Rheumatoid Arthritis within Foot and Ankle

Article featured on OrthoInfo

Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body. It most often starts in the small joints of the hands and feet, and usually affects the same joints on both sides of the body. More than 90% of people with rheumatoid arthritis (RA) develop symptoms in the foot and ankle over the course of the disease.

Description

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.

How It Happens

The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes an overactivity of this lining. It swells and becomes inflamed, destroying the joint, as well as the ligaments and other tissues that support it. Weakened ligaments can cause joint deformities — such as claw toe or hammer toe. Softening of the bone (osteopenia) can result in stress fractures and collapse of bone.

In RA, the lining of the joint swells and becomes inflamed. This slowly destroys the joint.

Rheumatoid arthritis is not an isolated disease of the bones and joints. It affects tissues throughout the body, causing damage to the blood vessels, nerves, and tendons. Deformities of the hands and feet are the more obvious signs of RA. In about 20% of patients, foot and ankle symptoms are the first signs of the disease.

Statistics

Rheumatoid arthritis affects approximately 1% of the population. Women are affected more often than men, with a ratio of up to 3 to 1. Symptoms most commonly develop between the ages of 40 and 60.

Cause

The exact cause of RA is not known. There may be a genetic reason — some people may be more likely to develop the disease because of family heredity. However, doctors suspect that it takes a chemical or environmental “trigger” to activate the disease in people who inherit RA.

Symptoms

The most common symptoms are pain, swelling, and stiffness. Unlike osteoarthritis, which typically affects one specific joint, symptoms of RA usually appear in both feet, affecting the same joints on each foot.

Anatomy of the foot and ankle

Anatomy of the foot and ankle.

Ankle

Difficulty with inclines (ramps) and stairs are the early signs of ankle involvement. As the disease progresses, simple walking and standing can become painful.

Hindfoot (Heel Region of the Foot)

The main function of the hindfoot is to perform the side-to-side motion of the foot. Difficulty walking on uneven ground, grass, or gravel are the initial signs. Pain is common just beneath the fibula (the smaller lower leg bone) on the outside of the foot.
As the disease progresses, the alignment of the foot may shift as the bones move out of their normal positions. This can result in a flatfoot deformity. Pain and discomfort may be felt along the posterior tibial tendon (main tendon that supports the arch) on the inside of the ankle, or on the outside of the ankle beneath the fibula.

Midfoot (Top of the Foot)

With RA, the ligaments that support the midfoot become weakened and the arch collapses. With loss of the arch, the foot commonly collapses and the front of the foot points outward. RA also damages the cartilage, causing arthritic pain that is present with or without shoes. Over time, the shape of the foot can change because the structures that support it degenerate. This can create a large bony prominence (bump) on the arch. All of these changes in the shape of the foot can make it very difficult to wear shoes.

Rheumatoid arthritis of the midfoot

This x-ray shows signs of RA of the midfoot. Note that the front of the foot points outward and there is a large bump on the inside and bottom of the foot.

Forefoot (Toes and Ball of the Foot)

The changes that occur to the front of the foot are unique to patients with RA. These problems include bunions, claw toes, and pain under the ball of the foot (metatarsalgia). Although, each individual deformity is common, it is the combination of deformities that compounds the problem.
The bunion is typically severe and the big toe commonly crosses over the second toe.

Illustration of bunion and claw toe

People with RA can experience a combination of common foot problems, such as bunions and clawtoe.

There can also be very painful bumps on the ball of the foot, creating calluses. The bumps develop when bones in the middle of the foot (midfoot) are pushed down from joint dislocations in the toes. The dislocations of the lesser toes (toes two through five) cause them to become very prominent on the top of the foot. This creates clawtoes and makes it very difficult to wear shoes. In severe situations, ulcers can form from the abnormal pressure.

Severe claw toes can become fixed and rigid. They do not move when in a shoe. The extra pressure from the top of the shoe can cause severe pain and can damage the skin.

Doctor Examination

Medical History and Physical Examination

After listening to your symptoms and discussing your general health and medical history, your doctor will examine your foot and ankle.
Skin. The location of callouses indicate areas of abnormal pressure on the foot. The most common location is on the ball of the foot (the underside of the forefoot). If the middle of the foot is involved, there may be a large prominence on the inside and bottom of the foot. This can cause callouses.
Foot shape. Your doctor will look for specific deformities, such as bunions, claw toes, and flat feet.
Flexibility. In the early stages of RA, the joints will typically still have movement. As arthritis progresses and there is a total loss of cartilage, the joints become very stiff. Whether there is motion within the joints will influence treatment options.
Tenderness to pressure. Although applying pressure to an already sensitive foot can be very uncomfortable, it is critical that your doctor identify the areas of the foot and ankle that are causing the pain. By applying gentle pressure at specific joints your doctor can determine which joints have symptoms and need treatment. The areas on the x-ray that look abnormal are not always the same ones that are causing the pain.

Imaging Tests

Other tests that your doctor may order to help confirm your diagnosis include:
X-rays. This test creates images of dense structures, like bone. It will show your doctor the position of the bones. The x-rays can be used by your doctor to make measurements of the alignment of the bones and joint spaces, which will help your doctor determine what surgery would best.
Computerized tomography (CT) scan. When the deformity is severe, the shape of the foot can be abnormal enough to make it difficult to determine which joints have been affected and the extent of the disease. CT scans allow your doctor to more closely examine each joint for the presence of arthritis.
Magnetic resonance imaging (MRI) scan. An MRI scan will show the soft tissues, including the ligaments and tendons. Your doctor can assess whether the tendon is inflamed (tendonitis) or torn (ruptured).

Rheumatology Referral

Your doctor may refer you to a rheumatologist if he or she suspects RA. Although your symptoms and the results from a physical examination and tests may be consistent with RA, a rheumatologist will be able to determine the specific diagnosis. There are other less common types of inflammatory arthritis that will be considered.

Nonsurgical Treatment

Although there is no cure for RA, there are many treatment options available to help people manage pain, stay active, and live fulfilling lives.
Rheumatoid arthritis is often treated by a team of healthcare professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons.
Although orthopaedic treatment may relieve symptoms, it will not stop the progression of the disease. Specific medicines called disease-modifying anti-rheumatic drugs are designed to stop the immune system from destroying the joints. The appropriate use of these medications is directed by a rheumatologist.
Orthopaedic treatment of RA depends on the location of the pain and the extent of cartilage damage. Many patients will have some symptom relief with appropriate nonsurgical treatment.

Rest

Limiting or stopping activities that make the pain worse is the first step in minimizing the pain. Biking, elliptical training machines, or swimming are exercise activities that allow patients to maintain their health without placing a large impact load on the foot.

Ice

Placing ice on the most painful area of the foot for 20 minutes is effective. This can be done 3 or 4 times a day. Ice application is best done right after you are done with a physical activity. Do not apply ice directly to your skin.

Nonsteroidal Anti-inflammatory Medication

Drugs, such as ibuprofen or naproxen, reduce pain and inflammation. In patients with RA, the use of these types of medications should be reviewed with your rheumatologist or medical doctor.

Orthotics

An orthotic (shoe insert) is a very effective tool to minimize the pressure from prominent bones in the foot. The orthotic will not be able to correct the shape of your foot. The primary goal is to minimize the pressure and decrease the pain and callous formation. This is more effective for deformity in the front and middle of the foot/
For people with RA, hard or rigid orthotics generally cause too much pressure on the bone prominences, creating more pain. A custom orthotic is generally made of softer material and relieves pressure on the foot.

Braces

A lace-up ankle brace can be an effective treatment for mild to moderate pain in the back of the foot and the ankle. The brace supports the joints of the back of the foot and ankle. In patients with a severe flatfoot or a very stiff arthritic ankle, a custom-molded plastic or leather brace is needed. The brace can be a very effective device for some patients, allowing them to avoid surgery.

