Darren McFadden’s Lisfranc Injury

Darren McFadden, running back for the Oakland Raiders, has reportedly been making great strides in his rehabilitation and training following a season-ending Lisfranc injury last season.  The running back has been reported to have been making cuts at full speed, an indication that he is feeling much better.

The Lisfranc joint is comprised of the tarso-metatarsal joints across the entire midfoot.  This includes the five metatarsals, and their articulations with their respective tarsal bones.  This joint complex is generally very strong, but can be injured in twisting injuries, with axial loading mechanisms of injury, crush injuries, or in high velocity injuries such as falls or motor vehicle accidents. 

Injuries to the Lisfranc joint can be devastating, particularly when they are not addressed properly.  Unfortunatley, this can happen often in the emergency room setting. The reason for this is that many Lisfranc injuries can show up as subtle changes on x-ray, and those unfamiliar with the injury may miss it.  In fact, it is one of the most commonly missed diagnoses. 

The anatomy of the midfoot and Lisfranc joint contributes to its stability, and lends to the relative infrequency of Lisfranc injuries.  Strong ligaments connect the three cuneiforms and the cuboid to their respective metatarsals, and the tendons and fascia of the foot contribute to it’s stability as well. 

For McFadden, his injury was considered a sprain, and was treated non-surgically.  He sat out the remainder of the season after it happened, but it was determined that he would not need surgery on his foot.  For many, this is not the case.

Surgical correction for Lisfranc injuries is recommended in many cases.  These cases often involve fractures of the bones of the midfoot, but may be purely ligamentous injuries.  Surgical correction may involve using screws and/or plates to hold the bones in place while the ligaments can heal.  For fractured bones, they may be pieced back together, and also held in place with screws and/or plates while they heal. 

Another option for treatment is to fuse the joints permanently that are affected by the injury.  This is known as arthrodesis.  Arthrodesis for Lisfranc injuries has become a more popular option, as research has shown that this may lead to a more functional and less painful foot.  Because there is limited motion at the tarso-metatarsal joints to begin with, eliminating motion at the joints altogether does not lead to a great difference in function. 

Non-surgical treatment for Lisfranc injuries is typically to keep the patient non-wieghtbearing in a cast or splint.  Evaluation by a podiatric surgeon is helpful to determine the definitive treatment for the injury.

For McFadden, hopefully he will return to play and will have a great season.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Diagnosis and Treatment of Acute Compartment Syndrome

The onset of acute compartment syndrome is something of great concern to the emergency room physician, trauma surgeon, and podiatric foot and ankle surgeon.  It is something that is routinely screened for an any lower extremity trauma.

The muscles of the foot and leg are divided into compartments, each of which is separated by a layer of fascia.  This dividing fascia is tough and restricting, and does not allow for much expansion of the tissues within the compartment.  Normally this is a good thing, as it helps separate and organize the muscle compartments of the foot and leg.  However, when the volume of the compartment expands following injury, these bands of tissue help to restrict the fluid, creating an increase in the compartmental pressure.  This increase in pressure can cause damage to the muscles, nerves, and vessels within the compartment, and can lead to tissue death if not addressed properly. 

Signs and symptoms of acute compartment pressure include intense pain out of proportion for the given injury, numbness or tingling in the toes, loss of function of the toes or an inability to move them, and coolness to touch caused by decreased blood flow.  Later in the development of compartment syndrome, pulses may be absent and the toes may turn white in color. 

The diagnosis of compartment syndrome is largely based on the history and physical findings, but a device called a wick catheter may be used to confirm the diagnosis.  This is an instrument that is mainly composed of a needle attached to a pressure gauge, which acts to measure the compartmental pressure.  The normal pressure reading for a muscular compartment should be between 0 and 10 mmHg.  Pressures between 10-20mmHg are closely monitored, as they may continue to increase.  Pressures above 30mmHg are considered diagnostic of compartment syndrome in most cases. 

Once the diagnosis of compartment syndrome is made, the patient must be taken to surgery right away.  A delay in surgical treatment may result in irreversible muscle and tissue damage.  Surgery for compartment syndrome involves releasing the fascia between compartments to relieve the pressure.  This procedure is known as a fasciotomy. 

