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.

Ankle Sprains

Ankle sprains are a common injury after a fall, sudden twist or blow to the ankle joint. Approximately 40 percent of those who suffer an ankle sprain will experience chronic ankle pain, even after being treated for their initial injury.

A review article published in the May 2009 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) explains that tendon injuries to the ankle can be a possible cause for this chronic pain. In some cases, the condition is untreated or overlooked which prolongs the pain and the problem. "When patients injure their ankles, the injury may not seem serious at first," explains Terrence Philbin, DO, lead author of the article and Fellowship Director of the Orthopedic Foot and Ankle Center in Columbus, Ohio.

"People may not seek medical attention and they can think it will just get better on its own. I think that is why this condition often goes undiagnosed." The authors of the article describe how in some cases chronic ankle pain may actually be the result of injuries to the peroneal tendons. The peroneal tendons are located behind the outside portion of the anklebone (called the fibula). The tendons help to stabilize the foot and ankle. Tendon injuries can include tendonitis or swelling around the tendons. In more severe cases, the peroneal tendons can actually tear or there can be a swelling of the tendons behind the fibula bone. This can cause the ligament that holds the tendons together to stretch out and tear, or even rupture. Symptoms associated with peroneal tendon injuries can include: Ankle pain that is not responding to treatment Swelling and tenderness around the outside of the ankle Pain behind the anklebone Pain that transmits from the ankle down into the foot.

The use of magnetic resonance imaging (MRI) or ultrasound can be helpful when identifying and diagnosing peroneal tendon injuries and disorders. "These imaging techniques offer a more complete look at the peroneal tendons," noted Philbin. "One might consider getting an MRI or ultrasound especially if you have chronic ankle pain." If the condition is caught early, non-operative treatment options can include: Rest, ice and elevation Anti-inflammatory medication Immobilization in a cast or brace Physical therapy More serious injuries of the peroneal tendons, including tears or ruptures, will very likely require surgery. 

Peroneal tendon injuries can happen suddenly or can develop over time. The injury is most common among athletes involved in sports that require repetitive ankle motion and in individuals who have high arches of the foot. A proper diagnosis is essential in order to treat peroneal tendon injuries correctly and to help alleviate chronic pain. Philbin reminds patients, "If you have ankle pain and it is not getting better, do not ignore it. Get it evaluated by a physician who has experience treating foot and ankle injuries."

We can try a variety of measures to reduce pain and swelling and disability from this condition. PRP injections, low profile bracing, and physical therapy are excellent nonsurgical options. Ultimately surgery would be considered pending the nature and severity of the problem, and how you respond or fail to respond with nonsurgical management. 

New data gleaned from five years of studies have shown that artificial sweeteners can lead to weight gain as the body forgets how to process real sugar.


Sweet taste without the guilt — this has long been the promise of diet sodas.

But researchers at Purdue University have found by reviewing studies done over the past five years that diet soda and other artificially sweetened products could cause the same health problems as regular soda. In review, Susan E. Swithers, a Purdue professor of behavioral neuroscience, discovered that with consuming artificial sweeteners like sucralose, aspartame and saccharin, the body loses its ability to process real sugar, which could result in weight gain.

With real sugar, messages are released to the brain and the gullet via hormones that regulate digestion and intake of food, blood sugar levels, and even perception of fullness and satisfaction from the food consumed. However, with no actual calories to process with artificial sweeteners, the body doesn't know how to react.
"You've messed up the whole system, so when you consume real sugar, your body doesn't know if it should try to process it because it's been tricked by the fake sugar so many times," says Swithers to CNN.

The end result, says Swithers, is that the body's metabolic system stops reacting to real sugars and doesn’t release the hormones that say, “That was delicious, I’m full.” This can cause an endless cycle of feeling hungry and wanting more sugar.  It has also been shown that people who regularly drink diet soda have a higher risk of weight gain, obesity and type 2 diabetes and heart disease.

However, representatives of the American Beverage Association disagree and argue that low-calorie products can be effective tools for weight control, calling the study “an opinion piece,” in a released statement, according to CNN.

Theresa Hedrick, nutrition and scientific affairs specialist for the Calorie Control Council lobbying group, told WebMD, "I think it's important to remember that low-calorie sweeteners are one aspect of a multifaceted approach to health or obesity prevention. ...They aren't magic bullets."

Weight gain is a major contributor to all foot and ankle problems, and our patients need to understand that weight loss therefore will directly impact the reduction of most foot and ankle pain. Ask us about your weight loss options today, or at your next appointment.