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I’m almost done with my website, wholefoot.com, and I’m ready to start blogging again. While I’ve been away, I’ve been thinking of ways to make these segments more useful. For the next several segments, I’m going to review some real cases that I have seen in my clinics. Now, from my perspective and that of other orthopedic and podiatric surgeons, these are not the most interesting cases. In fact, just the opposite, they will be the common things that I see everyday (although with the names changed). These cases will not highlight fantastic surgical salvations; they will highlight the diagnostic approaches and typical methods of managing these very common problems.
Matt is a 32 year old IT professional who twisted his ankle four months ago while playing basketball. The ankle has not felt normal since then. While he can walk and do his job, he is unable to return to any running or sporting activities.
When I examined Matt, he had a great deal of tenderness along the inner front and back portion of the ankle joint. His ankle joint was stable, meaning that the ligaments that restrain the ankle joint and keep it from falling out of position are functioning. The radiographs are normal.
This is one of the most common problems that I see, the ankle sprain that won’t quite go away. The initial goal is to make sure that no other serious commonly missed injuries are present. These are usually easy to find if you know where to look—the front of the calcaneus or heel bone, along the outside midfoot at the fifth metatarsal, and the outside of the talus. They are usually suspected by the pattern of tenderness and careful inspection of the x-rays. Additional tenderness on the front of the calf or near the knee can suggest a high ankle sprain, an injury of the ligaments that bind the tibia and fibula, the main bones of the leg.
It is important to make sure that the ankle ligaments are still working, that they haven’t healed in a lengthened position so that they no longer work. Matt’s ligaments seem fine.
So Matt is left with a painful ankle joint without a fracture or ankle instability. This is very, very common. Causes for this are bone bruises, damage to the joint cartilage, or scarring problems within the joint. If you look at the position that ankle is in at the time of the injury, the joint surfaces are knocked against each other in peculiar ways. This causes these bone bruises and joint injuries. Many times, however, a specific diagnosis is not found. Many studies have looked at ankle sprains and how people recover from them. After six months, more than 30% of people will have some degree of pain. Certainly, recovery is not as predictable as many people believe.
The next step is to determine what to do next. The options are non-operative methods such as pain medication, therapy, bracing, and intra-articular injections, further radiographic evaluation, and surgical management. I feel uncomfortable considering surgery in the absence of a more definite diagnosis. Matt and I discussed what other methods of non-operative treatment had to offer and decided to get an MRI.
An MRI is a radiographic test that is slightly different than an x-ray (more about MRIs). X-ray film image the body based on its ability to block x-rays. Bones that contain calcium are shown very well while soft tissues are only vaguely defined. MRIs image tissue based on its chemical composition, its water and fat content, using very strong magnets. The images can be displayed in two- and three-dimensions and can show damage in tendons, ligaments, and skin. While it is a very expensive test, it is appropriate when a problem does not respond to initial treatment like prolonged activity limitation and therapy and the diagnosis remains in question.
More to follow…
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
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Many common foot problems can be treated by proper shoe wear selection. Despite the fact that many blame their shoes for the development of their foot and sometimes their leg, hip and back problems, your foot problem is more likely to be due to a life of simple use, genetic factors, and deterioration of specific structures due to age, weight gain, and poor conditioning than poor shoes. Certainly, shoe wear selection is occasionally a significant factor in the development of hammertoes and bunions, but I have a number of patients with all types of foot complaints who have never worn fashionable shoes. That being said, there are a number of foot pains that can be improved by careful selection of shoes.
A major consideration when choosing shoes to fix a bunion or hammertoe deformity is the size and makeup of the upper of the shoe. A soft upper with plenty of room in the toe box is crucial to accommodate these deformities and avoid abrasion of the skin and rubbing of the tissue. Avoid synthetic materials such as vinyl or plastic that do not conform to the foot well and do not give. Avoid seams over areas of prominence such as along the bunion. Walk around in the shoes for a period. The best time to fit a shoe is in the evening when the foot will be maximally swollen.
