What’s Your New Years Resolution?

Many of us start the beginning of each New Year with a resolution. Whether it be a resolution to lose 20 pounds this year, do something good for others, develop a healthier lifestyle, pay off debt or quit smoking we set out on the road to success and by mid-February, we are floundering! This year, I want to hold you to those resolutions, especially the one you made to run that 5k, 10k or half-marathon.

This weeks tips are aimed to help keep your running legs hot, propelling you through the winter season toward achieving your goal!

1. Make sure to always warm up and cool down.

With any exercise routine, and especially while training for that race you’ve resolved to complete, warm up and cool down sessions are a must! The warm up allows your muscles to prepare themselves for the workout ahead, decreasing your risk of injury such as muscle strains and sprains. Try 10 minutes of walking or light elliptical training and a stretching session. It is especially important to stretch the muscles in your legs, including hamstrings, quadriceps and calf muscles, as those muscles will receive the highest demand over any other muscles in the body while running. Cooling down is also important, with 5-10 minutes of walking and a full-body stretching routine. This helps prevent build-up of lactic acid in the muscles decreasing the amount of “muscle pain” you will experience the following day.

2. Invest in a good pair of supportive running shoes.

Think about it: you run on your feet, your feet are supported by shoes, and those shoes transmit your body’s weight through to the ground. Do you really want all that force traveling through a worn-out pair of running shoes that could significantly increase your risk of foot and ankle injury? When you head to the shoe store, make sure to bring with you a pair of socks that you would normally run in. Also, if you have orthotic devices that you wear, bring those to try on with your potential new running shoes. Have your feet measured for accurate size and don’t be afraid to run around the store in shoes you are considering buying.

For more buying tips, check out the American Podiatric Medical Associations (APMA) website: http://www.apma.org/MainMenu/Foot-Health/Foot-Health-Brochures-category/Learn-About-Your-Feet/Footwear.aspx

3. Start off slowly.

It’s important that at the beginning of any exercise routine or new running workout, you advance your distance, pace and level of resistance slowly. If you advance too quickly with your body not apt to handle such an increase in activity level, your risk of injury skyrockets! Things like muscle strains, stress fractures and plantar fasciitis become real threats. Take it slow, gradually increase your pace and your distance over the weeks leading up to your race, and abide by tip #4: Enjoy rest days off.

4. Enjoy rest days off.

Taking rest days from your training routine, at least one day per week (two if possible) is very important for reducing your risk of injury and overloading your body. Your body needs days to recover from intense workouts and you feet need a break too!

Before starting any exercises or training routine it’s important to be evaluated by a physician to make sure you are in good physical health and able to handle the demands that will be placed on your body. In addition, you should be evaluated by your Podiatrist who can identify areas in your lower extremities that might lead to injury, while providing solutions to prevent such injuries. They can also suggest warm-up and cool-down exercises specific to the lower extremity that can be included in your routine. The APMA also suggests some lower extremity stretches. Check them out at: http://www.apma.org/MainMenu/Foot-Health/Foot-Health-Brochures-category/Sports-Medicine/Running-and-.aspx

Hit the trails while following these simple tips and you’ll be well on your way to accomplishing that New Years resolution to complete your 5k, 10k or half-marathon this year. See you on the road!

Why Does it Take So Long for My Fracture to Heal?

When patients are diagnosed with a fracture, the first question they have after the initial, “Do I have to have surgery” is: How long will it take to heal? The answer obviously depends on the location and severity of the fracture, but no matter the answer, the patient always expresses shock. They can’t possible fathom why it is going to take X-number of weeks for their fracture to heal. I’ll let you in on a little secret – there are a lot of factors that go into bone healing and the number of factors that play a part increases as the compliance of the patient decreases!

This week I hope to help you gain a general understanding of what the body must accomplish in order for bone to heal, in addition to some things you can do that might help along the healing process. We will evaluate bone healing from the approach that you have suffered a fracture that is not significantly displaced and does not require surgery, but that will require casting and non-weight bearing on the affected leg, with crutches for proper healing.

In school they teach physicians that specific cells called osteoblasts, osteoclasts and osteoid matrix are required for adequate bone healing. The names of these cells are unimportant but their presence at a fracture site is required for healing, allowing the body to form new and sturdy bone. In an optimal healing environment (which is what we are assuming), the cells are permitted to cross the fracture site, reaching the other side and filling the defect with new bone.

With that said, those cells move across the fracture site and lead to healing in a series of specific steps: the phases of bone healing.

