Foot and Ankle Center Blog

Posts for: October, 2014

               


 

The National Council on Aging (NCOA) launched the seventh Falls Prevention Awareness Day on Sept. 23, 2014 to heighten awareness of fall-related injuries among older adults. Although the risk of falling increases with age, falls are preventable and may be reduced by lifestyle changes and medical interventions.

According to the Centers for Disease Control and Prevention (CDC), medical injury and cost reports are troubling and causing alarm in the U.S. Unintentional falls were the leading cause of injuries and injury deaths for seniors age 65 and above during 2011. The $30 billion direct medical cost reported for 2010 is projected to reach $67 billion by 2020.

One third of the seniors will fall each year and the number of falls increases with age. Approximately 2.4 million seniors were treated in the emergency departments for falls that resulted in over 658,015 hospitalizations and 22,901 deaths. Females accounted for 68 percent of the falls (1,637,038) and 54 percent of the deaths (12,430) caused by falls. Males accounted for 32 percent of the falls (785,425) and 46 percent of the deaths (10,471) caused by falls.

The CDC reported that 20-30 percent of the moderate to severe injuries affected the ability of seniors to live independently, hampered mobility, and increased their risk of early death.

Fractures are the most common types of injuries caused by falls. Almost all of the hip fractures (95 percent) were caused by falls. Hip fractures accounted for nearly 25 percent of the injuries leading to death for seniors over 65, and 34 percent of the injuries leading to death for those 85 and older. The prognosis for recovery from a hip fracture is not positive. One out of five hip fracture patients die within a year of injury. Fall injuries are also the most common cause of nursing home placement; even more common than strokes.

The diagnosis of balance impairment is not a simple thing. It can be caused by such things as predisposing medical diseases, irregular gait (walking), visual impairments, peripheral neuropathy, vestibular (ear) impairments, foot deformities, improper footwear, medications, lower extremity problems, and a history of falls.

Across the country, multiple medical providers (such as primary care physicians, podiatrists, geriatric specialists, ophthalmologists, audiologists, cardiologists, occupational therapists, family nurse practitioners and physician assistants, registered nurses, and physical therapists) are working to develop treatment plans for patients with balance impairment.

There are no silver bullets or magical devices to prevent falls; however, research continues to determine the origin and cause (etiology), a comprehensive treatment plan can be developed to address balance impairment. This collaboration of effort becomes even more critical as the patient grows older.

Podiatrists can play an extremely vital role in fall prevention for seniors and are an important medical touch point in the cycle of care. Podiatrists are trained to identify patients who are at risk for falls. Many of these patients have osteoarthritis, weak muscles, unstable foot and ankle joints and pain, Dropfoot (Hemiplegia), posterior tibial tendonitis, tendon contraction, peripheral neuropathy, flatfeet, malformations in the toes, Equinus foot, Charcot foot, gait abnormality; and lack of muscle coordination (Ataxia).

I like to take a holistic approach with my senior patients to monitor their status and to determine if they are at risk for falling. This may include the following:
 

  • Addressing the physical and biomechanical cause for balance impairment
  • Providing home-care foot exercises
  • Channeling patients for physical or occupational therapy
  • Providing patient education, home safety tips, and other fall prevention tips
  • Asking patients to complete a fall risk assessment survey

There are a variety of products that may be prescribed to help a patient achieve better support and stability like orthotics, foot braces, and appropriate shoe gear. In certain instances, I may recommend an ankle-foot orthosis (AFO) because it can potentially reduce their risk of falling. The cost of the custom AFO is usually covered by Medicare and commercial insurance for patients who are documented to have orthopaedic risk factors for falls. The combination of these approaches will help prevent falls. My goal is to do whatever it takes to improve a patient’s quality of life so they can sustain independence and reduce the risk of injury and premature death.

 

John Sigle, DPM, FACFAS

If you have a balance impairment caused by a lower extremity problem and difficulty recovering from falls, contact Dr. John Sigle at 217-787-2700 for a consultation and risk assessment. Dr. Sigle has clinic locations in Springfield and Decatur. Visit the myfootandanklecenter.com to review information on risk assessments and related foot problems that cause balance impairment.

