Ankle Sprains

Treatment includes resting and elevating the ankle and applying ice to reduce swelling. Compressive bandages, braces or even a cast (in stage 4 severe ligament injury) also may be used to immobilize and support the injury during healing. Serious ankle sprains, particularly among competitive athletes, may require surgery to repair and tighten the damaged ligaments. Chance of surgery does increase if ankle sprains are not treated correctly.

  

To prevent ankle sprains, try to maintain strength, balance, and flexibility in the foot and ankle through exercising, stretching, and wearing well-fitted shoes. no flip flops or crocks  when running or exercising.

Ankle sprains are caused by an unnatural twisting or force on the ankle bones of the foot, which may result in excessive stretching or tearing of one or more ligaments on the outside of the ankle. The severity of the sprain can impact the degree of damage as well as the type and duration of treatment. If not properly treated, ankle sprains may develop into long-term problems.

In everyday practice at CFFA I see many examples where patients go to ER right after the injury and get Xrays and if there is no fracture present, they are told that it is just a sprain but no ankle brace and other offloading device is given therefore directly putting patient at risk for not correctly healing the injury. This incorrect treatment can cause future problems, specifically lateral ankle instability that requires surgery if early treatment is not performed.

 I always recommend that patients have ultrasound to evaluate the degree of Anterior Talo-Fibular ligament injury to determine the correct treatment protocol for them. Correct diagnosis is very important.

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

All about Bunions

What Is a Bunion?
A bunion is an enlargement of the joint at the base of the big toe -- the metatarsophalangeal (MTP) joint -- that forms when the bone or tissue at the big toe joint moves out of place. This forces the toe to bend toward the others, causing an often painful lump of bone on the foot. Since this joint carries a lot of the body's weight while walking, bunions can cause extreme pain if left untreated. The MTP joint itself may become stiff and sore, making even the wearing of shoes difficult or impossible. Bunions- from the Latin "bunio," meaning enlargement-can also occur on the outside of the foot along the little toe, where it is called a "bunionette" or "tailor's bunion."Symptoms

• Development of a firm bump on the outside edge of the foot, at the base of the big toe.
• Redness, swelling, or pain at or near the MTP joint.
• Corns or other irritations caused by the overlap of the first and second toes.
• Restricted or painful motion of the big toe.

How Do You Get a Bunion?
Bunions form when the normal balance of forces that is exerted on the joints and tendons of the foot becomes disrupted. This can lead to instability in the joint and cause the deformity. They are brought about by years of abnormal motion and pressure over the MTP joint. They are, therefore, a symptom of faulty foot development and are usually caused by the way we walk, and our inherited foot type, our shoes, or other sources.

Although bunions tend to run in families, it is the foot type that is passed down -- not the bunion. Parents who suffer from poor foot mechanics can pass their problematic foot type on to their children, who, in turn, are also prone to developing bunions. The abnormal functioning caused by this faulty foot development can lead to pressure being exerted on and within the foot, often resulting in bone and joint deformities such as bunions and hammertoes.

Other causes of bunions are foot injuries, neuromuscular disorders, or congenital deformities. People who suffer from flat feet or low arches are also prone to developing these problems, as are arthritic patients and those with inflammatory joint disease. Occupations that place undue stress on the feet are also a factor; ballet dancers, for instance, often develop the condition.

Wearing shoes that are too tight or cause the toes to be squeezed together is also a common factor, one that explains the high prevalence of the disorder among women. Read more here.

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

Hyperhidrosis of the Feet

Hyperhidrosis of the feet, also termed plantar hyperhidrosis, is characterized by excessive sweating of the feet that is not onset by any cause, such as exercise, fever, or anxiety. Most people suffering from hyperhidrosis of the feet also experience hyperhidrosis of the hands, or palmar hyperhidrosis. Approximately 1-2% of Americans suffer from this disorder.

Sweating is a healthy process utilized by the body in order to cool itself and maintain a proper internal temperature, which is controlled by the sympathetic nervous system. In individuals with hyperhidrosis, the sympathetic nervous system works in "overdrive", producing far more sweat than is actually needed.

