Big Toe Pain

Seemingly every year, there are more and more patients with lingering foot pain and difficulty in walking. This can be caused by the great toe joint. Some patients may think that bunions are the only thing that can cause this pain, but truly this is only part of the story. A number of studies in recent years show the natural progression of arthritis in toe joints which do not seem to have any bunion characteristics, such as prominent bone on the inside of the foot and deviation of the great toe towards the lesser toes. This can be related in most cases to a distant trauma which occurred an unknown time ago.

At FFLC, there are several pain management modalities to provide nonsurgical relief in this area, ranging from orthotics and cortisone injections, to the new Cold LASER therapy for recurrent pain which can reduce symptoms in chronic pain of arthritis significantly without medications.

Something as trivial as stubbing your toe, or landing abruptly and resultant pain in the bottom of the joint that seems to go away, may eventually return later on as a limitation in joint motion, and pain in the foot which is related to the adaptive and erosive side effects from "hallux rigidus". This is visible after age 50 and can affect men and women, and can be the major source of a significant amount of discomfort and limitation with walking.

At The Family Foot and Leg Center, numerous conventional and proven treatment protocols for patients are available to give you the best chance at pain free ambulation. If you have arthritic changes on a regular X-ray, and the deformity is not too severe, you may even qualify for the latest implant arthroplasty technique known as "joint resurfacing". This is a relatively advanced joint replacement which allows patients to walk immediately after the surgery, and there are no weight bearing restrictions with a very high success rate both in the short term and long term.

Not everyone is a candidate, but for those who experience such pain, will acquire immediate relief. After several weeks post operatively, your range of motion should be close to the other foot, and in most cases significantly increased from before the procedure is done. It is an outpatient procedure with strict criteria prior to undergoing this advanced modality. Numerous other therapies for other conditions of the foot and ankle are available, check out Family Foot and Leg Center and Naples Heel Pain for the latest in the care
of your foot and ankle conditions.

OCD of the Talus or O.L.T.

This refers to cartilage damage within the ankle joint, not to an obsessive compulsive disorder.

Pathology

Anterolateral lesions on the talar dome result from inversion and dorsiflexion forces, which cause the anterolateral aspect of the talar dome to impact the fibula. These lesions are frequently shallower and more wafer-shaped compared to medial lesions, possibly because of a more tangential force vector that results in shearing-type forces.

Posttraumatic medial lesions are deeper and cup-shaped. These arise from a combination of inversion, plantar flexion, and external rotation forces that cause the posteromedial talar dome to impact the tibial articular surface with a relatively more perpendicular force vector.

A study of the contact pressures on the talus with varying degrees of lateral ligament transections and ankle positions showed that the medial rim of the talus was subjected to high pressures, even without ligamentous transection. Another study revealed the difference in cartilage stiffness; the tibial cartilage is 18-37% stiffer than the corresponding sites on the talus.

The results of other studies showed that the mean cartilage thickness is inversely related to the mean compressive modulus. These findings may lend credence to the clinically observed etiology of osteochondral lesion of the talus or OLTs, such as repetitive overuse syndrome in medial lesions and an acute traumatic event in lateral lesions.

Observations from biomechanical studies suggest that the size of the lesion may affect the contact stresses in the ankle. Statistically significant changes in contact characteristics occur with lesions larger than 7.5 mm 15 mm; this finding indicates that lesion size may play a role in predicting long-term outcome.

Presentation

In most instances, the mechanism of injury is an inversion injury to the lateral ligamentous complex. Patients typically present with chronic ankle pain along with recurrent swelling and possibly, weakness, stiffness, instability and giving way.

Upon physical examination, asses joint laxity with the anterior drawer test and evaluate strength by comparison with the contralateral ankle. Joint laxity are uncommon findings upon physical examination. Palpation may reveal tenderness behind the medial malleolus when the ankle is dorsiflexed, indicating a posteromedial lesion. Anterolateral lesions may be tender when the anterolateral ankle joint is palpated with the joint in maximal plantarflexion.

Treatment

Medical Treatment

Conservative management of osteochondral lesions of the talus (OLTs) should be attempted first. Symptomatic patients with negative findings on plain radiographs should undergo an initial period of immobilization, followed by physical therapy. Studies indicate that a trial of conservative therapy does not adversely affect surgery performed after conservative therapy has failed. Patients whose plain images indicate OLTs and those who remain symptomatic after 6 weeks should undergo additional evaluation with MRI.


