News Category: Foot

The results of this study may help doctors and patients decide how to treat an acute rupture of the Achilles tendon. Previous studies support surgical repair over nonoperative treatment for this injury. This study confirms those findings and offers a comparison between the two treatment choices.

The main advantage of surgery compared with nonoperative care to repair the torn Achilles tendon is a lower rerupture rate. But the rates of infection, scarring, and nerve injury is much higher for surgical repair.

There is some suggestion that the complication rate after surgical repair of a ruptured Achilles tendon will continue to decline over the next few years with improved surgical technique. Surgeons can use minimally invasive (MI) methods. This allows for much smaller incisions and less disruption of the intact soft tissues.

After surgery, the patient can wear a special brace called functional bracing. The brace allows the individual to walk, exercise, and train for sports. Recovery is faster and return to work and sports occurs sooner. The risk of rerupture and other complications is low with bracing.

Nonoperative care is usually by casting or splinting to immobilize the leg. The foot is held in a position of slight plantar flexion (toes pointing down). This takes the pressure off the healing tendon. There is no risk of nerve injury as there would be with surgery. But recovery is delayed due to weakness of the injured calf muscle.

The authors of this study compare these two types of treatments. Patients with an acute Achilles tendon rupture treated within 72 hours were randomly placed in one of two groups.

Most injuries occurred in adults between the ages of 30 and 40. The injury happened while playing sports such as tennis, squash, and volleyball.

The first group had minimally invasive surgery to stitch the torn tendon back in place. A small incision (less than two inches long) was made. After surgery, a cast was applied and worn for one week. This was followed by six weeks of tape bandaging to protect the healing tendon. The foot was placed in slight plantar flexion using a heel raise. The height of the heel was slowly lowered over a period of several weeks until it was removed completely.

Patients in the nonoperative group were placed in a slightly plantar flexed cast for a week. This was followed by a period of time wearing a functional bracing system. The brace was made of lightweight plastic with a vacuum cushion inside. The sole was removable to allow for adjusting the amount of plantar flexion. The brace was to be worn continuously without taking it off between medical appointments. It was devised in such a way that the researchers would know if the patient took it off when he or she wasn’t supposed to remove it.

In both groups, full weight-bearing was allowed on flat surfaces. Crutches could be used at first but these were not needed after the first week.

Results were measured using complications (other than reruptures). The number of reruptures were recorded but not expected to be different between the two groups. Range-of-motion, strength, and pain were measured. Satisfaction with treatment, return to work, and participation in sports were additional results measured. Patients were followed for a full year.

As it turned out, there were more reruptures in the nonoperative group (15 per cent) compared to the surgical group (five per cent). The major complications were skin-related (infections, sores, blisters). Most of the skin problems occurred as a result of the brace (nonoperative care) or tape bandaging (used after surgery).

Early on after the treatment, patients in the surgical group were less satisfied and in more pain than the nonoperative group. But as time went by, this reversed. At three and 12 months, the opposite was true. The nonoperative group had more pain and was less satisfied than the surgical group.

Time off work was significantly longer for the nonoperative group. But more patients in the nonoperative group were able to return to their former levels of sport within one year compared to the surgically treated patients. Further evaluation revealed other reasons (job or family) for the difference between these two statistics.

In summary, when using complications after treatment as a measure of results, surgical management of acute Achilles tendon ruptures was favored over nonoperative care. Problems with skin breakdown using the brace suggest the need to look for ways to improve the bracing system.

Persistent ankle pain after an ankle sprain could be a sign of a condition called osteochondral lesion of the talus (OLT). The talus is a bone in the ankle between the calcaneus (heel bone) below and the tibia (shin bone) above.

The bottom of the tibia forms a dome over the top of the talus. With OLT, a piece of cartilage from the talus gets pinched by this dome. In more severe cases, a fragment of cartilage breaks off the talus but stays wedged in place. In the worst cases, the fragment is floating free in the joint space.

Other terms used to describe OLT include osteochondritis dissecans, transchondral fracture, talar dome fracture, and flake fracture. The condition is fairly uncommon. It is difficult to diagnose using X-rays, MRIs, or CT scans.

The authors of this study used arthroscopy to diagnose and treat OLT. They graded the condition based on severity as Grade I (mild) through Grade IV (severe). Treatment results were compared to see if outcomes were better for milder forms of the condition. Results showed that arthroscopic grading of OLT does predict final outcome after surgery. This is something that cannot be accomplished with X-rays or other more advanced forms of imaging.

Milder lesions without fragmentation had better results. Patients were more likely to have a good-to-excellent outcome without complications if the cartilage was not torn away. They were not able to compare results based on specific surgery done because there were too many different kinds of operations performed.

For example, some patients had holes drilled in the talus where the fragment had broken off. This procedure is called microfracture. It stimulates new growth of fibrocartilage. Other patients had the loose piece of cartilage removed (excision) with smoothing of the bone where the piece was broken off. And some patients had both excision and drilling.

Almost three-fourths of the group had good-to-excellent results. Most were able to return to all preoperative levels of activity. A few patients had complications such as plantar fasciitis, nerve pain or injury, or pain around the puncture wounds where the arthroscope entered through the skin. These problems all disappeared during the first six months of recovery.

Results of treatment did not appear to be linked with age, gender, or the side affected (right or left ankle). Delays between injury and surgery did not seem to make any difference in the final results. Worker’s compensation patients did have poorer results compared with those who were not on worker’s comp.

Follow-up was for at least five years. So it was possible to see if the long-term results changed over time. They found that more than one-third of the patients had a deterioration of their good results over time. Deep aching and pain with swelling recurred. Limited motion and instability occurred with degeneration of the joint. The reason(s) for this change was unknown.