Ankle brace

A custom-molded leather brace can be effective in minimizing the pain and discomfort from ankle and hindfoot arthritis.

Steroid Injection

An injection of cortisone into the affected joint can help in the early stages of the disease. In many cases, a rheumatologist or medical doctor may also perform these injections. The steroid helps to reduce inflammation within the joint. The steroid injection is normally a temporary measure and will not stop the progression of the disease.

Surgical Treatment

Your doctor may recommend surgery depending upon the extent of cartilage damage and your response to nonsurgical options.
Fusion. Fusion of the affected joints is the most common type of surgery performed for RA. Fusion takes the two bones that form a joint and fuses them together to make one bone.
During the surgery, the joints are exposed and the remaining cartilage is removed. The two bones are then held together with screws or a combination of screws and plates. This prevents the bones from moving.
Because the joint is no longer intact, this surgery does limit joint motion. Limited joint motion may not be felt by the patient, depending on the joints fused. The midfoot joints often do not have much motion to begin with, and fusing them does not create increased stiffness. The ankle joint normally does have a lot of motion, and fusing it will be noticeable to the patient. By limiting motion, fusion reduces the pain.
Fusion can be a successful technique. However, because patients with RA also show damaged cartilage and loose ligaments, the success rate of this type of surgery is lower in patients with RA than in patients without RA. The use of newer generation medication can slow the progression of the disease and impact the type of surgeries that can be performed successfully.
Other surgeries. The front of the foot is where there are more surgical options for some patients. Surgeons can now perform joint sparing operations to correct the bunion and hammertoes in some patients. Your surgeon will review the most appropriate options for your case.

Ankle

Ankle fusion and total ankle replacement are the two primary surgical options for treating RA of the ankle. Both treatment options can be successful in minimizing the pain and discomfort in the ankle. The appropriate surgery is based upon multiple factors and is individualized for every patient.

Ankle fusion and ankle replacement

This patient had arthritis of the hindfoot. It was treated by fusing all three joints of the hindfoot (triple fusion). An ankle replacement was also done in order to improve mobility and avoid the severe stiffness that would result from another ankle fusion. The ankle replacement implants can be seen here from the front and the side.

Patients with severe involvement of other joints around the heel or patients who have previously undergone a fusion on the other leg, may be more suited for ankle replacement. In addition, patients who have fusions within the same foot may be more suited for an ankle replacement.
Newer generation ankle replacement implants have shown promising early results. Ankle replacement implants have not yet been shown to be as long-lasting as those for the hip or knee, due to the fact that the newer generation of implants have not been available long enough to determine how long they will last.

Ankle fusion

These x-rays show an ankle fusion from the front and the side. The number and placement of screws and the use of a plate are dependent upon the surgeon’s technique.

Following ankle fusion, there is a loss of the up and down motion of the ankle. The up and down motion is transferred to the joints near the ankle. This creates a potential for pain in those joints, and possibly arthritis.
Patients are able to walk in shoes on flat, level ground without much difficulty after an ankle fusion, despite the loss of ankle motion. The joints in the foot next to the ankle joint allow for motion similar to the ankle joint, and help patients with fused ankle joints walk more normally.

Arthritis in subtalar joint

Over time, the increased stress that is placed on the rest of the foot after an ankle fusion can lead to arthritis of the joints surrounding the ankle. This patient had pain in the subtalar joint (arrow) and required an additional fusion of that joint to minimize the pain. Increased stress on other joints is the most concerning problem following ankle fusion.

Hindfoot (Heel Region of the Foot)

A fusion of the affected joints of the hindfoot is the most common surgery used to treat patients with flatfoot or arthritis of the hindfoot. A triple arthrodesis is a fusion that involves all three joints in the back of the foot. Occasionally, the joint on the outside of the foot is not fused if there is minimal to no involvement of that joint (this is at the surgeon’s discretion). This type of fusion eliminates the side-to-side motion of the foot, while preserving most of the up and down movement.
If RA is only in one joint, then a fusion of just that affected joint may be all that is needed.

Ankle fusion

(Left) In this x-ray, two of the three joints in the hindfoot have been fused. (Right) Just the subtalar joint is fused in this x-ray.

Any fusion of the hindfoot will limit side-to-side motion of the foot. This will affect walking on uneven ground, grass, or gravel. There is no method to replace the joints of the hindfoot.

Midfoot (Middle of the Foot)

Fusion is the most reliable surgical method to treat RA of the midfoot joints. If the shape of the foot is not normal, surgery is designed to help restore the arch and minimize the prominences on the foot.
There are joint replacement implants available for joints on the outside of the midfoot. This may preserve some midfoot motion. However, the use of these implants is at the surgeon’s discretion. These implants are not available for the joints on the inside of the midfoot.
Although the foot cannot be returned to a normal shape, the goals are to reduce pain in the foot and improve the potential for the patient to wear more normal shoes.

Reconstruction of collapsed arch

(Top) This x-ray shows RA of the midfoot that has collapsed the arch. (Bottom) The surgical reconstruction involved a fusion of the middle of the foot with plates and screws.

Forefoot (Toes and Ball of the Foot)

The choice of treatment for patients with a bunion or lesser toe deformities (hammer or claw toes) depends on a number of factors.
If the disease is very mild, joint-sparing procedures that preserve motion can be considered. The decision is dependent on the medication that the patient is taking and the amount of damaged cartilage that is present. A fusion of the great toe may be recommended despite that fact the bunion is very mild. If there is damage to the cartilage of the great toe joint, correcting the bunion will not minimize the arthritic pain.
If the RA has progressed and the lesser toes (two through five) have dislocated, a complex operation to minimize the pain and restore the shape of the foot may be recommended. The operation involves fusion of the big toe and removing a portion of bone of each of the metatarsals. This surgery removes the prominent bone on the bottom of the foot that is a source of the pain and allows the toes to re-align into a better position.
Occasionally, the lesser toe metatarsals can be preserved by shortening them to allow the toes to resume their position within the joints. This is not always possible, however, and the joint may have to be removed.

RA of the forefoot before and after fusion

(Left) RA of the forefoot. The big toe is deviated and crosses over the second toe, a typical appearance of a bunion. The lesser toes (two through five) are dislocated, resulting in painful and severe claw toes. (Right) This x-ray taken immediately after fusion of the big toe shows that the prominent bones on the ball of the foot were removed and the claw toes were corrected. The pins hold the toes in place while the soft tissues heal. The pins are removed in the office after 4 to 6 weeks with minimal discomfort.

To fix the bend in the toes themselves, the surgeon may suggest cutting a tendon or removing a small portion of bone of the toes to allow them to straighten. Pins that stick out of the foot are temporarily required and will be removed in the office after healing takes place.
There are some newer implants available that can be buried within the toes, which avoid the need for pins sticking out of the foot. These implants may not work if the bone is soft, or if significant destruction of the joints has occurred.
This operation puts a lot of stress on the blood vessels and skin of the foot. In severe cases, the toes may not survive the operation and may require amputation of a portion or the entire toe. This operation can provide the patient with a high level of function and the ability to enjoy a wider variety of shoewear.

Footwear

Reconstruction of the foot does not mean that a patient will be required to wear bulky and unappealing shoes every day. The patient shown here had both feet reconstructed. She is able to wear sandals and mild heels without difficulty. Although these types of shoes are not recommended all the time, they can be worn from time to time. Not all patients will achieve such an excellent result.

Preparing for Surgery

Many of the medications that help with RA also affect the ability of the body to heal wounds and fight infection. Your surgeon will work with your rheumatologist or medical doctor to review which of your medications will need to be stopped prior to surgery. Once the wounds are healed, the medication is typically resumed.
This period of time can be very difficult for patients with other areas of the body that are affected by RA. Many fusions require at least 6 weeks of time where no pressure can be placed on the foot. Making appropriate preparations to ensure you have help at home is crucial for success after surgery.


