Patient Testimony after Platelet Rich Plasma (PRP) with Dr. Jaramillo-Dolan

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

Patient's chronic pain leads to successful Plantar Fasciitis Surgery wit...

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

Patient Testimony after Dellon Procedure with Dr Wellens

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

Evaluating a Bunion

Evaluation of the condition we commonly call a 'bunion' is a rather complex process most podiatric physicians perform routinely. Many patients will present to the clinic with complaints of pain or pressure from "the bump on the inside of my foot." Of course, they will often call it a bump, bunion, or spur, but I have not yet had any patients present themselves complaining of their "hallux abducto-valgus deformity." Yet immediately, as a foot and ankle surgeon, I translate the "bump" into a triplane orthopedic deformity having osseous and soft tissue components and involving four separate bones. Interesting how quickly that happens when you think about it.

In the course of evaluation, clinical aspects such as how large the prominence is, how painful it is to pressure and movement, the tendency to track with range of motion, the extent and quality of motion, the amount of instability at adjacent joints, and secondary anomalies such as sub second metatarsal tyloma are noted. Plain-film radiographs are certainly a routine part of the complete examination, and will include the obligatory 3-projection series: dorsoplantar, medial oblique, and lateral images. From these projections, we define angulational values and make note of other anomalies such as degenerative joint changes, articular flattening, bone stock and width, and any adjacent conditions that may contribute to the deformity or require attention in the course of any corrective procedures.

Treatment options include bunion splint's, orthotics, anti-inflammatory medications, Cortizone injections, shoe gear modification,  and surgery as a last resort.

There are over 300,000 bunion operations performed in this country and overall it's a very successful way of helping with the deformity .

Surgery does require three weeks of wearing a boot but does not require any non weight bearing which used to be required in the past with older surgical procedures.

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

Plantar Fibroma

A plantar fibroma is a fibrous knot or nodule in the arch of the foot.  It develops as a benign growth of the fibrous tissue that makes up the plantar fascia, a large structure that runs along the entire plantar foot.  Plantar fibromas may develop in one or both feet, and will typically not resolve without treatment.  Fibromas develop as a defect in the growth of the fibrous cells, however, the exact mechanism that causes this is not clearly understood. 

Plantar fibromas begin as a noticeable lump in the arch of the foot.  They may increase in size over time, or may stay the same size.  They are firm to the touch, and may cause pain from an uncomfortable shoe irritating the lump.  However, not all people with plantar fibromas have pain as a symptom.  Generally plantar fibromas are isolated, but some people have several that develop on the same foot. 

A podiatrist may diagnose a plantar fibroma after examining the patient’s foot.  If there is pain associated with the lesion, it may recreate pain that extend into the toes.  MRI may be ordered in some cases to further evaluate the lesion with advanced imaging. 

Treatment of plantar fibroma begins with conservative therapy.  This may include anti-inflammatory medication if the lesion is irritating deeper structures, thereby causing pain.  A cortisone injection can also be used to help shrink down the fibroma.  This will typically only be a temporary fix, as the lesion may come back to original size. 

Accommodative orthotics may be used to relieve pressure to a plantar fibroma.  This is generally an orthotic with a piece cut out to fit the lesion. 

Surgical intervention relies on removing the lesion from the plantar fascia.  This should only be considered if the patient has not had any relief from conservative measures.  Typically, a small incision is made along the inside of the foot, and the fibroma is teased away from the plantar fascia.  Depending on the size and extent of the fibroma, some of the plantar fascia may need to be removed with the fibroma. 

Any new lumps or bumps on your feet, or on any part of your body for that matter, should be evaluated by a doctor promptly.  While most lesions are benign, some can be more ominous than others.  Plantar fibromas are just one example of a benign lesion that has a very small percentage chance of turning malignant.  For this reason, they should be evaluated thoroughly.  

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

Diabetic Charcot Foot

Charcot neuroarthropathy, often referred to as Charcot Foot, is an uncommon but devastating disorder of the bones and joints in the foot and ankle.  Most commonly Charcot Foot is seen in diabetic patients with neuropathy, but it has also been described in patients with neuropathy of other causes.