The authors were unable to provide treatment guidelines for OLT based on the results of this study. When to choose conservative care versus surgery remains a difficult decision. And it’s not clear how long conservative (nonoperative) care should be carried out before considering surgery. But the authors offered suggestions based on their own treatment methods. They recommended:

How soon after a Achilles tendon repair procedure is it safe to put weight on that foot? Does walking on the leg during the healing then delay recovery? These are questions researchers at the University of Alberta in Canada addressed in this study.

They looked at a group of 110 adults ages 17 to 65 with an acute complete Achilles tendon rupture. Everyone had surgery to repair the damage. The operation was done within the first two weeks after the injury. At first, all patients wore a posterior splint to support and protect the healing tendon.

They were all non-weight-bearing for the first two weeks. Then the patients were divided into two groups. The first group was allowed to put weight on the leg. The second group remained non-weight-bearing for another four weeks.

Patients were given a special ankle-foot support called a fixed-angle, hinged ankle-foot orthosis. This brace can be set to allow a certain amount of motion. In this study, the orthosis was set in a position of rest with the ankle and toes pointed down slightly (20-degrees of plantarflexion). The angle was slowly changed to zero-degrees over a period of two to three weeks.

Everyone did daily ankle motion exercises without the brace on. The weight-bearing group started putting weight on the leg right away. They were allowed to stop using the crutches. The other group kept weight off the foot and used crutches for another four weeks. A special sensor was placed on the orthosis to monitor patient cooperation with the non-weightbearing status.

Everyone was followed at regular intervals for up to six months. By the end of six weeks, the orthosis was discontinued and active rehab started. Exercises included foot and ankle motion and a strengthening program with resistance (rubber tubing, bicycling, heel raises).

The main measure of results was health-related quality of life. This was measured using the RAND 36-Item Health Survey (RAND-36). The RAND survey looks at physical and social function, mental health, pain, general health and vitality. The investigators also assessed activity level, calf strength, and motion. Any cases of re-rupture in either group was to be reported right away (there were none).

They found that after six weeks, the weight-bearing group had a better result. They had better scores on the RAND-36. They reported fewer physical limitations. And they returned to daily activities, work, and sports participation sooner. Putting weight on the injured leg and getting around easier brought an improved sense of well-being and improved quality of life.

But this difference was not apparent at the end of six months. By that time, both groups had the same results. Muscle weakness and poor endurance was obvious in all patients. The authors had expected faster recovery of strength in the weight-bearing group. But this did not happen.

Since there were no disadvantages in early weight-bearing, the authors have adopted this as their new standard of care. They will be carefully monitoring their patients for postoperative deep venous thrombosis (DVT; blood clots). But it is expected that muscular contraction that comes with weight-bearing will prevent blood clot formation.

The authors suggest continuing rehab beyond the standard six weeks’ time period. This will help patients recover strength, endurance, and proprioception (joint sense of position) and possibly prevent future problems.

Achilles tendon rupture is not a common injury but it is being seen more often now, particularly among middle-aged men who are so-called weekend-warriors or weekend athletes. Often, the injury occurs but the patient doesn’t see a doctor until about four to six weeks after the injury. At this point, the rupture is considered to be a chronic rupture. This delay could be because the injury wasn’t all too bad and the patient didn’t realize that he had damaged the tendon or, if it was more severe, it could have just been neglected or even misdiagnosed.

The signs and symptoms of an acute Achilles tendon rupture include a sharp sudden pain in the calf and this makes it fairly easy to make the diagnosis, although up to 20 percent can be misdiagnosed. Chronic rupture, on the other hand, may not cause much pain and can be easily misdiagnosed. The patients may still have satisfactory range of motion, although a limp may be noticeable.

Unlike treatment of acute ruptures (ruptures that have just happened), where doctors often disagree on the best methods, chronic ruptures are almost always treated with surgery.

The Achilles tendon plays a major role in walking and maintaining foot and ankle stability; it runs down the back of the lower leg to the heel. With a chronic rupture, the tissue can become quite thick and immovable, making it hard to move the ankle properly. Because the diagnosis is easy to miss at this point, there are several tests that may make it easier to spot. These include, the calf squeeze test. With the patient prone on the examination table, with feet over the edge, the physician squeezes the calf. If the Achilles tendon is intact, it will pull on the foot, causing it to flex.

Another test, the Matles test, is performed with the patient still prone but with the legs bent at a 90 degree, or right, angle. If the tendon is intact, the foot should stay straight. The O’Brien needle test is more invasive. With the patient still prone, a needle is inserted into an area near the Achilles tendon; the foot is then held by the physician and bent forward and backward. The movement should make the needle move with the movement of the tendon if the tendon is intact. Another test, using a blood pressure cuff, a sphygmomanometer, has also been used. The physician wraps the cuff around the patient’s calf and pumps up the cuff to 100 mm Hg of pressure. The reaction of the foot, while the calf has the pressure on it, will indicate if the tendon intact.

X-rays are helpful, but can also be used to rule out other problems, besides the tendon rupture or in addition to the rupture. Ultrasound is also useful but isn’t always accurate. Magnetic resonance imaging (MRI) can also be done as well.

When managing a chronic Achilles tendon rupture, physicians have the option of conservative, nonsurgical approach, or surgery. With the conservative approach, improvement usually is slow and the results, according to research, seem to be less successful than surgery. Patients who go with the conservative approach often benefit from bracing.

