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Central Florida Foot and Ankle Center101 6th St Nw Winter Haven, Fl 33881Phone: (863) 299-4551www.FLFootandAnkle.com

50 million Americans have toenail fungus. You don't have to be one of them

Central Florida Foot & Ankle Center, LLC101 6th Street N.W.Winter Haven, FL 33881Phone: 863-299-4551http://www.FLFootandAnkle.com

Posterior Tibial Tendon Dysfunction and Adult-Acquired Flatfoot

The posterior tibial tendon is one of the major supporting structures of the foot.  It functions to help add stability to the arch, and assists in normal gait fuction.  Posterior tibial tendon dysfunction is a condition caused by changes in the tendon, leading to a loss of this stability and a flattening of the arch of the foot. 

Posterior tibial tendon dysfunction, or PTTD, is often referred to as “adult-acquired flatfoot”.  This is because PTTD is the most common cause of flatfootedness in adults.  The condition can occur in one or both of the feet.  PTTD is usually a progressive condition, meaning that the arch will continue to flatten and the symptoms will worsen over time if not addressed. 

PTTD is most often attributed to overuse of the tendon, although there may be other contributing factors.  Inflammatory arthropathies such as rheumatoid arthritis can contribute to it’s development, as well as injuries to the foot and ankle, or other bony abnormalities of the foot. 

Symptoms of PTTD may include pain, swelling, or redness around the posterior tibial tendon.  This is located on the medial side of the foot and ankle.  As the condition progresses, pain may also develop in the arch of the foot or the ankle.  Arthritis of the joints of the foot and ankle may develop overtime, leading to worsening symptoms. 

The diagnosis of PTTD or adult-acquired flatfoot is largely a clinical diagnosis.  On physical examination, the pain may be localized to one or more of the effected areas.  The arch of the foot will usually appear flattened, and the forefoot may be abducted, or shifted laterally, in relation to the rearfoot.  This is known as the “too many toes” sign, as the examiner will be able to see more of the toes from behind the patient on the affected side than on the non-affected side.  Patients with PTTD may also have a difficult time rising to their toes on the affected side, especially when asked to rise to their toes using only one leg. 

X-rays are typically taken to rule out other potential causes of pain, such as arthritis, fractures, or dislocations.  They also serve as a baseline study to monitor the progression of the foot and ankle, should the symptoms worsen over time.  If a tear of the tendon is suspected, an MRI may be useful in determining the extent of the tendon tear. 

Treatment for PTTD will typically begin with conservative treatment.  This will involve things such as orthotics and other types of braces, anti-inflammatroy medications, and periods of rest and ice.  For patients with a painful flare-up of symptoms, a period of immobilization may be beneficial.  This would involve the use of a cast or immobilizing cast boot to protect the foot and ankle.  If some of the symptoms are related to arthritis of the nearby joints, such as the subtalar joint or ankle, a cortisone injection may be beneficial to relieve some of the pain. 

Surgical intervention may be warranted if conservative treatment fails, or is deemed to not be helping enough in managing pain and function.  Surgical treatment will vary depending on the symptoms, and the extent of foot and ankle deformity.  For patients with symptoms isolated to the tendon and not involving the surrounding joints, the foot and ankle surgeon may recommend “cleaning up the tendon” and restoring as much normal anatomy as possible to the tendon.  This is a procedure that is as minimally invasive as possible for these types of complaints.

For patients with more advanced pathology, a variety of approaches may be used.  Surgical techniques may involve repositioning the calcaneus (heel bone), shifting tendons in the foot, and repositioning the bones and joints of the midfoot to recreate a more functional foot.  Of course, these methods can vary greatly between patients, and depend on a number of factors.  Factors such as the patient’s lower extremity anatomy, age, weight, and overall health status should be considered in the pre-operative work-up. 

Surgical reconstruction of the foot and ankle is not without risk, and a thorough conversation should be had between the patient and doctor before surgery can be considered.  Time off of work, time to heal, and post-operative expectations of all parties should be discussed.  

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

Predislocation Syndrome

Metatarsalgia is a general term that is used to refer to pain in the metatarsal heads of the foot. This is the area of the metatarsal that forms the proximal half of the metatarsal-phalangeal (MTP) joints, which are the joints that connect the toes to the rest of the foot.  Pain underneath the second metatarsal head is a common clinical presentation. 

