Does early weight bearing improve outcomes for non surgical treatment of Achilles tendon rupture?

Non surgical treatment of Achilles tendon rupture has been shown to be equally effective to surgery. However, the best treatment protocol is still unclear, especially the role that early weight bearing bears on recovery. It has been hypothesized that early weight bearing can improve the tendon healing and increase the the quality of treatment because it improves the patients ability to function independently.

The purpose of this study was to compare immediate weight bearing with non weight bearing for non surgical treatment of the Achilles tendon. This protocol also included controlled early range of motion exercises for both groups. The results were measured with the Achilles tendon Total Rupture Score (ATRS), strength of heel-rise compared to the uninjured side, duration of sick leave, re-rupture and quality of life during treatment.

Both groups had the exact same eight week treatment protocol except that the experimental group was allowed to begin full weight bearing from day one. The control group was instructed to prevent any weight bearing for the first six weeks, and full weight bearing allowed for the last two weeks of treatment in the walking boot.

The results show that there was no significant difference in the scores between groups for the ATRS at both six and 12 month follow ups. The heel-rise work outcome also did not differ between the groups at the six or 12 month followup. The questionnaire about quality of life during the eight week treatment period showed that immediate weight bearing did significantly increase quality of life.

This report concludes that is it reasonable to recommend immediate weight bearing for patients being treated with non surgical protocol following Achilles tendon rupture. This is based on the fact that this research showed no detrimental effect on the long term outcome and did improve the quality of life during the initial eight weeks.

Nonoperative Treatment Options for Achilles Tendon Ruptures

The Achilles tendon is the thick tendon that connects your calf muscles to your heel. Injury to this structure can range from a simple, but painful, tendinopathy to full rupture where the calf muscle can no longer act to plantarflex the ankle. Rate of Achilles tendon rupture is on the rise and can be quite debilitating, preventing participation in sports and limiting walking ability. Despite the rising prevalence, treatment for Achilles tendon rupture is not consistent. 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, however, 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.

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.

A recent study looking at long-term outcomes and rerupture rates of the Achilles tendon using a weight-bearing cast fit with a Bohler iron found that only one in 37 patients suffered a rerupture two years after initial injury. Some of the potential side-benefits of early weight bearing may include earlier return to work, higher self-reported functional testing scores, faster gains in ankle plantar flexion strength, and less pain or weakness after cast removal. These side-benefits have not been significant effects reported in the literature, but that is likely due to the lack of research looking at this relatively new nonsurgical approach. 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. As previously mentioned, basic science supports the concepts of early weight bearing and early range of motion for the beneficial effects it has on the muscle composition and tendon healing.

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.

Review Article Sheds Light on Improved Surgical Technique For Hammer Toe

Toes are like teeth, you take them for granted until they hurt and then you realize how much you rely on them and are amazed at how much pain they can cause.  Toe instability resulting in a rigid deformity is a common foot problem.  A recent review article speaks to new knowledge of toe instability and a surgical technique that should be utilized—specifically, repairing the plantar plate.

In a healthy foot the tiny muscles of the feet and toes along with ligaments on the sides of your toe joints (collateral ligaments) and a thick piece of fibrous tissue on the pad of your feet and toes, called the plantar plate, help to resist the forces your toes undergo during walking and running. The second toe is most vulnerable to hyperextension because there is no muscle responsible for resisting your second toe moving towards your big toe. Authors of this review found that the plantar plate is primarily responsible for the stability at the second toe joint.  If this plantar plate is torn, due to abuse or trauma, and not repaired the toe instability becomes worse and typically results in a crossed toe.

Toe deformities go by various names depending on the direction the toe goes, but generally speaking a bent toe is called hammer toe which can turn into a toe stuck under or over the adjacent toe.  Any deviation from a straight toe is an indication of joint instability and should be addressed to prevent future pain and walking difficulty.

Hammer toe is caused by outside pressure (like high heels), inflamed joints, and autoimmune diseases. Predisposing factors include genetics, a longer second toe, flat feet, and an already poorly aligned big toe.  Curled toes, or hammer toes, most often happen to women older than 50 years old whose feet have been pressed into high heeled shoes with narrow toe boxes.  Men and younger people can also develop hammer toe, however it is more rare. Often, these deformities are ignored until they become fixed or the bones have fused into place. Fused toes are problematic because as we push off with our back foot while walking the toes must bend and tolerate 40 per cent of our body weight.

Symptoms of toe instability are pain on the bottom of your toe where it meets your foot, toe swelling and numbness, a feeling of walking on marbles, and a gradual change in the direction of your toe towards encroaching on its neighbor.  It may be uncomfortable to walk barefoot or feel better to walk on the outsides of your feet. Imaging, such as x-rays or MRI, can diagnose hammer toe.  However two simple tests combined show good diagnosis results: a drawer test to test the mobility of the joint, and trying to pull a piece of paper out from under the toe in standing.

