What is it?
A "sprained ankle" is one of the most common injuries a sports medicine physician encounters. It is also one of the most poorly understood by lay persons and health care providers (including physicians), and is often under treated. A severe ankle sprain, although treated properly, can still result in chronic instability of the ankle. Fortunately, most are not severe and with quick and proper treatment these injuries heal well.
Three essential ligaments cross the lateral (outside) surface of the ankle joint and are the most commonly injured with ankle sprains.
Anterior Talofibular Ligament (ATFL)
Posterior Talofibular ligament (PTFL)
Calcaneo Fibular Ligament (CFL)
Much more uncommonly, however, on the medial (inside) surface of the ankle joint, the deltoid ligament is injured.
Mechanisms of Injury
The injury is usually the result to the ankle turning in, commonly referred to as "going over the ankle." In squash this can occur with sudden pivoting or cutting movements. More often the ATFL and CFL are involved.
Classification of Ankle Sprains
First Degree: Most common and often neglected. The ligaments are stretched, not torn. There may be minimal to mild swelling and no instability. This patient usually treats him/herself and simply puts up with a sore ankle for a week or so.
Second Degree: Ankle ligaments are partially torn and bleeding into the surrounding soft tissue occurs resulting in ecchymosed (bruising and discoloration). Swelling and pain may be very minimal initially and gradually worsen over the next few days peaking within a week. This degree of tear requires varying degrees of immobilization and usually 3-6 weeks before the person van resume activities.
Third Degree: Most severe and ominous. Represents complete disruption of at least the ATFL and CFL and sometimes the PTFL. The ankle is unstable. X-rays are normal. Healing requires 8 to 10 weeks.
In the more mild forms of sprains the best treatment is known as R.I.C.E. This is an acronym which stands for Rest, Ice, Compression, and Elevation. The rest is quite self-explanatory and consists of non-weight bearing with crutches. The ice should be applied as ice packs, and these should be applied for the first 72 hours as much as can be conveniently performed in order to keep the swelling down. Compression consists of a tensor bandage which will help to limit the swelling, although occasionally a cast is required. Elevation must be performed to help keep the swelling down. This period of compression and elevation can often take up to 2-3 weeks if the sprain is bad enough. As the pain subsides an exercise program with physiotherapy can be started to increase the strength of the ankle and foot muscles. The advice of physiotherapists or similar knowledgeable individuals should be sought for proper teaching of these exercises.
Although somewhat controversial it is rare to operate on even severely sprained ankle injuries. In the U.S.A., immobilization involving bracing and non-weight bearing with crutches is usually employed.
Depending upon the situation, the surgical repair for instability, whether acute or chronic, is a viable alternative and can be very gratifying.
Perform stretching exercises.
Use proper footwear. Your shoe should have good lateral support, a relatively low heel (different from jogging shoes which have a built up heel and poor lateral stability) and rounded contours to avoid "going over." Shoes with a higher boot top ("high cuts") may be indicated for those with chronic instability. Lace-up ankle supports may be very helpful.
Avoid uneven surfaces which might include anything from your opponents foot to poor court flooring to uneven training ground.
Deciding on Surgery
If you get repeated ankle spraining easily, you may need to have your ligaments reconstructed. This will re-stabilize your ankle and allow you to return to sport without constantly worrying about re-spraining your ankle. It is a very satisfying procedure, but like all surgeries, does carry some elements of risk to it. Discuss these risks/advantages with your doctor.
What is it?
A bunion is a very common foot deformity that develops over the first metatarsal phalageal joint of the big toe of the foot (see diagram). The joint that joins the big toe to the foot is called the first MTP joint. When it becomes prominent and the big toe starts to become crooked this is known as a bunion. The term referring to deformity of the big toe as it becomes crooked is called Hallux Valgus. It is the bump itself that is known as the bunion. When it gets red and swollen over the bunion because it gets sore this is usually due to an inflamed soft tissue over the underlying bone.
The commonest cause of bunions is prolonged wearing of poorly designed shoes such as the narrow high heels that women wear. This is one of the reasons why bunions are much more common in women than in men. There is also a hereditary component to bunions in that many times we will see a grandmother, mother and daughter all with various stages of bunions. 38% of women in the United States wear shoes that are too small and 55% of women have some degree of bunion formation. Bunions are 9 times more common in women than they are in men.
