Foot and Ankle Conditions

What is an achilles tendon rupture?

An Achilles tendon rupture is the tearing of the large tendon on the back of your ankle that is responsible for allowing you to stand on your tiptoes. This is the tendon that is used by the two large muscles in the back of your lower leg considered your “calf”. This injury may occur in young athletes. However, this injury commonly occurs in the “weekend warrior”, specifically men aged 30-40. You will describe the injury as extremely painful, feeling like being hit by a bullwhip or a baseball bat in the back of your lower leg. You may describe a pop that is audible with an inability to ambulate after the injury. There may also be significant weakness with attempting to point of your toes towards the ground, or plantar flexing. This injury is typically caused by a rapid increase in use of the tendon in someone who typically does not perform high-intensity activity.

Treatment 

Treatment for an Achilles tendon rupture is divided into two different modalities. The first is nonoperative management. Traditionally, this has been reserved for lower activity individuals and those who do not wish to undergo an operative procedure. Nonoperative management involves cast immobilization in maximum plantar flexion, toes pointed down. This allows for the tendon to heal in a position that is similar to normal anatomy.  Prior literature has shown good outcomes with non-operative management. However, there has been a slightly increased risk for re-rupture in the non-operative group. The cast immobilization will take place for several weeks with a gradual transition to range of motion as the tendon heals. You will transition back to mobilizing in a boot in a protected fashion and will likely be weight-bearing in a traditional shoe by 8 – 10 weeks. This protocol may be adjusted on a patient by patient basis. Additionally, those patients at high risk for wound problems, including smokers and patients with diabetes or vascular disease, should seriously consider undergoing nonoperative management.

Surgical Intervention

 Surgical intervention, as expected, involves operative repair of the torn tendon. This utilizes an incision on the back of the calf, exposure of the torn tendon ends, and direct end to end repair utilizing surgical suture. Risks associated with the surgery include, but aren’t limited to,  wound problems, some numbness to the lateral calf, and infection. Results, however, are very good, and patients should expect to return to full function around the 12-16 week mark. Physical Therapy may be needed to restore full range of motion of the ankle as well as strength to the injured side calf muscle. As previously stated, patients with vascular comorbidities including diabetes as well as a history of smoking may consider undergoing nonoperative management. Details of your individual case will be discussed at length during your clinic visit.

Post Op

Post-operative protocols for Achilles tendon repair vary from practitioner to practitioner. However, a period of immobilization in plantar flexion will take place for likely 3-4 weeks. Transition to a boot, remaining in plantar flexion, will occur around the 4-week mark. Additionally, physical therapy will be utilized at this time to obtain dorsiflexion of the ankle to neutral. Once this is achieved, weight-bearing may occur in the boot with a heel lift. The following four weeks will include transition to weight bearing without a heel lift, in a regular shoe, with the goal of returning to running / sporting activity around the 12-16 week mark.  This progression will be governed by both Dr. Davis and your physical therapist. 

What is a bunion?

A bunion, medically termed hallux valgus, is defined as an angular abnormality of the big toe, causing cosmetic dissatisfaction and medial sided pain of the forefoot. Simply put, the big toe points, abnormally, to the outside of the forefoot, leaving a prominence on the inside that can yield soft tissue stress and pain. Typically, a bunion is more common in female patients, largely contributed to by fashion footwear. However, recently, it has been proven that there is a large genetic component present, contributing to similar abnormalities being experienced by family members. As the big toe continues to drift, encroachment on the lesser toes may occur, causing pain and soft tissue insult. Additionally, this abnormality causes an abnormal ability to bear weight through the medial column of the foot, causing overload of the midfoot/lateral foot. All of these problems can compound discomfort and lead to decreased ability to ambulate painlessly, severely decreasing quality of life. Regardless of severity, the presence of a bunion associated with dissatisfaction warrants evaluation and Dr. Davis will be able to appropriately guide you towards a treatment plan that is appropriate.

