What are some of the biggest challenges when recovering from an Achilles tendon rupture?

The biggest challenges or complications occurring after an Achilles tendon rupture include possibility of re-rupture, decreased quality of life during initial immobilization phase especially if this includes limited weight bearing, time off work, difficulty regaining full strength, and difficulty with full return to previous level of sport participation.

What is Morton’s Neuroma?

Morton Neuroma refers to the interdigital nerve entrapment in the third webspace (occasionally the second webspace) of the foot.

What is the rehab like following an Achilles tendon rupture being treated without surgery?

The initial treatment protocol includes immobilization in a walking boot and, according to Weisskirchner Barfod et al, this period lasts eight weeks. During this time you may be instructed to stay off the injured leg fully, and comply with a weight bearing restriction, however this study has shown that full weight bearing during this period causes no setbacks and can improve quality of life. (Be sure to ask your physician and follow their protocol.) During this eight week immobilization phase there will be use of multiple heel wedges, and they will be slowly removed over the course of this time. There may also be instructions for gentle range of motion exercises. After the initial eight weeks the patient will be released from use of the walking good and will begin progressive strengthening. This may include referral to a physical therapist to lead this phase, which can last several months depending on individual progress.

What is meant by a functional brace that can be worn after Achilles tendon rupture?

Functional non-operative management is a relatively new bracing concept that involves early weight-bearing and range of motion. These two rehabilitation factors have shown to prevent detrimental alterations in muscle characteristics and increase maturation of collagen fibers during the tendon healing process. There is some difficulty with beginning early range of motion, in that the brace or orthosis must be removable which is more costly and requires patient compliance. Simply adding weight bearing to the early rehabilitation protocol, however is much easier, and involves changing casts to one that has a weight bearing device, such as a Bohler iron, added. There are several variations to functional braces that range from the non-removable early weight bearing casts with a Bohler Iron to the more technically advanced removable orthoses that can be adapted for early weight bearing.

I have had plantar fasciitis for six months now and have worn the night splints and a walking boot and had custom orthotics made but still have it.  My doctor wants me to see a physical therapist.  What can they do for me and is this necessary?

A physical therapist will at your overall alignment (joint structure), how you move, and will tease out any muscle imbalances that might be contributing to your ongoing plantar fasciitis.  They also can perform adjustments if need be, fabricate orthotics, and use manual therapy as well as some modalities to help you get rid of the plantar fasciitis and hopefully keep it away for good.  Especially since you were in a walking boot for a while, follow up with some ankle strengthening is indicated.

I am told that I have plantar fasciitis but nothing I am doing is helping. My pain is on the inside of my foot, near my arch and is tingling and numb at times. Is this really plantar fasciitis?

Typically plantar fasciitis is described as a sharp, stabbing pain with the first steps in the morning that then diminishes as the day progresses. The pain originates more towards the edge of the heel than towards the arch. The symptoms you are describing sound more like Baxter Nerve entrapment. A good thorough assessment by a physical therapist or a physician should tease out the actual diagnosis.

I always thought that you had to have surgery if you rupture your Achilles tendon. Is this true?

No, however most research shows that surgical repair results in significantly lower rerupture rates at three and a half percent compared to non-surgical repair, which has a rerupture rate around twelve and a half percent. More recently research has indicated that a functional non-operative protocol results in rerupture rates similar to those who have undergone surgical repair, with one study reporting seven percent and another reporting eight percent rerupture rate following non-surgical early weight bearing protocols. Functional non-operative management is a relatively new bracing concept that involves early weight-bearing and range of motion. These two rehabilitation factors have shown to prevent detrimental alterations in muscle characteristics and increase maturation of collagen fibers during the tendon healing process. At this time the protocols for early weight bearing and early range of motion for non-surgical Achilles tendon repair and very inconsistent and are not research supported. It is clear that more research is warranted to help surgeons and patients justify their choice of surgical vs. nonsurgical repair and decide to participate in rehabilitation that incorporates early weight bearing and early range of motion. At this time, research does show that non-surgical repair with early weight bearing is a viable option that does not seem to increase risk of rerupture rate or other complications.

I am no longer able to straighten my second toe.  It does not hurt but I don’t like the way it looks when I wear flip-flops.  Is there anything I can do to straighten it out?