Plantar hyperhidrosis is considered primary hyperhidrosis. Secondary hyperhidrosis refers to excessive sweating that occurs in an area other than the feet, hands, or armpits, and this indicates that is related to another medical condition, such as menopause, hyperthyroidism, or Parkinson's disease.

The symptoms of hyperhidrosis of the feet can include foot odor, athlete's foot, infections, and blisters. Because of the continual moisture, shoes and socks can rot which creates an additional foul odor and can ruin the materials, requiring shoes and socks to be replaced frequently. In addition to the physical symptoms, emotional health is often affected as this disorder can be very embarrassing.

If left untreated, hyperhidrosis will usually persist throughout an individual's life. However, there are several treatment options available. A common first approach to treating hyperhidrosis of the feet is a topical ointment. Aluminum chloride, an ingredient found in antiperspirants, can be effective at treating hyperhidrosis if used in high concentration and applied to the foot daily. Some individuals can experience relief this way, while others encounter extreme irritation and are unable to use the product. Another procedure is the use of Botulinum Toxin A, commonly referred to as Botox. This is injected directly into the foot, and is effective at minimizing the sweat glands in the injected area. These injections must be repeated every 4 to 9 months.

If these treatments are ineffective, oral prescription medications may be taken in an effort to alleviate the symptoms. Again, some will experience relief while others do not. Going barefoot reportedly provides relief for most sufferers.

A final approach to combating hyperhidrosis of the feet is through surgery. Surgery has been less successful on patients with plantar hyperhidrosis than on those with palmar hyperhidrosis. It is only recommended when sweating is severe and other treatments have failed to work. This kind of surgery usually involves going into the central nervous system, and cutting nerves to stop the transmission of signals telling the foot to sweat.

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

Pediatric In-Toeing

In-toeing is a common complaint among parents who's children are at or near walking age.  It will frequently bring parents in with their young children, who may say that the child “walks funny” or is “pigeon-toed”.  It is most often noticed by the parents as the child begins to watch, typically around 12 months of age, but may present at anytime during childhood for various reasons. 

In-toeing, particularly in children less than 8 or 9 years old, is usually harmless.  It may represent a normal variation of anatomy and development, and will usually resolve with time.

However, what often brings parents in to the specialist’s office is that their child walks with limp, trips over their feet, is in pain, or has difficulty keeping up with their peers.  In these cases, a through evaluation of in-toeing is warranted by the specialist.

Of the many things that may cause a child to walk with their toes pointed inwards, there are three things that are seen most often.  These are internal rotational positions of the hip, leg, and foot. 

In the hip, femoral anteversion may cause the child to have an in-toed gait.  This is a condition whereby the femur is rotated inwards.  At the femoral head, where the bone inserts into the pelvis to create the hip joint, an increase in internal rotation can cause this to happen.  It is typically most noticeable around the time a child begins Kindergarten, at about 5 or 6 years old.  The child may “W” sit, where they sit with their legs behind them, putting pressure on the legs.  This can reinforce the malaligned position of the femur, and is typically discouraged in children with mild femoral anteversion. 

Most cases of femoral anteversion will resolve over time, reaching a normal position by the time the child is 10.  For severe cases, surgery may be necessary to cut the femur bone and rotate it into a more normal position. 

Working down from the hip, the next level that may cause pediatric in-toeing is in the leg at the tibia-fibula segmnt.  Internal tibial torsion is normal until the age of 2, where as the child walks the tibia begins to untwist.  The leg usually normalizes by the time the child is 10.  For severe cases of internal tibial torsion, resulting in significant disability or pain, surgery may be required to cut the tibia and fibula and realign them in a more normal position.

In the foot, a positional deformity called metatarsus adducutus may contribute to in-toeing.  This is commonly seen at birth, and may represent a normal variation.  In severe cases, treatment may be required to straighten out the foot.  Typically conservative measures are used first, such as straight-lasted shoes or specialized bars and braces that help to straighten out the foot.

If conservative therapy fails, surgery may be required to straighten out the foot.  However, this is reserved for severe, unrelenting and rigid cases.

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

Could Poor Circulation Indicate a Looming Heart Attack?