There are four muscle compartments in the leg to release; the superficial and deep posterior compartments, the lateral compartment, and the anterior compartment.  In the foot, there are also four main compartments; the medial, lateral, central, and interosseous.  Some references will divide the central compartment into a superficial, deep, and calcaneal compartment, and also consider each of the interosseous compartments their own separate compartment.  When acute compartment syndrome is diagnosed, both the leg and foot compartments will oftentimes be opened together. 

The incision sites are kept open, and local wound care is performed to keep the sites clean and prevent infection.  Compartment syndrome will generally keep a patient in the hospital for at least several days, while their condition can be monitored.  Any other injuries must also be addressed.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Green Running Shoes

Running shoe manufacturer Brooks recently announced plans to release a new, environmentally friendly running shoe in 2010. The shoe, which will be known as The Green Silence, will be available to customers in February 2010, and will boast a design that is made entirely of recycled materials.

The heel cups of the shoe will be reinforced with recycled CDs, while the laces, mesh, lining, and stitching will all be made from discarded plastic water bottles. Foam from old sofas will be reused in the collar, or padded area of the shoe, and the soles will be constructed out of recycled rubber. Brooks even claims that the midsole of the shoe is entirely biodegradable, a claim which the Federal Trade Administration of the United States remains skeptical of.

Even with those doubts, the trend towards more green and eco-friendly footwear is here. Shoe brands are using sustainable materials like hemp and recycled rubber more often, and companies are using more environmentally-friendly methods of producing and transporting their products.

The recycled materials that Brooks is using for its Green Silence are coming from various countries around the world, a point that many environmentalists would make that the company is not using local resources, which would be the most eco-friendly. However, Brooks states that the transportation involved only makes up a small percentage of the shoe’s total carbon footprint.

Brooks also encourages it’s customers to donate old shoes to Soles4Souls, a non-profit organization that distributes shoes to those in need. A similar program is run by Nike, called ReUse A Shoe, where the rubber from old shoes is recycled into turf for fields and other equipment.

While it may not be possible for Brooks to please every environmentalist with the Green Silence shoe, it is certainly a step in the right direction. For years now, running shoe and apparel brands have been using more sustainable products as a way of marketing a greener product. Companies have experimented with Beachwood as a material for socks, as it is highly sustainable and has great moisture-wicking properties. Merino wool has been a very popular material in running socks and clothes, as it is a natural fiber with excellent moisture wicking and cooling properties.

Companies that use silver as an additive for its antimicrobial properties have cleaned up the manufacturing process as well. What used to be a very polluting process has been cleaned up, with fewer emissions and less pollutants.

As these products become available, customers will start to request them, and look at the materials used in the products they buy. With a trend towards sustainability and greening our routines, running brands may be leading the foot race.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

New Drug for the Treatment of Gout

This Tuesday, a federal advisory committee recommended the approval of Krystexxa, a new drug that has been in development by Savient Pharmaceuticals. In clinical trials, the drug has shown to be an effective treatment for gout.

The committee recommended the approval by a landslide 14-1 vote. The drug now must be approved by the Federal Drug Administration (FDA) before Savient can begin producing, distributing, and marketing the drug. In the past, the FDA has been known to follow the advice of the advisory committees. If Krystexxa is approved, it will be the second drug for the treatment of gout approved this year, after 40 years without innovation in this particular area. Uloric, which is manufactured by Takeda Pharmaceutical, was approved for use in February.

Gout, which is a form of arthritis, is caused by a buildup of uric acid in the body. This uric acid can then be deposited in the joints. The deposits are known as tophi. The big toe is particularly susceptible to this searing pain caused by tophi, but other joints, including joints in the hands and elbows can also be affected.

The uric acid that builds up in the body is commonly associated with diet, as it is a metabolism defect. Foods such as alcohol (especially beer), red meat, and some seafood are commonly associated with gout. For this reason, gout has often been referred to as the “disease of the kings”, as these foods were historically only available to the wealthy. However, these foods have become more and more accessible to a larger percentage of the population, making gout more common, and less known as a disease of the rich. Increased incidence of gout has sparked a new interest in the medical research community.

Krystexxa is a form of uricase, an enzyme responsible for degrading uric acid in the body. The drug works by attacking the tophi, and helping to dissolve the deposits. In clinical trials, about forty-percent of patients saw significant improvement while taking the drug. Some patients reported that the tophi dissolved completely, and that they were able to walk and use their hands again without pain.

