The majority of ankle problems we see are the result of injury.  Sprains or fractures may occur when landing on an ankle, causing the ankle to twist.   Osteoarthritis and Rheumatoid arthritis may also affect the ankle. The majority of cases of osteoarthritis are the result of prior injuries to the ankle.

Ankle Sprain:

Ankle sprain refers to tearing of the ligaments on the outer or inner aspect of the ankle.  Ligaments on the outer ankle are more commonly injured. The medical term for the injury shown is inversion which is the most common mechanism of injury.

The severity of ligament disruption is graded from 1-3.  Grade 1 sprains involve strain to the ligaments with only a small amount of torn ligament fibers.  In grade 1 injuries, the ankle remains stable. In grade 2 injuries, more of the fibers are torn, and there is some loss of ankle stability.  In Grade 3 injries, the ligament is completely torn. There is usually tenderness on the inner aspect of the ankle. Grade 3 injuries are associated with more instability.

Diagnosis of Ankle Sprain:

Dignosis of ankle sprain is made based on history of the injury, tenderness and swelling on exam and xrays which differentiate sprain from fracture.   We also look for associated chip fractures to the talus ankle bone which may be associated with severe sparins. Ankle sprains are graded by the degree of laxity (looseness) on exam and stress Xrays.  Stress xrays are taken while moving the foot as shown in the diagram. The tilt of the talus bone of the foot relative to the tibia and fibula bones of the ankle indicate the degree of ligament injury.  If tilt is less than 10 degrees, the sprain is typically grade 1 or grade 2. More than 10 degrees or markdekly different from the opposite side is associated with grade 3 disruption. MRI can also show ligament injuries, but is seldom needed to diagnose routine sprains.  It is common for the ankle to turn black and blue and swell.

Treatment:

If the ankle is not grossly deformed, a trip to the emergency room is not essential. Sprains and minor fractures can be safely evaluated in a few days time.  Keep weight off the ankle, elevate to control swelling and ice if it helps the pain. NSAID’s or Tylenol may help the pain. Almost all sprains are associated with swelling and black and blue discoloration at the ankle, into the foot and sometimes up the calf.   As a rule, the only ankle injuries that require emergency room treatment are those with open wounds or fractures associated with significant deformity. If you do go to the emergency room, be sure to get a disc containing copies of your xrays for the doctor to review.

Almost all ankle sprains are treated non-suirgically.  In grade 1 and most grade 2 injuries, treatment involves protection and gradual return to weight bearing as pain allows.  Full healing may take 3 full months. Sometimes a boot, aircast type stirrup or elastic support may be used for comfort. If there is a fracture of the fibula, the small bone one the outer ankle, a cast may be used.  If the fracture is more than 3mm out of place, surgery is sometimes done.

Most grade 3 sprains are treated with a cast for 3 weeks, then gradual mobilization.  For highly competitive athletes, or sever injures, ligaments may be reapired surgically.

Chronic Instability / Recurrent Sprains:

In some cases, severe or repeated sprains of the ankle can lead to instability and frequent giving out of the ankle even with normal activity. In these cases, a reconstruction or repair of the ligaments may be performed. For many, repair of ligaments may be pefromed with local tissue (Brostrom procedure). For severe problems, sometimes grafts are placed to replace the function of the damaged ligaments. Unlike fractures which may heal “like new”, ligaments heal with sacar tissue which may result in permanent loss of some mobility and stability of the joint.

Achilles Tendon Disorders:

The achilles is the large tendon at the back of the foot.  It connects the calf muscles to the back of the calcaneus bone of the foot.  Trauma or inflammation can result in local tenderness, swelling and pain in this tendon making it difficult to walk.  Rupture of the tendon may occur suddenly during push off activity in sport. Tennis playsers describe the feeling as being hit in the back of the leg with a tennis ball.

Rupture may also follow chronic tendinosis or tendinitis.  Pump Bump is an irritation of the achilles tendon where it attaches into the calcaneus bone of the foot.  Ofted a bony prominence forms in this area making shoe wear painful.