Treatment of hammer toe depends on the extent of the instability of the toe joints.  Often, people do not seek treatment until the toe has completely crossed under or over and has become rigid. Conservative treatment is moderately effective for early joint instability and includes shoe modification (lower high heels, wider toe box, more cushion), pads placed in the shoes or rocker bottom shoes to redirect the forces across the foot during walking, or steroid injections at the joint (keeping in mind that any steroid relieves pain but does disturb the already fraying tissues). Keeping your foot, ankle, and calf muscles strong can also help, as well as checking in with a physical therapist to help correct any faulty movement patterns further up the chain.

Surgery is a common option, especially for more advanced stages of hammer toe. Two main approaches are used–one accessing the area from the sole of the foot and the other from the top of the foot.  Surgeons trim any unhealthy tissues and suture any obvious tears in the plantar plate and collateral ligaments.

In the past the collateral ligaments have been the primary tissue repaired. However, authors found better outcomes with surgery prioritizing plantar plate repair along with collateral ligament repair.  They found that this helped significantly with lasting deformity correction and improvement in pain and a person’s ability to function.

Physician’s Beware: MRI Inadequate for Synovial Sarcoma

In this case presentation, surgeons show how 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 patient in question.

This young man (a 17-year-old high school football player) started having pain on the bottom of his left big toe (first metatarsophalangeal joint). The pain started after someone stepped on his forefoot during football practice. There were no other remarkable symptoms or problems, no observed or felt masses, and no evidence of infection, fracture, or tumor.

Even so, there was a rare malignant soft tissue tumor that was eventually discovered. The pathway to that discovery was lengthy and involved multiple steps of conservative (nonoperative) care. Because the first MRI showed a partial plantar plate disruption, a diagnosis of turf toe was made and confirmed with a second opinion. Treatment then consisted of antiinflammatories and physical therapy.

When the patient did not improve, a one-month trial of nonweight bearing in a cast was tried. The treatment worked and the pain went away but as soon as the young man went back to his regular activities (including sports and marching band), the pain was back. He was referred to a larger medical facility and evaluated by a fellowship-trained foot and ankle surgeon. X-rays and MRIs were repeated. Bone scans were ordered. It still looked like he had an unhealed, but stable, partial plantar plate disruption.

In the end, it was decided to do surgery to repair the plate injury. And that is when the true cause of the problem was fully appreciated. When the surgeon made an incision he found a firm, gritty, brown mass. It was removed and sent to pathology where the diagnosis of synovial sarcoma was made by viewing the cells under a microscope. With this information, a full metastatic scan was performed with no evidence of spread elsewhere.

The surgeon removed the first and second toe in order to get all of the cancer. The pathologist confirmed there were wide margins, meaning a sufficient area of healthy, normal cells around the cancer cells. The young man was given a special custom-made shoe insert (called an orthosis) to help him walk normally.

It was a long wait from that first injury to the correct diagnosis and another year before he was back to full activities. The prognosis was good given his young age (younger than 25 years), the small size of the tumor (less than one centimeter), and lack of metastasis (cancer had not spread). Follow-up chemotherapy and radiation were not required because of these three factors (age, tumor size, no mets).

Looking back on this case, the authors offer the following comments. First, it was no surprise that X-rays were negative. This type of (radiographic) imaging does not show soft tissue malignancies. However, 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.

Second, they suggested that it was the tumor that weakened the anatomic structures of the foot (e.g., sesamoid complex under the big toe). Then getting stepped on was enough force to cause further disruption and the resulting pain. The malignancy may have prevented his body from creating a normal inflammatory response to repair the problem. That’s why his symptoms persisted for so long.

The authors encourage 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. Reports like this help point out that a normal reading on an MRI can be misleading.

In summary, synovial sarcomas are rare but occur most often in young, healthy adults. They are often overlooked and/or mistaken for other problems. The authors found 25 other cases reported of synovial sarcoma of the forefoot, so it may occur more often than anyone previously realized.

Update on Transplantation Techniques for Osteochondral Lesions

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 repair the cartilage have been developed and improved over the last 10 years.

In this review article, surgeons from the Hospital for Special Surgery in New York City bring us up-to-date on arthroscopic bone marrow stimulation, tissue transplantation, and the newer cell-based and biologic techniques for cartilage repair. The focus is on the treatment of osteochondral lesions of the talus. The talus is a bone in the ankle situated between the tibia (larger of the two lower leg bones) and the calcaneus (heel bone).

