The Foot & Ankle Institute at AMA Health

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• Achilles Tendon Pathology

  Acute Achilles Tendon Rupture The Achilles tendon is a band of tissue that connects the calf muscle to the heel. It is the largest and strongest tendon in the body. It functions to transfer push off force for the calf to the heel and is vitally important for walking and any sporting activities. Achilles tendon ruptures most commonly occur in athletic individuals in their 30’s, 40’s, or 50’s. The final result is a sudden application of force during a change of direction resulting in the rupture of the tendon. A rupture can occur when starting to run, stopping abruptly, jumping, or landing from a jump. Ultimately, regaining normal Achilles tendon function is fundamental to resuming an active and healthy lifestyle. Clinical Presentation Patients usually describe an initial sharp pain in addition to the sensation as if they were “hit in the back of the leg” with a ball, a bat, or kicked. At times, an audible “pop” may be heard. The rupture can be extremely painful. A fair amount of swelling and later discoloration is associated with the injury. Subsequently following the initial injury the pain varies a great deal. Some describe very little or no pain while others describes less but, persistent discomfort. Most individuals find it very difficult to walk after the injury. It is very rare that a rupture of the Achilles is partial. However, a painful Achilles tendonitis or a partial rupture of the calf muscle as it inserts into the Achilles can also cause pain in the area. Physical Exam and Imaging Studies Diagnosing an Achilles tendon rupture is made entirely on physical exam. A defect within the tendon at the site of rupture can be felt by lightly palpating the area. The main test to determine whether the Achilles has been ruptured is the Thompson test. The Thompson test involves placing the patient on their stomach and squeezing the calf muscle. If the Achilles tendon is intact, the foot will then rise or plantar flex. If it is ruptured, the foot will not move and will tend to be in a lower lying position. Plain film x-rays will be negative as the injury is to the tendon and there fore does not affect the bones or joints of the foot. Ruptures will be seen on MRI; however, an MRI is NOT indicated for acute ruptures unless there is some uncertainty about the diagnosis. An ultrasound may also be helpful to confirm the diagnosis of a rupture and may also help to monitor the healing in some patients who are treated non-operatively. Treatment The treatment of an Achilles tendon rupture has been shown to be most successful with surgical treatment however the injury can be also treated non-operatively. Both operative and non-operative treatments have advantages and disadvantages. The patient’s medical history, age, and activity level are the main points of focus when determining a treatment plan. Patients with significant medical problems or older age may be best served with non-operative treatment. Operative treatment is best suited for young, healthy, and active patients. Surgical repair of the ruptured tendon affords the patient a more favorable likelihood to return to their pre-injury level as well as in a more timely fashion. Overall, recent literature has suggested an associated increase risk of re-rupture and loss of physical function with non-operative treatment. Regardless of which treatment is best suited for the patient, each will require aggressive physical therapy during recovery. It is imperative to understand while Achilles tendon ruptures can be treated either non-operatively or operatively, they must be treated. A neglected Achilles tendon rupture will lead to a marked dysfunction of the lower leg with ambulation and potentially lead to a host of other problems. Insertional Achilles Tendinitis Insertional Achilles tendinitis is a chronic condition characterized by inflammation of the Achilles tendon. This occurs when the normal wear and tear of activity has caused degeneration of the tendon where it connects to the back of the heel bone. Symptoms often include pain, swelling, and difficulty wearing normal shoe wear. Bone spurs may develop and the damaged tissue of the tendon can begin to harden. Patients may often complain of a painful “bump” at the back of the heel. Achilles tendinitis may be treatable with rest, ice, and over-the-counter anti-inflammatory pain medication. Non-operative treatment usually involves a period of activity modification to let the symptoms settle, followed by a gradual return to normal activity. Some patients feel more comfortable in shoes with a slight heel wedge and opened back. A heel lift may also be beneficial to increase heel height, which tends to take some of the load off of the Achilles tendon. A consistent daily calf stretching protocol is also an important component of the treatment. At times, formal physical therapy may be recommended.

