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  • Achilles Tendonitis


    Achilles Tendonitis

    Achilles tendonitis is an inflammatory response to injury of the Achilles tendon. The Achilles tendon (calcaneal tendon) attaches the gastrocnemius, soleus, and plantaris muscles in the calf to the heel bone (calcaneus). It is the largest tendon in the body and is visible at the back of the ankle. Like all tendons, it is made from strong, dense connective fibers. Because of its position and function it is used during walking, running, jumping and similar actions. It is therefore vulnerable to damage from overuse and normal degeneration due to aging.

  • Ankle Osteoarthritis


    Ankle Osteoarthritis

    Arthritis means inflammation of the joints. Osteoarthritis is the most common of many different forms of arthritis and results from the normal aging process and use of the joints. It is also known as degenerative joint disease. It usually develops slowly over the course of many years, although some conditions may cause it to develop more quickly. Ankle osteoarthritis is usually the result of a previous injury to the ankle.

    At the points where bones meet to form joints there is a cushion of rubbery, smooth cartilage that protects the ends of the bones and, in the case of articular joints (where the bones form a movable joint) allows the bones to easily glide over each other. With time and use, or traumatic damage, the cartilage becomes thinner, rougher, and more brittle. Eventually a point is reached where the bone ends are no longer fully protected and they begin to rub against the roughened cartilage or each other. This friction causes inflammation and pain in the joint. As the osteoarthritis progresses the joint becomes less mobile and may become deformed, resulting in loss of full function. Due to insufficient blood supply, cartilage is not able to repair itself.

    The ankle actually has three joints. The inferior tibiofibular joint is the connection between the lower parts of the tibia (shinbone) and fibula (the outer bone of the shin). The talocrural joint, often called the true ankle joint, is formed where the distal ends of the tibia and the fibula enclose the upper surface of the talus (one of the bones in the hind part of the foot). Under the true ankle joint is the third joint, known as the subtalar joint, where the talus rests on top of the calcaneus (heel bone).

    As described above, osteoarthritis of the ankle develops primarily as a result of a previous ankle injury, for example a bone fracture. The articular cartilage may have been damaged directly, during the initial injury, or the injury may have caused a difference to the mechanical function of the joint, setting up abnormal stresses on the joint.

    Some conditions, for example being flat-footed, may predispose a person to ankle osteoarthritis, and carrying excess weight places increased strain on the ankle joint, which may lead to the development of arthritis.

    A family history of ankle osteoporosis will increase your risk of developing it as there appears to be a genetic component to the disease.

    • Pain in the ankle. At the start of the disease pain is usually present only when first moving, for example first thing in the morning. It may improve with continued movement but, as the condition progresses, pain may become constant and debilitating.
    • Loss of flexibility in the ankle
    • Joint stiffness and swelling
    • Reduced ability to bear weight on the ankle
    • In severe cases bone deterioration leading to deformity of the joint
    Your doctor will take your full medical history and ask you questions relating to your general health and activity level, any family history of osteoarthritis, any past ankle injuries, and your current condition and symptoms. Your ankle will be visually assessed for swelling and deformity, and physically examined and manipulated to evaluate the level of strength, stiffness and disability. Your doctor will listen for crepitus, which is a grinding noise commonly heard when bones rub directly against each other. You may be asked to walk so the doctor can assess your bone alignment and your particular gait.

    X-rays will be taken to view the condition of the bones. An MRI (magnetic resonance imaging) scan might be taken to look at the soft tissues of the ankle joint, for example, the articular cartilage and the ligaments and tendons. Bone scans may also be performed if your doctor thinks it necessary.

    Treatment for ankle osteoarthritis is usually non-surgical and is aimed at reducing painful symptoms and maintaining or improving joint function.

    Over the counter non-steroidal anti-inflammatory medicine (NSAIDs) and pain medication such as acetaminophen (Tylenol) will help reduce your symptoms. Your doctor may inject the ankle with a steroid that can provide rapid relief. These injections can be very effective but due to potentially serious side effects cannot be administered often.

    An ankle brace or an AFO (ankle-foot orthosis) can help support your ankle joint and reduce pressure on the bones.

    Wearing supportive shoes that are correctly fitted will ensure that your ankle is maintained in a correct position and abnormal force is not being placed on the joints. Low wide heels that can be laced up are preferable to open shoes, sandals or slippers. Heels that are slightly rounded at the back can help you walk more easily. Heel inserts can be used to help cushion shock as you walk, as can high quality insoles.

    If you are overweight, making an effort to lose some weight can relieve stress on the ankle joints, which carry almost all the body weight.

    Nutritional supplements such as glucosamine or chondroitin may support normal joint function.

    Physical therapy, including exercises to strengthen and increase the mobility of the ankle, will enable you to move your ankle more freely.

    If surgery is necessary your doctor will discuss the options available and make recommendations based on your particular condition. One possible procedure is called arthrodesis, which permanently fuses some bones together. Normal ankle function would be lost, but the bone fusion would prevent further painful movement of the bones against each other. Another, rare, surgical option is joint replacement. In this case damaged parts of the joint would be removed and replaced with artificial implants.

    Your doctor or physical therapist will probably suggest some exercises for you, and you should always seek medical approval before beginning an exercise program. In general, you should try to strengthen the muscles of the foot and ankle to help support the joint, and to increase the range of motion of the ankle. Non-weight-bearing exercise such as swimming and cycling can be helpful. Activities that cause increased pain should be eliminated.
  • Ankle Sprain & Instability


    Ankle Sprain and Instability

    The bones of the foot and ankle are held in position by a number of ligaments and tendons. Damage to these connective tissues, caused by forcing them to stretch beyond their normal range, results in an ankle sprain. Repeated sprains can lead to chronic instability of the ankle joint with the increased likelihood of further injury.

    Ligaments are strong bands of elastic connective tissue. The ankle joint has three ligaments on the lateral (outside) side of the ankle, and several on the medial (inside) side. Medial ligaments are stronger than lateral ligaments and limit the degree of inward rotation of the ankle.

    Tendons attach muscles to bones. When a muscle contracts, the tendon at its end pulls on a bone and causes movement of the bone. There are several tendons that cross the ankle joint as they connect leg muscles to the bones of the ankle and foot.

    Any of these structures is vulnerable to injury if subjected to sufficient force to stretch or tear them.

    Ankle sprains are graded according to the severity of the injury and can involve one or more ligaments or tendons. It is also possible that a complete rupture of a ligament away from a bone can tear off a portion of bone during the initial injury.

    Grade I sprains are relatively mild. Ligament fibers have been stretched but not torn and the ankle joint remains stable.
    Grade II sprains are considered moderate. They involve some torn ligament fibers. The ankle joint is abnormally loose when moved in certain ways.
    Grade III sprains are severe injuries. Grade III refers to complete tearing or rupture of the ligament. The ankle joint feels extremely unstable and may be dislocated.

    Failure to properly treat a sprain, or a return to normal activity before complete healing has taken place can lead to chronic instability with an increased likelihood of repeated sprains and of developing conditions such as arthritis.

    Any situation that forces the ankle to move in a direction beyond its normal range of motion will damage the soft tissues in the ankle. It can be as simple as stepping onto a piece of uneven ground and twisting the ankle, or during sports if the ankle is abnormally rotated. Sprains can also occur on falling from a height, or during a trauma such as a motor vehicle accident.

    Most sprains are caused when the ankle is twisted so that the sole of the foot faces the opposite foot and the outer ankle rolls towards the ground.

    • Pain on initial injury. The level of pain will depend on the severity of the sprain, but may be extreme.
    • Rapid swelling on the outside of the ankle and foot, followed by bruising.
    • Possible ‘pop’ or ‘click’ sound on initial injury.
    • Diminished ability to bear weight on the foot, the extent depending on the severity of the injury.
    • Sensation of the ankle being unstable and liable to fall out of position at any time.
    • With chronic instability there may be a locking or clicking feeling when the ankle is moved, and a sensation of vulnerability, as though the ankle might give way at any time.
    • Chronic instability will cause the ankle to turn over frequently, particularly on uneven surfaces or while playing sports.
    Your doctor will ask you about the circumstances of your injury and the type and severity of any symptoms you are experiencing. Your ankle and foot will be physically examined, including moving the ankle in certain ways to assess the muscle strength and laxity (looseness) of the ankle joint. The manipulation will help the doctor evaluate which ligament or ligaments have been damaged.

    X-rays will be taken to look for any bone fractures as ankle fractures produce similar symptoms to those of a sprain, and it is possible for a ruptured ligament to have torn away a chip of bone. An MRI (magnetic resonance imaging) scan may be taken so that the soft tissues of the ankle and foot can be clearly viewed and the extent of the damage evaluated.

    Initial treatment consists of rest, ice, compression, and elevation. It may be necessary for the ankle to be placed in a boot to immobilize it, and for you to use crutches temporarily to help you get around. If the injury is less severe and the ankle is able to bear some weight, a laced ankle brace for support may be sufficient. A moderate to severe sprain will require an immobilizing boot, and a sprain with a fracture will need a cast.

    Ice, crushed in a bag and covered with a towel, can be applied to the ankle for as long as is comfortable, several times a day, to help reduce swelling, as will elevating the ankle above the level of your heart. You can take over the counter pain medication and non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief and inflammation reduction.

    All ankle sprains will need physical therapy to help with rehabilitation. Sprains take a long time to heal and it is extremely important that they heal properly before too much activity is undertaken. Failure to spend the necessary time rehabilitating the ankle may lead to the need for surgery to correct chronic instability.

    The goal of surgery, though rarely required for ankle sprains, is to either tighten or reattach loose or ruptured ligaments. Although some cases can be treated arthroscopically (using narrow instruments inserted through tiny incisions) usually an open procedure is performed so that the connective tissues can be properly seen. If the ligament is unable to be repaired, sometimes a donor tendon can be fashioned into a new ligament and grafted on to the ankle.

    Physical therapy may include ultrasound and electrical stimulation as well as range of motion, balance, and strengthening exercises. Chronic instability of the ankle may require prolonged wearing of a supportive ankle brace to prevent the ankle giving way.

    • Strengthening the muscles of the lower leg and ankle will provide greater stability of the joint.
    • Warm up properly before exercise, and wear properly fitted and appropriate shoes.
    • Consider using a supportive ankle brace, particularly when first resuming sporting activities, or taping your ankle securely.

    Please visit these product links for additional treatment options.