Ankle injuries severe enough to damage the cartilage are common in sports athletes. Treatment is designed to restore the cartilage and give the athletes relief from painful symptoms. The final goal is to get them back into action at a level equal to (or even better) than before the injury. How well each of these techniques meets these goals is also reviewed (based on current outcomes reported in the literature).

Starting with bone marrow stimulation (e.g., microfracture, drilling of the subchondral plate) the authors provide a rationale for the treatment, description (drawings, CT scans), and currently reported results. Limitations of the procedure are also mentioned.

They do the same thing for autologous osteochondral transplantation (replacement of the defect with a tubular unit of donor hyaline cartilage and bone taken from the patient’s knee) and osteochondral allograft transplantation (replacement of large defect from a donor other than the patient).

The more complex, two-stage autologous chondrocyte implantation is discussed separately. There are two different ways to accomplish this technique: periosteum-covered technique and matrix-associated technique. Both involve 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). The matrix-associated technique is not currently available in the United States.

You have probably heard about stem cell research. 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.

And finally, one last biologic treatment to repair cartilage 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.

Morton’s Neuroma: Does Size Matter?

When it comes to the treatment of Morton’s neuroma, does size matter when results are measured between steroid injection and injection of just a numbing agent? Another way to pose the question is to ask: is there any difference in results when treating Morton’s neuroma with steroid injection versus an analgesic (like novocaine)? Does size make any difference?

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.

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.

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.

Also, an injection of lidocaine and cortisone into the area may help temporarily relieve symptoms. This is usually short-lived (days to weeks) and is mainly useful to help the doctor make a diagnosis. A study in Scotland was done to test out whether a corticosteroid injection is more effective than an anesthetic injection.

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. Ultrasound was used to guide the needle 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.

Tools used to measure results included a Foot Health Thermometer (used to record general foot health), the Manchester Foot Pain and Disability Schedule, and the Multidimensional Affect and Pain Survey (MAPS). Combined together, these patient-surveys provided 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. The ultrasound showed how large the neuromas were so the researchers could use that information to see if size matters. 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.

In summary, surgery to remove painful neuromas (which is often unsuccessful or causes other complications) may not be needed. The success of corticosteroid injections may be better than previously reported. At least according to the authors of this randomized, controlled trial, the use of methylprednisolone can provide effective relief of painful symptoms for at least three months. Longer follow-up will be conducted to see the long-term results as well.

First Report of Alternate Treatment for Hallux Rigidus

Degenerative arthritis of the big (great) toe is referred to as hallux rigidus. The joint affected is 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. In this report, surgeons from the Hospital for Special Surgery in New York City report on 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.

But the results are well-worth it as the surgeons report a 100 per cent success rate (bone healing). And 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. 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.

In conclusion, it is possible to use combination surgery to preserve the joint when surgically treating advanced cases of hallux rigidus. By using the standard tissue removal of bone spurs and damaged or degenerative bone and joint (cheilectomy) and then combining it with a lengthening osteotomy of the proximal phalangeal, motion and function of the joint can be saved. Patients are able to return to nearly normal weight-bearing almost immediately.

Two Types of Osteochondral Lesions of the Ankle Described

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).

Surgeons from South Korea compared a large group of patients (almost 300 people) with osteochondral lesions of the talus and described them in this article. These two basic types of lesions (chondral and osteochondral) have some differences that might be important clinically.

The authors focused on comparing patient demographics (age, sex, trauma, body size), characteristics of the lesions (size, location, number of lesions), and patient outcomes (pain, motion, function). They reported that two-thirds of the patients had chondral (cartilage) lesions and the remaining one-third had the full osteochondral (including cartilage and bone) type.

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).

And as it turned out, osteochondral lesions were more common in the younger (more active) patients (in their 20s) who might have better healing capabilities as well. Chondral (cartilage only) lesions were present more often in older, heavier adults (50 year old and older with higher body mass index or BMI). Trauma was a key feature for most of the patients in both groups. Symptoms lasted 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.

There wasn’t a lot of difference in lesion characteristics between chondral and osteochondral defects. Size and location of the lesions were very similar between the two groups. Chondral lesions in patients without a history of trauma were more likely to form cysts just under the cartilage. Older patients were more likely to experience impingement (pinching) of the soft tissues during ankle motion with the chondral type of lesions. Patients in both groups had equally improved symptoms (decreased pain and increased function) after surgery for either kind of lesion.

In summary, although there are differences in age, duration of symptoms, and body-mass index (BMI), clinical results were very similar for these two types of osteochondral lesions of the talus. Other studies have shown that the most important factor predicting success or failure of treatment is the size of the lesion (larger sizes are less likely to respond well). This study showed that the type of lesion (chondral versus osteochondral) is not as significant a factor in predicting patient outcomes.

