I need help making a decision about something. I had a very experimental procedure done to help repair a hole in the talus bone of my ankle. I’m back to playing basketball competitively and don’t want to do anything to mess things up. My surgeon wants to do a quick arthroscopic peek to look inside the joint and see how things look in there. Is there any other way to see what’s going on without poking a needle in there?

Results of treatment to repair or restore defects like this (called osteochondral lesions) can be measured by comparing MRI images before and after treatment. MRIs are able to show the location and depth of the defect as well as the presence and percentage of regenerated tissue and condition of the cartilage and bone. MRIs also show how well the new cells are integrated into the surrounding cartilage, joint surface, and edge of the lesion.

MRIs can show the percentage of defect filling and how much of the new tissue is actual cartilage versus fibrocartilage. Patients who develop more tissue like hyaline cartilage and less like fibrocartilage have a better chance of good recovery. In a recent study from Italy using stem-cells as a reparative agent, patients who had 80 per cent hyaline cartilage with only 20 per cent fibrocartilage had the best results.

Clinical outcomes are often considered the best measure of results. Using pain, motion, weight-bearing status, ankle alignment, physical activity, and level of sports participation treats the patient not the picture. Follow-up arthroscopic exams (referred to as second-look procedures are more invasive than MRIs and don’t provide complete structural information about the entire repaired area. It might be worth asking your surgeon about the possibility of using imaging over the second-look arthroscopy. There may be reasons why he or she suggested arthroscopy to take into consideration.

Can you help me sort out a problem I am having? I know I have a hole in the cartilage of my ankle bone from a hockey injury last year. We’ve been keeping an eye on it and hoping it might heal on its own. The fact that I’m young (20 years old) seems to be in my favor. But the latest MRI that was done showed a cyst was forming under the damaged cartilage. Is that good or bad?

Sprains, strains, fractures, and other trauma to the ankle can result in a condition known as osteochondral lesions of the talus or OLT. The talus is the bone located below the tibia (lower leg bone) and above the calcaneus (heel). The lesion or defect can affect just the cartilage lining the bone (called a chondral lesion) or the hole can go all the way down to the bone (an osteochondral defect).

Cysts that form under the cartilage are referred to as subchondral cysts and are seen more often in chondral type of osteochondral lesions of the talus (OLT). Cyst formation may be an indication that the reparative process got started but was interrupted and did not complete itself. Or it may be a signal of a degenerative process going on.

The cyst formation occurs more often in older adults without a history of trauma but can certainly develop in cases of sports trauma such as you report. Chondral lesions take longer to heal. This may contribute to the start of a degenerative process and subsequent formation of cysts.

Patients with osteochondral lesions have a better chance of self-healing compared with those who have the chondral type. This is because bone marrow cells (inside the bone) can move or migrate from inside the bone to the defect and stimulate healing. Chondral lesions don’t have that direct connection to bone marrow cells and must rely on far fewer bone marrow cells reaching the lesion. The cells come from the joint synovial membrane (lining around the joint containing fluid).

The size of the lesion (not just the depth) is the most important factor in healing osteochondral (or chondral) lesions. Larger defects tend to need surgical intervention to bring about healing. Your surgeon is the best one to review the significance of these findings for you. Your age, size (body mass index), activity level, and symptoms (along with characteristics of the lesion) will all be factors to consider when planning the appropriate treatment.

It’s amazing the kind of information you can get now about your health problems. I had an MRI done of my ankle after an injury and they sent me home with a CD of the images and a written report. It says I have an osteochondral lesion of the right talus. Can you please interpret what this means for me?

Sprains, strains, fractures, and other trauma to the ankle can result in a condition known as osteochondral lesions of the talus or OLT. The talus is the bone located below the tibia (lower leg bone) and above the calcaneus (heel). The lesion or defect can affect just the cartilage lining the bone (called a chondral lesion) or the hole can go all the way down to the bone (an osteochondral defect).

It is important to know what type of lesion is present. Patients with osteochondral lesions have a better chance of self-healing compared with those who have the chondral type. This is because bone marrow cells (inside the bone) can move or migrate from inside the bone to the defect and stimulate healing. Chondral lesions don’t have that direct connection to bone marrow cells and must rely on far fewer bone marrow cells reaching the lesion. The cells come from the joint synovial membrane (lining around the joint containing fluid).

According to some studies, osteochondral lesions are more common in younger (more active) adults (in their 20s) who might have better healing capabilities as well. Chondral (cartilage only) lesions are present more often in older, heavier adults (50 year old and older with higher body mass index or BMI). Trauma is often a key feature affecting most patients with either type of lesions. Symptoms may last longer in patients with the chondral type of lesions — possibly because of the delayed healing with reduced self-healing associated with this type of injury.

Chondral lesions in patients without a history of trauma are more likely to form cysts just under the cartilage. Older patients are more likely to experience impingement (pinching) of the soft tissues during ankle motion with the chondral type of lesions. Patients in both groups have equally improved symptoms (decreased pain and increased function) after surgery for either kind of lesion.