  • Ball of Foot Pain (Metatarsalgia)

    Ball of Foot Pain (Metatarsalgia)

    Metatarsalgia is the medical term used to describe pain and inflammation in the ball of the foot. The metatarsal bones are five long bones in the forepart of the foot that connect the arch with the toes. When pushing off to take a step forward, or when landing from a jump, the full weight of the body is distributed amongst these bones. The joints formed at their connection with the tarsal bones, and with the phalanges, or toe bones, are held in proper alignment by ligaments. Tendons attach muscles to the bones, and the ball of the foot is supplied with nerves and blood vessels. There is a pad of protective, shock-absorbing fatty tissue between these structures and the skin. A disruption, imbalance, or weakness in the normal structure of the foot can lead to metatarsalgia.

    A change in the distribution of weight on the metatarsals increases pressure on the bones, particularly the heads of the bones that connect with the toes. When a metatarsal head is pushed downwards, below the level of the other metatarsal heads, it is subjected to the full weight of the body at each step. Such abnormal pressure will eventually induce a painful inflammatory response.

    Often, several factors combine to produce metatarsalgia. These can include:
    • Foot shape: a high arch to the foot, an unusually long second toe, or very long metatarsals
    • Being overweight, which would increase pressure on the ball of the foot
    • Being very active, particularly in sports that involve running or jumping
    • Wearing shoes that fit poorly, have small, tight toe boxes, high heels, or thin soles
    • Foot conditions such as a bunion that can weaken the big toe and increase pressure on the ball of the foot, or a hammertoe, where one toe curls downwards and depresses the metatarsal head.
    • Stress fractures, which are tiny breaks in the bone, causing a shift in weight distribution
    • Conditions such as diabetes, arthritis, Freiberg’s disease, or Morton’s neuroma
    • Thinning of the fat pad: thinning can be caused by the normal aging process, by a dropped metatarsal head which gradually pushes the fat out of position, by extra pressure from wearing high-heeled or thin-soled shoes, or by some medical conditions
    • Bruising of the sesamoid bones at the base of the big toe
    • Nerve damage between the toes
    Symptoms usually develop gradually, but sometimes there can be a sudden onset of pain.
    • Pain, ranging from mild to severe and from aching to sharp, in the ball of the foot
    • Shooting pain, numbness or a tingling sensation in the toes (indicates nerve damage)
    • Pain in the ball of the foot near the big toe
    • Pain in the ball of the foot near the second, third, and fourth toes
    • Pain worse with pressure on the foot, and better with rest
    • Pain worse when walking barefoot, and when walking on a hard surface
    • Severe pain when pressing hard with your thumb on the head of your big toe (indicates damage to sesamoid bones)
    Due to the fact that many foot problems can cause symptoms of metatarsalgia, diagnosis will probably involve having an x-ray taken, as well as a thorough physical examination of the foot. You may be asked to stand and walk so the doctor can assess your posture and weight distribution on the foot. You will also be asked questions about your activities, any sports you may participate in, and your general lifestyle.

    Conservative (non-surgical) treatment usually relieves metatarsalgia. Your doctor will probably advise you to try one or more of the following:

    Rest the foot by avoiding activities that place undue pressure on the ball of the foot. You can still exercise, but limit this to low-impact activities such as swimming or bicycling, and strength training.

    Ice the foot by crushing ice in a bag and covering it with a towel then placing the bag under the ball of your foot. Keep your foot on the ice for as long as is comfortable, several times a day.

    Over the counter pain medication such as acetaminophen (Tylenol), ibuprofen (Advil), or naproxen (Aleve) can help with pain and inflammation.

    Wear shoes that are properly fitted, both for sports and daily activities.

    Use insoles, metatarsal pads or arch supports in your shoes. Several over the counter options are available. Insoles act as shock absorbers, metatarsal pads deflect pressure away from the ball of the foot, and arch supports assist by reinforcing the arch, thereby relieving pressure on the metatarsal bones. Custom made orthotics may be necessary for your particular foot, but these are expensive and it may be worth trying ready-made orthotics first.

    If metatarsalgia is being caused by Freiberg’s disease, nerve damage, or inflammation around the sesamoid bones, pain can sometimes be reduced by an injection of cortisone into the affected area. Such injections can provide long-lasting pain relief, but can only be administered a few times a year.

    Rarely, surgery to realign the metatarsal bones is required. As with all surgery, there are both risks and benefits to be weighed before a decision is made. Surgery normally involves cutting through the metatarsal bone and pinning it into its corrected position.

    • Wear properly fitting footwear at all times. Ideally, shoes should have low heels (not more than 1 inch high), thick soles and a wide, high toe box.
    • Avoid walking barefoot.
    • Restrict activities that aggravate the condition. If you are going to do a lot of walking or running, try to stay on softer surfaces.
    • Maintain a healthy weight.
    • Use insoles, pads or arch supports in your shoes.
    This link is to men's and women's comfort footwear which are designed to look atractive, and also accomodate a variety of foot condition treatments.
  • Broken Ankle


    Broken Ankle

    A broken ankle is a fracture to one or more of the bones that make up the ankle joint.

    Four bones connect in different ways to form what is called the ankle joint, although there are actually three joints within the ankle structure. The inferior tibiofibular joint is the connection between the lower parts of the tibia (shinbone) and fibula (the outer bone of the shin). The talocrural joint, often called the true ankle joint, is formed where the distal ends of the tibia and the fibula enclose the upper surface of the talus (one of the bones in the hind part of the foot). Under the true ankle joint is the third joint, known as the subtalar joint, where the talus rests on top of the calcaneus (heel bone).

    The bones and joints are held in position and supported by ligaments that are strong ropes of connective tissue attaching bone to bone, tendons that run from the leg muscles down to the bones of the ankle and foot, and a band of connective tissue between the tibia and fibula called the interosseous membrane.

    A broken ankle results in instability of any these joints, making weight bearing difficult or impossible until the fracture or fractures have healed.

    An ankle can be fractured in many ways. Simply rolling the foot over or twisting it beyond its normal range of motion by tripping or falling can be enough to dislocate the joint or break a bone. During a dislocation a ligament can be torn away from the bone, pulling off a piece of bone with it. Blunt force or other trauma, such as motor vehicle accidents, can result in crush injuries to the ankle.

    • Severe pain immediately upon injury
    • Swelling, tenderness to the touch, and bruising
    • Inability to bear weight on the foot
    • Possible deformity of the ankle
    A severely sprained or dislocated ankle can produce similar symptoms to a fractured ankle, so proper diagnosis is important.

    Your doctor will ask for your medical history, including any previous ankle injuries. The circumstances of your current injury will be discussed, and the type and severity of your symptoms. Your ankle will be physically examined and possibly manipulated to help the doctor determine the type and extent of your injury.

    X-rays are typically taken, as these will clearly show any fractures. Often X-rays will be taken of your leg and foot as well, in order to rule out other injuries. A stress test involves taking a special X-ray while the doctor puts pressure on a certain area of the ankle. This test can help determine whether surgery is needed. CT (computerized tomography) or MRI (magnetic resonance imaging) scans may be taken to provide more detailed images of the ankle bones and soft tissues.

    Initial treatment for a broken ankle is to place the ankle in a splint. This will provide support while allowing the swelling to subside.

    Further treatment will depend on the type and severity of the fracture. Ankle fractures often involve more than one bone and can also damage ligaments and tendons.

    Lateral Malleolus Fracture
    The distal (lower) end of the fibula has a bump that forms the outer anklebone, called the lateral malleolus. This can be fractured at various levels. Surgery to realign displaced bone fragments and hold them in place with orthopedic fixing devices may be required if the ankle is unstable. Otherwise, the ankle may be supported with a short leg cast. Regular X-rays would be taken to ensure the bones remained in position. Your doctor may allow you to place weight on the ankle immediately, or you may have to use crutches for up to six weeks.

    Medial Malleolus Fracture
    On the inner side of the ankle, the distal end of the tibia forms the medial malleolus, the inner anklebone. Fractures to this area often happen in conjunction with injury to other parts of the ankle. A non-displaced fracture will usually be treated with a short leg cast or brace, regular X-rays, and no weight bearing for about six weeks. Occasionally a non-displaced fracture will need surgery to allow earlier movement of the ankle and to reduce the risk of the bone pieces failing to unite.

    Posterior Malleolus Fracture
    Usually injured in conjunction with another bone or soft tissue structure, the posterior malleolus is at the back of the tibia. The joint may be unstable if the piece of broken bone is large, in which case surgery would be necessary. A stable fracture can be treated with a brace or short leg cast and the use of crutches for six weeks.

    Bimalleolar Fracture
    This injury usually results in an unstable ankle with two bones, normally the lateral and medial malleoli, broken. A bimalleolar equivalent fracture involves one broken malleolus together with an injury to the medial ligaments on the inside of the ankle. Surgery is nearly always needed to repair these fractures.

    Trimalleolar Fracture
    With this type of fracture all three malleoli are broken. As with bimalleolar fractures, these injuries make the ankle unstable and surgery is nearly always necessary.

    Syndesmotic Injury (High Ankle Sprain)
    An injury to the syndesmotic ligaments or interosseous membrane of the ankle is often treated in the same manner as a fracture, as the ankle is often unstable. High ankle sprains take longer to heal than the more common lateral ankle sprain. If there are associated fractures with the syndesmotic injury, prognosis is very poor without surgical repair.

    Ankle injuries take a long time to heal fully; at least six weeks for the bones to heal and longer for the ligaments and tendons. Some people find that it may be two years before they are able to walk without limping. Your doctor will tell you when you are able to start moving your ankle again, and at that point you can begin rehabilitation. Range of motion exercises will increase flexibility. When you can put weight on your foot, strengthening exercises will help you get back to your normal activities. It is extremely important to follow medical advice about when to start exercising, and then to do the exercises. Beginning too soon can lead to displacement of the bone fragments and the need to begin treatment again. Not doing the exercises may result in permanent stiffness and weakness of the ankle.

    There are different types of brace and support that you can wear to help you during the initial stages of rehabilitation, and when you resume sporting activities. Your doctor or physical therapist will advise you on the best for your particular ankle fracture.
  • Calcaneus (Heel Bone) Fracture


    Calcaneus (Heel Bone) Fractures

    The calcaneus is the heel bone at the rear of the foot. It connects with the talus bone of the ankle, and the cuboid bone in the mid-foot. The joint between the talus and calcaneus bones (the subtalar joint) is important for normal foot function.

    The calcaneus bone has a hard exterior shell and a spongy, softer bone interior. This structure means that, if fractured, the bone tends to fragment. A fracture is therefore a serious injury with potential for the development of chronic pain and arthritis.