Italians Offer New Approach to Osteochondral Lesions.

Ankle sprains and other significant trauma (e.g., bone fractures) can cause a condition known as osteochondral lesions. These are defects or “holes” in the cartilage lining a joint. Sometimes the damage is enough to create a hole all the way down into the bone. Since cartilage does not heal well on its own, this type of damage is permanent. Painful clicking and loss of motion and loss of function with early arthritis are likely.

Treatment for osteochondral lesions is the subject of much debate and research around the world. In this study, surgeons from the Rizzoli Orthopaedic Institute in Italy presented a new approach to the problem. The new technique is a one-step stem cell transplantation. The procedure is done arthroscopically, which eliminates the need for a more invasive open incision surgery.

Stem cells are basic building blocks of all cells. They have the ability to transform into all other cells including cartilage (chondral) cells. Once implanted into the defect, they can regenerate the hyaline cartilage that lines the joint surface (right next to the bone).

Forty-nine patients participated in the study. Stem cells were removed from the patients’ own pelvis (iliac crest) by inserting a needle into the bone marrow and withdrawing cells. The bone marrow was then prepared using a separator device that spins the cells down and separates out the needed cells. These cells were then mixed with a special powder to make a paste that could be placed into or onto the lesion.

Results were measured by comparing MRI images before and for up to four years after the procedure. 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.

Clinical outcomes were measured using pain, motion, weight-bearing status, ankle alignment, physical activity, and level of sports participation. At first, scores for the tests used to measure clinical outcomes showed a significant improvement. But between two and three years after the procedure, there was a decline in scores. Three-fourths of the athletes were able to go back to their previous level of sports participation. The remainder either shifted to a different activity or sport (with lower impact) or resumed their previous sport at a lower level than before the injury.

By analyzing all the data, the researchers were able to show that the larger the lesion and the longer the time between injury and repair, the worse the results. This conclusion has also been reported in other studies (using other repair techniques).

The authors suggest that this one-step arthroscopic approach using stem cells as a reparative agent has some potential. It is less expensive than other treatment techniques and does not require multiple surgeries. There were no complications in this group of patients. Many patients were able to return to normal but a few were actually worse off afterwards compared with before the procedure. It was thought that the lesions in these cases were deeper than in other patients who had a good result.

Patients who develop more tissue like hyaline cartilage and less like fibrocartilage have a better chance of good recovery. Specifically, patients who had 80 per cent hyaline cartilage with only 20 per cent fibrocartilage had the best results. More study is needed using this one-step stem-cell procedure and comparing results with other techniques before it will be used over other methods of repair.

Treatment of Achilles Tendon Rupture in Older, Less Active Adults

Older adults who rupture the Achilles (heel) tendon may end up with a case of Achilles tendinosis that requires a special kind of surgery. 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 (nonoperative) 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 this 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.

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.

Important Factors Affecting Outcomes of OAT Treatment for the Heel

Holes referred to as “defects” in cartilage and bone can be treated with a technique called osteochondral autograft transfer or OAT. Efforts are being made to identify factors that might predict a good or favorable result.

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.

Osteochondral autograft transfer (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 same patient’s joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

In this 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.

So what did they find? Ninety-five per cent (95%) of the group reported good-to-excellent outcomes. The most important factor 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.

Although a second-look arthroscopy is an invasive procedure, it 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.

The authors 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.

Prevention and Treatment of Foot Infections

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.

Prevention and management of foot infections is essential to avoid serious complications requiring amputation. In this article, five physicians from the University of Pennsylvania apply their combined knowledge and expertise in discussing the diagnosis and treatment of foot and ankle infections.

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 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).

Anyone with diabetes or any of these other conditions must be instructed in proper foot care. Inspecting the feet daily called surveillance is essential. Any areas of redness, swelling, bruising, or blistering must be evaluated by a physician. Recognizing signs of infection early and getting proper treatment (usually antibiotics) is the first tool against loss of limb.

The physician will be able to order lab tests and appropriate imaging studies to detect infection, evaluate the patient’s diabetic status, and look for fractures, dislocations, or other degenerative changes. Treatment to address those problems is important, too. When skin and nail bed infections have gone too far and abscesses are present, surgery might be needed.

One goal of treatment is to prevent the infection from spreading up the leg. If the infection enters the lymphatic or circulatory systems, total body toxicity can develop with organ failure and even patient death as the final outcome. The immunocompromised condition of many patients who develop limb- and life-threatening infections prevent them from recovering without medical assistance.