Tendonitis and tendinosis ofted causes local tenderness and may cause painful limp.  Tear of the tendon is distinguished by a palpable defect in the tendon coupled with a positive calf squeeze test.  (Thomas test) With the leg relaxed, the calf muscle is squeezed. With an intact tendon, the foot will move into a more toes down posture.  If the tendon is disrupted, the toes will not move. Patients also note that they have no pushoff on the affected foot. In a small percentage of cases, an MR can be sueful to visualize the tear.  Tear to the achilles may increase your risk for DVT blood clots due to inactivity of the muscle. In some cases, the doctor may prescribe blood thinners to decrease the risk.

Treatment of Achilles Tendinitis:

Achilles tendinitis may be persistent and difficult to treat.  Resolution of symptoms may take weeks to months. Treatment of the tendonitis is reducing inflammation and pain.  

  • NSAID anti-inflammatory medicines or oral steroids may be used to decrease inflammation.  
  • Physical therapy modalities including ultrasound and stretching
  • Cast or boot immobilization may be used for some patients.

Treatment of Achilles Rupture:

Most ruptures are treated with surgical repair.  Surgical repair restores better strength by restoring the normal length of the muscle / tendon unit.  Non-surgical treatment is indicated for patients who do limited walking and in patients where skin or medical conditions would prohibit surgery.  

Patients are in a compression dressing or cast for the first few weeks after surgery.  Time to mobilization depends on the severity of the injury and individual patient factors.  We typically try to get patients walking within 3 weeks of surgery. Gradual increase in range of motio and stretching typically astarts 3-6 weeks after surgery.   Strengthening begins at 8-10 weeks after surgery for most paitents. Return to sport is typically allowed at 9 months after surgery.

Treatment of Pump Bump:

Pump bump prominence at the back of the heel poses some unique treatment challenges.  The Achilles spreads in a thin layer over the back of the heel bone (calcaneius) and lies immediately beneath the skin.  The bone prominence frequently erodes some of the tendon as well. Non- surgical treatment includes NSAID medications, shoe wear modification to decrease trauma, and sometimes casting to decrease inflammation.  Surgical treatment involves removal of the bone prominence. `Removing the bump almost always involves removal and reattachment of the tendon. Since the structures are immediately beneath the skin. There is no overlying muscle.  Muscle provides protection and blood supply essential to healing. Therefore, surgical reattachment heals slowly, and there is increased chance of infection or problems with wound healing. Scars may be tender resulting in painful shoe wear.  Heling time is typically 3 to 6 months. For these reasons, surgery is reserved for the most symptomatic cases failing conservative care measures.

Heel Pain / Heel Spur / Plantar fasciitis:

There are several causes for heel pain.  Heel spur or plantar fasciitis is common.  Plantar fasciitis causes pain over the heel adjacent to the arch which is commonly worse with the first few steps.  While many associate these symptoms with heel spur, most patients with heel spurs on xray do not have plantar fasciitis.

Heel pad pain, “stone bruise” differs from plantar fasiitis in that the tenderness is in the center of the heel bone rather than on the inner aspect, near the arch.  Stone bruise may sometimes show as a bone bruise on MRI. MR bone bruising is thought to represent bleeding into the bone, or microscopic fractures.

Fractures:  Following trauma,  even minor fractures of the heel bone may be painful for many nonths.

Referred heel pain:  Back pain, sciatica, neuropathy and poor circulation can cause heel pain.  Referred pain is typically poorly localized. OPn exam tenderness is usually poorly localized.  In some cases dinding the underlying cause may be a challenge.

Diagnosis:

Evaluation of heel pain involves history of pain, trauma, examination of the foot for tenderness, neurologic and circulatory changes.  Xrays are used to evaluate for bone deformity, spurs and fracture. In some cases, MR may be used for further evaluation of the bone and soft tissue.