Most likely, when you go back to the surgeon for your follow-up visit, the results of the testing will be explained. You’ll have an opportunity to ask questions at that time. Hopefully, this information will aid you in understanding the basics of this condition so that you can ask more about your own specific situation.

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.

I have a foot condition known as hallux rigidus. I just call it a “tight toe”. Over time, I’ve noticed it’s actually getting worse. I’ve been told if I wait too long, I may end up with a joint fusion when I could have had a repair job. How do they decide when a joint like this is too far gone?

Degenerative arthritis of the big (great) toe called hallux rigidus affects the metatarsophalangeal joint (where the main bone in the foot meets the first bone of the big toe). The condition is characterized by degeneration of the articular cartilage (lining the joint), bone spurs called osteophytes, and significant narrowing of the joint space.

Treatment for painful, limiting hallux valgus is 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.

Deciding when joint reconstruction (referred to as cheilectomy) using one or several of the methods described depends on several factors. Your symptoms (e.g., pain, difficulty standing and walking) are usually what send you to the surgeon’s office in the first place. X-rays are used to determine the severity of the condition. There are different methods used to assign a “grade” to the condition (e.g., Grade I, II, III, IV).

The grade depends on how much of the joint surface has been destroyed. For example, lower grades (I and II) describe a joint with less than half of the surface damaged. Higher grades (III and IV) refer to patients with extensive degeneration of the joint (more than half destroyed).

In the past, cheilectomy was used for patients with Grades I and II and arthrodesis (fusion) was reserved for Grades III and IV. But more recently, surgeons have been trying to combine two surgical procedures for advanced hallux rigidus in order to preserve (save) the joint and motion.

Joint reconstruction (referred to as cheilectomy) using one or several of the methods described combined with a second procedure known as proximal phalangeal osteotomy has been described in a new study. 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. Keeping the joint intact and avoiding a fusion procedure, makes it possible for patients to walk right away. They use special (stiff-soled) shoes to protect the osteotomy site until the bone heals.

But the results are well-worth it as the surgeons involved reported a 100 per cent success rate (bone healing). The combined procedures make 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. As the long-term follow-up of this group of patients showed, no one had to eventually have a fusion. Foot function was maintained (at least in the early to mid-term results). It is speculated that joint degeneration may develop over time (perhaps even in the first 10 years after the surgical procedure). These patients will be followed longer to see just what does happen in the long-term period.

An orthopedic surgeon can evaluate you and help you plan a treatment that will meet your personal and physical goals. As with many health care conditions, earlier treatment often yields better results so at least getting a baseline evaluation is always a good idea.

I failed physical therapy for an Achilles tendon rupture. The injury happened too long ago. And I think I’m too old and too heavy for the tissue to repair itself. Are there any other treatment options? I’m not terribly active (okay, I’m a total couch potato) but maybe I could get out more if the foot didn’t hurt so much all of the time. What do you recommend?

Older adults who rupture the Achilles (heel) tendon may end up with a case of Achilles tendinosis that does not respond to conservative (nonoperative) care. Tendinosis refers to replacement of normal collagen fibers in the tendon with scar tissue or fibrous material. The substandard replacement tissue is weak resulting in pain, decreased strength, and loss of function.

When conservative care is not enough and traditional surgical repair is not possible, then an alternate two-part procedure may be necessary. Older adults who are inactive and overweight are the main candidates for this type of treatment.

The first step is debridement and involves removing the diseased tissue from the damaged and poorly repaired Achilles tendon. Any bone spurs that may have developed around the heel where the Achilles tendon attaches are also shaved away.

The second half of the surgery is a tendon transfer of the flexor hallucis longus (FHL). This tendon/muscle helps the big toe flex or bend. A portion of the FHL tendon was removed and threaded through a tunnel in the calcaneus (heel bone) made by the surgeon. The flexor hallucis longus (FHL) was then attached to the calcaneus where the Achilles tendon normally inserts.

In a recent study of 48 adults between the ages of 44 and 64 who had this procedure done, all were in the obese category (Body Mass Index of 30 or more). Everyone was followed for two years. Results were reported based on improvements in pain intensity, physical function, and disability. Ability to rise on one foot (called a single-leg heel rise) and balance were also evaluated for any changes.

Significant improvement was reported in all areas except the single-leg heel rise. But even though the heel-rise was not normal (due to loss of toe motion and weakness), no one seemed to be having any trouble walking normally. No one seemed to be having any problems with balance. Both of these functions do depend on the flexor hallucis’s ability to flex or bend the big toe. And almost everyone (97 per cent of the group) had no difficulty walking in sandals (keeping them on the feet).

There may be other options available for you as well. The first step is to go back to your surgeon and report your current situation and ask this question. Knowing of this one particular two-step procedure may help get the conversation going around options for you.

I’m lined up for surgery to help me with a long-standing problem with my Achilles tendon. The surgeon calls it a tendinopathy from an old Achilles tendon injury that was never treated. The surgery is in two parts. First, clean out the old, diseased tissue. Then use my big toe flexor muscle to replace the bad Achilles tendon. My question today is: what should I expect for recovery after this type of surgery?