• Ankle Pathology

  Chronic ankle instability is a condition caused by injury to the lateral or outer portion ankle ligaments. This can lead to a sense of instability and weakness in the ankle. The ankle may have the feeling of “giving out” during walking and other activities. Chronic instability may predispose the patient to get frequent ankle sprains even with a minor trauma or a subtle twisting injury. Ankle instability commonly affects athletes and is often caused by an initial severe ankle sprain that has not healed properly. A sprained ankle tears or stretches the ligaments that support the ankle joint, affecting balance, and if left untreated, can lead to chronic lateral ankle instability. The most common symptom of chronic ankle instability is an insecure, unstable feeling within your ankle. This symptom may also be accompanied by pain, tenderness, and swelling of the ankle. Some individuals may experience a repeated turning of the ankle when walking or running on uneven surfaces. The vast majority of patients with ankle instability can be treated without surgery by physical therapy, avoiding high-risk activities, and using a supportive ankle brace or shoe to reduce the risk of recurrent sprains. In some cases non-operative treatment is not successful and surgical correction is required to tighten up or reconstruct these ligaments. Acute Ankle Sprain An ankle sprain is a stretching or tearing of one or more ligaments that support the ankle joint. It is one of the most common musculoskeletal injuries. The injury occurs when the ankle rolls inward and is usually caused by a sports injury, accident, or stepping on an uneven surface. Patients typically have significant pain, swelling, stiffness, bruising, and usually a limp. At times a “popping” sound may be heard when the ankle is moved. In severe cases the patient may be unable to bear weight on the ankle. Initial treatment includes: rest, ice, compression, elevation, activity modification, and NSAIDs. Patient may also benefit from a short period of immobilization in a walking boot or ankle brace. Often physical therapy is required to strengthen and increase range of motion of the ankle once the initial pain and swelling has settled. Osteochondral Lesion of the Talus (OLT, OCD, Osteochondritis Dissecans) The talus is the lowermost bone in the ankle joint and is completely covered in cartilage to allow for smooth and fluid motion of the ankle joint. When the ankle joint experiences a traumatic injury, such as a severe ankle sprain, the cartilage may be damaged. This may lead to the condition known as either osteochondritis dessecans (OCD) or as an osteochondral lesion of the talus (OLT). Symptoms may include chronic localized ankle pain, discomfort when walking, clicking or catching, and swelling. Treatment usually begins with immobilization, physical therapy, ankle bracing and NSAIDs. Surgical treatment is indicated if these measures fail or if there is a displaced lesion. Surgery involves arthroscopic debridement and removal of the loose cartilage or bone within the joint. Peroneal Tendon Injury/Tendinitis Peroneal tendon injuries or tendinitis takes place when the tendons that run in a groove, behind the bony prominence on the outer aspect of the ankle are damaged. The inflammation or injury usually occurs due to the excessive and repetitive strain during standing or walking. Treatment is aimed at decreasing inflammation and correcting any predisposing factors. If there is severe damage or tearing of the tendons, surgical intervention may be necessary for repair.

• Arthritis

  Ankle Arthritis Ankle arthritis is a condition that causes pain, stiffness, and swelling of the joints and most commonly occurs over time.As we age, the cartilage that cushions the bones gradually wears down and leaves the bone ends uncovered causing symptoms to develop.Initially, patients may not experience any symptoms.However, as the condition progresses, symptoms may include pain, stiffness, swelling, instability, bone spurts, joint deformity, and difficulty walking.The condition can be aggravated and symptoms can intensify by increased standing, walking, and physical activity.If the nerves surrounding the joint become irritated, patients may experience numbness and tingling. Mild cases of ankle arthritis can be treated without surgery. Non-operative treatment is aimed at improving function and decreasing pain.It is based on limiting the amount of loading through ankle joint, controlling the symptoms, and decreasing ankle joint motion. Symptoms can often be curtailed with cushioned shoe inserts, soft ankle braces, anti-inflammatory medication, and cortisone injections.In moderate to severe cases or when non-operative treatment no longer responds, surgical treatment may be necessary and very beneficial for definitive management. The main operative procedure for the treatment of ankle arthritis is ankle fusion.The painful degenerative ankle cartilage is removed and the two main bones of the ankle are fused together forming one bone.While an ankle fusion prevents movement through the ankle joint, movement through the remaining joints in the foot allows the patient to walk normally. Ankle replacement may be an option for older patients who are not excessively active.Also, a replacement may be suitable for patients that have other fusions in their hindfoot. Similar to an ankle fusion, the damaged parts of the two bones of the ankle are removed and replaced with an artificial implant in order to simulate the nature performance of the joint.While this is a complex procedure, in the appropriate patient it is very successful and can last for numerous years. Hindfoot Arthritis: Patients experiencing hindfoot arthritis will complain of pain on one or both sides of the back of the foot just below the inside and outside of the ankle.Symptoms can progress over time and can most common cause is abnormal alignment of the heel bone or following a traumatic injury such as a calcaneal fracture.Initial treatment consists of comfort shoes, bracing the hindfoot, activity modification, and cortisone injections.Surgery is indicated when non-operative treatment fails.Fusion of the subtalar joint may often yield the most favorable outcome.However, when adjacent joint arthritis and/or foot deformity present as contributing factors, a double or triple hindfoot fusion may be recommended to reduce pain and restore function to the area. Midfoot Arthritis: Midfoot arthritis can be characterized by increased pain and swelling of the midfoot.Patient will experience discomfort underlying and overlying this area.Symptoms are aggravated by standing or walking and are frequently at its worst when first standing after sitting or lying down.It is not uncommon for an associated bony prominence to be present on the top of the foot.Usually the symptoms gradually develop over time, however can progress quite rapidly following a traumatic injury.Non-operative treatment is aimed at symptom control and usually consists of a combination of stiff-soled comfort shoe with soft upper, resting the foot, activity modification, anti-inflammatory medication, and cortisone injections.If pain persists after exhausting non-operative treatment, surgery necessitating a midfoot fusion may be recommended to reduce the pain in the area. Hallux Rigidus: Hallux rigidus or big toe joint arthritis is a common degenerative condition that affects the joint at the base of the big toe. This progressive arthritis leads to stiffness, pain, and bony prominences surrounding the joint. This can lead to difficulty fitting into shoes and eventual discomfort with standing or walking. This occurs over time and can become very symptomatic. There are beneficial non-operative options however depending upon the degree joint disease, a big toe joint fusion can afford the most predictable results.

