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common injuries - ankle

Ankle Sprains

Description
The ankle joint is formed by three bones, the tibia, fibula, and talus. The bones are held together by several strong ligaments, which provide stability to the ankle joint. A sprain is a tear, or injury to a ligament, of varying severity.
Ligaments(hide)

Ligaments are the strong tissues that connect a bone to another bone. Ligaments are very important in joint stability, by holding the bones in a joint together.

Excessive tension on a ligament will cause injury, also known as a sprain: A grade 1 sprain is a stretch injury to the ligament, without damage to its structure. These injuries typically heal rather quickly, with little long-term problems. A grade 2 sprain involves microscopic damage to the ligament, but the ligament remains structurally intact. These painful injuries will usually heal well, but often the joint needs to be supported while the ligament heals, up to 6 or 8 weeks. A grade 3 sprain involves actual disruption of the ligament, and may render a joint unstable. Depending on the location of the injury, the ligament may or may not heal on its own, and surgery to repair the ligament may be necessary for these injuries.

Common Causes
Twisting injuries to the ankle. Seen with rapid pivoting in soccer and basketball. Stepping off of a curb or step can twist or rotate the ankle. Depending on the direction the foot is twisted, different ligaments can be injured.
Symptoms
Pain in the ankle, varying from mild to quite severe. Often there is swelling, especially in the outside of the ankle. Walking and weight bearing may be difficult, with pain and feelings of instability.
Physical Findings
Tenderness over ligaments of the ankle. Swelling may be noted. Stress of the involved ligaments is quite uncomfortable.
Workup
History, physical examination, and x-rays are usually adequate to make the diagnosis. Occasionally, special stress x-rays are used to determine chronic instability.
Non-Operative Treatment
Treatment depends on the severity, or grade of the sprain. For mild, or grade 1 sprains, support until symptoms resolve. Moderate, or grade 2 sprains are treated with functional bracing, for several weeks. Severe, grade 3 sprains may require immobilization in a cast or brace to heal.
Surgical Treatment
Ligament repair or reconstruction.
Comments

Surgery is rarely indicated for an acute ankle sprain, except perhaps in the high-performance athlete. Ligament repair is effective for chronic instability.

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Achilles Tendonitis

Description
The Achilles tendon is a very strong tendon that connects the calf muscles to the heel. When the calf muscles contract, they pull on the heel, pushing the foot down. Thus the Achilles tendon lets us run, jump, and walk.
Tendons(hide)

Tendons are the strong whitish tissues that attach muscles to bones. All muscles cross a joint, and when the muscle contracts, the joint moves. If the muscle is overloaded beyond its normal strength, the tendon may begin to tear, causing a strain. These may range from a mild strain, which heals quickly, to a complete tendon rupture. Since the normal elasticity of the muscle causes the torn tendon to pull away from the bone, the tendon end does not remain near its normal attachment. This means that most complete tendon ruptures will not heal normally, and thus many complete tendon ruptures require surgical repair.

Common Causes
Typically an overuse injury, due to excessive jumping, or running up hills.
Symptoms
Pain in the back of the heel, increased with activity. Aching in the back of the heel when starting to walk.
Physical Findings
Tenderness along the Achilles tendon near its insertion into the heel. Often there is thickening or swelling of the tendon.
Workup
Diagnosis is made by history and physical examination.
Non-Operative Treatment
Rest, icing, avoidance of aggravating activity, and anti-inflammatory medications. Shoe heel lifts, and immobilization (casting or bracing) for severe cases. NO corticosteroid injections (can rupture the tendon-big problem).
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
Debridement of the tendon, or repair of the tendon for an Achilles tendon rupture.
Comments

Generally successfully treated with non-operative care.

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Plantar Fasciitis

Description
The plantar fascia is a broad band of tissue that runs from the heel to the base of the toes, on the sole of the foot. It helps to support the normal arch of the foot. It is usually under tension, much like the string that holds the bow part of a bow and arrow bent, or arched. The plantar fascia may become partially torn or inflamed at either end.
Common Causes
Overuse, seen with a change in running habits, poor running shoes, footwear with poor arch support, walking on hard floors. Associated with weight gain.
Symptoms
Pain in the sole of the foot, either at the base of the heel, or in the arch. Patients are generally comfortable sleeping, but report sharp or cramping pain with the first step in the morning. Often they find themselves hobbling around for several minutes. Symptoms typically ease during the day, but may become painful at the end of the day.
Physical Findings
Tenderness along the plantar fascia. Often patients have a tight Achilles tendon.
Workup
The diagnosis is made primarily by history and physical examination. X-rays of the heel may coincidentally show 'heel spurs', but the spur is not part of the problem (the fascia doesn't even attach to the spur)
Non-Operative Treatment
A combination of plantar fascia and Achilles tendon stretching, anti-inflammatory medication, arch supports, good shoes, avoiding walking barefoot, and avoiding aggravating activities. Nighttime splints are irritating to wear, but are very helpful. A trial of a single corticosteroid injection may be helpful, but should not be done repeatedly.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
Plantar fasciotomy.
Comments
The good news is that over ninety percent of patients can be successfully treated without surgery. The bad news is that it probably takes between six months and a year for a cure, and exacerbations are common.

Tarsal Tunnel Syndrome

Description
The posterior tibial nerve runs down along the inside of the ankle, down to the foot. It passes between the inside of the ankle, and under a thick band of tissue. If the nerve gets compressed, or squeezed, then it will not work properly.
Common Causes
May be due to direct trauma, or following an ankle injury. Swelling or inflammation of the other tendons inside the tarsal tunnel besides the nerve also increase pressure on the nerve.
Symptoms
Usually a vague burning or tingling running down along the inside and sole of the foot. Usually aggravated by activity, and relieved by rest.
Physical Findings
Tenderness along the course of the nerve, with reproduction of symptoms by pressure on the nerve.
Workup
History, physical examination, and possibly nerve conduction studies. X-rays are generally negative.
Non-Operative Treatment
Rest, avoiding aggravating activity, orthotics, anti-inflammatory medication, and a trial of a corticosteroid injection may all be helpful in reducing symptoms.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Decompression of the nerve by releasing the compressing structures, through a small incision, is generally curative.
Comments

This is an uncommon injury, and is frequently confused with other foot conditions.

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Interdigital Neuroma/Morton's Neuroma

Description
This condition develops when one of the nerves running along the sole of the foot becomes squeezed, or inflamed between two of the bones of the foot (metatarsals).
Common Causes
Usually related to poor shoewear, or increase in running/standing. When the toes and foot are unnaturally squeezed, there is pressure created on the nerves in the foot. The nerve becomes chronically thickened and inflamed.
Symptoms
Pain in the ball of the foot, often described as burning, or numbness, that may radiate into the toes. The space between the third and fourth toes is most common, but may occur in the space between the second and third toes as well.
Physical Findings
Tenderness, pain, or numbness in the third or fourth webspace with direct pressure on the nerve.
Workup
Diagnosis is based almost entirely on history and physical examination. X-rays are usually normal. Ruling out other causes of foot pain is required.
Non-Operative Treatment
Modification of shoewear, with a wider toe box, and good arch and metatarsal support. Orthotics may be helpful. Non-steroidal anti-inflammatory medication , and rest. A trial of a corticosteroid injection may be of both diagnostic and therapeutic benefit.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Excision of the swollen nerve (neuroma) is generally curative, also mild numbness between the involved toes may result.
Comments
Often simple, inexpensive measures can relieve this problem, before it becomes a much more difficult situation.