Surgical Therapy

Surgical management depends on several factors including patient characteristics like activity level, age, degenerative changes, as well as lesion location, size, and chronicity. However, surgical treatment adheres to 1 of the following 3 principles:

1) Loose-body removal with or without stimulation of fibrocartilage growth (microfracture, curettage, abrasion, or transarticular drilling)

2) Securing OLTs to the talar dome through retrograde drilling, bone grafting, or internal fixation

3) Stimulating the development of hyaline cartilage through osteochondral autografts (osteochondral autograft transfer system OATS, mosaicplasty), allografts, or cell culture (Carticel, Genzyme Biosurgery, Cambridge, Mass)

Arthroscopic intervention is associated with less surgical morbidity and joint stiffness, decreased rehabilitation time, and an increased functional outcome.

Postoperative Details

A postoperative rehabilitation program should be tailored to each patient's individual circumstances and goals by a licensed physical therapist. Generally, rehabilitation can begin after healing is demonstrated, which may occur after six to seven weeks of non-weight-bearing status if drilling or internal fixation was performed. With the goal of attaining full ankle range of motion, physical rehabilitation includes active and passive range-of-motion exercises and a home program, edema control, and strength and proprioceptive training.

Follow-up

Pain following operative treatment of OLTs is common for up to a year. MRI changes, such as edema, are slow to resolve and often match the patient's report of an achy feeling in the joint. After 6 months, a persistent effusion, a catching sensation, or severe pain signifies that healing is not progressing as intended, and further investigation with CT or MRI is appropriate.

Tennis and Common Injuries

With the season in full swing, more and more patients have tennis on their minds and sports often bring associated injuries.

Calf and Achilles tendon injuries

The usual underlying cause in both calf muscle and Achilles tendon injuries is a tight calf muscle-Achilles tendon unit. This muscle-tendon unit crosses both the ankle and knee. You can determine if your calf muscle-tendon complex is tight if you cannot raise the ball of your foot higher than the heel of that foot with the leg extended or straight. A sudden overload from pushing off your foot while your leg is fully extended is the most common cause of injury.

Your physician will evaluate your foot pain using physical exam as well as advanced imaging modalities like x-rays and ultrasound to formulate the best treatment plan possible for your condition.
Achilles tendiniits involves inflammation of the Achilles tendon due to overuse. To manage Achilles tendinitis, decrease playing time, use heel lift in your regular shoes, and stretch the calf muscles with your leg held straight.

A ruptured Achilles tendon is more serious than tendinitis. You may notice a sudden snap in the lower leg, as if someone has kicked you in the back of the foot. Since this is not a very painful injury, the player may be lulled into thinking that the injury is not as severe as it really is. After an Achilles tendon rupture, a player will be able to walk flat-footed, but will not be able to stand up on his or her toes on the affected side. Treatment involves casting or surgery, but surgery is recommended for most Achilles tendon ruptures, especially for athletes.

With tennis leg, which is a tear of the calf muscle on the inside of the leg, you may feel as if you have been shot in the upper calf by a pellet gun. This muscle tear can cause discomfort. It is important to stop playing at once and treat the calf muscle with RICE. Tennis leg may take several weeks to resolve.

Ankle sprains

Sprains of the outer ligaments of the ankle are common in tennis. You can minimize the risk by choosing shoes that are specifically designed for tennis and that have adequate support built into the outer counter of the shoe. The most effective treatment for ankle sprains is the usual RICE for 24 to 36 hours, then walking with adequate support on the ankle. In cases of severe pain, swelling, and bruising, see your doctor. Even for the most minor sprain, some sort of stabilizing ankle support is needed during play for six weeks.

Tennis toe can happen because the toes are jammed against the toebox of the shoe during quick starts and stops in tennis. Tennis toe is a hemorrhage under the toenail that can be very painful. To relieve the pressure, your doctor will treat it by drilling a hole in the toenail. To prevent tennis toe, keep your toenails cut short and wear shoes that provide adequate toe space.

For all cases of heel pain, see your foot doctor for evaluation.

What is Ankle Arthritis?

