Lower Extremities: Leg, Foot, Ankle

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Lower Extremities: Leg, Foot, Ankle

Conditions

Achilles Tendon Rupture and Tendonitis

The Achilles tendon is located behind the ankle and connects the heel of the foot to the calf muscles. An Achilles tendon rupture is when this tendon tears.

Achilles Tendon Rupture

The Achilles tendon is responsible for push off of the ankle. It connects the calf muscle to the heel bone of the foot.

Injury to the Achilles tendon can occur from a sudden jump or planting of the foot or can occur from chronic repetitive damage or tendonitis. Patients often complain of heel pain and a sensation that someone struck the back of their leg or they were "shot" in the heel when a tear occurs. A "pop" or "explosion" is frequently felt when the tendon ruptures. There is usually swelling and a defect of the tendon as well as weakness of the foot with a tear. Physical examination by a Foot and Ankle Specialist typically confirms the diagnosis, however in some rare cases an MRI scan may be needed to show the exact location of the tear and the distance between the two tendon edges.

Achilles Tendonitis

This condition is marked by inflammation and irritation of the Achilles tendon which is located in the back of the ankle. Achilles tendonitis is a fairly common overuse injury that often occurs in middle-aged, recreational athletes. Overuse of the tendon results in noticeable inflammation that may eventually lead to pain and swelling. In addition, Achilles tendonitis can also lead to a series of tears within the tendon, rendering it susceptible to rupture.

Arch Pain

Arch pain, or strain, is most often felt as a burning sensation along the long arch of the foot. There are a number of possible causes for this pain, but the most common are structural problems of the foot and stretching of the plantar fascia that supports the foot.

The latter is a common condition suffered by many athletes called plantar fasciitis. Plantar fasciitis results when the arch is excessively stretched, sometimes due to the condition known as flat feet. The resulting inflammation often leads to considerable pain in the arch and heel areas. The pain can be extreme after prolonged periods of rest such as after a good night's sleep.

If the strain on the arch continues over a period of time and left untreated, a bony protrusion may develop. This is called a bone spur and it is important to have it treated.

Arthritis

Arthritis is a condition that causes joint inflammation, swelling, and pain. The condition occurs when the lubricating cartilage in the joint wears away, leaving irregular cartilage and bone to rub against bone causing pain. This condition is common in people over the age of 50, but can start at younger ages. Several diseases can result in arthritis, but trauma and rheumatoid disease are the most common causes in the ankle. 

Post-traumatic Arthritis

Previous trauma is the single most common cause of ankle arthritis. Such injuries include previous fractures, joint dislocations, or severe ankle sprains, which can occur years before arthritis begins. These injuries can cause permanent damage to joint cartilage surfaces that helps to cushion joints. With time, the damage to cartilage worsens and the joints lose that protective covering. Ultimately, the bones in the joint grind against each other with little or no cartilage left. This causes joint inflammation, swelling, and pain.

Rheumatoid and Inflammatory Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease where the body's immune system turns against itself. Rather than working to protect the joints, the body actually produces substances that cause joint inflammation and destruction. RA is a long-term disorder that causes inflammation of multiple joints and surrounding tissue throughout the body. Of those individuals who suffer from RA, nearly 90 percent develop symptoms at the ankle or foot. In most cases, these symptoms initially appear in the toes and then involve the rear portion of the foot and ankle.

Bunions

Bunions are a common problem that most individuals experience as a painful swelling or a bony protuberance at the inner base of the big toe. This condition is the result of a malalignment of the first toe. These can be hereditary or secondary to wearing high-heeled or narrow toe-box shoes.

Symptoms often include pain, swelling, and abnormal position of the first toe. The technical term for bunions is "hallux valgus" (HV). This refers to the first toe or hallux moving away or abducting from the middle of the foot and then twisting in such a way that the inside edge actually touches the ground and the outside edge turns upward. This term describes the deviation of the toe toward the outside part of the foot.

If left untreated, bunions can worsen over time and cause considerable difficulty in walking, discomfort, and skin problems such as corns. In some cases, a small bursa (fluid-filled sac) near the joint becomes inflamed. This condition is known as bursitis and can cause additional redness, swelling, and pain.

Less frequently, bunions occur at the base of the fifth toe. When this occurs, it is called a "tailor's bunion" or bunionette.