Photo credit: izusek/iStock- See more at: http://www.healthycellsmagazine.com/articles/step-up-efforts-for-fall-prevention#sthash.xzQkEJut.dpuf 


                                               

Podiatrists play an extremely vital role in the prevention of falls for seniors. We are an essential medical touch point in the cycle of care because we are trained to identify patients who are at risk for falls, and able to address the primary biomechanical problems that cause falls. Problems that contribute to falls include osteoarthritis, unstable foot and ankle joints, weak muscles, Dropfoot (Hemiplegia), posterior tibial tendonitis, tendon contraction, peripheral neuropathy, flatfeet, malformations in the toes, Equinus Foot, Charcot Foot, gait abnormality and lack of muscle coordination (Ataxia).

According to a recent article in the Journal of the American Medical Association (JAMA), falls and related injuries are more than twice as high among adults with arthritis as arthritis-free adults. Because the growth rate for the population age 65 and older is expected to climb from 40.3 million in 2010 to 67 million by 2030, there is a serious need to step up efforts for fall prevention for seniors with arthritis and to provide intervention strategies for patients with arthritis of the foot and ankle.

The foot and ankle problems that place seniors at highest risk of falling have Chronic Ankle instability, Hallux Rigidus (hallux-rig-i-dus) known as big toe arthritis, and Ankle, Hindfoot, and Midfoot Arthritis. Here is a brief overview of the symptoms, causes, and treatments for these conditions.

Chronic Ankle Instability

Chronic Ankle Instability is characterized by a weak ankle that “gives way” on the lateral (outer) side of the ankle on a fairly regular basis. This occurrence is unpredictable and can occur while walking, running, or when standing. Common symptoms include pain, tenderness, and swelling.

The primary cause is usually the result of a prior ankle sprain or injury (i.e. fracture) that did not rehabilitate properly or fully heal. Consequently, the ligaments surrounding the ankle remain stretched, weak, and sometimes torn. Other causes are not injury related. These include arthritis, inflammation in the synovium (joint lining), and a buildup of scar tissue, a damaged nerve, or nerve entrapment condition.

Physiotherapy is the most common treatment to rebuild ankle strength. Special bracing is also used to provide support. Surgery is considered if ligaments need to be tightened on the outside of the ankle to add support. In some cases, a tendon may be grafted from the other ankle to rebuild stability.

Hallux Rigidus (Big Toe Arthritis)

Hallux Rigidus is a form of degenerative arthritis in the metatarsophalangeal (met-a-tar-so-pha-lan-gel-al) joint (MTP) that usually develops in adults between the ages of 30 and 60, and is more prevalent in females. This condition is the most common form of arthritis in the foot. It is a progressive condition that limits the toe’s range of motion over time.

This condition occurs when the cartilage of the big toe is injured or because of an abnormal foot anatomy that puts an excessive stress load on the MTP joint. The deterioration of articular cartilage covering at the end of the bone results in a bone-on-bone condition.

Initial symptoms include joint stiffness, swelling, pain, discomfort, and restricted range of motion. The condition tends to be aggravated during cold and damp weather. Walking becomes difficult and recreational activities are restricted. Manual labor that requires stooping or squatting is also restricted.

As the condition advances, pain is present even during rest. Walking becomes abnormal and evidenced with a limp. Bone spurs in the heel often develop making it uncomfortable to wear shoes, especially high heels. Often, these conditions lead to associated pain in the knee, hip, and lower back.

The actual cause of this condition is not known. Related risk factors include prior trauma, an elongated big toe, differences in foot anatomy, and family history. Any of these factors can contribute to wear and tear of the joint and development of arthritis.

Non-surgical treatments include anti-inflammatory and pain medications, cold and hot therapy, cortisone injections, and shoe wear and custom orthotics that limit MTP joint motion.

Surgery may be done if non-surgical treatments fail. Three options are used depending on the severity of the problem. These include the following: a Cheilectomy (kl-lek’-toe-me) for mild to moderate MTP damage; an Arthrodesis (are-throw-dee’-sis) permanent fusion of bones if the cartilage is severely damaged; or an Interpositional Arthroplasty (are-throw-plas’-tee) for patients with moderate to severe hallux rigidus who are unwilling to accept the loss of motion of the big toe.

