Archive for March, 2010

Stress fractures can result from a number of reasons. Most common causes for stress fractures are decreased bone density, post-op complications from a foot surgery, and athletic training error / overuse injury in athletes, dancers, and “weekend warriors.” It typically occurs in the second metatarsal…. The longest of all central foot bones and the one subject to the most loading forces. Since the second metatarsal tends to carry more of the body’s weight during athletic and dance activities, the increase in pressure results in osteoclastic activity and compensatory osteoblastic activity becoming imbalanced.

Symptoms:
– Increasing pain in the midfoot
– Pain at rest
– Pain during activities
– Swelling on the dorsum of the foot
There is a lack of physical signs in making this diagnosis. Stress fractures cannot be seen on plain film x-rays until a few weeks later when healing begins. For this reason, when patients present with the associated signs and symptoms podiatrists often prefer the use of bone scans that typically reveal hot spots in the area of the mid-foot in patients with common stress fractures. CT’s and MRI’s are also helpful in pinpointing the exact location of the stress fracture.
Upon diagnosis, the hallmark of treatment is immobilization through a casting boot for up to 3-4 weeks. Follow this with progressive ambulation and support in customized orthotics or shoe padding for 4-6 weeks and an intermission of the associated activity to promote healing. For the competitive athletes that require a faster recovery time, podiatrists may consider a bone growth stimulator to expedite the healing process. Anti-inflammatory drugs are also given to assist in relieving the pain associated with these fractures. Conservative management is usually successful when treating stress fractures and surgery is rarely required. Use of menthol cooling gels, like Biofreeze, has shown to be helpful in alleviating pain.
More information can be found here:
http://www.aapsm.org/ct0398.html
http://www.foothealthfacts.org/what-is/ns_stress-fracture.htm

Is Your Achilles “killing” you?

March 12th, 2010 by Dr.Chang

ACHILLES TENDINITIS is, as implied, an inflammation of the Achilles tendon. This tendon is the largest and strongest tendon within the body and it is an extension of the gastrocnemius, soleus and plantaris muscle (calf muscles) with insertion into the calcaneus (heel bone). Its location gives us the ability to rise on our toes therefore aiding in walking, running and jumping. Without the Achilles tendon, we won’t be able to generate propulsive power while walking or running. There are times when this tendon may undergo infection or trauma and result in inflammation but typically, inflammation problems associated with the Achilles are due to chronic overuse, athletic training error or arthritis.

Commonly seen in overused Achilles tendons:
-Riders/bikers – improper pedaling, seat height or failure to warm up or simply overtraining.
-Baseball- failure to stretch before and after the activity.
-Aerobics- repetitive improper positioning of the heel on the step/bench.
-Basketball – very common overuse Achilles injuries due to constant jumping which places a large amount of stress on the Achilles tendon.
Those with Achilles tendinitis typically present with pain in the heel when mobile, with the area of the Achilles sensitive to touch and the skin swollen and warm. Untreated Achilles tendinitis is commonly predisposed to Achilles tendon rupture so it is in the patient’s best interest to treat the tendinitis quickly.
Along with a physical exam to test for tenderness in the area of the Achilles and pain when on toes, podiatrists use imaging studies like X-rays to reveal arthritis if present, and MRI’s that will show the possible inflammation of the Achilles.
Treatment typically includes:
– Icing
– NSAIDS
– Limiting strenuous activity on the Achilles
– Changing exercise routines to less impactful activities such as swimming
– Rest
– Physical Therapy
– Podiatrists may suggest casting, walking boots, or bracing to prevent movement of the heel and aid in reducing swelling.
If conservative treatment fails, surgery may be required and it usually deems successful. Visit Dr. Murray and Dr. Chang for consult if you suspect Achilles tendinitis.

Treatment for Plantar Fasciitis

March 3rd, 2010 by Dr.Murray

This blog is a sequel to last week’s blog that discussed the epidemiology of plantar fasciitis. We will touch briefly on treatments/prevention used by podiatrists and discuss treatment pearls podiatrists tend to follow when athletes and dancers present to their office with plantar fasciitis.
Alternative Physical Activity is one of the first steps to treatment. It is important to change the cardiovascular fitness routine to one that avoids high impact on the plantar fascia. This means limiting running and jumping and pursuing swimming and upper body weights as an alternative method of cardiovascular fitness. This is often called a period of “Relative Rest”
Changing footwear is another critical treatment step. Barefoot and sandals should not be worn while trying to treat this condition, instead shoes with a slightly elevated heel and a strong mid-shaft insole, should be worn inside and outside the house. We favor the use of plantar arch strapping (taping) which proves to be very successful, especially in athletes and active people who want to maintain their busy lifestyle.
Home Therapy consists of stretching the heel cord to encourage healing, and massaging the foot to increase blood flow. Night splints are also indicated for plantar fasciitis as it maintains the foot in a passive stretch position to encourage healing. This prevents unwanted re-tightening of the fascial band during the night and reset of stretch receptors that trigger pain activation.
Customized orthotics is an important long term strategy in the management of patients with this condition. Additional adjuncts to expedite recovery include: physical therapy which proves to be useful in alleviating pain associated with plantar fasciitis, and anti-inflammatory drugs which are given to control pain when appropriate for the patient.
These conservative methods typically suffice when treating plantar fasciitis in up to 90% of people with this condition, however when not successful, corticosteroid injections are considered for the more severe cases. Along with these treatments, rest and the maintenance of a healthy weight can also limit predisposal to plantar fasciitis so it is highly encouraged. If pain persists and all conservative treatments are unsuccessful, surgery may be required to release tension on the plantar fascia ligament. We are also using the Topaz radio frequency coblation technique with great success on our patients. If you suffer from plantar fasciitis or know someone who does, Drs Murray and Chang, can offer complete evaluation and tailor an appropriate treatment plan designed around the persons needs.

Heel Pain

March 1st, 2010 by Dr.Murray

A very common complaint presented by patients to their podiatrist is that of heel pain. It is caused by a variety of conditions but this blog will discuss heel pain due to plantar fasciitis. Plantar fasciitis is the most common condition associated with heel pain, especially in athletes, dancers and individuals within the ages of 40-60. It causes a mild discomfort to an aggressive form of pain in the plantar aspect of the foot- in the area of the heel.

The plantar fascia ligament, illustrated in the picture below, runs between the calcaneus (heel bone) and the base of the toes and is defined as a strong connective tissue that helps in forming the arch of the foot. A person’s biomechanics, such as being flatfoot or having high arches can create a pressure on this tissue. Incorrect shoes or even physical activity as well as diabetes or arthritis can also impact this fascia. A surplus of exercise and physical activity, including excessive running and jumping can result in loss of elasticity and compliance overtime second to micro injuries. At the same time, individuals with inflammatory types of arthritis can unfortunately develop inflammation within the tendons consequently resulting in the same condition. While being overweight is a significant contraindication, walking or exercising in improper shoes can cause impairment in weight distribution considerably increasing the pressure on the plantar fascia. When overload occurs, microtears in the tissue present themselves, and the plantar fascia becomes inflamed, typically in its central band, resulting in what is known as heel pain.
Symptoms include:
Pain in the heel
Stabbing, burning, aching pain
Pain worse in the morning when stepping out of bed
Diminishing pain as the tissue “warms up”
Intensity of pain increases over a period of months.
Stay tuned for next week’s blog when we discuss ways to prevent, manage and treat plantar fasciitis.

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