A bent toe is typically due to ligamentous instability surrounding the toe joint.  Depending on the progression of the deformity (whether or not it is rigid or still flexible) there are several options.  Conservative treatment would be shoe alterations and physical therapy for foot strengthening and addressing your walking form.  Surgical treatment is typically reserved for more fixed deformities but can help with further progression of the toe deformity and involves suturing torn structures around the joint.

My mom has several toes that are painful and crossed under.  She says that I should not wear high heels because that is what caused her problem.  Is this true or am I just doomed to have my mom’s feet when I get older?

High heels are identified as a major cause for toes crossing or becoming stuck in a bent position, called hammer toe. Shoes with a narrow toe box or shoes that place an excessive amount of force across the base of your toes can cause hyperextension of the toe joints (bending past their normal range) and a stretching and tearing of the ligaments surrounding the toe joint. Genetics does play a small role, but is not as big of a factor as shoe choice. Wearing a flatter shoe with a wide toe box can help prevent problems with your feet in the future.

Our grandson was diagnosed with a rare tumor of the big toe called a synovial sarcoma. It wasn’t picked up on any X-ray or MRI and misdiagnosed as “turf toe.” But as our son (who is a medical student) pointed out, they didn’t do an MRI with contrast or they might have found it sooner. We are wondering why not?

As you probably know by now, synovial sarcoma is a malignant soft-tissue tumor that occurs most often in the extremities (arms and legs). A regular X-ray will not show soft tissue malignancies. It was unusual that the more advanced imaging (MRI) did not at least show some change in intensity to indicate a mass of this type.

MRI with contrast is not typically the next step in diagnosis when there has been no indication of a problem. It is a more expensive test and exposes the patient to a type of dye that is injected into the bloodstream just before (or sometimes during) the procedure. Certain abnormalities, such as tumors, will absorb the dye and show up very clearly on the MRI with contrast.

There have been reported cases where repeated MRIs did NOT reveal a malignant soft-tissue tumor later diagnosed as synovial sarcoma. As a result, an accurate diagnosis and appropriate treatment were delayed by a full year for the patients in question. This has led to a recent recommendation for physicians to consider synovial sarcoma when a patient presents with what looks like turf toe but has unusual patient history and lack of response to treatment.

Synovial sarcomas are rare but occur most often in young, healthy adults. They are often overlooked and/or mistaken for other problems. There have been 26 other cases reported of synovial sarcoma of the forefoot, so it is rare but may occur more often than anyone previously realized.

What’s the prognosis for a young adult (20 years-old) with synovial sarcoma of the big toe?

The name synovial sarcoma is a bit misleading since microscopic studies of the cells from these tumors show clear differences from true synovial cells. And the name would lead you to believe the tumors occur inside a synovial joint, when in fact, that is not the case. The tumors are close to joints and the cells resemble synovial tissue but that’s as far as the similarities go.

However, the term “sarcoma” does mean soft tissue malignancy and synovial sarcomas are malignant. Malignancy means they can spread to other tissues in the body causing disfigurement and even death.

In the case of synovial sarcoma, small tumors (less than five centimeters), in young people (less than 25 years old), and detected early can have a very good outcome with appropriate treatment (surgery to remove the mass). Wide margins (cutting around the tumor with normal tissue bordering the entire mass) must be obtained.

A delayed diagnosis with inappropriate treatment (e.g., in the case of misdiagnosis) has a less positive prognosis with an increased potential for cancer recurrence. Death occurs in as many as 40 per cent of the patients diagnosed with this condition after it has reached a larger size (five centimeters or more).

There have only been 25 or 26 reported cases of synovial sarcoma in the forefoot (including the big toe) so we do not have a large data group to rely on for these statistics. This malignancy occurs most often in young adults who are healthy and perhaps better able to respond well to treatment.

I’ve looked over all the different ways a hole in the talus bone of my ankle joint can be repaired surgically. I think I like the idea of using my own stem cells to generate new, normal cartilage. How well does this work?

When a joint is injured as a result of a joint sprain or fracture, there can be damage done to the layer of cartilage just above the joint surface. These are called osteochondral or chondral lesions and they occur in up to half of all ankle injuries. It sounds like this may be what you have.

There are several different surgical transplantation techniques to repair the cartilage (including stem cell transplantation) that have been developed and improved over the last 10 years. Treatment is designed to restore the cartilage and provide relief from painful symptoms.

The use of stem cells (taken from the patient’s own bone marrow) and then injected into the osteochondral lesion is under investigation. Early studies (with animals) are underway now but no conclusions have been reached yet regarding results. The stem cells are not used alone but along with another technique known as microfracture (tiny holes are drilled through the subchondral plate). Microfracture allows stem cells from inside the bone marrow to enter the defect and form fibrocartilaginous repair tissue.