There are small studies with results published for this type of procedure. We found three studies with 20 to 26 patients and another larger study with 48 patients. Results were similar for all three studies. We’ll fill you in on the larger one.

The study of 48 patients included adults between the ages of 44 and 64. They were all fairly inactive and overweight (actually in the obese category with a Body Mass Index of 30 or more). Everyone was followed for two years. Results were reported based on improvements in pain intensity, physical function, and disability. Ability to rise on one foot (called a single-leg heel rise) and balance were also evaluated for any changes.

The authors reported significant improvement in all areas except the single-leg heel rise. But even though the heel-rise was not normal (due to loss of toe motion and weakness), no one seemed to be having any trouble walking normally. No one seemed to be having any problems with balance. Both of these functions do depend on the flexor hallucis’s ability to flex or bend the big toe. And almost everyone (97 per cent of the group) had no difficulty walking in sandals (keeping them on the feet).

Keeping track of when patients experienced improvements, there were significant benefits from the surgery in the first three months. Improvements continued to be seen at the end of six months, 12 months, and even after 24 months. Most of the changes took place in the first year after surgery.

There were a few minor problems and complications associated with the surgery. A couple patients developed wound infections or blood clots. Pain in the scar was reported by four people. Unfortunately, one person fell and tore the reconstructed tissue.

The most surprising finding was the development of peroneal tendinitis (muscle in the lower leg). The authors were unsure how to explain that particular result. Perhaps there was more general tendinopathy (affecting more than just the Achilles tendon) present before surgery than they realized. Or maybe this was a new problem developing as a result of the surgery. They suggest further study to sort this out in an effort to prevent it from happening.

Your surgeon will also go over with you what to expect. That usually includes a list of things that could go wrong with any surgery and in particular, this procedure. If your case goes like the ones reported in the literature, you can expect a slow but steady progress toward improvement and full recovery.

After a very severe ankle injury, I found out I have a hole in the ankle bone that goes clear down to through the cartilage to the bone. The surgeon is recommending something called an OAT procedure. At age 55 (and being a post-menopausal woman), will this work for me? I don’t heal as well as I used to.

Holes referred to as “defects” in cartilage that go clear down to the bone can be treated with the technique you mentioned: osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (usually from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same person’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In a recent study from Korea, surgeons used a second arthroscopic examination a year later to evaluate the results of this procedure used on the talus (ankle bone). It is rare that a second-look arthroscopic exam is possible so the results of this study are important. Quality of bone and cartilage graft were evaluated using the second arthroscopy instead of MRI in order to get a better look at the results.

Using an analysis of many patient variables, the researchers were able to determine the most important factors affecting the final results. They investigated the role of age, gender, body mass index (BMI), duration of symptoms, severity (depth and size) and location of lesion, and presence of bone cysts as predictive factors of outcomes. They also looked at results based on patient satisfaction, pain, function, and activity level.

Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. Age was not a statistically significant factor. The most important variable in the result of the OAT procedure was actually a surgical effect. The surgeon must restore the joint surface smoothly, evenly, and anatomically accurately.

Impingement (pinching) of the surrounding soft tissues must be avoided. The graft shape and size must match the defect as closely as possible. And the graft must be covered over carefully with a patch to prevent “uncovered” areas. It seems that any gaps or uncovered spots quickly fill in with fibrous cartilage. The result is an unstable defect area.

The authors of this particular study suggest longer-term studies (beyond the one-year mark) in order to evaluate changes and look for influencing factors that might not show up in the first 12-months. They also commented that their study was fairly small in terms of number of patients (52 ankles). Therefore the study should be repeated with a larger number of subjects before accepting these results as the final word on the subject.

But it does offer some evidence that your age and potentially your postmenopausal status may not make a difference. These are good questions to ask your surgeon before having this procedure. Reparative surgery is important in this condition to avoid premature arthritic changes that can cause a chronically painful and unstable ankle.

I had an ankle injury that left a hole in my talus bone. After filling the hole in with cartilage and bone from my knee, the surgeon wants to do another arthroscopic exam to see how it looks. I’m not really wanting another surgery. Couldn’t they just do an X-ray to see what they want to see?

Holes referred to as “defects” in cartilage and bone such as you had can be treated with the technique you described: osteochondral autograft transfer or OAT. Osteochondral lesions refer to damage or defects to the joint cartilage (chondral) that go all the way down to the first layers of bone (osteo).

Holes in the osteochondral layer and/or loose fragments of bone and cartilage in the joint can cause pain, locking of the joint, and eventually osteoarthritis. To help prevent this from happening, treatment can be done with osteochondral autograft transfer (OAT).

OAT involves removing a plug of cartilage and bone from a healthy area (in this case from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the your ankle bone). The word “autograft” refers to the fact that you donate your own tissue for the procedure.

Efforts are being made to identify factors that might predict a good or favorable result. Surgeons might suggest using a second arthroscopic examination to evaluate the results of this procedure. Because it is an added expense and an invasive procedure, it is rare that a second-look arthroscopic exam is recommended. But quality of bone and cartilage graft evaluated using the second arthroscopy instead of X-rays or more advanced imaging like MRIs gives a much a better look at the actual results. The surgeon can see exactly how well the graft has taken, how much bone is growing, and any problems that might be developing.

