Wow! This week I had the worst chronic peroneal tendon rupture I have ever seen! My patient had sustained an “ankle sprain” about two years ago and wondered why her ankle looked more like a “cankle” two years later. She had a large lump just behind her fibular malleolus (a.k.a. the bone on the outside of your ankle). She noticed swelling on and off, but it never really went down all the way. She also had intermittent pain and felt like her ankle was unstable. Like most women with several children, she ignored it until it really became a lifestyle issue. She felt like she couldn’t exercise at all because her ankle felt so unstable.
Peroneal tendon injuries often occur with ankle sprains and are commonly overlooked until your ankle pain becomes chronic. The peroneal tendons stabilize the outside of your foot and ankle and allow you to turn your foot outward. There are two tendons which run side by side, behind your outer ankle bone, then split in the foot; one to the outside while the larger one dives under your foot and inserts in the arch just behind your big toe joint.
People with high-arched feet are more likely to experience peroneal tendon injuries.
Peroneal tendon injuries fall into three categories: tendonitis, tears, and subluxation. They are more common in active, athletic patients and can be acute (sudden) or chronic (lingering) in nature.
Tendonitis is inflammation, acute tears are caused by an injury and tendonosis (chronic tears) are usually caused by overuse and repetitive stress or chronic tendonitis. Subluxation usually occurs in an acute injury, like an ankle sprain, where the tendons actually dislocate onto the outer ankle bone and snap back and forth with activity.
The symptoms of a peroneal tendon injury can include swelling, pain, warmth, weakness and instability of the foot and ankle. Subluxation can also include a snapping feeling and sporadic pain with activity.
Treatment of peroneal tendon injuries is often delayed by misdiagnosis. If you are experiencing any of the symptoms of a peroneal injury, seek medical attention from a foot and ankle surgeon urgently. The longer the tendons go untreated, the more damage occurs. X-rays and physical examination usually lead to an MRI to solidify the diagnosis. My patient’s MRI showed a severe rupture of peroneus brevis with a bulbous scar tissue formation which you can see in the below picture. Peroneus longus was normal.
Treatment include rest, casting, functional orthotics, anti-inflammatory medication or injection therapy, physical therapy, bracing, and in some cases surgery. Obviously, my patient needed a repair. We excised the torn and hypertrophied part of the tendon, then repaired the rest and fixed her ligaments so she would stop being so unstable and finally lose her “cankle”. Here is the piece of abnormal tendon we excised. Wow! Big chunk!!
Your disability from a peroneal tendon injury can be significantly reduced by early intervention, so if you are experiencing any of these symptoms, call or contact the office and be evaluated. The sooner you have a proper diagnosis, the faster you will return to normal activity levels pain-free. If my patient had come in earlier to have her “ankle sprain” evaluated, conservative therapy might have healed her tendon injury!
Winter has decided to visit North Texas today. Two inches of ice covered by snow, and just in time for the Super Bowl. Time to think about trying to prevent slip and fall injuries. Lots of people fall on ice and snow every year-without serious injury. Not so fortunate were some 16,000 Americans who die each year from falls, according to the National Safety Council (NSC).
I wonder how many of them were runners? I watched from my window this morning as one of my crazy neighbors fell running on the sidewalk in front of my house. The snow had not even stopped coming down yet! Crazy! Even I ran on the treadmill this morning, and most of my peeps will tell you: I Hate Treadmill Running! Better the treadmill than the emergency room!
Falls rival poisoning as the number one home accident in the U.S. The number of injuries or deaths from falls due to winter conditions is not recorded by the NSC. But, safety experts agree that many injuries result from falls on ice-covered surfaces.
It's important that individuals recognize the hazards of slippery surfaces. Here are helpful hints from winter-safety experts that will reduce the risk of falling when slippery conditions exist:
Wear boots or overshoes with soles. Avoid walking in shoes that have smooth surfaces, which increase the risk of slipping. Trail running shoes are better than your regular road shoes.
Run or walk consciously. Be alert to the possibility that you could quickly slip on an unseen patch of ice. Avoid the temptation to run quickly. Run in high alert!