Treatment

Initial management for a bunion is conservative. When mild, symptoms may be managed utilizing changes in shoe wear, utilizing pads or depressive spacers to relieve areas of high pressure. Additionally, custom orthotics may be utilized to improve pain relief. Typically, however, conservative measures will not improve the anatomical status of the bunion. Bunion specific taping/bracing may delay progression. However, long term improvement is lacking. Additionally, therapies targeting pain control may be utilized, including oral anti-inflammatories, ice and activity modification may help get you back to acceptable painless function. Once conservative measures have failed, operative correction may be discussed. Operative intervention for painless cosmetic reasons, however, is typically contraindicated, believed to be exposing patients to risk for unnecessary reasons. This will be discussed at length during your clinic visit with Dr. Davis. 

Surgical Intervention

As you exhaust conservative options, the decision to move forward with operative intervention will be navigated. As with many Orthopaedic problems, bunion deformities have differing degrees of complexity that require patient specific treatment decision making. During your clinic visit, Dr. Davis will examine your foot in addition to utilizing radiographic evaluation to determine operative needs. Typically, operative bunion correction will require a combination of soft tissue balancing at the big toe utilizing surgical suture. Additionally, bony correction will be used to improve overall alignment and restore the medial column for weight bearing. Complications include bunion recurrence, wound healing issues, prominent hardware requiring removal as well as permanent medial foot numbness. These are, however, rare complications and the procedure typically yields satisfactory results. 

Post Op

Postoperatively, you will be splinted for 2-3 weeks to allow for soft tissue healing. Following this, transition to a boot will occur with weight bearing through the heal. The goal during the postoperative is to restore painless weight bearing in a regular shoe, through the forefoot, by 6 weeks postoperatively. Your specific postoperative protocol will be discussed, and all questions answered during your preoperative visit. 

What is a Cavus Foot?

Cavus foot is defined as a abnormality of the foot that results in a position characterized by a “high arch”.  This issue may present along a spectrum of severity. 

Occasionally, in the younger population, a subtle high arch may contribute to lateral ankle pain and recurrent ankle sprains. This “subtle cavus” abnormality rarely needs invasive Orthopedic intervention unless it is associated with recurrent, and unresponsive lateral ankle instability. If an ankle instability event requires operative intervention, identification of this subtle foot abnormality can prevent early failure following lateral ankle ligamentous reconstruction. 

This high arch abnormality may also present in a more severe form in either the pediatric or adult populations. This is commonly associated with an underlying neurologic disorder that may require further investigation to rule out. Patients present, typically, with vague foot and ankle pain. Occasionally, isolated pain and evidence of increased pressure, including sores and calluses, may take place on the lateral side of the foot as well as underneath the big toe. Goals of your initial visit will include identifying the cause of your abnormality as well as the complexities associated with your foot malposition. Dr. Davis will attempt to identify whether or not the abnormality is rigid or flexible,  helping to identify the  best treatment option for you. Additionally, your visit will include radiographs of your foot / ankle, usually standing in order to assess the dynamic position of your foot. Once this is performed, specific questions will be answered in an attempt to explain what is contributing to your foot malposition and abnormal mechanics.  This comprehensive evaluation, including physical examination and thorough imaging, allows for Dr. Davis to formulate a treatment plan specifically tailored towards providing you with the least invasive option with the highest likelihood of success.

Non Operative Treatment

It should be noted that, typically, there is no emergent need to move forward with surgical intervention for cavus foot. Initially, Dr. Davis will discuss non-operative treatment options to address cavus foot abnormality. If subtle and flexible, you may benefit from utilizing adjustments in your shoe wear, utilizing soft insoles, possibly with a lateral wedge or post to adjust the mid-foot / forefoot portions of your abnormality. Occasionally, patients may benefit from a lace-up ankle brace when participating in high-intensity activity or walking on uneven ground. This may negate their increased risk for having a lateral ankle injury. Patient specific bracing may be utilized if surgical intervention is not desired or needs to be avoided due to Medical comorbidities. Operative intervention may then be discussed following failure of nonoperative management.

Surgical Intervention

Having exhausted all nonoperative management, patients then moved towards the decision to have a surgical correction of their cavus foot. As we move towards this decision, Dr. Davis will attempt to assess your specific abnormality in order to determine if it is rigid or flexible. If flexible, operative correction will involve a series of soft tissue releases, possible tendon transfers and possible bony correction to allow for corrected alignment of your foot and equal weight bearing through the medial (inside) and lateral (outside) columns of your foot. Additionally, it is likely that some sort of Achilles tendon lengthening procedure will also occur to allow for appropriate dorsiflexion of your ankle. The details of your specific operative requirements will be discussed during your clinic visit. Please prepare questions if you have them. Risks associated with surgery include, but are not limited to wound problems, failure of tendon transfers, and failure of bony healing. These complications are rare and can be addressed with Salvage procedures at a later date if needed. To improve your chances of a good outcome, please minimize smoking, control your blood glucose, increase protein intake, increase vitamin D intake and remain compliant with post-operative instructions.