The authors offer a separate section in their article dealing with diabetic ulcers and diabetic foot infections. Again, prevention is the key to optimum care for these individuals. Besides skin inspection, proper footwear, use of orthotics when appropriate, and exercise are mainstays of prevention and management.

A physical therapist is often the healthcare professional who addresses many of the components of patient education and prevention related to skin surveillance, proper skin care, foot alignment, posture, and exercise. When infection, deep infection, and/or septic arthritis (joint infection) develop, treatment shifts to the physician and a more medical approach with diagnostic testing, use of antibiotics, and possibly surgery.

The authors conclude that with more than 18 million Americans who already have diabetes and millions more who are either pre-diabetic or who have undiagnosed diabetes, the need for prevention and proper management is more important than ever. This includes the topic of their article: foot infections that can cause serious disability, loss of limbs, and even death.

Seven Studies Shed Light on Treatment for Achilles Tendon Ruptures

You have probably heard of the “seven deadly sins” and if you watched Mickey Mouse cartoons, you may have even seen Disney’s version of “killing seven with one blow.” But you probably haven’t seen the results of seven level I random controlled trials evaluating treatment of acute Achilles tendon ruptures. That’s what we bring to you from this quantitative systematic review presented by the Department of Orthopaedic Surgery at the State University of New York at Buffalo.

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?

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.

Achilles tendon ruptures seem to be on the rise among athletes. 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.

In each of the seven studies included, 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).

By combining the number of patients together from all seven studies, there were 677 people (and outcomes) to examine and analyze. This type of study is both a systematic review (finding and reviewing all studies comparing these two treatments) and a meta-analysis (combining all patients together to form a larger pool).

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.”

The authors pointed out that there were more than seven studies available. In fact, there were over 1,000 articles on the topic of acute Achilles tendon ruptures. But with the strict criteria they used to ensure the best analysis with the most reliable results, only these seven articles could be included.

They advise that future studies are needed — especially to answer the question of treatment effect on muscle strength. This information would be very valuable for athletes who depend on return of full strength needed for jumping and running. But such studies would also provide high-quality research that yields meaningful, trustworthy data.

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.

Evidence to Support Shock Wave Therapy for Plantar Fasciitis

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. 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. 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.

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. Studies have not been done to determine the most optimal intensity to use when treating plantar fasciitis with shock wave therapy.

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 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.

Treatment of Achilles Tendon Rupture: What Do the Experts Say?

Researchers from the University of Western Australia are well-known for their reports and findings about Achilles tendon ruptures. Less than 10 years ago, they published a report on the use of splinting to treat this problem. Now they address the results between surgery and conservative care for this same type of 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. 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. 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 rerupture or other complications (e.g., infection, bleeding into the muscle, adhesions, altered skin sensation, blood clots). This meta-analysis of 14 studies with over 1000 patients 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, 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 had significantly higher rates of postoperative infection.

    Despite the studies already done, we still don’t know whether or not bracing right away should be the recommended treatment. We don’t know if speeding up rehab is a better way to go compared with immobilizing the leg in a cast and giving it time to heal. And it’s unclear why more people than ever before are injuring this part of the body.

    The authors say what is clear: the need for more, large randomized controlled trials to compare different treatment approaches. Surgeons and other physicians treating this problem need evidence-based guidelines for the early treatment of acute Achilles tendon injuries. High-quality, well-designed studies with clear methodology are needed!

    And a final note for surgeons: comparing different surgical techniques is also in need of some good, high-quality study designs. For now, with the limited number of studies available, the authors suggest that the six-strand repair method is not better or more advantageous than the two-strand repair. More complex reconstructions (over simple surgical repairs) don’t really yield better results either.

  • What To Do About Hallux Rigidus

    Hallux rigidus is a degenerative type of arthritis that affects the large joint at the base of the big toe. Degenerative arthritis can result from wear and tear on the joint surface over time. The condition may follow an injury to the joint or, in some cases, may develop with no known cause.

    In this review article, an orthopedic surgeon from the Hospital for Special Surgery in New York presents ways to treat this condition based on classification (severity). Nonsurgical management is always advised first and may consist of nonsteroidal antiinflammatory medications to reduce pain and swelling, shoe adaptations, and changes in activities.

    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.

    A rocker type of sole allows the shoe to take some of the bending force, and may be combined with a metal brace in the sole. These features help limit the flexibility of the sole of the shoe and reduce the amount of bend in the toe during walking.

    Most patients with this problem aren’t happy to wear the unfashionable shoes that might provide some pain relief for this condition. Likewise, younger adults may be unwilling to (or unhappy about) changing activity level.

    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.

