Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is an uncommon cause of chronic pain.  It may affect either the lower extremities or upper extremities, and is a difficult medical problem to diagnose and manage.  CRPS is characterized by intense pain out of proportion, which is commonly described as a burning sensation.  It can often masquerade as peripheral neuropathy or tarsal tunnel syndrome in the foot, or as carpal tunnel syndrome in the hand. 

Complex regional pain syndrome is a dysfunction of the autonomic nervous system.  It can often be divided into CRPS types I and II.  CRPS I is also referred to as reflex sympathetic dystrophy, and occurs when there is injury without direct trauma to a specific nerve.  CRPS II involves an injury including a specific nerve, which develops into complex regional pain syndrome.  The symptoms and progression of CRPS is the same in both types.

The symptoms of CRPS evolve in stages.  Stage one is the acute stage, where the onset of intense pain out of proportion is seen.  This may develop some time after an injury.  Temperature changes may be seen in the earlier stages, as well as muscle pain in the area.  In the second stage, the pain will worsen with associated muscle atrophy and weakness of the affected extremity.  The toenails or fingernails may show changes in growth, and there may be noticeable hair loss on the extremity as well.  The skin may begin to thin and become shiny, with associated color changes.  In the third and final stage of CRPS, there is prolonged and often permanent pain, with associated contracture of the limb.  By the time the disease progresses to stage three, x-rays of the affected limb may show atrophy of the bone.

Because of the rapid progression of complex regional pain syndrome, treatment of the condition depends on accurate and quick diagnosis.  Recent literature has pointed at triphasic bone scans as being the test of choice when a diagnosis of CRPS is possible.  However, even the bone scans fail to show changes consistent with CRPS all of the time.  

Specialists in pain management typically carry out treatment for complex regional pain syndrome.  Medications for pain relief as well as anti-depressants and anti-convulsants are often used.  Steroids may be used to help reduce inflammation in the affected limb.  Changes in bone density may be treated with drugs used for osteoporosis.  Injections with local anesthesia may be used to block the sympathetic nerve fibers of the autonomic nervous system.

Other therapies include the use of topical analgesics, alternating application of heat and cold, physical therapy-assisted exercise, transcutaneous electrical nerve stimulation (TENS), and spinal cord stimulation.  Attempted sympathectomy has been tried, with mixed results. 

Though it is an uncommon disease, complex regional pain syndrome can be extremely debilitating.  Thus, early detection and treatment is the key to success once CRPS is diagnosed.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
863-299-4551 
www.FLFootandAnkle.com

Calcaneal Stress Fractures

The calcaneus, or heel bone, is subject to stress fracture in the active person.  A stress fracture occurs when there are repetitive, abnormal forces being absorbed by a normal bone.  This commonly occurs in the calcaneus in runners or in military personnel that spends a lot of time marching.  It is particularly common in those individuals who have a sudden increase in activity, such as an increased mileage while running.

The symptoms of calcaneal stress fractures include heel pain that is made worse with activity.  The onset of pain is typically insidious, or gradual.  The pain is often differentiated from plantar fasciitis by squeezing on the heel bone from the sides.  This will often hurt in a calcaneal stress fracture, but not in plantar fasciitis. 

X-rays are taken if there is suspicion of stress fracture, but will often not show anything until 2-3 weeks after the injury has occurred.  By this time, it is more likely to see evidence of healing bone in the form of callus formation on the x-ray.  If a stress fracture is diagnosed, or is a likely diagnosis, the foot must be kept non-weight bearing and the patient must rest for a minimum of 6-8 weeks while the bone can heal.  If a person continues to walk and/or run on a calcaneal stress fracture, it can turn into a complete fracture of the calcaneus, which carries a much more ominous prognosis.

If a stress fracture is suspected, activity should be stopped and the person should see a foot and ankle specialist right away.  X-rays and a careful clinical examination are generally enough to determine the problem.  Occasionally a CT or MRI may be performed for a more thorough image of the calcaneus and the rest of the foot. 

Treatment for a stress fracture involves rest and cessation of weight-bearing activity.  The patient is often placed in a cast for several weeks while the bone is allowed to heal.  Crutches may be useful in offloading the foot.  Occasionally calcaneal stress fractures are seen on both feet.  In particular this can be seen in individuals beginning a new training program, such as an amateur runner who suddenly increases their activity. 

Upon returning to activity, it is important for the patient to begin a gradual return to activity.  Increasing their activity level too quickly can result in continued pain, additional stress fractures, and even a complete fracture of the previously affected bone. 

