Turf Toe

The simplest definition of turf toe is that it is a sprain of the main joint of the big toe. It happens when the toe is forcibly bent up into hyperextension, such as when pushing off into a sprint and having the toe get stuck flat on the ground.
Sprains of the big toe joint became especially prevalent in American football players after artificial turf became more common on playing fields - hence the term "turf toe." Artificial turf is a harder surface than grass and does not have much "give" when forces are placed on it.
Although often associated with football, turf toe occurs in a wide range of sports and activities.

The typical position of the foot when a turf toe injury occurs.

Anatomy
The big toe is made up of two joints. The largest of the two is the metatarsophalangeal joint (MTP), where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx). In turf toe, the MTP joint is injured.


The MTP joint is the large joint closest to the base of the big toe.

The joint is surrounded by important structures that hold it in place and prevent it from dislocating. Together these structures are referred to as the "plantar complex."
Plantar plate. This thick, fibrous tissue under the MTP joint prevents the big toe from bending too far (dorsiflexion).
Collateral ligaments. Located on each side of the big toe, collateral ligaments connect the phalanx bone to the metatarsal and prevent the toe from going too far side-to-side.
Flexor hallucis brevis. This tendon runs under the first metatarsal bone and attaches to the phalanx. It provides strength and stability to the big toe during push-off motions.
Sesamoids. These two small bones are enveloped in the flexor hallucis tendon, and help it to move more easily. In addition, the sesamoids provide stability to the MTP joint by helping to bear weight placed on the forefoot.

Several structures work together to protect and stabilize the MTP joint.

Description
The term "turf toe" refers to an injury of any soft tissue structure in the plantar complex, such as the plantar plate or a collateral ligament. These injuries can vary in severity — from stretching of the soft tissue to partial tearing, and even total dislocation of the MTP joint.
To help them plan treatment for turf toe, doctors grade the injuries from 1 to 3 - mild to severe.
Grade 1. The plantar complex has been stretched causing pin-point tenderness and slight swelling.
Grade 2. A partial tearing of the plantar complex causes more widespread tenderness, moderate swelling, and bruising. Movement of the toe is limited and painful.
Grade 3. The plantar complex is completely torn causing severe tenderness, severe swelling, and bruising. It is difficult and painful to move the big toe.

We have treated this injury on and off over the years with similar therapy. Rarely does this require surgery, and there is sparse literature which can be referenced to delineate whether grade 1 and grade 3 injuries are specifically nonsurgical or surgical. We have used a combination of PRP injections with hallux extension BK casting for this injury and have found good success. This is a non surgical approach and has had with it some good short term success. But this may still be a devastating injury for most athletes. (Even notable pros such as Deion Sanders, have had career ending versions of this injury).

Flatfeet could slow you down


How is this possible?
The results conducted by the American Podiatric Medical Association concluded that a staggering 73 percent of people asked said that they are suffering from foot pain.

The question is: why has foot pain become one of the most common complaints in the examination room?

For many people, this problem can be caused by one of the following: the kinds of shoes they wear, what activities they participate in, or how their feet are formed. Wearing poorly-fitting shoes can turn minor problems into major ones. People who engage in athletic activities are another segment of the population that are mostly affected by foot pain. Factors such as fallen arches, overpronation, and poor support can all be contributing factors to lower extremity pain. Parents can also be the cause of foot-related problems, because genetics play a role how the foot was formed in the womb. This can enhance the likelihood that someone will suffer from an array of painful foot conditions.

The Mechanics of the Foot
Flat feet can cause abnormal rotation of the feet when walking or running. Our feet handle balance, stability, and bear the weight of the body. The parts of the foot that help to keep the foot in harmony with the body include the arch, heel, tarsals and meta-tarsals. The arch provides stability by the following structures: the tendons, ligaments, and muscles. Pain can result from raised arches or abnormally-low arches, which can cause the foot to rotate abnormally. With high arches, the body’s weight is abnormally emphasized on the outer edge of the foot (oversupination). Conversely, overpronation happens with fallen arches because the weight of the body is concentrated on the inside of the foot, causing the ankles to roll inward .