    A calcaneal fracture may or may not involve the subtalar or surrounding joints. Intra-articular fractures (those that do involve a joint or joints) are more serious than extra-articular fractures because the articular cartilage between the bones is also damaged. Extra-articular calcaneal fractures can be stress fractures, caused by gradual injury or overuse, avulsion fractures, when part of the calcaneus is broken off when the Achilles tendon is torn away, or crush injuries that cause fragmentation of the bone.

    Calcaneal fractures are also described by type and severity. A stable fracture is a fracture where the bones remain properly aligned. A displaced fracture describes the misalignment of the broken bones, and will usually require surgical repair. An open fracture, otherwise known as a compound fracture, is when a broken bone has protruded through the skin, while a closed fracture describes broken bones that have not broken the skin, but may involve damaged soft tissues. A comminuted fracture is a fracture that has resulted in the fragmentation of the bone.

    The majority of calcaneal fractures occur as a result of a trauma such as a fall from a height, a twisting injury, or a car accident.

    Other causes are, as described above, overuse, repetitive stress, and ankle sprains that may tear away a piece of bone.

    Symptoms may vary according to the type of fracture that has been sustained.

    A traumatic fracture may produce a sudden and severe pain in the heel, the inability to put any weight on the heel, and swelling and bruising of the heel and ankle. There may be visible deformity of the heel.

    The symptoms of a stress fracture may include swelling of the heel area with pain that develops over a period of days to weeks. Initially the pain may merely cause you to limp slightly.

    Your doctor will take a general medical history from you and ask questions specifically relating to your symptoms, any previous foot injuries, and the circumstances relating to your current injury. Your foot and leg will be physically examined and compared with your unaffected leg.

    Depending on the circumstances of the injury, your spine and pelvis may also be examined.

    X-rays will be taken to view the calcaneus and other bones of the foot and ankle. You may have a bone scan, which involves having a small amount of radioactive material injected intravenously. The radioactive material accumulates in areas of activity (for instance where a fracture is healing); pictures taken will highlight these areas. It is likely that a CT (computed tomography) or MRI (magnetic resonance imaging) scan will also be done as these imaging tests show the soft tissues of the body more clearly than X-rays can.

    Treatment for a calcaneal fracture will depend entirely on the type and severity of your injury. The goal of treatment is to restore the heel to its proper structure and function.

    Fractures caused by a traumatic event will probably require surgery to repair the bone (and joints if involved), or to fuse bones together. Surgery is often necessary for avulsion fractures, and immediate surgery is always required for an open fracture. During surgery the pieces of bone will be repositioned and fixed together with screws, pins, or plates to hold them in the correct position while they heal.

    For some fractures, conservative (non-surgical) treatments may be sufficient. These treatments would include:
    • Rest: keeping weight off the heel allows the bone to begin to heal. Using crutches when walking helps to achieve this.
    • Ice, crushed in a bag and wrapped in a towel before being applied to the skin, helps to relieve pain and swelling. Ice should be applied several times a day, for as long as is comfortable, during the acute stage of the injury.
    • Compression: Wrapping the ankle and heel in a compression bandage provides some relief from pain and swelling.
    • Elevation: Raising the foot above the level of your heart helps to relieve swelling.
    • It might be necessary to wear a walking boot or cast for up to 8 weeks, in order to avoid any movement of the heel bone.
    You will be encouraged to begin moving the foot and ankle as soon as possible during the recovery period. You will be shown specific exercises that will increase foot function by enlarging the range of motion. Exercises will also help strengthen the supporting muscles. Gradually you will begin to put weight on the foot, but it is important to follow medical advice as too much weight on the foot too early may cause further damage and require surgery to correct. Initially you will probably wear a walking boot, and use crutches or a cane to limit the amount of weight placed on the foot.

    A calcaneal fracture is a serious injury that may lead to long-lasting problems. There is an increased risk of developing arthritis in the affected joint, with the associated pain and stiffness. A permanent loss of range of motion in the ankle is possible, and if the heel bone fragmented, there may be a discrepancy in the length of the legs, causing you to walk with a limp. Subsequent surgery is often necessary. You may need to use an arch support in your shoe, or a brace, on a permanent basis.

    If the original injury was mild you will probably be able to resume normal activity about 3 months after surgery. If, however, the injury was severe, it may take up to 2 years, and it is likely that there will be some permanent damage and loss of normal function.
  • Clubfoot



    Clubfoot is a relatively common condition, visible at birth, where one or both feet are abnormally positioned. Usually the baby is otherwise completely healthy. Clubfoot can be mild, moderate or severe, and as the condition will cause future difficulties if untreated, it is important to begin remedial treatment as soon as possible.

    The medical term for clubfoot is talipes equinovarus, taken from talus (ankle) and pes (foot), as the position of the foot means that the person would have to walk on the outside of the ankle, and equino (indicating that the heel is raised, as in a horse’s hoof) and -varus (turned inward).

    About 1 in every 1000 babies is born with clubfoot. It is an idiopathic condition, meaning that the cause is unknown, although there are predisposing factors:
    • There is a genetic factor in the development of clubfoot, and if you or your spouse had it, or any of your other children, there is an increased risk of a new baby also having the condition.
    • Males are slightly more likely to have clubfoot than females.
    • If a pregnant woman has a family history of clubfoot, and she smokes during pregnancy, the baby is 20 times more likely to be born with the condition.
    It is known that clubfoot is not caused by the position of the baby while still in the womb.

    Clubfoot is not a painful condition. Left untreated it will cause complications with walking and wearing normal footwear, which would quickly lead to the development of painful symptoms.

    Usually a clubfoot is twisted so that the top of the baby’s foot points down and inward. Sometimes the twisting can be so severe that the foot appears to be upside-down. The foot cannot be straightened by just moving the foot because the associated joints, muscles and ligaments are holding the foot in the distorted position.

    The calf muscles of the affected limb are often underdeveloped, and the clubfoot may be shorter than the normal foot.

    The presence of clubfoot is usually immediately apparent at birth, due to the position and shape of the foot or feet. X-rays might be taken of the feet to assess the severity and aid decision-making with regard to treatment.

    Sometimes clubfoot may be diagnosed during a normal ultrasound examination of the fetus while still in the uterus.

    A newborn baby’s bones and joints are very flexible. This makes early treatment the best option for the most successful outcome. The aim of treatment is to restore optimum position and function of the foot to avoid problems when the baby begins to walk. Left untreated, the child would be forced to stand and walk on the outside of the foot. This could lead to sores and calluses, the likelihood of arthritis, and quite severe disability.

    Parental involvement and willingness to follow medical advice is critical, as failure to adhere to the program will result in the baby’s foot reverting to its original clubfooted position.

    There are three methods of treating clubfoot: the Ponseti method, the French method, and surgery. Which option is chosen will depend on the initial level of severity, the orthopedic surgeon’s recommendation, and parental choice. In some cases both the Ponseti and French methods might be employed.

    The Ponseti method involves stretching and casting. The bones and joints of the foot are gradually encouraged into the correct alignment by manipulating them towards the right position and placing the foot in a hip to toe cast to maintain the stretch. The cast is removed every five to seven days, the foot manipulated further towards correctness, and a new cast applied. The process continues for six to eight weeks until the foot is in a normal position. For final correction, at this point the Achilles tendon is often cut and a cast applied to be worn for three further weeks. By the time this cast is removed, the tendon has repaired itself and is a proper length. Subsequent treatment involves stretching exercises and wearing a splint full-time for three to four months, then at night for three to four years. The splint is comprised of a bar with shoes at either end. Special shoes would be worn during the day. Excellent results can be obtained by strictly following all the elements of the technique.

    The French method works by manipulating the foot on a daily basis, followed by taping to hold the foot in position until the next day. This procedure continues for three months, after which the taping sessions are reduced to three times a week for another three months. When the optimum position has been achieved, the parents must perform daily stretching exercises on the baby’s foot, and apply a splint to be worn each night. This continues until the baby begins to walk. The French method is equally successful, but is chosen less frequently due to the difficulties of daily appointments for treatment.

    Surgery is necessary for some cases of clubfoot. Tendons can be lengthened, which would allow the foot to assume a more correct position. Following surgery, the baby would have to wear a brace for at least a year in order to avoid the foot reverting to the original deformed position. Surgery for clubfoot does result in some scarring, stiffness and muscle weakness.

    Sometimes clubfoot cannot be completely corrected, and the size of the foot and calf muscles in the affected leg may remain smaller than the other leg. This does not usually affect foot and ankle function and in most cases early treatment will mean that your child will be able to wear normal shoes, enjoy an active life, and participate in sports.
  • Flat Feet


    Flat Feet

    Flat feet (pes planus) is a term used to describe a common structural condition where the feet have no arch. If you have flat feet, the entire sole of the foot touches the floor when you stand. Flat foot is not necessarily a painful condition, although it can cause problems elsewhere in the lower limbs due to structures being pushed out of alignment. Flat feet can lead to conditions such as tendonitis, arthritis, bunions, hammertoes, shin splints and plantar fasciitis.

    The arch of the foot develops during childhood, so babies and toddlers have naturally flat feet that gradually develop arches. Some people never develop them. Others do, but age can cause the weakening of the posterior tibial tendon that runs from the tibia (shinbone), under the inner anklebone and into the long metatarsal bones of the foot. This tendon helps to support the arch, so if loose the arch may collapse.

    Obesity can be another cause of flat feet. Excessive weight on the tendon will stretch or damage it. Weight gain and hormonal changes during pregnancy can also weaken the tendon.

    Injury to the foot or ankle might cause the arch to collapse, and rheumatoid arthritis can progressively destroy tendon tissues.

    The Achilles tendon runs from the posterior calf muscles down to the heel bone and is visible as a cord at the back of the ankle. People with a short Achilles tendon may have flat feet.

    Rarely, flat feet in children are caused by tarsal coalition, a painful condition where two or more bones in the foot fuse together.

    Flat feet may or may not be symptomatic. If no discomfort is being experienced, no treatment is necessary. If symptoms are present, they may include:
    • Aching pain in the foot, especially in the arch or heel area, worse after standing for extended periods or playing sports
    • Swelling on the inside of the ankle, along the path of the posterior tibial tendon
    • Pain experienced in the calf, knee, hip or lower back
    • Stiffness in one or both feet
    An easy home test for flat feet is to wet your foot and stand on a surface that will show an imprint, such as construction paper, or a sidewalk. Flat feet will leave a complete impression of your foot (as opposed to there being a space where your arch did not touch the ground).

    Your doctor will physically examine your foot. You will probably be asked to stand and walk so that your doctor can evaluate the extent and severity of the condition, and see how weight is being distributed across the foot. You may be asked to stand on tiptoe so that your doctor can see if an arch forms when you do so. If it does, the flat foot is termed ‘flexible’ and no treatment is required. If no arch forms, the foot is called a ‘caled rigid flat foot’.

