Rehabilitation of Foot and Ankle Injuries

One of the most important aspects of foot and ankle injuries is the rehabilitation of those injuries, and a return to normal activity.  This is often done through strengthening, stretching, and balance exercises.  When combined, these three things can be a powerful means of rehabilitation and the return to previous mobility. 

As an example of how these activities work, let’s look at a typical ankle fracture that was repaired surgically, and is now being treated in a rehabilitation center by physical therapy.  For a patient coming in after surgery, the first thing that must be done is a thorough evaluation of the patient’s current level of mobility, strength, and balance. 

The patient’s mobility is assessed by measuring active movement and passive movement.  Active movement is the patient’s ability to move their ankle on their own.  Passive movement will involve the physical therapist or the treating physician moving the ankle joint through its normal range of motion with the  patient relaxed.  The patient may experience some pain with these mtoins, and it is important to let the treating practitioner know of this pain.  If the range of motion is limited, this will be an area to focus during rehabilitation.

Stretching is the only way to increase the amount of movement at a joint such as the ankle.  For ankle fractures, calf stretches are used to increase this motion.  However, stretching can be painful at the beginning of rehabilitation.  During this early period, range of motion exercises may be used instead in order to maintain the current amount of movement available at the joint.  This may involve the patient actively moving their foot up and down slowly, in a pain free range.  This is opposed to stretching, which is a prolonged hold at the end of the range of motion. 

Strength will also be assessed in the rehabilitation of an ankle fracture.  This is done by the practitioner applying pressure at the foot and asking the patient to hold and maintain their foot in the correct position while the practitioner pushes in the opposite direction.  If the patient is unable to perform this activity, it is seen as a deficit in strength. 

To strengthen the muscle groups involved, various exercises may be used.  In physical therapy, this will often involve the use of resistance bands or manual pressure from the therapist. 

Balance is assessed by asking the patient to stand on one leg and measuring how long they can stand like that.  This may be very difficult for paitients with a history of an ankle fracture.  It also may be assessed with the eyes closed or by having the patient stand or walk on an uneven surface.  Balance is only assessed in the beginning in the clinic for safety reasons.

Balance training exercises include the use of a balance board or wobble board, which forces the patient to balance on an uneven surface.  The ankle plays a critical role in balance, so restoring this function is a priority.  Increasing one’s balance after an ankle injury can also help prevent a future ankle injury. 

Later in rehab, the physical therapist will progress the patient to their previous activity level, whether that is walking, running, climbing stairs, or returning to sports.  The physical therapist, therefore, plays an important role in the rehabilitation of foot and ankle injuries.   

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Preventing Falls in the Elderly

The podiatrist’s role in preventing falls in the elderly has recently got some attention at the international level. At the national meeting of the American Podiatric Medical Association, podiatrist Doug Richie Jr. presented information regarding the podiatrist’s role in preventing falls in the elderly. Some of the research that he presented was from a study by a podiatry group in Australia, who have contributed significantly to the understanding of the topic.

The Australian study led by by Dr. Martin J. Spink of La Trobe University looked at the effect of a multi-faceted podiatry intervention for older adults compared to routine podiatry care. Multi-faceted intervention was defined as the use of customized foot orthoses, advice on footwear and a subsidy for footwear, home-based foot and ankle exercises, a pamphlet of information regarding fall prevention, and routine podiatry care for a period of 12 months.

The study found that the group receiving the multi-faceted podiatry intervention suffered from 36% fewer falls than the patients randomized to the routine podiatry care group. Muscle strength, range of motion, and balance were all significantly and statistically improved in the intervention group when compared to the routine care group.

This study, in combination of what we already know about falls in the elderly, could be a very important piece of information in the way that health care is delivered. Fall prevention is a major priority in hospitals, with everyone involved in patient care also involved in the prevention of falls. Falls in the elderly can lead to disabling and even life-threatening injuries such as fractures and head injuries. It has been reported that over half of people over the age of 65 years will experience a fall each year, and that a third of these falls will lead to significant injury. The amounts to a health care cost exceeding $20 billion in the management of these injuries, which is projected to double in the next 15 years due to the aging population in the United States. Clearly, the cost associated with these serious injuries is a potential source of savings when discussing Medicare/Medicaid funding.