People often complain that when they find shoes that fit the front of the foot that the shoe no longer fits the heel. The heel as a result tends to be loose and slides often coming off or irritating the heel. Adhesive pads are made will fill this area often solving the problem. They are often found in shoe or drug stores, but if you have difficulty locating them, they can be obtained from the Hapad Company (www.hapad.com, item HG). Another method of approaching this problem is to use a ¾ length arch support. This is one that comes to the end of the arch but does not extend beneath the ball of the foot.
Shoe stretchers can be purchased at a reasonable price at online stores such as www.heelingtouch.com or can be applied at a shoe repair store or orthotist shop. Several varieties can stretch the shoes in different directions, including width, height, and length. In addition, pegs can be added to relieve bunions, bunionettes and hammertoe deformities.
Rocker-soled shoes can alleviate certain foot problems, especially those problems that involve overusing the front of the foot such as plantar fasciitis, midfoot arthritis, metatarsal pains, or stress fractures. These shoes have a stiff sole that avoids stress concentrations on the ball of the foot and the sole is contoured so as to avoid an awkward gait as a result of the stiffness. The shoes also encourage an upright posture that is helpful in unloading the front of the foot. The claims regarding toning and shaping the buttocks are however unsubstantiated. Several companies including Dansko, MBT, Skechers, Timberline, Finn Comfort, New Balance, and Reebok now make these shoes. Not all shoes made by these companies are rocker soled however. There are also considerable differences in the fit and feel of these shoes. They are often referred to as toners. These shoes are widely available including a limited selection at many department stores. Other specialty shoe stores that target the “sensible shoe” market have a more extensive selection. Many of them are fairly fashionable. The Walking Company (at retail locations and www.thewalkingcompany.com) is an excellent source for these shoes as well as typically having a knowledgeable sales staff.
Orthotics are also very helpful in problems where limiting motion in the arch area is necessary. Most studies do not show an improvement in satisfaction or comfort with custom devices in people with typical foot shapes when compare to a non-custom insert. Occasionally, however, someone with a flat or very high arch does better with a custom insert. Custom inserts also work better in people where modification of design is necessary to aid in a particular deformity. A high quality off-the-shelf arch support should last 6-12 months.
While these shoes do help protect injured feet, there is no evidence that they protect the feet from the development of injuries. As the pain improves, you should transition to more flexible shoes to build the resilience of the foot structures including the bones, tendons and ligament. I compare this to the use of casts. Casts are helpful in the treatment of fractures, but I do not put them of feet to prevent fractures.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
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As children gear up for another summer, moms and dads will be looking towards new shoe purchases for school in the fall. The shopping cart will undoubtedly contain new shoes, shoes for gym and athletics and shoes for class. The “right” shoes should be purchased, but what is the “right” shoe? Price is certainly a consideration, but what else? Is an expensive shoe always the “right” shoe?
First, let’s make a distinction between healthy feet and painful feet. If a child’s foot is persistently painful, there is something wrong and this needs to be evaluated to determine what it could be. If a child’s foot is healthy and pain-free, then the goal of the footwear is to make sure that it stays that way. A second goal is to ensure that the foot develops properly.
Of greatest importance is fit. The shoe needs to be the right size and width. This is usually fairly easy to do with in any quality shoe store by an experienced clerk. Leave at least a ½ inch gap from the end of the toe to the end of the shoe. Using a fairly compliant upper, made from leather or other breathable expandable material is important.
Let’s take the question of foot development and shoewear first. Whether you believe in evolution or not, the foot is adapted to development in the absence of shoes. Our ancestors did not have the benefit of custom orthotics or advanced shoewear. Their feet developed without shoes or, at most, in moccasin-type shoes or sandals. A very interesting study was done by Drs. Rau and Joseph in India in 1992 evaluating the feet of children that grew up wearing shoes and those that did not. The rate of flat feet in the children that wore shoes was 8.6% while the rate in children that wore no shoes was 2.8%. If flat feet are considered an abnormal foot development, and this may or may not be true, then the best shoes for children are no shoes.
This is the U.S.A. and shoes are more or less required much of the time. The weather does not allow us to be unshod for many months of the year. Our children have also grown up with shoes and, therefore, their feet have adapted in very important ways to this. The muscles may be weaker due the lifelong usage of shoes and may not be resilient enough in many ways to be comfortable without shoes. We need to make our shoe wear decisions based on the amount of activity we are anticipating, what the feet have become accostumed to, and style.