    X-rays may be taken if your doctor needs to have a closer look at the bone structure of your feet. CT (computer tomography) or MRI (magnetic resonance imaging) scans may also be required to view the bones and soft tissues in the feet.

    Treatment is only necessary if flat feet are causing problems. A child with flat feet but no painful symptoms will continue to develop the same, regardless of any orthotics used. He or she will not make flat feet worse by leading a normal, active life.

    Tarsal coalition is treated primarily with rest, and sometimes a cast to restrict movement of the foot. If this fails to resolve the problem, surgery might be needed to repair the tendon or fuse some joints in the foot.

    For adults, the main treatment for flexible flat feet that are causing pain is the wearing of orthotic insoles or wedges. You can try readily available arch supports, or you may need to have custom orthotics made. Custom orthotics are specially molded to the exact contours of your feet. Although they will not cure flat feet, they can help alleviate painful symptoms by lifting the arch and redistributing weight across the foot.

    Exercises to stretch the Achilles tendon will help those whose flat feet are caused by a short tendon. Other exercises to stretch and strengthen the foot may help to relieve symptoms.

    Occasionally surgery is necessary to repair a badly torn posterior tibial tendon that has caused the arch to collapse with subsequent severe pain.

    You can help to reduce pain by resting the feet and avoiding activities that make the symptoms worse. Over-the-counter pain medication such as acetaminophen or ibuprofen can be taken as directed.

    Losing weight if you are overweight will reduce the stress placed on the arches and provide some relief from pain.

    Exercises to stretch the tendons in the foot and ankle, and to strengthen the supporting muscles, should be done regularly. Be sure to exercise each foot equally in order to avoid developing an imbalance between them, and always do these exercises barefoot.

    Simply spending as much time as possible barefoot, or in socks, will encourage the foot to use its muscles. Walking barefoot in sand is an extremely effective way to strengthen your feet.

    Calf stretch:
    Stand facing a wall and place hands on it for support. Lean forwards until a stretch is felt in the calves. Hold for 30 seconds. Bend at knees and hold for a further 30 seconds. Repeat 5 times.
    Achilles tendon stretch:
    Stand with your toes on the edge of a step and your heels over the edge. Have a support such as a wall next to you. Slowly raise your heels as high as you can, then lower your heels to their lowest point. Do this slowly and steadily in order to avoid damaging the tendon. Repeat 20 times.
    Toe spreads:
    Sitting, standing or lying down, fan out your toes as far as they will go, creating as much space between them as possible. Hold the spread for 10 seconds. Repeat 10 times.
    Toe points:
    Point your toes at an object, then flex the foot and hold for 5 seconds. Repeat 10 times.
    Tiptoe walking:
    Walk around on your toes, gradually building up to 5 minutes per day, without letting your heels touch the ground.
    Side walking: Place your feet shoulder width apart. Slightly bend your knees and roll the feet out so you are standing on the outer edges. Keep the weight on the outside of your feet and slowly rise up onto your toes. When you feel a stretch in the arch, hold the position for 5 seconds. Repeat this exercise 5 times a day.
  • Foot Drop

    Foot Drop / Ankle Contracture

    Foot drop, also known as drop foot or ankle contracture, is a muscular, neurological, or anatomical abnormality that causes an inability to properly lift the front part of the foot. The condition may be permanent or temporary, and can result in dragging of the front part of the foot on the ground when walking. Generally, foot drop is unilateral in that it affects only one foot, although certain conditions may result in both feet being affected (bilateral).  

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  • HIgh Ankle Sprain


    High Ankle Sprain

    A high ankle sprain is a serious injury to the syndesmotic ligaments of the ankle. These ligaments, the anterior inferior tibiofibular, posterior inferior tibiofibular, and the interosseous ligament, and the lower part of the interosseous membrane, form fibrous joints between the lower ends of the tibia and the fibula, providing critical stability to the ankle joint while at the same time allowing a slight degree of movement between the bones.

    This type of sprain is less common than a lateral ankle sprain, accounting for up to 10 percent of all ankle injuries. A correct diagnosis is difficult but important as the patient needs to be aware that a high ankle sprain has a longer recovery time.

    Injury to one or more of the syndesmotic ligaments occurs when ligament fibers are stretched or torn, causing the connection between the tibia and fibula to be weakened or, in severe cases, ruptured. A high ankle sprain often occurs in conjunction with other ankle injuries, such as a bone fracture, or sprains to other ankle ligaments.

    A high ankle injury often occurs during sports, when the ankle is forcibly pushed beyond its normal range of motion. External rotation, that is, the foot being forced outwards, causes many such sprains, although excessive motion in any direction can damage the ligaments. The degree and severity of the injury can vary and depend on the particular ligaments involved.

    Football, soccer, basketball, other contact sports players, and skiers are at risk of sustaining a high ankle sprain. Participating in these types of sport involves repeated quick changes of direction, which increases vulnerability to high ankle damage.

    • Pain, made worse with rotating and bending the foot upwards.
    • Reduced ability to walk due to pain when putting weight on the foot
    • Swelling, bruising, and tenderness on the front and outer side of the ankle
    Because the more common injury is a lateral ankle sprain, a high ankle sprain often goes undiagnosed. As high ankle sprains are often associated with other injuries X-rays, in conjunction with a medical history and physical examination, will be taken of the lower leg and ankle. Two specific tests can aid with diagnosis. The squeeze test consists of squeezing the tibia and fibula together at a point several inches above the ankle, which, in the presence of a high ankle sprain, will elicit pain below that point and into the ankle. During the second test your ankle would be rotated externally. Again, a painful response indicates a high ankle sprain.

    In addition, an MRI (magnetic resonance imaging) scan may be performed as these types of scan show the soft tissues more clearly than X-rays and will therefore reveal any tears in the ligaments or interosseous membrane.

    High ankle sprains are treated in the same manner as lateral ankle sprains, but they take longer to heal due to the instability of the ankle joint caused by the damage.

    Initial treatment consists of the following measures:
    Protection and Rest:
    You will need to immobilize the ankle to allow healing to begin. You will probably be placed in a walking boot or cast for a minimum of two weeks, and longer if the injury is more severe. You will have to refrain from any activity that puts pressure on the syndesmotic ligaments and rest the ankle as much as possible. Temporarily using crutches will help.
    Ice, crushed in a bag and the bag wrapped in a towel, can be applied to the ankle for as long as is comfortable, several times a day. This will help reduce inflammation.
    Taping the ankle with an Ace bandage will provide compression and support and will relieve pressure on the ligaments, thereby helping you to feel more comfortable. Be careful to tape the ankle firmly but not so tightly that you cause swelling.
    Raise the ankle above the level of your heart, whenever possible, to reduce inflammation and swelling.

    If the ligament has been completely ruptured, leading to a widening of the space between the tibia and fibula, you will probably need surgery to repair the damage. The space between the bones would be reduced and fixed in place using orthopedic screws inserted above the ankle joint. Following surgery your ankle would be placed in a cast for several weeks before you could begin partial weight bearing on the leg.

    Range of motion exercises followed by strengthening exercises and balance training could begin after the period of immobilization had finished. The time necessary for a full recovery from a high ankle sprain depends on the initial level of damage, but could take up to six months.

    • Perform strengthening exercises for your ankles.
    • Wear appropriate footwear.
    • Wear a brace or tape your ankle during sports, at least initially after recovering from your sprain and returning to activity.
    What to look for in an ankle brace:
    In order to be effective support for your ankle, the brace should have both medial and lateral support. It should be made of strong plastic or a similar type of material as a brace constructed from neoprene or other soft substance will not provide sufficient support.

    The brace should fit in your shoe comfortably, so take your athletic footwear with you when trying on ankle braces. Try several and choose one that feels comfortable but supportive.

    Follow medical advice and only begin exercising with your doctor’s approval. The following exercises will help improve your range of motion and ankle strength.
    Achilles tendon stretch:
    Lying down or sitting, loop a towel around your toes. Pull your toes upwards by pulling on the ends of the towel. Hold the stretch in the back of the ankle for 30 seconds. Repeat 3 times.
    Toe alphabet:
    Lying down or sitting, write the letters of the alphabet in the air with your toes.
    Toe Raise:
    Stand with your toes on the edge of a step and your heels over the edge. Slowly raise your heels as high as you can, then lower your heels to their lowest point. Repeat 20 times.
    Heel and Toe walk:
    Keeping control and going slowly, walk across a room on your heels only. Turn around and re-cross the room, but this time on your toes only.
  • Lisfranc Fracture


    Lisfranc Fracture

    A Lisfranc fracture, so-called after Jacques Lisfranc, a French surgeon in Napoleonic times, is a dislocation or fracture and dislocation of the joint between the midfoot and forefoot (tarsometatarsal joint). It is a relatively uncommon but severe injury with the potential for long-term complications.

    The ankle (tarsus) consists of seven bones. The anklebone (talus) and the heel (calcaneus) form the posterior part of the foot. The cuboid and navicular bones connect with the calcaneus and talus respectively and, articulating with the distal (furthest from the body) ends of the cuboid and navicular are the medial, intermediate, and lateral cuneiform bones. Together these form part of the arch of the foot and connect at their distal ends to the long bones of the foot, the metatarsals. Transverse ligaments hold the proximal (nearest to the body) ends of the four lateral (outer) metatarsals in their correct positions. Between the first and second metatarsals, however, there is no transverse ligament, and the particular structure of the bones at this point creates a weak area in the midfoot.

    A Lisfranc fracture is normally caused by a direct or indirect trauma to the midfoot, such as dropping a heavy object onto the foot or twisting the foot suddenly. Car accidents, industrial accidents, sporting injuries and falls from a height are common causes.

    Typical symptoms may include:
    • Pain and swelling on the top of the foot
    • Unwillingness or inability to put weight on the foot, due to pain
    • Bruising on the top of the foot and sometimes also in the sole
    • Gentle pressure on the joint area will cause pain to be felt, radiating to the sides of the foot.
    • Depending on the position of the dislocation, a lump might be visible on top of the foot
    • Obvious deformity of the foot
    This type of injury is often misdiagnosed because a dislocated joint can reduce (reposition) itself unaided. The original injury can therefore be difficult to detect. The extreme swelling can be an indication of a Lisfranc fracture, which carries a high risk of secondary complications, so early diagnosis and a careful and thorough examination is critical in order to preserve normal foot function and avoid chronic pain.

