Hammer Digit Syndrome

Hammer digit syndrome refers to a group of deformities of the toes that causes the toes to be in a fixed position. Depending on the type of deformity, this fixed position may be flexed (where the toes are pointed downwards) or extended (where the toes are pointed upwards). The deformities come in a wide range, with names like mallet toe, claw toe, and hammertoes. Of these types of digital deformities, hammertoes are the most common form.

Types of Deformity: The lesser digits of the foot (all but the hallux, or great toe) consist of three bones called phalanges, which are connected to a longer bone called a metatarsal. The joints between theses bones are named for the bones they connect, referred to as metatarsophalngeal joints, and the proximal and distal interphalangeal joints.

With hammertoes, the deformity is seen across all of the joints. This causes the toes to curl up in a predictable pattern, as seen in the picture above. The metatarsophalangeal joint will be fixed in an extended position (with the joint bent upwards) and the proximal interphalangeal joint will be fixed in a flexed position (with the joint bent towards the ground). The distal interphalangeal joint will commonly be bent in an extended position as well.

Mallet toes show a flexed joint only at the distal interphalangeal joint (the joint furthest down the toe, closest to the nail). Claw toes will show a flexion deformity at both the distal and proximal interphalangeal joints, which will curl the toe in the shape of a claw. Hence the name, claw toes.

Causes of the deformity: Normally, the toes are kept in their straight position by a balance from the muscles the insert into the digit. These include both intrinsic and extrinsic muscles of the foot. The extrinsic muscles the insert into the lesser digits are the extensor digitorum longus on the top (dorsal surface) of the foot, and the flexor digitorum longus on the bottom (plantar surface) of the foot. The intrinsic muscles include the lumbricales and interossei muscles, as well as the flexor digitorum brevis and the extensor digitorum breivs. Together, all of the muscles will help to balance the toes, keeping them straight.

When the muscular balance of the digits is lost, it can cause hammer digit syndrome to develop. Most commonly, this will result in the hammertoe variety. There are several different ways that this imbalance can occur.

· Flexor Substitution: The extrinsic flexors of the foot and toes all originate from the back of the leg, or the posterior compartments. These muscles insert into the foot , and act to bring the bones of the foot, including the toes, towards the ground. This is known as plantarflexion. When these muscles become weakened, particularly the soleus muscle, the other flexors are forced to substitute for the soleus. When the flexor digitorum longus substitutes for the soleus, it causes the toes to curl. This can contribute to hammer digit syndrome.

· Extensor Substitution: This is essentially the same mechanism as flexor substitution, but the problem originates with the extrinsic extensors of the foot. The extensors are located in the anterior compartment of the leg. In particular, when the tibialis anterior becomes weakened, the extensor digitorum longus will increase its pull on the toes. This will cause the toes to curl up.

· Flexor Stabilization: This is a problem with the intrinsic muscles of the foot, in particular the interossei and the lumbricales. These two groups of muscles function to stabilize the toes. When the muscles become weakened, such as in flat feet, the relative pull from the flexor digitorum longus increases. This will cause the toes to curl.

High-Heeled Shoes and how they contribute to Hammertoes: It is commonly accepted among podiatrists and other foot and ankle specialists that high-heeled shoes can help contribute to the development of hammertoes. This is due to the position that the foot is put in when wearing high-heels. When a foot is placed in a high heeled shoe, the foot is in a plantar-flexed position. This lengthens the extensor muscles of the foot (especially the tibialis anterior), which effectively weakens the pull of the muscle on the foot. Thus, extensor substitution is allowed to take place. Similarly, when a person wears high-heeled shoes all day, the flexors and intrinsic musculature is not functioning in its optimal motion. The long flexors of the toes can be over-worked, causing further curling of the toes. Therefore, he use of high-heeled shoes creates the perfect situation for hammertoes and other varieties of hammer digit syndrome to develop.

Complications of Hammer Digit Syndrome:

Because the toes are no longer straight in hammer digit syndrome, they may no longer fit properly into shoes. A toe that is curled up inside a shoe may be forced to rub up against the shoe, causing pain and hotspots to develop. These areas of friction can quickly develop into corns and calluses. The areas of friction are commonly seen on the top of the toes, at the joints.

Additionally, when the toes are curled up, weight can no longer be placed on the toes in the proper way. Therefore, the weight is shifted more onto the ball of the foot, which can cause large calluses to develop on the bottom of the feet.