If using surgery to correct the tendon rupture, there are different types of surgery to consider, depending on the rupture. If the rupture is no more than an inch (1 to 2 centimeters), it can likely be fixed with an end-to-end repair, while wider ruptures need to have the tendon lengthened or even supplemented by using tendon tissue.

Another type of surgery,a tendon alignment, is done by joining the ends of the ruptured area, while another method, using turndown flaps uses a flap that covers the rupture.

Using tendon tissue from another part of the body, from the fifth toe, for example, can also be used. Grafts from donors and synthetic grafts are also being used for these repairs.

The surgeries just described all needed traditional incisions and surgical techniques, but surgeons are now looking at endoscopic surgery for tendon repair as well. This type of surgery is becoming increasing popular because they require only a few tiny incisions, through which the surgeon manipulates the tools, using a camera to see inside the body. This type of surgery, called minimally invasive surgery has many advantages, including shorter healing times.

Management after surgery is very important to keep the integrity of the repairs. Although there don’t seem to be any long-term studies that look at the management after surgery, the current thought is that patients need to begin moving and using their foot as soon as possible after surgery. The foot would be immobilized, usually in a plaster cast, for two weeks, followed by a splint for another few weeks. At six weeks, the patient should gradually be able to begin using the foot as usual.

The authors of this article write that tissue engineering may be the future of chronic Achilles tendon rupture repair, with several studies that are ongoing now. In conclusion, they write that although the ruptures aren’t common, they can be debilitating and need to be managed effectively for the best possible outcome.

The Achilles tendon is a strong, fibrous tissue. It connects the muscles in the back of your lower leg, or calf, to your heel bone. The Achilles tendon is the largest and strongest tendon in the body as it bears forces of up to 12 times your body weight, which happens when you sprint. The tendon is surrounded by a tissue called paratenon, which helps the tendon move back and forth and supports the blood vessels that provide nutrients to the tendon. Because the tendon plays such a vital role in bearing weight and moving, it undergoes a lot of stress, which makes it prone to being injured. Problems with the Achilles tendon are among the most common seen in orthopedic clinics in North America.

This article reviews the incidence and etiology, or basis, of Achilles tendon injuries, as well as diagnosis and treatment.

Tissues that surround the Achilles tendon are rich in blood supply to provide nutrients to the tendon. The tendone itself is affected by several factors, such as age, sex, use or disuse, overload, endurance training, and resistance training. As people age, the tendon tissue can become less dense, losing some of its strength. This could be one of the reasons why tendon injuries happen more often in older athletes.

There are three main areas where you can have an Achilles tendon injury:

1- towards the center of the tendon, about two to six centimeters down from the top where it’s first felt below the calf. This injury is most common among younger, more active people. This can result in a total rupture (breaking) of the tendon.
2- a bursitis, irritation of the bursa, a fluid-filled sac that helps provide a gliding surface between tissues, just above the heel.
3- degeneration of tissue around where the tendon meets the ankle. This is seen most often as people age.

Some risk factors for problems with the Achilles tendon include obesity, high blood pressure and use of steroids. Sports and vigorous activities are also a risk for injuring the tendon. The most common action that causes injury is running, moving the back of the foot up and down excessively, and wearing incorrect shoes for the activity. According to one study, active athletes who were younger than 30 years were 2.5 times more likely to injure their Achilles tendon than someone who was not as active. An actual rupture, or tear, of the tendon, happens more often in people who participate in occasional sports or activities, after being sedentary for the most part. This happens frequently in sports like basketball and racquetball.

While many athletes stretch before participating in sports, the jury is still out as to whether stretching helps prevent tendon injuries. One theory about why the injuries occur is that the tendon is deteriorating and the tissues are breaking down with use. At some point, the force of movement causes the tendon to snap.

When diagnosing a tendon injury, physicians have used ultrasound. However, it’s not always possible to tell the difference between a partial or complete tear. Ultrasounds are good for following progress of treatment. In one study looking at using ultrasound for diagnosing Achilles tendon injuries, 125 patients were followed to see if their ruptured tendons would re-rupture. There were 67 patients who had surgery and 58 who did not have surgery. The ultrasound had been used to determine if the patients should have surgery. Those patients who had gaps larger than five millimeters received surgery. There was no significint rerupture rate found in either group, meaning that the use of ultrasound to find the larger ruptures appears to be successful in determining which patients should have surgery.

Other disorders are diagnosed with magnetic resonance imaging (MRI), which makes images with magnets rather than radiation or sound waves. The MRI can show signs of tendinosis inflammation of the tendon. In fact, one study found that patients who were diagnosed with an MRI with having significant changes in the tendon around the heel area and that they would then be better off having surgery than not.

Treatments for tendon injuries can be non-operative or operative. If a physician chooses a non-operative approach, the patient may be given eccentric training. Eccentric movements involve lengthening muscle fibers. The movements are the opposite of concentric movements, which involve contracting the muscles. Studies have shown that these exercises can reduce pain and speed up recovery of function. However, it appears that the exercises may really be effective only for athletes and not people how are usually not active. In a study of sedentary people with the tendon injury, only slightly more than half saw improvement with this treatment.

Other physicians have used shock wave therapy. Shock therapy uses thousands of targeted shock wave pulses aimed at the injured area. The shock waves cause mild, wanted, trauma to the area. This then causes inflammation or swelling and this breaks down scar tissue that may be causing the pain.

When looking at surgery for treatment, the haglund deformity, which is found at about the level of the top of a shoe at the back of the foot, can be corrected by surgery. While it used to be done with an open incision, now surgeons are working on using less invasive types of surgeries, using smaller instruments and small incisions.