Post Op

Postoperatively, you will remain in the postoperative splint for a period of 1 – 2 weeks. At your first postoperative visit, the splint will be removed and incisions will be assessed for any signs of delayed healing or wound problems. At this time, you’ll be transitioned to a short leg cast and you will remain non-weightbearing for 6-8 weeks, depending on the degree of correction performed. This is in order to maximize the chances of appropriate soft tissue and bony healing following your correction. You will be given pain medicine for pain control as well as a blood thinner to prevent blood clots postoperatively. The end goal is to be able to painlessly weight bear in a normal shoe around the 12 week mark. Physical therapy may be needed to restore strength and range of motion on a patient by patient basis.

What is a flat foot?

Flat foot, or pes planus, is an abnormality of the foot that can lead to medial sided pain and progressive collapse, resulting in a compromised foot that is unable to support the body during weight bearing. This issue is typically more common in women and presents later in life. Risk factors include obesity, diabetes, and inflammatory arthropathy.  Flat foot is caused by compromise of the posterior tibial tendon on the inside of your ankle that is responsible for maintaining your arch. This tendon becomes inflamed and then subsequently loses its function, resulting in an inability of the medial structures to maintain your arch through the gate cycle. Because this problem presents on a progressive spectrum, your symptoms may consist of only mild medial pain with weightbearing with a flexible, visibly “flat” foot. The problem could also, however, have progressed to complete arch collapse with evidence of soft tissue compromise. At your first Clinic visit, Dr. Davis will attempt to assess the stage of your foot abnormality. Utilizing physical exam and radiographic evaluation, he will determine the best route to provide you with quick pain relief and return to normal day to day function.

Treatment

Depending on the stage of your flat foot abnormality, treatment may range from conservative to extensive operative management. Patients presenting with minimal collapse, with minimal medial sided foot pain or lateral impingement, may respond well to conservative measures including custom orthotics/shoe wear. This conservative management may include a period of casted non weight-bearing with transition to an ankle foot orthosis that attempts to prevent further collapse.The goal in this setting is to relieve your pain initially while utilizing an orthosis to support the medial column of the foot and take tension off of your tendon. As pain subsides, physical therapy may be useful to assist in some tendon strengthening to attempt to reconstitute some of the medial arch if possible. This treatment regimen may also be applied to later stages of the disease in patients who, for one reason or another, do not wish to undergo an operation. Additionally, conservative treatment is utilized exhaustively for patients whose medical comorbidities elevate their operative risk.

Surgical Intervention

If conservative management has failed to provide pain relief and restore the ability to ambulate, operative intervention will be discussed. If your complaint is pain related with minimal deformity, you may respond well to a simple procedure utilized to clean the posterior tibial tendon on the inside of the ankle and minimize inflammatory tissue.This is fairly benign and the goal postoperatively would be to participate in early range of motion and transition back to normal function. If your deformity is more pronounced, you may require more extensive surgery involving both soft tissue and bony reconstructive work to reconstitute your medial arch and restore the appropriate weight bearing surfaces of your foot. The details of your operative case will be discussed specifically during your clinic visit with Dr. Davis. It is likely, however, that you will receive incisions both medially and laterally, as well as over your heel bone, in order to perform both soft tissue and bony correction. Additionally, if significant arthritis is present, fusion of several bones in your foot will be utilized for both pain relief and deformity correction.  Risks of the surgery include wound problems, failure of healing of tendon or bone in addition to postoperative stiffness. The outcomes of these operative corrections are good. However, due to the risk of complication, Dr. Davis will be sure to maximize non-operative treatment options prior to moving forward with operative intervention. 

