Tuesday, October 23, 2012

Kobe Bryant Foot Injury

Kobe Bryant sat out the Lakers' practice on Monday with a strained and bruised right foot.  He's officially listed as day-to-day. He may miss Wendnesday night game at the Staple Center against the Clipppers.

Saturday, October 13, 2012

Pierre Garcon's Toe Joint Injury.

Despite starting each of the past two games and making it through each unscathed, Washington Redskins wide receiver Pierre Garcon has yet to recapture the big-play form that he displayed during the first quarter of his team’s season-opening victory at New Orleans. Offensive coordinator Kyle Shanahan said that although it has helped having Garcon back on the field, he can tell the wideout remains less than 100 percent. In the season opener, Garcon – the Redskins’ biggest free agent acquisition of the offseason, signing a five-year, $42.5 million contract with $21.5 guaranteed – recorded four catches for 109 yards, including an 88-yard touchdown. On that touchdown play, Garcon injured his right foot, straining it near the ball of his foot. Garcon had to leave the game after only eight plays. X-rays revealed no breaks in the bone, but Garcon missed the next two games, and returned to action two weeks ago at Tampa Bay. But in the past two games, Garcon has combined for only four catches for 44 yards. (Washington Post)

Could this be turf toe as described by Dr. Brian Timm

Family Foot and Leg Center, PA
661 Goodlette Road, Suite 103
Naples, FL 34102

239 430 3668

Thursday, October 11, 2012

Yankee's Derek Jeter with bone bruise of the left foot

MLB injury list has Derek Jeter on there with a left foot bone bruise.  Bone bruises happens when there is a trauma to the bone, think of it as a punch delivered to the bone causing bone swelling.   The bone as an outer covering called the periosteum that carries blood to the bone and with a bone bruise, more blood is sent to the bone with healing factors to help heal this injury.   Can take up to 6-8 weeks for full resolution in most cases.
MRI's are useful as well as ultrasound can help detect this injury.

Dr. Kevin Lam
Director of Family Foot and Leg Center
Naples, FL

Tuesday, October 9, 2012

Posterior Tibial Tendon / Flatten Arches / Adult Acquired Flat Foot

If you have painful flat feet, you are not alone famous celebrities like: Kelly Osbourne, Gbenga Akinnagbe, Kim K. and many famous NFL, NBA athletes have flat feet. 

In the age of minimalist shoes and shoe makers such as vibrim, et al now concentrating on looks vs function, we are seeing a good amount of posterior tibial tendon injuries from mild to severe.     The posterior tibial tendon is a very important tendon that is the major supinator (holds up the arch) of the foot about the ankle.  When this tendon is injured inflammation starts, chronic inflammation can lead to tears and flattening of the arch.  There is a zone of hypovascularity behind the big ankle bone called the medial malleolus, this is where most tears are located. For some reason theres is the area of less bloodflow to the tendon.   Other areas of tearing and inflammation is where this tendon inserts into the navicular bone or to an accessory (extra) navicular bone called the os tibialis externum.   Chronic inflammation and tears can lead to a progressive flattening of the arch.  Hence one of our most common complaint is:" Doc my arch is falling and my ankle hurts."  Another complaint is the inability or difficulty in  walking up the stairs.   Ideally, we would like to see patients before the arch starts falling, once that process has started the tendon is already compromised.  

By MRI criteria the grading system as follows
Grade I: inflammation
Grade II: partial tears
Grade III: Rupture
For surgeons our grading system
Grade I: Inflammation
Grade II: partial tears
Grade III: Compromise of tendon with flexible collapse
Grade IV: Rigid flat foot deformity with compromised tendon

The area of red above shows the typical area of pain described by our patients upon presentation.  Palpation or touching of this area will reproduce pain.  
If you look from behind you will see the outward deflection of the heel along with "too many toes" sign when viewing the foot from behind.  In extreme cases patients can be have numbness in the foot from compression on the nerve that travels behind this tendon.   There is a tarsal tunnel where this important nerve runs in the medial ankle.    When the arch collapses the nerve is put under considerable stretch and pressure causing numbness / tingling.   A nerve conduction study can help to identify / quantify this phenomenon.

Conservative Treatment:
  • Immobilization with a boot or brace until tendon calms down
  • Physical therapy to strengthen the tendon and induce blood flow to the tendon
  • Orthotic therapy from your podiatrist or orthotist for mild to moderate cases
  • Gold standard for moderate to severe cases is the Ankle Foot Orthosis (AFO) which limited the ankle's pronation or flattening of the arch.  AFO such as a Richie, Arizona, Colorado, Stepwell, etc type braces.
  • TENS unit

Surgical Options:
Lateral column lengthening such as an Evan's calcaneal osteotomy where we place a bone wedge on the outside to bring the foot back under the ankle. This is the only procedure that can correct in all three planes of the foot. This is a very powerful procedure for adult acquired flat foot where the toes all point outwards in the typical "too many toes sign," when seen from behind.