Left untreated bunions will gradually become worse especially if women continue to wear the narrow pointed shoes. Not all bunions progress because if the patient starts wearing good shoewear and they are caught early enough they may not get any worse. In general however, they will certainly not get any better no matter how they are treated. We generally reserve surgical treatment for bunions that are painful. If they are not painful they should simply be observed and shoewear modified. Occasionally the patient will want the bunion corrected for cosmetic reasons.
There are a few basic pointers to remember when buying shoes. Do not buy shoes by simply buying the size that you think you should fit into. The shoe must be tried on and worn in the store for several minutes until you make sure that it is not compressing your foot. The shoe itself should look as close as possible to the normal shape of a foot. You should realize that the size and shape of your feet will change as you get older. With age your arch generally flattens out slightly and your foot will become slightly longer. As well the left foot will not always be the same size as the right foot. Shoes should be fitted at the end of the day when your feet are at their largest due to gravity and natural occurrence. You should stand during the fitting process and make sure that you measure width as well as for length of the shoe. Do not expect your shoes to stretch to fit you.
Indications for Surgery
Pain is the commonest indication for bunion surgery. You may also notice redness and inflammation and usually this means that the bunion has progressed to a point that it will not respond to simple modification in shoe wear. Eventually that major joint of the big toe will become stiff and this makes it difficult for activities such as climbing stairs and sports.
Types of Bunion Surgery
There are many different procedures described to correct bunions. You should be aware that usually just shaving the bunion off, although it is attractive and minimally invasive, is usually not enough. Initially the foot will look much better but with time the bunion will recur.
Arthrodesis refers to surgery performed on the great toe joint where the joint is fused. This is usually reserved for people with very severe deformities when other surgical options are impossible.
Bunionectomy refers to the simple removal of the bunion itself. This is seldom used because it doesn't correct the underlying bone problems.
Osteomety is the commonest surgical procedure. The bone is cut and the bones realigned and pinned in place until they heal so that the underlying bone deformity is corrected and the bunion will not recur.
The resection arstplasty refers to the removal of the toe joint and this creates a flexible scar that functions as the joint instead. In the past there has been some interest in implanting artificial joints but this has fallen out of favor due to the fact that they usually do not hold up with the normal every day stress that people put their feet through.
All patients should understand pre-operatively what they can expect from the surgery. The majority of patients who have bunion surgery are very pleased with their results and have a significant improvement in both their cosmetic appearance as well as the pain. Surgery does not however make it possible to fit into smaller shoes for the purpose of cosmetic reasons. If this is done the bunion generally will recur. You have to wear good shoe wear after surgery.
You should also be aware of the risks and complications and alternatives such as infections, nerve injury and recurrence of the bunion and failure of the hardware. Other medical risks such as blood clots in the legs and risks related to the anesthetic must also be considered. Unfortunately no surgery can be formed that is actually risk free no matter what kind of surgery is performed. Generally speaking bunion surgery is safe and effective. Surgery is performed on an outpatient basis unless there is underlying medical problems. The patient will enter and leave the hospital on the same day and the patient will have a choice of different anesthetics such as spinal, general anesthetic and various nerve blocks. The anesthesiologist will discuss this with the patient in detail.
Post Operative Care
Crutches will need to be worn for the first few days. After that a special boot is placed on the bandage and the patient can weight bear but will have to wear that special post-op shoe for approximately 4-6 weeks to ensure proper healing. This dressing has to be kept clean and dry but usually the patient can get around for day to day activities quite well after just 2-3 days. But they will have to modify their activities during the 4-6 week healing period.
TREATMENT OF FOOT PROBLEMS
Reasons for Foot Surgery
The more you know about what to expect, the more smoothly your treatment, either conservative or surgical, is likely to be. While each problem is unique, there are three basic goals: to relieve pain, to restore function, or to improve the appearance of your feet.
Feet that hurt interfere with your work, family, and your social life. Pain often signals an underlying problem. Fortunately, in many cases, foot treatment can correct the problem and relieve the pain.
If your feet are not doing their job, it is hard for you to do yours. When simply walking becomes a problem, your lifestyle is affected. But accepting a life of hobbling or sitting on the sidelines can make you old before your time. Foot surgery can be performed at almost any age - and in most cases, surgery can restore the normal use of your feet.
Although foot surgery is not usually performed for cosmetic reasons alone, it can often improve the appearance of your feet.
Anatomy of the Foot
Before you have your foot surgery, it helps to understand how your foot works in supporting you and carrying you from place to place. Knowing how skin and bone heal following surgery can help you to better understand the importance of post-operative foot care during your recovery.
