Arthroscopy of the ankle

Performing surgery through a small tube? This would have been considered science fiction a century ago. Now, surgery through small scopes is commonplace. This includes endoscopy in gastroenterology, laparoscopy in general surgery, and arthroscopy in orthopedics.
The use of small scopes (arthroscopes) to operate on joints was first described nearly a century ago, but was not developed until the 1970’s. Since then, the equipment, techniques, and indications for arthroscopic surgery have advanced significantly.
The knee has been the joint most commonly treated arthroscopically, but other joints are now being treated very successfully. Arthroscopy of the ankle joint has become very popular. The technique is useful for a variety of conditions.

Arthroscopic surgery of the ankle as many advantages over traditional open surgery. It involves very small incisions, has faster healing, and earlier ambulation. It is easily accomplished on an outpatient basis.

Arthroscopy allows better visualization of structures within the ankle joint that are sometimes not prominent on imaging techniques such as MRI. Through the small scopes inserted, bone and cartilage fragments can be removed. Ankle impingement by bony or soft tissue structures can be repaired. Reconstructive procedures can be performed. Reducing the thickness of inflamed joint soft tissue ( synovectomy) is a particularly popular and effective arthroscopic procedure.

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Warts of the foot and leg

Verruca vulgaris!
That sounds like a spell cast by Harry Potter, or a witch’s curse! This horrible- sounding phrase is the medical term for the common wart ( verruca is the Latin term for wart, and vulgaris means common). The term is used to describe warts on any part of the body, while those of the sole of the foot, so-called plantar warts, are called verruca plantaris.

Warts are benign skin lesions caused by a virus. The wart virus is everywhere in the environment, and is even thought to be part of the normal flora of our skin (along with many other viruses, fungi, and bacteria-Gross!). It is thought that the wart virus enters small cracks or wounds of the skin and start a wart lesion. Warts can spread from person to person by direct contact such as shearing shoes.

Conservative or nonsurgical treatment of warts is often effective and is generally tried initially before any surgical intervention. Conservative treatment can consist of paring down the outer callus layer and applying a medication to kill the virus. Sometimes a compounded prescription medication can be used daily by the patient to kill the virus.

Other interesting conservative treatments include oral cimetidine (a stomach medication), and therapeutic ultrasound. Cimetidine is thought to somehow stimulate immune system to fight off the wart virus. It is more effective in children that in adults. Another older treatment is the application of therapeutic ultrasound, which can kill off the virus.

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IF the Shoe Fits

Humans have worn shoes for the last 30,000 years. Although shoe shapes and materials have changed, the basic function of the shoe in protecting the foot remains the same. The challenge of properly fitting the foot into the shoe also remains. Improper fit not only adversely affects the shoes function, but it can also lead to foot pain and foot disorders.

A recent study involving over 1600 medical journal articles on shoe fitting and injury found significant associations between improper shoe fit and foot pain and disorders and impaired quality-of-life. Of the improperly fitted shoes, 98% were too short, 72% were incorrectly fitted for length and width, and 47% of footwear was smaller than the total area of the foot.

There is very little standardization of shoe sizing today. A given foot might wear several different shoes sizes and widths, depending on the shoe brand. Therefore, knowing one’s shoe size is a good place to start when shopping for shoes, but trying on several pairs until proper fit is obtained is essential. The best approach is to purchase shoes from a store where a training associated can measure the feet and assistin selection. Purchasing shoes online can be difficult in obtaining proper fit.

The most important aspect of shoe fit is length. It is recommended that there should be 10-20 mm length between the shoe at the tip of the longest toe, measured when standing. This is approximately the width of the thumb. Regarding width, this should be adequate room on the first metatarsal (behind great toe), and the fifth metatarsal (behind the fifth toe). The back of the heel (the heel counter) should fit snugly and should not move up and down walking.

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Sean, at 12 years of age, was the star forward on his soccer team. The season started out well, but after the second game, Sean developed pain in both heels. He, his parents, his coach, and his pediatrician were all perplexed, especially since he had no history of injury.

Someone told Sean’s parents about our office, and they made an appointment. On examination, there was pain on the sides and soles of both heels. X-rays were taken and showed a growth plate disturbance called “calcaneal apophysitis” or “Sever’s disease”. Sean was treated with strappings of the feet and modified rest. On follow-up a week later, his pain was gone and he was able to return to play with some heel cups in his shoes.

Several conditions can cause heel pain in children, including stress fracture, bone infections, and tumors. All of these more serious conditions are fortunately uncommon. The most common cause of heel pain in children is Sever’s disease. This benign condition , first described by American surgeon Dr. James Sever in 1912, is a temporary disturbance in the apophysis, or secondary growth center of the heel bone. It occurs in children of ages 8-15 years, especially athletic children. Treatment consists of temporary protection and immobilization of the foot with a strapping, or more rarely, a boot, for a week or two, followed by heel cups worn in the shoe for a few months.