    While waiting to see the doctor, resting, elevation, and the application of ice to the painful area may help to relieve symptoms. You can also take over-the-counter pain medication such as acetaminophen (Tylenol), ibuprofen (Advil), naproxen (Aleve) or aspirin, as directed.

    After your medical history has been taken, and the circumstances of the injury noted, your foot will be physically examined. One method of preliminary diagnosis is to gently move your foot in a circle while holding the heel steady. This will elicit only mild pain if the foot is sprained, but severe pain in the case of a Lisfranc fracture. The blood supply to the foot will be checked to ensure no damage to blood vessels has been sustained.

    Several X-rays may be taken, including your uninjured foot for comparative purposes. These may include weight-bearing X-rays, which can be uncomfortable but only take a few seconds. CT (computed tomography) or MRI (magnetic resonance imaging) scans may also be required to better view the hard and soft tissues of the foot.

    Lisfranc injuries are graded according to severity, and treatment depends on the level of damage suffered by the joint.

    Follow medical advice carefully for the best outcome. Returning to normal activity too soon after sustaining a Lisfranc fracture greatly increases the risk of further injury. A complication known as compartment syndrome might develop, where swelling and bleeding from the injury causes pressure within the muscle, which can damage blood vessels and nerves.

    If the injury is relatively mild and the bones have not been displaced, treatment will consist of resting the foot by wearing a cast and using crutches when walking. Putting weight on the foot is kept to an absolute minimum. A cast is recommended due to the potential for long-term disability after this type of injury. After about 6 weeks, when the cast has been removed, you will probably need to use a rigid arch support in your shoe. You will be taught how to do exercises to restore range of motion in the ankle and foot, and to strengthen the supporting muscles.

    Surgery is a common treatment for moderate to severe cases of Lisfranc fractures. Unless there is an imperative need for immediate surgery, it should be delayed until the swelling has gone down, in order to minimize the risk of damaging soft tissues. Surgery is performed to realign the dislocated bones and hold them in position during the healing process. Immediately following surgery, a padded splint would be worn until the swelling from the procedure had resolved, usually within 2 weeks. A short leg cast would be applied to immobilize the foot for between 6-8 weeks and possibly up to 3 months. Crutches would be used when walking, but weight-bearing activities would be prohibited until the cast was removed. If internal fixing devices such as pins, screws or wires were used to keep the bones in place during healing, they would be removed at this time. A walking brace or boot would need to be worn for several more weeks, and then an arch support in a stiff-soled shoe would be used until all symptoms had disappeared.

    There is always the risk of post-traumatic arthritis developing after injury to a joint. In some cases it might be necessary to undergo further surgery to fuse the joint if post-traumatic arthritis from a Lisfranc fracture is causing intolerable pain.
  • Morton's Neuroma


    Morton’s Neuroma

    A neuroma is a benign enlargement of tissue around a nerve. Although it is sometimes referred to as a benign tumor, it is not a cancer and will not spread to other parts of your body. A Morton’s neuroma affects a nerve that leads to your toes and is usually found in the space between the third and fourth toes. It is sometimes called an intermetatarsal neuroma due to its location. Irritation, caused by compression of the nerve, can lead to the development of a neuroma. Women are much more likely to develop a Morton’s neuroma than men, probably due to the types of shoes that women tend to wear.

    Any situation that constricts and irritates the nerves leading to the toes increases the risk of a neuroma forming.

    The most common cause is the wearing of certain types of shoe. Heels that are higher than 1 inch place more weight and pressure on the ball of the foot, and toe boxes that taper to a narrow point force the toes together in a way that compresses the nerves.

    Certain irregularities in the structure of the foot can predispose a person to develop a Morton’s neuroma. Examples of such irregularities are flat feet, overly flexible feet, bunions and hammertoes.

    Some activities, for instance sports that involve running or repeated pushing off from the balls of the feet, may trigger the formation of a neuroma, as can a direct injury to the foot.

    Symptoms often appear gradually and can first be felt as an occasional pain on wearing certain shoes or doing a particular activity. In the early stages the irritation lessens with rest. Over time the symptoms become more constant and more severe as the condition develops and the damage becomes permanent.

    These symptoms may include:
    • A feeling as though there is something small and hard in your shoe, or as though your sock is bunched up. It may feel as though the object is inside the ball of your foot.
    • Pain at the location of the nerve damage, made worse when putting pressure on the ball of the foot, or wearing high heels or shoes with a tapered toe box
    • Extreme pain on pressing the space between the third and fourth toes
    • A numbness, or sometimes a tingling or burning sensation in the affected area
    The sooner you make an appointment to see your doctor, the more likely it is that conservative treatment of a Morton’s neuroma will be successful. Delaying diagnosis and treatment increases the chances of permanent nerve damage and subsequent surgery.

    Your doctor will examine your foot carefully and palpate it in ways to elicit a pain response in order to determine the exact location of the damage. He or she will attempt to feel if any mass is present between the toes, or if there is an audible click on palpating the intermetatarsal space while squeezing the whole foot (Mulder’s sign). Testing the range of motion of the toes will help to rule out arthritis or other joint conditions.

    X-rays might be taken to look for stress fractures or arthritis of the metatarsophalangeal joints (joints between the metatarsals and the toe bones). Ultrasound can show thickening of the nerve and if such thickening measures greater than 0.1 inch, a Morton’s neuroma is indicated. An MRI scan may be used to assess the size of the neuroma, especially if surgery is necessary.

    Initial treatment is nonsurgical and usually involves the following measures:
    • Avoiding high-heeled, tight or narrow shoes. This allows the toes to spread out, relieving pressure on the nerve and giving it a chance to heal.
    • Applying ice, crushed in a bag and covered with a towel, to the affected area for as long as is comfortable, several times a day.
    • Taking NSAIDs (non-steroidal anti-inflammatory drugs) will reduce inflammation and pain.
    • Using inserts or pads in the shoes. A typical pad might be made of foam and is positioned under the space between the two affected toes. The effect is to keep the bones separate, which relieves pressure on the nerve. Pads and inserts are available over the counter, or custom-made orthotics can be ordered.
    • A corticosteroid injection into the affected area can provide rapid and long-lasting pain relief, but can only be administered a few times a year as they can cause damage to tendons and ligaments.
    • Increasingly, injections of diluted alcohol into the affected area relieve symptoms by poisoning the nerve tissue. Injections normally have to be repeated at intervals for several weeks, but success rates in clinical studies are high. This treatment is becoming a viable alternative to surgery.
    Over 80% of people suffering from a Morton’s neuroma find that the above treatments provide relief from their symptoms. If, however, conservative treatment fails, surgery can be performed to cut away a portion of the nerve, a procedure known as a neurectomy. The neuroma can be approached surgically from the top or bottom of the foot, according to the surgeon’s preference. Recovery times can therefore vary. As with all surgery, there are risks involved that should be discussed with your surgeon prior to making a decision.

    Another possible treatment is cryogenic neuroblation, where nerve axons are destroyed so that painful impulses cannot be transmitted. Although this procedure retains more of the original nerve than surgery or alcohol injection, results show that over the longer term, symptoms of neuroma recur more often.

    To avoid a recurrence of painful symptoms, make sure that your footwear is properly fitted. Shoes should have soft soles, heels no higher than 1 inch, and a wide and high toe box.

    Avoid activities that cause you to place repeated stress on the balls of your feet. Consider doing low-impact exercise such as swimming or bicycling instead of running.

    Maintain a healthy weight and use orthotics in your shoes if necessary.
  • Over Pronation


    Over Pronation

    Pronation is the term used to describe a natural movement of the foot when walking. When the gait is normal, the heel strikes the ground first. As weight is transferred forward, the arch of the foot flattens and the foot rolls slightly inwards. Body weight is then placed on the ball of the foot and toes, and the foot straightens and turns outwards as the toes push off. Overpronation occurs when the foot rolls inward too far. This causes all the muscles and tendons of the lower leg to twist excessively. Regular overpronation is believed to contribute to the development of many knee, lower leg and foot injuries such as heel spurs, plantar fasciitis, tendinitis and bunions. It is thought that as much as 60% of the population may overpronate.

    Overpronation often occurs in people with flat feet, whose plantar fascia ligament is too flexible or too long, and therefore unable to properly support the longitudinal arch of the foot.

    People tend to inherit the foot structure that leads to overpronation. In a normal foot the bones are arranged so that two arches are formed, the longitudinal and the transverse. Ligaments hold all the bones in their correct positions, and tendons attach muscles to bones. If the bones are held together too loosely, they will tend to move inwards as this is the easiest direction for them to go. Over time the soft tissue structures will adjust to the misalignment and the foot will become permanently over-flexible, with a flat arch.
    • Hormonal changes during pregnancy cause ligaments to weaken.
    • Rapid weight gain can weaken the arches.
    • Running on hard surfaces can lead to damaged arches.
    • The normal aging process will exacerbate the condition as ligaments and muscles weaken.
    Because overpronation affects the entire lower leg, many injuries and conditions may develop and eventually cause problems not only in the leg and foot, but also the knee, hips and lower back. Pain often begins in the arch of the foot or the ankle. Blisters may develop on the instep, or on the inside edge of the heels. As overpronation continues and problems develop, pain will be felt elsewhere, depending on the injury.

    One of the easiest ways to determine if you overpronate is to look at the bottom of your shoes. Overpronation causes disproportionate wear on the inner side of the shoe.

    Another way to tell if you might overpronate is to have someone look at the back of your legs and feet, while you are standing. The Achilles tendon runs from the calf muscle to the heel bone, and is visible at the back of the ankle. Normally it runs in a straight line down to the heel. An indication of overpronation is if the tendon is angled to the outside of the foot, and the bone on the inner ankle appears to be more prominent than the outer anklebone. There might also be a bulge visible on the inside of the foot when standing normally.

    A third home diagnostic test is called the ‘wet test’. Wet your foot and stand on a surface that will show an imprint, such as construction paper, or a sidewalk. You overpronate if the imprint shows a complete impression of your foot (as opposed to there being a space where your arch did not touch the ground).

    If a young child is diagnosed with overpronation braces and custom orthotics can be, conjunction with strengthening and stretching exercises, to realign the bones of the foot. These treatments may have to continue until the child has stopped growing, and orthotics may need to be worn for life in order to prevent the foot reverting to an overpronated state.

    Wearing shoes that properly support the foot, particularly the arch, is one of the most effective treatments for overpronation. Custom-made orthotic inserts can also be very beneficial. They too support the arch and distribute body weight correctly throughout the foot. Motion-control shoes that prohibit pronation can be worn, so may be useful for those with severe overpronation.