Run or walk cautiously. Your arms help keep you balanced, so keep hands out of pockets and avoid carrying anything that may cause you to become off balance. This even means leaving your precious water bottle at home.
Run or walk "small." Practice your "Chi" running and throw your center of gravity forward. Avoid an erect, marching posture. Look to see ahead of where you step.
When you step on icy areas, take short, shuffling steps, curl your toes under and run or walk as flatfooted as possible.
Run where the path has been cleared. Even in your own yard, remove snow immediately before it becomes packed or turns to ice. Keep your porch stoops, steps, walks and driveways free of ice by frequently applying ice melter granules. This is the best way to prevent formation of dangerous ice patches. Don't be stupid like my neighbor and try to run while snow is still flying!
Even when you practice safe running and walking habits, slipping on ice is sometimes unavoidable. It takes, on average, less than two seconds from the moment you slip until you hit the ground. That's precious little time to react. In that instant, the risk is an injury to your head, a wrist, hip, ankle or shoulder.
When falling, it is best to use a tuck-and-roll principle. It's important to tuck your body, lift your head and avoid trying to break the fall with a hand, which can cause a wrist injury. Ask Dr Karpati about her broken wrist from skiing the next time you are in the office. The idea is to make yourself as small as possible by rolling up into a ball.
People in North Texas hardly ever think about falling on ice and snow, but serious injuries can occur. If you are a klutz or are planning to spend a lot of time in the cold; following these guidelines may help protect you from serious injury this winter. If it is not a choice to hit the treadmill, practice caution while running in the snow and ice. If you do happen to fall and sprain your ankle or foot, call the office. Help is just a phone call away! And remember, just because you can walk on it doesn’t mean it is not broken.
Run Happy and Be Careful! Don't Be a Statistic!
I normally do not comment on football in my blog, but I have been asked this question so many times this week that it is comment worthy. For the record, even though I have allegiance to the New England Patriots and the Cowboys, I have always been a Brett Farve fan. He is the epitome of the endurance athlete as a football player, just like Cal Ripken was an example of the ever present endurance baseball player. (Yes, I love Cal too!) That aside, I think Brett is crazy to play tomorrow!
Why? First, he has two fractures in his foot and ankle. A stress fracture in his ankle and an avulsion fracture of his calcaneus (the heel bone). His ankle is already a disaster in which he has had at least 5 surgeries that we know of and has significant degenerative arthritis! Why make it worse? The season is a disaster and the Vikings are losing confidence in him. If he can’t move tomorrow, he is either going to get seriously hurt or get pulled by the coach. Why not sit voluntarily?
On the flip side, he probably needs an ankle replacement already. He could numb up his ankle, play, then risk crushing whatever cartilage was left. Stupid! And a bad example to younger football players. Face it: the season should be over and he should call it a career. (Which he should’ve done at the end of last season anyway!
Brett, don’t play. You risk hurting yourself more or at the very least looking more stupid that your antics have been in the last two years!
In the majority of younger patients with ankle arthritis, their arthritis is usually a secondary effect from too many ankle sprains. Most can relate a twisting type of injury which caused a deep cartilage injury that is often called osteochondritis dissicans. This has been seen to occur with no obvious trauma, but most can relate a history of a severe sprain. Over time, the injured cartilage starts to deteriorate, then flake and finally many patients have bone on bone contact which is extremely painful.
Osteochondritis often causes significant pain, swelling and stiffness in the ankle. Patients come in several months after experiencing a bad sprain complaining of continued popping, instability, stiffness and pain. Some complain of severe discomfort, but most relate a chronic annoying ache.
Ankle sprains should not be ignored, because many lead to chronic instability and eventual arthritis. A physical examination by your podiatrist is usually followed by x-rays. If plain film x-rays are negative, and you have had pain for more than 2 months from an ankle sprain; an MRI is indicated to rule out a cartilage injury of the talar dome. This MRI can evaluate the cartilage of the talar dome for obvious flaps and for subchondral injury to the underlying bone. A chip fracture can be quite painful and feel like a clicking every time you move your ankle.
Conservative therapy for osteochondritis includes bracing, physical therapy, anti-inflammatories and rest. Many people do well with just conservative therapy and maintain their joints by working on their proprioception and strength.
