Sunday, September 30, 2012

Colts Vontae Davis ankle or foot sprain

Initial reports is that Colt's Vontae Davis suffered and ankle sprain.   How could this be confused with what his is confirmed with having now a foot sprain?  Very easily upon a cursory review.  Let's review the anatomy of the area.   There is a joint below the ankle joint that is intimately connected with a very important foot joint the, subtalar joint (STJ).  The illustration below shows the mechanism of injury that can be the source of either an ankle  or subtalar / foot sprain.
The subtalar joint is more clearly defined in the radiograph below:
As you can see the the two joints are very close to each other and sometimes an athletic injury can have one or both joints sprained depending on how the foot is planted and twisted.  Artificial turf that is unforgiving in regards to sliding can make things worse as the foot can be stuck in one position and the rest of the leg is twisted by the force of a tackle, etc.   During the high speed game of football, these injuries are hard to avoid if your foot is planted, then a tackle or ankle/ foot twist happens with the mechanism shown above.
Treatment is usually an immobilization boot, CAM BOOT, for 4-6 weeks with physical therapy. Physical therapy can consist of cold laser therapy, prolotherapy, ultrasound, estim, etc.

Dr. Kevin Lam

Friday, September 28, 2012

Heel Pain or Tarsal Tunnel Syndrome

Your feet is burning, aching and painful with every step.   Most common and often first diagnosis that comes to mind for physicians is Plantar Fascitis or Heel Pain Syndrome.   Let's step back a little bit and go up a little higher.    Those symptoms can also mean many other things, but one should look at the diagnosis of tarsal tunnel syndrome and / or medial calcaneal nerve neuritis.   With the advent of minimalist shoes, heel pain as well as tarsal tunnel syndrome has been more prevalent in my practice.   Just as carpal tunnel syndrome is caused by overuse and repetitive motion of the hands and wrist, the tarsal tunnel can be aggravated via overuse and unprotected repetitive motion.

Clinical diagnosis is key with positive a Tinel's sign, or shooting pain when the nerve is tapped with the finger of a practitioner about the medial (inside) of the ankle.     EMG and Nerve conduction studies can be done but they are very inaccurate for early stages of this condition.  These neurological tests will only pick this compression neuropathy up when the disease has progressed to involve some muscle wasting.   Clinical suspicion and evaluation is the key to a diagnosis.

Then there is a nerve that goes right to the bottom of the heel causing pin point tenderness, but this also there can be pain along the inside of the heel.  The nerve that supplies this area can be inflammed by trauma or chronic irritation.   Clinical exam is the key once again.  The medial calcaneal nerve is drawn below for illustration purposes.

If you have been treated for plantar fascitis but you continue to have pain and notice some burning pain along the side of the ankle, you just may have Tarsal Tunnel Syndrome and / or Medial Calcaneal Neuritis.
Therapy, injections, supplements such as: NeurX can help to control the symptoms.  If the symptoms persists you should consult with your Podiatrist.  At the Family Foot and Leg Center, we have a center for peripheral neuropathy excellence.   Surgery is often very successful if done early before nerve degeneration / damage.

Incision placement for Tarsal Tunnel Surgery

Initial incision into the tarsal tunnel, notice the bulging vein and nerve.
Compression caused by deep fascia that holds your tendons and muscles in place.
Patient above had surgery today with immediate relief of her heel and shooting ankle pains.  Updates will be done.  Post operative course will involve taking NeurX twice a day as well as immobilization for 2 weeks to allow for proper skin healing.   Followed up with use of a walking boot for another 2 wks.

Visit for more information and stretching excercises for your condition. 

Wednesday, September 26, 2012

Effective Neuroma Treatments Without Surgery

Morton's neuroma is an inflamed nerve that causes pain, tingling and numbness in the ball of the foot. Many complain of a bunched up sock under the ball of the foot, while others complain of walking on a lump, a large pebble or a lamp cord. Some describe a "twang", like a guitar string, in the ball of their foot. The pain can dull in the ball of the foot or can be radiating, electrical, tingling or burning and shoot to the 3rd and 4th toes. The pain is worsened with tight shoes, standing, walking, hills and stairs and generally relieved by rest and removal of shoes.

The initial treatment for Morton's neuroma is to eliminate factors which may have caused or aggravated it. In many cases, tight shoes cramp the toes and press on the nerve, causing irritation, inflammation and pain. Over-pronation causes forefoot instability and excess movement of the long bones in the foot. This type of abnormal foot mechanics, in combination with soft, flexible shoes can cause a neuroma.
Icing the ball of the foot twice a day for 15 minutes and/or contrasting between hot and cold for 30 minutes each day will help decrease the inflammation. Anti-inflammatory medications, such as ibuprofen or naproxen, can also decrease the inflammation and the pain. A neuroma pad will help disperse forefoot pressure, decreasing irritation on the nerve. Steroid injections and nerve sclerosing injections may also be used.
When conservative therapy fails, surgery is recommended. Surgery involves releasing the ligament placing pressure on the nerve or removing the neuroma. When the neuroma is removed, permanent numbness at the toes will result, but toe function is not affected.
In a new study published in the Journal of the American Podiatric Medical Association, researchers found extracorporeal shockwave therapy to be a safe and effective treatment for Morton's neuroma. Extracorporeal shockwave therapy (ESWT) is a treatment which directs powerful sounds waves at an area of injury. The sounds waves create vibrations causing microtrauma to the tissues.

The body responds by creating new blood vessels and sending healing factors and inflammatory cells to the area to stimulate the natural healing process. ESWT has been used for the treatment of kidney stones for many years. In the year 2000, the FDA approved ESWT for the treatment of chronic plantar fasciitis, a painful condition in the heel. ESWT is not currently approved for the treatment of neuromas.
In this study, researchers divided twenty five patients with a Morton's neuroma, unresponsive to at least eight months of conservative therapy, to an active treatment group or a sham treatment group. Both groups were taken into the procedure room and given intravenous sedation and a local anesthetic. The active treatment group received extracorporeal shockwave therapy and the sham group received no treatment.

At 12 weeks following the procedure, the group with the extracorporeal shockwave therapy had significant pain reduction compared to the sham treatment group. Potential complications associated with extracorporeal shockwave therapy include bruising, pain, swelling, nerve damage and hemorrhage, but the incidence is less than 1%. This results of this study are encouraging and ESWT may prove to be an effective treatment alternative to surgery. But, this is a small study and further research is needed to evaluate the safety and efficacy of extracorporeal shockwave therapy for the treatment of Morton's neuroma.

FFLC has both the high energy and low energy modality for your care. Discuss with your doctor which is right for you.

Fridman R, Cain JD, Weil L. Extracorporeal Shockwave Therapy for Interdigital Neuroma. A Randomized, Placebo-Controlled, Double-Blind Trial. JAPMA. Vol 99, No 3, May/June 2009