Phase 1: Inflammatory – in this phase, the area between fracture fragments must fill with blood cells and macrophages (think Pac-Man) that remove broken bone from the area, setting the stage for bone forming cells to invade. This usually takes place during the first 3 days after fracture has been suffered, assuming immediate medial attention and casting has been achieved.

Phase 2: Reparative – in this phase, the cells that we discussed above will invade the area producing and reforming bone needed to fill in the defect. They deposit all the necessary components of healthy bone setting the stage for the 3^rd phase of bone healing. This phase lasts to about day 21 post-injury.

Phase 3: Remodeling – in this phase, all those cells and components of healthy bone that were deposited during the reparative phase are left to arrange themselves in the direction of healthy bone, matching that of the surrounding un-fractured bone. Blood supply is fully restored throughout the area of fracture and the bone will strengthen in response to forces applied to it. Therefore, sometime late in this phase of bone healing your cast will be removed and you will be permitted to place some weight on the affected leg, allowing the body to detect normal weight-bearing forces, strengthening and remodeling your bone in response to them. This process can last 6-8 weeks from the time the fracture was suffered and even longer if optimal conditions are not achieved.

When suboptimal conditions are present, where the patient is not immediately immobilized, does not remain non-weight bearing on the affected leg and fails to follow their Podiatrists instructions, these phases become skewed. What can happen is that motion at the site of initial fracture induces additional phases of bone healing that inevitably elongate the healing process.

So what can you do to help the bone healing process stay on course and prohibit those additional phases from coming into play with a longer healing time than is necessary?

1. Follow your Podiatrist’s instructions. Whether that be staying off your foot and using crutches for assistance or elevating your foot as much as possible, follow their instructions. Contrary to popular belief, we do know what we are talking about and we aren’t giving you any of those instructions for our own health, but rather, for yours!
2. Stop Smoking. It has been shown that smoking inhibits the natural course of bone and wound healing. Even cessation of smoking the day you suffer that fracture has been shown to make a difference. You don’t want to give your body any reason to slow down the process of healing because you need one more cigarette.
3. Eat healthy. Eating healthy affects levels in your blood called pre-albumin and albumin which, when you are consuming proper nutrition those levels reside around their normal values. Should they drop below normal, indicating poor nutrition, healing of bones and soft tissues becomes inhibited. Eating a balanced diet also provides your body with the calcium it requires to help build strong and healthy bone. Calcium is a major component in bone.

Understanding the healing process and following these simple guidelines can ease your fears about a long recovery and your fracture will be healed before you know it!

Don’t Get ‘Bitten’ by the Frost!

With Mother Nature’s most recent gift of ice and snow, it seems fitting that we talk about a cold related emergency: frostbite! Historically, frostbite was known to be a problem suffered only by military personal and hunters, who spent hours in sub-freezing temperatures due to the nature of their profession; however times have changed and civilians are now included in those at risk.

Frostbite occurs when tissues freeze after being exposed to temperatures below the skins ‘freezing mark,’ which is 2 degrees Celsius. Those individuals most susceptible still include military personal and hunters, but also include those of us who spend large amounts of time outdoors; whether that be all-terrain hikers, sanitation workers or recreational skiers. Other individuals most susceptible include those who are dehydrated, malnourished, intoxicated or elderly. Parts of the body that are most affected include areas that protrude from the body, meaning ones fingers, toes, ears, nose and cheeks!

There are two mechanisms by which tissues can freeze resulting in frostbite:

1. Directly: As the tissues are exposed to colder and colder temperatures ice crystals form within the tissues causing the surrounding cells to lose some of their water content (dehydrate). The state of dehydration leads to breakdown of the cell structure and results in frostbite.

1. Indirectly: Known as the “hunter’s frostbite,” this mechanism occurs when there is increased blood flow to the freezing tissues followed by decreased blood flow, and increased blood flow again. The alternating blood flow leads to inflammation and damage to the small vessels within the affected tissue, which in its most advance stages leads to inability for blood to reach those sites indefinitely, i.e. frostbite!

Whichever mechanism of ‘freeze’ causes the frostbite, symptoms typically present in the same fashion. Initially burning, numbness, tingling and/or itchiness in the affected area occurs, warning of impending freeze. When these sensations are experienced it’s best to get inside and warm up for a bit before heading back out into the cold temperatures. However, if you don’t notice these symptoms, or fail to heed their warning, progression of your ‘tissue freeze’ will continue. The affected areas will begin to turn white, there will be an absence of sensation and swelling will occur. In severe cases, blistering of the affected area occurs with purplish/blue color changes and hardening of the tissue or a “wooden” feeling to the skin. It is at this end-point that the danger of losing the affected part becomes reality.

