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Barbie Mcghay

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Does Pain In The Arches Require Surgery Treatment ?
Overview


Posterior tibial tendon dysfunction is one of several terms to describe a painful, progressive flatfoot deformity in adults. Other terms include posterior tibial tendon insufficiency and adult acquired flatfoot. The term adult acquired flatfoot is more appropriate because it allows a broader recognition of causative factors, not only limited to the posterior tibial tendon, an event where the posterior tibial tendon looses strength and function. The adult acquired flatfoot is a progressive, symptomatic (painful) deformity resulting from gradual stretch (attenuation) of the tibialis posterior tendon as well as the ligaments that support the arch of the foot.


Pain In Arch


Causes


There are many causes for a high arch (cavus) foot. In the United States, the most common cause for a high arch foot is a form of muscular dystrophy called hereditary sensorimotor neuropathy. Most people recognize this by the more commonly used name of Charcot Marie Tooth disease (CMT). This is a disease of the muscles and the nerves of the legs, and occasionally of the hands, in which certain muscles weaken while others retain their strength. The condition is transmitted as an autosomal dominant condition. This means that 50% of the offspring will statistically inherit the disorder. This is, however, just a statistic. In some families, all the children develop the condition while in others, none inherit it.


Symptoms


Go to a podiatrist at the first sign of symptoms. Besides pain on the bottom of the foot, additional symptoms may include burning sensation in arch, difficulty standing on tiptoes, inflammation, more pain after sleeping or resting, redness, heat, localized pain in the ball of the foot, sharp or shooting pain in the toes, pain that increases when toes are flexed, tingling or numbness in the toes, aching, pain that increases when walking barefoot, pain that increases when walking on hard surfaces, pain the increases when standing (putting weight on your feet) or moving around and decreases when immobile, skin Lesions, it?s important to get a proper diagnosis and treatment plan. Let?s go over the possible causes of the pain.


Diagnosis


Diagnosis of a plantar plate tear can often be challenging due to the complex nature of the anatomy of the foot. Careful history taking and an examination of the area of pain is required to determine the extent and cause of the tear. If necessary, further investigations such as x-rays or diagnostic ultrasound may be ordered by your podiatrist to help evaluate the severity of the problem.


Non Surgical Treatment


In mild cases patients would benefit from custom made semi rigid full length custom made foot orthoses fitted into appropriate supportive footwear, preferably with laces or a velcro straps. In more severe cases patients may require a custom made Arizona lace up ankle brace or a posterior shell Ankle Foot Orthosis. These offer significantly more control and support than the foot orthoses. In severe cases surgery may be required to repair the tibialis posterior tendon and realign the foot and ankle, or fuse the subtalar joint. It is important to note there are many risks involved in having surgery and these must be considered prior to going ahead.


Arch Pain


Surgical Treatment


In cases where cast immobilization, orthoses and shoe therapy have failed, surgery is the next alternative. The goal of surgery and non-surgical treatment is to eliminate pain, stop progression of the deformity and improve mobility of the patient. Opinions vary as to the best surgical treatment for adult acquired flatfoot. Procedures commonly used to correct the condition include tendon debridement, tendon transfers, osteotomies (cutting and repositioning of bone) and joint fusions.


Prevention


Early in the treatment of arch pain, consideration needs to be given to the cause and strategies put in place to prevent it happening again. Advice should be sought on the adequacy of footwear. Stretching exercises should be continued long after the symptoms are gone. Foot orthoses should be used if structural imbalances are present. Activity levels and types of activities (occupational and sporting) need to be considered and modified accordingly.


Stretching Exercises


People with flexible feet who develop fallen arches may benefit from foot strengthening exercises, notes the Nicholas Institute of Sports Medicine and Athletic Trauma. Standing on a towel in bare feet and grasping the material with the toes is an easy foot-strengthening exercise that can be done at home. Standing on one leg while arching and releasing the foot may also prove useful. Doctors may prescribe gentle stretching exercises for the foot and ankle tendons.

Adult Aquired Flat Foot Causes

Overview
Over 60 Million Americans suffer from Adult Acquired Flatfoot (AAF), otherwise known as Posterior Tibial Tendon Dysfunction or PTTD. This condition generally occurs in adults from 40-65 years of age, and it usually only occurs in one foot, not both. The Posterior Tibial (PT) Tendon courses along the inside part of the ankle and underneath the arch of the foot. It is the major supporting structure for the arch. Over time, the tendon becomes diseased, from overuse, and starts to lose it's strength. As a result, the arch begins to collapse, placing further strain on the PT Tendon, leading to further decrease in tendon strength, which causes further collapse of the arch. This is described as a progressive deformity because it will generally get worse over time.
Adult Acquired Flat Feet