Unfortunately, surgical intervention of ankle arthroscopy is often needed to remove the cartilage fragments and place tiny drill holes in the deficit to encourage the formation of fibrocartilage or scar tissue. Severe defects may require cartilage grafting.
So, for all you young sports stars out there: Remember that ignoring multiple ankle sprains and ankle instability is usually a prescription for long term arthritis. Osteochondiritis leads to good old fashion osteoarthritis. Arthritis pain can be treated with anti-inflammatories, bracing, and in severe cases; an ankle fusion of joint replacement. In the end, most people wish they had consulted their doctor for their ankle sprains early on and avoided long term arthritic pain.
Alert the Media! A below knee cast was seen to provide better and faster results than a removable walking cast or ace bandage in severe ankle sprains! Duh! You can't take off a cast and it forces you to be compliant. Most of our patients want to be compliant but life gets in the way. Ten days in a cast rapidly improves short term outcomes......what will they report next? That physical therapy imporves long-term outcomes? Who funds these studies? Can I get some of their money to prove common sense? Just kidding......
For complete article: click here
Primary source: The Lancet
Lamb SE, et al "Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomized controlled trial" Lancet 2009; 373: 575-581.
Additional source: The Lancet
Hertel J "Immobilization for acute severe ankle sprain" Lancet 2009; 373: 524-526.
Severe ankle sprains healed significantly more quickly with a below-knee cast or air-cell brace compared with a Bledsoe boot or a tubular compression bandage, investigators here reported.
The 10-day below-knee cast and the Aircast resulted in 8% to 9% improvement in the quality of 90-day recovery compared with a tubular compression bandage, Sarah Lamb, D.Phil., of the University of Warwick, and colleagues reported in the Feb. 14 issue of The Lancet.
The degree of improvement with the Bledsoe boot did not differ significantly from that of the tubular compression bandage, which was the least effective device.
The quality of recovery at nine months did not differ among the four devices.
"Contrary to popular clinical opinion, a period of immobilization was the most effective strategy for promoting rapid recovery," the authors said. "This was achieved best by the application of a below-knee cast. The Aircast brace was a suitable alternative to below-knee casts."
"Results for the Bledsoe boot were disappointing, especially in view of the substantial additional cost of this device," they added. "Tubular compression bandage, which is currently the most commonly used of all the supports investigated, was, consistently, the worst treatment."
Severe ankle injuries (grade II-III) can cause significant incapacitation and require three to nine months for recovery in most affected individuals, the authors noted. Systematic reviews have revealed lack of high-quality evidence to aid clinical decision-making related to management of severe ankle injuries.
For more information on the treatment of ankle sprains, click here.
Run Happy! And try not to fall down go boom!
It has been a rough early fall for Misty May-Treanor, Olympic Beach volleyball champion. She was in the preliminary rounds of "Dancing with the Stars" when she ruptured her Achilles tendon in practice. She had successful surgery on her tendon and hopes to be back to competition soon. Many people have asked "If such a terrible injury happened to such a conditioned athlete, how can I prevent it from happening to me?"
The Achilles tendon is the largest tendon in the human body. It is a large ropelike band of fibrous tissue in the back of the ankle that connects the powerful calf muscles to the heel bone (calcaneus). When the calf muscles contract, the Achilles tendon is tightened, pulling the heel. This allows you to point your foot and stand on tiptoe. It is vital to such activities as walking, running, and jumping. An Achilles tendon rupture is a complete tear through the tendon, which usually occurs about 2 inches above the heel bone.
The Achilles tendon can grow weak and thin with age and lack of use. Then it becomes prone to injury or rupture. Certain illnesses and medications can also increase the risk of rupture.
Rupture most commonly occurs in the middle-aged male athlete (the weekend warrior who is engaging in a pickup game of basketball, for example). Injury often occurs during recreational sports that require bursts of jumping, pivoting, and running. Most often these are racquet sports and basketball, but any forceful push off can cause a rupture. Most ruptures are obvious and the person experiences a sudden and severe pain may be felt at the back of the ankle or calf—often described as "being hit by a rock or shot." The sound of a loud pop or snap may be reported. Initial pain, swelling, and stiffness may be followed by bruising and weakness. The pain may decrease quickly and smaller tendons may retain the ability to point the toes. Without the Achilles tendon, though, this would be very difficult. Standing on tiptoe and pushing off when walking will be impossible. A complete tear is more common than a partial tear.