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Bone Grafting in Foot and Ankle Surgery

The use of bone grafts in foot and ankle surgery is a topic of interest to the podiatric surgeon.  Bone grafting may be used in various procedures to replace a defect in the bone, to extend or lengthen a certain bone in the foot, to aid in the fusion of two bones, or in other instances where extra material is needed.  A comprehensive understanding of the biologic principles of bone healing and bone grafting is necessary for the use of these materials.  Some of the information involved in bone grafting may be passed along to the patient as well.

In order for a bone graft to be useful in the body, it must possess certain properties.  These properties are osteoconduction, osteoinduction, and osteogenesis.  Osteogenesis refers to the formation of new bone.  This can only take place in a transplanted piece of bone that is used as a graft when the osteoblasts, or the cells responsible for laying down new bone, are transplanted with the graft and are kept alive.  This is really only possible in a bone graft that comes from the same person that it is being used in, such as a bone graft harvested from the iliac crest that is transplanted into the foot. 

Osteoconduction refers to the ability of a bone graft to allow as a matrix for new bone to grow into.  Once a bone graft is placed into the body, it must be resorbed and incorporated into the body.  A highly osteoconductive material would allow the cells responsible for new bone formation and vascular tissues to easily maneuver into the bone graft. 

Osteoinduction refers to the process by which new bone growth is stimulated in the host’s body.  This occurs when the host’s stem cells are activated and brought to the site of the bone graft, and differentiate into bone cells.  This process is induced by bone morphogenic proteins (BMPs), platelet derived growth factors, and an array of other chemicals, or cytokines, that attract cells to the area. 

Depending on the type of bone graft used, there is generally a mixture of osteoinductive and osteoconductive properties incorporated into the material.  The only materials that will have osteogenic properties are real bone of the patient. 

The use of cortical bone (the tough, highly consolidated outside of a bone) and cancellous bone (the spongier, highly vascular inside of a bone) is also a consideration in bone grafting.  Generally speaking, cancellous bone offers a structure that is highly osteoconductive and osteoinductive, while the cortical bone offers strength to the bone graft. 

Bone grafts are used with great success in foot and ankle surgery, largely due to the fact that these parameters are all considered by the operative surgeon.  The popularity of synthetic materials used as bone grafts speaks to the successful outcome of their use.

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Screening for P.A.D.

Peripheral arterial disease, commonly referred to as P.A.D., is a clogging of the arteries with fatty deposits. These fatty deposits, or plaques, can build up over time, slowly narrowing the arteries in the body. When the arteries become hardened and narrowed, it may also be referred to as atherosclerosis. P.A.D. is most common in the lower extremities, but can also occur in the upper extremities and in vessels supplying major organs like the kidneys or stomach. When the vessels of the legs are affected, it can lead to significant changes, which some people may attribute to “poor circulation”.

Peripheral arterial disease can often indicate a problem in not just the vessels of the legs, but in all the vessels in the entire body. For this reason, people with P.A.D. are at an increased risk for heart disease and stroke. When atherosclerosis occurs in the vessels supplying blood to the heart, it is called coronary artery disease (C.A.D.)

About 8 million Americans are affected by P.A.D., and the numbers are on the rise. This is partly due to a greater effort to screen for peripheral arterial disease, but may also be attributed to a greater incidence of the disease and an increase in risk factors across the American population. Risk factors for P.A.D. include diabetes, smoking, high blood pressure, high cholesterol, and a history of heart disease or stroke. African Americans are also at an increased risk for developing P.A.D.

Peripheral arterial disease is a slowly-developing process in the body, and as such, the signs and symptoms of the disease can be slow to develop too. In fact, they can often go unrecognized. Most commonly, the symptoms will include pain and cramping in the legs, thighs, buttocks, or feet that occurs while walking and is relieved with rest. This is referred to as claudication, and is a reproducible pain. This means that the pain will appear with a consistent amount of activity, such as walking two blocks before the pain begins. This pain is attributed to a lack of oxygen to the muscles, most commonly in the leg, due to the narrowing of the arteries supplying the muscles. Other symptoms may include pain at night in the toes or feet that disturbs sleep, or slow healing wounds in the legs and feet.

In the podiatrist’s office, screening for P.A.D. becomes routine, particularly when patients are at an elevated risk for developing the disease. Screening involves checking for pulses in the feet, and monitoring the time it takes for the skin to return to a normal color after the blood is pressed from it (capillary fill time). The pulses in the feet can also be listened to with a hand-held Doppler device. This allows your podiatrist to listen to the blood flow into your feet, and have an idea of the condition of your vessels.

Common tests for diagnosing peripheral vascular disease include the use of segmental pressure measurements, ankle-brachial indices, measurement of toe pressures, and measurement of transcutaneous oxygen pressures. These tests can give a comprehensive analysis of the blood flow to the feet. If it is necessary, an arteriogram can also be performed. This test involves injecting a dye into the arteries, then taking x-rays to visualize the vessels. This is generally only done for surgical planning, when it is determined that there is a total or nearly complete occlusion of a vessel, and it must be visualized pre-operatively.