New Mexico Orthopaedics is a multi-disciplinary orthopedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.
New Mexico Orthopaedics offers a full spectrum of services related to orthopedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.
Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopedic condition, and offer related support services, such as physical therapy, WorkLink and much more.
If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Recovering from an ankle sprain

Article featured on Harvard Health Publishing
All it takes is a simple misstep, and suddenly you have a sprained ankle. An ankle sprain is one of the most common musculoskeletal injuries in people of all ages, athletes and couch potatoes alike. The injury occurs when one or more of the ligaments in the ankle are stretched or torn, causing pain, swelling, and difficulty walking. Many people try to tough out ankle injuries and don’t seek medical attention. But if an ankle sprain causes more than slight pain and swelling, it’s important to see a clinician. Without proper treatment and rehabilitation, a severely injured ankle may not heal well and could lose its range of motion and stability, resulting in recurrent sprains and more downtime in the future.

Anatomy of an ankle sprain

The most common type of ankle sprain is an inversion injury, or lateral ankle sprain. The foot rolls inward, damaging the ligaments of the outer ankle — the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament. (Ligaments are bands of fibrous tissue that connect bone to bone; see illustration.)

Ankle ligaments

ankle-ligaments

Less common are sprains affecting the ligaments of the inner ankle (medial ankle sprains) and syndesmotic sprains, which injure the tibiofibular ligaments — the ligaments that join the two leg bones (the tibia and the fibula) just above the ankle. Syndesmotic sprains, which occur most often in contact sports, are especially likely to cause chronic ankle instability and subsequent sprains.
The severity of an ankle sprain depends on how much damage it does and how unstable the joint becomes as a result. The more severe the sprain, the longer the recovery (see “Grades of ankle sprain severity”).

Grades of ankle sprain severity

SeverityDamage to ligamentsSymptomsRecovery time
Grade 1Minimal stretching, no tearingMild pain, swelling, and tenderness. Usually no bruising. No joint instability. No difficulty bearing weight.1–3 weeks
Grade 2Partial tearModerate pain, swelling, and tenderness. Possible bruising. Mild to moderate joint instability. Some loss of range of motion and function. Pain with weight bearing and walking.3–6 weeks
Grade 3Full tear or ruptureSevere pain, swelling, tenderness, and bruising. Considerable instability and loss of function and range of motion. Unable to bear weight or walk.Several months

Immediate ankle sprain treatment

The first goal is to decrease pain and swelling and protect the ligaments from further injury. This usually means adopting the classic RICE regimen — rest, ice, compression, and elevation. If you have severe pain and swelling, rest your ankle as much as possible for the first 24–48 hours. During that time, immerse your foot and ankle in cold water, or apply an ice pack (be sure to cover the ankle with a towel to protect the skin) for 15–20 minutes three to five times a day, or until the swelling starts to subside.
To reduce swelling, compress the ankle with an elasticized wrap, such as an ACE bandage or elastic ankle sleeve. When seated, elevate your ankle as high as you comfortably can — to the height of your hip, if possible. In the first 24 hours, avoid anything that might increase swelling, such as hot showers, hot packs, or heat rubs. Nonsteroidal anti-inflammatory drugs such as ibuprofen can help reduce pain and swelling and may also speed recovery.

Ankle sprain medical evaluation

Unless your symptoms are mild or improving soon after the injury, contact your clinician. He or she may want to see you immediately if your pain and swelling are severe, or if the ankle feels numb or won’t bear weight. He or she will examine the ankle and foot and may manipulate them in various ways to determine the type of sprain and the extent of injury. This examination may be delayed for a few days until swelling and pain improve; in the meantime, continue with the RICE regimen.
X-rays aren’t routinely used to evaluate ankle injuries. Ligament problems are the source of most ankle pain, and ligaments don’t show up on regular x-rays. To screen for fracture, clinicians use a set of rules — called the Ottawa ankle rules, after the Canadian team that developed them — to identify areas of the foot where pain, tenderness, and inability to bear weight suggest a fracture. A review of studies involving more than 15,000 patients concluded that the Ottawa rules identified patients with ankle fractures more than 95% of the time.

Ankle sprain functional treatment

To recover from an ankle sprain fully, you’ll need to restore the normal range of motion to your ankle joint and strengthen its ligaments and supporting muscles. Studies have shown that people return to their normal activities sooner when their treatment emphasizes restoring ankle function — often with the aid of splints, braces, taping, or elastic bandages — rather than immobilization (such as use of a plaster cast). Called functional treatment, this strategy usually involves three phases: the RICE regimen in the first 24 hours to reduce pain, swelling, and risk of further injury; range-of-motion and strengthening exercises within 48–72 hours; and training to improve endurance and balance once recovery is well under way.
Generally, you can begin range-of-motion and stretching exercises within the first 48 hours, and should continue until you’re as free of pain as you were before your sprain. Start to exercise seated on a chair or on the floor. As your sprained ankle improves, you can progress to standing exercises. If your symptoms aren’t better in two to four weeks, you may need to see a physical therapist or other specialist.

Exercises to help restore function and prevent injury

Range-of-motion, stretching, and strengthening: First 1–2 weeks

flexes
Flexes. Rest the heel of the injured foot on the floor. Pull your toes and foot toward your body as far as possible. Release. Then point them away from the body as far as possible. Release. Repeat as often as possible in the first week.
ankle-alphabet
Ankle alphabet. With the heel on the floor, write all the capital letters of the alphabet with your big toe, making the letters as large as you can.
press-down-pull-back
Press down, pull back. Loop an elasticized band or tubing around the foot, holding it gently taut (A). Press your toes away and down. Hold for a few seconds. Repeat 30 times. Tie one end of the band to a table or chair leg (B). Loop the other end around your foot. Slowly pull the foot toward you. Hold for a few seconds. Repeat 30 times.
ankle-eversion
Ankle eversion. Seated on the floor, with an elasticized band or tubing tied around the injured foot and anchored around your uninjured foot, slowly turn the injured foot outward. Repeat 30 times.
ankle-inversion
Ankle inversion. Seated on the floor, cross your legs with your injured foot underneath. With an elasticized band or tubing around the injured foot and anchored around your uninjured foot, slowly turn the injured foot inward. Repeat 30 times.

Stretching and strengthening: Weeks 3–4

standing-stretch
Standing stretch. Stand one arm’s length from the wall. Place the injured foot behind the other foot, toes facing forward. Keep your heels down and the back knee straight. Slowly bend the front knee until you feel the calf stretch in the back leg. Hold for 15–20 seconds. Repeat 3–5 times.
seated-stretch
Seated stretch. Loop an elasticized band or tubing around the ball of the foot. Keeping the knee straight, slowly pull back on the band until you feel the upper calf stretch. Hold for 15 seconds. Repeat 15–20 times.
rises
Rises. Stand facing a wall with your hands on the wall for balance. Rise up on your toes. Hold for 1 second, then lower yourself slowly to the starting position. Repeat 20–30 times. As you become stronger, do this exercise keeping your weight on just the injured side as you lower yourself down.
stretches
Stretches. Stand with your toes and the ball of the affected foot on a book or the edge of a stair. Your heel should be off the ground. Use a wall, chair, or rail for balance. Hold your other foot off the ground behind you, with knee slightly bent. Slowly lower the heel. Hold the position for 1 second. Return to the starting position. Repeat up to 15 times, several times a day. This exercise can place a lot of stress on the ankle, so get your clinician’s go-ahead before trying it.

 


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.
New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.
Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.
If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Treating Ankle Injuries

Article featured on UCSF Health

Ankle sprains are the most common ankle injury among regular athletes and weekend warriors. The top orthopedic complaint, sprains occur in an estimated 27,000 Americans a day.
Many athletes, however, who suffer from ankle sprains tend to play right through their injury, which can lead to lifelong problems with recurring sprains, unstable joints, arthritis-like pain or other complications like tendon or cartilage damage. And the earlier in life a sprain occurs, the higher the chance of recurrence. Therefore, it’s important to properly treat initial sprains, especially in young athletes.
If you sprain your ankle and it hurts to run, you should sit out the rest of the game. Once a sprain has occurred, follow these three steps to help you recover:

Step 1: RICE

Follow the instructions represented by the acronym RICE as often as possible for three days. RICE stands for rest, ice, compression (with an elastic ankle wrap) and elevation (toes above the nose). For significantly swollen ankles or if limping persists for more than three days, you should see a doctor.

