It Feels Like My Ankle is Constantly “Giving Out.”

Often we have patients who present to the office with a feeling of “giving out” of their ankle that is not typically preceded by a triggering event at the moment they suffer that feeling. They often have associated ankle pain and relay a long history of athletic related ankle sprains or ankle fracture in the past. That one phrase, of feeling as if the ankle will “give out” combined with the patient’s history is often diagnostic of a common condition called Chronic Ankle Instability.

Instability at the ankle typically stems from the outside or lateral part of the ankle joint, where the most commonly injured ligaments in ankle sprains reside. The internal twisting of the leg and foot with an ankle sprain often times stretches, tears or ruptures these ligaments, and it is often very difficult for those ligaments to heal. In addition, healing takes place in a non-uniform fashion with improper rehabilitation, as most ankle sprains typically go unevaluated and untreated by the patients Podiatrist.

There are three main ligaments that make up the lateral ankle ligaments and often two of those are easily damaged in ankle injuries eventually leading to chronic instability secondary to laxity within these ligaments. The cycle is continues. Once those lateral ligaments are damaged, they tend to lengthen and have less inherent stability than prior to the first ankle sprain injury. This makes them prone to additional injury that occurs over and over again. In addition to a history of initial sprain, patients with a high-arched (cavus) foot type are prone to ankle injuries and eventual ankle instability because of the nature of their foot shape. The way the foot sits in this foot type lends itself to an increased risk of injury and eventual ankle instability.

Several diagnostic examinations can be performed to help the Podiatrist hone in on ankle instability as the underlying cause of a patient’s condition.

The first is simple palpation of the ankle joint. In any of these instances it is important to rule out any type of fracture to either the ankle or foot bones, so palpation of crucial areas is important. However, pain over the direct area where these lateral ankle ligaments reside is diagnostic of injury, especially when there is no pain on palpation to the bones that make up the ankle joint.

The remaining two examinations can be done with the aid of x-ray, where by the ankle joint is passively moved by the x-ray technician to specifically evaluate the strength of the tendon when compared to the opposite, unaffected ankle. The technician will try to pull the heel forward while stabilizing the leg in an examination called the Anterior Drawer Test, effectively evaluating the integrity of one of the lateral ankle ligaments. The next examination, referred to as Talar Tilt, evaluating the integrity of a different lateral ankle ligament. Positive results in performing either or both of these examinations indicates damage to the involved ligaments and thus is diagnostic of instability when associated with symptoms.

The key with chronic instability is to catch the instability before it becomes a chronic reoccurring problem. Early ankle support with bracing in addition to physical therapy will help decrease the healing time and increase the feedback from these ligaments as well as the ankle joint, helping to increase stability on the affected leg and reduce the occurrences of “giving out” episodes.

There’s Such a Thing as a Total Ankle Replacement?

Within the last several years, although around for decades, Total Ankle Replacements have been gaining popularity in both the Podiatric and Orthopedic medical fields as a means of treating chronic ankle arthritis and pain. On the tails of success of the total knee and total hip replacements, used for treating painful hip and knee joints that have become chronically arthritic, technology for total ankle replacements has taken flight.

To many, understanding the science and theory behind total hip and total knee replacements makes sense and it seems as though these procedures have been around for long periods of time. Total ankle replacements have been around since the 1970’s and although they originally gained popularity in Europe, there are currently four Total Ankle Replacement systems that are FDA approved and available for use in the Unites States of America.

Indications for a total ankle replacement include ankle joints that have reached end-stage arthritis with chronic pain and have not responded to other conservative treatment options. Those ankles most likely to suffer end-stage ankle arthritis are ankles in patients who have a history of ankle trauma (fracture, joint infection etc) that has led to chronic pain. Conservative treatment options that may be explored prior to consideration of total ankle replacement include: joint injections, immobilization, physical therapy, and ankle scope.

In the past and currently, although times are changing, the ‘gold-standard’ treatment for end-stage ankle arthritis has been ankle fusion. An ankle fusion basically employs a cleaning up of the inside of the ankle joint followed by permanent consolidation of the bones that make up the ankle. The procedures end result is a permanent loss of motion at the ankle joint. If you prohibit motion at the ankle joint, or any joint with chronic pain and end-stage arthritis, you eliminate pain. A loss of motion = a loss of pain. However, with ankle fusion procedures, the motion lost (beneficial in the normal gait cycle), requires your body to make adjustments in gait. This inconvenience, for patients suffering from chronic pain and arthritis is nothing in comparison to the elimination of joint pain, and patients tend to do extremely well post-operatively. However, total ankle replacements aim to preserve ankle joint motion while still eliminating pain.