Charcot foot is characterized most frequently as a red, hot, swollen foot.  It is typically painless, as the patient is neuropathic.  Charcot foot is often misdiagnosed as gout, cellulits, or deep venous thrombosis (DVT).  This usually happens in a primary care or emergency setting, where the clinician may not have a high suspicion for Charcot foot.  The consequences of a missed diagnosis or delayed treatment include a bony deformity, which can lead to ulceration and subsequent infection.  Thus, early diagnosis and initiation of treatment by a trained foot and ankle specialist is essential. 

The “rocker-bottom” deformity is typical of Charcot foot that has affected the midfoot, as is the case with the majority of patients.  This refers to an increased convexity of the bottom of the foot that is the result of excessive midfoot collapse.  When this happens, bone can protrude, which causes increased areas of pressure on the skin.  This increased pressure leads to ulceration if not addressed.

The pathophysiology of Charcot foot has been debated in the past, however current practitioners generally agree on the cause as a combination of neurovascular dysregulation and trauma to the foot or ankle as the inciting event.  The neurovascular dysregulation causes increased blood flow to the feet, which can “wash out” some of the bone density, making the bones and joints of the foot susceptible to injury.  Trauma may be in the form of a singular acute event, such as a fracture, but may also be from repetitive microtrauma from a previously existing foot deformity or a poorly fitting pair of shoes or a sudden increase in activity.  The uncontrolled inflammation associated with Charcot foot causes an increase in osteoclast activity, the cells responsible for degrading bone. 

Diagnosis of Charcot foot is made mostly as a clinical diagnosis.  The foot will appear red, hot, and swollen, and there may be a significant temperature difference between the feet.  X-rays are taken, but may only show subtle changes in bone quality and joint alignment if it is very early in the disease.  MRI can also be used to examine the bones and joints of the foot or ankle, but is not necessarily diagnostic of Charcot foot.  This is because the Charcot foot may look very similar to osteomyelitis, or an infection of the bone.  However, the information provided by imaging studies such as x-rays and MRI can help the clinician in diagnosing Charcot foot.

The most important aspect of treatment for Charcot foot is offloading of the affected foot.  This means that there is no weight placed on the foot.  This can be done by casting with either plaster or with a removable cast.  Some patients may be able to use crutches or a walker while the cast is on, however, for many patients a wheelchair is recommended.  This is due to the fact that excessive pressure on the unaffected site may lead to increased trauma to that side, thus possibly initiating a Charcot foot on the other side.  Approximately 30% of patients affected by Charcot foot will go on to develop Charcot foot on the opposite side. 

Medical treatment with bisphosphonates, drugs traditionally used to treat osteoporosis and some other disease of bone, has shown to be of some benefit to patients in some small study groups.  These drugs may include pamidronate (Aredia) or alendronate (Fosamax).  Treatment with intranasal calcitonin spray has also been used.  Calcitonin is a naturally occurring hormone that helps to regulate calcium and bone density in the body.  Additionally, some doctors have used anti-inflammatory medications in an effort to restrict some of the uncontrolled inflammation associated with Charcot foot. 

Surgical treatment can also be used to help patients with Charcot foot.  For patients with advanced deformities related to Charcot foot, surgery can be used to establish a more normal appearing foot, which can then be placed in a customized shoe or Charcot restraint orthotic walker (CROW).  The goals of surgery on the Charcot foot are to heal any current ulcers, prevent future ulceration and infection, and to fit the patient to a customized device.  These devices are generally worn by a patient with Charcot foot at all times, and are considered to be lifelong devices. 

Charcot foot continues to be an area of interest and research for many podiatric surgeons, and is an extremely debilitating and devastating syndrome.  The patients who develop Charcot foot need a lot of attention and counseling regarding their foot deformity, and adherence to medical and surgical treatment plans is essential for healing and for positive outcomes.  Charcot foot remains a difficult problem to treat, however, advances in the understanding of the syndrome and advances in technology have made for better outcomes. 