Claw and Hammer Toe

The claw toe and hammer toe deformities are conditions that are primarily caused by the wearing of footwear that is too tight and fits poorly. In some individuals, these deformities can be congenital or due to other problems.

Claw toes appear exactly as their name would suggest, like a closed fist. Because of the joint variations of the toes (big toes have two bones, the other toes have three), claw toes cannot occur in the big toe. Claw toes are the result of a muscle imbalance that causes some of the tendons and ligaments to become unnaturally tight. The cause of this imbalance includes rheumatoid arthritis, neuromuscular disorders, or other conditions. Because of the deformity, a rigid claw toe has very limited mobility and can be very painful.

A hammer toe is classified on the degree of mobility found in the joint itself. There are two types: rigid and flexible. A rigid hammer toe simply does not have much ability to move and even minimal movement can be painful. A flexible hammer toe, however, does have the ability to move and can be straightened manually.

Diabetic Foot Care

Diabetics are more likely to be hospitalized for a foot problem than for any other reason! A small cut in the foot of a diabetic can result in a serious consequence. Open wounds in a diabetic can become more easily infected than in a non-diabetic individual. This is because diabetic patients often have poor or compromised "micro-circulation," where the small end blood vessels in the foot are closed. This makes healing and fighting infection a greater challenge for the body. Diabetics can lack some of the "protective sensation" that most people have. That is the ability to feel and avoid painful foot situations, like stepping on a sharp object or the discomfort of improperly fitting shoes.

Through injury & a lack of protective sensation, an ulcer or open wound of the foot can occur. These are the leading cause for limb amputations in people with diabetes with approximately 100,000 leg or foot amputations performed annually in the United States. In fact, diabetes continues to be the most common cause of lower extremity amputations in the country with the rate 15 to 40 times higher than in a non-diabetic. All foot ulcers and wounds need to be inspected by a trained professional.

Flat Foot

Flat foot is a condition in which the arch of the foot has collapsed, with the entire sole of the foot coming into direct contact with the ground. Causes of flat feet include genetics, tendon failure, and abnormal tendon function and bone structure.

In most cases, there is no pain associated with flat feet. However, the condition may lead to misalignment to other structures of the feet. Pain may develop in the arch, calf, and perhaps the lower back. In severely flat feet, patients may have pain that makes moving and/or standing difficult. Prolonged standing or strenuous athletic activity often worsens this pain.

Fracture of the Talus

The talus is a bone that is an important part of the ankle joint. It helps to transfer weight and pressure forces across the ankle point. It is located between the tibia and fibula of the lower leg and the calcaneus or heel bone. The tibia and fibula are situated on top and around the sides of the talus and thus form the ankle joint. At the point where the talus meets the calcaneus, it forms the subtalar joint. This joint is essential for individuals walking on uneven ground.

Lisfranc Fracture/Dislocation

This injury is a both a fracture and dislocation to the middle of the foot. This is a very important area of the foot as there are a group of small bones that form the arch shape of the foot. These bones are connected to each other in this arch shape by a group of ligaments called the Lisfranc ligaments. Injuries to these bones and Lisfranc ligaments are often caused by falls, twisting injuries, or heavy objects dropping on the foot. The most common problem that can develop in the long-term after these injuries is arthritis in the middle of the foot.

Plantar Warts

Plantar Warts are benign growths on the bottom of the foot caused by a virus called the human papillomavirus (HPV). This virus enters the skin through small or invisible cuts. The wart develops in the outer layer of the skin and is typically covered with a layer of callus tissue. Sometimes small black dots are visible. These are blood vessels that grow within the wart. Over time, the wart can grow and other warts can emerge that sometime coalesce into a larger cluster called a mosaic wart. Although warts are generally harmless, they can be quite painful when present on weight-bearing areas of the foot.

Posterior Tibial Tendonitis

This becomes a fairly common problem for the foot as we enter middle age. The posterior tibial tendon (PTT) itself runs along the inner aspect of the leg and ankle. It helps support the arch of the foot. Posterior tibial tendonitis occurs when this tendon becomes inflamed through overuse. In more severe cases, the inflammation can cause the tendon to tear. Most patients with this problem complain of pain at the inner ankle and arch. Some people may feel unsteady when walking. Without treatment, this condition can cause collapse of the arch and development of arthritis.

