The USA is known for a variety of athletic activities and competitive athletes. Amongst this group of athletes are the Weekend Warriors. A Weekend Warrior is a healthy man or woman between the ages of 30-50, that is physically active from time to time. Achilles tendon rupture is the most common injury in this group of athletes, who normally have no history of problems in the affected leg. Frequency of Achilles tendon rupture is more common in men than women and more common in the left leg. Achilles tendon ruptures are also common in people who are in poor physical condition, taking fluoroquinolone antibiotics, are older in age, over work themselves, or have been using corticosteroids.
 
 
The Achilles tendon commonly ruptures in an area known as the watershed zone. The watershed zone is the area of the tendon 2-6 cm above the insertion of the tendon into the calcaneus and contains the smallest amount of blood supply making it susceptible to rupture. The Achilles may have a complete or partial tear, which is diagnosed by an MRI. Conservative and surgical treatment has long been debated for treatment of this problem. Surgery has a higher complication rate, but less chance of re-rupture. On the other hand conservative has less complications, but has a 3 times higher chance or re-rupture. Athletes are strongly recommended to undergo surgical treatment to properly realign the segments of the Achilles tendon, and get them back to physical activity in a shorter period of time with less chance of repeat injury.
 
The best way to treat an Achilles tendon rupture is prevention. Wearing proper shoe gear daily as well as athletic shoes with a good arch support for exercise will help relieve the stress on the Achilles. Warming up before starting a stretching or work out routine, followed by stretching of the calf muscles, see plantar fasciitis article, will relieve the tightness of the Achilles tendon and decrease the chance for rupture. Along with stretching the Achilles it is also important to strengthen the tendon. Most people think that performing calf raises will help strengthen the Achilles, however, doing eccentric muscle stretches by lowering your calves has more of a benefit and also helps to strengthen the tibialis anterior muscle, whose main function is to dorsiflex the foot. Performing the aerobic portion of a work out routine before strength exercises is important for rupture prevention. Strength exercises tend to tire out the muscle groups, making them more susceptible to rupture during physical activity. Lastly, if the Achilles tendon is painful after physical activity, DO NOT IGNORE IT! Treating tendonitis is easier then treating a rupture!
June 26, 2013
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There has been a sore, aching spot on the bottom of your foot for the past month. With every stride you feel as if you are stepping on a pebble, and your toes tingle. You may have an enlarged, thickened nerve commonly referred to as a neuroma. A neuroma may develop in many areas of the body, but it is more common in the intermetatarsal space between two of the long metatarsal bones of the foot. The frequent location is between the third and fourth metatarsals, known as a Morton’s neuroma. The compression on the nerve at this anatomic location may lead to swelling and permanent nerve damage if left untreated.
 
 
The classic symptom of a neuroma is localized pain between the toes, and the feeling that there is a stone or that the sock is bunch up in the shoe. Tingling, burning, and numbing sensations may be present to the affected toes, especially when wearing shoes. The symptoms may last for several days or weeks, but massaging the area of pain may provide temporary pain relief. A neuroma is often caused by continuous irritation to the nerve from wearing tight shoes, running or playing racket sports, a previous injury or trauma to the area, and certain foot deformities such as flatfeet or hammertoes. Diagnosis of a neuroma can be made mostly by clinical evaluation. The standard clinical diagnosis of neuroma is made by palpating the symptomatic interspace with one hand, and compressing the outer sides of the entire foot with the opposite hand to feel for a palpable click, Mulder’s sign. No every patient with a neuroma will produce a palpable click, however, pain radiating in the digits will also be produced with this particular maneuver. Radiographs will be taken to ensure there is no fracture. An ultrasound or MRI may also be performed to rule out other pathologies, or if surgery will be required.
 
 
There are many options for conservative treatment of a neuroma. Wearing proper shoe gear, with a wider toe box along with metatarsal padding or orthotics may relieve the compression on the metatarsals and the associated pain. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDS) will help reduce the inflammation and pain. If these initial therapies fail a corticosteroid injection may be done. The corticosteroid is mixed with a local anesthetic to relieve pain and reduce inflammation. A newer therapy for neuroma treatment is an alcohol sclerosing injection. It may take 4-7 injections for maximum relief to be obtained.
 