Treatment: There are a number of factors that play into the treatment of the different varieties of hammer digit syndrome. Most commonly a conservative approach is taken first. This would include things like trimming of the corns and calluses, a change in shoe gear to accommodate the deformity, and different padding techniques to help alleviate some of the pain. All of these measures will help relieve the pain associated with hammertoes, but will not correct the deformity.

The only way to truly correct the deformity is to have surgery on the toes. Depending on the extent of the deformity, the surgery may address only the soft tissues of the toes (the ligaments and tendons influencing the deformity) or it may include the removal of some of the bone in the toes.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

The Barefoot Running Debate

Barefoot running is a topic of much debate. The trend of runners shedding their bulky running shoes for lighter weight shoes or even no shoes at all as been progressively getting bigger over the past several years. More and more runners are joining the movement, and the shoe companies are responding. Nike’s Free series of running shoes have different gradients of cushioning depending on the level of barefootedness that a runner desires; Vibram makes a shoe that looks more like a glove for the foot, with individual toes and a durable rubber sole, but virtually no support or cushioning.

Advocates of the barefoot running movement point to the natural biomechanics of the body as the reason to follow suit. With barefoot running, the tendency to strike with the heel first is erased. The foot hits the ground in the midfoot area first, allowing forces to be displaced more evenly and to allow for the natural shock absorbing mechanisms of the body to work. Barefoot runners claim that this causes less overuse injuries like tendonitis and arthritis, as well as a decrease in knee and hip pain.

The other side of the argument points out that there are many hazards to running barefoot, particularly in a city on pavement. Foreign objects like rocks, glass, and metal may find their way into the runner’s feet, causing injury and possibly infection. Furthermore, the opposition to barefoot running points out that there are very few “perfect” feet out there, and that most people will require some level of cushioning and support.

The truth most likely lies somewhere in between these two extremes. There are many runners out there that would benefit from strengthening of the muscles of the foot, which may be achieved from running barefoot. However, this population is limited – not everyone will reap the benefits. For many athletes, particularly the less serious and beginners out there, the risks of barefoot running outweigh the advantages.

There is a ton of information on barefoot running, whether it is coming from the Internet or from a published book or from “expert” opinions. If you are one of the many that is considering or currently participating in barefoot running, it is important to be skeptical about this information, and to ease into any new exercise program. Running long distances barefoot takes a long time to work up to, and it may be difficult to achieve for the average runner.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW. Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Is it Athlete’s Foot, or Something Else?

That dry, itchy, burning feeling on your feet hasn't gone away in weeks. Is it athlete’s foot, or could it be something else?

Athlete’s foot is a common presentation to the podiatric physician. It is a fungal infection of the superficial skin layers, usually of the fungal genus Trychophyton, and is also called tinea pedis or ringworm of the foot. It causes flaking and scaling of the skin, which can lead to itching and other unpleasant sensations. It is common for tinea pedis to spread to other parts of the body, most notably the toenails. When the fungal infection spreads to the toenails (or it may originate at that location) it is known as onychomycosis. Tinea pedis and onychomycosis are a very common combination.

Athlete’s foot may be treated with a number of different pharmaceuticals, including over-the-counter medications as well as prescriptions. Over-the-counter medications include tolnaftate (sold as Tinactin), miconazole nitrate, and terbinafine (sold as topical Lamisil). Oral medications are available by prescription. Regardless of the type of medication used, however, the timeline for curing tinea pedis can often last more than six weeks.

The fungal infection is transmitted via contact, typically in damp environments such as locker rooms and bathhouses. Preventative measures against tinea pedis can be taken by preventing contact with public surfaces. Wearing sandals or bath-shoes in areas like this can help, as well as washing the feet with soap and water, drying completely, and wearing absorbent cotton socks. Excessive sweating of the feet, or hyperhidrosis, is often associated with tinea pedis, due to the increase in moisture in the area.

However, not all that looks like athlete’s foot is tinea pedis. Blisters of the bottom of the foot, particularly diffuse blisters from chronic friction, can often look like tinea pedis. These friction blisters may come from poorly fitting shoes or sandals, and are often seen in runners.

Erythrasma is a bacterial infection of the skin between the toes that can look like tinea pedis. The two diagnoses are differentiated with the use of a Wood’s Lamp, as well as a culture of the area.

Some other conditions that may mimic athlete’s foot include psoriasis, candidiasis (also a fungal infection, but of a different genus), and allergic reactions.

Additionally, there are several different forms that tinea pedis may take. The inflammatory form of tinea pedis may show as small blister-like lesions on the foot, which are filled with either a clear or slightly opaque fluid. The blisters may pop and ooze, causing more pain. This form of tinea pedis should be dealt with aggressively, as the discontinuities of the skin can lead to infection.