Treatment:

When most patients come to our office, they have already tried many of the over the counter treatments and splints. ;  Plantar fasciitis is the most common cause we see, and cortisone injection is one of the fastest and most effective treatments.  In some cases a few injections may be required. Other options include physical therapy, ultrasound and stretching. For some patients 3 weeks in a walking cast may break the pain cycle.  For cases failing prolonged non surgical care, plantar fascia release may be considered. The surgery involses release of the fasica near the heel bone. If the spur is large it may be removed, but in most cases the spur is left alone.  The procedure yields pain relief for about 70% of patients.

Treatment of heel pain for causes other than plantar fasciitis is determined by the underlying condition and cause.  Plantar fascia surgery is not effective for treating referred pain.

Leg Swelling, Leg Pain and Varicose Veins:

There are many causes for poorly localized leg pain.  The orthopedic evaluation of leg pain is predominantly limited to trauma to muscles and bones, rare tumors of muscle or bone, and shin splints. Veinous stasis, varicose veins and neuropathy are more common causes of leg pain and swelling.  These conditions are typically treated by your family doctor, vascular specialists or neurologist.

Significant veinous stasis answelling represents a risk for orthopedic surgery on the lower extremity.  Swelling and pain may limit your ability to participate in rehab. Ulceration of the legs may increase the risk of infection.  Many of these conditions are commonly associated with diabetes, obesity and other chronic illnesses as well.

Dark brown discoloration of the leg associated with chronic swelling is commonly due to veinous insufficiency.  Normally, there are valves in the veins of the leg that promote return of the blood to the heart. Blood clots, obesity and other factors may result in damage to the valves.  The result is blood pooling in the legs which results in chronic swelling and discoloration. Standing for prolonged periods may also predispose to these conditions. In all cases, full medical evaluation is recommended, as these conditions are typically chronic and can lead to serious complications.

Support hose / elastic hose may control some of the swelling and decrease discomfort. If your problems are mild, you can purchase support hose at local drug stores, on Amazon, or Healthylegs.com.  If you are simply trying to be more comfortable on your feet, consider the Jobst low gradient styles which are inexpensive and easy to put on.( male: https://www.healthylegs.com/mens/knee-highs?compression=11  female: https://www.healthylegs.com/mens/knee-highs?compression=11&gender=815 )  Stronger stockings tend to be more difficult to put on.  In many cases, they may require a prescription and fitting at a medical supply store or specialized pharmacy.

Resources in our area for vascular evaluation:

Contact your primary care physician for referral.

Some area options:

Mercer Medical group Princeton –  vascular http://pchonline.org/about/affiliates/mercersurgery.aspx

Dr. Oye:  Beckley http://www.wvvascularinstitute.com/

Dr. Graybeal:  http://www.betterveincare.com/

(note links and references are provided for your education and convenience. They do not represent a recommendation or endorsement of a specific product or treatment.)   Please feel free to contact us if you offer services that would be of benefit to our patients and would like to be included on our site.

Osteoporosis:

Osteoporosis is the most common bone metabolic disease in the United States.   Osteoporosis has no symptoms until fractures occur. Fractures of the hip, wrist and compression fractures of the spine are associated with osteoporosis. The consequences of the disease may be devastating, resulting in pain and severe loss of function.

Our practice deals with the consequences of osteoporosis.   Treatment after fractures begin has limited effectiveness. Be sure to talk with your primary care doctor about osteoporosis and your risk factors.

Screening bone mineral density tests are recommended for

  • Women age 65 years and older and men age 70 years and older, regardless of clinical risk factors
  • Postmenopausal women and men above age 50–69, based on risk factor profile
  • Postmenopausal women and men age 50 and older who have had an adult-age fracture, to diagnose and determine the degree of osteoporosis

Bone density measurement is a simple Xray test with low radiation exposure.  The test only takes a few minutes.

Bone mineral density determines how much calcium remains in the bone.  As shown above, osteoporosis results in thinner, weaker bone. Loss of calcium and strength results in significantly increased risk of fracture.