NERD ALERT!   The Evan's is the only flat foot procedure that can correct in all 3 planes (views) hence it is a very powerful / useful procedure.

Preoperative eval for an Evan's Calcaneal Osteotomy.   Notice the red line forming the angle the foot is collapsed with increased Calcanceal Cuboid joint angle.  Greater than 5 degrees is abnormal on this view.

Post operative view 7 months later shows the proper alignment and a more normal looking foot. Notice the darkened wedge in the heel bone.  Problem solved at FFLC

Medial calcaneal osteotomy where the heel bone is cut and shifted medially (inside) to realign the heel under the ankle joint.  This comes in handy when there is a deformity of the heel bone itself or when the Evan's calcaneal osteotomy was not sufficient to correct the deformity.  Below shows a case of double calcaneal  (Evan's and the medial calcaneal slide) osteotomy used to fix an adult acquired flat foot deformity.
Preop notice how the foot goes out 
After notes how the foot is now straight. 
Preop of the same patient different view showing the collapse

Post op lateral view showing both osteotomies stabilized and the hindfoot well aligned. 
Subtalar joint implants or arthroeresis procedure is when an implant is placed into a hindfoot joint to stop the pronation or flattening of the arch.   This procedure is a quick fix for some patients with mild to moderate disease but it is not covered by insurances and is deemed experimental even though it has been around for decades.    Some surgeons use this as their primary procedure, I would disagree with that mentality.  Trivia: First subtalar joint implants were made out of penile implants, cut and shaved to fit in the subtalar joint.   Currently, they are made of stainless steel or titanium. Below, shows before and after xrays of a painful pediatric flat foot that was corrected with a subtalar joint implant.  Notice the metal circle holding up the arch of the foot. This was done in a 16 year old patient with painful flat feet and did not resolve with orthotics therapy.  Some doctors will do this procedure for every patient with flat feet, but my personal preference is to do this only for certain patients that can not undergo a true reconstructive boney procedure or those that only want a quick fix with realization that they may require a more detailed procedure later when skeletally mature.  

Triple /double  arthrodesis where we fuse 2 to  3 major hindfoot joints to create stability. Recent studies found this procedure to have the most satisfaction rating amongst patients.  I would agree with this when used for Grade III or IV deformities, or if the patient is obese.  Below you will notice the before photo of the ankle with the arch collapsed.   The bottom shows the proper alignment of the joints with the arch restored.  More often then not, an achilles tendon lengthening would be required as an adjunct to this procedure.
Case #1 : Preoperative Double  Arthrodesis with collapsed foot. 
Case #1 Post op with fixation intact and foot in proper alignment

Case #2 Preop Triple Arthrodesis Procedure, notice the collapse and arthritic formation  circled in red.  Patient had severe pain and collapse
Case #2: Post operative Triple Arthrodesis 3 years later without pain in the ankle or foot.

Tendon transfers may also be done. There is a tendon behind the posterior tibial tendon, flexor digitorum longus)  that can be easily transferred forward, or used to replace the entire posterior tibial tendon. Usually the tendon used is the flexor digitorum longus which is right behind the posterior tibial tendon.

The choice of surgical intervention  can be a combination of those above. Your surgeon should have preferences  from their past experiences.  Beware of surgeons who only do this or only that procedure for PTTD.  Different stages of the deformity requires different procedures and your surgeon should have experience with treating various stages and treatment protocols for each.

Custom orthosis usually a UCBL type of orthosis
Proper shoes with proper support such a new balance line with rollbar
Avoid heavy workout in minimalist shoes.


In stage one of this disease which is just tendonitis without any collapse or tendon weakness,  stem cell injections into the posterior tibial tendon can help regeneration of the tendon without the need for surgery.    Most of the time, a CAM boot may be required after the injection for up to 6 weeks to allow for proper tendon healing. www.topstemcell.com

Dr. Kevin Lam
Clinical Director of FFLC
Naples, FL 34102
239 430 3668 option 2 for schedling.

Pre and Post Operative photos are actual patients of Dr. Kevin Lam
Choosing the right surgeon for these complex cases can mean a difference of painfree living vs a lifetime of disability.  All rights reserved.  You may not use these pictures without written permission of Dr. Kevin Lam

Thank you viewers for making this my most popular blog, I will continue to update and refine!