 
When these methods of conservative treatment fail there are two surgical approaches: a dorsal or plantar incision. The dorsal incision requires cutting the deep transverse metatarsal ligament as well as maneuvering around other delicate structures in the foot, before finally cutting out the pathologic area of the nerve. The patient will be able to put weight on the foot relatively soon after surgery. The downfall of this procedure is that the neuroma may grow back or a stump neuroma may form, bringing back the original painful symptoms. The dorsal incision approach may also lead to instability in the foot, which may also have to be corrected in the future. The second approach involves a plantar incision. The plantar incision involves cutting less tissue, and better visualization of the neuroma allowing for adequate resection of the nerve. There is less of a chance of the neuroma coming back, on the other hand sutures placed on the bottom of the foot means a longer recovery time. The patient may have to be non-weight bearing for up to 3 weeks.
 
 
A neuroma is an easily treated condition of the foot. See your local podiatrist to find out how your symptoms may be relieved.
June 26, 2013
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As a Podiatrist I commonly prescribe compression stockings for both women and men who experience swelling of their legs due to venous insufficiency or lymphedema. Most people associate these illnesses with compression stockings. Compression stockings deliver a gradient squeezing to the leg, which starts tightest at the ankle and decreases gradually as it goes up the leg. The muscle in the calf has a natural pump which pushes venous blood and lymph into circulation in the legs. Compression stockings offer assisstance when the natural pump is no longer functioning sufficiently enough to maintain appropriate flow. 
 
There are many people in the work force that must stand, sit, or travel for long periods of time. These people are the most at risk for getting varicose veins, venous insufficiency, edema, or lymphedema. The aching that comes with swollen legs is due to the pooling and back flow of blood. Compression stockings promote blood flow from the legs back to the heart and prevent the venous blood from becoming lethargic. The gradient action of compression stockings massages the calf muscles all day, whether you are sitting or standing. Wearing compression stocking at work and while traveling may prevent these disease from occurring. Compression stockings may help prevent deep vein thrombosis (DVT) and relieve the pain from the swelling that pregnant women experience in their legs.
 
Compression stockings may be sold over the counter or prescribed by your doctor. Over the counter stockings include pressures between 10-15 and 15-20mmHg. Pressure in compression stockings is measured in the unit mmHg. Any stocking over 20mmHg must be accompanied by a doctor’s prescription. Stockings can go up to the knee, thigh, or be full length panty hose. Compression stockings are different then regular socks because they go by the size of your calf instead of your shoe size. Before purchasing compression stockings you should measure the circumference of your calf and compare it with the measurement chart of the brand of stocking you are buying. Compression stockings can be challenging to put on for some people. If this is the case there are many devices to assist such as: rubber gloves, rubber mats, donning devices, and easy slides. For people who enjoy using lotion on their legs daily, latex compression stockings should be avoided. 
 
Compression stockings are more expensive than regular socks. Prices may vary anywhere from $15 to $70 dollar depending on style, brand, and pressure. Medicare Part B does not cover compression stockings; however, some private insurance plans provide coverage. People with advanced arterial disease of the leg, uncontrolled congestive heart failure, skin infections, fabric allergies, impaired sensitivity of the legs, and immobility should not wear compression stockings without consulting their doctor first. Wearing compression stockings as a prophylactic device may prevent these serious medical conditions from occurring and keep your legs young and healthy looking for many years to come.
Left without treatment, plantar fasciitis may take 6 months to 2 years to heal completely on its own. For most people the pain may be extremely uncomfortable and they will seek treatment after a few months. Treatment for this condition begins with conservative care and may advance to surgical treatment is the problem does not resolve. Plantar fasciitis is a common condition amongst very athletic people as well as overweight people. The first line of treatment consists of rest, icing, stretching exercises, and anti-inflammatory medications. When the plantar fascia is inflamed decreasing physical activity and resting will help to reduce inflammation quicker then continued activity. If the pain is bad your doctor may give you a walking cast or a soft cast to wear in order to decrease the pressure on the heel area. Some may recommend using crutches to help with walking till the pain is reduced. Icing the heel daily will help to reduce inflammation of the plantar fascia. A good way to ice the plantar fascia is to fill an empty plastic water bottle with water and put it in the freezer. You can then roll your heel over the ice for 10-15 minutes at the end of the day. Ibuprofen or a Medrol dose pack is commonly used along with stretching and icing to control the original inflammation of the plantar fascia.
 