• Bunions

  About Bunions A bunion (hallux valgus) is a common foot condition that involves a prominent bony bump on the inside of the big toe joint. In addition, the big toe may have the tendency to drift outward towards the second toe. Bunion deformities may worsen over time and cause excessive discomfort, pain, and swelling. This can lead to difficulty walking, ingrown toenails, corns, and calluses. Bunions can occur when there is an improper balance of forces exerted on the joints of the foot, which can result in instability of the big toe joint. This often is a result of shoes that do not fit properly, abnormal walking, inherited foot type, or positive family history. Bunions can also be caused by injury, birth defects, arthritis, and certain neuromuscular disorders. Bunions are typically not a serious condition; however, they can vary greatly in their extent and symptoms they cause. If left untreated, they may grow larger, become unsightly and more painful over time. Treatment for bunions depends on the severity and symptoms associated with the condition, although early treatment is considered most effective. For mild bunion deformities, treatment can consist of simply changing or altering shoes for accommodation. Also, padding, taping, or splinting the toe into a normal position may be beneficial.Furthermore, corticosteroid injections, orthotics, and physical therapy may also be recommended. In severe cases or instances when non-operative measures become insufficient to provide relief, surgical correction of the deformity may become necessary. Surgical treatment of bunions is often reserved for severe cases or when conservative treatment measures fail. Surgical treatment is not recommended for the correction of the cosmetic appearance alone. The most common type of procedures is a bunionectomy, during which the bony prominence is removed. Depending on the severity of the deformity, other procedures may need to be performed in conjunction with the bunionectomy. It is not uncommon for metal devices such as screws and plates to be used to hold bone structures in alignment as they heal.

• Flat Feet

  Adult Acquired Flatfoot Deformity The adult acquired flatfoot is a common deformity that affects one in four adults in the United States.The deformity may begin in childhood or be acquired with age.The foot may be flat at all times or the arch may fall when standing.The most common cause of flat foot deformity is Posterior Tibial Tendon Dysfunction (PTTD), in which the main tendon supporting the arch of the foot gradually weakens.Patients will often complain of persistent pain along the arch of the foot or describe their feet as “tired”.Standing, walking, or running for prolonged periods of time either at work or during physical activity can exacerbate symptoms.Not all patients will experience symptoms from this condition, however the deformity may worsen over time. Treatment of flatfoot deformity initially begins with lifestyle changes including weight loss as well as switching to a supportive athletic shoe. An additional key component to addressing the deformity is wearing an orthotic device to support the arch. Anti-inflammatory medication and formal physical therapy may also be beneficial. In severe cases, or those that do not respond to non-operative treatment options, surgery may be required to relieve symptoms and reconstruct the arch of the foot.