Microfracture Surgery for Greg Oden

Greg Oden, of the Portland Trailblazers, will be forced to miss the rest of the NBA season this year. The center, who was the #1 pick in the 2007 draft, has just recievd microfracture surgery of his left knee. Oden received a similar surgery on his right knee during his rookie year, which postponed his professional start.

Microfracture surgery is a treatment for an osteochondral lesion, which is damage to the articular cartilage within a joint. The knee is a common place for these types of injuries to occur, as well as the ankle. The surgery involves making tiny holes in the damaged cartilage, which allows for blood to access the area more easily. This brings in healing and growth factors, which can promote the generation of cartilage in the area. The new cartilage that forms is fibrocartilage, which not quite the same as the hyaline cartilage that forms the cartilage of the joint. However, this fibrocartilage does allow for a more normal range of motion postoperatively, and often can reduce the pain associated with an osteochondral lesion. In podiatry, it is common to see an osteochondral lesion of the talus following an ankle injury, which sometimes may be corrected with microsurgery.

A study out of Drexel University College of Medicine studied NBA players that received microfracture surgery of the knee between 1997and 2006. The study looked at a number of factors, and analyzed the player efficiency ratings (PER) of the NBA players both before and after the surgery. The study found that twenty-percent of the players did not return to the NBA. It also found that of the players that did return, only 17 of 24 players continued to play for more than two years, and that universally all players saw a reduction in their player efficiency rating as well as the number of minutes played.

What will be the fate of Greg Oden following his second microfracture surgery? There’s no way to know for certain, but the NBA is hopeful that he will recover and have a successful career. Certainly he will be able to have a normal life after the surgery, but will his knees be able to withstand the high impact of an NBA player? The high forces placed through the lower extremity during running and jumping, as well as the sheer forces place on the knees during cutting and pivoting moves may prove to be to much for the Portland Trailblazers’ center.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Platelet-Rich Plasma Therapy

In the world of sports injuries, healing time is of the utmost importance. The difference in a week for full recovery can mean the difference between making the playoffs and ending the season early. Because of this need for fast-tracking healing times, different innovations have become more popular in medicine. One of these innovations is the use of platelet-rich plasma.

Platelet-rich plasma (PRP) had been used previously as an adjunct to healing in spinal surgeries and in plastic surgeries with extensive soft tissue damage. The process involves drawing a small amount of blood from the patient (between 30mL and 60mL), putting the blood into a centrifuge, and spinning it down to separate the blood components. The plasma is separated from the cells, but the platelets are kept in the plasma. This platelet-rich plasma can then be injected back into the same patient, in the area that healing is needed. PRP has gained popularity, and has been used to treat tendon injuries, ligament injuries, cartilage injuries, muscle injuries, and for chronic wounds.

Part of PRP’s recent surge in popularity is due to its use in treating sports injuries. Professional athletes like Tiger Woods, Troy Polamalu, and Hines Ward have all received media attention from PRP therapy. Recently, Houston Texans wide receiver Andre Johnson has made the news for receiving platelet-rich plasma treatment. As more and more professional athletes use PRP therapy, it becomes more common for amateur athletes and weekend warriors to ask their doctors about the treatment.

The theory behind how PRP therapy works is somewhat simple. Platelets in the blood normally release chemical signals to promote healing at a specific site. These signals attract more platelets to the area, which increases the amount of signal being release, and thus the healing process continues. By removing blood from a person and concentrating the amount of platelets in a particular area, the healing time is theoretically increased.

In podiatry, common uses for PRP therapy include plantar fasciitis and Achilles tendon tears/ruptures. Both of these areas are prone to chronic injuries that can be very difficult to heal, and can often take a very long time for the symptoms to go away. Therefore, platelet-rich plasma therapy becomes an interesting option for these patients. These areas of injury can also have a relatively low blood supply, which may be why they are prone to injury in the first place. Injecting platelet-rich plasma into these areas can promote healing in an area that may be difficult for platelets to reach on their own.

While platelet-rich plasma seems to be a great therapy to boost the healing of certain types of injuries, there are certain limitations to its use. The studies that have been performed show inconsistencies in the method of use, as well as small sample sizes and a lack of control subjects. Additionally, there are many studies that show inconclusive results as to the efficacy of PRP. This takes away from the studies that show PRP to be an effective method of treatment, as the results may not be able to be repeated.

While there may be some controversy over its efficacy, PRP is still becoming a popular method of treatment for chronic injuries, particularly among professional athletes. This is due to a vast amount of resources for this patient group, as well as the desire to fast-track recovery time. As more studies are performed on the topic, watch for more solid results to be shown.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Metatarsalgia (Forefoot Pain)

The term metatarsalgia translates to “pain in the metatarsals”. It is most commonly used to describe pain in the metatarsal heads, at or near the ball of the foot. Though it is sometimes used as a discrete diagnosis, the term metatarsalgia is a very general term that does not offer a reason for the pain. There are a number of different conditions that can cause metatarsalgia, and many others that may mimic the findings.

