary radiation exits the tube and is directed toward the area of the patient being examined.  Of the three categories of X-ray radiation, primary radiation is the most dangerous and most intense.

The second type of X-ray radiation is referred to as secondary radiation, made of scatter or leakage radiation. Scatter radiation comes mostly from the patient when the primary beam is reflected off of the patient’s body. This type of radiation emission is most dangerous to personnel in the room. Leakage radiation is the energy waves that escape out of the X-ray tube.

The final and third category of X-ray radiation is remnant radiation, which is the energy waves that exit the patient and produces the image on the film.

Potential Dangers of X-ray Radiation:

X-ray radiation passes through body tissue and has enough energy to change the genetic make-up of cells that make up the tissues in the body. This can result in the overgrowth of cells. Of all the organs in the body, the lens of the eyes, sexual organs, white blood cells, and the thyroid gland are most sensitive to X-ray radiation. However, it takes an exceedingly large amount of radiation to damage the genetic components of cells and tissues.

In the case of pregnant women, the brain and spinal cord of the fetus is most sensitive to radiation and thus X-ray exposure is avoided during the 10th to 17th week of pregnancy. This time period corresponds to the growth period of these structures in the developing child. There are industry-accepted doses of radiation that can be exposed to a patient and rarely, if ever, does the amount of X-ray radiation performed exceed the maximum amount. In podiatry, it would require 5,000 X-ray exposures to be considered harmful to a pregnant woman, and this number is even higher for non-pregnant patients. Despite research showing low-risk from X-ray radiation, precautions and safety procedures are still practiced to fully protect the patient from potential damages.

Protection from X-ray Radiation:

There are two main forms of protection against overexposure of X-ray radiation, distance and shielding. Increased distance between a person and the X-ray machine decreases the amount of exposure to X-ray radiation. This is important for health care personnel, who frequently administer X-ray imaging.

The second form of protection against radiation is shielding. Commonly, a lead apron is worn by the patient to protect against unnecessary exposure to radiation to other parts of the body.

What to Expect When Taking X-rays:

A state certified radiology healthcare personnel places the lead apron on the patient. If the patient is female of childbearing age, she will be asked if she is pregnant. Then the strength of the X-ray beam is adjusted. Next the body part being studied will be correctly positioned. The person taking the X-ray will make sure everyone has cleared the area. A button is pushed to take the image accompanied by a buzzing sound. This sound indicates that the image is taken. In podiatry, there are at least two images taken for each X-ray study. The reason for this is that the foot is a three-dimensional object, but X-ray images are only a two-dimensional representation of the foot. Therefore, more than one X-ray view is needed to provide the podiatrist with a better visualization of the possible problems in the feet. Once the film has been processed, the film will have areas of black, which represent the soft tissues.  The X-ray beam has passes through these areas of the body and strikes the film or sensor at near full strength causing these areas to become fully exposed and appear black.  The image will also have areas that appear white. This represents areas where X-ray beams are stopped and absorbed therefore they do not reach the film or sensor. This occurs when the X-ray strikes hard tissue such as bone.