Ryan Howard Eager to Return to Phillies

Philadelphia Phillies’ first baseman Ryan Howard may be returning to play soon, following his surgery at the end of last season for a torn Achilles tendon.  Howard sustained the injury while making the final out in the 2011 NLDS game.  He had been showing signs of improvement during spring training, but developed an infection at the site of the repair, requiring revisional surgery.  He reportedly took his first batting practice last week.

What is an Achilles tendon rupture?

The Achilles tendon runs along the back of the leg and connects the calf muscles to the heel bone.  It is one of the strongest tendons in the body, and functions to help lift the heel while walking.  The Achilles tendon may sometimes be referred to as the “heel cord”.

The Achilles tendon can rupture when excessive forces run through the tendon as the muscle is contracting.  This may come from landing on the heel during sports such as basketball, or from accelerating too quickly.  It may also be caused by direct trauma to the back of the leg or foot. 

Achilles tendon ruptures are most commonly seen in the “weekend warriors”.  These are typically middle-aged individuals who participate in high-intensity sport for recreation, but do not have proper conditioning.  Less commonly, ruptures can be seen secondary to systemic inflammatory conditions such as rheumatoid arthritis, or with certain types of drugs such as steroids.

Signs and symptoms of an Achilles tendon rupture include a sudden onset of pain, which is often described as a snapping sensation in the back of the leg, as if one has been kicked.  There is often an audible “snap” or “pop”, and the area between the calf muscles and the heel will swell up almost instantly.  A person with an Achilles tendon rupture will usually have difficulty walking, particularly uphill or upstairs. 

Prompt treatment is required in the event of Achilles tendon rupture.  Until the person can be seen by a doctor, RICE therapy should be applied.  This includes rest, ice, compression, and elevation.  Rest should include staying off the foot, with a wheelchair or crutches if they are available.  Ice should be applied to the area, often with a towel protecting the skin from direct exposure.  Compression may be achieved with the use of an elastic bandage.  Elevation of the leg above the level of the heart will help decrease swelling and pain in the area. 

Diagnosis of an Achilles tendon rupture can be made through a thorough clinical exam.  This includes inspection of the back of the leg for a delve where the tendon is normally taught.  Motor testing will reveal a decrease in strength of plantarflexion (pointing the toes towards the ground) with associated pain.  Squeezing the back of the calf where the muscles are will also recreate the pain, and may show that the foot has limited or no motion compared to the unaffected side.  Imaging studies such as x-rays or MRI may be used to further evaluate the leg for any associated injury such as fracture or dislocation, as well as measure the extent of the tear. 

Treatment for Achilles tendon ruptures is broken down into non-surgical and surgical treatment.  Non-surgical treatment involves placing the foot and leg into a cast, and limiting the motion of the ankle joint.  This allows the ends of the tendon to repair and heal themselves.  This process can take anywhere from 8-12 weeks, and avoids surgery.   However, research has shown that there is a higher rate of re-rupture following conservative treatment versus surgical intervention.

Surgical intervention for Achilles tendon ruptures is often used, and there are a number of different procedures and techniques available.  Essentially, all of these techniques revolve around rejoining the broken ends of the tendon.  This may be done with sutures, tendon grafts, or techniques of lengthening the muscle and tendon, or even transferring a nearby tendon to help in the repair.  There are inherent risks involved in surgical treatment, including delayed healing and infection.  However, surgical intervention has been shown to have a lower rate of re-rupture, and is often used in younger patients and high performance athletes. 

Whether the treatment for an Achilles tendon rupture is surgical or conservative, physical therapy is required for rehabilitation.  This involves a number of exercises designed to help strengthen the muscles and tendons, and help retrain the body to adapt to the repair.  It can often take up to six months for a patient with an Achilles tendon rupture to return to their pre-injury level of athleticism and performance.  