Thursday, October 4, 2012

Joint Pain / Arthritis in the Big Toe

Often I would hear at the Family Foot and Leg Center here in Naples, FL, "Doc I have a bunion, or pain on the top of my foot around the big toe."  Technically the arthritis in the big toe can be called a dorsal (top) bunion.     As you can see from the xray to the side here there is a bump on top of the big toe joint.   There is also a lack of joint space in the big toe joint.
To the left here you'll see some spurring in the big toe joint.    The space is also narrowed.   Comparatively, look at the space between the 2nd metatarsal (long bone) and it's associated toe bone, there is a nice black gap in between, that gap is cartilage that is radiolucent (does not show on xray).
The condition is called, Hallux Limitus or Ridigus depending on the stage of the condition.  Causes range from: Post traumatic injury from soccer / football kickers, previous untreated big toe fracture, turf toe that caused joint injury, crush injury, poor choice of shoes or poor mechanics.
Your podiatrist will be able to tell you more about your cause.

Symptoms include: burning in the big toe joint, swelling, stiffness, deep throbbing pain, pain with change of weather, pain with bending the big toe joint.    Now one thing can be confused for hallux limitus is gouty arthritis, with gout youur joint will be red, hot and swollen and painful to even a bedsheet's pressure.    Hallux Limitus / Ridigus is more constant and consistent throbbing.    There are stages of Hallux Limitus, the case presented here is a Grade III where it is almost self fused.

Non surgical option will consist of using orthotics with a morton's extension, either rigid or made from cork.
Surgical options depend on the stage of the disease: injections, joint fusion, joint replacement.
Notice the top bump is gone
Joint space restored
The above real life case of Dr. Kevin Lam, the patient 5 years after a joint replacement with the arthrosurface implant. Patient remains pain free.    Not everyone is a candidate for this implant.  My personal criteria is 50 and over, good bone stock and people of mild to moderate foot activity.  If you are a 5 mile a day runner, you do not qualify.  Or if you are 30  years old, you do not qualify, etc.    Some doctors have stretched these rules.     Implants can be metal, silicone or a combination of such.    When you choose an implant make sure you realize that they may need to be replaced in 10 or 15 years, etc. Another surgery may be needed.

Fusion of the big toe has the best long term patient satisfaction according to new studies.  Our center offers that too but also gives our patient choices.   Fusion is great choice for active patients with debilitating pain. The end all procedure.  The decision should be between you and your doctor, get some opinions.   Beware of those that will tell you, I only fuse, or I only implant. There are choices and your doctor should be able to give you those choices and have the experience to guide you in the right direction.

Patient many years post arthrosurface implant, very happy about such, made a video about it and here it is.

Newest video with a full review and explanation about Hallux Limitus and Rigidus.

Dr. Kevin Lam
Family Foot and Leg Center, PA
 Naples, FL
239 430 3668

Wednesday, October 3, 2012

Panther's C Ryan Kalil / Santonio Holmes / Benson with Lis Franc's Injury

Cedric Benson now with Lis Franc's injury and out for 8 wks. Last time we saw this injury was with Santonio Holme's injury.   Another person to add to the Lis Franc's injury list:   C Kalil of the panthers has a left foot lis franc's ligament injury.   
THis must be a French Conspiracy on the football season. 

Find out more about Lis Franc's read on. 

Lis Franc's ligament is a small but important ligament holding the foot bones today, particularly the medial cuneiform to the base of the 2nd metatarsal (long bone).   Injuries to this ligament can be as mild as a sprain of the foot requiring 8 wks of a boot,  to fractures with dislocations that can debilitate the individual. Surgery is required if the pain does not resolve or if there is a large gap between the bones as noted below. 

Second opinion about Santonio Holme's foot injury reveals a Lis Franc's injury. Foot injuries can be devasting to the NFL player and can end your season like WR Santonio Holmes. How does this occur?  Mechanism can be from stepping on your foot, or you stepping down hard in an open hole causing the middle of the foot to buckle.   Can be seen in auto accidents where the person is pressing hard on the brakes to avoid a collision.   This can not only be season ending but career ending for some player, hope this is not the case for Santonio, only time will tell. 
LOOK at the Bottom of the first big bone (metatarsal) that is separated  from the 2nd big bone (2nd metatarsal)

Same foot as above with the area of injury enlarged.
You can see the separation better in the zoomed in picture.    This is a very serious foot injury that can career ending.  Not knowing the severity of his Lis Franc's injury, it is almost certain that he will always have some sort of pain or immobility from this.  Option for treatments involve, immobilization, prolotherapy,  Platelet Rich Plasma (PRP) injections, and even surgery.   Most patients will end up with chronic foot pain in that area that can develop degenerative joint arthritis over time thus requiring a fusion.    Below shows our technique for Lis Franc's Injury reduction.    There are numerous techniques from wires, screws, big halo's depending on surgeon's experience and preference.  Note that the goal of this surgery to realign the joints that are displaced.     

I certainly hope that this will not be career ending for Santonio, but these injuries can be very hard on a professional athlete and his foot will potentially never be the same. 

Disclaimer: These are not the xrays of Santonio's foot.     These are photos of an actual FFLC patient of Dr. Kevin Lam,  treated in Naples, FL. 

Dr. Kevin Lam
661 Goodlette Road, Suite 103
Naples, FL 34102