The Cheilectomy procedure is joint sparing, preserves joint motion, maintains joint stability, and alleviates pain caused when pushing off the toe. Arthrodesis is a permanent correction that eliminates pain but restricts movement of the big toe. Interpositional Arthroplasty replaces damaged bone with soft tissue to allow some motion in the big toe. It is effective but not as reliable as Arthrodesis.

Ankle, Hindfoot and Midfoot Arthritis DJD (Degenerative Joint Disease)

Arthritis is also common in the ankle, hindfoot, and midfoot. Ankle Arthritis is present where the tibia (shinbone) rests on the talus (upper bone of the foot). Hindfoot Arthritis is present in three joints: the subtalar or talocalcaneal (ta-lo-kal-ka-ne-al) joint (that connects the talus to the heel bone); the talonavicular joint (where the inner midfoot bone connects to the navicular bone); and the calcaneocuboid joint that connects the heel bone to the cuboid (outer midfoot bone). Midfoot Arthritis is present in the metatarsocuneiform joint where the metatarsals (forefoot bones) connect to the cuneiforms (small midfoot bones).

There are three types of arthritis. Osteoarthritis, commonly referred to as wear and tear arthritis, occurs after reaching middle age. Rheumatoid Arthritis is a chronic, progressive autoimmune disorder that attacks flexible (synovial) joints and destroys cartilage. It is a rare form of arthritis and mostly starts between ages 30-50; although younger people can have it. Post-Traumatic Arthritis can occur at any age following an injury such as a sprain, fracture, or torn/stretched ligament.

Arthritis symptoms of the foot vary depending where it is present; however, the common symptoms include swelling, stiffness and reduced mobility, tenderness and pain, and difficulty walking.

Nonsurgical treatment may include cold therapy, anti-inflammatory and pain medications, supportive footwear, custom orthotics, home therapy, alternate non-load bearing recreation and fitness activities, custom orthotics, foot braces, balance braces, casting, corticosteroid injections, and laser therapy.

Surgical treatment is considered when nonsurgical treatment does not provide sufficient response or pain relief. Surgery consists of Arthroscopic Debridement, Arthrodesis, and Arthroplasty. Candidates for joint replacement are at end stage arthritis and ankle joint surfaces are destroyed. Patients are in severe pain and unable to do normal daily activities. Because of advances in implant design, Arthroplasty is becoming the treatment of choice. It provides total relief from arthritis pain, and restores joint movement and patient mobility. Also, less stress is transferred to adjacent joints reducing the occurrence of arthritis. The outcomes for this procedure are very positive; however, if the implant fails, revision surgery is required.

A wide range of strategies are required to prevent falls. People with foot and ankle arthritis and balance impairments are at greatest risk. These patients should be channeled to a podiatrist for a comprehensive Fall Risk Assessment and treatment.

Visit myfootandanklecenter.com to view an assessment tool, and a video on MLS Laser treatment for pain management and arthritis.



Read more: http://www.sj-r.com/article/20141011/Blogs/141019924#ixzz3HMZaiCeP 


                        

Professional sports teams are fairly resilient and used to dealing with sports injuries. It’s a part of life. Last year, the Oklahoma City Thunder managed to play without Russell Westbrook for 36 games because of a knee injury. Their star, Kevin Durant, seemed to pick up the slack and excelled in his usual fashion. He averaged 35 points and 6.3 assists a game and the Thunder went 20-7. Durant played 81 games last year, logged in more minutes (20,717) than any other NBA player since 2007, and was selected as the NBA’s MVP.

Durant is known as Mr. Constant. During his career, he has missed only 16 games. According to a recent ESPN article, Durant logged additional minutes during the off season in 2010 when he played in USA World Cup games in Turkey, and in 2012 when he played on the Olympic team in London. It was obvious that last season took a toll on him when he opted out of playing for the USA Men’s Basketball team that won the World Cup in Madrid this past summer. Durant was drained physically and mentally.

As the Thunder marched into the NBA season, they had high hopes of having another winning season and contending for the Western Conference title and NBA championship with a healthy roster that was rested. Unfortunately, they had a rude awakening a couple of weeks ago when Durant fractured the outside of his right foot at the base of the fifth metatarsal bone. His fracture has been classified as a Jones fracture. Now, many people in the sports world are wondering if the injury could have been prevented by restricting his play. It seems that Durant’s great strength may have been his biggest weakness.