A second-look arthroscopy does provide an opportunity to treat any problems present, especially mismatching of the joint surfaces. Fibrous adhesions causing impingement can be removed. And any uneven margins can be smoothed over. Any gaps where the graft meets the defect can be filled in.

Sometimes I just don’t get the medical world. I took my mother in to the local clinic at the strip mall downtown. I thought she was having a heart attack. They seemed much more concerned about a sore on her big toe. She ended up with a bill for several thousand dollars for a foot infection. Go figure! And they never even checked her out for a heart problem. What do you make of all that? Am I way off base in my thinking here?

Anytime someone comes to a clinic or hospital, vital signs are taken as a routine first-step in the evaluation and diagnostic process. Questions are asked about history and current signs and symptoms.

From this information, the health care professionals make a mental list of possible problems. Further testing proceeds in order to make the final differential diagnosis (in other words, figuring out which one of the possible problems is the actual problem).

It is likely that in the first five minutes they were able to assess your mother and determine that she wasn’t having a heart attack. The symptoms and history are classic but they would rely on more than that — always taking measures to keep the patient safe and ensuring the best results.

If it turns out she had a sore on the big toe, the next concern is for foot infection. And there may have been something in the history to tip them off to look for such a thing. Diabetes is the first condition that comes to mind as a potential cause of a sore on the toe in an older adult.

Loss of sensation in the feet is the number one cause of foot amputations among patients with diabetes. Stubbing a toe or cutting the skin can go unnoticed in the absence of pain. Infection in an area with decreased circulation can go untreated for too long ending up in loss of toes, foot, and even the leg. In fact, two-thirds of all nontraumatic leg amputations are done on patients with diabetes. The potential seriousness of such a condition may be why they spent so much time and attention on the sore toe.

But perhaps your mother doesn’t have diabetes. Although diabetes is the number one cause of foot infections, such infections are also associated with other systemic conditions such as chronic kidney or liver disease, gout, and peripheral vascular disease.

Anyone whose immune system isn’t responding well (we say they are immunocompromised) for any reason are also at increased risk for foot sores leading to infections. The immunocompromised include the elderly, anyone taking immunosuppressant medications for rheumatoid arthritis or organ transplantation, AIDS patients, cancer patients, and anyone who is malnourished (alcoholics, people with eating disorders or chronic diseases).

This may not answer your question directly but what we hope to do is give you a bigger picture perspective so you can better assess your mother’s situation. Of course, this is all done in hindsight (after the fact). But spending a couple thousand dollars in diagnostic prevention may have saved your mother tens of thousands of dollars and loss of limb down the road.

I took my neighbor in to the emergency department over the weekend. She’s a known diabetic and was complaining she couldn’t feel her toes. I know they tell you not to use the emergency department for minor problems but I didn’t know what else to do. Is this something that could have waited until Monday? It was the first time she had ever have this happen and she was so panicked.

Loss of sensation is a common problem in people with diabetes. The disease affects circulation and blood supply to the hands and especially the feet. The first time numbness develops, it can be very anxiety producing.

As a nonmedical person yourself, it may not have occurred to you to look for other tell-tale symptoms of a problem that suggests immediate need for medical care. For example, fever, sweats, or nausea might signal an infection. Redness, swelling, blistering, or oozing of pus from the toe(s) would also be a red flag requiring medical attention.

You did the best you could under the circumstances. If you think there might be future times when you will be called upon to aid this person, it might be a good idea to get some information ahead of time. For example, keep handy contact information for her closest family members and her primary care physician.

Check your community for other (lower cost) options for those late night or weekend emergencies. Some hospitals have a 24-7 nursing service you can call with any medical or health-related questions. Some cities have local walk-in clinics that charge a single (pay upfront) fee and take care of any immediate problems. They are better trained and equipped to know when to send you/your neighbor to the emergency department or to seek more specialized services.

But to get back to the original problem, numbness in the feet of someone with diabetes does require diagnosis and management. Without proper sensation, it is easy to stub the toe, cut the skin, and develop a serious infection that could lead to amputation for this patient population.

An emergency room visit might not have been needed for this particular problem. But at least this visit will aid your neighbor in getting the proper education and treatment she needs. The first appearance of numbness is certainly a signal that further management is appropriate to prevent more serious problems from developing later.

I need some help with a decision I have to make about my ankle. I have an Achilles tendon rupture but I’m not sure if I need surgery or not. The physician’s assistant at the surgeon’s office talked circles around both options but I couldn’t tell which way to go and she wasn’t helping. What do you advise your patients?

For quite some time, there has been debate and controversy over the optimal way to approach management of the acute Achilles tendon rupture. Should it be treated surgically? Can the complications of surgery be avoided by going with a more conservative treatment plan? What is the best way to measure results? These uncertainties may be why your physician’s assistant wasn’t able to be more clear about which is the best treatment for you.