Causes
The cause of posterior tibial tendon insufficiency is not completely understood. The condition commonly does not start from one acute trauma but is a process of gradual degeneration of the soft tissues supporting the medial (inner) side of the foot. It is most often associated with a foot that started out somewhat flat or pronated (rolled inward). This type of foot places more stress on the medial soft tissue structures, which include the posterior tibial tendon and ligaments on the inner side of the foot. Children nearly fully grown can end up with flat feet, the majority of which are no problem. However, if the deformity is severe enough it can cause significant functional limitations at that age and later on if soft tissue failure occurs. Also, young adults with normally aligned feet can acutely injure their posterior tibial tendon from a trauma and not develop deformity. The degenerative condition in patients beyond their twenties is different from the acute injuries in young patients or adolescent deformities, where progression of deformity is likely to occur.

Symptoms
Not everyone with adult flatfoot has problems with pain. Those who do usually experience it around the ankle or in the heel. The pain is usually worse with activity, like walking or standing for extended periods. Sometimes, if the condition develops from arthritis in the foot, bony spurs along the top and side of the foot develop and make wearing shoes more painful. Diabetic patients need to watch for swelling or large lumps in the feet, as they may not notice any pain. They are also at higher risk for developing significant deformities from their flatfoot.

Diagnosis
In diagnosing flatfoot, the foot & Ankle surgeon examines the foot and observes how it looks when you stand and sit. Weight bearing x-rays are used to determine the severity of the disorder. Advanced imaging, such as magnetic resonance imaging (MRI) and computed tomography (CAT or CT) scans may be used to assess different ligaments, tendons and joint/cartilage damage. The foot & Ankle Institute has three extremity MRI?s on site at our Des Plaines, Highland Park, and Lincoln Park locations. These extremity MRI?s only take about 30 minutes for the study and only requires the patient put their foot into a painless machine avoiding the uncomfortable Claustrophobia that some MRI devices create.

Non surgical Treatment
A painless flatfoot that does not hinder your ability to walk or wear shoes requires no special treatment or orthotic device. Other treatment options depend on the cause and progression of the flatfoot. Conservative treatment options include making shoe modifications. Using orthotic devices such as arch supports and custom-made orthoses. Taking nonsteroidal anti-inflammatory drugs such as ibuprofen to relieve pain. Using a short-leg walking cast or wearing a brace. Injecting a corticosteroid into the joint to relieve pain. Rest and ice. Physical therapy. In some cases, surgery may be needed to correct the problem. Surgical procedures can help reduce pain and improve bone alignment.
Flat Foot

Surgical Treatment
Surgical intervention for adult acquired flatfoot is appropriate when there is pain and swelling, and the patient notices that one foot looks different than the other because the arch is collapsing. As many as three in four adults with flat feet eventually need surgery, and it?s better to have the joint preservation procedure done before your arch totally collapses. In most cases, early and appropriate surgical treatment is successful in stabilizing the condition.

What Is A Posterior Tibial Tendon Dysfunction

Overview
Adults with an acquired flatfoot deformity may present not with foot deformity but almost uniformly with medial foot pain and decreased function of the affected foot. Patients whose acquired flatfoot is associated with a more generalised medical problem tend to receive their diagnosis and are referred appropriately. However, in patients whose ?adult acquired flatfoot deformity? is a result of damage to the structures supporting the medial longitudinal arch, the diagnosis is often not made early. These patients are often otherwise healthier and tend to be relatively more affected by the loss of function resulting from an acquired flatfoot deformity. The most common cause of an acquired flatfoot deformity in an otherwise healthy adult is dysfunction of the tibialis posterior tendon, and this review provides an outline to its diagnosis and treatment.
Acquired Flat Feet

Causes
Causes of an adult acquired flatfoot may include Neuropathic foot (Charcot foot) secondary to Diabetes mellitus, Leprosy, Profound peripheral neuritis of any cause. Degenerative changes in the ankle, talonavicular or tarsometatarsal joints, or both, secondary to Inflammatory arthropathy, Osteoarthropathy, Fractures, Acquired flatfoot resulting from loss of the supporting structures of the medial longitudinal arch. Dysfunction of the tibialis posterior tendon Tear of the spring (calcaneoanvicular) ligament (rare). Tibialis anterior rupture (rare). Painful flatfoot can have other causes, such as tarsal coalition, but as such a patient will not present with a change in the shape of the foot these are not included here.

Symptoms
Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms here. Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle. Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time. When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain. Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoewear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes. Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoewear is not used.

Diagnosis
Observe forefoot to hindfoot alignment. Do this with the patient sitting and the heel in neutral, and also with the patient standing. I like to put blocks under the forefoot with the heel in neutral to see how much forefoot correction is necessary to help hold the hindfoot position. One last note is to check all joints for stiffness. In cases of prolonged PTTD or coalition, rigid deformity is present and one must carefully check the joints of the midfoot and hindfoot for stiffness and arthritis in the surgical pre-planning.

