Turf Toe

With the advent of football season starting this past weekend, I thought it appropriate that we try to “tackle” common injuries suffered during the season. As some of you may know, when players in the NFL are injured it completely messes up our Fantasy Football seasons and we quickly scramble to pick up “free agents.” Aside from our frustrations, however, it’s the players who are suffering from ankle injuries, muscle sprains, tendonitis and so forth. Understanding some of their conditions might provide us with a small amount of sympathy for the ridiculous amount of money they’re making to sit on the sidelines!

Professional athletes are considered to be in tip-top shape compared to the average citizen, and many people wonder how, being in such great shape, they still manage to injure themselves. I can assure you, although some injuries occur secondary to poor preparation most occur secondary to over-use, direct impact, or abnormal force vectors through the body.

This week I would like to discuss Turf Toe. It seems like an ambiguous diagnosis, but it is a real diagnosis with those most frequently afflicted being athletes that play on turf surfaces. The actual injury is a disruption of the plantar ligaments (those underneath) the big toe secondary to hyperextension, or excessive bending of the toe upwards in relation to the foot.

The injury occurs when the athlete’s cleat gets ‘stuck’ in the turf surface while the body is moving in a forward direction. This motion forces the big toe to extend, abnormally, before the cleat can release itself from the surface. This hyperextension can induce an overstretching of the plantar ligaments, a partial tear, a complete tear, and even cause damage to the big toe joint if it becomes compressed during the injury. Almost immediately pain becomes evident to the player, but professional athletes tend to play through pain until it’s absolutely unbearable. However, this pain is usually accompanied by swelling and difficulty in bending the toe, realized when the athlete removes his or her cleat after a game.

The tenants of any injury apply to treating Turf Toe: RIICE: Rest, Ice, Immobilization, Compression and Elevation. Rest and Immobilization will prevent further injury to the plantar ligaments in addition to giving them a chance to repair themselves. Ice, compression bandaging of the toe and elevation will help decrease swelling and subsequently decrease pain to the joint. Of course, non-steroidal anti-inflammatory drugs such as Ibuprofen can be utilized to decrease pain and help control inflammation as well. Athletes are typically encouraged to keep off their toe/foot for at least 3 days, after which partial weight bearing in a rigid soled shoe, to prevent motion at the joint, can be attempted

It is always wise, when a Turf Toe injury is possible, to be evaluated by a Podiatrist. X-rays can help rule out damage to the joint and physical therapy will help get the athlete back to their game in no time! It is likely that with return to activity, protection of the toe will be exercised through taping and shoe accommodations to keep motion to a minimum. Obviously, depending on the extent of damage, more time away from the game may be necessary to allow for adequate healing, but at the professional level, those athletes are looking at a maximum of three weeks on the sidelines. Too early a return to activity can lead to further damages to the joint, including arthritis and eventual loss of motion, so caution should always be exercised!

Next week, I’ll be discussing muscle pulls and tears including those most commonly suffered in professional athlete: the hamstring, and achilles tendon.

Think R.O.D.

Over the last three weeks we’ve been discussing the most common complications to affect the diabetic patient in the lower extremity. Diabetic neuropathy with circulatory compromise and increased plantar foot pressures all contribute towards an increased risk of diabetic ulceration in such patients.

I’ve given you many helpful tips for decreasing your risk of developing each of those three complications, and again I’ll reiterate that prevention is your best option! However, despite your best efforts, if you do develop a “neuropathic ulcer,” you will be facing an uphill battle in getting that ulceration to heal. This week I hope to help you identify signs and symptoms of an ulceration that needs immediate treatment, increasing your chances of healing that area quickly.

First and foremost, you should understand what I mean when I say “neuropathic ulcer:” this is an ulceration found in an area of the foot where you lack sensation such that the causative agent (whether a foreign object or friction) went undetected by you. Treatment begins with recognition of the ulceration at home during your daily foot checks. Once you’ve identified a break in the skin or ulcerative area, you should immediately call your Podiatric Physician for an appointment. This last step is very important, no matter how large or small the area of ulceration may be, because these wounds have a history of quickly deteriorating.

Now, if the area in question is discovered on a Friday after your Podiatrist’s office has already closed for the weekend, there are some signs and symptoms you need to be on the lookout for. These signs/symptoms will help you determine if you need to seek immediate treatment at an Emergency Room, or if you are able to wait it out until Monday. In deciding this, think ROD: Redness, Odor, Drainage.

R = Redness: If the skin surrounding the ulceration is extremely red, hot and swollen, this is a cause for concern. Even more emergent is recognition of red “streaking” from the area of ulceration up towards the core of the body. Streaking is a sign of infection that is penetrating the lymph system and needs immediate attention. As an aside, if you are having any symptoms of a systemic infection, such as fever, chills, nausea or vomiting, you are also in need of immediate treatment.