    Many surgeons favor arthrodesis, or fusion, of the MTP joint for severe hallux rigidity. To fuse a joint means to allow the two bones that form a joint to grow together and become one bone. The joint between the two bones is removed and the two bones are held together by some type of fixation device such as staples, wires, metal plates, or screws. This results in a pain free joint but one that no longer moves.

    Replacing the joint with an artificial joint is another treatment option 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 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.

    The authors note that there is a need for improved implant designs and materials for joint replacements. Right now, joint replacement is not considered the best approach to the problem of 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.

    Extra Bone in Feet Cause Problems for Dancers

    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.

    In this report, two dancers with painful accessory navicular bones are featured. The article is intended to help those who treat dancers to recognize the possibility of accessory navicular (or other) bones and what to do about it. Treatment can be conservative (nonoperative) or surgical. The goal of the dancer is to return to full participation in dance. The decision to do surgery is usually 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).

    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.

    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.

    Changes in Treatment for Achilles Tendon Rupture

    Research continues in the area of treatment for Achilles tendon ruptures. The last 10 years has brought a change from placing patients in a nonweight-bearing cast to using an ankle-foot orthosis (AFO) instead. An AFO is a brace usually made from plastic or light metal (carbon fiber). It allows for early weight-bearing. The question now is what’s the best AFO design for 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. This action causes your foot to point down and helps you rise up 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.

    In severe cases, the force of a violent strain can rupture the tendon. The classic example is a middle-aged tennis player or weekend warrior who places too much stress on the tendon and experiences a tearing of the tendon. In some instances, the rupture may be preceded by a period of tendonitis, which renders the tendon weaker than normal.

    Traditionally, this type of injury required a long period of time for healing, recovery, and rehab. Management with early weight-bearing is helping change that. And this study is contributing to the collection of knowledge we have about the effects of AFO designs.

    Using 15 normal, healthy adults, the researchers compared three different AFOs with four different heel-wedge combinations. That gives a total of 12 different possible combinations. The heel wedge is used to place the ankle in a position of plantar flexion (toe pointed) in order to take stretch and pressure off the Achilles tendon while it is healing.

    The goal is to find the position that protects the healing Achilles while still allowing function in order to avoid atrophy (wasting) of the gastroc-soleus muscle group. The benefit is to restore motion and strength faster and therefore allow the patient to return to daily (and sports) activities sooner with less disability.

    A special in-shoe pressure system was used to measure the amount of pressure placed on the ankle and Achilles for each of the 12 combinations. A special tool called an electrogoniomter was used to measure ankle and foot range of motion while walking with each of the AFO designs/wedge angles. Each individual walked in their own shoes first then in the AFOs with various heel wedges.

    They found that walking speed was affected by wearing a higher wedge (placing the ankle in more plantar flexion). Not surprising was the fact that motion (dorsiflexion, the opposite of pointing the toe) was restricted more with a higher wedge.

    With smaller wedges, more dorsiflexion was allowed and more pressure was placed on the forefoot/less pressure on the heel. The more rigid AFO used in the study (a rigid rocker-bottom design) resulted in less pressure on the heel and more pressure on the forefoot.

    In fact, the greatest heel pressures were measured when subjects wore the rigid rocker-bottom AFO. When this AFO was combined with the thickest wedge, there was more motion restriction than any other AFO/wedge combination.

    This makes sense because the amount of load placed on the Achilles tendon, heel, and forefoot depends on motion at the ankle. When more dorsiflexion is allowed, force is transferred from the heel to the forefoot. Less dorsiflexion means less transfer of force from the heel to the forefoot so there is less pressure on the forefoot and more on the heel.

    How does this all translate to someone who has a ruptured Achilles tendon? Remember, the people in this study all had normal Achilles tendons and no previous foot or ankle injuries. The authors say they can only “infer” how rehab of patients with acute rupture of the Achilles tendon would go.

    Reducing ground-reaction forces and the degree of loading by using an ankle-foot orthosis with wedging is an important rehab strategy. Weight-bearing is allowed but in a protected mode. The foot and ankle are held in a plantarflexed position so the Achilles tendon can heal properly. If the ankle is dorsiflexed, the Achilles tendon is lengthened. Healing of the tendon in a lengthened position results in severe problems later.

    One of the carbon-fiber AFOs used in these trials did not limit or restrict dorsiflexion enough so it would not be recommended for patients with acute Achilles tendon ruptures. The rigid-rocker bottom orthosis restricted ankle dorsiflexion the most but put a lot of pressure on the heel causing heel pain.

    From this study, it looks like a carbon-fiber AFO with one heel raise would satisfy all needs. The ankle would be kept from too much dorsiflexion but still allow a near-normal walking pattern. This study does not answer the question of how much force is applied to the healing tendon with this configuration. And it is possible that each patient will have a different force tension the healing Achilles could handle.