 
A tight Achilles tendon is a common co-morbidity with patients afflicted with plantar fasciitis. Stretching out the Achilles tendon with help to decrease the pull of the Achilles on the calcaneus and take the tension off the plantar fascia. Stretching before you get out of bed can help take the painful edge out of the first few steps in the morning as well. Take a towel and place the belly of the towel around your foot. Grab the ends of the towel with your hands and pull back. You can also take a tennis ball and roll your foot over it for a minute or so before you get out of bed. When you sleep your foot is usually in a position which allows the plantar fascia to contract, making the first few steps in the morning more painful as you stretch that contraction out. When stretching is no longer enough to relieve the pain of the plantar fascia, you can try a night splint. A night splint will keep the plantar fascia stretched out the entire night so no contraction occurs, and there is less pain upon the first steps in the morning.
 
 
 
For patients with more severe heel pain, or who have tried conservative treatment with minimal relief of pain your Podiatrist may recommend a cortisone injection. These injections contain a local anesthetic along with a steroid to provide both immediate and long term relief. One injection may give one to three months of relief. It is not recommended to give more then 3ml’s of any one steroid in the same place within a 6 months to 1 year time frame, so most Podiatrists with only give .5ml’s-1ml of steroid in each injection so multiple shots may be given.
Supporting the heel and the arch of the foot is commonly used in conjunction with other conservative treatment methods. An arch support will prevent the arch from collapsing and prevent tension on the plantar fascia. There are many types of arch supports out there that may be used for this purpose. In patients that find that the arch supports relieve their pain, their podiatrist may prescribe a custom orthotic to use to prevent the abnormal motion that caused the irritation to begin with.When all methods of conservative treatment fail, and the pain is still unbearable, your podiatrist may recommend an endoscopic plantar fascial release (EPF). An EPF will release all of the medial and central bands of the plantar fascia. Some of the lateral band may be released or left intact depending on how extensive the pain is at this point. This surgical procedure is quick and takes less then an hour in the operating room.
June 26, 2013
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Ranging from meek discomfort to incapacitation, heel pain affects over 2 million
American every year. The most frequent cause of heel pain is inflammation of the connective tissue band that runs on the bottom of the foot called the plantar fascia. When this band is inflamed, torn, or ruptured it can cause a significant amount of pain which medical professionals deem “Plantar Fasciitis”. The plantar fascia supports the arch of the foot, and is susceptible to calcifications called heel spurs. A common misconception is that the heel spur is the cause of the heel pain. In about 50% of cases people with heel spurs have no symptomatic heel pain. 
 
There are many causes of plantar fasciitis. Individuals who run or stand for long periods of time on hard surfaces or have a tight Achilles tendon and calf muscle are susceptible for strain and micro tears of the plantar fascia. Patients that are over weight, have high or flat arches, or wear poorly fitting shoes may also strain the plantar fascia. The key symptom of plantar fasciitis is pain on the first steps in the morning, called “Postatic dyskinesia”. Pain often occurs after long periods of rest, standing for long periods of time, and being very active throughout the day. Pain of the heel bone closest to the arch when pressed on is positive for plantar fascial irritation. A combination of patient history and clinical exam will be enough for most doctors to diagnose plantar fasciitis.
 
There are other foot diseases that may manifest as heel pain. These include calcaneal stress fractures, tarsal tunnel syndrome, fat pad atrophy, posterior tibial tendonitis, and Subtalar joint arthritis. Radiographs, therapeutic/diagnostic injections, nerve conduction velocity tests, or MRI studies may rule many of these diagnoses out. Once the diagnosis has been made there are many ways to treat the heel pain caused by plantar fasciitis. Part 2 of this entry on Monday will explore these options.




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