As you probably understand better now than before your injury, the Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb.

The risk of rerupture is the primary concern when evaluating which treatment plan works the best. Other ways to assess outcomes can include strength, time to return to work or play, and complications. Besides re-rupture, postoperative problems (not likely with conservative care) can include infection, nerve damage, unacceptable cosmetic appearance (due to fibrosis and scarring), and blood clots.

A recent study was done to help surgeons in the evaluation process to know what works for which patients. The conclusions they came to from the information gathered might be of interest to you. Patient results were compared from conservative to operative care. The main goal was to see what the re-rupture rate was for operative care versus conservative (nonoperative) care. Secondary measures were as described above (strength, return to work/sports, and complications).

There were four major findings. First, open repair had a significantly lower rate of reruptures compared with conservative care. There were almost three times as many reruptures in the conservative care group compared with the surgical group.

Second, the number of deep infections was much higher in the group that had surgery. No one had infection in the conservative care group. Almost three per cent of the surgical group developed a deep infection that required additional medical care and delayed recovery.

Third, nerve damage and dissatisfaction with the scar were never problems in the nonoperative group but were reported in the surgical group. The number of blood clots was not significantly different between the two groups. And the time to return to work or play was shorter for the surgical group but the statistical values did not reach significance.

And fourth, strength could not be used as an outcome measure because the way strength was assessed was different from study to study. As a result, the strength measurements were not considered “standardized.”

On the basis of this systematic review and meta-analysis, surgeons can expect to reduce a patient’s risk of rerupture with surgical treatment of acute Achilles tendon ruptures. But the higher risk of postoperative complications must be taken into consideration. Athletes and active patients may prefer the stronger tendon that comes with surgical repair. Less active and older adults with fewer biomechanical demands on the damaged tendon may opt for the nonoperative approach.

I am a fashion model at a very high level with a serious problem. I fell during one of our shows and ruptured my left Achilles tendon. The doctor I saw wants to do surgery but I can’t afford to have any scars on my legs. How big is the scar and how much will it show? Is there any way around this problem?

The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb.

Treatment for an acute Achilles tendon rupture can be with conservative (nonoperative) care or surgery to repair the damage. Surgery involves reattaching the two ends of the tendon to repair the torn Achilles tendon. This procedure is usually done through an incision on the back of the ankle near the Achilles tendon. Numerous procedures have been developed to repair the tendon, but most involve sewing the two ends of the tendon together in some fashion. Some repair techniques have been developed to minimize the size of the incision.

In the past, the complications of surgical repair of the Achilles tendon made surgeons think twice before suggesting surgery. The complications arose because the skin where the incision must be made is thin and has a poor blood supply. This can lead to an increase in the chance of the wound not healing and infection setting in. Now that this is better recognized, the complication rate is lower and surgery is recommended more often.

But the risks of adhesions developing and an unsightly scar are still greater with surgery than without. As a model, you are more likely to be wearing shoes with elevated heels, which puts the tendon in a shortened position. A slightly pointed foot with elevated heal is required during the healing process. Surgery may not be needed if conservative care can restore needed motion and strength for this type of work.

What you should keep in mind during the decision-making process is that rerupture of the Achilles tendon is three times more likely in patients who opt for conservative care over surgery. So there are trade-offs and factors to consider with both treatment approaches. Before agreeing to surgery, you may want to get a second opinion and/or consider a trial of conservative care first.

Athletes and active patients may prefer the stronger tendon that comes with surgical repair. Less active and older adults with fewer biomechanical demands on the damaged tendon may opt for the nonoperative approach.

Have you ever heard of using shock therapy for plantar fasciitis? It’s like the kind they use to break up kidney stones. How does it work on the foot without destroying the tissue?

Plantar fasciitis is a painful condition affecting the bottom of the foot. It is a common cause of heel pain and is sometimes called a heel spur. Plantar fasciitis is the correct term to use when there is active inflammation. Acute plantar fasciitis is defined as inflammation of the origin of the plantar fascia and fascial structures around the area. Plantar fasciitis is usually just on one side. In about 30 per cent of all cases, both feet are affected.

Treatment is usually with conservative (nonoperative) care. This could include stretching, wearing a splint at night, the use of antiinflammatory medications, and/or a special arch support to help reduce the pressure on the fascia.

Shock wave therapy is a newer form of nonsurgical treatment. It uses a machine to generate shock wave pulses to the sore area. This type of shock wave therapy was, indeed, first used to break up kidney stones. It has been used in treating plantar fasciitis for the last 10 to 15 years. Patients generally receive the treatment once each week for up to three weeks.

It is not known exactly why it works for plantar fasciitis. It’s possible that the shock waves disrupt the plantar fascial tissue enough to start a healing response. The resulting release of local growth factors and stem cells causes an increase in blood flow to the area.

This type of treatment produces a rising acoustic (sound) wave that causes high energy and pressure against the tissue. It may destroy sensory nerve fibers that send pain messages to the brain, thus turning off those messages. Recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.