Preservation of motion while eliminating a patient’s pain would be far superior to ankle fusion, where motion is eliminated. Total ankle replacements are intended to allow the patient to ambulate with “normal” use of their ankle joint. If ankle replacements become the ‘gold standard’ of treatment in treating end-stage ankle conditions, they provide a viable option for patients before consideration of fusion.

Not all patients are candidates for total ankle replacement, so a discussion of all options should be explored with your Podiatrist. In addition, the technology is still expanding, but in the coming years it looks to be a promising alternative to treating patients with chronic ankle arthritis and pain.

Over the Counter “Custom Fit” Orthotic Inserts

Last week we talked about custom molded orthotic devices and the differences between those that are functional and those that are accommodative. Just as a reminder, functional orthotic devices are made to align the foot in a neutral position and work to support the surrounding structures, allowing the foot to function as normally as possible. Accommodative orthotic devices are indicate for patients with rigid deformities and accommodate the foot rather than attempt to realign it. A great example of the use of accommodative orthotics is in diabetic patients, as they will allow off-loading of high-pressure areas prone to ulceration.

We also briefly touched on the idea of “custom orthotics” being sold over the counter. If I didn’t make myself clear last week, let’s be clear this week: If you are purchasing something over the counter and off-the shelf in a drug store, they are not custom orthotics. Custom orthotics can only be manufactured in an orthotic lab using casts and/or scanned images of your feet, sent to the lab with specific manufacturing instructions from your Podiatrist.

What I want to discuss this week is the claim that such companies are making, like the newly advertised “Dr. Scholl’s Custom Fit Orthotic Insert Kiosk,” and what they actually mean when they say “custom fit.”

If you have yet to see the commercial, check out the Dr. Scholl’s website: http://www.footmapping.com/footmapping/about-the-kiosk/index.jspa

There, you can watch a video on how the Kiosk works and how it recommends which ‘custom orthotics’ to select off-the shelf. Let it be known that Dr. Scholl’s is not the only company who sells “custom orthotic inserts over the counter,” but it happens to be their commercial that sparked my writing about this topic.

Now, many of you might be confused, because this particular Kiosk “maps” your foot, similar to scanned images that might be taken by your Podiatrist if you’re set to purchase custom orthotics. This mapping allows the computer to understand the basic make-up of your foot and uses that information to generalize your overall foot-type. The kiosk will then suggest to you, based on the mapping of your foot, which Dr. Scholl’s “custom fit orthotic insert” best suits your generalized foot-type. You will be directed to either the left or right side of the Kiosk, where your ‘custom fit orthotic’ awaits you!

In reality, what this Kiosk is suggesting to you is what we as Podiatrist’s call, a Pre-fabricated Orthotic Device.” What that means is that those orthotic devices are manufactured to fit a generic foot-type. There might be one device that is pre-fabricated for a generic flat-foot and another pre-fabricated for a generic high-arched foot, but in no way is your foot, or anyone else’s foot generic. You have a specific foot that differs from each and every other individual, therefore, although these Pre-fabricated orthotic devices may help, they cannot be called “Custom Fit Orthotic Devices” because they were not made to specifically fit your foot.

Now with that said, if you remember back to last week, there are instances where as Podiatrist’s we will recommend an over the counter orthotic device to you. The recommendation depends on the deformity for which you present with in addition to whether the Podiatrist believes an over the counter, non-custom device will be beneficial. If they deem that an over the counter device would be suitable, or suggest such a device as a starting point, what you will be purchasing is a pre-fabricated orthotic device such as mentioned above at the Dr. Scholl’s Kiosk. It is not custom to your foot, but it may be sufficient enough to provide you significant relief.

Dr. Scholl’s is not the only company who manufactures such pre-fabricated devices; in fact there are hundreds of companies that offer these. You’re Podiatrist will most likely have a manufacturer who they particularly like and will recommend to you, should pre-fabricated orthotic devices be a viable option. It never hurts to mention or ask your Podiatrist about trying such orthotics prior to ordering a custom molded pair. As was mentioned last week, custom molded orthotics although necessary in some instances can be expensive, and we are not in the business of bankrupting our patients.

Functional versus Accommodative Custom Orthotics

I recently saw a commercial that was advertising a ‘Dr. Scholl’s Custom Fit Orthotic Insert Kiosk’ and I wondered, how exactly they were custom fit if there were only several inserts to chose from? It started me thinking about orthotics and how often the general public makes mention of them, but how little they generally know about their specifics. I wanted to take the opportunity, over the next several weeks to discuss what custom orthotics are and what you would be getting when you purchase something over the counter or from a Kiosk.