    One good treatment is to walk barefoot as often as possible. Not relying on shoes to support the arch will encourage proper muscle use. Practicing yoga can help to correct poor posture and teach you how to stand with your weight balanced evenly across the whole foot.

    Exercises to strengthen and stretch supporting muscles will help to keep the bones in proper alignment.

    Duck stance:
    Stand with your heels together and feet turned out. Tighten the buttock muscles, slightly tilt your pelvis forwards and try to rotate your legs outwards. You should feel your arches rising while you do this exercise.
    Calf stretch:
    Stand facing a wall and place hands on it for support. Lean forwards until stretch is felt in the calves. Hold for 30 seconds. Bend at knees and hold for a further 30 seconds. Repeat 5 times.
    Golf ball:
    While drawing your toes upwards towards your shins, roll a golf ball under the foot between 30 and 60 seconds. If you find a painful point, keep rolling the ball on that spot for 10 seconds.
    Big toe push:
    Stand with your ankles in a neutral position (without rolling the foot inwards). Push down with your big toe but do not let the ankle roll inwards or the arch collapse. Hold for 5 seconds. Repeat 10 times. Build up to longer times and fewer repetitions.
    Ankle strengthener:
    Place a ball between your foot and a wall. Sitting down and keeping your toes pointed upwards, press the outside of the foot against the ball, as though pushing it into the wall. Hold for 5 seconds and repeat 10 times.
    Arch strengthener:
    Stand on one foot on the floor. The movements needed to remain balanced will strengthen the arch. When you are able to balance for 30 seconds, start doing this exercise using a wobble board.
  • Peroneal Tendonitis


    Peroneal Tendonitis

    Peroneal tendonitis is inflammation of the peroneal tendons. The tendons are part of the peroneus brevis and peroneus longus muscles that help to stabilize the foot when walking, and control the eversion, or movement to the outside, of the foot. They run down the lateral (outer) length of the fibula (one of the lower leg bones), through a groove behind the lateral malleolus (outer anklebone), and along the outer edge of the foot to attach to bones in the foot. Contraction of the peroneal muscles causes the tendons to glide within the groove, causing the foot to either point down or out to the side.

    These tendons are exposed to repetitive stress and are vulnerable to damage. Small tears, usually along the line of the tendon, can gradually accumulate and eventually cause symptoms. The normal response of the body to injury is inflammation and swelling as healing nutrients are brought in the blood to the damaged area. This inflammatory response causes pain and, in the case of peroneal tendonitis, may cause a patient to limp when walking, or, if severe enough, prevent participation in normal sporting activities.

    Although a particular accident such as an ankle sprain may be the cause of peroneal tendonitis, more usually it develops over time with repeated stresses placed upon the tendons. It can develop during recovery from an ankle sprain when the peroneal muscles have to work harder to support an unstable ankle joint. The natural shape of the foot may be a predisposing factor: for example, a high arch commonly places disproportionate stress on the tendons. The natural aging process can also be a factor as it leads to brittle tendons that are more susceptible to damage.

    Typical symptoms of peroneal tendonitis may include:
    • Ache above or below the outer anklebone, which may be during or after exercise, at night, upon getting up in the morning, or, if the condition is severe, constant
    • Prominent peroneal tendons when standing
    • Noticeable limp when walking
    • Possible swelling visible behind the outer anklebone
    • Warmth in the affected area
    • Tenderness behind the outer anklebone when pressed
    • Numbness or burning sensation on the outside of the foot
    • Decreased ability to evert the foot (move the foot outwards)
    Your doctor will ask you about your medical history, including any previous injuries to your ankle, leg or hip. You will be asked about your general health, level of activity and any sports that you may participate in. Your current condition will be discussed and your doctor will ask about any injury that caused the initial pain. Your symptoms will be noted and considered.

    Your foot, ankle and lower leg will be physically examined. You may be asked to walk so that the doctor can evaluate your gait and the natural positioning of your feet. Your ankle will be manipulated to assess the strength and stability of the joint, and it will be palpated (touched) to determine areas of tenderness.

    X-rays will probably be taken to rule out bone fractures, and an MRI (magnetic resonance imaging) scan may be performed to view the ligaments and other soft tissues of the ankle and to determine the presence and extent of any peroneal tendon tears, along with any other soft tissue injuries.

    Treatment depends on the severity of the injury. Inflammation without peroneal tendon tears will usually subside with nonsurgical methods. Such treatment includes:
    • Relieving pressure on the tendons to prevent further injury and allow healing to begin. A brace such as an ankle lacer or a short-leg walking boot can be worn for two to four weeks to immobilize the ankle.
    • Ice, crushed in a bag and with a towel protecting the skin, can be applied to the inflamed area for as long as is comfortable, several times a day. This will help to reduce inflammation and relieve pain.
    • Over the counter pain medication can be taken, such as acetaminophen (Tylenol) or NSAIDs (non-steroidal anti-inflammatory drugs).
    • Refraining from activities that put pressure on the tendons, for a few weeks, will allow healing to take place.
    • Wearing orthotics, if you have a high arch, will adjust the position of your foot so as to relieve pressure on the peroneal tendons. The most useful orthotic for this condition has a recessed area under the head of the first long bone in the foot.
    • Physical therapy, to treat the acute phase of the injury and then to strengthen muscles, improve balance, and increase range of motion, may include such measures as ice, heat, and ultrasound.
    • Cortisone injections provide relief in cases where symptoms will not abate, but due to the risk of rupturing a tendon, these injections are seldom given.
    In some instances surgery is necessary to trim any damaged tendon, repair any tears or improve the track behind the fibula that the peroneal tendons run along. Other surgical procedures might include repairing the thick tissue over the tendons that normally holds them in the groove. The peroneal tubercle, a lump of bone on the outside of the heel, may need removal if it is enlarged and irritating the peroneal tendons. Likewise, any bony spur on the back of the fibula that is causing inflammation can be trimmed. Rarely, the heel is surgically repositioned to redistribute force more equally over the rear part of the foot. Occasionally, if a peroneal tear involves more than 50% of the tendon, the tendon is stitched to the other tendon for stability. In general, a careful assessment is made of the stability and alignment of the ankle, and surgical procedures performed to relieve pressure on the peroneal tendons.

    Following surgery you would wear a short-leg cast for up to six weeks and then a walking boot for another month.

    Whether or not you have had surgery, physical therapy will play a large part in rehabilitating the ankle. A return to your normal activities, especially sports, must be undertaken slowly and carefully so as not to inflame the vulnerable tendons. Full recovery can take several months.

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  • Plantar Fasciitis

    Plantar Fasciitis

    The plantar fascia is a wide, thick, flat band of fibrous connective tissue that runs from the heel to the ball of the foot and serves to support the longitudinal arch and transmit weight across the foot when walking or running. It is subjected to enormous stress at every step and although it is tough and elastic, it is vulnerable to damage. When injured it can become inflamed and painful, the condition known as plantar fasciitis.

    Occasionally the terms plantar fasciitis and heel spurs are used interchangeably. Although they are often associated (about 70% of people suffering from plantar fasciitis have heel spurs, visible on an X-ray), they are not necessarily connected.

    Plantar fasciitis is a common condition, often caused by overuse. Athletes are prone to developing it because of the repetitive stress placed on the ligament. A sudden increase in the intensity of training, or switching to a harder surface, can cause tears and inflammation.

    Other causes include:
    • A rapid increase in weight, which places extra stress on the plantar fascia.
    • Wearing poorly fitting shoes that do not support the foot properly.
    • Arthritis
    • Diabetes
    • Structural abnormalities of the foot such as flat feet, over-pronation, or high arches
    • Tight calf muscles or tight Achilles tendons
    • Biomechanical factors such as an unusual way the foot strikes the ground
    • Pregnancy: during pregnancy hormonal changes cause ligaments to soften. There is also additional body weight adding to stress on the plantar fascia
    • Occupational factors such as a job that requires standing for long periods
    Pain from plantar fasciitis is usually felt near the point where the ligament attaches to the calcaneus (the heel bone) and is often described as an aching, shooting or burning sensation. Overnight the discomfort tends to lessen but, on first stepping onto the foot in the morning, the tight plantar fascia is again stretched and the pain can be quite severe. With gentle use the tissues of the ligament warm up and symptoms diminish, although the pain is likely to return with standing, walking, running, climbing stairs, or other physical activity, or after a period of resting.

    Your doctor will ask you questions about your symptoms, what activity or time of day makes the pain better or worse, and any injuries to the foot you may have suffered. Your general health, lifestyle, and level of physical activity will also be discussed.

    You will probably be asked to stand and walk around so that the doctor can evaluate how weight is distributed across the foot and whether any biomechanical factors might be contributing to your symptoms. Your foot will be physically examined.

    If considered necessary, for instance if the doctor suspects that there might be a bone fracture, X-rays will be taken of your foot.

    Initial treatment of plantar fasciitis is conservative (non-surgical). It will probably take several months to fully recover. Typical measures include:
    • Rest: Avoiding activity that triggers pain will allow the ligament to rest and the tissues to begin healing.
    • Ice: Placing your heel on a bag of crushed ice (wrapped in a towel), or rolling the sole of the foot over a frozen bottle of water, will help to reduce swelling and pain.
    • Medication: Over-the-counter pain medicine such as ibuprofen (Advil), naproxen (Aleve) or aspirin will reduce inflammation and pain.
    • Footwear: Change your shoes to ones with good supportive arches. Another method is to insert heel cups in both shoes to relieve pressure on the plantar fascia. Avoid walking barefoot, especially on hard surfaces.
    • Night splint: Wearing a splint during the night keeps the ligament stretched so that it does not tighten up and cause pain when first stepping on the foot in the morning.
    • Exercise: Although prolonged physical activity will exacerbate your symptoms, it is extremely helpful to perform stretching exercises for the tissues around the heel bone, especially first thing in the morning.
    • Maintain a healthy weight to avoid adding stress to the ligament.
    If the above measures do not provide relief, your doctor can administer a cortisone injection. This carries the risks of rupturing the plantar fascia, or causing the pad of fat under the heel to atrophy, both of which would worsen, rather than lessen, your symptoms. Although these problems only affect a few sufferers, doctors are often reluctant to use cortisone injections as a treatment.

    An experimental treatment is showing signs of being a successful option for plantar fasciitis. ESWT (extracorporeal shock wave therapy) inflicts tiny traumas to the ligament, which is believed to trigger tissue repair.

    If all else fails, surgery to loosen the plantar fascia may be considered, but conservative treatments should be attempted first, for at least one year, before surgery is discussed. The success of surgical treatment is unpredictable.