Step 2: Rehabilitation

To prevent permanent damage to the ankle, take steps to achieve better range of motion (flexibility), balance and strength. Many of these exercises can be done at home.

Range of motion exercise

Place one foot on a stairway step. Allow the back heel to stretch downward over the edge of the step. Hold each foot in this position for 30 seconds.

Balance restoration exercise

Stand on one leg with your eyes closed. Gradually build up to standing 30 seconds on each leg. Repeat three times.

Strength exercise

Lie on your side on the sofa, with the upper leg hanging over the edge. Place the top of your foot through the handles of a plastic shopping bag filled with one to two pounds of weight (one or two cans of soup). Slowly lift your toes toward the ceiling and hold for three seconds. Repeat 10 times.

Step 3: Supportive devices

When back to playing sports, previously injured athletes should probably wear an ankle brace, no matter how much they have rehabilitated their ankle or how good their sneakers. An injured ankle will never have the same support again, so a brace should be considered.

Step 4: If pain continues

For ankle pain and significant instability that persists despite adequate rehabilitation or physical therapy, you should see a doctor for further evaluation. You may have injured the cartilage or tendons in your ankle, which may require special testing.

UCSF Health medical specialists have reviewed this information. It is for educational purposes only and is not intended to replace the advice of your doctor or other health care provider. We encourage you to discuss any questions or concerns you may have with your provider.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.
New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.
Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.
If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Everything You Should Know About Repetitive Strain Injury

Everything You Should Know About Repetitive Strain Injury (RSI)

Article Featured on Healthline.com

What is repetitive strain injury?

A repetitive strain injury (RSI), sometimes referred to as repetitive stress injury, is a gradual buildup of damage to muscles, tendons, and nerves from repetitive motions. RSIs are common and may be caused by many different types of activities, including:

  • using a computer mouse
  • typing
  • swiping items at a supermarket checkout
  • grasping tools
  • working on an assembly line
  • training for sports

Some common RSIs are:

Keep reading to learn more about this type of injury.

What are the symptoms of RSI?

RSI frequently affects your:

  • wrists and hands
  • forearms and elbows
  • neck and shoulders

Other areas of your body can also be affected.

Symptoms include:

  • pain, ranging from mild to severe
  • tenderness
  • swelling
  • stiffness
  • tingling or numbness
  • throbbing
  • weakness
  • sensitivity to cold or heat

Symptoms may begin gradually and then become constant and more intense. Even with initial treatment, symptoms may limit your ability to perform your usual activities.

What are causes and risk factors for RSI?

RSI can occur when you do repetitive movements. Those movements can cause your muscles and tendons to become damaged over time.

Some activities that can increase your risk for RSI are:

  • stressing the same muscles through repetition
  • maintaining the same posture for long periods of time
  • maintaining an abnormal posture for an extended period of time, such as holding your arms over your head
  • lifting heavy objects
  • being in poor physical condition or not exercising enough

Previous injuries or conditions, such as a rotator cuff tear or an injury to your wrist, back, or shoulder, can also predispose you to RSI.

Desk jobs are not the only occupations whose workers are at risk for RSI. Other occupations that involve repetitive movements and may increase your risk include:

  • dental hygienists
  • construction workers who use power tools
  • cleaners
  • cooks
  • bus drivers
  • musicians

How is RSI diagnosed?

If you have even mild discomfort completing certain tasks on your job or at home, it’s a good idea to see your doctor to talk about RSI. Your doctor will ask you questions about your work and other activities to try to identify any repetitive movements you do. They’ll also ask about your work environment, such as whether you work at a computer or have an ergonomic work station. They’ll do a physical exam as well. During the exam, they’ll perform range of motion tests and check for tenderness, inflammation, reflexes, and strength in the affected area.

Your doctor may also order magnetic resonance imaging (MRI) or ultrasound to assess tissue damage. An electromyography (EMG) may be ordered to check on nerve damage.

For mild damage, your doctor may refer you to a physical therapist. If the damage is severe, they may also refer you to a specialist or surgeon.

How is RSI treated?

The initial treatment for RSI symptoms is conservative. This may include:

  • RICE, which stands for rest, ice, compression, and elevation
  • nonsteroidal anti-inflammatory drugs (NSAIDs), both oral and topical
  • steroid injections
  • exercises, which may be prescribed as part of a physical therapy treatment plan
  • stress reduction and relaxation training
  • wrapping the area or securing it with a splint to protect and rest the muscles and tendons

Your doctor and physical therapist can also suggest adjustments to your work station, such as readjusting your chair and desk if you work at a computer, or modifications to your movements and equipment to minimize muscle strain and stress.

In some cases, surgery may be necessary.

What’s the outlook for RSI?

Your outlook with RSI depends on the severity of your symptoms and your general health. You may be able to use conservative measures to modify your work routine and minimize pain and damage. Or, you may have to stop certain tasks at work for a while to rest the affected area. If other measures don’t work, your doctor may recommend surgery for specific problems involving nerves and tendons.

Tips for preventing RSI

If you sit at a desk, follow the traditional advice from parents and teachers: Sit up straight and don’t slouch! Good posture is the key to avoiding unnecessary stress on your muscles. This takes practice and mindfulness. There are also many exercises you can do to improve your posture.

  • Adjust your work station to promote good posture and comfort.
  • Sit in a chair that gives you support for your lower back and keep your feet flat on the floor or on a foot rest. Your thighs should be parallel to the ground, and your hands, wrists, and forearms should be aligned. Your elbows should be in line with your keyboard to avoid strain.
  • Avoid sitting cross-legged.
  • If possible, spend some of your computer time at a standing desk. Slowly increase the amount of time you stand, aiming for 20–30 minutes each hour or more.
  • Place your computer monitor about an arm’s length away from you. The screen should be at eye level so you’re looking straight ahead.
  • If you’re on the phone a lot, use a headset to avoid straining your neck, shoulders, and arms.

Taking frequent breaks from your desk throughout the day is as important as having an ergonomic workstation.

  • get up to stretch or walk around
  • do shoulder stretches at your desk
  • march in place
  • wiggle your fingers and flex your wrists

Those may sound like little things, but mini breaks can make a big difference in preventing RSI.

If your work is not at a desk, the same principles apply. Maintain good posture, figure out the least stressful positions for the repetitive tasks required, and take frequent mini breaks. If you have to stand a lot, use an antifatigue mat. Use extension poles for cleaning tools to avoid straining your arms, and lift heavy loads properly. If you use tools, take breaks throughout the day to stretch and flex your fingers and wrists.

Most occupations have been studied in detail and have guidelines for reducing worker stress while doing specific tasks. The National Education Association, for example, has a handbook on RSI that provides tips for teachers, drivers, food workers, custodians, and others.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Causes of foot pain all runners need to know

Causes of foot pain all runners need to know

Article Featured on OSMS

A total ankle replacement, also called total ankle arthroplasty, is a surgical treatment option for patients suffering from ankle pain, typically due to arthritis or injury. If this pain is impacting a patient’s quality of life or keeping them from walking comfortably, they might benefit from a total ankle arthroplasty. While lesser known than a total hip, knee or shoulder replacement, total ankle replacements are gaining popularity.

Read more

Tips for Preventing Foot and Ankle Injuries

Tips for Preventing Foot and Ankle Injuries

Article Featured on UCFS Health

Foot and ankle injuries are common in sports, especially running, tennis and soccer. But sports enthusiasts can decrease the risk of injury by taking some precautions.

