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Wednesday, August 27, 2014

Foot Fractures more common during "ankle sprains."

"Doc I sprained my ankle and it has been hurting for the last month,the ER says my ankle is not broken," the patient.  

Heard this a million times. What we have always trained our staff at FFLC is to take the Ankle and Foot films in these cases. The reason is that most ankle sprains are just that, sprains of ankle ligaments.   BUT foot fractures due to twisting of the ankle is more common than ankle fractures.
  • Fifth metatarsal base fractures
  • 5th metatarsal base fracture
    Surgical fix with screw. 
  • Anterior process calcaneal fractures 
  • Jones' Fractures.
  • Lis Franc's fracture / dislocations
I know the last one personally. I twisted my foot during Brazilian Jujitsu practice and immediately my foot and ankle swelled up.   Being a foot / ankle doctor, the treatment that night consisted of ICE, rest and ace wrap, the next morning Xrays were taken.  Luckily, no fractures but I did have a lis franc's sprain which has taken up to 6 months to get me back to 90 % of my physical activity.    

So when you think of ankle sprains now, think, check the foot!


Tuesday, August 19, 2014

Worker's compensation and Motor Vehicle Accidents of the Foot / Ankle

Often the difficulty comes from a patient waiting too long to seek medical attention or they do not tell all their complaints to their treating doctor.   They can be concentrating only on one area of the body, eg: shoulder / back pain but forget about the ankle injury and thinks that it is only a sprain.  There are times when clinicians can get tunnel visioned in treating one area of significant injury but inadvertently do not address another area. Being trained in trauma surgery and reconstructive surgery, I have seen the neglected ankle sprain being a tendon rupture / ligament rupture, nerve damage, etc.     MRI's and through physical exam by a specialist physician are very useful around the time of the injury to see active swelling, injury to the tissues in question.   This can help to answer the age old question of if this a new injury from this accident or a preexisting injury or even an aggravation of a preexisting condition.    

If you need a second opinion after any accident about your foot / ankle concerns seek a board certified expert with experience in trauma care and reconstruction. Independent medical examinations (I.M.E.) can be done to help also.


Monday, August 18, 2014

Life altering ankle sprain why you should see a doctor.


Hint: NOT AN ANKLE SPRAIN but ligaments and tendon ruptures



Active tennis coach who took a wrong step and twisted his ankle on the court while teaching about 4 months ago, ankle never felt better and in fact worsened and also feels unstable on this ankle.   Pain, burning sensation noted about the outside ankle bone.   MRI notes tears in both tendons on the outside as well as 2 ligament tears.  There are 3 ligaments on the outside of the ankle the Anterior TaloFibular Ligament (ATFL), Calcaneal Fibular Ligament (CFL) and the Posterior TaloFibular Ligament (PTFL) as well as 2 tendons the Peroneus Brevis and the Peroneus Longus tendon. 

Most people will shrug off an ankle twist and think that if they can still put weight on the foot, they are fine, just a sprain.   This is just one of the complications of a neglected "ankle sprain."      In fact, often ankle fracture are less painful than a ligament tear.    There are also discussions with new imaging technology that even those injuries classified as sprains are actually mini ruptures of the ankle ligaments.   Repeated injury can cause lengthening of the ligaments and predispose a person to more injury in the future if significant injury has not already been done. 

Back to this case:  This person injured tore two of the 3 lateral ankle ligaments, then the two tendons were injured in the same accident.  Bracing and therapy would not help in this situation though was suggested by the insurance company and the independant far from caring reviewing orthopedic surgeon hired by the insurance company to deny MRI's and surgeries.   Orthopedic surgeon or podiatrists are hired to do reviews of these cases to first deny MRI's and then to deny surgeries.   Acting as a patient advocate in this case and many calls made, finally an MRI and surgery was done, the orthopedic surgeon's callus opinion was overturned by a case manager. 

Surgery involved arthroscopy of the ankle joint to assess the cartilage and remove any inflammed tissue in the ankle, patient did have an anterior lateral impingement syndrome that was cleared with arthroscopic tools through a 4mm portal.  Both tendons repaired, bone removed from the outside of the heel bone, the peroneal tubercle is a natural occurring structure but in this case worsened his situation.   New ankle ligaments were made for this patient with his native tissue, yes, we can make new ankle ligaments. 


Updates to follow: 






Silver retractor points at the Peroneus Longus tendon that is scarred to wall of heel bone. Brass colored retractor on the Peroneus Brevis tendon, notice the bulbus tear just to the right of the retractor.  
Notice the tear of the Peroneus Brevis tendon with a bone (peroneal tubercle wedged between the tendon)
Same issue as above with instrument pointing at the peroneus brevis tear.



Monday, August 11, 2014

Saltwater Catfish Barb injuries

While fishing Naples Pier, there are days when it seems that the only fish around are the catfish eating your precious baits.  Or in the backwater.   Few injuries have come into the office when people tried to kick the catfish off the pier or dock while wearing sandals, crocs, etc only to get a catfish barb in the toe or foot.  They are very painful injuries, not only because of a puncture wound but also because of a protein toxin in the spines.     While you can get most of the barbs out, it breaks off easily and stays under the skin.   This will be very painful.   What to do in the situation?

1) Soak in warm / hot water without scolding your skin
2) Seek medical attention for xrays and possible extraction under local or general anesthesia
3) Retrieval of barb by a medical professional
4) Antibiotics as a precaution.