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Soccer is by far the most popular sport in the world. According to FIFA, soccer’s world governing body, over 240 million worldwide play soccer. Billions more watch the game. In the USA, youth soccer is very popular, with over 2.3 million young people participating.

Soccer is known as “football” in most of the world. In fact, the term “soccer” was coined in 1895 and is derived from the formal name of the game, “association football”. Games similar to modern soccer have been played around the world since ancient times.

The injury rate in soccer is only 1/5th that of American football. About 60% of soccer injuries involve the lower extremity, of which 25% involve the foot or ankle. Common injuries include ankle sprains, foot fractures, Achilles tendinitis, Achilles tendon rupture, stress fractures, plantar fasciitis, and muscle strain.

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Fungus Toenails

Thick, ugly toenails.

Everyone has seen them, nobody wants them! People often associate these unhealthy nails with fungal infection.
In truth, about 40-50% of thick, discolored toenails are due to fungal infection. The other 50-60% aredue to a variety of other conditions, including psoriasis, lichen planus, injury, and , most commonly, degenerative changes of the nail.

T is important to determine the exact cause of diseased toenails, as the treatment varies based on the cause. Your podiatrist can determine the diagnosis by taking a small clipping of the nail and sending it to a laboratory for analysis. When the results are available, treatment options can be discussed.

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Overweight, Obesity and Foot Pain

Obesity is a true epidemic. According to World Health Organization statistics, worldwide obesity incidence has tripled since 1975, with 1.9 billion people being overweight and 650 million being obese. In the USA, 36.5% of the population is obese, and it is expected that by 2030, the incidence will climb to 50%. More alarming is the fact that childhood obesity rates have increased from 4% in 1975 to 18% currently.

Overweight and obesity are associated with higher rates of foot and ankle problems that in normal weight individuals. Additionally, certain conditions are more common in overweight people. These include heel pain, plantar fasciitis, midfoot pain, acquired flatfoot, arthritis, as well as edema (swelling),vein problems (including varicose veins and thrombophlebitis), balance problems, gait problems, knee pain, hip pain, back pain, and poor foot function. Diabetes is also associated with obesity.

Overweight children are especially prone to foot problems, especially flatfoot deformity. These conditions, if untreated, can lead to more serious problems in adulthood.

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Most of us have observed small children walking on their tip-toes. About 5% of children toe-walk. Often, this is a phase or habit which stops after a short time. In other cases, however, it can represent a problem requiring treatment.

Any child who continuously walks on their toes should be evaluated by a podiatrist. The podiatrist will observe the child’s gait and will examine range of motion and strength of the foot and leg. Sometimes, an X-ray may be taken to rule out bone or joint abnormalities.

The majority of cases of toe-walking are “idiopathic” or habitual. These cases have no identifiable underlying cause, but often still require treatment.

Another common cause of toe-walking is called “equinus”, which is tightness of the Achilles tendon and the muscles of the back of the leg. This tightness pulls the Achilles tendon down too much as the child walks.

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Flip-flops and your feet

Florida living promotes the casual lifestyle and casual attire, including flip-flops. These skimpy sandals are seen everywhere. The variety of available flip-flops is endless, from the cheap, dollar-store type to contoured, thick-soled flip-flops to elegant sequined sandals.

Are flip-flops a healthy choice of footwear? According to extensive biomechanical research conducted over the last ten years, no! To keep the flip-flop on during gait, the toes must bend and grasp the sole of the shoe with each step. This strains several tendons of the foot, resulting in compensatory problems such as plantar fasciitis and Achilles tendinitis. Some studies have also associated flip-flop use with knee and back pain.

Flip-flops are especially dangerous for people with neuropathy and for those with balance problems, as they can increase fall risk. They can put diabetic patients at risk for chafing, getting foreign bodies in the shoe, and for microtrauma.

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And Lower Extremity Stress Fractures

Dr. Breithaupt was puzzled. The year was 1855, and this Prussian army doctor was noticing that many of his young military recruits were experiencing severe pain in their feet or ankles early in their basic training, particularly after prolonged marching. Dr. Breithaupt discovered that the soldiers were actually developing incomplete fractures of the bones from overuse. He called the condition “march foot , and wrote the first paper describing it. Today we call it “stress fracture”.

Stress fractures are defined as incomplete partial fractures of bones. They comprise 10% of all sports injuries, with 99% of them occurring in the lower extremity.

Unlike “pathological fractures” which occur in weakened or porotic bone (especially in elderly patients), stress fractures occur in otherwise healthy bone due to repetitive mechanical loading. It non-athletes, they often occur when a sedentary period is followed by a sudden increase in activity, or performance of an unaccustomed activity. In athletes, they occur after increasing level of training too quickly.

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