COI: Foot and Ankle pain? What's the best way to help?
Hello everybody, hope you guys are safe at home. My name is Dr. Jeeten Singha and I’m a foot and ankle surgeon at Connecticut Orthopaedics and I’m on faculty at the Connecticut Orthopedic Institute at Midstate Medical Center where I perform most of my surgeries. Today I will be discussing with you guys about common Foot and Ankle conditions and injuries. The objectives of this talk is going to be discussing all aspects of foot, ankle, as well as toe injuries and how to prevent and look out for the different injuries that you may sustain that can be chronic or acute and traumatic. Before we get started, I want to go over the anatomy of the Foot and Ankle. The foot is very complex and it has 28 bones and 33 joints. The toes make up the front of the foot then there’s the middle of the foot which we call the mid-foot and then there’s the hindfoot which is the back of the foot that encompasses the heel and the ankle. Some of the common injuries that I see for the toes include an ingrown nail which can cause significant irritation and swelling and redness to the toe whether you cut your nails too short or you got a bad pedicure. There’s also something called a “Turf Toe” injury which I see in my athletes, especially football players, it happens when you sprain or hyper-extend the big toe joint from a push off position. There’s also arthritis of the big toe which is known as hallux rigidus which causes bone spurs specifically to the top of your big toe joint and causes significant pain and discomfort. In my practice, there’s many different concerted methods that we can do such as cortisone injections, customer orthotics, oral anti-inflammatories to help calm the arthritis down, however, if this all fails, we do perform surgeries whether it’s joint salvage or joint fusions depending on what the x-rays show. The other deformities that I see of the toes are claw toes and hammer toe deformities. Here you see a picture of a surgery performed before the hammer toes, on the left, and then on the right you can see the surgery afterwards. Probably one of the most common things I see is heel pain and not all heel pain is the same. I really want the patients to understand that there’s different etiology of heel pain. Out of the different etiologies that I have listed here, the most common is plantar fasciitis. Now what plantar fasciitis is, is an inflammation of the ligament at the bottom of the heel. The ligament is called the plantar fascial and the most common symptoms that patients would complain of or that you will see is that you will have pain first few steps in the morning or when you’re getting up from a seated position there are significant pain and discomfort. On X-rays are might be a heel spur as well but it is very important to know that it’s not the heel spur that’s specifically causes the pain, it’s the actual inflammation of the ligament that attaches at the heel. Again, we’ll take X-rays when you come in for a visit and we’ll evaluate that. The other common etiology of heel pain is the back of the heel where the Achilles tendon inserts. Now that’s achilles tendonitis at the insertion there that’s different from plantar fasciitis because again plantar fascial is direct pain at the bottom of the heel and achilles tendonitis is on the back of the heel. So out of those two, the next step would be a Stress Fracture of the Heel. Now the Stress Fracture of the Heel has completely different symptoms compared to the first two that we talked about. The Stress Fracture of the Heel, you’re going experience pain constantly throughout the day; it doesn’t get better as you walk on it, it just gets worse and especially if you’ve been on your feet for a long period of time let’s say your working an 8-hour shift, 10-hour shift at the end of it, your heel really bothers you and most likely that’s a stress fracture. The last etiology of heel pain is something called Tarsal Tunnel. I know that many of you are probably familiar with Carpal Tunnel and Carpal Tunnel is on the wrist; Tarsal Tunnel is in the ankle on the inside where the nerve going toward your heel is entrapped and causes numbness and tingling at the heel. There’s various treatments for all these different etiology of heel pain. We start with conservative therapy including anti-inflammatories, a cortisone injection, we do physical therapy, I educate my patients on proper supportive shoe gear as well as custom orthotics which we mold our patients for in our office and we have the ability to make them custom orthotics, and then surgery is always reserved for the very end. Another common element that patients will suffer from is arthritis of the foot. Remember for the first side I talked to you about there being 33 joints in the foot alone as well as 28 bones and now with arthritis is, is that it’s a degeneration of the cartilage caps that are surrounded in the joints of the foot. Patients also will complain about pains of the balls of your feet and there’s different ideologies of that as well something called fat pad atrophy meaning the fat that used to be up the balls of your feet had thinned out as you’ve gotten older and as you started to become more active throughout the years. Some people may also experience bone spurs in the top of their feet that make it very difficult to get their shoes on and they always state that when they were shoes really rubs and hurts and just generalized tired and achy feet.
Bunions. Now, you may have bunions or you may know somebody that has bunions. Most people always will think that they have an idea of what a bunion actually is, but a bunion is not just a bump that grows in the side of your big toe, it’s an actual shift in the metatarsal which is a long bone of the toe and it completely shifts outward and your toe starts drifting inwards. Now, this causes a dislocation of the big toe joint which also caused a significant pain and discomfort for most patients. As you can imagine, it’s very hard to get your feet into supportive shoes and shoes in general when you have big deformities of a bunion such as these on the pictures. Bunions are genetic, they’re progressive as well, meaning that they get worse over time so whether your mother, grandmother, Grandpa, Grandma, somebody passed these genetics down to you and you’re pre-disposed to having Bunions. So the question I most get from patients is when do I, when when do I need surgery? Surgery for bunions is generally reserved for when you have significant pain that’s impacting your daily activities. We do not perform cosmetic foot surgery, so when your bunion is bad enough that you cannot get into supportive shoe gear, you cannot perform daily activities such as running and exercising and wearing the shoes that you want, that’s what we recommend surgery for this, but in-surgery, for the most part, is fairly straightforward and most patients we have them walking out of the operating room in a boot without needing caps or any crutches. Another common ailment that people suffer from are something called Flat feet or Collapsed Arches and this gets worse for patients as they get older as well and it’s most from the dysfunction of the posterior tibial tendon; that’s the tendon on the inside of your foot and ankle that helps hold the arch and throughout the years, as we have gotten older as you were born with flat feet the tendon ends up giving out and this leads to a significant amount of foot pain, ankle pain, knee pain, hip and back pain. Some of the therapy that we can do is again, custom orthotics. We recommend good shoes and surgery once again to reconstruct the foot is held to the very last stage. And if you look at the picture here and you’re looking at the back of the heel, you can see that the foot is collapsing inward and again in the left picture, you can see that the foot has been pointing outwards and there’s a too many toes sign mean that the toes you can see from the back.