Post Op

Typically, postoperatively, you will remain in a splint for a period of two weeks to protect your soft tissues. At your first postoperative visit, your incisions will be checked and you will be transitioned to a cast for an additional 4-6 weeks. , Progressive progression back to weight-bearing will occur with the goal of weight bearing in a normal shoe at the 3-month mark. Long-term orthotic use may be beneficial. Additionally, formal Physical Therapy may be utilized to restore mobility of the ankle / subtalar joint as well as restore normal gate biomechanics. All of this will be discussed at length between you and Dr. Davis. 

What is hallux rigidus?

Hallux rigidus is defined as osteoarthritis of the great toe, or “big toe”. Patients present with progressive, worsening pain of the great toe in association with decreased motion. Decreased motion of the great toe drastically affects the ability to walk, and especially run, normally. In the early stages, the great toe may become stiff. This is usually associated with increased times of activity and is worse late in the day. As the pain and range of motion continue to deteriorate, the ability to painlessly ambulate becomes more difficult. The cause of this problem is largely unknown. However, it is thought to have an inherited component. The anatomic shape of the great toe joint may contribute to those with a predisposition to develop arthritis. Additionally, certain trauma to the foot may result in the development of this condition. 

Treatment

Initial treatment for hallux rigidus, like many osteoarthritic conditions, is conservative. In the early stages, pain responds well to a regimented dose of anti-inflammatory medication. Additionally, things like ice and elevation may provide symptomatic relief. Occasionally, patients respond well to an injection of steroid to provide symptomatic relief. Although patients have mixed results from conservative modalities, these options may delay the need for operative intervention for a period of months to years. 

Surgical Intervention

As conservative modalities are exhausted, operative intervention will be discussed. As with most problems caused by osteoarthritis, the need for surgical intervention is guided by the effect the symptoms have on your quality of life. Once the decision to move forward with surgery occurs, stratification takes place based on severity. Patients with early hallux rigidus may benefit from a small bony resection that would allow for restoration of motion, providing improvement in function. This, however, may not provide significant pain relief. As symptoms worsen, small bony resection will not address the debilitating pain that can accompany this problem. As symptoms progress, fusion of the great toe joint will provide consistent, reproducible pain control with a low complication rate. Your specific case, along with surgical options and expectations will be discussed at length with Dr. Davis during your clinic visit.

Post Op

Typically, patients have a short period of splint immoblization to allow for soft tissue healing. At your first postoperative visit, splinting will be discontinued with transition into a boot. Patients with a small bony excision will begin weightbearing as soon as your soft tissues are healed. For patients receiving fusions, if your soft tissues are healing appropriately, weight bearing through your heel will be allowed for mobilization. You will then be followed over the subsequent weeks, with radiographs to assess the bony healing of your fusion. Once radiographic evidence of healing is present, transition to a regular shoe will occur. 

What is a high ankle sprain?

A high ankle sprain is a rotational injury to the ankle that is defined by a compromise in the overall stability of the ankle joint. Specifically, the ligaments responsible for maintaining the relationship of your lower leg bones, the tibia and fibula, are injured and unable to perform their function. This injury carries another degree of severity from low ankle sprains or typical “rolling of the ankle”. During your evaluation, Dr. Davis will determine if your ankle is stable utilizing a combination of physical exam and radiographic evaluation. Questions may still remain, however, from the results of static x-rays. Therefore, a stress radiograph may be used to assess the dynamic stability of the ankle joint. These injuries are fairly rare in isolation. Therefore, concern for damage to the ankle joint surface as well as other tendinous structures warrants thorough investigation. 

Treatment

For isolated high ankle sprains without evidence of ankle instability, patients respond well to conservative measures, typically involving cast or boot immobilization and non weight bearing for a period of 3-4 weeks. Following this immobilization, you will be transitioned back to weightbearing with the help of physical therapy to guide transition back to sport. It is not uncommon to have residual pain or apprehension as far as 6 months after the initial injury. Results, however, are good in this patient population.

Surgical Intervention

If it is determined that the ankle is unstable, operative intervention will likely be needed to prevent inappropriate early degeneration of the ankle joint. Traditionally, screws placed from the fibula bone to the tibia bone, or “trans-syndesmotic screws”, have been used to restore the relationship between the two bones until the ligamentous structures heal. These screws may or may not need to be removed at a later date. More recently, suture constructed “tight-rope” fixation has been utilized to tether the fibula to the tibia in a similar fashion. This may allow for earlier return to sport without the need for hardware removal. Your specific case and operative indications will be discussed at length during your clinic visit. 