Durant and his team of medical experts considered all options, but they made a joint decision that surgery was his best option. Last week, surgery was performed at a clinic in Charlotte, North Carolina. General Manager Sam Presti reported that Durant will be re-evaluated in six weeks.

Of course, fans and sportswriters are already trying to predict when he will return. AP Sports even estimated that he will be back at the beginning of December and have 65 games remaining. Sam Presti said that Durant will be evaluated in six weeks, but that does not mean he will return that soon. In fact, the odds are slim that he will return that fast. A Jones fracture is a difficult condition that may take longer to recover. The typical time for full recovery is around 20 weeks. Durant is the Thunder’s greatest asset, and they are not going to jeopardize his longevity with an early return unless he is fully capable of performing at peak levels.

A Jones fracture is in the fifth metatarsal on the lateral side of the foot. It is the long bone that connects to the little toe. Fractures in the fifth metatarsal are the most common, especially among athletes. The following are the three types of fractures at the proximal fifth metatarsal: Avulsion fracture, Jones fracture, and Shaft fracture. The proximal metatarsal has been classified into three zones.

Fifth metatarsal fractures

Zone 1 Avulsion Fractures account for over 90 percent of the fifth metatarsal fractures. Non-displaced fractures in this zone are usually treated non-operatively and do well with conservative treatment.

Avulsion fractures are located at the base of the fifth metatarsal. They are usually an acute fracture caused by an extreme and sudden hindfoot inversion injury (twisting or rolling of the ankle). This results in an extreme tension in the lateral band of the plantar aponeurosis and peroneus brevis tendon that are inserted into the proximal base of the fifth metatarsal. The tension is so great that it causes the base of the metatarsal to fracture. The fracture can be an incomplete or complete separation. Non-displaced fractures in this zone are usually treated non-operatively and do well with conservative treatment.

Zone 2 Jones fractures account for approximately 4 percent of the fifth metatarsal fractures. It can be acute or chronic injury. Jones fractures are recognized for prolonged healing, nonunion and complications. The fracture extends from the lateral aspect of the fifth metatarsal toward the fourth and fifth metatarsal facet. The location is the principal cause of the problem. It has a poor blood supply to promote healing. Also, the muscles, tendon and plantar fascia that attach to the tuberosity of the fifth metatarsal cause excessive motion that contributes to nonunion.

The fracture can be the result of an acute injury that applies a sudden and extreme adductive force to the lateral border of the forefoot that is in a plantar flexed ankle position. It can also be a chronic injury that results from a long-term stress fracture. Inherent foot and leg shapes can also impede healing. People who have a high arch in their foot or walk on the outside of their foot are more prone to get a Jones fracture.

This fracture can be treated non-operatively or operatively, but the treatment of this fracture is controversial. Non-operative treatment is standard protocol for this fracture if there is no displacement but many. Many studies indicate poorer union rates with non-operative treatment and long times to achieve union.

It is not uncommon for Jones fractures to recur if the bone fracture was not aligned properly, or if it did not union during non-operative treatment. Also, recurrence can be influenced by age, inherent foot shapes, improper physical therapy, and failing to gradually ease back to normal activities. Operative treatment may be required to correct these deficiencies and to prevent the bone from breaking again.

Operative treatment is typically pursued for larger displacements (>2 mm) and if the cuboid joint articulation is involved (>30 percent). Operative treatment is also pursued for patients with a delayed union, and for athletes with an acute fracture.

Operative treatment provides higher union rates, less risk of recurrence, shorter recovery time, and earlier return to sport. Operative treatment is typically selected for younger and professional athletes.

Zone 3 Shaft (Stress) fractures account for approximately 3 percent of the fifth metatarsal fractures. These fractures occur at the distal (end of joint) to the fifth metatarsal joint in the proximal diaphysis (shaft). A chronic stress fracture is caused by repetitive cyclic overloads that can result from a sudden increase in walking or running. It is commonly seen in athletes. Over time, the stress fracture can become a complete break. This fracture can be treated non-operatively or operatively. This type of fracture has an increased risk of nonunion, and is the hardest to heal. Operative treatment is the primary course of action, especially among athletes.