Stress fractures are a very common part of my practice that I see and most people wonder what exactly is a stress fracture, I’m sure you’ve heard of the term, but a stress fracture is an overuse injury and the most common areas are the metatarsals are the long bones of the foot. Now if you look at the X-ray on the left, that was taken when the patient first comes in and initially complaining of pain and discomfort to the top of the foot and then three weeks later we take a picture and an X-ray and you can see there’s some callus formation and that was the area of the fracture. Now a stress fracture is not a complete break in the bone, it’s little internal cracks that you have within the bone so for my marathon runners, for my athletes out there that have just been training really hard, this ends up happening. There’s different etiologies of this improper shoe here being one of them vitamin D deficiency as well. Ankle sprains. Ankle sprains are very very common occurrence throughout the U.S. especially in our active and healthy population. This occurs when the ligaments that surround the ankle are stretched out and torn. So an ankle sprain is not a complete break or fracture bone, it has to do with the ligaments and what ligaments are, are rubber band-like structure that holds bone to bone, okay, and when you sprain your ligament or you roll your ankle out, you stretch out these ligaments and the ligaments are not like a rubber band or they’re not like where they just stretch out and snap back together they’re kind of like clay or Play-Doh or they stretch out and stay that way. So the range can be from mild to severe ankle sprain and an ankle sprain, I always tell my patients it’s not just an ankle sprain people shouldn’t just try to walk it off and try to be the tough guy or tough girl, you know, there has to be proper treatment for this because if there’s not proper treatment this can significantly weaken your ankle in the future and making it more susceptible to injury as well as instability and arthritis in the future. When you do have an ankle sprain you see the picture on the bottom here left that you can see their significant swelling and bruising and pain, the first thing I want to do is something called “RICE Therapy” okay, so the R in RICE stands for rest, I is for ice, C is for compression, and E is for elevation. When you come and see me depending on how significant your injury is, we can put you in a boot or we’ll do brace and then we do anti-inflammatory as well as physical therapy to help calm this down and surgery for this is usually reserved for neglected ankle sprains meaning that if somebody had a really significant ankle sprain what’s a 5-10 years ago and they never were treated properly and now they’re complaining of significant instability and weakness in their ankle and then we reserve the surgery to go in there and tighten the ligaments down.
A big part of my practice, obviously, is traumas and fractures as well; anywhere from ankle fracture, the X-ray picture there is of an ankle fracture that required surgical intervention where we put plates and screws to hold the bones back together in place. I see Achilles Tendon ruptures as well and you know for my tennis players or football players or any other athletes, just weekend warriors, Achilles Tendon ruptures, if you have it, you will know that a significant and is painful and it’s in the back of the Achilles. Most of my patients will say that they heard a loud snap, they felt like a somebody kicked him in the back of their calf and that’s usually some of the common findings of an Achilles Tendon rupture. You see a lot of foot fractures as well as different sports injuries like you see the pictures there of an ankle injury that an NFL player has sustained ligament injuries that we have talked about in the previous slide as well.
And finally I see a lot of tendonitis as well. So there’s different types of tendonitis but I’m just going to talk about the three most common ones in the Foot and Ankle. The most common one is the Achilles Tendon that we briefly touched on in previous slide. The Achilles Tendon is on the back of your leg the calf muscles become the Achilles Tendon in the insert in the back of your heel and usually patients will complain about tightness and pain in the back of their calf heel for Achilles. Now posterior tibial tendonitis I think we have touched also in the previous slides, but that is the pain of the posterior tibial tendon which is on the inside of your ankle that holds up the arch of the foot, so people that have flat feet generally will complain of posterior tibial tendon pain once again on the inside of the ankle. Peroneal tendons are the tendons on the outside of the ankle and most people that have high arch feet tend to have peroneal tendonitis and all these tendonitis are from chronic use for the most unless you have, like I said, an Achilles tendon rupture from an acute injury while playing a certain sport. Poor biomechanics as well as poor foot structure unfortunately can lead to this as well and a lot of the times people, you know, you can’t control the foot that you were born with right? But we can help you put your foot in a better supportive shoe and better orthotics so I do educate my patients quite a bit on proper shoe gear, the benefits of custom orthotics, the benefits of physical therapy, and training properly and using the right biomechanics. And that concludes my talk today thank you so much for watching, once again my name is Dr. Jeeten Singha and all the information could be found on my website, which I have linked there that also has links to the various ailments that I treat as well as the different conditions that we see and the phone numbers listed there as well if you want to call for an appointment. Thank you and have a great day and stay safe.