Friday, November 8, 2013

5 things you must know about Achilles tendon disease

5 things you must know about Achilles tendon disease

Did you know that Achilles tendon ruptures represent a large portion of sports-related injuries and are seen in younger patients and older ones as well.  The average age is 29-40 with a male to female ratio of 20:1. 
In fact, "weekend-warriors" is a term used to classify patients above the age of 35 who participate in occasional exercise activities and especially those that involve high-impact sports such as basketball and soccer.  Those patients are statistically known to be at the highest risk for sustaining Achilles tendon ruptures.
Progression of Achilles Tendon disease

Achilles tendon anatomy.  Image from Gray's Anatomy Text..
Here are Five important facts you must know when dealing with Achilles tendon disease:
  • Achilles tendon disease is progressive - It involves a chronic and repetitive process of micro-tearing and degeneration within the tendon.  This process weakens the tendon and can eventually lead to spontaneous ruptures
  • Pain is not always a clinical symptom of Achilles tendon disease - In fact, the more chronic is the tearing, the less likely pain is involved and thus anti-inflammatory medications would not work
  • Tight calf muscle groups increase the load on the "diseased" tendon
  • Foot-type and mechanics can make you susceptible to Achilles tendon disease
  • Specific family of antibiotics, namely Fluroquinolones, have shown association with Achilles tendon disease and spontaneous ruptures.
Here are important elements to consider for treatment of Achilles tendon disease:
  • Temporary immobilization in a boot/cast is to be expected in the initial "inflammed-state"
  • Shoe-gear modifications, foot-orthoses, physical therapy and stretching exercises are pillars  in the treatment process because they loosen the load off of the tendon
  • Platelet-Rich Plasma injections have shown tremendous promise and results in the treatment especially amongst the athletic/active population
  • Shockwave therapy has also shown great benefits from a non-operative point of view
  • Surgical intervention is warranted if no clinical improvement is seen with non-operative approaches and it involves debridement of the tendon with either a reconstruction of the diseased tendon or a tendon transfer from another tendon in the body. 
    • Recovery involves immobilization in the cast for 3-4 weeks then followed with a period of 4-6 weeks of CAM boot immobilization with Physical therapy
    • Results on average are rated as good to excellent.
If you have any questions about Achilles tendon disease or ruptures, then please consult with your foot and ankle specialist.

Ingrown toenails - 5 important facts and how are they treated?

Have you ever experienced pain, redness, swelling, and even drainage from the "inner" fold of your toenails? Have you been told that this can eventually "grow out"? In reality, ingrown toenails are common in the practice of the foot and ankle specialist but their treatment carries some misconceptions.

Presentation of an ingrown nail with localized infection

Note drainage from inner fold of nail consistent with infected ingrown nails

Here are 5 things you must know about ingrown toenails:
1) Untreated ingrown toenails can cause infections in the skin, bone, and result in life-threatening infections also referred to as "sepsis"
2) Genetics and foot-architecture can play a role for ingrown toenails
3) Cutting toenails too short and into the "corners" can cause ingrown toenails
4) The great (big) toenail is most commonly affected
5) Only definitive way to treat ingrown nails is surgical

Surgical treatment involves an array of different local procedures to remove the "ingrown" component of the nail without compromising the remainder of the nail. In most cases, a chemical treatment is also applied to prevent the nail from growing back "ingrown".

So what does the procedure entail?
1) Typically an in-office setting with local anesthetic infiltrated to "numb" the toe
2) Removing the ingrown component of the nail from the tip to the root
3) Draining and debridement of any infected tissue or abscess.
4) Application of chemical treatment to inhibit nail (matrix) cells from growing back in the in-grown position
5) Application of an antimicrobial dressing that stays on for one day.

Post-operative management?
Although most foot and ankle specialists have different protocols, on average most would agree on a protocol that involves the following:
1) Daily dressing change with a Bandaid until the drainage from the toe completely resolves
2) Following with your provider between 7-14 days after the procedure to ensure no infections. At that point, patients are typically given a prescription for topical solutions to prevent infections and promote the healing of the skin.

If you have any questions about ingrown toenails then please consult with your foot and ankle specialist.

Top 3 reasons why your golf game can be affected by your foot pain

Has your foot pain affected your golf game recently? Have you noticed a change in your swing because of guarding and inability to pivot your foot? The reality of the matter is that there are contributing forces to the golf swing and poor foot mechanics can result in foot pathology that would ultimately affect the quality of the golf swing.

Here are three reasons why your golf swing can be affected by your foot pain:

Great toe joint arthritis - This is a common condition that we see in a large patient spectrum and it is independent of age. The top two reasons that patients develop great toe joint arthritis are: Genetics and/or a history of trauma to the joint. Patients with great toe joint arthritis develop significant pain and stiffness over time, which results in an inability to "push-off" the toe. By guarding the pain, your foot position and mechanics are thereby compromised which leads into a less effective swing.

Plantar fasciitis - This is a condition that involves an inflammatory response at the ligament/tendon structure (plantar fascia), which inserts at the heel. This results in significant pain at the heel and "tightness" in the arch. This, in turn can inhibit the foot from completely planting and thus, will reduce the effectiveness of the swing. We often see this condition in conjunction with tightness of the posterior muscle group which contributes to the pain and inability to plant the heel on the ground.

Achilles Tendonitis - This is a condition that also involves an inflammatory response but this time at the tissues surrounding the Achilles tendon insertion. This is precisely located at the back of the heel and is also seen in conjunction with tightness of the posterior muscle group. The result of this condition is again an inability to plant the foot or push off, which would also compromise the swing.

Here are ways to address those problems:

By relieving the contracture and "tightness" of the posterior muscle group
Physical therapy
Can comprise of ultrasound and other hands-on modalities to improve range of motion and relieve tight muscle groups
Mechanical control of the foot - Foot or Ankle and Foot Orthoses
In doing so, there is a lesser tendency or chance of aggravating the tendons.
Vitamin supplementation and antioxidants
Reduce associated swelling and pain
Shock-wave therapy
Using a combination of low intensity ultrasound guided shockwaves, an inflammatory response can be induced in the chronic tendon disease and promote healing.
Surgical repair
Most definitive but is contingent on the type of problem at hand. Typically outpatient type of setting with a brief period of Non-weight bearing (no walking)If you have any questions pertaining to any of the aforementioned conditions, then consult with your foot and ankle specialist