When surgery is not the first choice, it is needed if the non-operative treatments fail. The type of surgery performed depends on the injury, the severity, and the precise location. In some cases,surgeons may choose to make the tendon longer in order to lessen the stress on the tendon. This procedure has been successful, according to results of one study.

If a patient has ruptured the Achilles tendon, surgery can help relieve the stiffness and withering of calf muscles (atrophy). Surgery will also reduce the chances of the patient developing a blood clot or re-rupture of the tendon after healing. The strength of the repaired tendon depends on the type of material the surgeon uses when suturing (stitching) the tendon back together. As well, the strength depends on the post-surgery period.

After surgery, usually the leg is kept in a cast for about six weeks, with the patient not being allowed to bear weight on the foot. After the six weeks, the patient begins exercising and then gradually progresses through more intense exercise until full function or as close to full function is regained. Several studies have been done to see which type of rehabilitation method is best, but the treatments in use now all seem to have the same outcome, more or less.

If a physician chooses to treat a ruptured tendon without surgery, the leg will likely be casted for several weeks, with gradual use and weight-bearing on the foot. However, many physicians do not recommend this treatment as non-operative treatments have a high rerupture rate, longer rehabilitation periods, and lower successful return to previous levels of activity.

In conclusion, the authors write that the common injuries with the Achilles tendon are more common in active people, regardless of their age. The currently used protocols for weightbearing after surgery seems to be relatively successful, although doctors are working on using less invasive methods of surgery, which will also affect rehabilitation. the recommend that future studies be done to gain more insight into the issues of treating Achilles tendon injuries.

Although fractures of the ankle and of the metatarsals (toes) are common, fractures and dislocations in the midfoot are not. Their treatment, however, is vital because of the importance of the midfoot in weightbearing between the front and the back, and the gait. The authors of this article researched diagnosis and treatment of midfoot trauma

The disc-shaped bone in the middle of your foot, the tarsal navicular bone can be broken in one of three ways:

1- Avulsion: where a tendon pulls away from the bone
2- Tuberosity: where the end or edge of the bone is broken
3- Body: the bone is broken along the area of the middle

The cuboid bone, a cube-shaped bone, helps support the foot, near the fourth and fifth metatarsals. These bones are rarely fractured on their own. When they do break, it’s often because of an injury like an ankle sprain or from a high-level trauma like a car accident.The way the bone is broken is often called a nutcracker fracture. Fractures can also be the result of a crushing injury.

The cuneifrom bone is closer to the first and second metatarsals. This bone is often fractured along with metatarsal fractures, but can be broken alone. The tarsometatarsal joint, also called the Lisfranc joint can become injured, causing significant damage. This joint is where a cluster of small bones forms an arch on top of the foot.

In order to diagnose midfoot injuries, the first step is the physical examination. if pain is found in the mid-foot or in the joints, x-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) should be performed.

When examining the foot, local tenderness or deformity, as well as bruising or limited range of motion are also signs of injury. X-rays should be done at rest and with weight-bearing as this affects the joints. CT scans are better if stress injuries are suspected, while MRIs are better for tuberous injuries.

Treatment of midfoot injuries can be surgical or nonsurgical, depending on the injury, the location, and the extent of the injury. Minor injuries usually heal with casting or bracing, while more unstable injuries may need surgery for stability. Whether the injury is in a weight-bearing portion of the foot is also a consideration when thinking about surgery. According to research, both surgical and nonsurgical treatments appear to have the same outcome for patients with navicular injuries, so the decision should be based on issues such as if there was any loss of bone in the fracture, how big the gap is in the dislocation or fracture, and if there is any instability in the foot.

With cuboid injuries, nonsurgical treatment may be done if there is no loss of bone length, and if the gap is less than 2 millimeters. Treatment in this case would be casting for about four to six weeks. If surgery is performed, the patient will not be able to bear weight for at least four weeks. If the cuboid injury was due to crushing, surgery is needed to reconstruct the area.

Injuries in the cuneiform bone are less responsive to nonsurgical treatment and need to be treated aggressively. This means surgery to bridge the break while healing occurs. Finally, tarsometatarsal injuries, which are more common in athletes, must be treated aggressively as well, but can be treated nonsurgically if the gap is less than 2 millimeters. If there is any sign of instability, then surgery should be done.

The authors conclude that the importance of treating midfoot injuries adequately is shown in how the midfoot is needed for the weight-bearing relationship between the front and the back of the foot. It is also important to ensure that the patient is able to walk with a normal gait and not a limp.

In this case report, orthopedic surgeons from Switzerland present a patient who developed an unusual type of compartment syndrome. Compartment syndrome is an increased amount of pressure from swelling inside a small space. Usually this occurs in an area where a group of muscles are contained by fascia (connective tissue lining).

The most common site of compartment syndrome is the lower leg. It’s a potentially dangerous condition. Blood supply to the area is cut off. Without treatment right away, nerve damage and death of the muscles can occur.

Most of the time, compartment syndrome is caused by trauma to the soft tissue or bone. Repetitive microtrauma from overuse or chronic activity is a typical risk factor. But in the case of this 40-year old marathon runner (male), exertion was the main cause of the condition.

Symptoms of severe pain, swelling, and pale looking skin were reduced dramatically with surgery. Surgery was done to decompress the medial compartment of the foot. The surgeons reported opening the foot and finding a swollen, blue-color abductor hallucis muscle.

MRIs taken before the procedure confirmed the diagnosis and helped show the surgeon exactly where the problem was located. This information helped avoid unnecessary cutting of the fascia.

Recovery went well for this patient. The stitches were removed two weeks after the surgery. He was up and putting partial weight on that leg several days post-op. By the end of two weeks, he was full weight-bearing. At six weeks, he was back to jogging without any pain or swelling. A full recovery was made without problems or complications.