As Podiatrist we prescribe patients custom molded orthotics for a variety of foot ailments, but often, if we feel as though their condition would benefit from an over the counter orthotic insert, we start there. The one thing all patients and members of the general public can agree on is that custom molded orthotics can be expensive and are often uncovered by insurance companies. As Podiatrist’s we are not in the business of bankrupting our patients and thus if we feel that an over the counter orthotic would be sufficient enough to help your current condition, that is our first recommendation. However, there instances where we know that custom molded orthotics are the best option for you and the one that will provide the greatest relief, so in some circumstances they are our first recommendation.

There are two main types of custom molded orthotics that we prescribe, known as Functional and Accommodative orthotics. What people typically think of when they think of orthotics are those that are functional; coincidentally that type is the most often prescribed.

The general objective of any functional orthotic, regardless of the condition it is prescribed for, is to allow the foot to sit in as neutral a position as possible. By neutral position, what I’m referring to is the position of your foot where the tendons and ligaments surrounding the ankle are aligned in their most advantageous position, allowing the foot to function as “normally” as possible while eliminating compensation for any abnormality. In many conditions the orthotic is indicated to block abnormal motion of the foot by bringing the ground up to the foot (via the orthotic material) helping to decrease pain and deformity. To show the diversity of conditions for which functional orthotics can be utilized, a very limited list of conditions is detailed below:

Hallux limitus/rigidus
Pes plano valgus (collapsing/flat foot)
Cavus foot (high arched)
Limb-length discrepancies
Bunion deformities
Plantar fasciitis
Neuromas
Neuromuscular conditions

The objective of an accommodative orthotics is to accommodate the foot rather than to place the foot in a neutral position. These are often utilized in patients who have rigid conditions where the foot would not benefit from repositioning. Therefore, accommodative orthotic devices are prescribed for patients who need pressure alleviation at areas of high-pressure, such as diabetic patients with areas prone to ulceration. In such situations realigning the foot via the use of functional orthotics may do more harm to the patient than good.

Regardless of whether the functional custom orthotic or the accommodative function orthotic is utilized, they are both manufactured from a cast and/or digital image of your foot. Those casts or images are sent to a laboratory specializing in orthotic manufacturing and the custom orthotics come to life with adherence to specific manufacturing instructions from your Podiatrists. Custom orthotics are exactly that: custom to your foot through the cast or images sent to the orthotic laboratory. As we’ll discuss in the coming weeks, anything purchased over the counter cannot be custom if there are only a few varieties to choose from and if your “foot images” were not sent to a specialized orthotic laboratory for manufacturing of your orthotic devices from those images.

In efforts not to overwhelm you with the wealth of information regarding orthotics, we will stop here for this week. Next week, we will tackle the topic of over the counter orthotics versus those that are custom molded; how they differ and what those over the counter ‘custom fit orthotics’ really are.

Pretty in Pink…Nail Polish??

Summer is essentially here with the heat we’ve been having recently, thus men and women alike are flocking to nail salons hoping to perfect their toenails for sandals and peek-toed heels! This week we’re taking the opportunity to remind you of some ‘salon smart’ tips that will help you select a salon that’s clean so you receive that pedicure you’ve been craving, while keeping your risks of infection low!

1. Assess the salons cleanliness: Look around when you enter a nail salon and check to see if they have bottles of cleaning products near their pedicure soaking tubs. Are they cleaning out the tubs after each client? Soaking tubs are the areas in a salon that carry the highest risk of infection, so use caution! Have they autoclaved their tools between each client? The only way to ensure that nail tools are completely sterilized is through the use of an Autoclave (those little “hot boxes” where tools are placed between each client). Without Autoclave sterilization the tools are only “clean,” and may have lingering organisms present.

2. Purchase your own set of tools: Many salons provide clients the option of purchasing their own “nail tools,” for which you are the only client using those tools. Investing the extra few dollars on that first visit will provide you a decreased risk of infection and peace of mind, knowing that only those tools have touched your feet. You no longer need to worry about who’’s toes were being worked on before yours, and what “bugs” may be passed from them on to you.

3. Ask the salon personnel NOT to push back your cuticles: The nail cuticle is one your body’’s protection mechanisms for keeping bacteria out. By pushing the cuticle back, you open up the possibility of infection, as bacteria can now enter underneath the cuticle. Interrupting the natural function of your cuticles combined with un-sterilized tools and dirty soaking tubs is a sure bet for infection!