Classically, four stages of frostbite have been described from 1^st degree being the most benign and resulting in no permanent injury or tissue damage to 4^th degree frostbite being the most harmful with complete tissue death and loss of the affected part. There are also categories of frostbite such as Chilblain’s and Frostnip that don’t fall into one of the four stages, and are characterized as milder forms of the typical frostbite. In any situation, if you are even the tiniest bit suspicious of frostbite, it is important to seek medical attention immediately. Treatment, including controlled/monitored rapid re-warming of the affected area will help save as much tissue as possible.

Frostbite is not an injury you want to suffer from so prevention is key, but if you find yourself in a situation where frostbite seems probably remove yourself from the cold temperatures immediately and seek medical attention for evaluation and appropriate treatment.

Protect those areas most at risk by bundling up with gloves or mittens, hats, earmuffs, wool socks and water proof shoes next time you head out to shovel your sidewalk or make snow angels in some fresh powder!

DVT: Take Two!

Last week we discussed risk factors associated with the development of a Deep Venous Thrombosis (DVT). A DVT, to reiterate, is a clot in the deep venous system of the leg; the vessels responsible for carrying blood from the extremities back up to the heart for re-oxygenation and recirculation. We mentioned that a DVT can occur in anyone, but that certain risk factors such as stasis, tobacco use, estrogen use and heart conditions in addition to a history of DVT can predispose patients to development of a blockage. For a full list, including information about each risk factor, please refer back to the Blog entitled: What are My Risk Factors for a DVT?

This week, as promised we will focus on diagnostic testing that can rule-out or confirm a DVT, and if confirmed, the course of treatment that can be expected to follow.

Symptoms associated with a DVT typically present as a painful, red, swollen and hot leg. These symptoms, with or without the presence of risk factors should raise your index of suspicion for a DVT and medical attention should be sought immediately. As mentioned, should you present to your Podiatrist’s office with such symptoms you would be immediately referred to the nearest Emergency Department, therefore, starting at the Emergency Department is a wise choice!

When you arrive, it is important to explain to the admitting nurse all symptoms that you are experiencing as well as mentioning any risk factors associated with the development of a DVT. Although the process may be scary, it is important to convey all information and your suspicion of a DVT so that the Emergency Department staff takes you seriously and prompt evaluation can take place.

With suspicion of a DVT you will immediately be set up with an IV and medications given that can help break up a clot, should one be present or medications that can thin the blood to decrease the risk of additional clotting and migration of an existing clot. It should also be expected that you have blood drawn for evaluation of your base-line status in addition to looking for any imbalances in your electrolytes or blood counts. There is a specific blood test that can be conducted called a D-Dimer Test. This test looks for a specific chemical in the blood that if present can indicate the presence of a clot. It is not specific or diagnostic of a DVT but can help lead the Physicians in the right direction.

Additional tests such as a Venous Duplex Ultrasound can be conducted to look specifically at the deep veins of the lower extremity for direct visualization of a clot. The Ultrasound is completely non-invasive and consists of an Ultrasound Technician using a camera with ultrasound gel on your legs to locate a clot. Should they find one, the Technician is usually able to tell if the clot is new or if it has been present for sometime (noted by how hard the clot appears), which will help guide your treatment.

If a Deep Venous Thrombosis is detected, immediate treatment is indicated, as progression to a Pulmonary Embolism (PE) is the largest complication of a missed or under treated DVT. A PE is defined as the progression of clot from the deep veins of the leg to the lung, blocking off a section of the lung. It often becomes difficult to breath and in worst case scenarios, can be fatal!

Anticoagulation therapy is a treatment modality most of us have heard of in some form or another, usually referred to as “blood thinning.” It is the best and most effective treatment for DVT’s and helps reduce the risk of progression of your DVT to a PE. Medications that can be used in both the short and long-term include Heparin and Warfarin (Coumadin). In the hospital you will likely be started on Heparin and transitioned to Warfarin prior to being discharged home. The indication for blood thinning in patients with an acute DVT includes 3 months of therapy and in patients with recurrent episodes of DVT’s or a multitude of associated risk factors, longer.

Anticoagulation therapy requires weekly monitoring to ensure that your blood levels are thin enough, but not too thin, thus prior to any long-term treatment, you should discuss all options with your Physician. There are other options that can be explored in patients that are not candidates for anticoagulation and those should be discussed with your doctor as well.

Just remember, that if you suspect a DVT prompt recognition and treatment are a necessity, so seek medical attention immediately!

What are My Risk Factors for a DVT?