If a low level of activity is anticipated, then nearly any shoe is appropriate. If long periods of standing, walking, or sports are necessary, the shoe should be snug enough around the midfoot and heel to avoid rubbing on the skin and have a heavier weight sole which protects the foot from motion by being stiff. One reasonable test to judge the stiffness of the sole is to grab the heel in one hand and the toe in the other and try to fold the shoe. If it folds easily, it will not protect the midfoot joints and small muscles in the foot from work. If the child is used to a high degree of activity and usually wears flexible shoes, then a flexible shoe may be reasonable. If the child normally wears tennis shoes, is rarely barefoot, or is unused to the rigors of athletics, then a firmer shoe may be more comfortable.
Like the muscles and bones the foot contains, the foot will develop resilience according to the amount of force that it is used to. Activity, and the affect the shoes have on the stress the foot is accustomed to, should be increased slowly to avoid overuse injuries. These simple principles are all that you need to ensure that gets the “right” shoes.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
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Ankle sprains are an unfortunate and common injury in sports including basketball, soccer, and football. Often ankle sprains heal without a great deal of treatment, but at times, they can take a long time to finally resolve. So what are ankle sprains, why do they occur, and what can you do about them?
An ankle sprain is a tearing of the ligaments that support the outside of the ankle. These ligaments guide the ankle through its motion, ensuring that the joint surfaces do not rock into an abnormal position so that they do not become damaged. When the ankle ligaments tear, there is bleeding, which leaks into the skin usually causing bruising along the heel, back of the calf, and top of the foot. In addition to the torn ligaments, the joints themselves get knocked around and bruised also. The joints can even chip.
The ligaments tear because they are pulled apart. One way that the ankle ligaments tears is that the body weight is applied to the leg while the foot is out of position. Another way is that weight is suddenly shifted to the outside of the ankle while the foot is planted, such as when you cut sharply while running.
Things that might predispose you to an ankle sprain could be the shape of the foot and leg, the strength of the muscles and the tightness of the ligaments. Muscle strength can be improved by conditioning exercises, especially exercises that emphasize control of the ankle and improve the flexibility and coordination of the foot. A therapist or trainer can help you with this type of rehabilitation. There is little that can be done about the tightness of the ligaments or the shape of your foot short of surgery, so we will not discuss that in this article. One important part of ankle sprains that can be adjusted is the stability of the ankle with the shoe, which may be one of the critical mechanisms causing ankle sprains.
As anyone who has ever tried to walk on a pogo stick or stilts knows, one of the keys to mastering these skills is to keep the foot and the stick in close contact at all times. Once they come apart, you’re done. It’s the same with shoes during sports. If there is a lot of motion between the shoe and the foot, you’re going to have trouble.
To illustrate this better, let’s break down an ankle sprain step-by-step (figure 1). A. The ankle allows the foot to move from flexion to extension. The subtalar joint motion allows side-to-side motion or technically inversion (tilting the heel toward the midline) or eversion (tilting the heel away from the midline). The ligaments on the sides of the joint control this motion and act as tethers on the joint and keep the surfaces of the joint in close contact.
The average direction of the body weight on the ankle can be approximated by an arrow, the axis of body weight. The axis of body weight in normal standing or walking, more or less, goes from the hip joint to the heel and center of the forefoot. When the axis lies between the inner and outer ligaments, there is very little tension on the ankle ligaments. If the axis of body weight begins to creep to the outside of the ankle, tension on the ligaments occurs. If enough tension builds up, the ligaments tear.
B. If an uneven surface is encountered, the heel and forefoot will tilt to accommodate it. However, if the shoe is not securely applied to the foot, the foot will slide toward the outside of the shoe.
C. As the outside border of the foot drops over the edge of the sole of the shoe, it begins to twist the foot even more. Inverting the subtalar joint as far as it will go and stretching the lateral ankle ligaments.
D. The foot then begins to roll off of the obstruction, and will continue to invert until the ankle or side of the foot hits the ground, tearing the ligaments.