Treatment for P.A.D may involve surgery by a vascular surgeon to stent the vessels, or to create a bypass in the arteries. There are also medical treatments that can be used to bust up the clots in the arteries. The P.A.D. Coalition, a non-profit organization that promotes screening and education about peripheral vascular disease, recommends the following lifestyle changes that can help prevent or treat mild to moderate peripheral vascular disease:

• Quitting smoking
• Lowering blood pressure to 140/90 mmHg, or 130/80 mmHg for people with diabetes or chronic kidney disease
• Lowering LDL (“bad) cholesterol to less than 100 mg/dL. For people at an increased risk of heart disease or stroke, the target number may be less than 70 mg/dL.
• Lowering HgbA1c (glycosylated hemoglobin) to less than 7% for diabetic patients
• Using anti-platelet medications such as aspiring or clopidogrel under the supervision of a doctor
• Eating healthy
• Regular exercise, such as walking at least 30 minutes per day, 3-4 days per week.

Peripheral arterial disease has become a serious problem, and can lead to poor wound healing, gangrene, infection, and amputation. For this reason, it is commonly screened for in the podiatrist’s office. If you have any questions, or feel that you or someone you know may be affected by P.A.D., talk to your doctor today. Catching it early can make a huge difference in the outcome of the disease.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Lyme Disease

Lyme disease is a complex, multisystem illness that is caused by the microorganism Borrelia burgdorferi. Borrelia burgdorferi is a tick-borne spirochete, which is transmitted by Ixode ticks. The ticks act as a reservoir for the bacteria, which can then be transmitted through their bites. Typically the tick must stay attached to a human source for 24-48 hours in order to transmit the bacteria. The disease was first recognized in 1975 in Lyme, Connecticut, for which it is named.

Lyme disease can be broken down into three stages. The first stage begins after a period of 3-30 days, and is characterized by a classic “bulls-eye” lesion, also known as erythema migrans. This is pictured above, and is seen at the site of infection. It may be accompanied by fever, malaise, headache, and joint and/or muscle pain.

The second stage occurs 1-6 months following the initial stage. Arthritis is the main presenting symptom, with associated muscle pain and swollen lymph nodes. A certain percentage of patients will neurological symptoms, including meningitis or Bell’s Palsy. Some will present with carditis as well.

The third stage may occur months to years after exposure. There is chronic neurological involvement, most commonly a subtle form of encephalopathy that affects mood, memory, and sleep. Arthritis and muscle pain may be a chronic symptom by this stage.

Treatment of Lyme disease depends on the stage of the disease at presentation as well as the symptoms. Antibiotics are used in the early stages to fight the spirochete infection. Doxycycline, tetracycline, and amoxicillin have all been used. Neurological abnormalities may be treated with cephalosporins or penicillin. As for the arthritis associated with Lyme disease, the symptoms are generally treated much like any other arthritis. NSAIDs with or without intra-articular steroid injections may be of benefit.

Of course, the disease should be treated before it progresses from the first stage. With the presence of arthritis plus a history of possible exposure to ticks and a bulls-eye rash, antibiotics should be started. Laboratory testing is typically limited to a blood draw to look for IgM antibodies. However, this will often take 3-6 weeks to show up. Therefore, antibiotics may need to be started before an absolute diagnosis can be made. An ELISA test or a Western blot can be performed to confirm the diagnosis after empiric therapy is started.

Incidence of Lyme disease is most common in wooded areas. In particular, the disease persists in the Northeastern United States, as well as parts of Minnesota, Wisconsin, and Northern Michigan.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Pilon Fractures

The term ‘pilon’ was first used in 1911 by French radiologist Destot to describe the ankle joint. It is derived from the French word for ‘pestle’, and helps to describe both the shape of the ankle joint as well as the mechanism of this type of injury. Pilon fractures occur when axial compression is applied through the ankle joint, exceeding the amount of force that the ankle can transmit through the body. When this happens, a serious injury may occur, shattering the tibia and sometimes the fibula as well.

Pilon fractures are uncommon, accounting for 7% of all tibia fractures and less than 1% of all lower extremity fractures. They are an interesting subject, however, due to the orthopedic challenges that they present. Many pilon fractures will also be open fractures, meaning that the skin has been compromised in the injury and the bone may actually be visibly protruding from the skin. Higher impact injuries, such as from a motor vehicle accident or a fall from a height will involve a fracture of both the tibia and fibula. Lower impact injuries, such as skiing accidents, may only involve a fracture of the tibia. These fractures are generally intra-articular, which adds to their complexity.