There are different types of shock wave therapy. In this study, researchers from Taiwan conduct a systematic review and meta-analysis comparing the effectiveness of two major types of shock wave therapy. The most common type is called focused shock wave therapy (FSW). A newer, alternative form called radial shock wave therapy (RSW) was also evaluated.

Focused shock wave (FSW) therapy is just as it sounds: the energy wave is directed at a specific area. FSW concentrates the wave field whereas radial shock wave (RSW) disperses the energy over a wider range. With RSW, it is not necessary to find the painful spots before applying the energy wave.

I am a physiatrist interested in treating plantar fasciitis with shock wave therapy. What’s the latest thinking about this modality? Does it work? Is there evidence for a best way to apply the energy?

As you already know, treatment is usually with conservative (nonoperative) care. This could include stretching, wearing a splint at night, the use of antiinflammatory medications, and/or a special arch support to help reduce the pressure on the fascia.

Shock wave therapy is a newer form of nonsurgical treatment used when other forms of conservative care fail to produce the desired results (primarily pain relief). Shock wave therapy uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks.

Studies have shown that this form of treatment can help ease pain, while improving range of motion and function. But there have not been large randomized controlled studies to compare different ways to use the shock therapy. Most recently, a group of researchers from Taiwan conducted a systematic review and meta-analysis comparing the effectiveness of two major types of shock wave therapy (focused shock wave (FSW) therapy and radial shock wave (RSW) therapy). The results may be of interest to you.

Focused shock wave (FSW) therapy is just as it sounds: the energy wave is directed at a specific area. FSW concentrates the wave field whereas radial shock wave (RSW) disperses the energy over a wider range. With RSW, it is not necessary to find the painful spots before applying the energy wave.

A particular area of interest in this study was to see the value in using different intensity levels, which represent energy flow through the tissue. Turning the intensity up may provide more pain relief but could also temporarily increase pain, local swelling, and tenderness. High intensity FSW also required the use of local anesthesia, which can have its own negative side effects.

Focus shock wave therapy can be delivered in three intensities: low, medium, and high. Patients receiving FSW were divided into three groups based on the intensity of wave delivery. Patients receiving RSW made up the fourth group. Results were measured based on pain reduction and overall success of the treatment. The goal was to see if one type of shock therapy was superior to the others in treating plantar fasciitis.

What did they find? Well, first of all, any type of shock wave therapy yielded better results than a “sham” or placebo (pretend) treatment. The best results were gained using radial shock wave (RSW) therapy. Focused shock wave (FSW) gave the best results when used at the highest energy density tolerated by the patient in the medium intensity range.

For those who use this modality to treat plantar fasciitis, the authors say don’t go out and purchase a radial shock wave machine if you already have a focused shock wave device. Anyone like you who is just considering purchasing this equipment is advised to select radial shock wave therapy. It costs less and gives better results with fewer potential side effects.

My husband is going in for surgery to repair a ruptured Achilles tendon that just happened two days ago. The surgeon briefly mentioned I would have to help watch out for any post-operative complications. The nurse said she would go over all this with me before he is discharged. Now I’m wondering what sorts of problems can develop?

The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb. Several different problems can occur that affect the Achilles tendon, some rather minor and some quite severe.

These problems affect athletes most often, especially runners, basketball players, and anyone engaged in jumping sports. They are also common among both active and sedentary (inactive) middle-aged adults. And the number of Achilles injuries seems to be on the rise. These problems cause pain at the back of the calf. Severe cases may result in a rupture of the Achilles tendon.

The best way to manage acute Achilles tendon ruptures has not been discovered. One important outcome of successful treatment is to avoid the number one complication: rerupture. Other complications can include infection, bleeding into the muscle, adhesions, altered skin sensation (nerve injury), and blood clots.

Most of the complications involving infection occur as a result of surgery. Those patients who are treated with cast immobilization are more likely to develop problems from the cast (e.g., sores, swelling from a too-tight cast).

Since most surgical patients are put in a cast to immobilize the leg after surgery, you will be told how to monitor your husband for any problems. Sometimes it’s as simple as just looking at and feeling the toes for warmth and color (indicators of circulation). Your husband will be able to report any other problems such as pain, numbness, throbbing sensations, and so on.

The nurses are very good about giving written information about what to watch for. You will be given a telephone number to call in case of any developing problems or emergencies. Don’t hesitate to call if anything comes up you are unsure about. Early intervention taking care of problems can keep small problems from becoming big ones.

I need some quick help. Just took my son to the doctor’s for a calf injury. Looks like he has a torn Achilles tendon. Doc gave us the run down on surgery versus no surgery and what to expect. I need a few more details before deciding which way to go. What can you tell me? What works best? How do we decide?

The best way to manage acute Achilles tendon ruptures has not been discovered. One important outcome of successful treatment is to avoid rerupture or other complications (e.g., infection, bleeding into the muscle, adhesions, altered skin sensation, blood clots). A recent meta-analysis of 14 studies with over 1000 patients performed at the University of Western Australia provides some helpful information.