What strategies can we use to avoid this? The traditional sport shoe attempts to stabilize the shoe by applying stiff (usually artificial leather) cups or reinforcements to the heel and outer border of the forefoot, keeping the foot from sliding off of the sole of the shoe. With continued use of the shoe, these reinforcements soften, so replacing the shoes can be helpful. A high top can increase the stability of the shoe by extending the upper onto the ankle increasing the leverage on the foot, reinforcing the lateral ligaments. An ankle brace similarly reinforces the ankle but can actually increase the instability of the shoe-foot connection. This is especially true when the shoe does not fit well over the brace.
Ektio, a newer shoe company, has developed a line of shoes engineered toward improving the stability of the foot and shoe. First, it has fasteners, which secure the shoe to the foot. Second, they have reinforced the stiffness of the upper along the lateral heel and forefoot to resist shifting of the foot. Third, the shoe has slight bumpers along the lateral heel and forefoot to resist rotation of the shoe. Consumer reviews are very positive for the shoe and it may help many to decrease their reliance on ankle braces for certain sports.
Barefoot or minimalist shoes over the last few years has become very popular especially among distance runners. Running while barefoot or wearing minimalist shoes increases feedback from the foot about the ground conditions. The decreased stiffness of the sole of the shoe allows the foot to adjust to changes in the contour of the ground. The ability of the foot to adjust to irregularities allows it to risk catastophic injury by resisting complete inversion. The challenge of foot torsion and ground accomodation also helps to condition the small muscles within the foot, which may improve stability over the long run. Running barefoot or in minimalist shoes decreases the motion between the foot and the shoe and this should improve ankle stability. There is also very little in the way of a sole, therefore, there is no elevated sole to role over. The disadvantage of barefoot running is the lack of protection of the foot from concentrations of stress and from damaging objects on the ground. Any new shoe especially a minimalist shoe should be broken in. More accurately, the foot needs time to adjust to the new stresses that minimalist shoewear presents to the foot to prevent overuse injuries.
There are many methods of approaching ankle sprain protection. The right one is the one that works for you. Discuss this with your physician, therapist, trainer or coach. Much of shoe wear selection is dependant on the needs of the sport. A heavier shoe may be necessary for a sport in which you can expect some contact with the other players. Experiment with it and decide for yourself what works best for you.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
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Hammertoes are a collection of toe deformities. Although many people define hammertoes in different ways, we will use it in its broadest sense as a term describing all deformities of the smaller toes in which the toes curl. The typical hammertoes is a deformity of the toe where the PIPJ flexes. This causes this joint to be prominent on the top edge, often the knuckle pads are knobby or discolored from the position and the pressure from shoewear.
Deformities at other joints are common. The most frequent associated deformity is an extension deformity at the MPJ. This raises the toe against the shoe wear. The deformity can even progress to the point where the MPJ becomes dislocated. On occasion, however, the joint can be in normal alignment. The deformity at the DIPJ can be extension or flexion. A variant of the hammertoe is the mallet toe in which the DIPJ only is deformed into flexion.
Any of these joints can be turned to the inside or outside in addition to the other deformity. In fact, one of the most common of these deformities is the “cross-over second toe”. In this deformity, the second toe completely overlaps the big toe. This can make it extremely difficult to fit the foot into shoes. Many people also become very conscientious of the appearance of this deformity.
The most frequent complaint from a hammertoe is pain underneath the toe in the ball of the foot. Other problems arise when the toe hits the shoe, when a prominent corner of the toe. A callus can form over the top of one of these boney prominences or in between the toes. A callus or even a sore can form also at the very tip of the toe when the toe is not flexible and the tip jams against the floor with weightbearing.
What causes hammertoes?
This is an area of some discussion among medical professionals. Occasionally, people state that they are lifelong or occurred at birth. More commonly they developed their position after an irritation of the MPJ, most commonly the second MPJ, in the ball of the foot. It is likely that this irritation of the MPJ is a Forefoot Overload Syndrome. Irritation of the MPJ is often associated with prominence or increased length of the second metatarsal in relation to the adjoining metatarsals. It is also commonly associated with bunion. Bunions are often accompanied by decreased pressure on the portion of the ball of the foot under the big toe. This pressure is partially transferred to the second toe and thus overloads this portion of the joint wearing out the ligaments stabilizing the joint.