Pain in the second metatarsal most commonly occurs in the presence of hallux limits.  Hallux limitus is a condition in which the first metatarsophalangeal joint (the joint that connects the big toe to the rest of the foot) does not have the appropriate amount of motion required for normal function.  When there is not enough motion available in the first MTP joint, the ground reactive forces are transferred to the lateral, smaller MTP joints.  Most often, it is the second MTP joint that takes the brunt of this force.

If the second toe has a hammer digit deformity, in which the joints of the small toe remain contracted, it can exacerbate the problem.  When a hammer toe is present, the metatarsal head is pointed down towards the ground, or plantarflexed.  This plantarflexed position of the metatarsal adds to the amount of force.  Equinus deformities, in which the ankle joint is tight, can also contribute to the problem by placing additional pressure on the forefoot.  The pain will be especially great when the patient walks down stairs, as they lead with their toes. 

When this second metatarsalgia is present for a long period of time, a condition known as predislocation syndrome may occur.  This is most commonly described in the second toe, though it may be seen in any of the lesser digits.  Predislocation syndrome occurs when the plantar plate, which is a portion of the joint capsule, becomes damaged.  This damage can attenuate, or thin out, the structure.  This attenutation can lead to joint instability, and can cause the second toe to end up pointing upwards and medially or laterally.  Thus, the condition is also sometimes referred to as a crossover toe deformity, as the second toe may overalp the first or third toes. 

The diagnosis of predislocation syndrome is largely made using clinical judgement, though x-rays are necessary to rule out any underlying pathology, such as fractures or complete dislocations.  An MRI may also be ordered, though it is not always necessary.  The MRI will show the ordering physician whether the plantar plate is torn, attenuated, or if there is any other potential pathology causing the deformity. 

Initial treatment typically involves icing the affected area, rest, and the use of non-steroidal anti-inflammatory medications.  Orthotics may be used to manipulate the position of the foot while walking or running, and various strapping and padding methods may alleviate some of the pain. 

Surgery becomes warranted if there is a failure of conservative therapy.  Typically surgery will address any bony deformities of the foot first, such as hammer digits, metatarsals that are functionally too long, or other problems.  In the case of concomitant hallux limitus, procedures of the first MTP joint may be required to restore normal function to that joint and to take pressure off of the second MTP joint. 

When the plantar plate is ruptured or damaged, that too can be repaired with a direct approach.  This has traditionally been done through an approach through the bottom of the foot, though it has recently been described as being repaired through the top of the foot.  

 Central Florida Foot & Ankle Center, LLC 

101 6th Street N.W. 

Winter Haven, FL 33881 

Phone: 863-299-4551 

www.FLFootandAnkle.com

New Implant Technology Under Investigation

Researchers at the University of Alabama at Birmingham have published an early study on the use of nanodiamonds in joint implants.  The investigators seek to find if the nanodiamonds can improve the metallic interface of the joints, which can often shed debris and cause problems within the body. 

            When metallic debris is created within a joint that has had an implant placed in it, it triggers the body’s immune system.  This can cause a cascade of events, which includes increasing the activity of bone-eating cells near the implant.  When these cells have increased activity, it can cause the implant to loosed, which is a major cause of implant failure. 

            Using a nanodiamond coating, the reaserchers have found, causes less debris to form, which in theory could improve implant success rates.  This is important, because the amount of implants used in America alone is tremendous.  Over 400,000 knee implants and over 325,000 hip implants are placed in Americans every year, not to mention the number of implants used in other parts of the body. 

            Joint implants of the foot and ankle are often used in the first metatarsophalangeal joint, lesser metatarsophalangeal joints, and in the ankle.  Should the nanodiamond technology catch on in the hip and knee implants, it will almost certainly be applied to foot and ankle implants. 

            Much more knowledge of the effect of nanodiamond particles on the body is needed before this technology can be used in humans. While the nanodiamond coating may eliminate the metallic debris that is formed, the constant pressure and grinding forces placed through joint implants can still cause a small amount of the diamond nanoparticle coating to become loose.  The effect of this debris in the body must be known before it can be applied.  Currently, animal models are being used to investigate this. 