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

Analyzing the Marcus Thames Injury

Marcus Thames, of the New York Yankees, suffered an ankle injury in Wednesday’s game against the Rays. He is now listed as day-to-day, as the X-rays have reportedly come back negative.

The injury came after Thames stepped on his own bat after a single to left field. Footage of the play can be seen on the MLB.com website, which you can check out here.

After watching the footage, the injury appears to have been an inversion injury of the ankle. Incidents like this can lead to ligament strains and ruptures, tendon tears, and even fractures of the fibula or tibia. The X-rays ordered following Thames’ injury was likely to rule out fractures.

Being listed as day-to-day is likely an indication that Thames’ injury is not very severe. A possible ligament strain or partial tear is possible, particular of the anterior talo-fibular ligament. This structure composes part of the ligamentous support of the lateral ankle, and is susceptible to injury.

Another diagnosis that is highly possible is an injury to the peroneal tendons. There are a number of different ways for a tendon to be injured, most of which are classified by which layer or area of the tendon is injured, or by whether the etiology is acute or chronic. In this situation, the etiology would be acute (from the incident of the injury) and the area injured would most likely be in the tendon close to the insertion into bone. If we were looking for a fracture, it would most likely be found at the base of the fifth metatarsal (where the peroneus brevis inserts) or at the base of the first metatarsal and medial cuneiform (where the peroneus longus inserts).

Since the X-rays were “negative”, a fracture of this nature is not likely. This should come to good news to Thames and the Yankees, who have seen a plague of outfielder injuries this spring.

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

www.FLFootandAnkle.com

David Beckham Tears Achilles Tendon

David Beckham returned to Britain on Monday after being sidelined with an injury last week in Finland. The soccer superstar suffered a total tear of the Achilles tendon during the game, and will be sidelined for several months to recover. This comes as a huge blow to Beckham, who was hoping to play in the World Cup this June. This would have been Beckham’s fourteenth consecutive appearance in the World Cup.

The injury occurred last Sunday, in an AC Milan game. Beckham has been on loan to AC Milan from the Los Angeles Galaxy. Beckham came to Major League Soccer’s L.A. Galaxy in 2007 when he signed a $250 million dollar deal, a record for soccer players, and throwing him into the ranks of some the biggest sports contracts ever.

Following the injury, Beckham was brought to Turku, Finland where he was operated on.

According to Dr. Sakari Orava, the surgeon who performed the procedure, Beckham will be in a cast for three to four weeks, followed by months of rehabilitation. In general, the time it takes for a complete recovery takes around six months. This is likely to be minimum amount of time it will take for David Beckham to return to playing.

The Achilles tendon is a continuation of the gastrocnemius and the soleus muscles, which are collectively considered to be the muscles of the calf. The muscles combine to form the Achilles tendon, with then inserts into the calcaneus (heel bone).

With tight calf muscles, there is extra strain put on the tendon. With enough downward force, such as from landing on the foot from a jump, can tear the tendon. The calf muscles play a huge role in most sports, as they help us run, jump. Pivot, and maneuver in many different activities.

In Beckham’s case, and in many other cases, the tendon can be completely ruptured. When this happens, there are both surgical and non-surgical options. Surgically, the tendon is sewn together with durable sutures. The foot is then put into a cast for three to four weeks, or until the tendon can heal itself.

In non-surgical treatment, the foot may be put into a cast without any repair of the tendon itself. The tendon will actually heal itself over time. Studies show that after one year, the results of both surgical and non-surgical care are about the same.

Surgical intervention, however, has been shown to provide results faster than non-surgical options. There is also a slightly greater chance of a second tear or rupture when the tendon is not repaired surgically. For these reasons, it is understandable that David Beckham and his trainers and doctors opted for surgical treatment.

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

The Battle at Marathon

As the spring approaches, we are entering into the marathon-training period (if you haven’t begun training already, that is). The arduous task of running 26.2 miles is taken on by thousands of people every year. The training is an intense process, usually lasts about three months, and is topped off with the physically, mentally, and emotionally draining challenge of running a marathon. You may be asking yourself at this point, “Why would anyone want to do this?”

Well, it all begins with the Greek legend of Pheidippides. The story goes that at the Battle of Marathon, the messenger Pheidippides was sent to Athens to report that the Persians had been defeated. After running the entire distance without stopping, Pheidippides burst into assembly to exclaim “Nenikekman”, which is translated as ‘We Have Won’. Pheidippides then collapsed and died.