Post Op

Postoperatively, you will remain non-weightbearing for a period of 6-12 weeks depending on your athletic status/situation. Typically, ligaments require at least 6 weeks to heal. This is the timeline to initiate return to weightbearing. Then, over the next several months, transition to straight line running, followed by agility drills will progress. Once cleared, return to full athletic activity can occur. If restoration of ankle stability occurs, good outcomes can be expected. 

What is a Lisfranc Fracture?

A lisfranc fracture, typically, occurs due to a high energy trauma to the midfoot. The lisfranc joint is a ligamentous relationship formed by the bones of the midfoot. This relationship is important because it is responsible for the structural integrity of the foot needed to bear weight through the forefoot. The strong ligamentous structures in this area maintain this structure to the midfoot that allows the achilles tendon mechanism to act through the hindfoot to progress the body forward during gait. When an injury occurs, a dorsiflexion force occurs to a foot that is plantar flexed, causing fracture and ligament avulsions through the midfoot joints. Due to this, the integrity of the foot is lost. Patients feel extreme pain, sense instability and notice swelling with ecchymosis (purple/redness) to the bottom of the foot. If your evaluation is in the emergency room, Dr. Davis will perform a neurovascular exam to the foot to confirm that impending neurologic injury isn’t iminent. Workup will utilize plain radiographs of the foot and likely a CT scan to assess the relationship at the lisfranc joint and the remainder of the midfoot. Occasionally, radiographs may not evidently determine if an injury has occurred and stress radiographs will have to be performed to determine stability of the midfoot. 

Treatment

If the clinical signs of a lisfranc injury are present, but minimal displacement through the lisfranc joint has occurred, non-operative management may be appropriate. However, if instability occurs through the midfoot, surgical intervention is needed to restore the midfoot’s integrity.

Surgical Intervention

Surgery for lisfranc injuries usually has to be treated in a staged manner due to the swelling associated with the soft tissues around the foot. This usually involves the use of an external fixator. An external fixator is a combination of pins and bars placed in the bones of the foot and the tibia that allows for the bony relationship in the midfoot to be restored and held in place by bars on the outside of the skin. Once the swelling has minimized, incisions can be made around the foot and plates and screws will be utilized to correct deformity and hold the bones in the correct position. Occasionally, due to the severity of the injury to the joints of the foot, a fusion will take place, eliminating the joints completely and restoring stability to the foot. Discussion will be had during your evaluation by Dr. Davis to discuss surgical options. 

Post Op

Postoperatively, maintenance of stability is paramount. You will be placed in a splint for 2 weeks postoperatively. At the two week mark, radiographs will be taken and sutures will be removed. Cast placement occurs until the 8-12 week mark. You will remain non weight bearing for a period of 12 weeks postoperatively to allow the bony anatomy to heal well.

What is a low ankle sprain?

A low ankle sprain is an injury to the ankle that typically occurs when the ankle is “rolled” inward. In doing so, it is common to have stretching or tearing of the ligaments on the outside of the ankle that are responsible for maintaining stability. These injuries typically occur in athletes, especially involving indoor sports such as volleyball and basketball. However, injuries are very common occurrences in other sports and not uncommon in non-sports related scenarios. Patients typically present with acute pain on the outside of the ankle, with a history of a “pop” experienced at the time of injury. Swelling and pain can be significant, causing concern for fracture. However, it is fairly common to have an isolated soft tissue injury with this pattern. At your initial visit, radiographs will be obtained to rule out acute bony injury. Additionally, you will be examined thoroughly in an attempt to identify the presence of injuries to the ligaments, tendons and articular cartilage of the ankle joint. Occasionally, an MRI may be needed to further assess the status of your injury. 

Treatment

Treatment, for the vast majority of these injuries, consists of non-surgical management. This, however, does not mean “doing nothing”. Following 1-2 weeks of immobilization to mitigate pain and swelling, you will initiate a physical therapy regimen. Therapy will begin by focusing on restoration of full range of motion of the ankle. Once achieved, proprioceptive, or “feeling in space” training will occur in addition to gait training to restore confidence in the ankle joint. This will be followed by strengthening, focused on the lateral ankle. Examples of these exercises may be found here. As strength increases followed by a decrease in apprehension and pain, progression to running followed by agility activity is initiated. The goal of therapy is quick return to sport. However, it isn’t uncommon to be performing below acceptable competitive standards for up to 6 weeks.

