Posts Tagged ‘atheletics’

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

 

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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.

Buying Athletic Shoes for Your Foot Type

February 28, 2010

Buying athletic shoes can be a very daunting task, especially with the never-ending options of shoes found at stores. However, there is a science to athletic shoes, so you can find a pair that are best for you and decrease the chances of injury to your feet with some fundamental knowledge.

Before buying an athletic shoe, you must know what type of foot you have. Of course, there are subtle differences in everyone’s feet, but in general, there are three main foot types and athletic shoes, subsequently, are made for each of these foot types.

Foot Types:

1. Neutral foot: A neutral foot has a medium arch, which allows the pressure and force of running to be evenly distributed throughout the foot.  Additionally a neutral foot has an adequate amount of pronation, a movement that occurs during weight bearing where the bottom aspect of the arch moves toward the floor. Therefore the arch gets lower and the foot is more flexible in a pronated state. Since a neutral foot has the necessary amount of pronation, this foot is flexible enough to absorb the pressure of running and walking and adjust to changing terrain.  Also, a neutral foot has an adequate amount of supination. Supination is a movement of the foot where the arch of the foot rotates off of the floor creating a higher arch and a more rigid foot. With an adequate amount of supination, a neutral foot is rigid enough to push off the ground without causing injury. Recommended shoes for a neutral foot type are stability shoes.

2. Over Pronated/Flexible foot: This foot type has a very low or flat arch, which increases pressure on the inside of the foot and big toe during walking or running. This usually results in an increase of skin thickness on the inside of the big toe and ball of the foot.  Also, this type of foot is more flexible than a neutral foot. In the pronated position the foot is not rigid enough to push off the ground. Since an over pronated is a more flexible foot, motion-control running shoes are recommended for this foot type.

3. Over Supinated/Rigid foot: An over supinated foot has a very high arch, which increases pressure throughout the heel, the outside of the foot and ball of the foot. Compared to an over pronated foot, an over supinated foot is rigid and is not able to absorb the forces applied to the foot than the other foot types. An over supinated foot/rigid foot type benefits more from a cushion running shoe.

Shoe Types:

1. Motion control shoes: This type of shoe is best for patients with excessive pronation or a flat arch. The back of the shoe that cups the heel is known as a heel counter. The heel counter in a motion control shoe is rigid to prevent excessive pronation that occurs in a flexible foot. Additionally, the outline and shape on the bottom of motion control shoe is straight and broad at the front of the foot.  This shape is also designed to improve stability like have a wide wheelbase on a car.

To test a motion control shoe, grasp the heel counter with your hand and squeeze the heel counter. The heel counter should not deform with compression of your hand.

Another way to test for motion control is to grab the front of the shoe with one hand and the back of the shoe with the second hand and twist the shoe. The shoe should not deform with the twisting motion. The final test to determine the amount of motion in the shoe is to bend the front and back of the shoe together like a book. The bend of the shoe should be at the ball of the foot where the foot pushes off the ground during activity and should not bend in the middle of the shoe.

2. Cushion shoes: This type of shoe is best for patients with excessive supination or a high arched rigid foot. Cushioned shoes decrease pressure on the feet by absorbing forces transmitted from the ground while running. The outline and shape on the bottom of cushion shoes tend to curve at the front of the foot with extra padding at the front and middle of the shoe. Additionally, cushion shoes tend to have an hourglass shape when looking at the sole where the middle part of the sole is narrower than the front or back. Compared to motion control shoes, it is easier to twist a cushion shoe. Additionally, when bending the front and back of a cushion shoe together like a book, the bend is also at the ball of the foot, but the amount bend is greater and easier to perform than a motion control shoe.

3. Stability shoes: This type of shoe is recommended for a neutral foot type. This shoe has components of both a motion control shoe and a cushion shoe. The outline and shape on the bottom of stability shoe is semi-curved at the front of the foot. This type of shoe has cushion for absorbing forces from activity, but also like motion control shoes, has a firm heel counter, but is not as rigid as a motion control shoe.

General Shoe Fitting Rules:

1. Measure both feet standing

2. Try on shoes later in the day when feet are more swollen

3. Try on shoes half a size larger to compare fit

4. Leave one finger width from the end of the longest toe to the end of the shoe

5. Wear the shoe indoors first for 10 minutes or more to make sure it is comfortable

6. Shoes should not need a break-in period they should be comfortable when you try them on.

7. Make sure nothing pinches you inside the shoe

8. Do not wear a shoe for the first time in a race.

Replacing Shoes:

Shoes should be replaced about every 300-500 miles of running or walking or 45-60 hours of a sport activity. If there is creasing around the shoe lining, new athletic shoes must be considered. Another test to determine when to replace shoes is by seeing whether or not the shoe is uneven when it is placed on a flat surface.