Meralgia Paresthetica

Meralgia paresthetica is an uncommon pathology of the lateral femoral cutaneous nerve.  It is most commonly caused by entrapment of the nerve as it courses through the inguinal ligament.  The nerve originates from the spinal cord at the L2-L3 level, and courses underneath the inguinal ligament as it travels into the thigh.  The nerve has no motor control, but it relays sensory information from the anterior-lateral thigh. 

Symptoms of meralgia paresthetica include a burning, tingling, numb, or painful sensation to the anterior-lateral thigh.  Most commonly it affects only one side of the body, but may affect both sides at the same time.  There is no loss of strength associated with meralgia paresthetica, as there is no motor function of the lateral femoral cutaneous nerve. 

The condition is most commonly caused by compression of the nerve, particularly underneath the inguinal ligament.  This compression may come from a heavy tool belt or utility belt applying pressure to the nerve, or it can come from increased pressure from the abdomen in obese individuals.  Rarely, the symptoms come from a space-occupying lesion along the nerve contents such as a tumor, or from a lesion along the psoas muscle. 

The diagnosis of meralgia paresthetica is made through clinical exam.  Tapping along the inguinal ligament may reproduce the symptoms, which is highly suggestive of meralgia paresthetica.  Occasionally EMG or nerve conduction studies may be ordered, however, this is usually only the case when ruling out pathology of the spinal cord, nerve roots, or compression of other nerves of the lower extremity.  In particular, pathology of the femoral nerve may present with similar symptoms, but will also show a loss of strength in the quadriceps muscle.

Treatment of meralgia paresthetica is supportive.  Weight loss in obese individuals has been shown to relieve symptoms.  Removal of a heavy tool belt or other form of compression along the nerve will also generally relieve symptoms.  Medications used for nerve pain such as gabapentin may also be used, with some patients reporting good results.  Injections with local anesthetics and steroids may eliminated pain temporarily, for a long period of time, or even permanently.  Surgical decompression of the nerve may be performed, but is reserved for unrelenting conditions.  Interestingly, meralgia paresthetica has been shown to be more common in diabetic individuals than in the general population, after controlling for weight differences.

If you have symptoms of meralgia paresthetica, or of any other nerve compression, it is important to discuss this with your doctor. Be sure to tell them of any other symptoms that may be associated with the pain, such as muscle weakness or fatigue, changes in vision or hearing, or numbness and tingling in any other parts of the body.

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

The Subtalar Joint

The subtalar joint sits below the ankle joint, and is composed of the articulation between the talus and the calcaneus.  It plays a crucial role in the normal function of the foot, and allows for motion along an axis that runs through three planes of the body; the frontal plane, the sagittal plane, and the transverse plane.  Motion along the subtalar joint axis is defined as pronation and supination.  The pronation and supination allows the foot to adapt to uneven surfaces, and functions as the connecting joint between the ankle and the rest of the foot. 

The articulation between the talus and the calcaneus is actually composed of three separate articular surfaces; the posterior articular facet, the middle articular facet, and the anterior articular facet.  Together, these three articulations create a joint between the two bones. 

The joint is stabilized by a number of ligaments that connect the talus to the calcaneus.  The ankle ligaments also help to stabilize the talus within the ankle joint, and keep it improper alignment with the calcaneus.

Pathology of the subtalar joint may include primary osteoarthritis, arthritis secondary to fractures of the ankle and/or calcaneus, tarsal coalition, inflammatory conditions, and a number of other problems that can affect bones and joints.  Subtalar joint arthritis is a very common etiology of subtalr joint pain.  When the subtalar joint becomes an area of pain, it is often confused for ankle pain.  Thus, when people come to the doctor with a complaint of ankle pain, they are often shocked to find out that it is not actually their ankle that hurts, but their subtalar joint. 

Subtalar joint pain, particularly when it is due to arthritis, can be differentiated from ankle pain with a careful clinical exam, as well as the use of diagnostic injections.  Diagnostic injections involve injecting a small amount of local anesthetic, a numbing agent, into the painful joint.  If all of the pain is relieved, than it can be deduced that the subtalar joint is the source of pain.  If some, but not all of the pain is relieved, than it is possible that the ankle or other surrounding joints, or the soft tissues around the joint may be the source of the problem. 