Non surgical Treatment
There are many non-surgical options for the flatfoot. Orthotics, non-custom braces, shoe gear changes and custom braces are all options for treatment. A course of physical therapy may be prescribed if tendon inflammation is part of the problem. Many people are successfully treated with non-surgical alternatives.
Flat Feet

Surgical Treatment
For those patients with PTTD that have severe deformity or have not improved with conservative treatments, surgery may be necessary to return them to daily activity. Surgery for PTTD may include repair of the diseased tendon and possible tendon transfer to a nearby healthy tendon, surgery on the surrounding bones or joints to prevent biomechanical abnormalities that may be a contributing factor or both.

Achilles Tendon Rupture Painful



Overview
Achilles Tendonitis
Achilles tendon rupture is an injury that affects the back of your lower leg. It most commonly occurs in people playing recreational sports. The Achilles tendon is a strong fibrous cord that connects the muscles in the back of your calf to your heel bone. If you overstretch your Achilles tendon, it can tear (rupture) completely or just partially. If your Achilles tendon ruptures, you might feel a pop or snap, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly. Surgery is often the best option to repair an Achilles tendon rupture. For many people, however, nonsurgical treatment works just as well.

Causes
Inflammation/strain of the tendon is usually caused by overuse, for example, frequent jumping in volleyball, netball or basketball. It is often also caused by a sudden increase in certain types of training, such as hill sprinting or track running, particularly when running in spikes. Tendinopathy can also be associated with ageing. Our ability to regenerate damaged tissue decreases as we age and the quality of the tendon deteriorates. However, the better news is that sensible training can actually strengthen all our soft tissue (tendons, ligaments and muscle). Tightness in the calf muscles will demand greater flexibility of the tendon, which inevitably results in overuse and injury. Biomechanically, the tightness can reduce the range of dorsiflexion (toe up position) in the ankle, which increases the amount and duration of pronation. This problem is known as overpronation.* This reduces the ability of the foot to become a rigid lever at push off and places more lateral and linear forces through the tendon. This imbalance can translate into altered rotation of the tibia (shin bone) at the knee joint and, in turn, produce compensatory rotation at the hip joint with subsequent injuries to the shin, knee and hip. Pronation is part of the natural movement of the subtalar joint in the foot. It allows ?eversion? (turning the sole outwards), dorsiflexion and abduction (pointing the toes out to the side). Pronation is a normal part of the gait cycle, when walking and running, and it helps to provide shock absorption in the foot. When pronation is excessive, the foot has a tendency to roll inward more than normally acceptable. One sign of overpronation is greater wear on the inside of your running shoes than on the midsole. Lack of stability around the ankle joint can also be a contributory factor, as recurrent ankle sprains appear to be associated with a high incidence of Achilles tendonopathy. Wearing shoes that don?t fit or support the foot properly can be a major contributing cause of Achilles tendon injury.

Symptoms
You may notice the symptoms come on suddenly during a sporting activity or injury. You might hear a snap or feel a sudden sharp pain when the tendon is torn. The sharp pain usually settles quickly, although there may be some aching at the back of the lower leg. After the injury, the usual symptoms are a flat-footed type of walk. You can walk and bear weight, but cannot push off the ground properly on the side where the tendon is ruptured. Inability to stand on tiptoe. If the tendon is completely torn, you may feel a gap just above the back of the heel. However, if there is bruising then the swelling may disguise the gap. If you suspect an Achilles tendon rupture, it is best to see a doctor urgently, because the tendon heals better if treated sooner rather than later. A person with a ruptured Achilles tendon may experience one or more of the following. Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf, often subsiding into a dull ache. A popping or snapping sensation. Swelling on the back of the leg between the heel and the calf. Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes.

Diagnosis
A diagnosis can be made clinically, but an MRI or ultrasound scan can confirm it. On examination, the patient will present with reduced plantarflexion strength, a positive Thompson test and potentially, a palpable gap in the Achilles. The whole length of the tendon should be examined to check for injuries that can occur at the insertion and the musculotendinous junction.

Non Surgical Treatment
If you suspect a total rupture of the achilles tendon then apply cold therapy and compression and seek medical attention as soon as possible. In most cases surgery is required and the sooner this takes place the higher the chances of success. If the injury is left longer than two days then the chances of a successful outcome decrease. Cold and compression can also be applied throughout the rehabilitation phase as swelling is likely to be an issue with such a serious injury.
Achilles Tendonitis

Surgical Treatment
The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together. Depending on the condition of the torn tissue, the repair may be reinforced with other tendons. Surgical complications can include infection and nerve damage. Infection rates are reduced in surgeries that employ smaller incisions. Rehabilitation. After treatment, whether surgical or nonsurgical, you'll go through a rehabilitation program involving physical therapy exercises to strengthen your leg muscles and Achilles tendon. Most people return to their former level of activity within four to six months.