Tendon strain or tendon inflammation (tendonitis) can occur from tendon injury or overuse and can lead to a rupture. Most likely, although not reported, Misty May-Treanor had a minor chronic tendonitis from her volleyball competitions and then aggravated it with the strain of dancing. "Dancing with the Stars" training has been reported to be significant and quite taxing even to the athletes that are competing!
How can I prevent this happening to me? Treat any tendon symptoms before they lead to rupture! Call your doctor if you have any signs of minor tendon problems including pain with activity, swelling and problems with standing on your toes. Tendon strain or tendon inflammation (tendonitis) can occur from tendon injury or overuse and can lead to a rupture. Prevention centers on appropriate daily Achilles stretching and pre-activity warm-up. Maintain a continuous level of activity in your sport or work up gradually to full participation if you have been out of the sport for a period of time. Good overall muscle conditioning helps maintain a healthy tendon.
What should I do if I think my Achilles tendon is injured? Any acute injury causing pain, swelling, and difficulty with weight-bearing activities such as standing and walking may indicate you have a tear in your Achilles tendon. Seek prompt medical attention from your doctor or emergency room. Do not delay! Early treatment results in better outcome. The majority of people return to normal activity levels with either surgical or nonsurgical treatment. Most studies indicate a better outcome with surgery. Athletes can expect a faster return to activity with a lower incidence that the injury will happen again. Return to running or athletics is traditionally about 4-6 months. With motivation and rigorous physical therapy, elite athletes may return to athletics as early as 3 months after injury.
Remember that your Achilles tendon is needed for almost all activities! Treat it right and see your podiatrist if you have any symptoms of Achilles tendonitis to avoid an Achilles tendon rupture like Misty May-Treanor!
This week a very good runner from Wichita Falls came in with an Achilles tendon problem. He gave a horrible story of a primary care physician who injected his Achilles bursae TWICE with cortisone. He was looking for better answers and was willing to drive almost 2 hours south to find them.
I was almost apoplectic! Injected his tendon or even around his tendon?! In my world, that’s almost borderline malpractice; but I can’t fault the physician, she obviously didn’t know any better and was trying to treat the patient. Bottom line: Go to a sports medicine physician. We would all tell you the same thing: injecting the Achilles tendon can lead to spontaneous rupture which would basically end his running days. Look at poor Dan Marino…a ruptured Achilles tendon ended his Hall of Fame career!
Let’s talk about Achilles tendon injuries. They are very common especially in runners with high arched feet or very flat feet. Both of these foot types put way too much torque on the tendon and will cause a wear and tear tendonitis that eventually becomes tendonosis without proper treatment.
Tendonitis results from overuse. Long-standing tendonitis becomes tendonosis (degeneration of the tendon) which is much harder to treat. This overuse can happen over a period of time or can happen over a weekend. Those of you who exercise regularly or are in training for an athletic event, as strong as the Achilles tendon is, this work horse could use a break every once in a while! With chronic, long term, sustained use, this tendon becomes strained. It also can become just as strained with whom we fondly refer to as the “weekend warriors”. You know who you are! You are the ones who think it perfectly o.k. to hike the Appalachian Trail or take the steep way down the Grand Canyon over a three day weekend because “it was there”! Marathon runners who decide they can run the Western States 100 without the proper training….you can't hide for long....I will find you....
The simplest form of treatment can involve rest, heel lifts, icing, inserts, night splints, custom orthotics and anti-inflammatories. More complex forms Achilles tendonitis can include immobilization through a boot or cast, physical therapy, and in the most resistant cases, surgery. Active release myofascial release is very helpful. Thank God for David Bloom at Restoration Physical Therapy and Dr. Darryl Laney at Laney Chiropractic in Keller! Most of my long-standing Achilles tendon injuries are successfully treated with aggressive PT and manipulation on top of orthotic control. The longer you have it, the worse it gets. Do not let it get that far. Tendonosis is a chronic degeneration that can lead to splitting of the tendon and long term disability!