When the MPJ becomes inflamed, the ligaments start to fail. Usually the ligaments allow the joint to extend, although the ligaments can also begin to fail so that the toe drifts toward the inside or outside of the foot. As the MPJ starts to extend, the flexor tendons on the bottom of the toe begin to flex the PIPJ and DIPJ. Over time, the ligaments within these joints become so stiff that it is even difficult to straighten the toe manually with your hand.
A peculiar thing can happen to the toe as it gets into this process. The ligaments constraining the flexor tendons can also begin to stretch allowing the tendons to slide from their normal position on the bottom of the MPJ. They can continue this slide, sometimes fairly abruptly, until they flip to the side of the joint. This most commonly occurs in the second MPJ when the second toe crosses over the big toe. When the tendons assume this position, they no longer work properly. Instead of doing their normal function of flexing the toe joints, in this new position, they instead cause the toe to deviate to the side, usually the inside of the joint. The extensor tendons, because they no longer are opposed by the flexor tendons in their new position, begin to extend the toe even more.
A second method for the development of hammertoes involves damage to the nerves. When nerves are damaged especially by metabolic problems such as diabetes or in congenital problems, the longest nerves are often the most prone to injury. The longest nerves of the body are those that give sensation to the toes and those that control the muscles in the foot. These muscles are called the intrinsic muscles and are most important in control of the PIPJ and MPJ of the toes. When the nerves are damaged, these muscles become fibrotic and loss their fine balance and can lead to deformity of the joints resulting in a stiff hammertoe. This is the problem commonly seen in diabetics with hammertoes.
The final method and least common is trauma. A direct blow such as a stubbing injury to the toes can injure the ligaments around any joint in the toe, just as it can in the hand when you jam your finger. This can lead to a hammertoe deformity.
What else could it be?
By far and away, the most important cause of foot deformity is hammertoe deformity. The few mimics of hammertoe deformity can usually be eliminated by a careful physical examination. Tenderness is usually well localized to the MPJ of the affected toe and not into the web spaces or into the toes themselves or into the midfoot.
Other problems that may be confused with hammertoe may be:
- Interdigital neuroma or Morton’s neuroma (usually in the web space, primarily the one between the third and fourth toes)
- Stress fracture of the metatarsal (usually swollen and the tenderness generally is along the metatarsal shaft away from the joint, often a swelling is appreciated on the bone)
- Traumatic fracture of the phalanges (if severe, can cause deformity, tenderness is uaually located on the affected bone and radiographs show the fracture)
- Soft corn in between the toes (usually fairly plainly seen on physical examination
- Osteochondrosis of the metatarsal head (usually evident on radiograph)
What do you do about it?
Evaluation
Radiographs are critical for eliminating several important other problems. Osteochondrosis of the metatarsal head and stress fractures may be suggested by physical examination, but can only be excluded by radiographs. However, for non-operative treatment, they can sometimes be delayed.
Laboratory examination is infrequently necessary unless gout or other inflammatory or infectious process is suspected.
Other radiographic examinations such as MRI, bone scan, or CT scan are sometimes ordered to rule out malignant processes or stress fractures which are not apparent on radiographs. As a rule, these studies are rarely necessary.
Treatment
When embarking on the non-operative treatment of any problem, the goals of treatment have to be carefully defined. Some goals of non-operative treatment are not achievable. Once a deformity has occurred, there are really no reasonable methods of reversing it. However, reduction of much of the symptoms associated with a hammertoes deformity is possible.
The acute inflammation of the MPJ leads to hammertoe deformity nearly 50% of the time. Occasionally, the deformity can be accompanied by movement of the toe to the inside or outside which can complicate the deformity. One concept in the treatment of this deformity would be to position or splint the deformity until the acute inflammation subsists. There have been no studies to examine this. I have not found a taping or splinting technique that is both effective and comfortable. Commercial devices such as as the Bundin splint or toe crests are generally only able to position the toe if the deformity is very flexible. Taping techniques are able to adequately position the toe, but typically cut into the dorsum of the toe in a manner that is not tolerated for long without pain or skin breakdown.