Surgical Intervention

If non-operative management fails, defined by residual instability or intolerable pain, there are safe, reliable surgical procedures utilized to address lateral ankle instability. Typically, you will undergo an ankle arthroscopy. This allows for thorough assessment of the ankle joint, with appropriate “clean-up” of inflamed tissue that could be a pain generator. Additionally, this allows for assessment of the articular surface of the joint as well as appropriate opportunity to address problems found. Once the arthroscopy is complete, an open incision to the lateral ankle is made. Suture anchors are utilized to aid in reconstruction of the torn/stretched ligaments contributing to abnormal symptoms. Occasionally, a larger “suture tape” will be needed if your tissue integrity is poor. Lastly, Dr. Davis will thoroughly assess your foot/ankle bone anatomy. Occasionally, correction of some mild bony malalignment may be required to insure that the soft tissue reconstruction will heal. The details of your case and planned operative intervention will be discussed at length during your preoperative visit. Risks are fairly minimal, however, occasional wound healing issues, infection and damage to nearby nerves may occur. These are well documented complications and thorough care will be taken to avoid them. 

Post Op

Postoperatively, you will be immobilized in a short leg splint. Additionally, patients are made non-weight bearing initially to aid in soft tissue healing. At the two week postoperative visit, removal of sutures with transition to a boot occurs. This will be work, with gradual transition to weight bearing, until 6 weeks postoperatively. Throughout, focus on toe curls, as well as ankle range of motion, should occur. At the 8 week mark, transition to an aircast will occur with continued functional progression. This will occur until 12 weeks. From 3 months to 6 months, discontinuation of the aircast will occur and transition to a lace up brace takes place. As the patient is able, initiation of higher intensity activity may occur and return to sport is allowed. This regimen is variable depending on repair quality, patient functional status, and return to sport goals. 

Associated Links

• Peroneal Tendon Injuries
• Ankle Arthroscopy
• Lateral Ankle Exercises

What are peroneal tendon injuries?

Your peroneal tendons are the tendons that travel on the outside of your ankle, inserting on the lateral side and the bottom of your foot. These tendons fulfill multiple roles. However, they are major contributors to lateral ankle pain and instability when a patient has suffered multiple low ankle sprains. In addition to lateral ankle ligamentous injury, ankle sprains may result in peroneal tendon damage that results in chronic instability of the ankle and pain. When you are seen by Dr. Davis, he will evaluate the strength and function of these tendons in association with your symptoms. These tendons, when functional, are responsible for everting your ankle, or holding it “out”. When acutely or chronically injured, patients may suffer from difficulty resisting inversion of the ankle when walking on uneven surfaces. Dr. Davis will order radiographs to assess your overall foot and ankle alignment. However, in the setting of peroneal tendon pathology, an MRI scan will likely be needed to assess the anatomic damage. This will be discussed at length during your visit.

Treatment

Initially, injuries to the peroneal tendons, much like traditional ankle sprains, may be treated with non-operative, conservative modalities. These include a period of rest/immobilization followed by ice to decrease inflammation. Additionally, as pain subsides, strengthening exercises directed at the lateral ankle will be recommended. Once strength improves, this allows for resistance to the inversion force that causes the pain to occur. Once non-operative modalities have failed, operative treatment options will be discussed with Dr. Davis.

Surgical Intervention

Addressing the peroneal tendons operatively will likely involve a procedure involving an arthroscopy of the ankle and lateral ankle ligamentous repair. The ankle arthroscopy will allow for assessment of the joint for any cartilaginous damage. This also allows for the removal, or “cleaning”, of any scar tissue or joint tissue that may be causing pain. As the lateral ankle ligaments are addressed, the peroneal tendon sheath will be opened sharply, allowing for peroneal tendon exposure. Dr. Davis will then clean the tendons and perform low profile suture repair of the damaged tendons. He will then close the sheath, ensuring that the tendons glide smoothly. 