The role of the podiatrist in preventing falls is likely to increase with more knowledge and awareness of the subject. This prevention hinges on early detection of potential risk factors, including existing foot and ankle pathology, diabetic neuropathy, impaired vision, and impaired mobility just to name a few. Conservative measures such as muscle strength testing, range of motion testing, gait analysis, and the use of customized orthotics and bracing can have a great impact on the health and well-being of the elderly patient, and prevent a potential fall.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Tightrope Fixation for Syndesmotic Injuries

A newly emerging trend in foot and ankle surgery is the use of the Tightrope end-button device made by Arthrex. The device is a special type of suture material called fiberwire, attached to two small buttons at either end. A small needle is used to pass the suture through two bones, and then the suture material can be tightened to bring the bones together.

One of the uses of the device is in injuries to the tibiofibular syndesmosis. The syndesmosis is composed of several ligaments, including the anterior tibiofibular ligament, posterior tibiofibular ligament, and the interosseous tibiofibular ligament. Together this structure helps keep the fibular and tibia together, adding stability to the ankle joint.

In ankle fractures, the tibiofibular syndesmosis is often disrupted. If left unaddressed, the diastasis, or separation, between the tibia and fibula can lead to dysfunction and arthritis. A syndesmosis injury can often occur as an isolated event, sometimes referred to as a high ankle sprain.

The standard method of addressing this injury is to place a screw across the syndesmosis, sometimes referred to as a trans-syndesmotic screw. These are often placed through the bones until the ligaments can heal, and is then removed. However, complications such as broken screws and failed healing of the syndesmosis lead to research into alternatives.

The Tightrope design allows for some motion to occur at the tibiofibular syndesmosis. This allows for a more natural motion at the joint. The manufacturers state that the device never needs to be removed, so long as there aren’t any complications with the fixation, due to its allowance of micro-motion. This is in contrast to screw fixation, which necessitates another surgery.

Studies have shown good short-term results using the Tightrope for repair of syndesmotic injuries. It has been shown to be as effective as screw fixation in allowing for healing. While there are no long-term results available yet, nor are there any published studies comparing Tightrope fixation to screw fixation, the results thus far have been promising. Several studies are in development to more rigorously study this new form of fixation.

At least one study, however, has shown some complications from the use of the Tightrope device. Wilmott et al (Injury 2009) showed several soft tissue complications resulting from the use of the Tightrope. There study was small, however, and the patients involved in the study did show healing of the syndesmosis with use of the fixation device.

While it may be a new trend emerging in foot and ankle surgery, there is certainly more evidence necessary before Tightrope fixation for syndesmosis injuries can become the standard of practice. Larger, long-term studies will be necessary, comparing the device to fixation with screws.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Swanson Implants for First MTP Joint Arthritis

The first metatarsophalangeal joint (MPJ, MTP Joint, or MTPJ) is highly susceptible to arthritis. This is the joint in your foot that attaches the big toe to the first metatarsal. It is a very important joint, and allows for propulsion during gait. There is a great amount of force that is put through the joint when walking, which is quickly absorbed through a number of joints in the foot. Because of this great amount of force place through the joint, it is also highly susceptible to arthritis.

Arthritis of the great toe joint, much like arthritis of any other joint, can be very difficult to treat. It is a painful condition that doesn’t always respond well to medications. There is no real cure for arthritis, and some people are affected by it at a much earlier age than others. Arthritis of the first MPJ is complicated by the fact that it is a weight-bearing joint.

Conservative treatment of first MTPJ arthritis is generally focused on preventing the advancement of arthritis by accommodating any foot deformities that may be present with orthotic devices. A foot deformity that increases pressure or force at the first MTPJ will speed up the progression of arthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used, such as naproxen or ibuprofen. Icing, protective measures, heat, and a number of other non-surgical therapies are often used with varied results.

Surgical options for the treatment of first MTPJ arthritis include a number of procedures, including fusion of the joint, osteotomies (bone cuts), resection of some of the bone, and joint implants, to name a few. Joint implants come in a variety of designs.

One of the types of implants commonly used is the Swanson-type implant. This is an implant that is made of a silicone, and has two stems. One stem is placed into the metatarsal, and the other into the proximal phalanx. Some of the bone must be removed for each stem to fit into its respective end, and a small hole is reamed out to place the stem. Once the implant is placed, it creates a false joint. The first MTPJ, therefore, would have a more functional and painless range of motion. This is the goal of the surgery.