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

Dwayne Wade Still Sitting Out With Sprained Ankle

Last Friday, Miami Heat star Dwayne Wade added yet another injury to his list.  After landing awkwardly on his ankle while going after a loose ball, Wade left the game and didn’t come back.  Last night he sat out again as the Heat took on the Spurs.  The Heat were able to defeat the Spurs easily without Dwayne Wade, who remains out with a sprained ankle indefinitely. 

Ankle sprains are a common injury, particularly in athletes.  Most commonly an ankle sprain occurs from an inversion injury, where the ankle is forced to roll outward over a stationary foot.  Less frequently, a medial sprain may occur where the ankle rolls medially (towards the middle of the body). 

Inversion injuries such as Dwayne Wade suffered from on Friday can result in a number of different injury patterns, and can frequently involve a fracture of one or more bones of the ankle or foot.  Thankfully, the x-rays were negative for fracture in this case. 

The lateral ligaments of the ankle include the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament.  In a lateral ankle sprain, one or more of these ligaments may be injured.  Generally speaking, the anterior talofibular ligament is injured first, followed by the calcaneofibular ligament.  The posterior talofibular ligament is less frequently included in these types of injuries. 

The degree of the sprain is often defined as well.  The degree of the sprain refers to the amount of damage to the injured ligament.  If the ligament is not torn at all, it is considered a first degree sprain.  In second degree sprains, a partial tear may be seen.  In third degree sprains, the ligament is entirely ruptured and may even require surgical repair in some cases.  The degree of the sprain is often evaluated with an MRI. 

In Dwayne Wade’s case, he is walking without a cast or surgical boot.  This is a good sign, as it indicates that the sprain is less severe.  Still, this injury comes as Dwayne Wade was already nursing a sore left foot and a muscle strain in the calf.  Rehabilitation of these injuries is certainly a concern for the Miami Heat, who are searching for a championship in this abbreviated season.  While they seem to be able to still win with Dwayne Wade on the sidelines, it begs the question if they can continue to win in the post-season without the star guard.  

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

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

Tinea Pedis

Tinea pedis is a superficial infection of the feet with dermatophytes, a subset of fungus that lives off of the keratin in the skin. It is the most common fungal infection of the body, and is typically characterized by a burning, tingling, or stinging feeling in the feet and toes. Tinea pedis may also be referred to as athlete’s foot.

Tinea pedis is often broken down into four distinct entities. The first is chronic tinea pedis, which is most classically described as a silvery, scaly appearance of the bottoms of the feet, in a moccasin-like appearance. This means that the extent of the infection is diffusely spread across the entire plantar surface of the foot, and commonly expands up into the toes and the sides of the foot, where a moccasin may come in contact with the skin. The organism that most commonly causes this form of tinea pedis is trychophyton rubrum, or t. rubrum.

Another distinct form of tinea pedis is the vesiculobullous or acute vesicular form. This condition is most commonly caused by the organism trychophyton mentagrophytes (t. mentagrophytes). In addition to the burning, tingling, or stinging sensations associated with tinea pedis, the acute vesicular form will also show very small blisters, typically in the arch of the foot. This form of tinea pedis shows acute inflammation, and is often treated with a topical steroid as well as a fungicide.

Acute interdigital tinea pedis is also a common form caused by t. mentagrophytes, and is seen in between the toes, extending down onto the bottom of the feet towards the ball of the foot. This condition may or may not be inflammatory. When acute inflammation is present, a steroid/fungicide combination may also be used for treatment.

Acute interdigital tinea pedis may progress to the more serious but less common ulcerative tinea pedis. Ulcerative tinea pedis occurs when a case of untreated interdigital or vesicular tinea pedis causes severe breakdown of the skin, and a secondary bacterial infection ensues. This bacterial infection superimposed on a fungal infection can cause a great amount of skin loss on the bottoms of the feet, and can lead to a disabling condition. Treatment typically involves a fungicide/steroid combination as well as oral antibiotics.