Working with With Achilles Tendonitis Painfulness
Overview


Achilles TendinitisAchilles tendonitis is commonly seen in athletes who sustain an increase in training load, and is most often due to overuse. Tendons respond poorly to overuse, therefore healing is slow. This can leave a tendon pathologically defective, which decreases tendon strength and leaves it less able to tolerate load, thus vulnerable to further injury or tendinosis. Extrinsic factors contributing to this condition include training errors and inappropriate footwear. Intrinsic factors include inflexibility, weakness and malalignment. In other situations, there will be clinical inflammation, but objective pathologic evidence for cellular inflammation is lacking, and in these conditions the term tendinosis is more appropriate. Tendinosis is a degeneration of the tendon?s collagen in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results. Even tiny movements, such as clicking a mouse, can cause tendinosis, when done repeatedly.


Causes


There are hundreds of tendons scattered throughout our body, but it tends to be a small handful of specific tendons that cause problems. These tendons usually have an area of poor blood supply that leads to tissue damage and poor healing response. This area of a tendon that is prone to injury is called a "watershed zone," an area when the blood supply to the tendon is weakest. In these watershed zones, they body has a hard time delivering oxygen and nutrients necessary for tendon healing, that's why we see common tendon problems in the same parts of the body. Tendonitis is most often an overuse injury. Often people begin a new activity or exercise that causes the tendon to become irritated. Tendon problems are most common in the 40-60 year old age range. Tendons are not as elastic and forgiving as in younger individuals, yet bodies are still exerting with the same force. Occasionally, there is an anatomical cause for tendonitis. If the tendon does not have a smooth path to glide along, it will be more likely to become irritated and inflamed. In these unusual situations, surgical treatment may be necessary to realign the tendon.


Symptoms


Achilles tendinitis symptoms present as mild to severe pain or swelling near the ankle. The pain may lead to weakness and decreased mobility, symptoms that increase gradually while walking or running. Over time, the pain worsens, and stiffness in the tendon may be noted in the morning. Mild activity may provide relief. Physical exam may reveal an audible cracking sound when the Achilles tendon is palpated. The lower leg may exhibit weakness. A ruptured or torn Achilles tendon is severely painful and warrants immediate medical attention. The signs of a ruptured or torn Achilles tendon include. Acute, excruciating pain. Impaired mobility, unable to point the foot downward or walk on the toes. Weight bearing or walking on the affected side is not possible.


Diagnosis


A doctor examines the patient, checking for pain and swelling along the posterior of the leg. The doctor interviews the patient regarding the onset, history, and description of pain and weakness. The muscles, tissues, bones, and blood vessels may be evaluated with imaging studies, such as X-ray, ultrasound, or MRI.


Nonsurgical Treatment


See your doctor or sports physiotherapist for further advice. You may be prescribed anti-inflammatory medicine and a rehabilitation programme. Sometimes, the ankle may be put into a walking boot or cast to immobilise the ankle in the short term. Gentle calf stretching is the first stage of rehabilitation. Don?t stretch to the point of pain. Strengthening the Achilles tendon is the second stage. Your doctor or sports physiotherapist will be able to advise you on exercises for this. Special exercises called eccentric calf raises, that contract the calf muscle as it is lengthening (during the lowering part of the movement), are the standard exercise used in the rehabilitation of Achilles tendon injuries. Sometimes a heel raise or orthotics may be useful. As symptoms resolve, resume normal weight-bearing activities gradually. Avoid running until all tenderness has gone. Swimming or cycling in low gear are good replacement activities.


Achilles Tendon


Surgical Treatment


Histological and biological studies on tendon healing have made it possible to envisage surgical repair using a percutaneous approach, with the following objectives, a minimal, and not very aggressive, operation, which is quick and easy and within the capabilities of all surgeons, the shortest hospitalisation period possible, above all, early and effective re-education, providing a satisfactory result both in terms of solidity and the comfort of the patient. The percutaneous tenosynthesis TENOLIG combines stability, reliability, patient comfort and lower overall social and professional costs for this type of lesion.


Prevention


A 2014 study looked at the effect of using foot orthotics on the Achilles tendon. The researchers found that running with foot orthotics resulted in a significant decrease in Achilles tendon load compared to running without orthotics. This study indicates that foot orthoses may act to reduce the incidence of chronic Achilles tendon pathologies in runners by reducing stress on the Achilles tendon1. Orthotics seem to reduce load on the Achilles tendon by reducing excessive pronation,