Ligaments are flexible bands of fiber joining bone to bone. The foot has over 100 ligaments. Joints form where two bones meet. The 33 complex joints in each foot permit flexibility. Bones form the basic supporting structure of your foot. There are 26 bones in each foot. Tendons are tough, fibrous cords that connect muscle to bones. Muscles help move the feet and toes. When a muscle contracts, it pulls on a tendon, which in turn moves the bone.
The Healing Process
All foot surgeries involve the skin, and in some cases, the bone inside must be cut as well. When you understand the healing process, you can help make your foot surgery a success.
Skin heals in phases. First, it grows together so the stitches can be removed. The scar may look slightly inflamed; some redness and swelling are normal. After about six months, the scar blends with the surrounding skin.
Bone also heals in phases. A bone-like "cement" forms, bridging the affected bone and allowing it to bear weight. Later, the extra bone is dissolved, and in about six months, the bone is back to normal strength.
A bunion is an enlargement of bone in the joint at the base of the big toe. Bunions are most often inherited. Tight shoes do not cause bunions, but they can aggravate them. There are several types of bunions and surgical treatments for each. Your surgery may be similar to some of the common examples listed.
A positional bunion develops when a bony growth on the side of the metatarsal bone enlarges the joint, forcing the joint capsule to stretch over it. As this growth enlarges, it pushes the big toe toward the others making the tendons on the inside tighten. This, in turn, forces the big toe further out of alignment. The bunion presses against the shoe, irritating the skin, and causing further pain.
Structural bunions occur when the angle between the first and second metatarsal bones increases to a point where it is greater than normal. The increase angle of the metatarsals makes the big toe bow toward the other toes. Sometimes bony growths may form. Irritation and swelling may often follow. The tendency toward developing this painful condition is usually inherited. A structural bunion becomes severe when the angle between the metatarsal bones of the first and second toes grows greater than the angle of a mild structural bunion. Again, a tendency toward developing this condition is usually inherited. The big toe bows toward the others, sometimes causing the second and third toes to buckle. Irritation, swelling and pain may increase when tight shoes are worn.
While not a true bunion, this condition is often associated with bunions. Bunions, left untreated, can increase wear and tear in the joint of the big toe, break down the cartilage, and pave the way for degenerative diseases such as arthritis. Pain and stiffness are symptoms of both.
A muscle imbalance or abnormal bone length can make one or more small toes buckle under, causing their joints to contract. This in turn, causes the tendons to shorten. Corns (build-ups of dead skin cells where shoes press and rub) often form on the contracted joint, and may become irritated and infected.
When hammertoes are flexible, you can straighten the buckled joint with your hand. Flexible hammertoes may progress to rigid hammertoes over time. Corns, irritation, and pain are common symptoms. Function is often limited as well.
A rigid hammertoe is fixed; you can no longer straighten the buckled joint with your hand. Corns, irritation, pain, and loss of function may be more severe for rigid hammertoes than for flexible ones.
Curled Fifth Toe
The little toe may curl inward underneath its neighbor so that the nail faces outward. With this inherited problem, the fat pad on the bottom of the toe (normally used for walking) loses contact with the ground. Corns and pain may result.
Second Metatarsal Plantar Callus
When the second metatarsal bone is longer or lower than the others, it hits the ground first - and with more force than it is equipped to handle at every step. As a result, the skin under this bone thickens. Like a rock in your shoe, the callus causes irritation and pain. The treatment for this is an osteotomy. The second metatarsal bone is cut, and the end of the bone is then "lifted" and aligned with the other bones.
A heel spur is a bony overgrowth on your heel bone (see Plantar Facitis). It may be stimulated by muscles that pull from the heel bone along the bottom of the foot. High-arched feet are especially apt to have too-tight muscles here. Heel spurs may cause pain when the foot bears weight. They can be treated first with an injection, anti-inflammatory medication, as well as arch supports if indicated. If this fails, they can then be treated with surgical excision and a plantar release. The band of tight muscles is released to relieve the abnormal stress. The bone spur is surgically removed.
When a nerve is pinched between two metatarsal bones (usually the third and forth metatarsals), enlargement of the nerve may occur. Abnormal bone structure contributes to the cause, but too-tight shoes can aggravate the condition. You may experience sharp pain in your toes that may become severe enough to keep you from walking.
Excision: A small portion of the nerve is removed. As a result of this, a small area is usually permanently numbered, but this is preferable to pain.
You can usually bear weight right away, but you must return to have your dressing changed. Keep your incision dry until the stitches are removed.