Do your feet and legs cramp when walking?  Do you have pain at night when laying down or when your feet are elevated?  If so, you may have a condition know as peripheral arterial disease.

Peripheral arterial disease, or PAD, is a condition where the arteries of the lower extremity become narrowed due to plaque build up and/or stenosis of the arteries. Plaque build up, or atherosclerosis, is when cholesterol and other substances in the blood cause debris to stick to the insides of the artery. Over time, this can narrow the artery, much like grime can narrow the plumbing in your home.

Symptoms of PAD include cramping upon activity in the calves, thighs, or feet. This pain is usually reproducible with a certain distance, and is relieved with rest. Other signs of PAD may include hair loss in the feet and legs, coldness in the toes, color changes in the feet with a change in position, and absence or weakness of pulses on physical exam.  Sometimes people with peripheral arterial disease will say something about having “bad circulation”. 

Left untreated, peripheral arterial disease will get progressively worse as the arteries continue to narrow.  Pain can increase in frequency, and the distance that a person will be able to walk without pain will decrease.  Poor circulation in the feet can also lead to poor wound healing and areas of gangrene development in the toes.

Risk factors for peripheral arterial disease include smoking, obesity, high blood pressure, high cholesterol, and diabetes. Advanced age can also contribute to the development of PAD, as well as inactivity.

The diagnosis of PAD is made through a detailed history and physical exam, which should include checking pulses to the feet and inspection for other signs.  Often non-invasive vascular testing is ordered in the clinical setting.  This involves putting blood pressure cuffs up and down the legs at different levels and measuring the pressure difference through the leg.  This can help isolate the area of disease.  The amount of oxygen reaching the toes can also be measured clinically, which can also help monitor the disease. 

For patients with peripheral arterial disease, screening for plaque build up in all parts of the body is essential. Atherosclerosis is a systemic disease, and the coronary arteries supplying the heart and carotid arteries supplying the brain can also show signs of disease. Unaddressed, this build-up can lead to heart attack or stroke.

It is for this reason that it is incredibly important for patients with risk factors to be screened for PAD.  The risk of heart attack and stroke associated with peripheral arterial disease has been well documented.

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

Os Trigonum Syndrome

The os trigonum is an accessory bone found in the posterior foot.  It is seen directly behind the lateral tubercle of the body of the talus in 2.5% to 14% of people.  It is a round, triangular, or oval shaped bone that is variable in size, but is typically quite small compared to the surrounding bones.

Os trigonum syndrome may be seen in people with the anatomical variant, and presents as pain in the back of the ankle.  This is due to impingement of the bone, and the condition is sometimes referred to as a posterior impingement syndrome.  Pain may be reproduced when the patient goes up on their toes, thus adding pressure to the posterior ankle.  This is particularly noticeable in ballet dancers or in athletes that spend time on their toes. 

Diagnosis of the condition is made largely on clinical suspicion and presentation, and is confirmed with x-rays.  The accessory bone may be seen on x-ray.  In conditions where the bone is not seen on x-ray, an MRI may be ordered to further assess the area.  MRI may show a separation between the body of the talus and the accessory bone, as well as any swelling in the area. 

Conservative therapy such as rest, ice, and orthotics may be beneficial to some, although surgical excision is usually necessary to relieve the symptoms.  The accessory bone may be removed completely, in an attempt to relive pain and restore function.  For the competitive athlete or ballet dancer, this may mean a period of rest from activity while their surgical site heals. 

Os trigonum syndrome should be differentiated from other possible etiologies of pain, such as tendinitis of the flexor hallucis longus tendon, which runs in close proximity to the os trigonum.  Fractures and osteochondral defects of the talus should also be ruled out, particularly in cases with a report of trauma to the area.  Space-occupying lesions such as soft tissue tumors (usually benign in nature) should also be ruled out, particularly when there is no evidence of accessory bone on plain film x-ray.  The entire foot and ankle complex should be thoroughly evaluated for an other sprains and strains that may be present.

Remember that pain is an indication that something is wrong, and should never be considered “normal”.  Athletes are notorious for “playing through the pain”, but should be evaluated by a foot and ankle surgeon for any acute or chronic pain that they may be having.

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

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