The authors published this case report to highlight the fact that compartment syndrome can occur as a result of exertion. Although it’s uncommon, when it occurs, immediate diagnosis and treatment are required for a successful result.

Achilles’ tendon injuries are fairly common. Getting ankle range-of-motion back can take quite some time. Finding a test that could be used to screen for injury-prone athletes could help prevent such injuries.

In this study, researchers from Japan look at the relationship between the Achilles’ tendon and ankle joint flexibility. They show that stiffness of the Achilles’ tendon account for decreased ankle joint motion.

Passive stretching of the muscle-tendon unit can help improve ankle joint flexibility. Stretching the gastrocnemius (calf) muscle belly also helps lengthen the Achilles’ tendon.

Stretching should be done passively until the person feels a strong stretch. If there is a pain sensation, then muscle activity will increase reflexively to protect the joint. The end result is increased stiffness with a loss of flexibility.

Stretching should be done with enough load to alter the elastic properties of the tendon. The stretch must be held long enough to lengthen the soft tissue so that they cannot fully recover within one minute.

Despite the influence of tendon length on the ankle, joint flexibility has its own limits. Stiffness of the ligaments and joint capsule may contribute to ankle joint stiffness. This study did not look at the link between those soft tissue structures and ankle joint motion. It was a small study (six men, six women) so future research with a larger number of subjects is still needed.

In this study, motion control shoes were compared to neutral shoes in recreational runners with flat feet. The medical term for flat feet is pronation. Women who ran short distances (1.5 km or about one mile) several times a week were tested. They all had signs of over pronating.

Muscles along the inside of the ankle and foot called invertors are supposed to control foot pronation. Less active invertors place the foot at increased risk for injury.

Without proper control of the foot, pronation occurs. An increase load is transferred to the medial (arch side of the) foot and under the first metatarsal (big toe) area. Then the foot can’t handle the impact during running.

Using motion control shoes prevents excessive pronation. This means fewer pronation-related injuries. The shoes have a special design using different materials to absorb the impact of landing.

Testing showed the plantar force load using the special shoes was the same at the beginning and at the end of the 1.5 run. Without the adapted shoes, the load increased at the end of the relatively short run.

It’s not known whether the motion control shoe design has the same beneficial effect over longer distances. More studies are needed to find out the effect with more miles. It does appear that injuries related to excessive pronation may be prevented for recreational runners over short distances.

In this update on plantar fasciitis, clinical guidelines for the evaluation and treatment of this condition are offered. The authors use the best evidence available to bring us up to date on the prevalence, pathologic process, and risk factors linked to plantar fasciitis. Examination, diagnosis, and treatment interventions are also summarized.

Heel pain is the most common symptom associated with plantar fasciitis. The pain occurs when putting weight on the feet after a long period of rest or immobility. Getting up in the morning and putting the feet on the floor evokes the strongest painful reaction. But symptoms are most pronounced after any period of time off the feet. And the pain gets worse after standing on the feet for too long.

Other factors that can increase the risk of developing plantar fasciitis include limited ankle motion and obesity. Obesity is determined by a body mass index (BMI) greater than 30 kg/m2. The clinician’s examination will pay close attention to the presence ofany of these risk factors.

For anyone with this type of heel pain, there are other causes of heel pain that must be considered. These can include a stress fracture, bone bruise, nerve compression, or tumors. Pain can also be referred to the heel from a pinched nerve in the low back region.

X-rays may be used to look for heel spurs as a cause of the problem. But for the most part, imaging studies aren’t needed to diagnose plantar fasciitis. The patient’s history and clinical presentation are usually fairly obvious when it’s plantar fasciitis. There are several tests used by doctors and physical therapists to identify the presence of plantar fasciitis.

Treatment is usually nonoperative. A physical therapist may use any number of different intervention methods. This may include modalities such as ultrasound or iontophoresis, manual therapy and mobilization, and stretching. Taping, orthotic devices (placed inside the shoe), and night splints may also be given a try. The authors describe in greater detail each type of treatment mentioned here.

The clinical guidelines for plantar fasciitis are simply that. They are not a gold standard that must be adhered to for every patient with plantar fasciitis. Guidelines are made on the basis of the most current evidence. As future studies are published, guidelines for examination, diagnosis, and treatment may change.

Therapists are advised to document in the patients’ chart any changes made from the guidelines. Other acceptable methods of care may be used for some patients. Each clinician must make the best decision for each patient based on individual needs and differences.

Sometimes surgery is needed to correct a condition called hallux valgus, otherwise known as bunions. With good results, the patient has reduced pain and improved function. The toes are lined up better. The foot has a more pleasing look cosmetically.

One popular method for repairing this problem is the Ludloff osteotomy. Dr. K. Ludloff reported the first results using this technique more than 100 years ago. The first intermetatarsal angle is corrected by cutting a portion of the main bone in the big toe and rotating it back toward the foot.

The procedure has been modified over the years. The incision is now made along the inside medial portion of the foot (instead of along the bottom of the foot). The new approach includes the use of two screws to hold the bone in its new place. The use of hardware to hold bony parts together is called internal fixation.

In this study, the intermediate-results of a modified Ludloff osteotomy were reported. The operative technique was described in detail with drawings and X-rays to show the steps in the procedure. There were 125 feet having bunion surgery included. All patients had painful bunions and a first metatarsal angle of 15 degrees or more.

Results were reported using before and after measures of function, motion, and X-ray results of alignment. Two age groups were compared (over 60 years, 60 and younger). Using 60 as the dividing point for age between the two groups was arbitrary and not used because of some significant factor.