Treatment

* Conservative Treatment

Zone 1 Avulsion fractures that are non-operative require protected weight bearing with use of a stiff sole shoe, boot, or a cast. Weight bearing activities can advance as tolerated by pain. Patients may return to work but it is not unusual for symptoms to persist for 6 months.

Zone 2 Jones fractures (in recreational athletes) and Zone 3 Stress fractures that are non-operative require a non-weight bearing short leg cast for 6 to 8 weeks. If radiographs confirm delayed or nonunion, an external, low-level Pulsed Electromagnetic Field Bone Stimulator (PEMF) device can be used as a non-surgical option to increase healing rates. This is followed by 6 to 8 weeks in crutches and Cam walker boots to gradually transition into full weight bearing. Stiff-sole shoes should be worn when the fracture heals. Typical healing time is around 15-22 weeks.

* Operative Treatment

Operative treatment for Zone 1 Avulsion fractures is rare but can happen if there is a substantial joint displacement or if tuberosity avulsion involves a significant amount of joint surface. Open reduction and internal fixation is performed. Typically small fragment screws are placed across the medial cortex of the proximal and obliquely through the tuberosity.

Operative treatment is recommended for Zone 2 Jones fractures if there is displacement (>2-3 mm), and for competitive and elite athletes. Operative treatment will minimize possibility of nonunion or prolonged restriction from activity. An Intramedullary Screw Fixation procedure is the most common procedure for Jones Fractures. A surgical incision is made at the base of the fifth metatarsal and an X-ray machine is used to help guide the placement of the screw, drawing the two fractured ends together. Screws are not removed unless they cause discomfort. Other procedures like tension banding percutaneous pinning, and external fixation may be used as well.

Reconstructive surgery is sometimes needed to alter the shape of the foot or alignment. These procedures include the following:

* Implanting bone grafts in the fracture site

* Lateralizing Calcaneal Osteotomy procedure is performed to shift and reposition the heel to the outside

* Dorsiflexing 1st metatarsal osteotomy is performed on people with high arches to realign the 1st metatarsal (big toe) if it is angled downward

Operative treatment is recommended for Zone 3 Stress fractures with sclerosis or non-union cases, and for athletic people. Internal compression fixation with plates and screws are commonly used. In some cases, bone grafts are surgically implanted in the fracture site. A dynamic pressure plate can be used for a transvers fracture and secured with monofilament K-wire. Oblique fractures can be addressed by use of cortical or cancellous screws.

Post–operative treatment includes a non-weight bearing cast for 6 to 8 and gradual transition into full weight bearing during the next 6-8 weeks. This is accomplished by the use of a weight bearing removable boot and shoe Orthosis. Low impact activity can gradually begin until the fracture site is not tender. Patients usually return to full activity within 20 to 21 weeks.

Complications

Possible complications of surgery are infection, damage to the blood vessels, sural nerve damage, blood clots and bleeding, wound healing, non-union, increased fractures that occurred during operative treatment, and risks associated with anesthesia. Non-union complications are present in Zone 2 Jones Fracture because of poor blood supply; and the use of smaller diameter screws associated with delayed or non-union

The complications for fixations include a high failure among elite athletes and for athletes that return to sport prior to radiographic union. Re-fracture distractions or mal-reductions after fixation are also attributed to adverse effects on the metatarsal shaft and medial cortex often requiring reconstructive surgery. Lastly, there may be discomfort from the screws and difficulty with shoe wear.

Summary

The populations at greatest risk for fifth metatarsal fractures include athletes, people with diabetes greater than 25 years of age, and elderly women with osteoporosis. The Jones fracture is a serious injury that can limit full mobility and cause further complications. If treated correctly and in a timely fashion, most patients will regain full function. This can be a debilitating injury if it is not treated in time.

The type of treatments selected for fifth metatarsal fractures depend on the location of the fracture, the type of fracture, and other related symptoms. Both conservative and operative treatments have good outcomes but careful consideration is required to select the appropriate treatment that will help restore full function.