            Of course, what is not discussed alongside the research is the cost of such technology.  The cost of using a diamond nanoparticle will almost certainly increase the cost of the implant.  This should be balanced with the increase in success rates seen.  There would need to be a significant increase in implant success rates to begin implementing this technology.  But even if the cost of the implant is increased, if the success rates are in fact much higher, it will most likely decrease the cost of care, lessening the need for secondary and revisionary surgery, and increase the patient satisfaction following surgery.

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

How is a Bunion Fixed?

One of the most common surgical procedures that a podiatrist performs is bunion correction.  Bunions are a result of hallux abducto valgus, a deformity of the foot that leads to increased pressure at the first metatarsophalangeal joint.  Bunions can become extremely painful, and can limit a person’s activity level and restrict them to only certain types of shoes.  Conservative therapy can help to alleviate some of the symptoms of bunions, but even the best methods of strapping and bracing do not correct the problem.  Surgical correction of hallux abducto valgus and the bunion associated with the deformity is paramount to treatment.

A small incision is made along the medial side of the metatarsaophalangeal joint, where the bunion is.  This incision site is then deepened until the joint is reached, being careful to avoid the nerves and veins that run in the area.  Once the joint is reached, the joint capsule can be cut to access the bone.

The surgical approach to bunions most commonly involves an osteotomy, or cutting of the bones, at the head of the first metatarsal.  This is the part of the metatarsal that is closest to the joint.  By cutting the metatarsal, the operating surgeon is able to reposition the head of the metatarsal in a more functional position, thus eliminating the bunion.  The bone is then fixed with one or two screws, which keep the two pieces of the bone in place while it can heal.  Any remaining bone in the area that may be prominent or painful is also removed.

Some other approaches to bunions may involve simply removing the painful bump, repositioning the metatarsal head to gain more motion at the joint, or the use of joint implants.  Some bone cuts may be positioned further away from the joint, which allows for a greater correction of a more significant bunion.  A number of different surgical osteotomies have been used over the years.

A lateral release may be performed as well, which is when the tendons on the lateral side of the metatarsophalangeal joint are cut.  The tendons that course through the foot and function at the first metatarsophalangeal joint often become contracted in the presence of hallux abducto valgus.  These structures are cut in order to reposition the toe in a more straightened position. 

Following all of the corrective procedures in bunion surgery, the final step is to close everything up, layer by layer.  The joint capsule is often closed using a technique to tighten it, as the once prominent joint has now been removed.  This leaves an excess of tissue that should be addressed.  The skin is then closed with suture, and stitches may be left in for two or three weeks.  Some sutures are absorbable, and there is no need to take them out. 

After the surgery, the patient is usually placed in a bandage and a surgical shoe, which they are allowed to walk in.  Patients receiving bunion surgery are instructed to only walk a little bit, and to keep the foot elevated most of the time.  This is done so that the body has time to heal the surgical wounds that have been created.  They are typically seen in the podiatrist’s office following the surgery, or in some sort of follow-up clinic. 

Some amount of pain and swelling is to be expected following surgery, as the surgery itself can be rather traumatic.  This swelling should resolve after a week or so, and the pain should go away also.  Pain is usually addressed with oral pain medications.  Elevation of the foot and ice placed behind the knee or calf for fifteen minutes at a time will also help with pain and reducing swelling. 

Typically the skin will heal after two or three weeks, at which time the sutures, if necessary, can be removed.  Once the sutures are removed and the skin is healed, the patient may either continue in the surgical shoe, or return to a stiff-soled shoe or gym shoe.  Much of the post-operative treatment plan is surgeon-dependent.  The bones will typically heal in six to eight weeks.  In the post-operative period, it is common for the surgeon to obtain x-rays to evaluate the status of the bones.  This helps to determine the post-operative course.

Bunions are sometimes corrected in conjunction with other deformities of the foot, such as hammertoes or tailor’s bunions.  If there are other areas of pain in the foot besides the bunion, be sure to point them out to your doctor.

Talk to your podiatrist if you have painful bunions or any other painful foot condition.  Conservative therapy will generally be attempted first, but surgical intervention should be discussed with the operating doctor.  They will be able to fill you in on details regarding pre-operative preparation, the surgery, and the post-operative treatment protocol.  