True metatarsalgia results from increased pressure in the metatarsal heads. This is most commonly the result of biomechanical deformities such as hallux valgus or an elevated first ray. Conditions like this may also be associated with bunion formation. Most frequently it is associated with a flatfoot, or a foot that is prone to pronation syndrome. However, increased pressures through the metatarsal heads may also be seen in a high-arched foot, or pes cavus.

Another common cause of metatarsalgia is a thinning of the fat pads at the bottom of the foot. Fat pads are normally found underneath the heel and at the ball of the foot. These well-organized structures help to cushion the forces applied to the foot while walking. In older people, the fat pads can thin as a normal part of aging, a component of some disease processes, or with the use of some drugs such as oral steroids. When the fat pad at the ball of the foot thins, the cushioning underneath the metatarsal heads is lost, and metatarsalgia may ensue.

Pain in the metatarsal heads is also commonly seen with hammertoes, as the contracted digits force the metatarsal heads into the ground with excessive force. Over time, this can create a painful situation.

Other conditions of the foot may appear as metatarsalgia, but may actually be a different pathological process. Neuromas, particularly those found between the metatarsals such as Morton’s neuroma, can appear at first as metatarsalgia. Stress fractures of the foot may also lead to pain in the ball of the foot or at the metatarsal heads.

Rheumatoid arthritis may appear initially as metatarsalgia, and should be ruled out as a part of the clinical exam. This may include x-rays as a diagnostic study, which can also look for avascular necrosis of the metatarsal heads as a cause of the pain. Tendinitis, bursitis, and capsulitis (a swelling of the joint capsule) can also appear as metatarsalgia. It is up to the clinician evaluating the patient to differentiate between these pathologies.

The best treatment, therefore, for metatarsalgia, is to address the underlying cause of the condition. If it is a biomechanical etiology, such as from over-pronation, conservative therapy may address correcting the deformity. The use of custom orthotics or another type of shoe insert is commonly employed as a first-line treatment. Simply resting and icing the area while taking anti-inflammatory medications may alleviate the pain, but can also delay the proper and necessary treatment. Custom orthotics, specialized shoe inserts, a change in shoes, and possibly shoe modifications will all help the person with a loss of the protective fat pads found on the bottom of the foot as well.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

Pes Cavus

A high-arched foot, referred to medically as pes cavus, is a foot in which there is a large opening of the inside of the foot when bearing weight. A high-arched foot is the opposite of flat feet, and is considerably less common than flat footedness.

Pes cavus may be an asymptomatic foot type, and may actually be beneficial in sports such as long distance running. The foot is fixed in a downward position, or plantar flexed, and is often quite rigid.

In the symptomatic patient, there may be difficulty in shoe fitting. Custom orthotic devices for the foot are often necessary, and children with high-arched feet may have difficulty walking. Some common complaints of symptomatic pes cavus patients include metatarsalgia, ankle instability, and corns and calluses of the feet where ill-fitting shoes may be rubbing.

The causes of pes cavus are as varied as people with the foot type. There is often no identifiable underlying cause, most commonly observed in the asymptomatic patient. There are a number of neurological disorders that can lead to pes cavus, including Charcot-Marie-Tooth, cerebral palsy, and multiple myeloma. Pes cavus may also be seen in some cases of diabetes and following stroke.

When being evaluated by your physician for pes cavus, there are a number of questions you may be asked. Some topics might be:

• Progression: Have your feet always had a high arch, or is it a new development?

• Location: Is the high arch on both feet? Is it noticeably higher on one side? Have you noticed any changes to your hands?

• Associated Symptoms: Have you had any burning, tingling, numbness or pain in the hands or feet? Have you recently been sick or been caring for an ill person? Have you had any previous injuries to the foot?

Generally, the treatment for high-arched feet is to accommodate any injuries, prevent further injuries with the use of orthoses, and to use properly fitting shoes. This conservative treatment is effective in most.

Surgical treatment is only used for severely symptomatic feet, and only after conservative treatment has failed. The goal of surgical treatment in pes cavus is to bring the foot flat to the ground, thus allowing for weight to be distributed evenly through the foot. A number of different surgical procedures and techniques exist, and each patient should be considered unique. Often there is a combination of soft tissue and bony procedures that are required, and a joint fusion (arthodesis) may be necessary for proper function.

Central Florida Foot and Ankle Center, LLC.

101 6TH St. NW.

Winter Haven, Fl. 33881

863-299-4551

www.FLFootandAnkle.com

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