Currently, microfracture is available as a repair technique for osteochondral defects, holes, or lesions. Stem cell transplantation is still in the experimental/research stage. There is one other biologic treatment to repair cartilage that you might be interested in knowing about. It is with the use of hyaluronic acid. Hyaluronic acid is a substance normally contained within the joint (synovial) fluid. It helps keep the joint surfaces moving smoothly.

Hyaluronic acid injections into the joint have been done after microfracture and compared with patients who had microfracture without the hyaluronic acid injections. Outcomes with a limited number of patients show that results are much improved in the microfracture plus hyaluronic acid injection group over the microfracture-only group.

As you might expect, there is a need to compare all of these approaches to see which one works best for different groups of patients. Outcomes of well-designed studies with carefully selected patients will go a long way in guiding future treatment plans for osteochondral lesions of the talus. Your orthopedic surgeon is the best one to advise you on which approach would be best for your particular injury.

Last year, I sprained my ankle but that wasn’t the worst of it. Evidently, the injury was enough to damage the joint surface of the talus bone. Now I have a hole (the orthopedic surgeon calls it a “defect”) that needs filling. Is this like having a filling put in a tooth? How does it work?

When a joint is injured as a result of a joint sprain or fracture, there can be damage done to the layer of cartilage just above the joint surface. These are called osteochondral or chondral lesions and they occur in up to half of all ankle injuries. Surgical transplantation techniques to fill in the defect (hole or lesion) and repair/restore the cartilage have been developed and improved over the last 10 years.

There are several different way to do this — a few may seem like filling a tooth. For example, autologous osteochondral transplantation is a filling of the defect with a tubular unit of donor hyaline cartilage and bone. Autologus means the plug of donor tissue is taken from the patient (usually the knee). Osteochondral allograft transplantation is another method for filling large defects but uses tissue harvested from a separate donor rather than from the patient (that’s what allograft means).

There is a more complex, two-stage autologous chondrocyte implantation technique available. It involves removing good, healthy chondrocytes (cartilage cells), taking them to the lab and making more chondrocytes, and then reimplanting the cells into the lesion (defect or hole in the cartilage). Again, this is somewhat like filling a hole in a tooth.

Each method of repair has its own advantages and disadvantages. The operative treatment for this problem is carefully selected for each patient in order to provide the best possible results. The surgeon who is treating you will explain which approach is recommended for you and why. You can certainly ask this question at your next appointment to better understand the treatment planned for you.

I have a Morton’s neuroma. My foot doctor gave me a special pad to wear that hurts as much as the stupid neuroma. Is there anything else that can be done? I know we are trying to avoid surgery but this is becoming unbearable.

Interdigital neuroma (sometimes called a Morton’s neuroma) is the medical term for a painful growth in the forefoot. The pain is most commonly felt between the third and fourth toes but can also occur in the area between the second and third toes.

The most common cause of pain is thought to be irritation on the nerve. The chronic nerve irritation is believed to cause the nerve to scar and thicken, creating the neuroma. Many foot surgeons feel that the problem may arise because the metatarsal bones squeeze in on the nerve, and the ligament that joins the two bones irritates, or entraps, the nerve. Entrapment of the nerve that is in the space between the toes is thought to lead to the chronic irritation and pain you are experiencing.

The pain occurs most often in the ball of the foot when weight is placed on the foot. Many people with this condition report feeling a painful catching sensation while walking, and many report sharp pains that radiate out to the two toes where the nerve ends. There may be swelling between the toes or a sensation similar to having a rock in the shoe. This can feel like electric shocks, similar to hitting the funny bone of the elbow. Although it’s not life-threatening, this condition can be very disabling.

Treatment usually begins with changes in shoe wear. Sometimes simply moving to a wider shoe will reduce or eliminate the symptoms. A firm, crepe-soled shoe may help. The firm sole decreases the amount of stretch in the forefoot as the affected person takes a step. This lessens the degree of irritation on the nerve.

A special metatarsal pad can also be placed within the shoe under the ball of the foot. It sounds like this is what you are trying out now. The pad is designed to spread the metatarsals apart and take pressure off the neuroma. These simple changes to your footwear may allow you to resume normal walking immediately. But with the continued pain you are reporting, you may want to try cutting back more on activities for several weeks to allow the inflammation and pain to subside.