Post Op

Post operatively, you will be placed in a splint for several weeks, depending on the structures that have been repaired. As your soft tissues heal, your ankle may be removed from the splint and placed in a boot. This allows for range of motion stretching. As time progresses, peroneal tendon exercises will be initiated as tolerated, allowing for physical therapy to guide proprioceptive training. This is the bodies training of its position in space, allowing for you to minimize the occurrence of lateral ankle instability events. Continued brace wear for high impact/movement activity may be needed for a period of up to a year.  

What is plantar fasciitis?

Plantar fasciitis is a painful condition that is very common in today’s population, affecting the bottom of your foot. The “plantar fascia” is a band of connective-like tissue that arises from your calcaneus, or “heel bone”, on the inside of your foot, to your forefoot. This is a contributor to your foot’s “arch”. Occasionally, due to overuse or a change in activity, this fascia becomes inflamed and very painful. This, most commonly, presents as significant pain on the inside, or medial side, of the heel bone, feeling like a marble in your shoe that hurts with every step. Occasionally, the pain may be present in your mid-arch or forefoot as well. The structural alignment and mechanics of the foot make certain people predisposed to developing plantar fasciitis more often than others. Additionally, the presence of a tight calf, or heel cord, may also lead one to have an easily inflamed plantar fascia. Additionally, obesity is a risk factor for developing this condition. Plantar fasciitis usually presents with significant discomfort that is worse when just getting out of bed. There may be some mild relief as the foot gets “stretched out” throughout the day. However, the pain usually returns with a vengeance at night. During your clinic visit, Dr. Davis will likely examine your foot, palpating the painful location to pinpoint the diagnosis. Additionally, he will assess your overall foot position and the tightness of your foot/lower leg. Radiographs are usually not needed to diagnose or aid in treatment of this condition. Additionally, he will perform a neurovascular exam on the plantar surface of your foot to screen for nerve symptoms, possibly cluing in to compression of the plantar nerves at the ankle, called “tarsal tunnel syndrome”. Once this is ruled out, treatment modalities may commence.

Treatment

In the vast majority of cases, non-operative management will lead to relief from the debilitating symptoms of plantar fasciitis. This will involve initiating a scheduled anti-inflammatory medication for several days to weeks, with utilization of plantar fascia specific stretching and massage. This helps to free up the tension of the plantar fascia as well as the sensitivity that develops. Dr. Davis will review these techniques with you in the clinic. Icing is also beneficial, and many chose to utilize a frozen water bottle rolled on the bottom of the foot to provide relief. Calf, or heel cord, stretching also provides relief by delaying the initiation of the plantar fascia throughout the gait cycle, decreasing its stress and inflammation. Additionally, a plantar fascia “night splint”, or “night sock” keeps the ankle at neutral while sleeping, preventing the development of calf and foot tightness that occurs overnight and leads to significant morning discomfort.

Following failure of these conservative modalities, positive results have been seen with shockwave therapy. This can be uncomfortable, but has shown positive results out to 6 months and is FDA approved.

Surgical Intervention

If all measures of conservative management have failed, operative intervention may be necessary. This would involve a release of the calf muscle, leading to increased mobility of the ankle or foot. This is called a gastrocnemius recession. Additionally, minimally invasive release of the plantar fascia can be performed to provide relief. However, this is also associated with delayed recover and wound complications. Therefore, it is important to take conservative care seriously to confirm that all options have been exhausted prior to the decision to pursue operative intervention.

Post Op

Post operative management will involve a period of non-weightbearing in a cast with early transition to physical therapy to allow for wound healing and pain tolerance. As the wounds heal, therapy will be focused on the maintenance of ankle dorsiflexion (upwards motion of the ankle) to maintain flexibility through the foot. Return to weight bearing will be discussed in the clinic and be on a patient by patient basis. 

What is tarsal tunnel syndrome?

Tarsal tunnel syndrome is a condition that affects the sensory nerves that innervate the bottom of the foot. Due to a multitude of factors, these nerves become inflamed. This is likely due to compression of the nerves at the medial ankle, similar to carpal tunnel syndrome at the wrist or cubital tunnel syndrome at the ankle. Symptoms classically present as burning pain on the bottom of the foot. However, vague foot discomfort that worsens with long periods of standing/walking may also point towards tarsal tunnel syndrome. Occasionally, this diagnosis may take some time to diagnose, with attention being delegated to ruling out more worrisome problems. Physical exam may elicit tenderness at the medial ankle, the point of maximal compression of the nerve. Occasionally, muscle wasting may occur in the foot and a provocative compression test at the ankle may bring the nerve’s problem to light. Typically, radiographs, and occasionally an MRI are gathered to assess for structural causes of nerve constriction. However, an EMG/nerve conduction study may be performed to hone in on the problem at the ankle. 