When you hear someone talking about a DVT or Deep Venous Thrombosis, even if you don’t fully understand the process of the condition, it makes you a little nervous! DVT’s, in the eyes of the general public, and in the eyes of medical professionals, are not something to “mess around with.” The seriousness of the condition, if caught early can quickly be diluted, but if a DVT is not detected or progresses beyond its initial stages, complications become real threats!

To take a step back for a minute, lets talk specifically about what a DVT is, and what it means in terms of presenting symptoms. The vasculature in the leg, and in the remainder of the body for that matter has two main systems. There is an arterial system that is responsible for brining blood from the heart out to the body providing oxygen and nutrients to the tissues allowing them to thrive. There is also a venous system, which is responsible for carrying deoxygenated blood from the body’s tissues back up to the heart and lungs for re-oxygenation and recirculation. For all you engineers out there, it’s a closed-circuit system!

Specifically in the lower extremities, the venous system, that which is responsible for carrying blood back up to the heart, is divided into a superficial (meaning close to the skin’s surface) and a deep (meaning hiding within the musculature of the leg) system. All blood within the superficial system is funneled into the deep system before it can be returned to the heart. A Deep Venous Thrombosis is a clot or a blockage in the deep venous system of the leg, meaning blood from both the superficial and deep systems of the affected leg can not properly return to the heart, as all blood must return through the deep veins.

When a blockage occurs (DVT), the patient may feel no symptoms at all, but more than likely the patient will notice pain, redness, increased temperature to touch, and swelling all within the affected leg. These symptoms, in addition to some of the associated risk factors for a DVT should raise immediate suspicion and requires immediate medical attention.

Speaking of risk factors, there are categories of patients who are more likely to suffer a DVT than others, and although it is rare to develop a DVT in the absence of such risk factors it is possible.

Here are a few common risk factors for the development of a DVT:

1. Stasis – periods of immobilization of the lower extremities such as casting after an injury or surgery, or long periods where the legs are stationary such as long airplane rides.

2. Hypercoagulability – some individuals are more prone to clotting than others secondary to genetically inherited disorders called thrombophilias.

3. Damage to vessel walls – injury to the venous system directly from any traumatic injury or recent surgery can be a predisposing factor

4. Heart Conditions – such as atrial fibrillation, congestive heart failure and past history of a myocardial infarction (heart attack).

5. Obesity – carrying extra weight tends to induce an increase in pressure on the deep venous system predisposing the vessel walls to damage, and thus increasing the risk of DVT

6. Tobacco Use – smoking can also induce damage on the vessel walls in addition to affecting the bloods ability to remain fluid and free-flowing.

7. Estrogen Use – a side effect of virtually any oral contraceptive available for women is development of a DVT.

8. Past history of a DVT – those patients with a previous DVT history have a much higher predilection to developing a DVT again.

To reiterate, if you suspect a DVT with or without associated risk factors, you should seek immediate medical attention. If you had presented to your Podiatrist office and a DVT was suspected during your visit, you would immediately be referred to the emergency room, so if you are at home, start with the emergency room first.

Next week we will discuss what to expect upon your arrival to the emergency room with suspicion of a DVT so that a diagnosis can be made or excluded. In addition we will discuss treatment options so as to prevent progression of a DVT into a more serious complication: Pulmonary Embolism.

Compartment Syndrome: A Rare but Serious Sequelae

Over the last several weeks we’ve talked about some injuries to the lower extremities that are suffered under high-energy mechanisms (calcaneal fractures and 5^th met base fractures), meaning a large force on the body has created the injury. We’ve talked about what to do when you suspect an injury, including early evaluation by your Podiatrist. Aside from an improved outcome through receiving early treatment and immobilization with either casting or surgical means, as Foot and Ankle specialists we are always on the lookout for Compartment Syndrome.

Well, what is that? Compartment syndrome, also known as neurovascular compromise (neuro = nerves; vascular = blood supply) needs to be ruled out every time an injury to the lower extremity occurs. When swelling occurs post-injury, pressure can build-up within the compartments of the leg or foot and can inhibit the function of both the nerve structures and the blood vessels within that same area. If function of those structures is inhibited for too long of a time period, permanent damage and impaired function can result, with possible loss of portions of the foot that have been compromised.

First and foremost, it is important that you be evaluated as soon as possible when you’ve suffered a lower extremity injury, especially those suffered via high-energy mechanisms. Prompt evaluation by a Podiatrist can recognize early indicators of compartment syndrome in addition to early intervention for relief of compartment pressure to free up those impinged structures.