Other treatments directed to the painful area can help control pain and swelling. Examples include ultrasound, moist heat, and soft-tissue massage administered by a physical therapist. Physical therapy sessions sometimes include iontophoresis, which uses a mild electrical current to push anti-inflammatory medicine to the sore area. This treatment is especially helpful for patients who can’t tolerate injections. For those who can handle an injection, a combination of lidocaine and cortisone into the area may help temporarily relieve symptoms.

I’m going to have a steroid injection into my very large Morton’s neuroma. Do you think a big one like mine is less likely to get better with just one injection? Will I end up having to go back for more?

The question of whether size matters when treating Morton’s neuroma) by steroid injection has been raised by a group of researchers from Scotland. Usually, this type of treatment involves an injection of lidocaine and cortisone into the area. There is some evidence that this approach may help temporarily relieve symptoms. But this is usually short-lived (days to weeks) and is mainly useful to help the doctor make a diagnosis.

The study performed at The Royal Infirmary of Edinburgh in Scotland was done to test out whether a corticosteroid injection is more effective than an anesthetic injection. In the process, they used ultrasound imaging to guide the needles and were thus able to measure the size of the neuromas and study the influence of size on the results.

Half of the 131 patients (85 per cent women, 15 per cent men) were given a single injection of methylprednisone (a corticosteroid antiinflammatory) combined with an anesthetic (numbing agent) directly into the neuroma. The other half received the same treatment but with just the anesthetic (lignocaine).

Results based on pain, function, and patient opinion of their own general health were measured one- and three-months later. Patient-surveys were used to gather information on pain, work and activity levels, walking, sense of well-being, emotional pain, rating of general health, and quality of life.

They found a significant difference (greater improvement in the corticosteroid group) one month and three months after treatment. It turns out that size did NOT make a difference. Patients with small to large neuromas received the same amount of relief and improvement with the corticosteroid injections. For the most part, results favored the use of corticosteroid injection. Complete pain relief was not reported in either group. Longer follow-up will be conducted to see if the benefits continue into the long-term as well.

I am a semi-professional dancer with a few years left in me but my big toe on the left side is going. I’ve been told I have a degenerative joint called hallux rigidus. The only treatment is to cut out the damaged part and/or fuse the joint. I’m definitely NOT ready for that. Do you have any other suggestions?

There is a new study out from the Hospital for Special Surgery in New York City that may be of interest to you. They see many athletes and dancers with a wide range of orthopedic problems who want to remain active.

Treatment for painful, limiting hallux valgus is usually surgical. In early stages (mild to moderate disease), there is a wide range of surgical approaches that can be taken. The surgeon can simply remove the bone spurs or take out the damaged portion of the joint surface. Sometimes releasing the soft tissue (capsule or synovium) is sufficient.

In more advanced cases, arthrodesis (fusion) of the joint is advised. In the report from the Hospital for Special Surgery results are given for 64 patients who had a combination of two surgical procedures for advanced hallux rigidus.

Joint reconstruction (referred to as cheilectomy) using one or several of the methods described was combined with a second procedure known as proximal phalangeal osteotomy. After removing one-third of the big toe’s metatarsal head, a wedge-shaped piece of bone was cut out of the phalange (toe bone). By moving the two remaining pieces of bone apart, it was possible to lengthen the metatarsal, thereby maintaining the length of the toe after removing the metatarsal head.

By combining these two techniques, the surgery is considered a joint-sparing (saving) procedure. By keeping the joint and avoiding a fusion procedure, patients are able to walk right away. They use special (stiff-soled) shoes to protect the osteotomy site until the bone heals.

There is a100 per cent success rate for bone healing. The procedure makes it possible for the first toe to bend as it should so that when walking, the patient can properly roll over the big toe to push the foot off the floor. This motion is called dorsiflexion. In order to preserve metatarsophalangeal dorsiflexion (toe bend before toe off), the patient does lose a portion of the opposite motion (toe pointing called plantar flexion.

These results are a significant improvement over foot function reported after an arthrodesis (fusion) procedure. But the results may not be enough for someone who is a dancer and requires extreme foot flexibility. Given your diagnosis and desire to keep dancing, it may be worth exploring these additional options.

Often, surgeons with this type of expertise are willing to see if some type of surgical modification would work for you. It may require some creative changes in your movement patterns but perhaps that won’t be such a bad thing when looking for new ways to express yourself through dance.