With the exception of the more serious ulcerative form, most cases of tinea pedis are successfully treated with topical medications. Topical medications consist of a fungicide with or without a very low dose of steroid. The steroid is included in forms of tinea that include inflammation, and serves to decrease some of that inflammation. However, in cases without inflammation, a steroid should not be used so as to avoid the unnecessary side effects associated with steroids. In cases such as chronic tinea pedis, a plain fungicide will suffice.

Patients with severe inflammatory tinea pedis or a case that has not responded to topical treatment after at least one month may be considered for oral medications. Oral medications do come with inherent risks, in particular the risk of liver damage. Blood work is performed before oral anti-fungal medications are prescribed for tinea pedis and/or fungal nail infections.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Ganglion Cyst

A ganglion cyst is a soft tissue mass that is filled with a protein-rich fluid. They are walled off from the surrounding soft tissues with a thin wall, and may be single or multi-chambered. Ganglion cysts are most commonly found on the backs of the hands and wrists, or on the top of the foot and ankle. They can sometimes be worrisome to the patient when they develop, but it should be comforting to the patient to know that they are benign and usually harmless.

Ganglion cysts can develop in a variety of different tissues, including nerves, tendons, and joints. The exact mechanism of their development is not completely understood, but they are usually attributed to repetitive trauma. In the foot and ankle, an irritating shoe may be the cause.

The symptoms are dependent on which structures are affected and on the size of the growth. If nerves ate involved, there may be a bunring or tingling sensation, or the area may go numb. There is typically pain involved in any ganglion cyst, particularly when they grow in size and become irritated.

Historically, ganglion cysts used to be referred to as “bible bumps”. This is due to the fact that they used to be treated by slamming a large book, such as a bible, onto the back of someone’s hands with a ganglion cyst. Not surprisingly, this turns out to be a terrible treatment for ganglion cysts. It leads to a high rate of recurrence, and is probably quite painful.

Today, ganglion cysts are treated in a more precise manner. X-rays are typically taken as a first line diagnostic exam to rule out other pathological processes, such as invasive tumors, malignancy, and soft tissue calcifications. Ultrasound is becoming more popular as a diagnostic exam for ganglion cysts, as it is a quick, easy, and inexpensive method of visualizing the cyst beneath the skin. MRI may be used as well, but is more expensive, time consuming, and is generally reserved for surgical planning.

Treatment of a ganglion cyst usually begins with aspiration of the cyst with a small needle. Removing the fluid can relieve some of the pressure on the area, as well as serve as a definitive diagnosis. The area is typically numbed prior to aspiration, to provide comfort for the patient. A steroid is often injected into the area as well to reduce swelling and inflammation. Padding the area may also prove to be helpful in treatment, but is usually not sufficient on its own.

Some ganglion cysts may require surgical removal for complete relief. It should be noted, however, that the recurrence of ganglion cysts is very high in both surgical and non-surgical treatment.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Tarsal Coalition

A tarsal coalition is when two tarsal bones (the bones of the mid- and rear-foot) become fused. This can cause pain and a loss of motion at the effected joint, as well as other biomechanical symptoms.

The most common joint to be effected by a tarsal coalition is the subtalar joint, which is a joint formed by the articulation between the talus and the calcaneus. There are actually three facets between the two bones that help to form the joint – the anterior, middle, and posterior facets. Most commonly, a talocalcalcaneal coalition is formed between the middle facets. When a coalition exists between the talus and the calcaneus, it may present as a rigid flatfoot deformity with considerable decrease in range of motion.

Other tarsal coalitions that are occasionally seen include calcaneo-navicular and talo-navicular coalitions, though these are much less common than talocalcaneal coalitions. Overall, the incidence of tarsal coalitions is about 1% of the population. There is a familial inheritance that is often seen with tarsal coalition, though it is not thoroughly understood.