The authors report that both groups reported pain relief and improved function. They were pleased with how the foot looked cosmetically. The use of pain relievers and antirheumatic drugs was decreased for 86 per cent of the patients by the end of four weeks.

Overall, younger patients had a better outcome compared to the older adults. They were more likely to form a healing callus at the surgical cut on the bone. The callus is a combination of cartilage and bone cells. These two new tissues grow in size until they cross the gap in the two bones.

Older adults took longer to heal. Delayed union with a gap in the bone at the osteotomy site was more common in older patients. As a result of this study, the surgeons advise using X-rays early on after the operation for the older patients. This step will help evaluate the healing process.

Anyone with low bone mass should avoid putting full weight on the operated side until callus formation is seen. Weight bearing is avoided until enough bone callus is seen at the surgical site.

Sometimes the foot needs protection with a special shoe or an insert inside the shoe called a foot orthosis. The orthosis absorbs shock and cushions, supports, and controls the foot.

In this article, two shoe and orthotic specialists called pedorthists review shoes and orthoses used for a variety of foot problems. Anyone from a sports athlete to an older adult with diabetes can benefit from foot orthoses.

The insert can be modified for each person. Areas of high pressure can be off-loaded. Tender sites can be cushioned to avoid skin break down. Some deformities can be corrected to improve motion and function. Rigid deformities can be stabilized and supported. The end result is to relieve pain and prevent the condition from getting worse.

Shoes that have many modifications already built-in may be enough support for some problems without using an orthosis. Flares, a strip of firm material, along the inside or outside of the main body of the shoe can help stabilize the foot. There are also different kinds of soles. For example, a steel or graphite shank may be used between the layers of the sole to provide a firm support.

The authors provide drawings and descriptions of half-a-dozen other soles available. These include a mild rocker sole as well as a heel-to-toe, toe only, severe angle, negative heel rocker and double rocker sole. Modifications to shoe soles are made to reduce bending stresses through the midfoot and forefoot.

The second half of the article is a review of foot orthoses. These shoe inserts can be purchased off-the-shelf and used as is. Or they can be custom-made by a pedorthist. Custom-made means a mold or model of the patient’s foot is used to construct the device. A three-dimensional (3-D) scan of the foot can be used to make a computer-generated model.

Orthotics come in a wide range of materials and densities. Most people can use a prefab orthotic. Patients with severe deformities, loss of sensation, and/or pressure ulcers often need a custom foot orthosis.

Selection is based on the desired function of the insert. For example, soft, less dense materials can be used with preventive padding for the active patient who is not too large or overweight. This type of insert is called an accomodative foot orthoses.

A semi-rigid orthosis has a soft, top layer of cushion over a firm, supportive base. This design distributes support across the foot without compressing the tissues. Patients with pressure over areas of bone can use this type of orthosis to off-load the weight-bearing surfaces. The semi-rigid orthosis is also good for reducing shear needed to get rid of blisters and prevent calluses from forming.

More involved custom foot orthotics are needed for patients with foot amputations. The rigid foot orthosis provides good arch support but does not mold or conform to bony prominences on the bottom of the foot. They are made of rigid plastics and are not easy to adjust. Rigid orthoses give excellent support but they do not cushion, protect, or absorb shock. However, they hold up well and last a long time.

Each type of shoe and/or foot orthotic has a special purpose. The pedorthist properly modifies and fits the shoe to each patient. As a member of the foot care team, the pedorthist finds the best solution for each individual patient. Goals are identified and the shoe or foot orthoses is designed, manufactured, fit, and modified as needed. Patients are followed closely to ensure success and avoid further foot problems from developing.

A common cause of heel pain that is occurring with increasing frequency is Achilles tendinopathy, or Achilles tendonitis. Tendonitis is the inflammation or swelling of the tendon.

People at highest risk for Achilles tendinopathy are those who are obese, hypertensive, or who have diabetes or other endocrine disorders. External factors that raise the risk included training errors (for athletes), excessive mileage, excessive hill training, and sudden increases in training intensity. Other risk factors include being older, male, or exposed to steroids and fluoroquinolones.

The treatment of Achilles tendinopathy centers on relieving the pain and allowing the patient to resume proper range-of-motion and ability to bear weight so he or she can return to usual activity. The standard first-line treatments for this include anti-inflammatory medications, strengthening exercises, heel-lift orthosis, custom orthosis, or immobilization. IF these do not work, which happens in about 29 percent of patients, surgery becomes an option.

Unfortunately, complications from surgery include such problems as delayed wound healing, tendon rupture, scarring and nerve irritation. Also, the success rate ranges from 67 percent to 97 percent. Earlier research has found that patients who were not athletic experience more complications and a longer recovery period than did athletes. As well, non-athletic patients did not have as high a success rate as did the athletic patients.

The authors of this study wanted to see if shock wave therapy (SWT), already used with success to treat other musculoskeletal disorders, would be a good treatment option for Achilles tendinopathy. Earlier studies did show some success with this treatment. In one study, pain and function scores improved among patients who received multiple-treatment low-energy SWT. Patients who undergo low-energy SWT do not need anesthesia to the area and multiple treatments are performed. On the other hand, high-energy SWT is more painful and does require some sort of local or regional anesthesia. However, usually it is performed in one session only.

Patients who were included in the study had a minimum of six months history of chronic noninsertional Achilles tendinopathy and had undergone a minimum of three nonsurgical treatments without obtaining relief.

There were 34 patients in the treatment group, ranging in age from 27 to 76 years. The subjects had the tendinopathy on average, 12.7 months. Eighteen subjects participated in regular athletics and nine were manual laborers. The 34 patients in the control group ranged in age from 18 to 75 years and had the tendonitis for an average of 11.7 months. Sixteen of the subjects participated in athletics and six were manual laborers.