    Ideally, these should be done twice a day, but primarily first thing in the morning. Be sure to exercise both legs to avoid developing an imbalance.
    Calf stretch:
    Stand facing a wall and place hands on it for support. Lean forwards until a stretch is felt in the calves. Hold for 30 seconds. Bend at the knees and hold for a further 30 seconds. Repeat 5 times.
    Toe dips:
    Stand with your toes on the edge of a stair step or something similar, with your heels hanging over the edge. Place one hand against a wall for support. Slowly lower one heel until you feel a stretch in the back of the heel. Hold the stretch for 10 seconds then raise the heel up again. Repeat 10 times.
    Plantar fascia stretch:
    Sitting on the floor, bend one leg over the other and rest the ankle on the straight thigh. Hold the heel of the bent leg with one hand and the toes with the other. Pull the toes towards the shin until a stretch is felt on the bottom of the foot. Hold the stretch for 10 seconds. Repeat 3 times.
    Toe pull:
    Sitting on the floor, loop a towel or exercise band around the top half of your foot. Keep your knee straight and toes pointed at the ceiling. Pull on the ends of the towel so that your toes are drawn towards you. Hold for 10 seconds. Repeat 3 times.
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  • Posterior Tibial Tendon Dysfunction (PTTD)

    Posterior Tibial Tendon Dysfunction (PTTD)

  • Posterior Tibial Tendonitis


    Posterior Tibial Tendonitis

    The suffix ‘-itis’ denotes inflammation; so posterior tibial tendonitis describes inflammation of the posterior tibial tendon.

    Tendons are found at either end of each muscle, and their function is to attach muscles to bones. The posterior tibial tendon runs from the posterior tibial muscle in the calf, down behind the inner anklebone (the medial malleolus), and across the instep where it divides into three parts, each of which inserts into a different bone or bones of the middle and hind foot. One of the main functions of the posterior tibial tendon is to support the medial arch in the foot. It also assists the foot to turn inwards, and to point the foot and ankle downwards.

    Tendons are formed from strands of a strong connective tissue called collagen. The strands are bundled together rather like a rope. With age and use, some of the strands become frayed or broken, weakening the tendon. The process of repair causes scar tissue to form, which leads to a gradual thickening of the tendon. Accumulated scar tissue can form nodules in areas of the tendon, a process called tendonosis. Areas of tendonosis are inherently weaker than the original collagen tissue, increasing the risk of rupturing the tendon.

    Areas of tendonosis can become inflamed, leading to tendonitis. It often begins where the tendon passes through a tunnel behind the medial malleolus. The outer covering of the thickened tendon rubs against surrounding structures and becomes irritated.

    The main symptom of posterior tibial tendonitis is pain felt in the inner lower leg, the ankle and the instep of the foot. Symptoms usually develop gradually and are felt after activities that include repeated contractions of the posterior tibial muscle, such as running or jumping. There may be swelling along the path of the tendon. If the tendon is ruptured the foot will have a clearly visible flat arch.

    Diagnosis is usually made by way of a physical examination of the foot, noting where pain and swelling is present. Very occasionally an MRI (magnetic resonance imaging) scan is required to view the soft tissues.

    Successful treatment of posterior tibial tendonitis largely depends on the willingness of the patient to comply with medical advice. Early treatment is preferable, as good results can be obtained within a few weeks, whereas ignoring the condition for a long time may mean treatment lasting for several months.

    Conservative (non-surgical) treatment consists of resting the foot by avoiding time spent on your feet and completely avoiding any activity that aggravates the condition. This will decrease the amount of stress on the tendon and allow the tissues to begin healing. When you do have to walk, it may be necessary to use crutches, and use firm arch supports in your shoes.

    Over-the-counter pain medications such as ibuprofen (Advil and others), naproxen (Aleve and others) or aspirin, may be recommended by your doctor to relieve pain and inflammation.

    Elevating the foot above the level of your heart whenever possible will decrease pressure on the tendon and relieve swelling.

    Your doctor may provide a treatment called iontophoresis. This procedure administers cortisone medication (a pain-relieving anti-inflammatory substance) through the skin to the tissues of the tendon, using gentle electrical currents. This treatment runs less risk of rupturing the tendon than a traditional cortisone injection.

    A physiotherapist might administer ultrasound and massage to relieve pain. You will be shown how to do exercises to stretch and strengthen the calf and foot muscles.

    Surgery may be necessary if conservative measures fail. The surgeon can remove areas of thickened tendon sheath tissue in a procedure known as debridement. Alternatively, tears in the tendon might be repaired with sutures, or the tendon might be strengthened with a tendon graft. If the medial arch is flat, due to a ruptured tendon, and the resultant misalignment of the bones is causing pain and cannot be remedied in any other manner, several bones in the foot can be fused together by the removal of the joints.

    Rehabilitation after surgery will depend on the particular procedure you had, but soft tissues will take about eight weeks to heal. You may wear a walking boot during this time, and use crutches when walking. A graduated program of exercise will be developed for you.

    These should only be done with the approval of your health care practitioner. Always exercise both limbs to avoid developing an imbalance between the legs.
    Towel stretch:
    Sit on the floor and stretch one leg out in front of you. Loop a towel around the ball of your foot and your toes and, keeping the leg straight, pull on the ends of the towel to draw your foot towards you. Hold the stretch for 15-30 seconds. Repeat 3 times.
    Calf stretch:
    Stand facing a wall and place hands on it for support. Lean forwards until stretch is felt in the calves. Hold for 30 seconds. Bend at knees and hold for a further 30 seconds. Repeat 3 times.
    Calf raise:
    Stand with your feet shoulder width apart. Lift your heels off the floor as high as possible then slowly lower to the ground. Repeat 10 times for 1 set. Build up to 3 sets.
    Side leg raise:
    Lie on your side with the injured leg uppermost. Keep the leg straight. Tighten the quadriceps (thigh muscles) of the upper leg and slowly raise the leg about 10 inches. Slowly lower again. Repeat 10 times for 1 set. Do 3 sets.
    Balance 1:
    Begin by standing on one leg for 1 minute. When you can do this easily, progress to doing it with closed eyes.
    Balance 2:
    Stand on one leg and pass a ball around your back. When this becomes easy, do it with closed eyes.
    Balance 3:
    Stand on one leg and pass a ball under the other (raised and bent) leg. When this becomes easy, do it with closed eyes.
    Wobble board:
    A wobble board is very effective for balancing exercises, but can be tricky, so if possible have a physiotherapist show you how to use one properly.
  • Sesamoiditis


    Sesamoiditis is the term used to describe inflammation of the tendons surrounding the sesamoid bones in the ball of the foot, under the big toe.

    Nearly every bone in the human body is connected to another bone by way of a joint, but in the hand, knee, and foot there are some bones that are instead embedded in tendons or muscles. In the foot there are two, occasionally just one, very small sesamoid bones in the flexor brevis muscle and its associated tendons. The flexor brevis muscle is used to bend (flex) the big toe. The bones are found close together, but unconnected. The sesamoid bones act as pulleys: because of their presence, the tendon is unable to completely flatten and therefore slides over the bones, providing a more consistent pull on the toe. Their position means that the sesamoid bones in the foot bear considerable weight when a person is standing, walking, running, squatting or jumping. They are thus subject to stress and vulnerable to damage, particularly among groups of people such as runners and dancers.

    Injury: Sudden trauma or repetitive stress can cause injury to the tendons around the sesamoid bones, or a fracture of the bones themselves. Injury triggers a painful inflammatory response. The onset of sesamoiditis is usually gradual and often caused by an increase in the level or intensity of activity.

    Structural factors: The risk of developing the condition is increased if you have high arches, which cause more weight to be born by the balls of the feet. Your sesamoid bones may be larger than normal, in which case they bear extra weight during each step. If the fatty pad on the ball of your foot is thin, there is less protection for the bones. If the first metatarsal (the long bone in the foot that connects to the first big toe bone) is naturally positioned pointing slightly downwards, the sesamoids will be lower and therefore subject to more weight and pressure during walking. Overpronation, a condition where the foot rolls inwards excessively, also results in extra pressure on the sesamoids.

    Lifestyle: If your activities and lifestyle regularly include running, dancing, squatting for extended periods, wearing high heels for extended periods, or other situations in which your big toe is flexed upwards and weight is being placed on the ball of the foot, you are at risk of developing sesamoiditis.

    Age: Osteoporosis may weaken the sesamoid bones, leaving them more vulnerable to fracture, and osteoarthritis can trigger the growth of bone spurs, which can irritate and inflame the surrounding tendons.

    Injury to tendons can cause quite severe pain. With a trauma, the pain will be immediate and localized under the big toe on the ball of the foot. Repetitive stress injury will cause gradually developing pain that starts as a mild ache and tenderness to pressure. The pain will be worse when walking barefoot or wearing thin-soled shoes, but will be better with rest and elevation. As the condition worsens, pain will become more constant and is often experienced as intense throbbing. The big toe joint may be stiff, and there may be some swelling or bruising. Moving the toe upwards will make the pain worse.

    Your doctor will ask you questions relating to your symptoms, any trauma to the foot, and more general questions about your lifestyle, particularly any sports or activities that you engage in.

    You will have a physical examination of the foot, during which the doctor may manipulate the big toe to locate the area of pain and which movements make the pain worse. He or she will also assess the degree of flexibility of the toe.

    X-rays of the foot will be taken. Occasionally an X-ray of the unaffected foot will also be taken, for comparative purposes. X-rays clearly show bones, and therefore are a useful tool in the diagnosis of sesamoiditis. Sometimes an X-ray is inconclusive, in which case a bone scan may be performed.

    Conservative (non-surgical) treatment is usually successful, but in cases where such measures have failed to provide relief, surgery can be performed to pare or remove the sesamoid bones. Surgery can lead to other, related problems, so is only performed if absolutely necessary.

    For sesamoiditis without a bone fracture, the following measures should help:
    • Avoid any activity that worsens the pain.
    • Rest the foot by limiting weight-bearing activities and perhaps using a crutch when walking.
    • Take over-the-counter pain medication such as acetaminophen (Tylenol), ibuprofen (Advil), or aspirin, as directed.
    • Ice the foot by crushing ice in a bag, wrapping the bag in a towel, and applying to the ball of the foot. Keep the ice in position for as long as is comfortable, and repeat several times a day when the pain is acute.
    • The big toe can be taped into a slightly downward position, to relieve stress on the sesamoid tendons.
    • Wear shoes that are long enough and that have cushioned soles and low heels. Try inserting a cushioning pad (dancer’s pad) inside the shoe, placed under the sesamoid bones. In some cases wearing a shoe with stiff soles may be more comfortable.
    • Your doctor may administer a corticosteroid injection to relieve pain and inflammation. This often provides immediate relief from symptoms.
    • Your doctor may recommend that you wear a brace on the lower leg for 4-6 weeks.
    • Custom orthotics will redistribute weight away from the sesamoid bones and can be worn with cushioning pads.
    If the sesamoid bone has been fractured it is more likely that you will need to wear a brace for a few weeks. The big toe may be taped in order to restrict movement of the joint while the bone heals. Orthotic inserts and cushioned pads can reduce the weight borne by the sesamoids.