    This study does not answer the question of whether starting patients with three heel wedges and gradually reducing to one heel wedge is helpful. But the study does provide a starting point from which to begin evaluating actual patients. Finding the best rehabilitation protocol may take some time but it will be well worth the effort if it enables patients to return to full function sooner.

    What Is Cuboid Syndrome?

    In this review article, a physical therapist from the University of Wisconsin – La Crosse explains what a cuboid syndrome is, causes, effects, diagnosis, and treatment. A complete review of the anatomy, mechanics during standing and walking, and clinical presentation are also included. Other names for this condition are cuboid fault syndrome, dropped cuboid, subluxed cuboid, locked cuboid, peroneal cuboid syndrome, and lateral plantar neuritis.

    The first thing to know about cuboid syndrome is that it causes pain along the lateral (outside) edge of the foot. The cuboid bone is one of many bones in the foot. It is situated close to the center of the foot and is surrounded by other bones. It is an oddly shaped bone with smooth places (the articular surfaces) where the other bones connect and are held together by ligaments and tendons.

    The main area where the cuboid bone makes contact with the calcaneus (heel bone) is called the calcaneocuboid (CC) joint. This is an important joint for stability, load transfer, and movement of the foot and ankle. As some of the names for this condition suggest, a shift in the position of the cuboid bone can cause loss of motion with the bone “locked” in place. The surfaces of the connecting bones no longer line up. This effect with the accompanying symptoms is a cuboid syndrome. When this happens, we say the joint has lost its congruence.

    The loss of congruence can be small enough that it doesn’t show up on an X-ray or other types of imaging studies. Pain develops along the lateral side of the foot. It feels like a ligament sprain. Loss of ankle and/or foot motion is common. Putting weight on the foot (especially the outside edge of the foot) becomes difficult. The ability to stand, walk normally, or hop on the painful foot is affected.

    Lateral foot pain could be caused by a number of other problems. The list of possible sources of lateral foot pain includes gout, compression neuropathy of the sural nerve, ankle impingement, tendinopathy, or congenital fusion of the bones in that area (calcaneus, navicular, talus).

    Even though cuboid syndrome is fairly common, there haven’t been enough studies done to find reliable and accurate tests to diagnose the problem. The examiner must rely on the patient’s history, perform some clinical tests (e.g., palpation, movement of the bones, movement of the joints), and treat the problem.

    The history may be helpful (if there has been trauma) but in many cases, there is no known cause. Anything that disrupts the joint alignment between the cuboid and the surrounding bones can result in a cuboid syndrome. X-rays may be taken to rule out bone fracture(s).

    Cuboid syndrome is clearly a mechanical problem but one that could be caused by impaired muscle or tendon function, faulty anatomy such as flat feet, being overweight, or wearing the wrong kind of shoes. Other factors that may increase the risk of developing cuboid syndrome include poorly constructed orthotics (shoe inserts), training on hard or uneven surfaces, and overtraining without enough rest or time to recover.

    As these risk factors suggest, athletes and especially ballet dancers are affected most often by cuboid syndrome. In fact studies show that four per cent of all athletes with foot pain have pain coming from the cuboid gone. And in several studies, 17 per cent of ballet dancers examined with lateral foot pain had cuboid syndrome. Anyone (athlete or nonathlete) who has sprained an ankle is also at risk for this problem.

    If the treatment for cuboid syndrome is applied and the symptoms go away, the diagnosis may be confirmed.
    Treatment is with manipulation of the bones. The therapist holds the foot to stabilize the bones around the cuboid and then applies a force to shift the bone back in place. The patient may feel and/or hear a click or pop. Immediate pain relief is often reported after manipulation.

    For those professionals who examine and treat foot pain, the tests used to evaluate the cuboid position and movement are included in this article. The author provides photos and descriptions of each test (e.g., dorsal-plantar cuboid shear test, midtarsal supination test, midtarsal adduction test). Two techniques used to manipulate the cuboid are also featured (the cuboid whip and the cuboid squeeze).

    From experience, the therapist notes that it may take more than one manipulation to completely resolve the problem. The longer the patient has had this condition, the more likely that a series of manipulations will be needed. Manipulation may be followed by local treatment such as icing, taping, ultrasound (heat), massage, or electrical stimulation. Stretching of the leg muscles and/or shoe inserts to support the cuboid bone may be provided.

    In cases of recent ankle/foot sprain, a high-velocity thrust manipulation may not be appropriate. It may be better to apply this treatment method after the injured soft tissues have had time to heal and can withstand the force of a manipulative movement.