The cause of congenital tarsal coalition has been an area of interest for quite some time. It was first proposed in 1897 that they were caused by the incorporation of accessory bones within the joint, but was later postulated that the bones actually failed to separate in the fetus. The latter of the two explanations is the more commonly accepted situation.

Tarsal coalitions may also be acquired from trauma to the joint, degenerative changes to the joint such as what is seen in osteoarthritis, and fractures through the joint space.

Diagnosis of tarsal coalition comes from a combination of clinical findings, as well as x-ray, CT, and MRI imaging. Imaging techniques allow a doctor to visualize the joints to evaluate for fusion.

Clinical findings include pain, stiffness and decreased range of motion at the joint, rigid flatfoot deformity, and local tenderness and possibly swelling.

Conservative treatment is usually initiated once the diagnosis is made. This most commonly includes custom-made orthotic devices that prevent the effected joint from moving too much. The movement of the fused joint is what causes much of the pain. Immobilization may be required with an ankle brace or other device. Physical therapy can help in some cases, as well as shoe modifications to accommodate the coalition.

Surgical treatment can include either removal of the coalition or a fusion of the joint to prevent movement altogether. There are several different ways of performing each of these types of procedures, depending on the individual patient and situation.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Heel Spur vs. Plantar Fasciitis

The terms “heel spur” and “plantar fasciitis” can often be confused. The two diagnoses are unique from one another, but are related and are often seen together. It is helpful to understand the difference between the two, and to understand how they relate to each other.

Plantar fasciitis refers to a process that elicits pain in the bottom of the heel, along the bottom of the foot, and sometimes even into the toes. It is caused by excessive stress placed on the plantar aponeurosis, a thick piece of fibrous tissue that expands the length of the foot. The pain is most commonly seen at the origin of the plantar aponeurosis, or the plantar fascia, which is at the bottom of the calcaneus (heel bone).

The term plantar fasciitis is somewhat of a misnomer. The suffix “-itis” at the end of the word implies that there is inflammation in the plantar fascia. While this may be present in some cases, a majority of cases do not have any associated acute inflammation. Because of this, the term plantar fasciosis is probably a more appropriate term, which would refer to the condition as a chronic condition of pain. In scientific research, it is commonly referred to as plantar fasciosis.

A heel spur, on the other hand, is a piece of bone coming off of the bottom of the calcaneus. This is called an ostephyte. The cause of heel spurs is not completely understood, but it is generally accepted that they form from tractional pull on the calcaneus from the structures attached to the bone. This may include several muscles of the foot as well as the plantar aponeurosis.

Heel spurs are commonly associated with obesity, and can be seen in a number of different foot types. It has been reported that up to 92% of patients with heel spurs will develop ostephytes at other parts of their body. A heel spur on an x-ray can look like a very sinister problem, but it should be noted that the size of the heel spur does not correlate with the amount of pain associated with the problem. In fact, it is common to find that people will have heel spurs on both of their feet, yet only one side will be symptomatic.

Because both of the conditions are associated with each other, and the complaints of each are so similar, they may often be treated in the same manner. Generally a combination of rest, ice, stretching of the plantar fascia, and anti-inflammatory medications are sufficient in treating the conditions.

Strapping and taping are often employed by a physician to treat the problems, and orthotics may be prescribed as well. Functional orthotics may help to correct some of the biomechanical problems that lead to these two related conditions. By forcing the foot to function in a neutral position, much of the pull on the calcaneus can be eliminated. This can prevent the tensile pull on the calcaneus that can form heel spurs, as well as relieve the tension on the plantar fascia that may be causing the plantar fasciitis. Soft cushioning materials may also be used in the case of heel spurs to alleviate the pain.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Morton’s Neuroma

A neuroma is a benign growth in the tissue surrounding a nerve. This growth causes an enlargement of the nerve, which can lead to pain. Neuromas are fairly common in the feet, and are typically seen in the intermetatrsal nerves. These are the nerves that run up the metatarsal bones in your foot. The most common site for a nueroma to form is in the third intermetatarsal space, which is in the ball of the foot between the third and fourth toes. This is referred to as a Morton’s Neuroma.