The implants have a lifespan of around 30 years, and are generally well tolerated. Occasionally the implants can breakdown at a faster rate, and cause a condition known as detritic synovitis. This is a condition caused by small particles of the silicone being sheared off within the joint, which leads to inflammation.

These double stem silicone implants are not for everyone, and are generally not used in younger patients, due to the lifespan of the implant. There are a number of different surgical methods for treating first MTPJ arthritis; this type of implant is only one.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Classification of Ankle Fractures

Ankle fractures are one of the most common injuries to the lower extremity. The injuries are almost always due to a twisting injury, where the foot is planted flat on the ground and the leg is forced in a twisting or sliding pattern. Ankle fractures are a frequent occurrence in high impact sports, as well as from everyday-type injuries. The anatomy of the ankle helps to define this injury, and a number of structures are at risk.

The ankle joint is composed of the tibia and fibula, which are the bones of the lower leg, as well as the talus, which is a bone of the foot. The tibia and fibula join at the syndesmosis, a structure that is key in holding the ankle in place. The tibia and fibula form a groove for the talus to move through, ensuring stability through range of motion at the ankle. A number of ligaments hold these structures together, mainly the lateral ankle ligaments and the medial ankle ligaments. The medial ankle ligaments are commonly referred to as the deltoid ligament.

A series of tendons run across the joint from the leg into the foot. These tendons belong to muscles that control the movement of the foot, including plantarflexion (pointing the foot in a downward position), dorsiflexion (bringing the foot upwards), inversion, and eversion. There are also a number of arteries, veins, and nerves that run across the ankle joint that provide blood and sensation to the foot.

Injuries to the ankle, as common as they are, can be described by several different classification systems. The two most commonly used are the Lauge-Hansen and Danis-Weber systems.

The Lauge-Hansen system classifies ankle fractures based on the mechanism of injury, taking into account both the position of the foot at the time of injury as well as the movement of the leg. For example, one of the categories for the classification is supination-external rotation. The first term denotes that the foot was in a supinated position at the time of injury. The second term indicates that the leg was externally rotated in relation to the foot, causing the injury. The four categories originally described by Lauge-Hansen included supination-external rotation (the most common mechanism of ankle fracture), pronation-external rotation, supination-adduction, and pronation-abduction. Another category was later added, pronation-dorsiflexion, indicating that the force causing the injury was an axial force through the bottom of the foot that would drive the talus bone up through the tibia. This, however, is more appropriately addressed as a pilon fracture.

Within each category of Lauge-Hansen mechanism, there are different stages indicating how extensive the damage is to the ankle joint. These stages correlate with the ankle structures effected by the injury. Shown in the diagram above, starting from top left and moving clockwise, are the supination-adduction, pronation-abduction, pronation-external rotation, and supination-external rotation injuries. The stages indicate the structures involved.

Another commonly used classification system for ankle fractures is the Danis-Weber classification. This is based on the anatomy involved in the injury, particularly the tibia-fibula syndesmosis, which is the joint between the two bones. The classification is based on the level of the fibular fracture associated with the injury. If the fracture is below the level of the syndesmosis, it is considered a type A injury. Type B would be at the level of the syndesmosis, and type B would be above the level. Danis-Weber classification helps to indicate the amount of damage to the tib-fib syndesmosis. Levels B and C are associated with damage to the joint, which may lead to instability of the ankle if not addressed during the treatment of the fracture.

The classification of ankle fractures is a very academic topic, and is used primarily to communicate between physicians treating the injured patient. Other descriptors may be beneficial in describing the injury, but the classification systems are a quick and easy way to relate what is going on with the injury between doctors and those involved. Because of the reliable patterns of ankle fractures, these classification systems are fairly universal, and have a good inter- and intra-observer reliability.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Accessory Navicular

The navicular bone, located on the medial (inside) foot, is sometimes associated with an accessory bone. This accessory bone is most commonly referred to as an accessory navicular or os tibiale externum, but may also be called navicular secundum, prehallux, bifurcate navicular, accessory tarsal scaphoid, extra scaphoid, or a divided navicular. The accessory bone may be fused (attached) to the navicular, or it may be located within the tendon of the posterior tibial muscle, which attaches to the navicualr at this point.