Stiff Big Toe

One of the most common problems involving the first big toe joint is arthritis. Arthritis at this particular area is also called hallux rigidus. The first toe joint is referred to as the metatarophalangeal (MTP) joint. This joint is where the first metatarsal head meets with the small bone of the big toe. Due to the mechanics of our feet, the big toe joint is especially prone to developing arthritis.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is compression or squeezing on the posterior tibial nerve at the inner aspect of the ankle. This painful condition is often due to injury or inflammation. Similar to carpal tunnel syndrome, tarsal tunnel refers to the compression of a nerve in a confined space. The tarsal tunnel is an area created by the very strong, laciniate ligament that covers a bony canal through which pass some of the major nerve, artery, vein, and tendons of the foot. Individuals who suffer from tarsal tunnel syndrome exhibit symptoms that include tingling, burning sensations, numbness, and shooting pain. These symptoms occur most often at rest or just before sleeping at night.

Procedures

Ankle Arthroscopy Surgery

Ankle Arthroscopy

When is it Time to Think About Surgery?

You may need ankle arthroscopy surgery if you are experiencing ankle pain, limited motion or instability of your ankle. These symptoms may be caused by bone spurs, loose bone/cartilage, or inflammation of soft tissue.

About the Surgery

Ankle arthroscopy surgery involves a few small incisions around the ankle and is performed under general anesthesia. Using a camera, your surgeon can see the inner tissues of the ankle on a monitor. Many problems can be diagnosed and corrected once the arthroscope is in place. The procedure will take approximately one hour and you will wake with a bulky dressing covered by an ace wrap on your ankle. Once you are awake and taking fluids, your IV will be removed and you will be allowed to go home. You will need someone to drive you home after surgery.

Preparing for Surgery

Pre-admission testing may be done before surgery to ensure that you are healthy enough for the planned procedure. Testing may include lab work, an EKG and a chest x-ray. You are encouraged to stop smoking before surgery to prevent lung complications or delayed healing. Please bring your surgical boot to surgery. Anti-inflammatory medications, aspirin and blood thinning medications should be stopped one week before your surgery unless otherwise specified by your doctor. These medications affect your blood clotting ability and could increase your risk for bleeding.

What to Expect After Surgery

Please wear the surgical boot when you walk until you are seen for your first post-op appointment. Your surgeon may not allow you to bear weight on your foot and you may need to use crutches or a roll-about scooter until otherwise instructed. You may notice swelling and weakness of your ankle initially. You may move your ankle as tolerated while seated or lying down. Elevate your foot while you are seated and apply ice (20minutes on/20minutes off) to help with any swelling. The surgical dressing can be removed 24 hours after surgery and you may shower. Do not submerge your incisions in a bathtub/pool/hot tub until the stitches have been removed and the incisions are completely closed. Do not put lotions or antibiotic ointment on your incisions. Keep the incisions covered with band aids until they stop draining. When you can walk confidently in the boot, you may remove it to drive (as long as you are not taking narcotic pain relievers). You should have an appointment to see your surgeon 2 weeks after surgery to have your sutures removed.

Complications and Risks of Surgery

Blood clots: Symptoms of a blood clot include pain, swelling or redness of your calf or thigh. Call the office immediately if you develop any of these symptoms or go to the emergency room. If you develop sudden shortness of breath go to the emergency room or call 911. Walk every hour during the daytime. Patients who are immobile for prolonged periods of time are at a higher risk of blood clots.

Infection: Infection is rare but can occur following surgery. You are at a higher risk for infection if you have diabetes, rheumatoid arthritis, chronic liver or kidney disease or are taking steroids. Symptoms include: fever or chills, drainage, redness, foul smell or increased pain at the incision sites. Call the office immediately if any of the symptoms occur.

Anesthesia: Respiratory failure, shock, cardiac arrest and death are always possible during surgery. Patients with long-term kidney, heart, liver or lung disease are at a higher risk. Nausea and vomiting from anesthesia can be common. Coughing/deep breathing exercises and drinking plenty of fluids help to flush out the anesthesia gases.

Nerve damage: Damage to the nerves surrounding your ankle is rare but can occur. Notify your surgeon if numbness or tingling is prolonged or worsens after surgery.

Bleeding: Trauma to the arteries and veins surrounding your ankle is rare but may occur. It is common for some bruising and discoloration around the ankle after surgery. Bright red bloody drainage from the incisions, which cannot be stopped with compression, should be reported to our office or go to the emergency room.