All patients were adults who had injured their Achilles tendon in the previous three weeks. Most were males who were engaged in athletic activities at the time of their injury. Analysis of all the data collected from the studies showed the following:

  • There were fewer cases of rerupture when patients had surgery to repair the torn tendon.
  • When short-term immobilization in a cast is followed by the use of a functional brace (instead of surgery), rates of re-rupture were the same as with surgery. This approach is referred to as accelerated rehabilitation.
  • The best way to avoid rerupture appears to be with surgical intervention followed by cast immobilization.
  • The highest rate of reruptures occurred in patients treated nonoperatively just with cast immobilization.
  • Complications (other than rerupture) were higher in the surgical patients.

    Sports athletes or other participants in sports activities can expect to get back to full swing of daily activities and sports involvement six months after surgery. Whether the surgery is done percutaneously (through the skin) or with open incisions doesn’t seem to affect the results in terms of the rerupture rate. Patients in the open incision group did have significantly higher rates of postoperative infection.

    The final decision may be influenced by the patient’s age (young adults tend to heal faster than the elderly), severity of the injury, and surgeon’s preferences. At least from the results of this meta-analysis, percutaneous repair with cast immobilization after surgery seems to offer the best long-term results.

  • I have severe toe arthritis in my big toe on the right side. Got it from a time years ago when a draft horse stepped on that toe. It’s pretty painful and I’m hobbling around. The surgeon suggests an operation called cheilectomy. What can I expect from this procedure?

    Degenerative arthritis that affects the large joint at the base of the big toe is referred to as Hallux rigidus. Degenerative arthritis can result from wear and tear on the joint surface over time. The condition may follow an injury to the joint such as you described.

    The degeneration causes two problems–pain and loss of motion in the metatarsal phalangeal (MTP) joint of the big toe. Without the ability of the MTP to move enough to allow the foot to roll through a full step, walking can become painful and difficult. Nonsurgical management is always advised first and may consist of nonsteroidal antiinflammatory medications to reduce pain and swelling, shoe adaptations, and changes in activities.

    When conservative care doesn’t help, surgery may be the next step. There are three main surgical choices: cheilectomy, arthrodesis (fusion), and joint replacement. Surgery has helped many people with this problem with a reported rate of patient satisfaction of up to 95 per cent.

    A cheilectomy is a procedure to remove the bone spurs at the top of the joint so that they don’t bump together when the toe extends. This allows the toe to bend better and reduces the amount of pain while walking. To perform a cheilectomy, an incision is made along the top of the joint. The bone spurs that are blocking the joint from extending are identified and removed from both the bones that make up the joint. A little extra bone may be taken off to ensure that nothing rubs when the hallux is raised. The skin is closed and allowed to heal.

    Cheilectomy will allow you to keep your joint motion. Though it has been observed that maintaining and even increasing motion does not always mean your ability to walk normally is restored. Studies show that pain relief and even positive patient satisfaction are not directly linked with return to normal joint motion. The reason(s) for this remain unknown at this time.

    In about one-third of all cases treated with cheilectomy, there is a return of the extra bone growth that form bone spurs. It seems that less active (often older) patients may have better results compared with younger, more active adults. This is especially true when looking at results for patients who are engaged in high-level sports activities.

    Cheilectomy may not be the end of the line in terms of treatment for some patients. Arthrodesis (joint fusion) may be required in time. This is especially true for patients with severe hallux rigidus. There are other surgical procedures that are slight variations of these three approaches. For example, cheilectomy may be combined with a phalangeal osteotomy. The surgeon removes a wedge-shaped piece of bone from the middle toe bone in order to take pressure off the joint. Some patients can be successfully treated with just the osteotomy procedure.

    Another alternative approach (more for the younger patient) is the interpositional arthroplasty. In this procedure, the surgeon removes the base of the toe bone (phalange) and places a “spacer” in the hole left. The spacer is made up of a rolled up piece of tendon. The surgeon may have to release the tendon that inserts into the base of the phalange for this to work best. This decision is made at the time of the surgery.

    After surgery, it will take about eight weeks before the bones and soft tissues are well healed. You may be placed in a wooden-soled shoe or a cast during this period to protect the bones while they heal. You will probably need crutches briefly. A physical therapist may be consulted to help you learn to use your crutches.

    The incision is protected with a bandage or dressing for about one week after surgery. The stitches are generally removed in 10 to 14 days. However, if your surgeon used sutures that dissolve, you won’t need to have the stitches taken out.

    I have a condition the surgeon calls rigid hallux (or maybe it’s the other way around: hallux rigid — I can’t remember). Anyway, it’s some kind of big toe arthritis. I’m looking into the different treatment options. The surgeon is advising I strongly consider a joint replacement. What can you tell me about these — especially how well something like this would hold up with all the walking I do for my job as a mail carrier.

    You are probably thinking of a condition called hallux rigidus, a degenerative type of arthritis that affects the large joint at the base of the big toe. The degeneration causes two problems–pain and loss of motion in the metatarsal phalangeal (MTP) joint of the big toe. Without the ability of the MTP to move enough to allow the foot to roll through a full step, walking can become painful and difficult.