Treatment

Treatment, initially, will likely be directed towards activity modification to aid in eliminating things that incite an inflammatory episode. Some medications, including anti-inflammatories as well as medications directed towards nerve discomfort, may be used. These, however, typically do not cause significant improvement. As this problem progresses, the nerve irritation becomes a progressive condition that typically requires surgical intervention to address. However, conservative attempts to minimize nerve irritation should take place.

Surgical Intervention

Once conservative measures have failed, the discussion regarding the decision to move forward with operative intervention will occur. The operation involves release of the medial structures that are causing constriction of the tibial nerve. A medial longitudinal incision will be performed with careful dissection down to the sheath over the neurovascular bundle. This tissue will be dissected, carefully, to allow for complete release of the nerve from the back of the leg, to the ankle down into the foot. Once complete release occurs, thorough cleaning of the wound will occur with multilayer closure. A splint or soft dressing/boot will be placed depending on the status of your soft tissues. Risks and benefits associated with this operation will be discussed during your preoperative visit.

Post Op

Postoperatively, a sterile splint or dressing will be placed to protect the soft tissue closure. At two weeks postoperatively, stitches will be removed and the wound will be assessed. Weight bearing may be initiated at this time and range of motion exercises will be implemented as well. If needed, physical therapy may assist in this process. Return to activity, or sport, will depend on your ability to regain your confidence in your extremity following the operation. However, it isn’t uncommon to be in recovery for several weeks. This will be discussed with Dr. Davis during your postoperative course.

What is a turf toe?

Turf toe is a problem typically dealt with in high impact, occasionally contact, athletes participating on hard surfaces. This encompasses a large variety of sporting participation in the US. The problem involves damage to the ligaments in the bottom of the foot, between the midfoot and the great toe. This location is called the “plantar plate” and is responsible for assisting in “push off” through the forefoot. In turf toe, this structure becomes attenuated, causing pain, discomfort and instability. Occasionally this injury will be associated with fractures of the bones of the toe or the small bones below the toe, called the sesamoid bones. At your initial visit, Dr. Davis will perform an exam, assessing the location of your pain and attempting to determine the level of instability of the first toe. This will also include the need for radiographs to give more insight into the severity of the injury. Occasionally, when diagnosis is difficult to ascertain, MRI scan may be used to focus on the soft tissue anatomy of the plantar plate and the sesamoid complex. Once the diagnosis is made, discussion will be had regarding treatment modalities that will be undertaken to fast track recovery and return you to athletics.

Treatment

In the vast majority of cases, a thorough trial of non operative management will be undertaken. Due to turf toe association with overuse, activity limitation as well as a period, usually 3-4 weeks, of limited weight bearing will be performed to decrease inflammation. A scheduled course of anti-inflammatory medicine in addition to traditional nonoperative modalities will occur. These include ice, elevation and stretching. If stability is unable to be restored with nonoperative modalities, patients will occasionally require operative intervention to restore stability to the first toe. This injury, however, has been known to be devastating to the career of high level athletes.

Surgical Intervention

Following failure of conservative management, surgery is indicated in those with continued pain and instability who are unable to discontinue the activity that insights symptoms. This would involve a series of small incisions, removal of inflamed tissue from the area and repair, using suture, of the plantar plate ligament, restoring stability to the first toe. Occasionally, the small sesamoid bones will need to be repaired as well utilizing a small screw. This will be discussed at length during your preoperative visit. 

Post Op

Postoperatively, you will remain non weight bearing for a period of 4-6 weeks, with transition back to gradual weight bearing. Therapy will be directed to muscle training and strengthening with the goal of return to sport in the 4-6 month range. This will be discussed and guided with Dr. Davis during your postoperative period. Additionally, a short course of aspirin therapy will be utilized to prevent blood clot during your non weight bearing period.