Classification systems for pilon fractures include the Ruedi and Allgower classification, which was the first one described in 1969. Later, the AO/OTA classification was established in 1996, which gave further detail as to the extent of the injury. Both systems differentiate between number of fracture fragments, displacement of fracture fragments, and articular involvement. These systems are useful in communicating the extent of the injury, however little intra- and inter-observer agreement has been seen with the use of either of the two systems.

Diagnosis of pilon fractures is made with medical imaging. X-rays are typically ordered first, followed by a CT scan. CT scans will allow the foot and ankle surgeon to visualize the number of fracture fragments and the arrangement of the injury, and will help in planning the surgical correction.

Because of the type of injury that causes a pilon fracture, the patient is usually brought in to the emergency room and is treated first by the trauma team. This would include management of airway, breathing, circulation, disability, and exposure to any contaminants and/or toxins. Once the patient is stabilized, the fractures may be treated. There is a high correlation between pilon fractures and spinal fractures, so imaging should include the entire vertebral column.

While historically pilon fractures have been treated conservatively, most physicians would agree that treatment with surgery is necessary to regain function of the limb. Early reasons to avoid surgery were poor outcomes and increased risks involved with surgery, however, modern surgery has evolved to have a much greater success rate than in the past.

Surgical treatment of pilon fractures is most commonly done in a two-stage fashion. The first stage involves putting an external fixation device on the leg. These are done as either ankle-spanning (pins are placed through the talus, the bone that sits in the ankle joint) or as ankle sparring (no pins are placed through the talus). Today, ankle-sparring procedures have become more popular as they decrease damage to the joint itself. The external fixator is used to help realign the fracture fragments, and uses the theory of ligamentotaxis to do so. Once the fragments have bee realigned, and most of the initial swelling has decreased since the injury, a more definitive procedure may be performed to fix the ankle and leg

This commonly involves the use of either metal plates or an intramedullary nail, or both. Intrameduallry nails are long nails that are placed longitudinally through the bone. This gives the bone strength and helps to realign the fractures. The plates will also help to realign fragments, particularly of the fibula, should it be involved in the fracture. A variety of techniques may be used surgically, depending on the extent of the injury and the damage done to the bones.

Prognosis of pilon fractures depends heavily on the extent of injury. Numerous studies have shown that the more significant the injury, the greater chances of post-operative complications, infection, delayed union, malunion, and non-union. Good results may be seen with fractures that show minimal displacement and comminution (meaning that there are several fracture fragments), though unsatisfactory results are more commonly seen with more extensive comminution, joint involvement, and displacement of fracture fragments. Advances to surgical technique have made the outcomes more favorable in recent years, yet there is still an increased risk of post-operative sequelae with more extensive injury.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Study Looks at Limb-Length as a cause of Plantar Fasciitis

A recent study published in the Journal of the American Podiatric Medical Association looked at limb-length discrepancy as a cause of plantar fasciitis. The article, written by Mahmood et al., analyzed 26 patients with unilateral heel pain that was previously diagnosed as plantar fasciitis. The limb-length of the patients was then measured, using a combination of methods. The results of the study showed that there was a strong correlation between a longer limb and unilateral plantar fasciitis pain.

Taking a further look at the results of the study, it was found that the vast majority of the unilateral heel pain was found on the same side of the body as the longer limb. Presumably, a longer limb would function in a more pronated position during stance. This would put extra strain on the plantar fascia, the large, thick strip of aponeurosis running along the bottom of the foot.

The study also looked at Body Mass Index (BMI) as a possible cause of plantar fasciitis, however, the results were not significant for these two factors to be correlated.

Plantar fasciitis is one of the most common conditions that podiatrsts see, and is the most common cause of heel pain in the adult population. There are a number of different theories on why it develops, most of which focus of the biomechanics of the foot and lower extremity. This study by Mahmood et al. is one of few peer-reviewed journal articles to research the etiology of the common disorder.

Treatments for planar fasciitis are as numerous as the possible causes of the problem. Conservative therapy includes things like stretching, ice, rest, temporary arch supports/padding, night splints, functional orthotic devices, and oral anti-inflammatory medications such as NSAIDs. Other measures may include corticosteroid injections, extracorporeal shockwave therapy (ESWT), or platelet-rich plasma (PRP) therapy. Still more drastic measures may include surgical intervention, when all other conservative therapies have failed.

The authors of the study highlight an important decision in the possible treatment of plantar fasciitis associated with a limb-length discrepancy. That is the use of a hell lift in addition to the use of a functional orthotic device. The hell lift addresses the difference in limb length, which may be the etiology of the condition. Thus, the treatment would address the root of the problem, and not merely the symptoms.

More research into the etiology of plantar fasciitis is warranted, as this is an extremely common condition. Limb-length may be just one of many possible causes, and more studies like this one will be needed to determine them.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com