Arthritis is a disease commonly affecting the elderly and it can affect any joint in the body. The usual symptom of arthritis is pain.

There are two types of pain associated with arthritis: acute and chronic pain. Acute pain goes away after resting and is temporary. Chronic pain is constant pain and doesn't easily go away. The pain may lessen over time but it is still there. Chronic pain is always a symptom of osteoarthritis and rheumatoid arthritis.

Weight bearing joints are almost always affected by chronic pain. A good example is arthritis affecting the ankles causing severe heel pain. This involves joints between the shin bone and ankle bone or better known as tibiotalar joint. Ankle arthritis is common in the elderly because of the natural degeneration of the joints. At the tip of each bone is found a special tissue called cartilage bone. This bone is found inside each joint and it has a very smooth surface. As we get older, the smooth surface kind of roughens a bit and this is the cause of the arthritis pain. In worse cases, some patients have totally worn out the cartilages and the actual bones are rubbing against each other. Undoubtedly this causes extreme pain.

Ankle arthritis can also be found in the younger age group especially if the joint got injured. Frequent sprains can damage the cartilages. Being overweight can also put too much stress to the joints and the cartilages get to rub hard at each other because of the weight.

Shockwave Therapy: Will It Work For Me?

Shockwave therapy for the treatment of heel pain is a Non-invasive, PAINLESS procedure used to manage that nagging pain you feel that "you've tried everything for," and feel with every step you take!

That's right, no hospital, no operating room, no surgical blades, no bandages, no stitches, no PAIN!!

Shockwave therapy is performed by using a machine on which the heels are placed. It then expels high energy sound waves into your heel through the skin. These 'sound waves' move through the soft tissue structures and bone in your heel and break up some of the scar tissue that causes your discomfort. The special products in your body that heal tissue are attracted to the shockwaves, and a healing response occurs over time!

Heel pain is a common among patients treated at major health centers in the world! Many patients, young and old, are competitive and/or leisurely tennis and golf players. These individuals typically complain of pain in the heel(s) most intense with the first few steps taken during the competition that 'eases up' as the game goes on. At time the pain is felt in the arches, or even in the back of the heel.

Eventually, the pain becomes aggravating enough that it is felt with every step attempting to return a serve, or with every long drive down the fairway. When arch supports, custom orthotics, and cortisone injections fail, that is when shockwave therapy is introduced!

So¦.you're wondering what the recovery process is after shockwave therapy?

The procedure takes about half an hour per foot. Patients walk in, have the procedure, and walk out with a walking boot worn for an unspecified time period at your doctor's discretion, depending upon the origin of your heel pain (minimum of 24 hours, maximum of 2 weeks).

Patients report NO pain during the procedure and mild tenderness after the procedure for approximately 48-72 hours. You can walk, drive, go to the grocery store, sunbathe & swim, and go to dinner the evening of the procedure! Again, no hospitals, no operating room, no surgical blades, no bandages, no stitches, NO PAIN at all!!

How many treatments?

The number of treatments is dependent upon the type of shockwave therapy recommended for you, as well as your personal schedule and flexibility. To sum things up, there are two types of shockwave therapyHigh Energy and Low Energy. High energy shockwave therapy requires one treatment, and the sound waves are of a higher frequency level. Low energy is one treatment weekly for 5 weeks, and the sound waves are of a lower frequency level. Patients respond positively to both high and low energy shockwave therapy.

What are the disadvantages?

Unfortunately the majority of insurance companies do not cover the procedure despite shockwave's impressive beneficial results in the medical literature. Therefore, shockwave therapy is an out-of-pocket expense. The medical community is hopeful that shockwave therapy will be compensable by insurance companies in the near future.

Why should I choose shockwave therapy over a surgical procedure?

Because ESWT shockwave therapy has been found to be equally beneficial to an open surgical procedure, without the risks that open surgeries introduce (pronounced pain, swelling, infection, & the need for another surgery/revision).

Managing Toe Pain

It seems that every year, we see a lot of patients from all over the country who experience pain while walking which can be cause by the great toe joint. Some patients may think that bunions are the only thing that can cause this pain, but truly this is only part of the story. Numbers of studies in recent years show the natural progression of arthritis in toe joints which do not seem to have any bunion characteristics, such as prominent bone on the inside of the foot and deviation of the great toe towards the lesser toes, and this can be related in most cases to a distant trauma which occurred an unknown time ago.