Serious Foot Issues May Occur with Flat Feet A quick way to see if fallen arches or high arches are an issue is to find a good area where a foot impression can be made, such as on concrete. Immerse on foot in cold water and then stamp your foot onto the dry surface. Then, lift the foot off the ground and see the impression that is left by the foot. A flat foot with overpronation will leave a complete mark where the entire foot has touched the ground. A high arch will leave just a part of the ball of the foot’s outside portion, and heel of the foot. Either of these arch conditions can cause painful bony growths in the heel because the foot has to deal with too much pressure in places it is not intended to handle.

Orthotics Provide Effective Relief for Therapy For Plantar Fasciitis
People suffering from fallen arches, heel spurs, or who need plantar fasciitis treatment can get relief by using the best orthotics available in their shoes. They offer the needed support to fix the weak structures in the foot, such as those that make up the arch. They also offer cushioning in areas where too much pressure occurs, such as in the heel or ball of the foot. Orthotics are available in an array of sizes and types and are made to keep up with anyone’s activity level.

Make an appointment today for more information. 

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:

Stretching
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

What you should know about your feet during pregnancy

Did you know that during pregnancy, your feet experience dynamic changes attributed to fluid retention and increase in soft tissue.  Believe it or not, this is not secondary to stretching, weakness, or ligament laxity.

Here are 5 important facts to know about your feet during pregnancy:

1. Feet measurements in width and length are increased during pregnancy.
2. Edema (swelling) in the feet, ankles, and legs are common and can be expected.
3. Venous insufficiency and varicose veins can be seen in the foot and leg.
4. Conditioning exercises are not only important to maintain posture but also decrease load on the foot and ankle.
5. During GAIT, pregnant women have increased demand on the calf-muscle group and over-pronate

In order to help prevent foot problems during your pregnancy, here are three proven methods:

1. Compression stockings and edema control with elevation
2. Custom or physician approved orthotics to improve foot function and mechanics
3. Stretching and conditional exercises to help limit load on the weakened muscle groups

If you have any questions or discomfort with your feet during your pregnancy, then consult with your foot and ankle specialist.

What you should know about ankle arthritis?

Ankle arthritis can be very debilitating and although the prevalence is 9 times lower than knees and hips, the symptoms are much more magnified.  In fact, according to a recent study the quality of life of patients with ankle arthritis was in many cases worse than that of patients with hip arthritis.

Arthritic ankle joint with significant loss of joint space

5 important facts to know about ankle arthritis:

1. Unlike the hip and knee, ankle arthritis is typically caused by trauma and/or abnormal ankle mechanics
2. Other less common causes include: inflammatory arthropathies, hemochromatosis, neuropathic arthropathy, bone tumors, and infection.
3. Cartilage in the ankle joint is much more stiffer and resilient in comparison to the knee joint.
4. The ankle joint carries up to 5 times the normal body weight.
5. Both operative and non-operative treatments exist as viable options.

5 important non-operative treatments:

1. Ankle-Foot-Orthoses (AFO): Function to limit the mobility of the Ankle joint and thereby limiting the associated pain
2. Corticosteroid injections: Function to limit the associated inflammatory process with motion of the arthritic joint
3. Physical therapy: Improve GAIT, strengthen muscles, and improve function of contracted tendons secondary to the arthritic joints.
4. Vitamin supplementation: Antioxidants can help with pain control and associated inflammatory response
5. Hyaluronate injections: Typically indicated for knee cartilage/joint.  Those injections carry components of healthy joint fluid.  Studies have shown good results in patients with ankle arthritis

Example of an Ankle-Foot-Orthoses  used for patients with ankle arthritis

3 most viable options for operative treatment:

1. Ankle joint diastasis: Preserves joint and encouraged in early staged arthritis.  Can be useful in select patients.
2. Ankle joint arthrodesis: Results in complete fusion of the joint, thereby eliminating any joint motion and associated pain.  The body compensates by observing motion at the distal joints of the foot during the GAIT cycle.  It is considered to be the "gold-standard" in surgical management of ankle arthritis since it carries the most predictable of results.
3. Ankle joint replacement surgery: The joint is completely replaced with a metallic-implant.  It does preserve some limited and pain-free motion of the joint.  It is gaining popularity in the U.S. and is indicated in a very select group of patients.  Newer generation implants carry longer longevity and are more predictable.

Ankle joint replacement with metallic implant

If you have any problems with ankle arthritis, then consult with your foot and ankle specialist.