The treatment was performed with a regional anesthetic (block) to the ankle, with or without intravenous anesthesia, depending on the patients’ choice. Local anesthesia was not used so as not to interfere with the function of the SWT. Following the procedure, the patients’ heels were assessed for bleeding, bruising, or swelling. Discharge instructions were that they were allowed limited activity for the first 24 hours following the procedure but then could resume activity as symptoms were relieved.

The patients were assessed using the Visual Analog Scale (VAS), which measures pain on a scale from one to 10, with 10 being the most severe pain ever. The Roles and Maudsley scores were measured by a subjective four-point scale, with one being “excellent,” and four being “poor.”

Before treatment, the SWT group reported a VAS mean score of 8.2 +/-0.9. This decreased to 4.4 +/-0.9 after one month. In the control group, the mean VAS score before treatment was 8.4 +/-0.9 and 7.1 +/-0.9 at three months. After 12 months, the VAS of the control group was 2.2 +/-1.2 and the control group was 5.6 +/-0.7.

Using the Roles and Maudsley score, the SWT and control groups both had a mean of 4 before treatment. This dropped at one month to 2.3 for the SWT and 3 for the controls. At three months, the scores were 1.9 and 2.9, respectively, and at 12 months, the scores were 1.9 and 3, respectively.

In reviewing the findings, the authors write that this study showed that there were no significant complications (two patients complained of pain during treatment and one had redness of the skin that resolved on its own) and that the treatment was effective for this group of patients for whom traditional treatments did not work.

Two types of treatment programs for the treatment of Achilles’ tendinopathy were compared in this study. Tendinopathy refers to damage to the tendon. There is usually pain, swelling, and impaired contraction of the tendon where it inserts into the muscle and bone.

Such types of injuries are common in runners or in athletes engaged in jumping activities. But the everyday, average person who is not athletic can also have an Achilles’ tendon injury.

The two treatment programs were: eccentric loading and low-energy shock wave therapy (SWT). Eccentric loading is a calf strengthening exercise program. The patient stands on a step facing forward as if going up. All the body weight is on the forefoot of the injured leg.

The heel is slowly lowered below the step. The patient uses the uninjured leg and arms to pull back up to a neutral (starting) position. The exercises were gradually increased until the patient could do three sets of 15 repetitions twice a day. The exercises were done every day with the knee bent and with the knee straight for 12 weeks. Eventually they added a backpack of weights to load the exercise further.

SWT was done once a week for three weeks. A special device was used to send a strong shock through the skin to the tissues. The pulses were sent in groups of eight per second. The shock wave radiated or dispersed through the tissue to the site of injury.

Patients were followed up at four months and again at the end of one year. Results were measured and compared in terms of pain, function, and activity. A special survey designed for patients with Achilles tendon injuries was used. It is called the Victorian Institute of Sport Assessment-Achilles [VISA-A] questionnaire.

In this study, more patients were helped by shock wave therapy than by a program of eccentric loading. The SWT group recovered faster and more completely by the end of four months. The results were still good after a year. Long-term results are not available.

Shortened Achilles’ tendons can be painful and reduce an athlete’s performance. Stretching may help but studies show that eccentric training works very well. During an eccentric muscle contraction, the muscle and its tendon starts in a shortened position and then lengthen as the body part moves.

It’s not clear why this type of training works so well for Achilles’ tendinopathy. Tendinopathy refers to any injury of the tendon. This may include microtears and inflammation. In this study, researchers from Belgium and New Zealand team up together to understand the reason why eccentric mechanical loading is a successful rehab technique for this problem.

Two groups of healthy adults were included. All subjects were recreational athletes. One group followed an eccentric training program focused on the calf muscles for six weeks. Heel drop exercises were done daily. The second was a control group. They did not do the exercises or any special program.

The results were measured by comparing ankle motion and Achilles’ tendon stiffness before and after the program. Ultrasound and dynamometer measurements were also used. These tools showed how much stretch occurred within the tendon structure.

The authors report that dorsiflexion ankle motion was increased in the eccentric-training group. Dorsiflexion is the movement that decreases the angle between the foot and the leg. During dorsiflexion, the toes are moved toward the knee. It is the opposite motion to plantar flexion (pointing the toes).

At the same time, the passive resistance torque of the plantar flexor muscles was decreased. Torque refers to the force on the ankle by the Achilles’ tendon. Increased torque keeps the ankle from full dorsiflexion.

Decreased torque increases the ankle motion. Along with reduced torque, decreased stiffness and increased relaxation of the muscle and tendon fibers allow for greater dorsiflexion.

These findings support the idea that structural changes occur in the plantar flexor muscles as a result of the eccentric exercise program. A similar exercise program may be helpful in preventing Achilles’ tendinopathy. More study is needed to confirm this idea.

Doctors face daily challenges in the treatment of a wide range of medical conditions. Helpful hints and clinical tips on specific procedures are useful for the management of some patients.

In this article, the focus is on aspiration (drawing fluid out) and injection of the first metatarsophalangeal (MTP) joint. Patients with gout may need this procedure. The MTP joint is also known as the big toe or great toe. This joint is discussed because getting a needle into the area can be difficult.

When swelling is present, it can be a problem to recognize guiding points on the surface anatomy. There may be bone spurs along the joint line making access impossible. And the surgeon must avoid puncturing nerves, blood vessels, and tendons in the same area.