Accessory navicular is present from birth, and results from a secondary ossification center of the bone. This means that there is an additional area of bony growth in the growing foot, which may eventually attach to the main portion of the navicular by either a bony attachment or with cartilage.

Symptoms of an accessory navicular include pain associated with shoes rubbing against the bony prominence, or pain developing from an eversion-type twisting injury. In the event of a twisting injury, the accessory bone may become detached from the main body of the navicular, essentially acting as a fracture of the bone.

Identification of the os tibiale externum, or the accessory navicular, begins with a thorough hirtory and physical examination. Frequently the accessory bone can be felt through the skin, or even seen on gross examination. X-rays are typically required to differentiate the accessory bone from an enlarged navicular or any other type of fracture of the bone. An MRI is not always necessary, but may be ordered if the diagnosis is not definite.

Once the condition is recognized, treatment may begin with conservative therapy, often involving padding the area and preventing it from rubbing against a shoe. In the event of a fracture through the bone, or a detachment of the bone from the main body of the navicular, it may be immobilized in a hard or soft cast. A number of factors play a role in this clinical decision-making.

Eventually, surgical removal of the accessory bone may be required to alleviate the symptoms. Depending on the particular type of accessory navicular, a number of different surgical techniques may be used. This is at the discretion of the treating foot and ankle surgeon. Typically, the offending bone will be removed in order to relieve the symptoms.

Post-operative care generally consists of protection with a cast, or a soft bandage and a surgical boot. Keeping off of the foot is usually indicated in allowing the foot to heal. Some pain and swelling should be expected. Analgesics may be used to alleviate some post-op pain, and elevation, ice, and rest are typically used to remove some of the swelling associated with the surgery. Details of the surgery may be discussed with your foot and ankle surgeon, including post-operative planning and the risks associated with surgery.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Dyshidrosis

Dyshidrosis is a disorder of the skin that is characterized by small blisters on the hands and/or feet. It is also known as pompholyx, podopompholyx, cheiropompholyx, acute vesiculobulbous hand eczema, and dyshidrotic eczema.

Most commonly the condition presents on the fingers and toes, in particular it may be present on the lateral sides of the digits. Dyshidrosis is a pruritic, or itchy, condition, particularly when it is located on the sides of the digits. It typically begins as a number of small, tense blisters, which are deep seated in the skin. Over time these small blisters may coalesce into larger blisters, but do not commonly rupture. However, if the vesicles do rupture, this may lead to secondary bacterial infections.

It was previously believed that dyshidrotic eczema was caused by faulty sweat glands, which led to the name “dyshidrosis”. However, this hypothesis has been refuted due to the evidence that shows that the vesicular lesions are not in fact related to the eccrine sweat glands.

It is commonly accepted now that dyshidrotic eczema is a multifactorial disorder, which is commonly related to other skin conditions and precipitating factors. In particular, atopic diathesis (such as hay fever, eczema, asthma, and allergic sinusitis) has been shown to be present in as many as 50% of patients with Dyshidrosis.

While excessive sweating may not cause it, dyshidrosis has historically been linked to an excessive output of sweat. However, cases reported of dyshidrosis without hyperhidrosis (excessive sweating) dispute the causation. It is possible that dyshidrosis is linked to anxiety, stress, and frustration, which may cause outbreaks or exacerbate the symptoms.

An association with nickel sensitivity has also been reported. Systemic exposure to high levels of nickel may be from foods that are high in nickel, such as cocoa, chocolate, whole grains, and nuts. Diets that restrict intake of these foods have been shown to reduce the number of outbreaks of dyshidrotic eczema.

Chemical and mechanical irritants have also been indicated as a cause of dyshidrotic eczema outbreaks. This may include things such as keeping the hands and feet damp, using strong soaps or detergents on the hands and feet, exposure to latex or other materials that cause documented allergic reactions, such as bandages, skin tapes and plasters. Dyshidrosis may also be seen in correlation with fungal and/or bacterial infections of the feet. There has also been a well-documented inheritance pattern and genetic predisposition to dyshidrotic eczema.

Dyshidrotic eczema is diagnosed by first ruling out a number of other possible diagnoses. This may include infection, allergic reaction, blistering disease such as pemphigus vulgaris, and a number of other dermatological conditions.