We offer several pain management modalities to provide nonsurgical relief in this area, ranging from orthotics and cortisone injections, to the new Cold LASER therapy for recurrent pain which can reduce symptoms in chronic pain of arthritis significantly without medications.

Something as trivial as stubbing your toe, or landing abruptly and resultant pain in the bottom of the joint that seems to go away, may eventually return later on as a limitation in joint motion, and pain in the foot which is related to the adaptive and erosive side effects from "hallux rigidus". This is quite prevalent after age 50 and can effect men and women, and can be the major source of a significant amount of discomfort and limitation with walking.

At The Family Foot and Leg Center, we offer numerous conventional and proven treatment protocols for our patients to give you the best chance at pain free ambulation. If you have arthritic changes on a regular x-ray, and the deformity is not too severe, you may even qualify for the latest implant arthroplasty technique known as "joint resurfacing". This is a relatively advanced joint replacement which allows patients to walk immediately after the surgery, and there are no weight bearing restrictions with a very high success rate both in the short term and long term.

Not everyone is a candidate, but for those who are, you will experience immediate relief. After several weeks post-operatively, your range of motion should be close to the other foot, and in most cases significantly increased from before the procedure is done. It is an outpatient procedure, and we have strict criteria prior to undergoing this advanced modality.

We offer numerous other therapies for other conditions of the foot and ankle, and I urge you to check out our website regularly as changes are constantly bringing our current and future patients up to date on the latest in the care of your foot and ankle conditions.

Painful Neuromas of the Foot

Neuromas are tumors or new tissue growth that contain nerve fibers and neurons. These growths usually occur around nerve tissues and can occur anywhere in the body. In the most common neuroma that occurs on the foot is Morton's neuroma.

Mortons neuroma or sometimes referred to as intermetatarsal neuroma are non-neoplastic tumors, meaning there are no actual nerve growths and only nerve swelling occurs. This is commonly found at the balls of the feet between the metatarsal bones. Generally, neuromas can spontaneusly grow anywhere in the foot, but this type is commonly located between the 3rd and 4th toes.

Morton's neuroma occurs because of constant compression of the nerve due to improper footwear. This compression irritates the nerve causing it to thicken and enlarge.

Initial symptoms are numbness, burning, or tingling sensation of the foot. With constant use of improper footwear, the nerves become more inflamed and enlarged. This causes severe foot pain that persists for several days and not relieved by rest. Some patients experience permanent nerve damage.

Non-surgical treatments can be done for mild to moderate neuromas.

1. Cold packs help minimize pain and swelling.

2. Orthotic devices and paddings can help lessen the pressure on the nerves of metatarsal arch.

3. Pain relievers can be taken to reduce inflammation and pain.

4. Steroid injections help reduce local swelling and inflammation.

Surgical treatment is reserved only if the above treatments are unsuccessful. Usually, cryosurgery of the neuroma is the preferred procedure because of high success rate.

Common Treatments for Achilles Tendonitis

The Achilles tendon is the largest tendon in the body. It is located at the back of the foot and serves to attach the back of the heel bone to the large calf muscles. Since it is subjected to large amount of stress during running and jumping, it is prone to injury and can cause heel pain.

Achilles tendonitis or Achilles tendinopathy is the most common form of injury to the Achilles tendon. This is a condition where the tendon is inflammed and irritated, this can cause swelling and pain felt behind.

Heel pain in Achilles tendonitis is generally associated with an increase in running or jumping intensity or frequency. Acute tendonitis is characterized by pain at the onset of activity and fades as the exercise progresses. Pain usually subsides with rest. Chronic Achilles tendonitis may develop if acute tendonitis is not managed properly or left untreated.

There are several ways to treat Achilles tendonitis. The most basic step is to rest the affected foot to allow the inflammation to subside. Try not to use low-heeled shoes and putting heel lifts into the shoes can help. It is also recommended to avoid barefoot walking.

NSAIDS or non-steroidal anti-inflammatory drugs can be taken to relieve inflammation. NSAIDS are an over the counter medication and are available in many areas.