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

Cavus Foot

The cavus foot, or pes cavus, comes in a variety of forms.  Most notably, it is characterized by a high arch.  While many may think that having a high arch is a good thing, having too high of an arch can lead to difficulty fitting shoes, pain in the ball of the foot (metatarsalgia), painful hammering of the toes, and increased pressure on the lateral or outside of the foot.  This increased pressure may result in pain and even fracture of the bones.  Callus development in areas of increased pressure is typical.  Advanced cases of pes cavus can often lead to a feeling of instability, particularly in the ankles. 

An important aspect in the diagnosis of pes cavus is the etiology of the condition.  Many times this foot type is associated with neurological disease and weakness of the peroneal muscles and/or the anterior muscles of the leg.  These muscles insert into the foot, and control the motion and function of the foot.  Some neurological causes of pes cavus include Charcot-Marie-Tooth, cerebral palsy, muscular dystrophy, spina bifida, poliomyelitis, and tumors of the central nervous system. While these condtions can be rare, it is important to let your doctor know of any progression of the deformity, any numbness or tingling in the feet and/or hands, and any other associated symptoms such as tripping or instability. 

When the etiology of the cavus foot is unknown, it is referred to as idiopathic.  This diagnosis is one of exclusion, and should not be made until a through evaluation is performed.

The next step in evaluating the cavus foot should be to determine whether the deformity is flexible or rigid.  In other words, is the foot stuck in the high-arched position, or is it able to be manipulated into a more normal position?  This helps determine treatment methods that your doctor may suggest.  It also helps determine surgical procedures that may be required in the future to correct the deformity, should they become necessary.

The apex of the deformity should then be determined.  This is done by looking at x-rays of the feet.  The deformity may be coming from one of three main regions of the foot; the forefoot, midfoot, or hindfoot.  In forefoot deformities, it is often one or more of the metatarsals that are malpositioned, causing the rest of the foot to alter its motion to accommodate the deformity.  The apex may also be located in the midfoot, with the lesser tarsal bones such as the cuneiforms, navicular, and cuboid defining the deformity.  In rearfoot pes cavus, the position of the talus and the calcaneus determine the position of the rest of the foot.  Of course, combinations of several deformities can exist as well.

Along with a thorough history and physical, nerve conduction studies and/or muscle testing may be performed to help determine the cause of the deformity.  The treating physician should have a high index of suspicion for a neuromuscular etiology.  Family history of neurological disorder or of pes cavus running in the family should be mentioned.

Treatment of pes cavus is initiated with conservative measures in the vast majority of cases.  This may include things like physical therapy, custom molded or over-the-counter orthotics, shaving of painful calluses, and bracing for unstable ankles.  A large percentage of patients will find great benefit from conservative treatment alone.

In cases of failed conservative treatment, surgical intervention may become an option.  Pes cavus has been discussed in the medical literature for over one hundred years.  Much of our understanding of surgical correction of the deformity comes from cases of polio, where those affected by the disease were left with non-functional limbs.  Research and technology have improved the outcomes of surgical correction for pes cavus drastically over the years.

For those with flexible pes cavus, soft tissue procedures may provide adequate correction of the deformity.  This can include a plantar fasciotomy and/or various tendon transfer procedures.  For those with a non-progressive form of pes cavus, this may be the only correction needed. 

For those with rigid deformity, or those with more advanced pes cavus, bone cuts may be necessary to bring the foot to a normal position.  Depending on the apex of the deformity, this may include cuts in the metatarsals, in the calcaneus, and/or cuts in the lesser tarsal bones. 

In progressive deformity, fusion of joints is usually required to establish a more normal foot.  Arthrodesis, or joint fusion, can help prevent recurrence of severe deformity in those with a progressive cavus foot type.

Of course, a through evaluation is required before any decisions can be made regarding treatment of the cavus foot.  It is important to discuss with your doctor and a foot and ankle surgeon the various options for treatment.  Be prepared to answer questions regarding the progression of the deformity, any signs of neurological involvement such as numbness, burning, or tingling in the hands and/or feet, and if there is a family history of similar conditions.  These are all important aspects of the diagnosis and treatment of the cavus foot.  

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

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