    With time and careful treatment your symptoms of sesamoiditis should disappear. To avoid recurrence of the condition, wear orthotics in your shoes, minimize time spent wearing high heels, and be careful not to overdo activities that trigger pain.

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  • Stress Fracture


    Stress Fracture

    Stress fractures are tiny bone fractures, predominantly found in the weight-bearing bones of the lower limbs, which occur as a result of repetitive forces placed upon the bone that outstrip the bone’s ability to repair itself. They are sometimes known as fatigue, or hairline, fractures.

    Bones are living tissue and as such are continually involved in a process of repair and regeneration. Subjecting the bones to stress stimulates them into building new and stronger bone. Weight-bearing exercise, in particular activities and sports that involve running and jumping, cause the bones to be both compressed and twisted. Bones respond to such forces by breaking down old cells and building new bone to strengthen the areas under stress. If the rate of micro traumas to the bone surpasses the rate of bone repair, the tiny cracks, known as stress fractures, will not be able to heal. It is during periods of rest that new bone cells are added, so insufficient recovery time can lead to more severe damage and, eventually, chronic pain.

    Various risk factors will increase a person’s vulnerability to developing stress fractures.

    Certain inherent risks include:
    • Low bone density
    • Misalignment of the lower limb or foot
    • A discrepancy in leg length
    • Foot structure: either flat feet or high, rigid arches
    • Gender: Women are slightly more susceptible, especially young female athletes, who may suffer from what is known as ‘the female athlete triad’, a combination of an eating disorder, irregular menstruation, and osteoporosis.
    • Menstrual irregularities
    Other risks include:
    • Overuse: this is the primary cause of stress fractures, and athletes among the people most at risk. Muscle fatigue can contribute to the formation of stress fractures: If the muscles are weakened by overuse, they may be unable to absorb enough shock, which is then transferred to the bones.
    • Suddenly increasing the rate or intensity of training. As an example, up to half of the injuries suffered by military recruits are reported to be stress fractures of the long bones in the foot (metatarsals). These injuries are often called ‘March’ fractures as they frequently arise from marching.
    • Changing the training surface to one that is harder than usual
    • Wearing incorrect footwear that fails to properly support the feet
    • Eating a diet that does not include enough calcium, vitamin D, or calories, all of which are critical for building strong bones
    • Chronic use of some medications, for example, steroids
    Initially, symptoms usually appear as a mild pain that occurs during activity, especially towards the end of a period of training or participation in a sport. There may be some local tenderness, swelling or bruising. Gradually the pain starts earlier and worsens in intensity with each subsequent training session. When the damage has progressed to a certain point, pain persists even when at rest, and night pain becomes common.

    The pain might be experienced as a deep ache, made worse with pressure on the affected area, particularly if both sides of the area are pressed at the same time.

    Your doctor will make a diagnosis based mainly on your medical history, risk factors, and a physical examination. Questions, relating to the type and level of your sporting activity, diet, and footwear, will help the doctor to assess your individual risk factors. The physical examination might include asking you to perform particular movements in an effort to induce the pain. The structure, alignment, flexibility, and strength of the lower limb will be evaluated.

    X-rays might be used for diagnostic purposes, although often stress fractures are too small to be seen, at least until the formation of healing tissues is visible. MRI (magnetic resonance imaging) and CT (computed tomography) scans tend to be of more use. Sometimes a bone scan might be performed, which involves the intravenous injection of a radioactive dye. The radioactive material accumulates in areas of rapid bone changes, and can sometimes show activity at stress fractures, but such scans, although sensitive, are not always very specific.

    Rest is the primary treatment for stress fractures. Any activity that causes pain must be avoided in order to allow the bones enough time to heal properly. This period of enforced rest may last from 4-12 weeks, depending on the location and severity of the damage.

    During the acute phase, it may be helpful to apply ice to the painful area. The ice should be crushed in a bag and covered with a towel before being applied, and kept on the affected area for as long as is comfortable.

    Over-the-counter pain medication such as acetaminophen (Tylenol) or NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil), naproxen (Aleve) or aspirin can be used, although there is some evidence to show that using NSAIDs may inhibit bone repair.

    Your doctor might recommend temporarily using crutches or wearing a brace. In moderate to severe cases a splint or cast, worn for 6-8 weeks, might be necessary.

    The return to activity must be undertaken slowly and carefully and at a recommended rate of not more than a 10% increase in intensity per week. Your doctor or physiotherapist may help you by devising a graduated exercise program. Doing too much too soon will delay recovery and increase the risk of damaging your bones again.

    Surgery is uncommon for the treatment of stress fractures.

    Wearing correctly fitted footwear is extremely important. Shoes should provide proper support and adequate cushioning. Training shoes should be replaced frequently. Orthotic inserts can be very helpful if you have flat feet or high arches.

    Ensure that you eat a diet rich in calcium and vitamin D and that provides enough calories for your activity level.

    When training, increase the intensity by small increments to reduce the risk of overstressing your muscles and bones.

    Alternating running with other activities, for example bicycling or swimming, can help avoid overloading certain muscles and bones.

    If you experience any pain or swelling in the foot or lower limb while participating in a particular sport or activity, stop and rest for a few days.
  • Turf Toe


    Turf Toe

    Turf toe, or metatarsalphalangeal joint sprain, is an injury to the ligament in the ball of the foot, under the big toe.

    The first metatarsalphalangeal joint is found at the junction of the medial (nearest the arch) long bone in the foot, and the first bone of the big toe. As well as the ligaments and muscles associated with the joint, there are two sesamoid bones embedded in a tendon that serve to increase the amount of power in the muscles.

    The joint functions as a hinge, allowing the big toe to move up and down. When a step is taken, weight is transferred from the heel to the ball of the foot and finally to the big toe as the foot pushes off from the ground. The base of the big toe lifts during the push off movement. If the big toe remains flat on the ground instead of lifting, the joint can be extended beyond its normal range of motion. If this happens, the ligament that runs under the big toe and connects the bones can be stretched or torn. In severe cases, the capsule around the joint may also be injured. Another situation that can result in damage to the joint is compression of the toe, which can happen if the toe slides forward and strikes the end of the toe box in the shoe, an injury known as 'jamming'.

    Turf toe is so-called because athletes playing on artificial turf commonly suffer from this injury. Artificial turf is a harder surface than grass, and wearing 'turf shoes' that grip the surface excessively increases the risk of jamming the big toe.

    Martial arts practitioners and dancers are also at risk of turf toe, as the movements involved require repeated extension of the big toe.

    Injuries usually happen suddenly, but turf toe can develop gradually.

    The condition causes instability of the joint, the risk of dislocation of the big toe, and potential extra wear and tear on the joint that may lead to the early development of arthritis.

    • Hyperextension of the big toe, either suddenly or repeatedly
    • Blunt trauma to the end of the big toe - 'jamming'
    • Wearing footwear with soles that are too flexible
    • Playing on hard surfaces, or artificial turf
    The initial injury may not always be noticeable, due to being distracted by the particular activity in which the athlete is involved. Symptoms may only begin to appear some time after the event. The primary symptom is pain at the base of the big toe, in the ball of the foot. There may be localized swelling, and the toe joint may be stiff. Occasionally there may be redness visible at the site of injury. Pain may subside with rest, only to reappear with the resumption of activity. A 'pop', either audible or felt, may be experienced at the moment of injury.

    The diagnosis of turf toe is usually quite simple. Your doctor will take a full medical history, noting in particular any previous injuries to your foot. He or she will ask you about the specific circumstances of the injury, and also about your occupation, lifestyle, level of activity, and the types of footwear that you use.

    Following the medical history, a physical examination of your foot will take place. The location of the pain will be noted, as will any swelling or stiffness. The big toe may be lifted, which will cause pain if the ligament has been sprained. The range of motion of the joint will be assessed and the foot will be compared with the unaffected foot.

    X-rays may be taken to rule out a possible bone fracture or arthritis, and in certain circumstances an MRI (magnetic resonance imaging) or CT (computer tomography) scan may be necessary.

    As with most joint injuries, the severity of the damage is graded, with stage 1 being relatively mild, and stage 4 the most severe.

    It is very important to take the time necessary in order to let the ligament heal properly. If you try to return to your previous level of activity too soon you run the risk of damaging your joint again.

    Initial treatment consists of resting the damaged ligament. Your doctor may recommend immobilizing the joint by taping the big toe to the next toe. Taping the toe will also provide a measure of relief from pain. You may also need to use crutches to avoid placing weight on the toe when walking, or you might be instructed to wear a walking boot.

    During the acute phase, applying ice to the painful area will help to relieve swelling and discomfort. Crush ice in a bag and wrap the bag in a towel before placing on the skin. Keep the area iced for as long as is comfortable, and repeat several times a day.

    Elevating the foot above the level of your heart whenever possible will reduce swelling, and you may take over-the-counter pain medication as needed and as directed by your doctor.

    It may take three to four weeks for the pain to subside, and physiotherapy might be helpful to regain full range of motion of the toe joint, especially if the joint has been immobilized for some time.

    A turf toe T-strap is an inexpensive, readily available strap that is placed over the big toe to restrict the movement of the joint.

    Dancer's pads are also inexpensive and easily obtained. They are inserts that can be applied directly to the skin, just behind the ball of the foot, in order to deflect weight away from the first metatarsalphalangeal joint. They can also be placed in the shoe, under the inner sole.

    Turf toe plates are orthotics designed to limit the range of motion of the big toe. They are made of composite carbon graphite, which results in a very thin but stiff shoe insert. These are more expensive than straps of pads, but are very effective for the treatment of turf toe.

MMAR Medical is proud to feature a comprehensive “Most Common Foot and Ankle Injury Library” as a free resource to sports medicine professionals and individuals seeking a better understanding of possible Foot and Ankle injuries. The following articles are written by professional medical copywriters, with the intent to make it easy to understand the most common  Foot and Ankle injuries. Each article addresses a specific Foot and Ankle injury or condition, related symptoms, the possible causes of the issue, and recommended treatments, including rehabilitation techniques and  Foot and Ankle bracing and support options.