Warm up prior to any sports activity

Lightly stretch or better yet, do a slow jog for two to three minutes to warm up the muscles. Don’t force the stretch with a “bouncing motion.”

Condition your muscles for the sport

The amount of time spent on the activity should be increased gradually over a period of weeks to build both muscle strength and mobility. Cross training by participating in different activities can help build the muscles.

Choose athletic shoes specifically for your foot type

People whose feet pronate or who have low arches should choose shoes that provide support in both the front of the shoe and under the arch. The heel and heel counter (back of the shoe) should be very stable. Those with a stiffer foot or high arches should choose shoes with more cushion and a softer platform. Use sport-specific shoes. Cross training shoes are an overall good choice; however, it is best to use shoes designed for the sport.

Replace athletic shoes when the tread wears out or the heels wear down

People who run regularly should replace shoes every six months, more frequently if an avid runner.

Avoid running or stepping on uneven surfaces

Try to be careful on rocky terrain or hills with loose gravel. Holes, tree stumps and roots are problems if you are trail running. If you have problems with the lower legs, a dirt road is softer than asphalt, which is softer than concrete. Try to pick a good surface if possible. However, if you’re racing, be sure to train on the surface you’ll eventually run on.

Be careful running too many hills

Running uphill is a great workout, but make sure you gradually build this up to avoid injuries. Be careful when running downhill too fast, which can often lead to more injuries than running uphills!

Prevent recurrent injuries

Athletes who have experienced ankle injuries previously may benefit from using a brace or tape to prevent recurrent ankle injuries.

Listen to your body

If you experience foot and ankle pain during a sport, stop the activity or modify the activity until the pain subsides. Also, if you have been injured, you should go through a period of rehabilitation and training before returning to the sport to prevent recurrent injuries.

Running and Tennis Injuries

Running and tennis injuries include ankle sprains, Achilles tendonitis and plantar fasciitis. Ankle sprains, a partial or complete tear of any of the ligaments responsible for supporting and stabilizing the ankle joint, usually result from landing on an uneven surface and having the foot turn awkwardly.

Injury to the Achilles tendon, the strongest and largest tendon that connects the back of the calf muscle to the heel bone, occurs from overuse and is usually an acute inflammation or a partial tear. If the tendon is weak, it can rupture with the right force.

It is also common for the plantar fascia, the tough tissue that maintains the arch of the foot and runs from the heel to the toes, to become inflamed, resulting in heel or arch pain.

Runners also may experience injury to the tendons or ligaments located on the outside and inside of the ankle and stress fractures of the foot bones. In running, any one incident may not be enough to fracture the foot; however, over time, repetition of abnormal forces or stress can cause the bone to weaken or break. Five to 15 percent of all running injuries are stress fractures. Of those injuries, 49 percent occurred in those who ran between 25 miles to 44 miles per week.

Soccer Injuries

Unlike foot and ankle injuries in tennis and running, which are usually overuse injuries, soccer injuries often result from trauma such as a direct blow to the lower leg. Because soccer is a contact sport, collision injuries from striking another player are common, accounting for 30 percent of all soccer injuries.

Ankle injuries in soccer account for 20 to 30 percent of all soccer injuries—the most common being ankle sprains. Soccer players also may experience turf toe, a sprain that results from stubbing the toe while running or improperly planting one’s cleats.

Treatment

Treatment for these injuries varies depending on the severity of the injury. Most strains and sprains can be treated with rest, ice, compression and elevation (RICE). Moderate to severe cases, however, may require some form of immobilization such as a brace or a cast. Certain injuries that don’t heal within the expected time frame may require surgery.

It is important to seek medical attention as soon as possible for foot and ankle injuries, especially if it is causing you to limp or there is swelling. Prompt and appropriate treatment and rehabilitation ensures the best possible recovery.

Broken Ankle (Fracture) Facts

Article Featured on eMedicineHealth

What Is a Broken Ankle?

Ankle injuries are among the most common of the bone and joint injuries. Often, the degree of pain, the inability to walk, or concern that a bone may be broken is what usually causes people to seek care for an ankle injury. The main concern is whether there is a broken bone vs. an ankle sprain. Frequently it is difficult to distinguish a fracture (broken bone) over a sprain, dislocation, or tendon injury without X-rays of the ankle.

  • The ankle joint is made up of three bones that fit anatomically (articulate) together, the tibia, fibula, and talus (some medical experts also include the calcaneus bone and label the joint as the subtalar joint and consider it part of the ankle):
    • The tibia, the main bone of the lower leg, makes up the medial, or inside, ankle bone.
    • The fibula is a smaller bone that parallels the tibia in the lower leg and makes up the lateral, or outside, ankle bone.
    • The far ends of both the tibia and fibula are known as the malleoli (singular is malleolus). These malleoli are the lumps of bone that you can see and feel on the inside and outside of the ankle. Together they form an arch or mortise (a recess) that sits on top of the talus, one of the bones in the foot.
  • A fibrous membrane called the joint capsule, lined with a smoother layer called the synovium, encases the joint architecture. The joint capsule contains the synovial fluid produced by the synovium. The synovial fluid allows for smooth movement of the joint surfaces.
  • The ankle joint is stabilized by several groups of ligaments, which are fibers that hold these bones in place. They are the capsule ligament, deltoid ligament, the anterior and posterior talofibular ligaments, and the calcaneofibular ligament. Some of these ligaments may be disrupted if the ankle is fractured.

What Are the Signs and Symptoms of a Broken Ankle?

Signs and symptoms of ankle injuries and ankle fractures tend to be obvious.

  • Pain is the most common complaint.
    • Sometimes the pain will not come from the exact area of the fracture.
    • The person may experience associated foot fractures (especially on the side of the small toe) or knee that also cause pain similar to ankle pain.
    • It is usually pain in the ankle that stops individuals from walking.
  • Swelling frequently occurs around the ankle.
    • Swelling suggests either soft tissue damage with possible blood around the joint (hemarthrosis) or fluid within the joint itself, most likely blood.
  • A person may see bruising around the ankle joint, although not immediately. The bruising can track down toward the sole of the foot or toward the toes.
  • In severe fractures, there may be obvious deformities of bones around the ankle.
    • Skin may be stretched over an underlying broken bone.
    • Bone may be exposed.
  • If the ankle joint is dislocated, the foot and leg bones will be misaligned and will appear deformed.
  • If people injure nerves or blood vessels that supply the foot, there may be more pain along with pale skin in the foot, numbness, or an inability to move the foot or toes.

What Is the Difference Between Ankle Sprains and a Broken Ankle?

The difference between a broken ankle and a sprained ankle is that a fracture or break in the bone is necessary to have a broken ankle. Any crack, break, or chip in the anklebone is considered a fractured ankle. A sprained ankle is an injury where there is tear or disruption of the ligaments (the fibrous tissue that holds bone to bone in a joint). A severe injury to the ankle can consist of both a fracture and a sprain at the same time. Depending on the type and severity of the fracture or the sprain, the prognosis of a sprain may actually be worse than a fracture.

What Causes a Broken Ankle?

When a person stresses the ankle joint beyond the strength of its elements, the joint becomes injured.

  • If only the ligaments give way and tear, the damage is a sprained ankle.
  • If the ligaments that stabilize the joint are completely disrupted, the bones can come apart and the ankle can become dislocated.
  • If a bone gives way and breaks, the damage is an ankle fracture.
  • Fractured ankles can occur with simultaneous tears of the ligaments. This can happen in several ways:
    • Rolling the ankle in or out
    • Twisting the ankle side to side
    • Extreme flexing or extending of the joint
    • Severe force applied to the joint by coming straight down on it as in jumping from a high level

What Are the Types of Ankle Fractures?

The type of ankle fracture classification depends upon the location of the fracture and which bones of the ankle are fractured. There can be one bone injured, or multiple bones injured. The type and severity of the fracture will determine the treatment by the orthopedic surgeon; a classification list is as follows:

Lateral Malleolus Fracture

  • The lateral malleolus is the bump on the outer part of the ankle and is made up of the fibula bone.