Central Florida Foot and Ankle Center, LLC. 
101 6TH St. NW. 
Winter Haven, Fl. 33881 
863-299-4551 
www.FLFootandAnkle.com

Springtime Running Tips

Springtime is here and running season is back!  If you're looking to get back into running shape, shed a few winter pounds, or even run your first marathon, here are a few tips to get you started.

Check your gear. How old are your running shoes?  Did you get them last summer?  Maybe the year before?  Have you been beating them up on the treadmill all winter long?  Chances are, you'll need a new pair to start running with.

Look at the EVA padding along the shoe. The EVA, or ethylene-vinyl acetate, is that layer of foam between the upper and the rubber sole of the shoe. Are there vertical creases in the EVA that don't go away?  This is one of the signs that the shoe's padding is wearing thin, and isn't doing its job anymore. Also take a look at the bottom of the shoe. The sole of the shoe should have a nice tread on it, and the wear pattern should go down the middle of the shoe. If the sole is very worn down, particularly if it unevenly worn down, a new pair may be necessary.

Start slow. Even if you've been running on the treadmill all winter, running outside can take some adjusting. Pavement is much harder than treadmill running, and can be much less forgiving on your muscles and joints. Overuse injuries like stress fractures and tendinitis are extremely common in the beginning of the training season.

If you haven't been running at all, starting slow is especially important. Going from the couch to running several miles can be very hard on the body. Warm up with stretching and a brisk walk before getting into a quicker pace.

Stay hydrated. Running outside in the heat can cause you to sweat even more than usual. Drink a glass of water about 20 minutes before going for a run, and be sure to bring some extra water with you for longer runs. Gatorade and other sports drinks can help replenish electrolytes, which are also lost during heavy sweating.

Watch the sun exposure. While it may feel great spending time in the sun, too much exposure can increase the risk of skin damage and development of skin cancer. Be sure to wear sunscreen, sunglasses, and a sun hat to limit your exposure. If you are fair-skinned and burn easily, you may consider wearing a lightweight long-sleeved t-shirt when running outside.

Enjoy yourself. Spending time outside running can boost your mood and energy level, and can make you feel great. It is a great way to get exercise, and a great way to enjoy the weather.

Central Florida Foot and Ankle Center, LLC. 
101 6TH St. NW. 
Winter Haven, Fl. 33881 
863-299-4551 
www.FLFootandAnkle.com

Dustin McGowan with Plantar Fasciitis

Dustin McGowan, pitcher for the Toronto Blue Jays, has recently been diagnosed with plantar fasciitis in his right foot.  This injury comes as part of a streak of injuries to McGowan, most notably Tommy John surgery on his throwing shoulder as well as suffering from several other shoulder and labrum injuries.  The right-hander was just given a two-year, $3 million contract extension to stay with the Jays. 

The plantar fasciitis injury, luckily, is being reported as not serious.  Blue Jays fans and teammates hope that McGowan can recover quickly, and perhaps in time for the season opener.  Dustin McGowan is currently listed as day-to-day. 

Plantar fasciitis is a condition of the foot that most commonly presents as heel pain.  It is common to feel the pain with the first few steps of the day, or after a period of rest.  The pain can be excruciating for some, while others may be able to deal with it.  The pain may ease a bit after the first few steps following rest are taken, but will typically develop as the day progresses.  This is especially true for people who spend a lot of time on their feet.

Plantar fasciitis is caused by excessive strain on the plantar fascia, which is a structure located on the bottom of the foot.  This excessive pressure may come from things such as foot mechanics, foot structure, increased activity, or excessive weight.  The condition may begin as an acute inflammatory reaction to this excessive strain, but generally presents as a chronic condition.  

Most cases of plantar fasciitis will resolve with rest, ice, anti-inflammatory medications, and orthotic devices.  The orthotics may be over-the-counter type devices or custom molded to a person’s foot.  Other methods of treatment may include injection of cortisone into the area, ultrasound therapy, or other advanced modalities. 