    Replacing the joint with an artificial joint is one of several treatment options usually recommended for moderately involved joints. (Arthrodesis or fusion still produces better results for patients with severe hallux rigidus). In the joint replacement procedure, one or both of the joint surfaces is removed and replaced with a plastic or metal surface. This procedure may relieve the pain and preserve the joint motion. The major drawback is that the artificial joint probably will not last a lifetime and will require more operations later if it begins to fail.

    There are actually several different ways to accomplish a joint replacement. A total joint replacement removes and replaces both sides of the joint. This type of procedure requires a conical stem that sits down inside the toe bones on either side of the joint. The implants can be made of ceramic, titanium, cobalt-chrome, or titanium combined with polyethylene (plastic) parts.

    Metatarsal hemiarthroplasty replaces just one side of the joint — between the bone closest to the big toe joint (metatarsal) and the middle phalangeal bone. Limited studies have been done using this approach but patient satisfaction is reportedly high (100 per cent) with no implant failures or need for revision surgery.

    There is a need for improved implant designs and materials for joint replacements. Right now, joint replacement is not considered the best approach for everyone with hallux rigidus. Joint replacement is most likely helpful in the case of moderately involved rigid hallux. Problems with subsidence (implant sinks down into the bone), implant loosening, and implant stems poking out through the bone keep this treatment option as second best to arthrodesis (first choice). More research is also needed to find more successful, acceptable nonoperative ways to treat this problem.

    I am a fairly new dance instructor so I don’t have a lot of experience with dance injuries (other than my own). One of my young students has been told she has a bridge of bone attaching the navicular bone in her foot to another bone. This is causing quite a bit of pain in her foot when dancing. Should I advise her to stop dancing? Is there anything I can do in class to help her?

    Many people are born with oddly shaped bones, extra bones, or fused bones and never know about it. In fact, studies show up to one-third of the general population have what is called an accessory (extra) bone. Sometimes these extra bones are in the joint and sometimes they occur embedded in a tendon or muscle.

    Most of the time, unless the bone is prominent, no one knows about them. But dancers and other athletes are often the first to notice problems. The strain and stress on the feet from repetitive movements, wearing special (toe) shoes (dancers), and the positions assumed (up on toes, feet turned out) can cause tenderness and pain in the foot and/or ankle.

    The navicular bone of the foot is one of the small bones on the mid-foot that is often an accessory bone. The bone is located at the instep, the arch at the middle of the foot. One of the larger tendons of the foot, called the posterior tibial tendon, attaches to the navicular before continuing under the foot and into the forefoot. This tendon is a tough band of tissue that helps hold up the arch of the foot. If there is an accessory navicular, it is located in the instep where the posterior tibial tendon attaches to the real navicular bone.

    Treatment for a painful navicular bridge can be conservative (nonoperative) or surgical. Of course, the goal of the dancer is usually to return to full participation in dance. The need for surgery is determined after conservative care fails to provide pain relief or improve function.

    The most successful nonoperative approach to a painful accessory navicular bone in a dancer’s foot has not been determined. Some methods used include cryotherapy (cold) to help manage the pain, iontophoresis (treatment for inflammation), passive and active range-of-motion for the foot and ankle, and strengthening exercises for the leg and hip.

    Other areas to address may include balance, endurance, and proprioception (awareness of joint position). A physical therapist can be very helpful in providing this type of program and advising you as the instructor in what you can do to guide your student.

    Care must be taken to avoid making things worse for the dancer. Prescribing supportive shoes won’t work for someone who needs to dance barefoot or wear thin slippers, toe shoes, or flat-soled leather shoes. A program to return the dancer to practice (dance classes), performance, and competition must be gradual but progressive. At the same time, the injured tissue must be protected and allowed to heal.

    Other considerations in prescribing rehab include age of the dancer and status of his or her skeletal maturity. Younger dancers who have not reached full growth yet may still have open growth plates that could be injured or damaged during retraining. So your participation and cooperation in guiding this student is a very important part of the recovery process.

    For the best and fastest results, dancers are encouraged to follow the therapist’s and physician’s recommendations for activity restriction or modification. The therapist will help the dancer identify areas of weakness that may be contributing to the problem.

    For example, weakness in the hip muscles or decreased hip motion can cause a change in the alignment of the knee, ankle, and foot. The result can be overloading of the soft tissues and bones and then injury (or reinjury). By correcting these dance technique faults, the dancer may be able to return to dance without having the symptoms come back.

    Surgery may be unavoidable. This is most likely in cases where the extra bone is large or connected to another bone by a bridge of bone. The use of taping, padding, or modalities (e.g., cryotherapy, iontophoresis) just isn’t enough to change the structure. Once the extra bone or bony bridge has been removed, then a gradual return to activity is allowed. Rehab and specific training for return to dance (or other sport) begins. The dancer or athlete should be advised that the process can take several months but the end result is often excellent.

    Communication will be the key for you. Stay in touch with the family and physical therapist. Invite the therapist to class so he or she can observe the student and your instruction. Advice and guidance offered in class can be very instructive and beneficial to all the dancers.