Posts Tagged ‘Foot’

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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Peripheral Neuropathy and Diabetic Foot Ulcers

April 3, 2014

 

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What is peripheral neuropathy?

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

 

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

 

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

 

Foot exam

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

 

Diabetic foot wounds – how are they treated?

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

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

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

 

Metatarsal Stress Fractures

November 9, 2013

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Metatarsal Stress Fractures

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

What is a Stress Fracture?

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

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

Metatarsal Stress Fractures

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

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

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

Clinical Presentation

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

What are the Risk Factors?

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

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

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

Physical Examination

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

Imaging

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

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

Treatment of Metatarsal Stress Fracture

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

Source Material

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

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

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.