Thinking of waiting to see if it works itself out or are trying to work through the pain? Let us help you reconsider. Chronic Achilles tendonitis (tendonosis) results in degeneration and breakdown within the tendon and this, in turn, can lead to a partial tear or full rupture. Now that will put you out for more than a couple months! If you are experiencing a nagging pain or swelling to the Achilles tendon or the back of the heel, call or contact the office to have it evaluated. It is that simple!
Spring is in the air in North Texas. The brief snows are gone and recreational sports are starting their schedules. The soccer, baseball and lacrosse leagues are having their first games; the high-school track team is gearing up for competition, and The Leukemia Society’s Team-in-Training groups are just starting to increase their mileage aiming for an early summer marathon finish. Spring is in the air, and our old friend the ankle sprain is starting to show up more frequently in the office. Basketball and volleyball seasons are always the main producer of this injury; but you would probably be surprised how many ankle sprains occur in outdoor sports like soccer, baseball, lacrosse and of course track and field. Ankle sprains have been reported to be approximately 20% of all sports injuries with more than 25,000 occurring every day in the United States.
Uneven, wet fields coupled with early season fatigue and competitive full-contact intensity equal injuries. The ankle is the joint that compensates for uneven surfaces. 85% of ankle injuries are sprains, which are caused by a failure to compensate for this uneven footing. Jumping, cutting, and pivoting put the ankle at risk. Many athletes put themselves at further risk by not rehabilitating these injuries properly, returning to sport too early, and giving themselves an inadequate adaptive ability to uneven surfaces or sudden twisting. The use of narrow cleats with minimal arch support or the use of running shoes for a court sport can also place an athlete at risk for ankle sprains.
Ankle sprains occur in runners mainly because they are chatting away as they are on a long run and are simply not paying attention. How many runners have you seen fall off the curb or in a pothole while running? Lots…Pay attention to where you are going and you can prevent this type of injury. If you know you are a klutz, run on an even surface, like a track, when you are tired or distracted.
If you have an ankle sprain, you should be evaluated by a sports medicine podiatric foot and ankle surgeon if you have localized pain, swelling and bruising, as well as inability to walk more than 5-7 steps comfortably. Many a foot fracture has been missed in the emergency room when x-rays were taken only of the ankle and not the foot. The fifth metatarsal is often broken with the same mechanism of injury of an ankle sprain, so the foot should be evaluated as well. If severe ligament injury is suspected, an MRI can evaluate the grade of injury. This is really what decides whether surgery is needed for full recovery.
Treatment for ankle sprains really depends on the degree of severity, which can only be determined by your doctor. Initial treatment always includes “R-I-C-E” therapy – Rest, Ice, Compression, and Elevation. Pain and edema is usually controlled with NSAID’s (non-steroidal anti-inflammatories) like ibuprofen. Bracing or casting coupled with non-weightbearing on crutches may be needed in more severe injuries to rest and stabilize the ankle while it heals. Return to pain-free range of motion (ROM) and stability is the goal. Surgery is only recommended in Grade 3 severe injuries in athletes or in those patients who have had multiple ankle sprains and suffer from chronic ankle instability. Long-term ankle instability can often be avoided with an aggressive physical therapy program. Bracing should only be used in the short-term during rehabilitation because long-term bracing actually causes atrophy and decreased ROM.
Physical therapy is needed for all ankle sprains. The goals of physical therapy should be to regain full ROM, strength and proprioception (where your brain thinks your ankle is in space). Regaining strength in the peroneal tendons as well as overall balance training are the keys to successful rehabilitation of an ankle sprain. A maintenance program of ankle strengthening, stretching, and proprioception exercises helps to decrease the risk of future ankle sprains, particularly in individuals with a history of multiple ankle sprains or of chronic instability.
Bottom line: if you happen to fall down and go “Boom”, have your ankle sprain evaluated by a podiatric foot and ankle surgeon. Delaying treatment and rehabilitation can lead to life-long instability.
For more information on ankle sprains, go to our home page and click on "All About Feet".
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