Treating subtalar joint arthritis begins with conservative therapy.  This may consist of various padding and strapping methods, orthotics, and the use of cortisone injections into the joint.  Oral anti-inflammatories, ice, physical therapy, and other modalities may be tried as well.

Occassionally, the arthritis is severe enough to warrant surgical intervention.  Most commonly, subtalar joint arthritis is treated surgically with a fusion of the joint, also known as an arthrodesis.  In subtalar joint arthrodesis, the talus is fused to the calcaneus.  This removes all motion available at the joint, thus eliminating the pain associated with its movement.  The joint will not move after it has been fused. 

Screws are used to hold the bones in place while they heal together, and a period of non-weight bearing is generally employed for a minimum of 6-8 weeks.  After this period of time, the patient may be transitioned to a partial weight-bearing status, for another period of 4-6 weeks.  After the bones have completely healed, normal activity may begin again.

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

Plyometrics for Lower Extremity Power Training

Plyometrics is a form of exercise that is designed to improve muscular power, speed of contraction, and improve the response time of the neuromuscular system. It is typically used by competitive athletes as a form of cross-training, but recently has become more po pular in the non-professional athletic community. The technique involves combining muscle loading and fast contractions in order to improve muscle power. Muscle power includes not just strength of muscles (i.e., how much weight a person can lift) but also considers the speed at which that force is delivered.

In particular, plyometrics are used to strengthen and train the muscles and reflexes of the lower extremity, as well as improve core strength. Research has shown that the use of plyometrics in professional athletes has increased performance as well as decreased the incidence of injury.

Specific exercises include a variety of different lunge and squat techniques. The plyometric exercise consists of a fast elongation phase of contraction (eccentric phase) followed by an amortization or resting phase, which is then followed by a short burst contraction phase. For example, this may involve a quick squat, followed by a brief period of rest, followed by a jump off the ground.

The science behind plyometrics revolves around the specific muscle fibers being trained. The muscle fibers of the body consist of slow-twitch (type I), fast twitch type A (type IIA), and fast twitch type B (type IIB). In plyometrics, the fibers being worked are the fast-twitch fibers. Plyometrics also helps train the muscle reflexes that help control muscle contractions.

Plyometrics can be a excellent adjunct to an training or exercise program, but should only be undertaken by those in good physical condition. Because of the high impact nature of many of the exercises, those engaging in plyometrics should be ready for this impact. The technique used is of utmost importance, so as to avoid injury when training. Age is also a consideration, as many people of advanced age are advised against high impact activity due to arthiritis, osteoporosis, or other conditions that may jeopardize the safety of the individual.

There is not usually much equipment required for plyometrics. Generally a pair of sturdy training shoes designed for lateral movements, comfortable clothes, and enough space to move around is all that is needed. Many people follow instructional videos, or participate in organized classes that can help with technique. Plyometrics is an intense workout, so if you’re planning on trying it, be sure that it is safe by talking to your doctor about your new exercise plan. And bring plenty of water.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Smart Toe implants for Hammertoes

Hammertoes involve a contracture deformity at one or more of the joints in the toe. The most common deformity seen involves a flexion contracture at the proximal interphalangeal joint and an extension contracture at the distal interphalangeal joint. There are also isolated deformities of the distal interphalangeal joint known as mallet toe, and dual flexion contractures at the distal and proximal interphalangeal joints known as claw toes. A deformity may also be present at the metatarsophalangeal joint in any of these hammer digit variations.

Clinically, it is important for the evaluating physician to recognize if the deformity is flexible or rigid. Flexible deformities can be treated in some cases conservatively with orthotics, which serve to neutralize the deforming forces. Hammertoes are typically caused by a biomechanical abnormality that leads to a loss of muscle balance in the digits. Flexible hammertoes can also be treated surgically with a flexor tendon transfer or a simple flexor tenotomy.

For rigid deformities, conservative therapy involves accommodation and palliation. Corns that develop from the prominent joint rubbing against shoes can be shaved down, and corn pads and toe spacers can be used to make the person more comfortable. Wider and deeper shoes will also help for many.