Another approach to treatment of the forefoot pain especially the pain in the ball of the foot is to wear a stiffer soled shoe. The stiffness in the sole of a shoe that has a firm rocker sole or has been modified by a steel last in the stole or a spring steel insert placed into the shoe will disperse stress concentration into the ball of the foot. This decreases pain. Metatarsal pads placed into the shoe and metatarsal bars placed onto the shoe can disperse pressure and reduce pain.
Pressure on deformed toes can be lessened by selecting shoes that have extraroom in the toe box and an upper soft enough to avoid concentrations of pressure. If a shoe has a compliant upper, often it can be stretched by a commercial shoe stretcher that can be purchased or accessed through a pedorthist or in most shoe repair shops.
Separating toes using toe spacers, either silicone or foam rubber or toe sleeves can lessen pressure from toe nails or prominent bones on adjacent toes or on the toe tips.
Steroid injections are relatively effective in decreasing the inflammation of the MPJ. The procedure can be administered by a doctor familiar with the technique in the office. Overall, the degree of pain associated with this is relative mild with 80% of patients in my clinic reporting pain only slightly more than a flu shot. Over the short run, over half of the patients note significant reduction of the pain. However, it is not in my opinion a cure, but should be thought of as a treatment of the inflammation that can be used to blunt the pain from the problem while it improves on its own eventually or until a treatment program can be initiated. Side effects from steroid injection include injection site pain in about 25% which generally lasts for 24-48 hours. Some clinicians have voiced concern about further damage to the surrounding ligaments and there may be an increased chance of hammertoe formation after this. Until specific studies are available that examine the rate of hammertoe formation after inflammation of this joint both with and without the concommittant use of intra-articular steroids, it is difficult to say whether this is a complication or a result of the natural course of the problem.
Finally, rehabilition programs, in my opinion, can be helpful in the treatment of this problem. A simple program is outline in this website which is geared toward the reduction of forfoot overload..
Surgery
Surgical treatment of MPJ synovitis and hammertoe deformity is directed to the overall deformity and anatomical factors which may contribute to it. Certainly, if synovitis of the MPJ without deformity is present, removal of the inflammatory tissue around the joint is a reasonable approach . I find that this is rarely the case.
More extensive surgical treatment may involve the lengthening, cutting or redirecting of certain tendons to straighten the various joints involve. Cutting the ligaments around the MPJ and lengthening the extensor tendon is common. Temporary pinning of the MPJ is often necessary to allow the cut ligaments to heal in the proper length and position for a period of 2-4 weeks. Release of the flexor tendon will often loosen the PIPJ and DIPJ enough to allow for straightening of these joints. Commonly, transferring these cut flexor tendons around the base of the proximal phalanx can assist in reestablishing the flexion of the MPJ. Resection of the PIPJ or DIPJ can be added with the intention of obtaining boney fusion of the two bones around the joint if the joint remains stiff. A shortening osteotomy of the metatarsal, cutting the metatarsal bone and removing a section or allowing one end of the cut bone to slide against the other to shorten the length of the bone, is possible if the metatarsal bones are unusually long relative to the ones next to it.
If possible preservation of the joint surfaces of the MPJ is preferable to resection of these joints or replacement with silicone devices.
The procedures are constantly changing and a comprehensive discussion of the exact approach to all the variety of forefoot deformity is beyond the scope of this chapter. The exact approach to any one foot deformity will vary from surgeon to surgeon. My own approach is constantly being modified as new devices and information on new techniques become available.
What can go wrong?
The most common and troubling problem that can happen after structural correction of a hammertoe is that the deformity can recur or other deformities can be created. This is most common when there is deviation of the toe toward the inside and outside or when a dislocation is present.
Numbness is generally present to some extent as the sensory nerves at this level are very small, numerous and easy to injure.
Persistent pain.
What are some new treatments on the forefront of medicine?
