ANKLE / FOOT
Julie G in Lompoc, CA
September 9, 2016
I have seen Dr. Fry twice now, both times have been a pleasant experience. His staff was wonderful, I called on Wednesday had an appointment the following week. Dr. Fry is very knowledgeable and sympathetic to my pain. I would highly recommend him to any one seeking orthopedic treatment.
This is a common injury where the foot twists beneath the ankle during sports. There is usually stretching or tearing of one or two ligaments (bone to bone connections) on the outside of the ankle. Pain can persist for as long as six to eight weeks. Treatment involves regaining proprioception (the ability of your brain to know where the foot is without looking at the foot) using an ankle brace and physical therapy exercises. Although it’s rare, sometimes a chip from the chondral surface (surface covering cartilage) of the ankle joint requires further investigation, when there’s prolonged pain. Surgical intervention is rare, and involves tightening or reconstructing the torn ligaments.
High Ankle Sprain
The so-called “high’”ankle sprain (syndesmotic injury) is a disruption of the connection between the two lower leg bones (tibia and fibula). This can cause pain all the way up to the knee. Diagnosis may require a “squeeze test” which involves squeezing the bones together below the knee to see if it causes pain at the ankle. Special x-rays can confirm the diagnosis. This condition is treated surgically because the ankle is unstable and requires fixation between the bones to heal. Patients use crutches for six weeks, followed by gradual increase in weight-bearing. Sometimes the hardware is removed depending on patient and surgeon preference.
One of the more commonly broken bones in the foot is the fifth metatarsal (small toe bone) on the outer border of the foot. This can occur with trauma, but can also occur with relatively trivial injuries in the setting of osteoporosis/osteopenia (weak bones; see stress fracture section below). This injury is typically visible on regular x-rays and is typically treatable without surgery. I usually use a walking boot (“ski boot”) which allows the patient to bear weight. Due to the blood supply, this injury may require prolonged healing times – sometimes three to four months. In the very active individual, there is the option of early surgical intervention to facilitate faster healing.
This is inflammation of the structures that maintain the arch of the foot. The “spring ligament” extends from the calcaneus (heel bone) to the inner border of the bottom of the foot. This typically causes its worse pain in the morning getting out of bed and putting your foot on the floor. This is due to the ligament contracting overnight, and then suddenly being stretched in the morning with standing up.
Treatment includes good arch supports, stretching exercises for the ligament (for example rolling a can of soup back and forth under the foot), and a nighttime stretching splint to prevent the ligament from contracting overnight. If these treatments are ineffective, local steroid injection can help. Surgery on the ligament is rarely performed due to mixed results.
A crack in one of the foot bones can occur in the setting of osteopenia (slightly weakened bones) or osteoporosis (markedly weakened bones). The most common bone injured is the second metatarsal (this connects to the second toe). A common scenario is a female in her fifties who has taken up walking and then suffers unrelenting foot pain. If x-ray doesn’t reveal the injury, an MRI or bone scan would be the next step in diagnosis. Stress fracture is typically treated with a walking boot, sometimes for two to three months, depending on the degree of tenderness and how quickly the bone heals.
It’s crucial to determine why the bones are weak and how to prevent similar injuries. Typically a DEXA scan is used to evaluate bone density in other parts of the body. We also make sure the patient takes adequate calcium and vitamin D (vitamin D is necessary to deliver the calcium out of the gut and into the bones). Consistent low-impact exercise is also very important. Other drugs designed to lessen bone resorption may be considered if necessary (but involve risks that may be unacceptable to some patients).
The Achilles tendon can sometimes become inflamed or even partially torn with overuse. There is typically pain over the back of the ankle and difficulty with climbing stairs or other strenuous activities that involve push-off of the foot. Treatment is typically oral anti-inflammatory medication, and sometimes immobilization of the ankle in a walking boot to give it time to heal. There are people who benefit from PRP injection as well, which involves drawing blood from a vein and spending it in a centrifuge to isolate the platelet rich layer which contains healing factors in the blood stream. That layer is then injected into the injured tendon. It is rare that the issue becomes a surgical problem. Eccentric strengthening is one of the most important therapy exercises to help facilitate healing.