To help physicians navigate this procedure, supplies needed are listed. Then a review of surface anatomy along with patient and joint position are offered. A photo of the traction used to pull the joint space open is included. This information will help the physician find the right space between the joints in which to insert the needle.

The correct needle angle is important to avoid the bone and locate the pocket of fluid. It may be necessary to use the anatomy of the unaffected foot and toe as a model of what is normal. Comparing the healthy side to the swollen, involved toe can help guide the physician.

Specific techniques for preventing leakage of corticosteroids injected into the joint and spritzing the aspirant are included. Spritzing fluid taken from the joint is a way to spray a few drops onto a slide. The slide can then be analyzed under a microscope.

This article was the fifth in a special series on joint aspiration and injection. Previous reports have included basic information on this topic as well as techniques for specific sites. So far the elbow joint, elbow bursa, and shoulder joints have been discussed. Watch here for review of future topics on this subject.

In this study, researchers found that early motion may be the key factor in the successful treatment of Achilles tendon ruptures. Debate has been ongoing for years as to whether Achilles tendon ruptures should be treated surgically or not.

Two groups of patients with acute Achilles tendon ruptures were compared. All patients had been injured within the last 10 days. Group one was treated with a cast for 10 days but no surgery. Group two had surgery to repair the damaged tendon. They were put in a special cast called a hanging equinus cast.

The equinus cast placed the foot in a toe-down position. It prevented the patients from dorsiflexion (moving the foot toward the face). The equinus cast allowed the foot to dorsiflex to neutral and hang down (toes pointed) as far as possible.

Everyone in both groups followed the same rehab program. Exercises, weight bearing, stretches, and exercises were started at the end of the first 10 days.

Results were measured using ankle joint range of motion, calf circumference, and function. The number of re-ruptures and/or complications was also recorded. There was no difference between the two groups when motion was measured.

Reruptures, infections, and wound complications were rare. These problems were much lower in both groups than reported in other studies. The authors suggest that controlled, early motion after Achilles tendon rupture is the missing key to success in treatment.

With early motion to enhance tendon healing, surgery may not be needed after all. Similar results have been shown in other studies for tendon ruptures of the hand.

Exercise is encouraged for everyone but especially those who have chronic conditions such as diabetes or heart disease. Older adults with orthopedic or foot problems may be at risk from aerobic exercise that is repetitive and prolonged.

In this study, a group of physical therapists measured the amount of pressure put on the foot during five types of aerobic exercise. They measured the differences in pressure under the forefoot, arch, and heel.

Two groups of healthy adults were included. The first group was 19 to 35 years old. The second group was middle-aged between 45 and 60 years old. Measurements were made during walking, running, elliptical training, stair climbing, and recumbent biking.

Each of these exercises requires different movement patterns and weight distribution. Too much pressure for too long can cause pain and tissue injury. This is especially true for anyone with loss of sensation from neuropathic foot disorders.

The authors found that pressure varied on the forefoot, arch, and heel depending on the activity. For example, peak pressures were lowest on the forefoot while biking. The contact area under the forefoot was the greatest during running and walking.

Pressure under the arch of the foot was highest during running. Heel pressure was the highest during walking and running and lowest during biking. The only difference between the two age groups was that a larger area of the foot was subject to pressure in the younger age group. This was true for all the activities.

The authors conclude that biking and stair climbing may be best for anyone who needs to protect the forefoot. For example, patients with diabetes are at risk for foot ulceration when pressures are too high.

Anyone with heel pain from bone spurs may want to choose biking, stair climbing, or elliptical training over walking or running. Contact time is the longest during elliptical training making this choice less favorable for anyone at risk for tissue injury.

Rupture of the Achilles’ tendon is a fairly common injury. The Achilles’ attaches the calf muscle to the calcaneus (heel bone). Surgery to repair the injury may be needed. Rehab can be long and slow.

In this study, researchers from Japan report on the results of a modified method of Achilles’ tendon repair. The goal was to allow early weight-bearing and faster return to daily activities.

All patients were active adults between the ages of 16 and 54 years. Both high-level and recreational athletes were included. Surgery was done to adjust the length of the tendon. It was then stitched back in place. A Tsuge suture was used with a figure-eight at one end and a single knot at the other end.

The position of the uninjured ankle was used to determine the appropriate tendon length of the ruptured tendon. Everyone followed the same rehab program:

A painful thickening of the Achilles’ tendon is called a tendinopathy. This condition is a common cause of calf pain in many middle-aged recreational athletes. Effective treatment for the problem is under investigation.

In this study, 100 patents with chronic Achilles’ tendinopathy were divided into three different treatment groups. The results of each treatment were compared. The first group performed eccentric muscle contractions. Eccentric refers to movement that lengthens a muscle from a shortened position.

The second group wore a brace called the AirHeel brace. This removable ankle brace was specifically made for patients with Achilles’ tendinopathy. The AirHeel was worn during the patients’ waking hours.

The third group was treated with a combination of eccentric exercise-training and the AirHeel brace. The authors outlined the progression of exercises used over a period of 12 weeks. The exercises were done with the knee straight and with the knee in a slightly bent position.

Patients were followed for one full year after the treatment ended. Results were measured by pain levels and function. Ultrasound studies were also done before and after treatment. The researchers compared tendon thickness and structure.

Any side effects of treatment such as tendon rupture, discomfort, or severe pain were recorded. Some patients reported pain during the exercises. Others had discomfort wearing the AirHeel due to a poor fit.

The authors could not find any difference in the results from the three groups. Patients in all three groups improved with less pain and increased function observed. This study did not support the theory that the AirHeel (alone or with exercise) helped the healing process. More study is needed to find an effective treatment for acute Achilles’ tendinopathy.