Contact Dr. Sigle at the Foot & Ankle Center of Illinois at (217) 787-2700 to explore your treatment options. Dr. Sigle’s clinic locations are in Springfield and Decatur. He is also has clinic at the SIU School of Medicine, Division of Orthopaedics. Visit www.myfootandanklecenter.com for additional information on foot care.


Read more: http://www.sj-r.com/article/20141028/Blogs/141029478#ixzz3HfOyQZJq 


STEP UP EFFORTS FOR FALL PREVENTION

Illinois Laser Center on October 08, 2014

By John M. Sigle DPM, FACFAS, Foot & Ankle Center of Illinois, Illinois Laser Center


The National Council on Aging (NCOA) launched the seventh Falls Prevention Awareness Day on Sept. 23, 2014 to heighten awareness of fall-related injuries among older adults. Although the risk of falling increases with age, falls are preventable and may be reduced by lifestyle changes and medical interventions.

According to the Centers for Disease Control and Prevention (CDC), medical injury and cost reports are troubling and causing alarm in the U.S. Unintentional falls were the leading cause of injuries and injury deaths for seniors age 65 and above during 2011. The $30 billion direct medical cost reported for 2010 is projected to reach $67 billion by 2020.

One third of the seniors will fall each year and the number of falls increases with age. Approximately 2.4 million seniors were treated in the emergency departments for falls that resulted in over 658,015 hospitalizations and 22,901 deaths. Females accounted for 68 percent of the falls (1,637,038) and 54 percent of the deaths (12,430) caused by falls. Males accounted for 32 percent of the falls (785,425) and 46 percent of the deaths (10,471) caused by falls.

The CDC reported that 20-30 percent of the moderate to severe injuries affected the ability of seniors to live independently, hampered mobility, and increased their risk of early death.

Fractures are the most common types of injuries caused by falls. Almost all of the hip fractures (95 percent) were caused by falls. Hip fractures accounted for nearly 25 percent of the injuries leading to death for seniors over 65, and 34 percent of the injuries leading to death for those 85 and older. The prognosis for recovery from a hip fracture is not positive. One out of five hip fracture patients die within a year of injury. Fall injuries are also the most common cause of nursing home placement; even more common than strokes.

The diagnosis of balance impairment is not a simple thing. It can be caused by such things as predisposing medical diseases, irregular gait (walking), visual impairments, peripheral neuropathy, vestibular (ear) impairments, foot deformities, improper footwear, medications, lower extremity problems, and a history of falls.

Across the country, multiple medical providers (such as primary care physicians, podiatrists, geriatric specialists, ophthalmologists, audiologists, cardiologists, occupational therapists, family nurse practitioners and physician assistants, registered nurses, and physical therapists) are working to develop treatment plans for patients with balance impairment.

There are no silver bullets or magical devices to prevent falls; however, research continues to determine the origin and cause (etiology), a comprehensive treatment plan can be developed to address balance impairment. This collaboration of effort becomes even more critical as the patient grows older.

Podiatrists can play an extremely vital role in fall prevention for seniors and are an important medical touch point in the cycle of care. Podiatrists are trained to identify patients who are at risk for falls. Many of these patients have osteoarthritis, weak muscles, unstable foot and ankle joints and pain, Dropfoot (Hemiplegia), posterior tibial tendonitis, tendon contraction, peripheral neuropathy, flatfeet, malformations in the toes, Equinus foot, Charcot foot, gait abnormality; and lack of muscle coordination (Ataxia).

I like to take a holistic approach with my senior patients to monitor their status and to determine if they are at risk for falling. This may include the following:

  • Addressing the physical and biomechanical cause for balance impairment
  • Providing home-care foot exercises
  • Channeling patients for physical or occupational therapy
  • Providing patient education, home safety tips, and other fall prevention tips
  • Asking patients to complete a fall risk assessment survey

There are a variety of products that may be prescribed to help a patient achieve better support and stability like orthotics, foot braces, and appropriate shoe gear. In certain instances, I may recommend an ankle-foot orthosis (AFO) because it can potentially reduce their risk of falling. The cost of the custom AFO is usually covered by Medicare and commercial insurance for patients who are documented to have orthopaedic risk factors for falls. The combination of these approaches will help prevent falls. My goal is to do whatever it takes to improve a patient’s quality of life so they can sustain independence and reduce the risk of injury and premature death.