Placing ice to the swollen area can help reduce the inflammation. Cold therapy reduces pain and swelling because ice causes the blood vessels to narrow, limiting internal bleeding to the injured area. Icing also numbs the inflamed part, making it less painful. However, do not apply ice directly to the skin and instead wrap it in a thin towel before using over the injury.

If heel pain persists, immobilization of the foot can help. Foot orthotics or below the knee cast can be advised to help the Achilles tendon heal more rapidly, especially in chronic cases that do not respond to conservative measures.

Family Foot and Leg Center is a medical center specializing in healing health issues with lower leg and ankle. Come to us to get treatment for all your foot and lower leg disorders or obtain information about our practices at www.FamilyFootandLegCenter.com

Foot Pathology and Heel Pain

In humans, the heel is a bony prominence due to the calcaneus or heel bone. Other structures found on the heel are the plantar fascia and the attachment of the Achilles tendon. The plantar fascia is a stong fibrous tissue located below the foot.

These structures are important to maintain balance while running, jumping, or doing any activities involving the foot. Also, all these parts work in harmony while bearing weight. The heel is constantly exposed to stress due to opposing pulling forces done by the plantar fascia and Achilles tendon. The heel is also the first structure of the foot that hits the ground when walking or running. No wonder the heel has so much pathology.

The prevalent cause of heel pain usually involves the parts mentioned above.

When the plantar fascia gets irritated or injured this is called plantar fasciitis. Plantar fasciitis is usually seen in active individuals involved in sports. It is also seen in elderly patients where the plantar fascia weakens due to degeneration. The condition can also affect those who are not very active but have diabetes, are overweight, or use improper footwear.

Achilles Tendonitis is term used for an inflamed Achilles tendon. The causes of Achilles tendinitis are very similar to plantar fasciitis but it is fairly common in people involved in sports like runners and jumpers who overuse the Achilles tendon. On the other hand, plantar fasciitis is more common in individuals who develop injuries due to weight bearing.

Both conditions can be very painful and debilitating, but if the injury is not that severe the RICE method (rest, ice, compress, elevate) usually can reduce the pain. But if pain persists a visit to your podiatrist is your best option to properly treat your heel pain.

Flat Foot in Adults

A flat foot is a condition where the inner structures of the foot cannot sustain or maintain its arch. This is where the sole of the foot entirely comes in contact with the floor.

The arch of the foot is made up of several bones tightly held together by tendons and ligaments. This arch helps support and balance the weight of the entire body.

When walking, these structures constantly adjust to the terrain. The foot needs to be flexible in order to balance and bear the weight of the body as well as adapt to uneven surfaces. To be able to do this, the arch of the foot is needed.

All of us are born with flat feet. As the bones of the foot develop and the ligaments and tendons strengthen, the arch forms slowly. But in some cases, the arch never develops. It is estimated that 30% of the general population develop unilateral (flat foot) or bilateral (flat feet).

However, there are some adults who do not exhibit any symptoms or do not experience foot pain because they have a "flexible flat foot". However, when there is pain, this could be due to a deformity or injury to the tendons, ligaments, bones, or muscles of the foot.

There are several tests that could identify a specific cause of flat foot, so a visit to a foot specialist is recommended.

Family Foot and Leg Center is a medical center specializing in healing health issues with lower leg and ankle.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome occurs when there is compression of the posterior tibial nerve in the ankle, causing foot or heel pain. This condition is very similar to carpal tunnel syndrome in the hand, where the median nerve is compressed.

With tarsal tunnel syndrome, compression of the tibial nerve occurs within a tunnel created by a floor consisting of the calcaneus and bounded by the medial malleolus- the bump on the inside part of the ankle- and the far corner of the heel bone. The roof of the tarsal tunnel is formed by a retinaculum- a tough piece of fibrous tissue.

Within the tarsal tunnel run a number of tendons as well as the tibial nerve, and the posterior tibial artery.

In other patient, tarsal tunnel syndrome can occur even if the nerve compression is found elsewhere. An example would be a patient who has a pinched nerve in the low back along with tarsal tunnel syndrome. This condition is termed "double-crush" syndrome, where there is compression at least two locations.

Another problem is that those who suffer from tarsal tunnel syndrome may have peripheral neuropathy. This condition occurs when there is damage to the small nerves in the feet. A tingling sensation and numbness are typical symptoms. Diabetes and thyroid disorders are among the diseases associated with peripheral neuropathy are d.