4. Give your toenails a rest: Frequently taking off nail polish and allowing the nails to “breath” helps prevent extra moisture from building up under the nail, subsequently decreasing your risk of infection by bacteria or fungus. In the winter months when sandals are infrequently worn, try to go without nail polish as much as possible. In the summer, when you know you won”t be on vacation or won”t need your nails looking “pretty in pink” for a certain event, take the polish off and give your toenails a break.

5. If you”re diabetic, pedicures are NOT recommended: As mentioned above, dirty tools, soaking tubs, and interrupted cuticles all combine to create a high risk for infection. The risk of infection from a pedicure is the same for clients with and without diabetes, but in the diabetic, the healing potential can be significantly decreased. Due to the nature of diabetes and the course it takes within the body, blood supply to the toes may be decreased, and without adequate blood flow, the cells in your body that fight infection are less likely to reach the site. This can lead to an infection that, in severe cases, runs up the foot and leg and if not caught early and treated aggressively can lead to loss of toes! In addition, healing potential for diabetics is decreased and for the same reasons infection takes a greater toll; the cells in the blood needed for wound healing are less likely to reach the areas where they are needed. In short, if you”re diabetic, it’’s wise to avoid pedicures at a salon. Instead, do your own pedicures at home where you can be sure everything is clean and leave your cuticles intact.

Hopefully these tips will pop into your head as you contemplate your next pedicure. It’’s important for feet to look nice for the summer months eliminating embarrassment with sandals where toes are exposed, but it’’s more important to avoid infection and its long-term complications!

How Did You Get Osteomyelitis?

Last blog entry gave a very brief overview of some of the more common imaging studies that Podiatrist’s tend to order to help them confirm their diagnosis. It reading that blog, your interest may have been peeked when the idea of bone infection was introduced, as it was discussed under several of the imaging modalities since bone infection can be captured in various ways. This week, I hope to indulge your newfound interest and provide some insight into the topic of bone infection. This topic is not an easy one to broach, as there are many questions when dealing with bone infections that must be answered. The why and the how of bone infection in a patient can sometimes be very clear-cut and in other patients, can be quite a mystery. The key, however, in treating bone infections is prompt diagnosis!

Let’s break it down a bit:

What is a bone infection? Bone infection, more commonly referred to as Osteomyelitis (Osteo = bone; meylo = marrow; itis = inflammation) is exactly as it sounds. Infection, much the same as would present in the skin, invades into bone allowing bacteria to thrive and wreak havoc. The severity of the bone infection depends on a number of variables, some of the more important of which are: how much bone is infected, the condition of the surrounding soft tissue structures, if the infection has traveled to other areas of the foot and leg, and the health status of the infected patient.

Who gets bone infections? Patients who are at a higher risk include those who have suffered an open fracture (one where the skin was opened upon fracture of bone) and those who present with chronic (long standing) open and infected foot ulcerations/wounds. However, anyone can suffer from osteomyelitis. In reactivated forms of osteomyelitis, bone infection occurred years ago but the infection suppressed by the body; secondary to trauma to the previously infected area, reactivation can occur.

When should you become suspicious of a bone infection? Those patients who should have the highest index of suspicion for a bone infection are those patients who are at a higher risk (i.e. open fracture patients and those with long standing infected wounds). If you are being treated for a long-standing non-healing wound, additional imaging studies may be recommended to rule osteomyelitis in or out. In a healthy patient signs of infection include redness, swelling and heat in the suspicious area, but in those patients with chronic wounds and a compromised immune system, such as Diabetics, those same symptoms may never present themselves.

Why is early recognition key? Early recognition is key so that initiation of treatment is prompt. The earlier bone infections are diagnosed, the better the treatment outcomes. The worry is that bone infections will continue to spread to adjacent bones and additional soft tissue structures causing larger infections that are more difficult to treat with antibiotics alone.

Where is the most common location in the foot and ankle? The most common location of osteomyelitis in the foot is underneath the metatarsal heads. The metatarsal are the long bones of the foot that connect to the toes. The location of the metatarsal heads is in the approximate area of the fat-pad of the forefoot. This area is most commonly affected because the metatarsal heads are under high pressures throughout gait.

How do we treat bone infections? Treating bone infections is very tricky and among other things, Podiatrists must carefully consider each patient before deciding on a treatment regimen that is best for that particular patient. Almost all patients will be placed on antibiotics, but depending on the severity of the infection depends on if those antibiotics will be administered in pill form or via an IV (intravenous) infusion. If you have a bone infection, expect to be on antibiotics for 4 weeks at the very least, but typically longer courses are required. If a bone infection has become so severe that antibiotics are only effective in keeping the infection at bay but will not eliminate the bacteria from the body all-together, surgical intervention is usually necessary. Surgery entails finding the source of the infection and any collections of infectious fluid and draining them, in addition to washing-out all the surrounding soft tissues and removing any bone that is dead/dying.