Treatment of dyshidrosis is largely symptom based, and many cases will clear spontaneously within several weeks. Topical steroids are often used to reduce itching, and oral steroids are occasionally used in cases of intense outbreak. When blisters are present, draining of the blisters may be appropriate, as well as using compression bandages with drying agents such as Burow solution. A number of other treatments have been used experimentally, such as Botox injections, UV-A light therapy, Nickel chelators, and a number of oral medications.

Other therapies include diet modifications to avoid exacerbating foods, as well as behavioral modifications to avoid irritating substances. Allergy testing may be indicated for patients with a known or suspected allergy to certain substances.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Nail Changes in Systemic Disease

(Hutchinson’s Sign in melanoma)

An important aspect of the clinical exam for podiatrists is the careful examination of the toenails as well as the fingernails. A variety of systemic diseases can appear in both the hands and feet, and analysis can often lend itself to revealing an underlying systemic condition. The following is a brief list of some of the changes to the nail and fingers and toes, as well as the underlying conditions associated with the changes.

• Nail Clubbing – This is a condition that is caused by a thickening of the soft tissue beneath the proximal portion of the nail plate (the area closest to the knuckle, or the distal interphalangeal joint). A specific finding of nail clubbing is to put the two index fingers next to each other, with the nails facing each other. If the distal interphalangeal joints of the two fingers touch, and the distal end of the nails do not come in contact with each other, it may indicate clubbing of the digits. Nail clubbing is most commonly associated with pulmonary disease, such as emphysema, cystic fibrosis, lung abscess, pulmonary fibrosis, and bronchogenic carcinoma. It is also commonly seen in inflammatory bowel disease, celiac disease, and cirrhosis of the liver.

• Nail Pitting – Most commonly associated with psoriasis, nail pitting is a series of small, punctate depressions in the nail. It is caused by a defect in the layering of the nail plate as it grows out of the nail matrix. Nail pitting may also be seen in systemic diseases such as Reiter’s syndrome, connective tissue disorders, sarcoidosis, and pemphigus. A localized dermatitis may also cause nail pitting, if it disrupts the normal growth of the nail plate.

• Koilonychia – Also termed “nail spooning”, koilonychia gives the nails a spoon-like appearance, with a central depression of the nail plate. It may be due to repeated chemical exposure or trauma to the nail, but is also associated with a variety of systemic conditions. Hemochromatosis and iron-deficiency are two of the conditions that the clinician should be suspicious of when koilonychia is found. Koilonychia can also be a normal variant in the infant child, which usually resolves with age.

• Onycholysis – This is a separation of the nail plate from the underlying nail bed, most commonly at the distal end of the nail, and usually caused by trauma, warts, onychomycosis, or as a finding of psoriasis. However, in the absence of these explanations, it may be associated with hyperthyroidism. When onycholysis is seen in hyperthyroidism, the condition is termed “Plummer’s nails”.

• Leukonychia – Any whitening of the nail in a random, non-linear pattern may be termed leukonychia. It is a very common finding in the nails of both children and adults. Many people will have several white spots on one or more nails, that grow out with time. These are benign lesions that are of no consequence, are believed to be caused by random microtrauma to the nail matrix. A whitening of one or more nails in a linear fashion that parallel the lunula (the half-moon shaped lighter portion at the proximal end of the nail) may indicate a number of systemic disease, and should be evaluated by a physician.

• Longitudinal Linear Lesions – Darkened lesions that run longitudinally along the nail should always be shown to a clinician. Benign lesions must be distinguished from melanoma, which can be seen growing underneath the nail plate. Unexplained darkening in a longitudinal pattern along the nail plate should be considered malignant until proven otherwise with a biopsy.

This is simply a brief listing of some of the changes seen in the nail and surrounding tissues associated with a variety of systemic diseases. Always let your doctor know of any recent changes to your nails.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Dog Eats Toe, Saves Owner’s Life

Strange news from Grand Rapids, Michigan today as a Jack Russell terrier saved its owners life after gnawing off the man’s big toe.

Yes, you read that correctly.

Forty-eight year old Jerry Douthett’s dog, Kiko, sniffed out an infection that had been growing in Jerry’s toe for several months. The wound had been the result of a small sliver that Douthett had attempted to remove himself by cutting at it with a knife. What ensued was a serious infection that would swell greatly over time, and eventually would spread to the underlying bone.