Surgical correction of a rigid hammertoe can involve either an arthroplasty or an arthrodesis. Arthroplasty involves cutting some of the bone out of the joint, which creates a wider, more mobile joint. Arthrodesis is a fusion of the joint, which helps to straighten out the toe. The Smart Toe implant is a newer piece of hardware that helps in arthrodesis procedures.

The smart Toe device is placed in the two bones that create the joint, either at the proximal or distal interphalagenal joints of the digit. This allows for a fusion of the joint. The hardware is composed of metal that expands once placed into the body, and keeps a rigid fusion of the joint. They are kept frozen, and heat allows them to expand. Using a Smart Toe avoids having a pin coming out of the tip of the toe, which can potentially lead to infection or loss of correction at the joint.

Smart Toe comes in both straight models and in models that have a slight bend to them. The 10 degree bend allows for the tip of the toe to touch the ground easier, and provides a more natural looking correction. Smart Toe has become a popular option in the treatment of hammertoes by podiatrists, due to the ease of use and to patient satisfaction.

If you are considering treatment for hammertoes, talk to your provider about the different options, and which options would be best for you.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Corns and Calluses

Corns and calluses of the feet are a common problem for many people. They develop because of repeated friction to the area. This may be the result of poorly fitting shoes, or biomechanical abnormalities that cause a person to put excessive pressure in one area of the foot. A corn develops on either the top or outside of the foot, while a callus develops on the bottom of the foot. Corns are usually in one particular area, such as on the tops of the toes, while calluses can be more diffusely located on the bottoms of the feet. A corn can also develop in between the toes as a result of the bones of the toes rubbing against each other and the skin between them becoming thickened. When this occurs, the corn is known as heloma molle.

A corn will appear as a thickened lesion, which may or may not be painful. Because of the increased friction to the area, the body's response is to increase skin production to protect the tissues below the skin. This is what causes the skin to thicken, become dry and flaky, and to often become elevated compared to the surrounding skin. Corns and calluses may become painful if they are neglected.

Generally, corns and calluses are not a huge problem. They can cause local discomfort, but will usually resolve quickly when the outside force causing increased pressure or friction is removed. This may be something as simple as changing a pair of ill-fitting shoes or using a small piece of padding in the area.

For diabetics and other people prone to peripheral neuropathy, corns and calluses can be more of a concern. Becuase of the loss of sensation to the feet in diabetic and other forms of peripheral neuropathy, a person may never feel the pain from increased friction and callus formation. Without feeling that pain, the skin can break down and an ulcer can form. When an ulcer forms, they can be very difficult to treat and rely on off-loading the area to remove unwanted pressure. Because of this concern, it is important for diabetics to check their feet daily, and to have their doctor or podiatrist inspect them as well.

Professional treatment may become necessary when corns and calluses become painful, particularly if it is difficult for one to care for their own feet. This would include elderly and diabetic populations, as well as those with chronic back pain and other conditions limiting mobility. Removing the callus with a scalpel blade is often a quick way to make a patient feel better. Treatment should also focus on removing the causative factor of corns and/or calluses. This may include padding, strapping, or orthotics. In some situations when a bony prominence may exist causing undue pressure and pain in the area, a small piece of the bone can be removed surgically to relieve the pressure.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Achilles Tendon Ruptures

The Achilles tendon, or tendo-Achilles, is a large, rope-like tendon that runs along the back of the leg and inserts into the calcaneus, or heel bone. The tendon is comprised of two muscles coming together, the gastrocnemius and the soleus. It is the longest tendon in the body, and functions to lift up the heel when the calf muscles contract. This is a vital function for activities such as walking, running, and jumping. When the calf muscles contract, the heel is pulled up, allowing us to point or toes. A complete tear through the tendon is known as a rupture, and most frequently occurs in the area 2-3 inches above the heel.

As a person ages, a tendon can become weak and thin. This underlying weakness of the Achilles tendon is typically present in a total rupture. Some medications such as corticosteroids or certain antibiotics, as well as illnesses such as arthritis or diabetes may also weaken the Achilles tendon.

Most frequently, Achilles tendon ruptures are seen in middle-aged male athletes. These “weekend warriors” will usually injure themselves during a sport that requires sudden bursts of activity, in particular racquet sports like tennis or squash, and basketball.