When you present to the Emergency Room, you should expect the area of injury to be examined, but there are a few specific signs/symptoms we will be looking for to help us rule out compartment syndrome. Palpating your foot for pulses, the temperature of the foot and how quickly your toes “pink up” after pressure (capillary refill time) will give us a lot of information about compromise of blood vessels. Next, evaluation of the nerves to your foot and leg will be conducted where feeling on the injured foot will be compared with feeling on the non-injured foot. Several tools, such as a cotton-swab or a small piece of fishing-line will help with the comparison.

If all points of the examination are within normal limits compartment syndrome can be ruled out and standard evaluation and treatment of your injury will ensue. If there are several red flags in the examination, there is an additional evaluation with a Wick’s Catheter that can be conducted. The Wick’s can take a measurement of the pressure within the compartments of the leg and foot to determine if increased pressures are present and thus confirming a diagnosis of compartment syndrome. If the diagnosis is confirmed, immediate relief of the compartment pressure must take place to prevent long-term complications to the nerves and blood vessels significantly decreasing the risk of loss of portions of the foot secondary to compromise.

The “Gold Standard” for treatment of compartment syndrome is fasciotomy. Basically, what that means is that several small incisions will be made over the areas of concern for increased pressures, essentially relieving the pressure within the compartments of the foot and decreasing the risk of “neurovascular compromise.”

Compartment syndrome as a sequelae of high-energy injuries is rare, but can occur, thus early evaluation of your lower extremity injury is imperative to early recognition and prevention of long-term complications. Most often, evaluation will rule out compartment syndrome and early treatment of your injury can begin. In those rare instances where compartment syndrome is a real threat, you’ll be happy that prompt intervention took place, because even though the road to recovery will be long, function, sensation and blood flow to your leg and foot will be restored preventing the risk of long term disability!

Ankle Fracture Season is Among Us!

With the snow and ice fast approaching the number of patients heading to the emergency room with suspected ankle fractures is quickly rising! In previous Blogs we’ve talked about ankle fractures, but this week I want to talk about a different type of fracture associated with ankle injuries: the 5^th metatarsal base fracture!

The 5^th metatarsal bone is a long bone in the foot that connects the rearfoot to the 5^th toe. It is one of five metatarsal bones in the foot, each corresponding to a digit. Fractures of the 5^th metatarsal base (the end of the bone closest to the ankle) are commonly associated with classic ankle injuries where the foot turns inward.

There is a muscle that passes along the outside of the ankle and inserts into the 5^th metatarsal bone at its base called the peroneus brevis (PB). With an ankle sprain or injury where the foot turns inward, the PB contracts and pulls on the 5^th metatarsal base, sometimes so strong that it avulses, or pulls a piece of bone away from the rest of the metatarsal bone. Therefore, when you twist your ankle and have not suffered an ankle fracture, you may not be completely ‘home-free;’

You should be suspicious of a 5^th metatarsal base fracture any time that you are suspicious of an ankle injury. However, residual pain along the outside of the foot along the 5^th metatarsal bone is a good indicator of injury to that area. Try sliding your finger along the outside border of your foot from your 5^th toe back towards your heel. Along the way you should feel a “bump” which is the landmark of your 5^th metatarsal base. Pain in that are can be indicative of a fracture, as that is the most likely place where the PB would have pulled off a piece of bone. Be particularly suspicious if the pain in that area has not improved several days after your ‘ankle twisting incident.’

Fractures of the 5^th metatarsal base are particularly tricky to treat because the blood supply to that area of the bone is delicate. In the area of such fractures, two blood supplies are coming together, and disruption of their connection via fracture can permanently hinder the healing process, as blood supply is imperative to bone healing. Keeping that in mind, early detection of a 5^th metatarsal base fracture is important so that immobilization can be initiated as soon as possible. The goal of immobilization is to decrease motion at the site of the fracture to encourage healing making the delicate blood supply less of a factor!

There are several ways in which immobilization of the fracture site can be initiated and the choice depends on the severity of the fracture. If the fracture is well aligned and shows no gapping between fragments, conservative treatment with immobilization in a short leg cast is indicated. If the fracture is displaced and there is significant gapping between the fragments, the fracture is unlikely to heel unless the fragments are brought back closer together. In this case, surgery may be indicated to place a pin or screw across the fracture site and immobilize the fragment with the “hardware.” A short leg case is still indicated to ensure that the patient remains non-weightbearing and minimizes the risk on non-healing.

In either scenario, 4-6 weeks in a cast should be expected so that the bone has time to heal. Once healing is noted and pain in the area of the fracture is severely decreased or absent, transition into a walking cast and eventually back into a comfortable supportive sneaker can be allowed.

Next time you twist your ankle, don’t be fooled into thinking is just an ankle injury, unless you’ve been cleared by your Podiatrist and no 5^th metatarsal base fracture has been suffered!