What do the numbers mean?

I’ve had my study, now what do the numbers mean?    You want your results to be T score more than -1 (minus 1) and Z score more than -2 (minus 2).

The T score compares you to patients at ideal or  peak bone mineral density. Osteopenia means there is loss of bone, not yet severe enough to be called osteoporosis. The results are interpreted as follows:

  • T-score of –1 to –2.5 SD indicates osteopenia
  • T-score of less than –2.5 SD indicates osteoporosis
  • T-score of less than –2.5 SD with fragility fracture(s) indicates severe osteoporosis

The Z score compares you to others of your gender and age group.  Z scores are interpreted as follows:

  • Z-score values of –2.0  or lower are defined as “below the expected range for age”
  • Above –2.0  as “within the expected range for age.”

Baseline lab tests for osteoporosis:

In many cases, some or all of these tests may be performed by your doctor as part of your routine checkups.  It is a good idea to check to see if these tests have been done. If you have osteoporosis on the bone density test, be sure to discuss the full workup with your physician.

CBC to look for anemia.  At age >60 with anemia, further testing should be done for multiple myeloma.

Creatinine, renal function

Calcium, phosphorus, magnesium:  Evaluate calcium metabolism critical to bone health

Liver functions:  Evaluate for underlying liver disease or alcohol use

25 OH vitamin D level:  Low vitamin D has significant adverse effect on bone metabolism.

Thyroid functions: Thyroid dysfunction is highly associated with osteoporosis

More sophisticated testing may be indicated for specific individuals to evaluate for other causes of osteoporosis.

Prevention and lifestyle:

  • Eat a balanced diet high in fruits, vegetables, calcium, and vitamins.
  • Get enough calcium. The recommended total intake of is 1,200 mg daily; for best absorption, if taking supplements, divide doses into 250-500 mg doses throughout the day. Of the two types of calcium, calcium carbonate is best absorbed when taken with food but calcium citrate can be taken on an empty stomach.
  • Get enough vitamin D. NAMS and the National Osteoporosis Foundation recommend at least 800-1,000 IU per day for women age 50 and over who are at risk of vitamin D deficiency. Vitamin D deficiency can be caused by inadequate sun exposure (for example, those who live in northern latitudes). I  Vitamin D testing is a part of the lab evaluation for osteoporosis. **Too much vitamin D can be harmful. High dose vitamin D therapy should be prescribed and supervised by your doctor.
  • Avoid alcohol and smoking. Heavy alcohol intake (more than 7 drinks per week) increases the risk of falls and hip fracture and women smokers tend to lose bone more rapidly and have lower bone mass than nonsmokers. Stopping smoking is one of the most important changes women can make to improve their health and decrease risk for disease.
  • Be physically active every day. Weight-bearing exercise (for example, fast walking, hiking, jogging, and weight training) may strengthen bones or slow the rate of bone loss that comes with aging. Balancing and muscle-strengthening exercises can reduce the risk of falling and fracture.
  • Consider therapeutic medications. Currently, several types of effective drugs are available. Healthcare providers can recommend the type most appropriate for each woman.
  • Eliminate environmental factors that may contribute to accidents. Falls cause nearly 90% of all osteoporotic fractures, so reducing this risk is an important bone-health strategy. Measures include ample lighting, removing obstructions to walking, using nonskid rugs on floors, and placing mats and/or grab bars in showers.
  • Be aware of medication side effects. Some common medicines make bones weaker. These include a type of steroid drug called glucocorticoids used for arthritis and asthma, some antiseizure drugs, certain sleeping pills, treatments for endometriosis, and some cancer drugs. An overactive thyroid gland or using too much thyroid hormone for an underactive thyroid can also be a problem. If you are taking these medicines, talk to your doctor about what you can do to help protect your bones.

Assessing your risk of fracture – The FRAX score:

You can calculate your risk of fracture on line here: https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9

Note:  there is a calculator on the right side of the screen to convert your height and weight from pounds to KG and inches to cm.