High-Arched Feet (Pes Cavus)
The shape of your foot often determines the kinds of foot problems you will have. Your feet may have unusually high arches due to an imbalance of muscles and nerves, which is usually inherited. Too high arches can cause various problems - tired or aching feet; and calluses. High arches are not usually investigated with surgery but most often treated with arch supports.
Flat Feet (Pes Planus)
Flat feet can be hereditary and are caused by a muscle imbalance. Feet with low, relaxed arches may bring on such problems as hammertoes and bunions; arch, foot, and leg fatigue; calf pain; and an overly tight heel cord (which makes the foot even flatter). Loose joints move to freely, causing pain and instability. Flat feet are also usually treated with arch supports.
Orthotics (also called orthoses or orthotic devices) are prescribed, custom0made arch supports. They fit inside most shoes and "bring the floor up to your feet."
A podiatrist may prescribe them to help correct such problems as high arches and flat feet. Also, following some foot surgeries, orthotics can help support the correction that was achieved.
To be fitted with orthotics, your podiatrist will first take an impression of your feet. Your orthotics are then fashioned from leather, plastic, or other materials. Their fit is checked at an office visit and adjustments can be made as you wear them. Expect an initial "breaking-in" period; you may need to build up wearing time gradually (as you would with contact lenses).
If your bunions or hammertoes are bad enough, they may need surgical correction. This is a gratifying operation that can provide both pain relief and improved appearance.
All surgery carries risks including stiffness, persistent pain and swelling, recurrence of problem, damage to nerves, hardware breakage, blood clots in the legs, anesthetic problems, inability to correct the problem, etc. Make sure you understand the risks and alternatives prior to surgery.
Your recovery, like your foot problem and surgery, is as unique as you are. In addition to the previous tips given on follow-up care for each surgery, here are some pointers that can help you recover quickly and without complications, and help get you back on your feet again.
Pain: To help relive pain and reduce swelling in the first 24 to 48 hours after surgery, apply an ice pack to the affected area and elevate your foot above heart level, as recommended. Pain is usually most severe the second and third days after surgery, and after you first begin to walk again.
Bathing: You will need to keep your foot dry. Getting the stitches wet can lead to infection, so be sure to keep your foot outside the shower or bath.
Weight-Bearing: Bearing weight and walking can stimulate circulation and promote healing. But overtaxing a healthy foot can detract from the results of your surgery.
Shoes: Our team may give you a wide surgical shoe to wear on the affected foot. A surgical shoe stabilizes and protects the foot as it heals.
Returning to Work: How soon you can return to work depends on the type of surgery you had and the activities you job requires. You can generally return earlier to a desk job than to physical labor. Consider beforehand how much time you can take off from work until you are back on your feet.
RUPTURES OF THE ACHILLES TENDON
Rupture of the Achilles tendon is one of the most devastating injuries which the competitive and recreational athlete can suffer. Overall it is not as common an injury as, for example, tendonitis of the elbow, but it is much more difficult to treat in the higher levels of competitive sports. Although it is not entirely avoidable, there is much that can be done to reduce your chances of suffering such an injury.
First it is necessary to understand the anatomy of the area. The tendocalcaneus (Achilles tendon) is the thickest and strongest tendon in the human body. It is approximately 15 cm long and begins in the mid-aspect of the calf and extends distally (towards the foot) to its insertion on the heel bone (calcaneus). It actually originates from three separate muscles which join together to form the strong muscular group which is responsible for pushing the foot downward to provide the push-off for propelling the body forward. This is especially accentuated in sports such as squash where a rapid push-off is required. It is obvious, therefore, that when this tendon ruptures it is a major injury.
The classic history of the injury is that it usually occurs in males, although it certainly occurs in females as well. It most commonly affects people aged 30-50 but can cross all age groups. Unfortunately, it can particularly affect athletes and will simply occur as they are pushing off to reach forward, although it has been known to occur when the athlete is simply in the ready position anticipating forward movement. The classic story is that the athlete feels a sudden pain in or just below the calf and, due to the sudden nature of the pain and the sensation of a direct blow, turns around to see who hit him with the tennis ball. The sudden pain stops play immediately and medical attention should be sought without delay.
The medical and surgical treatment is controversial at times. This is mostly related to the fact that treatment is difficult and there is no one simple answer to the problem. The leg can either be operated on or casted for a prolonged period of time, and there are proponents of both types of treatment. However, with either treatment there is a long period of casting and immobilization of up to ten weeks with a long and arduous course of physiotherapy after the casting is over. Surgical repair is most commonly advocated for the more distal (lower) injuries which are closer to the insertion on the calcaneus (heel bone). Often at higher levels of competition it is a career-ending injury in spite of vigorous surgical or casting treatment. Although the athlete is able to recover, they rarely attain the high level of sport which they were at prior to the injury.