O = Odor: If the area smells fruity or has an unbearable odor associated with it, this may be an indication of local infection across the base of the wound. If this is the only symptom, what you should do is clean the area with warm soap and water, dry it completely and place a clean dry bandage over the area, to be changed each day until you’re able to see your Podiatrist. If this odor is associated with systemic symptoms, excessive redness or streaking and alarming drainage, you are in need of immediate treatment.

D = Drainage: If there is green or thick yellow drainage coming from the area, typically associated with an odor, you need to be seen immediately. This is a definite sign of local infection, and one that may spread quickly, so it’s important to seek medical attention.

As a disclaimer, if you are unsure that your wound meets any of these criteria, my advice would be this: go to the Emergency Room. It’s better to be reassured that everything is okay than to miss an ulceration that’s quickly deteriorating. In addition, if the ulceration seems to be changing for the worse and digressing quickly, you should also seek immediate treatment.

Decreasing You Risk of Ulceration

Over the last two weeks we’ve been discussing diabetic complications of the lower extremities; an important topic in terms of raising awareness and helping you to prevent or slow progression of such complications. This week, I want to focus on the function of the foot in the diabetic population and again, how prevention is your best option for decreasing your long-term risk of complications.

In the diabetic population, equinus is the overwhelming commonality between patients suffering from plantar wounds associated with diabetic neuropathy. Equinus, to explain it simply, is a lack of dorsiflexion, or ability to raise the foot at the ankle joint past 90 degrees (neutral position). The ankle and foot function best in gait when dorsiflexion at the ankle is at least 10 degrees past the neutral position. When this is decreased, excess pressure is placed on the plantar forefoot throughout gait, and increased pressures automatically lead to an increased risk in ulceration.

Patients develop equinus from a lack of flexibility in the musculature of the leg, namely the calf. Whereby, dorsiflexion becomes decreased because it is those muscles in the calf that are responsible for lifting the foot above that neutral position during gait. If those muscles are tight or contracted, which occurs in patients who don’t stretch or exercise on a regular basis, equinus and increased forefoot pressures result.

Increased pressures in any area of the foot create a major risk in the diabetic patient, and such pressures can also be induced by tight fitting shoes, open-toed sandals that rub between the toes, and areas of friction along bunion prominences or on the tops of contracted digits (hammertoes) in closed-toed shoes. The reason increased pressures are such a risk is that in places of friction, typically not felt by the neuropathic diabetic patient, a pre-ulcerative lesion may develop. The area goes undetected, unless you’re religiously checking your feet on a daily basis for new lesions (which you should be doing!), and the pre-ulcerative lesion turns into a wound.

Again, you are faced with the issue of non-healing secondary to poor circulation (which we discussed last week), such that the nutrients needed for wound healing carried by the blood have difficulty getting to the area. In addition, if you have not addressed the issue of equinus or the problem shoes that created the initial friction, you’re bound to have problems in the future, even if you’re able to heal this time around. So what can you do? Again, the answer is prevention!

There are two important ways in which you can take control of the deforming forces of equinus and increased pressures placed on the foot:
1. Stretch – By stretching the musculature in your calf and increasing the flexibility around the ankle joint (decreasing your equinus), you will greatly decrease pressure placed on the plantar forefoot and decrease your risk of ulceration. There are several exercise, that are easy to do:
a. Wall Stretch: With your feet shoulder width apart, one foot in front of the other, place your hands on the wall in front of you. Keeping the back leg straight and the front leg bent slightly at the knee, lean into the wall. You should feel a light stretch in the calf of the straight leg. Hold this for 20-30 seconds, take a 15 second break and repeat 10 times. Then switch front and back feet, so that you can stretch the opposite side. Again, hold for 20-30 seconds, repeating 10 times.
b. Heel Drop: This exercise will require a set of stairs with a railing available for balance. Place the balls of both feet on the step, knees straight and allow the heels to suspend off the step and drop down below the level surface via your body weight. You should feel a light stretch in the calf of both legs. Hold this for 20-30 seconds, take a 15 second break and repeat 10 times.
2. Invest in a pair of diabetic shoes – Especially important for those patients with diabetic neuropathy, but important for any diabetic patient. Diabetic shoes have a custom molded insert with a wide and deep toe box. The insert is made from a mold of your foot and alleviates all areas of pressure on the plantar foot. The wide and deep toe box allows the foot room within the shoe, preventing areas of friction on boney prominences. Diabetic shoes essentially alleviate all friction areas, thus decreasing your risk of pre-ulcerative areas and ultimately of developing an open wound.

As you can see, the power again remains in your hands when it comes to decreasing your risk of complications associated with diabetes! With diet and exercise, controlling your blood glucose levels, managing your co-morbidities and preventing areas of pressure in the foot, you’ll be well on your way.