Osteomyelitis can be a scary and tricky diagnosis to face, but conversations with your Podiatrist (should you be diagnosed) can be very informative and will lead you towards the most appropriate treatment path with the greatest outcome for healing!

Imaging, Imaging and More Imaging!

As Podiatrist’s we order A LOT of imaging studies for our patients. Such studies include x-rays, MRI’s, CT Scans, Bone Scans, and Ultrasound to name a few. It may sometimes seem unnecessary and annoying because treatment is occasionally postponed until the results of such studies are received, but I assure you, they have their purpose. This week, the intent is to briefly describe some of the imaging studies we order, why we order them and how they differ from each other. However, it should be understood that we do not arbitrarily order imaging studies to help us come up with a diagnoses, but rather we use them to confirm our suspicions of a diagnosis.

X-rays: This is typically the first imaging study that will be performed by your Podiatrist. X-rays primarily capture the bones of the foot and ankle and for this reason, they are typically ordered for fractures, bunions, hammertoes, and any pathology that may disrupt the bone including diffuse bone infection, bone tumors, gout and arthritis to name a few. They also allow us to take a closer look at the position of the bones during stance, providing a snapshot of how your foot functions during gait (walking). X-rays, although they can’t specifically convey information about the soft tissues (muscles, ligaments, tendons) they can show swelling, which most often correlates with a clinical picture. Finally, they can show calcified vessels: blood vessels in the lower extremity that have become hardened and thus indicate poor blood flow to the lower extremity. Limitations to x-rays, as mentioned above include soft tissues structures, which need further imaging studies for complete evaluation. In addition, x-rays have a lag time in recognizing stress fractures and acute (early) bone infection. For a plain x-ray to show either of those two pathologies, the pathology needs to have been present for about 10 days; long enough for significant bone destruction (50%) to be visualized on x-ray. For that reason, with a high clinical suspicion of either of those two pathologies, additional imaging studies are typically performed.

MRI’s (Magnetic Resonance Imaging): If we want to get a better picture of soft tissue structures including muscles, tendons, and ligaments in the lower extremity, MRI’s are a good option. MRI’s have the ability to hone in on inflammation within or surrounding a tendon and clearly show ruptures of such structures. They focus less on bone pathology when referring to fractures (CT’s are more accurate), but they are superior to CT scans in diagnosis bone infection (osteomyelitis). The reason being that they provide excellent visualization of the medullary canal of the bone (the central area where bone infection tends to migrate), and thus help Podiatrists determine how far the infection has spread and how aggressive their treatment regimen needs to be. Finally, they are the best option diagnosing pathology between bone and soft tissue, where it needs to be determined if bone pathology has spread into adjacent soft tissues and vice versus. The only downside with MRI usage is that, should a patient have any metal or stainless steel anywhere in their body, these studies cannot be performed as they interact with the magnets within the MRI machine.

CT Scans (Computerized Tomography): These scans are excellent for visualizing bone to a greater degree than standard x-rays can show us. Often CT Scans are ordered for evaluation of complex fractures such as Lisfranc fractures and calcaneal fractures. They can more accurately show fractures too small to be visualized on plain x-ray in addition to helping to determine the amount of joint surface involved in the pathology. CT scans can also be used in diagnosis of bone infection, but MRI’s are typically a better option as they can more accurately capture the medullary canal. CT scans can be used in patients with metal or stainless steel implants, thus are a good alternative for patients who can not undergo MRI evaluation.

Ultrasounds: This imaging studying is becoming more and more popular among Podiatric Physicians, whereby diagnosis of various pathologies can be made through its use. The test takes little time, making it more convenient for the patient in addition to providing quick results to you Podiatrist. Ultrasounds are very useful for tendon pathology, meaning any deformity or abnormality in a tendon, such as rupture, tear, or inflammation surrounding a tendon, which indicates aggravation of the tissue. These studies are also becoming more popular for use in diagnosing neuromas (inflammation of nerve tissue in the web-spaces) and have provided use in guiding injections of the foot for more accurate medication placement.

Although it can seem burdensome, imaging studies do help us confirm our suspected diagnoses and are often necessary for treatment to begin, so we appreciate you taking the time to have them completed per our request. The hope is that you now have a greater understanding of each of the imaging modalities discussed above, and can thus understand why we request them to be performed. Certainly, each type of imaging study discussed above encompasses a broader range of uses, but those discussed this week are the primary reasons for viewing in the foot and ankle.