Medications can also cause a peripheral neuropathy and various chemotherapy agents given for cancer.

Excessive alcohol and tobacco use as well can cause peripheral neuropathy as can exposure to heavy metals. The most common symptom of tarsal tunnel syndrome is foot pain, which can also be accompanied by numbness and tingling.

Tapping on the tibial nerve at the tarsal tunnel may cause pain and tingling to occur. The clinical impression can be confirmed with electrical testing (electromyography and nerve conduction). Electrical testing is important to evaluate the patient for other nerve entrapment problems such as a pinched nerve in the back. Peripheral neuropathy can also be diagnosed. Magnetic resonance imaging (MRI) and ultrasonography may be useful in evaluating a patient for underlying reasons for tarsal tunnel syndrome.

Medical therapy for tarsal tunnel syndrome may start with local injection of steroids into the tarsal tunnel. Physical therapy may be of some value in reducing soft-tissue edema which can ease pressure on the compartment.

Splints and braces may be helpful for patients who have anatomic abnormalities in the hindfoot and ankle.

When conservative therapy fails to help the patient's symptoms, surgical intervention may be warranted.
When a patient doesn't improve and has persistent pain, associated plantar fasciitis may be a cause of persistent pain in the medial heel region after surgery.

There is a plethora of advanced therapies, particularly MicroVas and TENS therapy. Both are instrumental in relieving symptoms, either as a preoperative modality or post operative, and therapeutic medicines such as as gabapentin are also helpful.

The Basics of Ankle Arthritis

The conditions of ankle arthritis can be really painful since the entire body weight is on your lower extremiteis while walking.

Conservative treatment can involve NSAIDS, physical therapy, injection therapy and ankle braces. Surgeries involve ankle arthroscopy (scope), implants, ankle stabilization procedures and fusions. The treatments of ankle surgery are not always successful like knee and hip implants.

The configuration of the ankle joint is difficult to formulate. Also the surface area to weight ratio is a challenge to duplicate. The problem can be tackled by seeking advice from a foot surgeon. Presently the United States and for many years Europe has been using a remarkable technique for this problem. It is known as ankle arthrodiastasis.. The process simply distracts the ankle joints and regenerates the cartilage which decreases the pain.

Currently, various institutions are combining the above procedure with joint replacement therapy. The procedure of joint fluid replacement therapy is not yet currently FDA approved for use in the ankle joint, so the patient must be fully informed of such.

Family Foot and Leg Center in Naples has been doing this procedure with good success in patients between 80%-90% improvement in pain. This is a good substitute to ankle fusion, which is a permanent procedure in which the surgeon puts two bones together to act as one, taking away the painful joint.

In fact, rheumatoid arthritis is the most common form of feet disorder. It is a degenerative disease of joints which involves the breakdown of cartilage. The symptoms are aching of feet and severe immobility in certain cases. It usually attacks the joints which render them to become weak and eventually prone to such dysfunctionality.

Common Causes of Heel Pain

Heel pain is probably one of the most common pathologic problem of the foot. We sometimes experience foot pain after long periods walking especially after spending a day at the mall. We can also develop heel pain after long periods of standing, just like when we stand on line or if our jobs involve hours of standing.

The heel pain that is produced is due to the enormous strain the feet have to endure during this time, trying to balance your whole body and also carry your weight at the same time. This is the reason why you have to often rest your feet. Most often, you could feel your feet straining and trying to tell you to give it a break.

Pain is one indicator for injury. Of course, pain has different intensities and people have their thresholds against pain. At first, the pain of the foot is bearable so we commonly ignore this condition. We only take notice of foot pain when the pain becomes so severe that it is no longer bearable. In this case you may need a foot doctor to check if there are pathologic conditions contributing to the pain.

Most often the cause of foot pain involves a structure found just below the foot called the plantar fascia. This plantar fascia is a strong fibrous tissue connecting the heel to the toes and is also responsible for the arch of the foot. Due to overuse, this fascia can get injured and cause inflammation, this is called plantar fasciitis. Though this condition could be easily treated by resting the foot, the pain can persist and can be debilitating so then it is advisable to seek a podiatrist.