Symptoms of an Achilles tendon rupture are a sudden and severe pain in the back of the calf. There may be an audible popping or snapping sound when the tendon ruptures. Walking may still be possible, but strength of push-off with the toes will be weakened. Bruising and difficulty walking may follow the initial pain and swelling.

If you are exhibiting signs of an Achilles tendon injury, there are several tests that a doctor can perform in the office to determine the likeliness of a total rupture. The doctor may have you lie flat on your stomach, while they feel the back of your calf. A slight depression can often be felt where the tendon should be tight. Another test is to squeeze the calf muscles of the affected side. In a normal person, squeezing the calf will cause the foot to plantarflex, or point the toes. In someone with a total rupture of the Achilles tendon, this motion will be lost. A partial tear of the Achilles tendon will typically still cause the motion to occur, as some of the residual fibers are left intact.

An MRI or ultrasound may also be ordered in order to confirm the diagnosis. These imaging studies can show the foot and ankle surgeon whether or not the injury is a partial tear or complete rupture, and will help determine the extent of the injury.

Treating an Achilles tendon rupture can either be surgical or non-surgical. The non-surgical method involves placing the foot and ankle in a cast for 2-4 weeks, at which time the cast may be replaced. This allows the foot to be immobilized while the tissues heal. Casts are typically changes in order to allow slow stretching of the tendon so that it does not heal in a contracted position.

PRICE therapy also applies to Achilles tendon injuries. This involves protection (via a cast or brace), rest, ice, compression, and elevation to relieve some of the swelling.

Surgical treatment involves repairing the ruptured tendon by suturing it back together. Research has shown that in both competitive and non-competitive athletes, there is a decreased risk of re-rupture with surgical repair. There has also been some evidence to show that the time to recovery is faster using surgical repair than with non-surgical management. There are inherent risks involved with any type of surgery, however, including risks associated with anesthesia, infection, non-healing of wounds, scarring, bleeding, nerve injury, and blood clots developing in the legs.

Preventing Achilles tendon injuries, especially in older athletes, revolves around stretching the muscles before activity. This is a critical step in any workout, yet is often skipped over.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Jones Fracture

A Jones fracture is a fracture of the fifth metatarsal base. The pain will be located in the middle of the foot in the area of the fracture. A person who has sustained a Jones fracture will have pain and swelling in the area, and will typically have difficulty walking. In injury was first described in 1902 by Sir Robert Jones, a British orthopedist.

Jones fractures are diagnosed by using x-rays. The ordering physician will usually be able to see the fracture line through the fifth metatarsal. The fracture is located at the proximal end of the fifth metatarsal, through the diaphyisis. This is the long, tubular part of the bone.

Because of the location of a Jones fracute, they can often be difficult to heal. The area of bone that is fractured lies between the insertion point of two tendons. These tendons function to pull the bone in two different directions. When there is a fracture between theses two insertion points, that can lead to a lot of motion at the fracture site and therefore, prolonged healing time.

This area of bone also has a decreased blood supply when compared to the bone surrounding it. This is sometimes referred to as a watershed area in the medical community, meaning that the area of bone is not well vascularized, which can also lead to a longer time to heal.

In order to allow a Jones fracture to heal, the patient must be non weight-bearing for a minimum of four to eight weeks. However, due to the decreased vascularity and excessive motion caused by tendon insertion and muscles originating from the area, this is often not enough time for the fracture to heal. In some cases, it may take up to twenty weeks for the fracture to heal.

Surgery is often indicated for a Jones fracture. Reattaching the broken bone using pins, screws, or plates will frequently allow a stable fixation of the fracture. This stable fixation is key to the healing process. The prognosis for Jones fracture is greatly improved with the use of surgical correction.

Other fractures of the proximal fifth metatarsal include avulsion-type fractures as well as stress fractures. These types of fractures generally heal faster and more readily than the Jones fracture, partly because of where they occur in the bone. The areas of the bone affected by these other fractures are generally more protected by the tendons inserting in the area, and have a greater vascular supply. These types of cases typically will not require surgery, and will respond well to casting and immobilization.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com