    Anyone with lateral foot pain who does not respond to treatment for a cuboid syndrome may have some other problem. At that point, reevaluation is required. It may be that there is a sprain severe enough to require unloading with a cane or crutches or off-loading in a cast or splint. If an X-ray has not been previously taken, this may be the time to take one.

    The author concludes that further research is needed in this area. Evidence-based guidelines for the diagnosis and management of cuboid syndrome currently do not exist. It would be helpful to know if there are any predictive risk factors for success or failure of manipulation for this problem before applying the technique. Since cuboid syndrome is fairly common, this information could potentially benefit many people (athletes as well as nonathletes).

    Results of Surgery to Correct Tailor’s Bunions

    Most people are familiar with bunions of the big toe but have you ever heard of a bunionette on the little toe side of the foot? With a bunion of the big toe, a large bump seems to grow out of the side of the great toe. But in fact what is happening is that the two bones that meet to form the big toe joint angle away from each other. A bump we call a bunion forms at the end of the metatarsal (long bone of the toes).

    The bunion that develops is actually a response to the pressure from the shoe on the point of this angle. At first the bump is made up of irritated, swollen tissue that is constantly caught between the shoe and the bone beneath the skin. As time goes on, the constant pressure may cause the bone to thicken as well, creating an even larger lump to rub against the shoe.

    A bunionette is similar to a bunion, but it develops on the little toe side of the foot where the small toe connects to the foot. This area is called the metatarsophalangeal joint, or MTP joint. A bunionette here is sometimes referred to as a tailor’s bunion. It formed because tailors once sat cross-legged all day with the outside edge of their feet rubbing on the ground. This produced a pressure area and callus at the bottom of the fifth toe.

    Today a bunionette is most likely caused by an abnormal bump over the end of the fifth metatarsal (the metatarsal head) rubbing on shoes that are too narrow. Some people’s feet widen as they grow older, until the foot splays. This can cause a bunion on the big toe side of the foot and a bunionette on the little toe side if they continue to wear shoes that are too narrow. The constant pressure produces a callus and a thickening of the tissues over the bump, leading to a painful knob on the outside of the foot.

    Treatment initially is directed at obtaining proper shoes that will accommodate the width of the forefoot. Pads over the area of the bunionette may help relieve some of the pressure and reduce pain. These pads are usually sold in drug and grocery stores. They are small and round with a hole in the middle, like a small doughnut.

    If all else fails, surgery may be recommended to reduce the deformity. The surgeon may shave the metatarsal head and reshape it but recurrence of the problem is reported with this approach. More often, the surgeon will opt to remove the prominence of bone underneath the bunion to relieve pressure. Surgery may also be done to realign the fifth metatarsal if the foot has splayed. The boney bump can be removed (cut out) with a small chisel or saw and the remaining bone edges smoothed. Once enough bone has been removed, the skin is closed with small stitches.

    If the angle of the metatarsal is too great, the fifth metatarsal bone may be cut and realigned. This is called an osteotomy. Once the surgeon has performed the osteotomy, the bones are realigned and held in position with metal pins or wires. The hardware remains in place while the bones heal (usually four weeks).

    Now the osteotomy procedure can be done percutaneously. The surgeon can insert the surgical instruments through a very small incision that doesn’t require opening the foot up with a large incision. The obvious advantages to this technique are shorter operating time and fewer complications. Of course the next question is: how well does the percutaneous osteotomy for Tailor’s bunions work?

    Surgeons from the University of Verona in Italy report on the results of a series of 21 patients who had a total of 30 percutaneous osteotomies of the fifth metatarsal. They used X-rays to look at the results and patient interviews to find out about patient pain, function, and satisfaction.

    Once the osteotomy was done and the bones were realigned properly, the surgeon used a kidney-shaped pad under the fifth metatarsal with tape to reduce pressure on the surgical site and to hold the corrected alignment during healing (about six weeks). Patients were allowed to walk without crutches but they did use a special shoe with a flat rigid bottom (sole). The shoe kept them from bending the toes and thus from putting pressure on the base of the toes.

    Everyone was followed for at least three years. Some patients have been in the study for as long as 12 years. The results are reported as follows: 73 per cent (almost three-fourths of the patients) had no pain and no limitations after recovery. Twenty per cent (20%) had to wear comfortable shoe and experienced mild decrease in function. And seven per cent (7%) still had pain due to mild, persisting malalignment.

    X-rays showed complete and successful union of the bones at the osteotomy site for all patients in the study. No one reported stiffness of the fifth metatarsal joint. There were no other reported complications or problems.

    The authors concluded that percutaneous osteotomy for Tailor’s bunionette is safe, reliable, and effective. The short operative time, minimal disruption of soft tissues around the bone, and quick return to weight-bearing status are three major advantages of this updated surgical technique.