Medial Malleolus Fracture

  • The medial malleolus is the bump on the inside of the ankle and is made up of the tibia bone.

Posterior Malleolus Fracture

  • The posterior malleolus is the bony prominence on the back side of the tibia, and is rarely injured on its own.

Bimalleolar Fractures

  • “Bi” means two, so two bones of the ankle are fractured with a bimalleolar fracture.
  • Most commonly the lateral malleolus and the medial malleolus are the bones that are fractured.
  • Bimalleolar fractures often make the ankle joint unstable.

Trimalleolar Fractures

  • “Tri” means three so in a trimalleolar fracture, all three malleoli (medial, lateral, and posterior) bones of the ankle are broken.
  • These are unstable injuries often caused by a large amount of force, disruption of the ligaments, or a dislocation.

Syndesmotic Injury

  • Also called “high ankle sprains.”
  • Usually a result of ankle eversion (outward twisting of the ankle joint).
  • May or may not be associated with an actual fracture of the bones of the ankle, but is often treated as a fracture.
  • May involve fracture of the fibula (outer bone in the lower leg) higher up in the calf near the knee (proximal) in severe ankle sprains, also called a Maisonneuve fracture.

There are other names for ankle injuries; however, most will fit into the general types listed above.

Which Type of Doctor Treats a Broken Ankle?

A broken ankle may be diagnosed by a general practitioner (family doctor, internist, pediatrician), or an emergency medicine doctor in a hospital. The patient may be referred to a podiatrist (foot specialist) or an orthopedic surgeon for the care and further treatment of the broken ankle depending on the severity of the injury or the need for possible surgery.

When Should You Call a Doctor If You Think That You Have A Broken Foot?

If a person has injured an ankle, contact a doctor or go to an emergency department. Seek medical treatment for an ankle injury in the following situations.

  • The person cannot bear weight on the ankle.
  • The pain remains intolerable despite using over-the-counter pain medications.
  • Home care fails to reduce the pain.
  • The foot or ankle becomes numb, partially numb, or pale.
  • A gross deformity of the ankle bones is present (this may indicate an ankle dislocation)
  • Open wound or bleeding over the injured area
  • Bones or bone fragments visible outside the ankle skin
  • Inability to move the toes
  • Inability to move the ankle
  • Cold or blue foot

How Is a Broken Ankle Diagnosed?

A doctor will evaluate the ankle to determine if there is an ankle fracture or if the joint has been damaged sufficiently to become unstable. Joint instability often suggests multiple fractures, a fracture with a ligament injury, ligament injury alone, or dislocation.

The doctor will seek a history of the injury and will ask questions to determine the possible fracture patterns.

  • Where does it hurt now?
  • How long ago did the injury happen?
  • Does the knee, shin, or foot hurt also?
  • How did the injury happen?
  • Did the ankle turn in or out?
  • Did the person hear a crack or a pop?
  • Was the person able to walk immediately after the injury?
  • Can the person walk now?
  • Does the person have any new numbness or tingling in their leg, ankle, or foot?
  • Has the person had previous ankle fractures, sprains, or surgeries on the injured ankle?

The doctor will perform a physical exam, looking for:

  • Evidence of bruising, abrasions, or cuts
  • Swelling, bleeding, and tissue damage
  • Pain, deformities, and the grinding or movement of broken bones of the knee, shin, ankle, and foot
  • Pain, excess looseness of a joint, or complete tear in ligaments
  • Fluid in the joint and joint stability
  • Seeking a pulse and looking for injured arteries
  • Testing sensation and movement in both the ankle and foot
  • Ankle X-rays if a broken bone is suspected; some doctors may try to avoid unnecessary and costly X-rays by following certain guidelines such as the Ottawa ankle rules (see reference 2)
  • X-rays of the knee, shin, or foot depending on where pain is; children may get a comparison X-ray of the uninjured ankle to see subtle changes in growth plates due to injury.

What Home Remedies and First Aid Methods Treat a Broken Foot at Home?

If a person suspects an ankle fracture, call a doctor or go to a hospital’s emergency department immediately. Until a person can get to a hospital or doctor’s office they may try the following:

  • Stay off the injured ankle to not to injure it further.
  • Keep the ankle elevated to help decrease swelling and pain.
  • Apply cold packs to the injured area to decrease swelling and pain. Do not apply ice directly. Cold packs are effective for the first 24 to 48 hours.
  • Ibuprofen (Advil, Motrin, etc.) is ideal for ankle injuries because it acts as both a pain medicine and a medicine to decrease inflammation.

What Is the Treatment for a Broken Ankle?

  • Doctors usually place a splint on the injured ankle for a few days to 2 weeks until the swelling decreases around the joint. The type of fracture and the stability of the fractured joint will determine the type of splint (cast or walking boot) that will be used, or whether surgery is needed.
  • Some minor ankle fractures do not require a splint or cast. In these cases the fracture will be managed as an ankle sprain.
    • Because these fractures are very small, they heal well with this management.
    • With any injured ankle, however, a person should not bear weight until advised to do so by a doctor or orthopedist.
  • After the swelling decreases and the patient is reexamined, an orthopedic doctor or a primary care doctor may place a better-fitting cast on the ankle. Depending on the type of fracture, the patient may be placed in a walking cast, which can bear some weight, or the patient may need a non-weight-bearing cast that will require the use of crutches to assist with walking.
  • Depending on the degree of pain, the doctor may prescribe pain medication. The patient should use the pain medication only as needed. Do not drive or operate heavy machinery while using these medications.

When Is Surgery Necessary for a Broken Foot?

Fractures that are severely displaced or may involve a dislocation will need to be realigned (reduced) in the emergency department. If the realignment is incomplete or if the underlying injury is severe, surgery is usually needed. If the fracture breaks through the skin (compound fracture), it will usually require surgery to clean the area thoroughly and limit the chance of infection.

Do You Need to Follow-Up with Your Doctor After the Ankle Has Been Treated?

Follow-up care for an ankle fracture depends on the severity of the fracture. Consultation with an orthopedist is recommended for most fractures. In some instances, a surgeon may need to be consulted, especially if there is any vascular compromise or deformity due to the fracture.

  • The patient may need emergency surgery, next-day follow-up, or follow-up in 1-2 weeks with an orthopedic doctor.
  • The patient may require follow-up with a family doctor.
    • If the patient’s injured ankle was splinted on the initial visit, he or she will probably need to have a cast placed on the ankle during the follow-up visit.
    • Recovery time varies depending upon the type of fracture or need for surgery. The average fracture requires 4-8 weeks for the bone to heal.
    • With severe ankle injuries, the doctor may recommend physical therapy for rehabilitation after the acute phase of healing.

What Is the Recovery Time for a Broken Ankle?

Most simple fractures heal well with immobilization and non-weight-bearing activity. Complex fractures may have good to fair outcomes, depending on the severity of the fracture(s), the effect of rehabilitation on function and the development of arthritis.

  • Patients can expect recovery from most ankle fractures, depending on how severe they are, to take 4-8 weeks for the bones to heal completely and up to several months to regain full use and range of motion of the joint.
  • More severe fractures, especially those requiring surgical repair, will take longer to heal; some may need implanted supports (metal rod or plate and screws) that may be removed later or left in place.
  • Fractures of any type increase the likelihood of developing arthritis in the affected joint. The more severe the fracture, the higher the risk of developing some degree of arthritis.

How Can a Broken Ankle Be Prevented?

Preventing ankle fractures can be difficult.

  • Many occur as “slip and fall” incidents. Being careful in activities is the best prevention.
  • Proper footwear when participating in sports also may reduce ankle fracture risk.
  • Splints, braces, or taping of a previously injured ankle may decrease the possibility of further injury or fracture.
  • Maintenance of strength of the muscles that stabilize ankle is an important part of prevention of ankle injuries.

 


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Do you need bunion surgery

Do you need bunion surgery?