Occasionally, a case of plantar fasciitis may be bad enough to warrant surgical correction.  These cases are generally instances where conservative therapy has failed after several months or even years.  Surgical intervention involves cutting a small portion of the plantar fascia to relieve some of the tension on the structure.  The plantar fascia serves to keep much of the integrity of the structure of the foot, so caution should be taken by the foot and ankle surgeon not to compromise this integrity. 

As for Dustin McGowan, hopefully his case of plantar fasciitis will resolve soon.  Keep an eye on his progress to see how this injury will affect his starting date this season. 

Central Florida Foot and Ankle Center, LLC. 
101 6TH St. NW. 
Winter Haven, Fl. 33881 
863-299-4551 
www.FLFootandAnkle.com

Fractures of the Calcaneus

With springtime upon us, warmer weather is coming, and spring-cleaning is right around the corner.  As people dust off the ladders and start climbing to fix the shutters and clean out the gutters, emergency rooms start seeing fractures of the calcaneus in waves. 

Fractures of the calcaneus, or heel bone, are the most commonly seen foot fractures, comprising about 75% of all foot fractures.  This makes up between 1-2% of all fractures of the body.  The most common mechanism of injury in a calcaneal fracture is a fall or jump from a height, as well as motor vehicle accidents. 

Fractures of the calcaneus can be devastating.  Because the skin and soft tissue surrounding the bone is so thin, the fractures can often present as open, and are prone to infection.  The crushing nature of the fracture has been likened to an egg exploding. 

The subtalar joint, which sits between the talus and the calcaneus, is commonly affected by most calcaneal fracture patterns. When the fracture line goes through the joint surface on the calcaneus, post-traumatic arthritis can develop.  The subtalar joint plays a key role in connecting the foot to the ankle, and injuries to this joint can have a huge impact on daily activities.  Thus, one of the critical things for the foot and ankle surgeon to evaluate is the integrity of this joint following injury. 

When a person presents to the emergency department with a suspected calcaneal fracture, the first thing that is done after the patient is evaluated and stabilized is to take x-rays of the foot.  Often the x-rays will not show the physician the entire picture, so a CT scan is usually necessary.  The CT scan can give much better images of the bones and joints involved. 

The decision to operate on a fractured calcaneus depends on a number of variables, both intrinsic to the injury pattern as well as factors determined by the patient’s overall health.  Patients that have diabetes, poor vascular flow to the legs, increased age, or other injuries that are more urgent than the foot may not be god candidates for surgery.  These patients, in certain circumstances, may be better off with limited intervention or conservative therapy, which may or may not be followed by further intervention in the future.

Looking at the injury pattern can also determine if surgical intervention is necessary.  Fractures that are displaced, meaning that the fragments are separated from each other and don’t line up anatomically, may need surgery to bring the pieces back together.  However, when the calcaneus is broken into too many pieces, or highly comminuted, surgery may not increase the likelihood of a positive outcome.  The condition of the skin can also influence the decision.  If the skin is very swollen, or if there is a lot of blood in the skin, surgery may be postponed until the swelling has a chance to subside.

Surgery for calcaneal fractures has been an area of great interest in orthopedic and podiatric surgery for a very long time, and continues to be an area that is discussed at length.  A number of different surgical techniques exist, and every case is different.  The research has led to greater outcomes following surgery, but a calcaneal fracture can still turn into a truly life-altering event.  

Central Florida Foot and Ankle Center, LLC. 
101 6TH St. NW. 
Winter Haven, Fl. 33881 
863-299-4551 
www.FLFootandAnkle.com

Billups Out for Season with Achilles Tear

Chauncey Billups will be forced to sit out the rest of the NBA season with a torn Achilles tendon.  The injury came in Monday night’s game against the Orlando Magic, as Billups’ Clippers went on to beat the Magic 107-102 in overtime.  Billups, who is 35 years old, reports that he had not previously had any pain in his Achilles tendon.  The tear, however, was confirmed with MRI on Tuesday.  Billups will undergo surgery to repair to torn tendon, and promises to return to the league.