The distance that Pheidippides had just completed is where the distance of a marathon run comes from. The Greek messenger, in travelling from Marathon to Athens, would have had to either crossed or ran around Mount Penteli. If he had travelled South around the mountain, which he presumptively had done, he would have completed a distance of just over 26 miles. There is some debate as to whether Pheidippides ran South of the mountain, or if perhaps he ran through the mountain, crossing straight rather than around. If he had done this, the original distance that Pheidippides ran would be significantly less than 26 miles.

The modern marathon evolved from more recent events. The marathon was first introduced during the 1896 Summer Olympics in Greece. The event was not designed with a set distance in mind, but rather with the route extending from Marathon to Athens. This was a distance of 24.85 miles. Spiridon “Spiros” Louis was the first winner of the marathon, with a time of 2 hours 58 minutes and 50 seconds.

The Olympics committee would use the idea of connecting two points on a map together as a design for the marathon event for the next six Olympic games. It wasn’t until the 1924 Olympics that the set distance of 26.22 miles was adopted. The official distance, set by the International Amateur Athletic Federation (IAAF) measures exactly 26 miles and 385 yards. This is now the distance that is used as a standard for marathon runs.

There are over 800 marathons that are organized every year. Of the most prestigious are the Boston, New York, Chicago, London, and Berlin marathons. The Boston Marathon is the longest standing of any of the annually held marathons. The tradition was started in 1897, following the popularity of the event from the 1896 Olympics. It is held every year in April, and attracts an average of about 20,000 registrants. The record for registrants was set in 1996, with 38,000 people registered to run. Time trials for the event make it difficult to enter, and it sets the scene for a very competitive event. Winners receive cash prizes, with first place overall in both men’s and women’s receiving $500,000 each.

The marathon experience has come a long way since its beginnings. What was once a Greek legend has turned into a rite of passage for serious runners. It is a distance that once attained warrants a bumper sticker, showing a glimpse of history in a strong symbol of modernism.

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

Highlights from the Winter Olympics

The Vancouver games have come and gone, and with them came great athletes into our homes and onto our televisions. The spotlight is on skiing, snowboarding, skating and hockey, the last of which has desperately tried to reach out to fans from the professional level. Well this past February, that light has shone in attention for the NHL and more.

Al Michaels and Bob Costas handled most of the NBC broadcast, guiding us through the world that is the Olympics. Stories of the highs and lows of tremendous athletes’ careers were told to us.

There was Joannie Rochette, the Canadian figure skater won the bronze medal just days after her mother died of a heart attack.

And Nodar Kumaritashvili, the Georgian luge slider that died in a horrendous crash while practicing.

And there was the USA-Canada hockey rivalry in the women’s division followed by the same set-up in the men’s division, of which both gold medal games went to the Canadians, in Canada.

Names like Bode Miller, Lindsey Vonn, and Shani Davis are etched into our memories, their gold medals gleaming.

Certainly, the drama was thick.

Through all of the back-stories and interviews, through the kiss-and-cry area in figure skating, and through the entire Olympics backdrop, there were some incredible displays of athletic performance.

Apollo Ohno, the U.S. speed skater that came into the games a heavy favorite demonstrated his strength both on and off the ice. NBC aired footage of Ohno working out on dry-land, stretching and warming up for the race. The stretches put so much weight on the lateral ligaments of the ankle, that the commentary mentioned the “do not try this at home” cliché.

The lateral ankle, of course, is a site of common pathology. Strains, sprains, tears and fractures all occur frequently at this site.

The exercise Ohno was performing demonstrated his strength and balance necessary for speed skating.

Shaun White showed us how to fly through the air, flipping around on a snowboard and landing a gold medal with an incredible performance. White’s signature move, the Double McTwist, had to wait to be displayed until after the official event in an encore run. The trick was deemed to be too dangerous for the Olympic games, and was thus banned from Vancouver.

Yes, the Winter Olympics is a grand affair. They bring us sports that we would otherwise rarely see. Curling, Nordic freestyle skiing, Biathalon, and ice dancing all become a part of our vernacular, if only for a brief time.

In addition to the athleticism on display, the theatrics of the Olympics holds nothing back. The grand finale: Michael Buble on a float in the arena that houses hockey and ice skating, singing ‘O Canada” with an amazing amount of Canadian celebrities and Mounties and dancers in a parade. It is an impressive event, and it fit well within the Vancouver 2010 Winter Olympics.

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