It is obvious that the best thing to do with the injury is to avoid it in the first place. This can be done very simply with stretching exercises prior to the workout. All stretching exercises, whether they are done for the Achilles tendon or for any other muscle group in the body, should be done with the speed of a glacier; that is to say that they should not be rapid twisting motions or pumping motions up and down. The affected area should be put on a stretch and then held for 15 seconds just below the feeling of discomfort. The best way to determine exactly how much of a stretch should be put on a limb is strained but still comfortable. The stretch should be held for 15 seconds and repeated several times prior to workout if the best results are to be obtained. This also promotes flexibility as well as protecting the tendon from injury.
By far the best treatment of this injury is prevention itself and although the stretching exercises do take a few minutes of time, they are well worth the effort and should be part of every athletes warm-up to avoid this devastating injury.
PLANTAR FASCITIS (HEEL SPURS)
Plantar fascitis is a common foot problem in sports participants. It starts as a dull intermittent pain in the heel which may progress to a sharp persistent pain. Classically, it is worse in the morning with the first few steps or at the beginning of sporting activity.
The plantar fascia is a thick fibrous material on the bottom of the foot. It is attached to the heel bone (calcaneus) and fans forward toward the toes. It is responsible for maintaining the arch of the foot.
The problem usually occurs when part of this inflexible fascia is pulled away from the heel bone. This causes an inflammation and thus pain. Plantar fascia injuries may occur at the midsole or towards the toes. Since it is difficult to rest the foot, a vicious cycle is set up with the situation aggravated with every step. In severe cases, the heel is visibly swollen. The problem progresses rapidly and treatment must be started as soon as possible.
As the fascia is pulled away from the bone, the body reacts by filling in the space with new bone. This causes the classic "heel spur." This heel spur itself is a secondary X-ray finding and is not the problem, but a result of the problem.
Flat pronated feet
High arched rigid feet
Inappropriate or improper shoes
Toe running, hill running
Soft terrain (i.e. running in the sand)
Arch Supports - These are custom made from molds taken of your feet.
Rest - Use pain as your guide. If your foot is too painful, bearing sports can be temporarily replaced by swimming and/or cycling to maintain cardiovascular fitness. Weight training can be used to maintain leg strength.
Ice - Icing your heel (frozen peas) for 15 minutes several times a day will reduce inflammation. You should also ice your heel after activity for 15 minutes.
A physician may on rare occasions prescribe anti-inflammatory pills. These are important in reducing the inflammation in your foot.
The initial objective of physiotherapy (when needed) is to decrease the inflammation. Later the small muscles of the foot will be strengthened to support the weakened plantar fascia.
A cortisone injection is usually quite beneficial if the above have not solved the problem. It is a local injection and it is very safe in this area.
Surgery is occasionally required for plantar fascitis. The tension on the plantar fascia is released, and the spur may be excised.
Risks include skin breakdown, infection, slow healing, nerve or blood vessel damage, blood clots, and other complications. Discuss these with our team prior to your surgery and make sure you understand them.
Plantar fascitis can be aggravated by all weight-bearing sports. Repetitive foot landing, such as occurs in running and jogging, will aggravate the problem. When the problem is severe the best sports are ones which are non-weight-bearing (i.e. swimming, cycling). Go back into other sports slowly. If you have a lot of pain either during the activity or following morning, you are doing too much.
It is possible for shoes to cause the problem. You may need different or new shoes. A knowledgeable salesperson can be invaluable.
The following exercises are designed to strengthen the small muscles of the foot to help support the damaged area. If performed regularly, they will help prevent re-injury.
Place a towel on the floor. Curl the towel toward you, using only the toes of your injured foot. Resistance can be increased with a weight on the end of the towel. Repeat 20 times.
Run your foot slowly up and down the shin of your other leg as you try to grab the shin with your toes. Repeat 30 times. A similar exercise can be done by curling your toes around a tin can.
Stand feet together. Rotate your knees outward while attempting to grab the floor with your toes using the muscles of your foot. Hold 10 seconds, then relax. Repeat 20 times.
Lean against a wall with your back knee locked. Press forward until a stretch is felt in your calf muscle. Hold for 15 seconds.
Then bend your knee until a stretch is felt in your Achilles tendon. Hold a further 15 seconds. Repeat 3 times. You should feel a pull in your muscle and tendon, but no pain.