Achillles tendon tears can often occur just like they have to Chauncey Billups, with no real history of pain in the area.  However, what is common in Achilles tendon tears is that there is degenerative disease in the tendon that precedes the tear.  This degenerative disease is usually appreciated in the operating room under direct visualization when the tendon is repaired, even when the MRI reads the tendon as normal.  This is because the changes can often be too subtle to pick up MRI.  The degenerative condition is referred to as tendinosis of the Achilles tendon, and when there is an acute incident of pain without a rupture, it is called tendinitis.

Surgical repair of Achilles tendon tears and ruptures involves cleaning up the ends of the tendon and removing any scar tissue that may be present in the tendon.  A more normal shape and appearance of the tendon is achieved using strong sutures to and strength to the tendon as it heals.  Post-operatively, the patient is placed in a cast and remains non-weight bearing for several weeks.  Following removal of the cast, aggressive physical therapy is initiated for rehabilitation.  The timeline for complete healing of the surgical site is usually between three and six months, and a return to full strength may come after complete healing has occurred.  In a professional athlete such as Chauncey Billups’ case, this usually means the season ends early. 

Billups, a five-time NBA All-Star, will certainly be missed on the court.  He is considered one of the strongest leaders in the league, and has a way of boosting team morale both on and off the court.  He was picked up by the Los Angeles Clippers from the New York Knicks, and has become a key role in the team’s ascent to the top of the Western Conference.  They are in serious contention for the championship this year, in part due to Chauncey Billups.  Hopefully he will be back on the sidelines soon, his presence giving the Clippers motivation to win. 

  

Central Florida Foot and Ankle Center, LLC. 
101 6TH St. NW. 
Winter Haven, Fl. 33881 
863-299-4551 
www.FLFootandAnkle.com

Gronkowski Expected to Play in Super Bowl

The New England Patriots’ victory on Sunday over the Baltimore Ravens sends the Pats to the Super Bowl, but a scary moment came in the third quarter when tight end Rob Gronkowski went down with what looked like a serious injury.  After catching a short pass, Gronkowski was tackled and had his left ankle trampled in the process.  The injury looked bad at first, and Gronkowski was helped off the field.  He later returned to the game in the fourth quarter, but was seen wearing a boot after the game.

The Boston Herald is reporting that Gronkowski’s ankle is “fine”, and that he’ll be ready to play in two weeks when the Patriots take on the New York Giants in the Super Bowl.  This news comes as a relief to Patriots fans everywhere.

Ankle injuries in football and other sports are a common occurrence.  The anatomy of the ankle is such that a number of different structures may be injured following trauma to the ankle.  The most common types of injuries are sprains of the lateral ankle ligaments.  These include the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL).  The medial ankle ligaments include the superficial and deep deltoid ligaments, which are less commonly affected by rotational ankle injuries. 

Fractures of the ankle can also occur, including fractures of the lateral malleolus (outside ankle bone), and the medial malleolus (inside ankle bone).  The talus, which sits between these two structures in the ankle joint, can also be affected.  Most commonly, the talus may have an osteochondral lesion, which is a chip in the joint surface. 

High ankle sprains are injuries to the syndesmosis of the ankle, and can be very slow healing injuries that are prone to complications.  These can be quite severe injuries, and may be associated with the development of long-term instability of the ankle.

A number of tendons cross the ankle joint, and can also become damaged in an injury.  Most notably, the peroneal tendons, which run along the outside of the ankle, may become strained or even dislocated in a rotational-type of injury. 

Fractures of some of the bones of the foot may also be seen in rotational-type ankle injuries, including the fifth metatarsal, the cuboid, the navicular, and the anterior process of the calcaneus.  A thorough work-up with x-rays is almost always warranted. 

While it is not clear what anatomic structures Rob Gronkowski’s injury involves, it is good news that the medical staff is anticipating his return for the Super Bowl.  He is certainly a major asset to the Patriots, and plays a vital role in their offense.  

Central Florida Foot and Ankle Center, LLC. 
101 6TH St. NW. Winter Haven, Fl. 33881 
863-299-4551 
www.FLFootandAnkle.com