Article Featured on AAOS

Most people with bunions find pain relief with simple treatments to reduce pressure on the big toe, such as wearing wider shoes or using pads in their shoes. However, if these measures do not relieve your symptoms, your doctor may recommend bunion surgery.

There are different types of surgeries to correct a bunion. Bringing the big toe back to its correct position may involve realigning bone, ligaments, tendons, and nerves.

Are You a Candidate for Surgery?

In general, if your bunion is not painful, you do not need surgery. Although bunions often get bigger over time, doctors do not recommend surgery to prevent bunions from worsening. Many people can slow the progression of a bunion with proper shoes and other preventive care, and the bunion never causes pain or other problems.

It is also important to note that bunion surgery should not be done for cosmetic reasons. After surgery, it is possible for ongoing pain to develop in the affected toe — even though there was no bunion pain prior to surgery.

Good candidates for bunion surgery commonly have:

  • Significant foot pain that limits their everyday activities, including walking and wearing reasonable shoes. They may find it hard to walk more than a few blocks (even in athletic shoes) without significant pain.
  • Chronic big toe inflammation and swelling that does not improve with rest or medications
  • Toe deformity—a drifting in of the big toe toward the smaller toes, creating the potential for the toes to cross over each other.

Photo and x-ray of foot deformed by a bunion

(Left) A bunion that has progressed to deformity with the big toe crossing over the second toe. (Right) An x-ray of the same bunion shows how far out of alignment the bones are.

Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

  • Toe stiffness—the inability to bend and straighten the big toe
  • Failure to obtain pain relief with changes in footwear
  • Failure to obtain pain relief from nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. The effectiveness of NSAIDs in controlling toe pain varies greatly from person to person.

Deciding to Have Bunion Surgery

After bunion surgery, most patients have less foot pain and are better able to participate in everyday activities.

As you explore bunion surgery be aware that so-called “simple” or “minimal” surgical procedures are often inadequate “quick fixes” that can do more harm than good. Although many bunion procedures are done on a same-day basis with no hospital stay, a long recovery period is common. It often takes up to 6 months for full recovery, with follow-up visits to your doctor sometimes necessary for up to a year.

It is very important to have realistic expectations about bunion surgery. For example, bunion surgery may not allow you to wear a smaller shoe size or narrow, pointed shoes. In fact, you may need to restrict the types of shoes you wear for the rest of your life.

As you consider bunion surgery, do not hesitate to ask your doctor questions about the operation and your recovery. Some examples of helpful questions to ask include:

  • What are the benefits and risks of this surgery?
  • What are the possible complications and how likely are they to occur?
  • How much pain will there be and how will it be managed?

Be sure to write down your doctor’s answers so you can remember them at a later time. It is important to understand both the potential benefits and limitations of bunion surgery.

Surgical Procedures

In general, the common goals of most bunion surgeries include:

  • Realigning the metatarsophalangeal (MTP) joint at the base of the big toe
  • Relieving pain
  • Correcting the deformity of the bones making up the toe and foot

Because bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, bunion surgery includes correcting the alignment of the bone and repairing the soft tissues around the big toe.

Your doctor will talk with you about the type of surgery that will best correct your bunion.

Repairing the Tendons and Ligaments Around the Big Toe

In some cases, the soft tissues around the big toe may be too tight on one side and too loose on the other. This creates an imbalance that causes the big toe to drift toward the other toes.

Surgery can shorten the loose tissues and lengthen the tight ones. This is rarely done without some type of alignment of the bone, called an osteotomy. In the majority of cases, soft tissue correction is just one portion of the entire bunion corrective procedure.

Osteotomy

In an osteotomy, your doctor makes small cuts in the bones to realign the joint. After cutting the bone, your doctor fixes this new break with pins, screws, or plates. The bones are now straighter, and the joint is balanced.

Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.

As discussed above, osteotomies are normally performed in combination with soft tissue procedures, as both are often necessary to maintain the big toe alignment.

Foot x-rays showing a bunion corrected with osteotomy

X-rays taken from the top and the side of the foot show a bunion corrected with osteotomy.

Arthrodesis

In this procedure, your doctor removes the arthritic joint surfaces, then inserts screws, wires, or plates to hold the surfaces together until the bones heal. Arthrodesis is commonly used for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery.

X-rays of an arthritic foot before and after arthrodesis

The x-ray on the left shows severe arthritis of the MTP joint. After arthrodesis (shown on the right), the entire foot is realigned. An advantage of arthrodesis is that no additional procedures are necessary to correct the bunion.

Exostectomy

In this procedure, your doctor removes the bump from your toe joint. Exostectomy alone is seldom used to treat bunions because it does not realign the joint. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion.

Exostectomy is most often performed as one part of an entire corrective surgery that includes osteotomy, as well as soft-tissue procedures. If a doctor performs exostectomy without osteotomy, however, the bunion deformity often returns.

X-rays of a bunion before and after exostectomy

The x-ray on the left shows a mild bunion bump before exostectomy. After the procedure (right), the bump has been shaved but the toe deformity remains and is actually worse; the big toe drifts closer to the other toes and the metatarsal bone sticks out further.

Resection Arthroplasty

In this procedure, your doctor removes the damaged portion of the joint. This increases the space between the bones and creates a flexible “scar” joint. Resection arthroplasty is used mainly for patients who are elderly, have had previous unsuccessful bunion surgery, or have severe arthritis not amenable to an arthrodesis (see above). Because this procedure can change the push off power of the big toe, it is not often recommended.

X-ray of a failed resection arthroplasty and photo of a shortened big toe

This x-ray shows a failed resection arthroplasty. Although the damaged bone of the MTP joint was removed, scar tissue did not fill the space between the bones. The bone edges are still in contact. The photograph shows that without the needed scar tissue, the big toe is shortened. This makes it more difficult to push off while walking.

Preparing for Surgery

Medical Evaluation

Before your surgery, you may be asked to visit your family doctor for a complete physical examination. He or she will assess your health and identify any problems that could interfere with your surgery. If you have a heart or lung condition or a chronic illness you will need a preoperative medical clearance from your family doctor.

Medications

Tell your doctor about any medications you are taking. He or she will tell you which medications you can continue taking and which you should stop taking before surgery.

Tests

You may require several preoperative tests, including blood counts, a cardiogram, and a chest x-ray. You may also need to provide a urine sample.

To help plan your procedure, your doctor may order special foot x-rays. These x-rays should be taken in a standing, weight bearing position to ensure your doctor can clearly see the deformity in the foot. These x-rays assist your doctor in making decisions about where along the bone to perform an osteotomy in order to provide enough corrective power to straighten the toe.

Your Surgery

In planning your surgery, your doctor will consider several things, including how severe your bunion is, your age, your general health and activity level, and any other medical issues that may affect your recovery.

Almost all bunion surgery is done on an outpatient basis. You will most likely be asked to arrive at the hospital or surgical center 1 or 2 hours before your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. Most bunion surgery is performed with anesthesia that numbs the area for surgery but does not put you to sleep.

  • Local anesthesia. An ankle block numbs just your foot.
  • Regional anesthesia. A popliteal block works for a longer period of time compared to an ankle block and numbs more of the leg. The numbing medicine is injected behind the knee.
  • Spinal anesthesia. This injection will numb your body below your waist.
  • General anesthesia. This form of anesthesia will put you to sleep.

The anesthesiologist will stay with you throughout the procedure to administer other medications, if necessary, and to make sure you are comfortable.

Procedure

Depending upon your bunion and the procedures you need, your doctor will make an incision along the inside of your big toe joint or on top of the joint. In some cases, more than one incision is needed to correct the bunion deformity.

Surgical photo of an osteotomy

This surgical photograph shows a saw cutting the bone to perform an osteotomy.

The surgical time varies depending on how much of your foot is malaligned. Surgery will take longer if your deformity is greater or if more than one osteotomy is required. Every bunion correction is a little bit different, and there is no reason to be concerned if your surgery takes more time.