Douthett’s wife, a registered nurse, recognized the infection as possibly related to diabetes, and urged her husband to seek medical attention. After weeks of delay, Jerry would finally be forced to heed this advice.

The canine-amputation resulted in a hospital visit that would uncover Jerry’s type II diabetes, as it was undiagnosed at the time. Doctors removed what was left of the gnarled and infected toe at the hospital.

Kiko had been sniffing at the wound for quite some time, but was finally able to rid his owner of the infected toe when Jerry came home from a bar. Jerry had drank several beers and margaritas, and fell fast asleep upon arrival. Jerry would wake up later to a missing toe and pool of blood in his bed.

"The toe was gone," said Douthett. "He ate it. I mean, he must have eaten it, because we couldn't find it anywhere else in the house. I look down, there's blood all over, and my toe is gone."

What Kiko was able to sniff out is unfortunately a fairly common situation in the diabetic foot. A loss of pain sensation in diabetic peripheral neuropathy can allow someone to have a serious foot infection without much pain. This is also what would help Kiko chew off the toe without causing too much pain. Combined with the diminished immune system of the diabetic patient, this sets up a dangerous situation.

Now that Douthett is out of the hospital, he has sworn off drinking and is trying to take better care of his health. This starts with working to control his diabetes.

For diabetic patients, it is crucial that they check their feet for open wounds or areas that look like the skin is breaking down. These areas can quickly become infected. For a person with diabetes, something as simple as a hangnail could turn into a big problem. Jerry Douthett learned this in a difficult way.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Rickets

Rickets is a softening of the bones in a child, sometimes referred to as childhood osteomalacia. It is caused by a decrease in calcium absorption, most commonly due to a decrease in activated vitamin D.

Vitamin D is an essential component of calcium metabolism in the body. Activated vitamin D allows for the absorption of calcium from our diet. Without it, much of the ingested calcium in our diet passes through the intestines without being absorbed and utilized by the body.

The activation of vitamin is a complex reaction that is activated by UV light, in particular UV-B from the sun’s rays. A certain amount of exposure to sunlight is required to generate activated vitamin D everyday. In an adult, it takes approximately 15-20 minutes of direct sunlight on non-protected fair skin to generate approximately 10,000 IU of vitamin D everyday.

In children, however, the amount of time required to activate an appropriate amount of vitamin D is unknown and is difficult to measure. Factors such as age, skin tone, body mass, geographical location and season will all play a role in altering the total. In children, 400 IU of vitamin D are required daily to prevent Rickets and to maintain a healthy level of calcium in the body. It has been shown that children with darker skin pigmentation may require 5-10 times as much sunlight exposure as fair skinned children to activate the daily requirement of vitamin D.

Children aged 3-18 months are at a particularly high risk for the development of rickets, because their bones are growing rapidly at this point in development. High risk groups include children that are strictly breastfed, children with darker skin pigmentation, and children with very limited exposure to sunlight.

In developed countries like the United States, the incidence of Rickets is extremely low (approximately 1 in 200,000 will develop the condition). However, in the developing world, it remains as one of the more common conditions attributable to malnutrition. A lack of vitamin D in the diet is to blame; foods rich in vitamin D include eggs, butter, fish liver oils, fortified milk, and oily fishes such as tuna, herring and salmon.

Symptoms of rickets are due to a lack of calcium, most notably the skeletal deformities that result from the softening of the bones. This includes the classic bow-legged appearance of the tibia and femur, cranial and spinal deformities, and costochondral swelling (swelling along the ribs at their attachment with the cartilage, also known as “rachitic rosary”). Other symptoms include muscle weakness, growth disturbances and failure to grow, dental problems, bone pain, and an increase risk of fractures.

The Indoor Air Quality Act of 1989 reported that Americans spent roughly 93% of their day indoors, which only further compacts the problem of limited sunlight exposure and the development of rickets. Due to the modern lifestyle of developed countries, as well as campaigns to limit sun exposure due to its influence on developing various forms of skin cancer, it is predicted that the incidence of rickets may rise in the future. This has already been observed in Western countries.

Treatment of rickets may be multi-faceted, but includes supplementation with activated vitamin D as the mainstay. Increased exposure to sunlight may be recommended in some cases, though the risk of skin cancer from over-exposure warrants a word of caution. In cases where skeletal deformity has developed, accommodative bracing, orthotics, and other devices may be used.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com