Returning to Work

Patients may return to work as soon as they feel comfortable. Patients with labor intensive jobs may require restrictions for the first few weeks following surgery which limit prolonged standing/walking, ladder climbing or repetitive stair climbing.

Gastrocnemius Slide Surgery

Gastrocnemius Slide

When is it Time to Think About Surgery?

A gastrocnemius slide surgery is indicated for patients who have a contracture (tightness) in their outer calf muscle (the gastrocnemius), and have failed non-operative management. Often a regular calf stretching program and use of orthotic devices in your shoes can lead to successful non-operative management of symptoms. However, in some instances surgical treatment is indicated. Gastrocnemius contracture results in the inability to bring the ankle joint past a neutral position (right angle to the lower leg) with the knee straight. Rather than “walk on their toes” most people naturally and unconsciously “compensate” by having more motion through the joints in front of the ankle. This midfoot compensation often leads to increased repetitive pressure to various structures in the foot during standing and walking. Therefore, the presence of a contracture may lead to painful conditions of the foot.

About the Surgery

The outpatient procedure takes approximately one hour and is performed under general anesthesia. A small incision (approximately 1/2 inch) is made on the inside area of the lower leg and the gastrocnemius tendon is exposed. Several tiny rows of incisions or a single incision is made across the tendon to allow it to stretch and lengthen. Patients will now have the same ankle motion with their knee straight that they previously had with their knee bent. The skin incision is sutured closed and a dressing is applied.

Preparing for Surgery

Pre-admission testing may be done before your surgery to ensure that you are healthy enough for the planned procedure. Testing may include lab work, an EKG and a chest x-ray. You are encouraged to stop smoking before surgery to prevent lung complications or delayed healing. Please bring your surgical boot to surgery. Anti-inflammatory medications, aspirin and blood-thinning medications should be stopped one week before your surgery unless otherwise specified by your family doctor. These medications affect your blood clotting ability and could increase your risk for bleeding.

What to Expect After Surgery

Please wear the surgical boot when you walk until you are seen for your first post-op appointment. The boot may be removed for hygiene purposes only for the first two weeks. The dressing over the incision may be removed after 48 hours and you may shower. Do not submerge your leg in water until the incision is healed and free of any scabs. Do not apply any lotions or antibiotic ointments to the incision. Keep the incision covered with clean dry gauze until you are seen in your doctor’s office 3 weeks after surgery. Your sutures will be removed at that appointment. You must wear your boot while sleeping for the first two weeks after surgery.

Complications and Risks of Surgery

Blood clots: Symptoms of a blood clot include pain, swelling or redness of your calf or thigh. Call the office immediately if you develop any of these symptoms or go to the Emergency Room. If you develop sudden shortness of breath go to the nearest Emergency Room or call 911. Walk every hour during the daytime. Patients who are immobile for prolonged periods of time are at a higher risk of blood clots.

Infection: Infection is rare but can occur following surgery. You are at a higher risk for infection if you have diabetes, rheumatoid arthritis, chronic liver or kidney disease or if you are taking steroids. Symptoms include: fever or chills, drainage, redness, foul smell or increased pain at the incision sites. Call the office immediately if any of these symptoms occur.

Anesthesia complications: Respiratory failure, shock, cardiac arrest, and death are always possible during surgery. Patients with long-term kidney, heart, liver, or lung disease are at a higher risk. Nausea and vomiting from the anesthesia can be common. Coughing, deep breathing exercises, and drinking plenty of fluids will help to flush out the anesthesia gases.

Nerve damage: The sural nerve runs along the top of the muscle being lengthened (the gastrocnemius). Although uncommon, injury or irritation of the sural nerve may lead to pain and/or numbness around the outside of the foot. Notify your surgeon if numbness or tingling is prolonged or worsens after surgery.

Tethering of the skin: The skin incision may adhere to the tissue overlying the calf muscle. This can cause tethering of the skin when the calf muscle moves. Your doctor may instruct you in deep massage to this area to break up these adhesions.

Calf weakness: Some initial calf weakness occurs in all patients. This weakness typically resolves within 6-9 months of surgery.

Recovery Period

The average recovery period is approximately 6 weeks. Patients may be allowed to return to a sedentary job within a few days after surgery. Patients with labor intensive jobs that require prolonged standing or squatting/kneeling or stair/ladder climbing may not be able to return to work for approximately 8 weeks or may return sooner with restrictions on these types of activities. You may not drive for 3 weeks if your surgery was on the right side.

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