Morton’s Neuroma can occur in anyone, but is most typically seen in females between the ages of forty and sixty. Early symptoms of a neuroma may include sharp or shooting pains in the affected area, a burning sensation in the area, or numbness and tingling in the toes. Many of these symptoms may resolve with rest and taking off the shoes, and you may feel some relief from rubbing the area. A common compliant of patients with a Morton’s Neuroma is that it feels like they are stepping on a pebble, or that there is a lump in their shoe.

There is no single clear cut reason that neuromas form, but there have been several proposed mechanisms. The one that is the most universally accepted is the idea that the neuroma is a response to the pressure of the metatarsals sqeezing on the nerve. This may be due to poorly fitting shoes, especially high heels. Why it occurs so frequently at the third intermetatarsal nerve in particular may be due to the thickness of this particular nerve – it is slightly thicker than the other intermetatarsal nerves.

The clinical picture of a neuroma is usually enough to diagnose the problem, but x-rays are usually taken to rule out things like stress fractures and other problems. MRI may also be used to diagnose neuromas more definitively, but due to cost is not generally done.

Treatment of neuromas including Morton’s Neuroma may include a change in shoes, padding, orthotics, medications, injections, and physical therapy. Generally a wider shoe will help relieve some of the pressure on the neuroma, which is often the source of the pain. Padding the area underneath the ball of the foot can also prevent the nerve from being pinched by the bones. Orthotics are typically used to treat biomechanical problems such as over-pronation, which may be the underlying cause of a neuroma. Injections of steroids as well as oral pain-relief medication are typically used in the acute setting, but will not address the underlying cause of the neuroma.

Ultimately, you and your doctor may decide that surgery is an option. This is generally a decision that will have to be made after some other therapies are employed first.

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

What is Clubfoot?

Clubfoot, or talipes equinovarus, is a fairly serious deformity of the foot and ankle that may be treated by a podiatrist or an orthopedic surgeon. It is defined as a deformity in which the ankle is in a fixed equinus position (meaning that the ankle is pointed down, or plantarflexed), and the rearfoot is in a fixed varus position (meaning that the heel is inverted, or pointed towards the middle of the body). These two abnormalities will additionally position the forefoot towards the middle of the body.

Clubfoot has an incidence of about 1-2 per 1000 live births. This number, however, increases with a family history of clubfoot. In those with a parent, sibling, or cousin with clubfoot, the incidence rate jumps to 1 in 20. When two family members were born with clubfoot, the chances are 1 in 5. Though the exact cause of talipes equinovarus remains unknown in the majority of cases, these numbers strongly suggest a hereditary nature of the deformity.

When a child is born with a clubfoot deformity, the situation is best addressed immediately, while the bones and ligaments of the foot and ankle are still the most pliable. This means that within the first 24 hours of the infant’s life, an attempt will be made to correct the deformity without surgery. Casting methods are used, where the foot, ankle, and leg are manipulated into a more normal position, and a cast is put on in an attempt to correct the positional deformity. Casts are changed every couple of days, until hopefully the deformity is corrected. The specifics of this casting technique were developed by Igancio V. Ponseti, MD, an orthopedic surgeon who just recently passed away at the age of 95.

In many cases of clubfoot, the Ponseti method is successful in correcting the deformity within the first six to eight weeks of life. Unfortunately, there are cases that do not respond to this casting technique, and surgery may be required to achieve a foot that is more functional. Additionally, some cases of clubfoot go unnoticed or undiagnosed until later in the child’s life, where non-surgical intervention may not be a viable option anymore.

Clubfoot is often seen co-existing with other musculoskeletal anomalies and other abnormalities. Some of these conditions include cleft lip, cleft palate, scoliosis, deformities of the upper extremities, torticollis (a fixed contraction of the sternocleidomastoid, a muscle in the neck), cardiac abnormalities, and hip dislocation. Clubfoot is also seen as an occasional or regularly occurring deformity in over fifty named congenital syndromes.

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