Afterward, you will be moved to the recovery room. You will be ready to go home in an hour or two. Be sure to have someone with you to drive you home.

Photo and x-ray of a foot after osteotomy for a bunion

(Left) The bunion that was shown at the beginning of this article as it appeared immediately after surgery. (Right) An x-ray showing the bones in alignment after surgery. Osteotomies were performed on both bones; screws and plates hold the bones in place. Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

Complications

As with any surgical procedure, there are risks associated with bunion surgery. These occur infrequently and are usually treatable — although, in some cases, they may limit or extend your full recovery. Before your surgery, your doctor will discuss each of the risks with you and take specific measures to avoid complications.

The possible risks and complications of bunion surgery include:

  • Infection
  • Nerve injury
  • Failure to relieve pain
  • Failure of the bone to fully heal
  • Stiffness of the big toe joint
  • Recurrence of the bunion

Recovery at Home

The success of your surgery will depend in large part on how well you follow your doctor’s instructions at home during the first few weeks after surgery. You will see your doctor regularly for several months — occasionally up to a year — to make sure your foot heals properly.

Dressing Care

You will be discharged from the hospital with bandages holding your toe in its corrected position.

Because keeping your toe in position is essential for successful healing, it is very important to follow your doctor’s directions about dressing care. Do not disturb or change the dressing without talking to your doctor. Interfering with proper healing could cause a recurrence of the bunion.

Dressing applied to foot after osteotomy

Legend: Your doctor will apply your dressing in a specific way to keep the bones in correct position.

Reproduced from Hirose CB, Coughlin MJ: Proximal and Distal First Metatarsal Osteotomies for Hallux Valgus, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 535-539.

Be sure to keep your wound and dressing dry. When you are showering or bathing, cover your foot with a plastic bag.

Your sutures will be removed about 2 weeks after surgery, but your foot will require continued support from dressings or a brace for 6 to 12 weeks.

Medications

Your doctor will prescribe pain medication to relieve surgical discomfort. The most effective medications for providing postsurgical pain relief are opioids. These medications are narcotics, however, and can be addictive. It is important to use opioids only as directed by your doctor.

As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

In addition to pain medicine, your doctor may prescribe antibiotics to help prevent infection in your wound for several days after surgery.

Swelling

Keep your foot elevated as much as possible for the first few days after surgery, and apply ice as recommended by your doctor to relieve swelling and pain. Never apply ice directly on your skin. It is common to have some swelling in your foot from 6 months to a year after bunion surgery.

Bearing Weight

Your doctor will give you strict instructions about whether and when you can put weight on your foot. Depending upon the type of procedure you have, if you put weight on your foot too early or without proper support, the bones can shift and the bunion correction will be lost.

Some bunion procedures allow you to walk on your foot right after the surgery. In these cases, patients must use a special surgical shoe to protect the bunion correction.

Many bunion surgeries require a period of no weightbearing to ensure bone healing. Your doctor will apply dressings, a brace, or a cast to maintain the correct bone position. Crutches are usually used to avoid putting any weight on the foot. A newer device called a knee walker is a good alternative to crutches. It has four wheels and functions like a scooter. Instead of standing, you place the knee of your affected foot on a padded cushion and push yourself along using your healthy foot.

In addition to no weightbearing, driving may be restricted until the bones have healed properly — particularly if the surgery was performed on your right foot.

No matter what type of bunion surgery you have, it is very important to follow your doctor’s instructions about weightbearing. Do not put weight on your foot or stop using supportive devices until your doctor gives approval.

Physical Therapy and Exercise

Specific exercises will help restore your foot’s strength and range of motion after surgery. Your doctor or physical therapist may recommend exercises using a surgical band to strengthen your ankle or using marbles to restore motion in your toes.

Marble pick-up exercise for foot

Specific exercises such as the marble pick up exercise will help restore full motion to your foot.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Always start these exercises slowly and follow instructions from your doctor or physical therapist regarding repetitions.

Shoe Wear

It will take several months for your bones to fully heal. When you have completed the initial rehabilitation period, your doctor will advise you on shoewear. Athletic shoes or soft leather oxford type shoes will best protect the bunion correction until the bones have completely healed.

To help prevent your bunion from recurring, do not wear fashion shoes until your doctor allows it. Be aware that your doctor may recommend that you never return to wearing high-heeled shoes.

Avoiding Complications

Though uncommon, complications can occur following bunion surgery. During your recovery at home, contact your doctor if:

  • Your dressing loosens, comes off, or gets wet.
  • Your dressing is moistened with blood or drainage.
  • You develop side effects from postoperative medications.

Also, call your doctor immediately if you notice any of the following warning signs of infection:

  • Persistent fever
  • Shaking chills
  • Persistent warmth or redness around the dressing
  • Increased or persistent pain, especially a “sunburn” type pain
  • Significant swelling in the calf above the treated foot, especially if there is a “charley horse” pain behind the knee, or if your develop shortness of breath.

Outcomes

The majority of patients who undergo bunion surgery experience a reduction of foot pain, along with improvement in the alignment of their big toe. The length of your recovery will depend upon the surgical procedures that were performed, and how well you follow your doctor’s instructions.

Because a main cause of bunion deformity is a tight-fitting shoe, returning to that type of shoe can cause your bunion to return. Always follow your doctor’s recommendations for proper shoe fit.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Ankle sprains: what's normal and what's not?

Ankle sprains: what’s normal and what’s not?

By Alexandra E. Page, MD | Featured on AAOS

Ankle sprains are the most common sports injuries, with an estimated 25,000 occurring every day in the US.

Sprains can happen with any sport, including just walking across the yard! Ankle sprains are most common in ball sports such as basketball, soccer, volleyball and others.

What happens? The ankle is designed to have much more motion with the foot turning in, which is how sprains usually happen. The term “sprain” refers to any ligament injury. Ligaments are the tough fibers that connect bones to each other to give the skeleton strength while still allowing joints to move.

The most common ankle sprains involve tearing of the ligaments on the outside of the ankle. The ligament tearing leads to bleeding deep inside, which you see as bruising on the skin.  Fortunately, your body is designed to heal injuries, so these ligaments will almost always heal on their own.

As with any injury, your body quickly sends blood to start the healing process, which leads to the swelling. Remember: your heart is the pump and it is a long way to pump the blood back up from the ankle. For many people, some swelling will continue long after the sprain has “healed” and you are back to activities. This is, again, due to the distance from the ankle to the heart. At night, the swelling gets better but, with activity during the day, the fluid from normal blood flow leads to gradual swelling.

Rest, ice, compression, elevation, known as RICE, is a good way to treat an ankle sprain. This decreases the swelling, lessens your pain, and allows your body to heal the injury. Studies have shown that the sooner you return to activity, the better and typically the faster you will recover.

If pain allows, start moving the ankle early.

When to seek care: If it hurts too much to put any weight on the ankle and you can’t walk, seek treatment immediately. Depending on the amount of injury to the ligaments, it may be days, weeks, or even months to return to high-intensity sports. Sometimes recovery may be slow but, if it gets better day by day or week by week, you are on the right path.

If the ankle seems to stop improving and you just can’t get back to your activities then your orthopaedic surgeon can help.

Prevention: It is always better to avoid the sprain in first place! Remember to stretch before sports to prevent ankle and other injuries to all your bones and joints. Some studies show that taping or an ankle brace can help avoid repeat sprains if you have had sprains in the past.

Don’t let fear of an ankle sprain keep you from your sport. Your orthopaedic surgeon wants you to stay in motion to stay healthy!


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

What May Cause Foot Pain After Running

What May Cause Foot Pain After Running

By Christine Luff| Featured on Verywellfit

Are you feeling post-run pain in your arch, top of foot, toes, heel, side of foot, toenails, or maybe more than one spot? Foot pain is a common ailment among runners and also one that can be confusing because the causes and treatments for the pain can vary widely.

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