Best way to treat this?   Do not get close to the barbs with your hands or your feet. FFLC treats these injuries on an emergent basis with in office xrays, and ability to clean the wound and retrieve the barb from your foot or lower leg.   At times admission to hospital to get general anesthesia may be required.


Thursday, August 7, 2014

Buy Shoes For Back to School, how to avoid foot pain for your child.





  1. 75 % of american buy shoes too small for themselves imagine their children?
  2. Need at least 1/2 inch or a thumb's width between the longest toe to the end of the shoe while the child is standing
  3. Running shoes are not recommended for everyday usage for walking and activities.  Running shoes are meant to be light for competition, not deal with the punishment of everyday walking and grueling activities.  
  4. Wrong shoes are the major reason for pediatric heel / achilles and knee pain. 
  5. Get you child's feet measured at least once a year professionally by a podiatrist , pedorthist, or qualified shoe salesman
  6. The shoe measuring instrument, brannock device,  is meant to be used while standing, not sitting.   
  7. Width of the shoe is as important as the length of the shoe. 
  8. Painful flat feet? Need to see a podiatrist ASAP before other symptoms start. 

Wednesday, August 6, 2014

Posterior Tibial Tendon Dysfunction Grade II

Our very own Dr. Ramy Fahim discusses treatment for Grade II of this disease.
There are various ways to treat this deformity from stents such as the hypocure to bone fusions, bone slides, reconstructions, etc.

Below are videos of a single arthrodesis to the triple arthrodesis.   Arthrodesis or fusion is the mending or bringing together two or more bones.    Set it and forget it as Ronco used to say.  Fusions are typically for more advanced disease such as grade III or IV or if the patient is overweight with grade II disease.  

Grade I :  Tendonitis
Grade II: Tendonitis / Tearing
Grade III:  Flexible adult flat foot
Grade IV: Rigid adult acquired flat foot




Popping Peroneal Syndrome, Ankle Popping / instability by Dr. Kevin Lam





Peroneal Subluxation Syndrome.





  1. Does your ankle pop on the "outside" during certain movements?
  2. Pain on the outside of the ankle? 
  3. Unstable ankle, feeling of about to fall off the ankle
  4. Burning pain outside the ankle. 
  5. Audible popping sound when you are rolling your ankle around. 
  6. Visually see your tendon on the outside rolling and popping? 

Tuesday, August 5, 2014

Achilles tendon ruptures fixed with PRP and casting



Not all achilles ruptures require surgery.    
Some patients do well with casting and Platelet Rich Plasma injections.  See the difference in this video.
One important fact about this process is that it works best when we get the patient early in the rupture, when the tendon has not retracted up the leg.    

Sunday, August 3, 2014

Malignant Melanoma on the Leg PART 2

Followup from my earlier blog about Malignant Melanoma 5 years in duration. Lucky for this patient his was a superficial spreading kind and has not grown deep enough to spread beyond the local skin.  A 1 cm margin of safety excision will be done in accordance to NIH guidelines.    Cure rate is in the high 90 % mark.  Patient will need followup with Dermatology and now living in FL will need a whole new look at sunscreen and sun clothing such as those from coolibar, etc.
When in doubt biopsy it out, it can save a life.

Another leg and life saved at the Family Foot & Leg Center, PA.

American Idol Michael Johns dies of Blood clot from Ankle. What you need to know now!

According to Entertainment Weekly, the Australian born singer, who was on the Fox program in 2008, died Friday at age of 35.   He apparently died of a blood clot in the ankle?   How can you die from a blood clot in the ankle one may ask.     Without knowing the official reports, based on the news that out there  about his death a blood clot in the ankle is noted as the cause of death.  I am assuming that he died from a clot that started in the ankle / calf and travelled to his lungs.    This is called a pulmonary embolism, AKA P.E. as noted in the medical text and jargon.

How do you get a blood clot in the ankle /calf.  One way is sitting still on a flight or any situation for along time with blood pooling in the legs, the blood then clots in deep leg veins causing swelling due to the blood not being able to return to the heart.   When a clot breaks off and does return, it is lodged in a pulmonary vessel causing difficulty in oxygen exchange in the lung tissues.  Depending on the location and size of the clot this could cause some serious damage leading to death.

Risk factors:
Being overweight and inactive, being on birth control pills, being immobilized after an injury  in cast, being immobile while on a long flight or drive, genetic clotting disorder, smoking, family history of blood clots etc.   Any combination of the above can be a recipe for disaster.   If you are having surgery of the lower extremity and have any of the risk factors above or combination of such, notify your surgeon ahead of time where proper tests can be done as well as proper post operative protocols can be done to help prevent most blood clotting situations, nothing is 100% in medicine.  I have seen people with bunion surgery go onto having these clots.


Symptoms include: swelling of legs, coughing, radiating pain to the arm / chest, deep pain in one or both legs with swelling, severe varicose veins, redness of the leg (s), difficulty breathing, feeling tired / light headedness,  looking pale / clammy or discolored skin, rapid / irregular beating heart etc.

Mayo clinic information
NIH Source on pulmonary embolism.

Disclaimer: as of this writing, I do not have the official report of his death,  only information out there at this time is death due to blood clot in his ankle.    This is the most common way you can die from a blood clot originating in the ankle, him being a star from American Idol probably travels a great deal on airplanes and sitting still for long periods of time between performances.