A number of new devices have come onto the market for the fusion of the PIPJ and DIPJ. The result has been more secure and less troublesome fixation of these parts of the surgery.
Innovative tendon transfer and ligament repair techniques have also been introduced. However, these methods have not really been evaluated by investigators that did not develop the techniques. Unfortunately, these further tests have often dampens the enthusiasm for promising techniques.
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Take home points:
- Injuries follow predictable course of healing.
- Various methods of protection are useful early on, but should be gradually withdrawn as the injury heals.
- The wide-spread belief that foot injuries require “support” or protection indefinitely can be detrimental to the health and resilience of the foot.
All body tissue follows a predictable sequence of healing whether that tissue is bone, tendon, or ligament. Understanding this pattern can help us to devise intelligent and rational methods of approaching these injuries. This pattern is easy to understand even for someone without a medical background. It is also important to understand that in long-standing injuries that all of these stages may be occurring in different areas of the injury. I find that there are three distinct stages to healing a foot injury.
The first step is injury. Some might call this inflammation, but it is important to stress that inflammation from a cellular or chemical standpoint is a brief and minor part of this stage. During this stage, there is mechanical damage to the tissue. Bleeding and bruising may or may not be present. The tissue damage incites white blood cells to come into the area of the damage and breaks down the damaged tissue. The chemicals that are released also increase blood flow into the area so that large concentrations of oxygen and other nutrients are available for the repair process. The tissue strength weakens considerably during this stage. This stage can last from several days to several weeks.
The pain during this stage is usually sharp and throbbing. Immobilization of the extremity or protection from the extremes of motion can be helpful. A fractured bone may require casting as could a ruptured or strained tendon. While anti-inflammatory medications can help with the pain, it is unclear how these medications affect the progression of healing. There is some evidence that these medications may interfere with bone healing in animal models. The effect on the repair of other soft tissues is unknown but, in my opinion, probably there is very little positive or negative effect.
The next step is consolidation. During this period, an immature scaffold or scar develops that begins to stabilize the injury. This scaffold does not have the mechanical properties of the original tissue. While it may, in many ways, function in the same ways that the original structure did, it is weaker and will be prone to overuse, possibly even rupture. This stage can last from a couple of weeks to a couple of months.
Protection of the injured structure is important during the consolidation stage. In a bony injury such as a fracture, a brace would be appropriate. Ruptured or repaired tendons should be moved to prevent scarring to the bed of the tendon. Exposure to limited amounts of stress is helpful in strengthening and reforming the tissue, preparing them later for normal usage. Excessive stress or motion at the injury site may retard the formation of some types of tissue such as bone. Exercises should emphasize flexibility in the joints and limited amounts of strengthening. Protected weight-bearing can often be resumed. Often, in foot injuries, protective shoes or boots may be helpful in providing protection.
The final stage is maturation. In this stage, the injured structure begins as a relatively disorganized scaffold and becomes more organized and reforms itself along the lines of stress. Tendons begin to have fibrous structure. Bone spicules begin to form along the axis of stress. The mechanical strength begins to approach normal.
Gradual resumption of normal activities begins in this stage. This should proceed in a stepwise fashion. An example is walk before you jog. Jog before you run. Run before you return to sports. There should be many sub-steps between these milestones and multiple degrees of endurance. Pain, especially pain that increases with the activity, is a useful signal that the return to activity is too rapid. To some degree, this stage can continue for years. Much of the maturation continues even after the injury is asymptomatic.
Understanding this process helps to make the recovery process easier to fathom. It also clarifies the use of various braces for protection. Feet, like other musculoskeletal parts of the body, were not designed or did not evolve to be protected or supported. While certain irreversibly damaged feet may require protection indefinitely, the use of protection should ideally be limited. The modern usage of orthotics and high-tech “supportive” shoes, while helpful in the early stages of healing, should be gradually discontinued. It is my belief that usage of these devices in healthy feet has the potential to increase the possibility of injury by protecting the feet from normal stresses. This is much the way that an astronaut protected from gravity looses bone mass and strength when in space for long periods. Stresses stimulate the bones, ligaments, tendons, and joints to make themselves stronger (Wolff’s Law). Remember, the goal is to return to normal.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
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