There are some side-effects that have been reported with the use of Krystexxa, including an increase in the prevalence of cardiovascular complications and allergic reactions. Committee members state that it is unclear whether the increase in cardiovascular conditions, however, is due to the drug or due to chance, based on the small trial size. The FDA, nevertheless, is expected to approve the drug, as the striking benefits for patients with chronic gout outweigh the side-effects.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

Shin Splints! Are They Avoidable?

One of the most common injuries that runners suffer from is shin splints. Shin splints can be a very painful experience, but it is fairly avoidable and very manageable.  What causes the pain is an overloading of the tibialis anterior muscle and the connective tissue that connects this muscle to the bone.  The tibialis anterior muscle connects to the outside of the shin bone, and plays a crucial role in keeping the foot stable while walking and running. 

            Because it is an overuse injury, shin splints are most often treated with “RICE” therapy – that is rest, ice, compression, and elevation.  Resting is most important, because further exercise will only further aggravate the condition.  Icing the area, as well as taking over-the-counter pain relievers such as ibuprofen will help to relieve some of the pain associated with shin splints.  Compression with a sock or specialized compression sleeve, as well as elevating the leg while resting will help as well. 

            In addition to RICE therapy, check the shoes you’re wearing when you get the shin splints.  If you’re running, look at your running shoes.  Do they fit properly?  Are they heavily worn on the bottoms?  Do they support your feet well?  If you’re walking when you get them, are you wearing proper walking shoes?  Sometimes wearing thin sandals while walking long distances can give you shin splints quickly. 

            Shin splints may be painful, but know that they are usually only temporary.  It is no reason to give up the morning walk or run.  One way to prevent getting shin splints to add strength training to your exercise routine.  Strengthening the muscles of the calves can help prevent ever getting shin splints, as these muscles help to balance the activity of the tibialis anterior during gait.  Also, wearing the proper shoes will help give your shins extra cushioning, preventing some of the impact that causes shin splints.  Adding low impact exercise will also help lessen the burden on your body in general.  Try mixing in swimming or biking to your exercise routine, or some low impact aerobics.

            As with any injury or pain that you’re suffering from, it’s important to tell a doctor about it if it doesn’t go away with rest, ice, compression, and elevation.  If the shin pain develops after a fall or other impact, a doctor will need to take x-rays to rule out a stress fracture or other type of injury.  

Central Florida Foot and Ankle Center
101 6th St Nw
Winter Haven, Fl 33881
Phone: (863) 299-4551
www.FLFootandAnkle.com

Server's Disease and Osgood-Schlatter Disease

If you know a young athlete that’s having some trouble with heel pain, it may be Sever’s disease.  Sever’s disease is a condition common in growing athletes, where the growth plates in the heel are subjected to repetitive microtrauma.  This microtrauma, or tiny cracks in the growth plate, is the most common cause of heel pain in male athletes aged 10-14.

Sever’s disease is a self-recovering ailment.  That is, with rest and minimized impact to the heel (i.e. less running) the pain will subside on its own.  Symptoms include pain in the heels, especially while playing a sport or immediately following, as well as pain in the heels when waking up.  The pain is also felt from squeezing the calcaneus, or heel bone. 

Treatment of Sever’s disease is typically rest, ice, compression, and elevation (The R.I.C.E. method).  Orthotics or heel cups are often beneficial, as these tend to reduce the shock that the heel absorbs while running and playing sports.  Also, the young athlete should wear a proper fitting shoe, with firm support and a heel that is able to absorb some of the shock.  Stretching the calf muscles and hamstrings has also shown to be beneficial.

Osgood-Schlatter disease is a related disease that is inflammation of the growth plates at the top of the tibia, or shin bone.  Similar to Sever’s disease, Osgood-Schlatter’s is often seen in young athletes.  It is different however, in that it primarily presents as knee pain.  This knee pain occurs in both knees about 25% of the time.

Osgood-Schlatter disease can be attributed to overuse, especially sudden overuse, of the quadriceps muscles.  This is the group of muscles that are on the front of the thigh, and act as extensors of the leg, such as the motion in running and jumping.  The tendon that attaches the quadriceps to the patella (knee bone) and to the tibia ends up pulling very hard on the tibia just below the knee, causing microtrauma to the tibial tuberosity, the point where the tendon attaches.  This microtrauma is what causes the inflammation of the growth plates in the tibia, which in turn causes knee pain.

            The treatment of Osgood-Schlatter disease is similar to that of Sever’s disease.  Rest, ice, compression and elevation are the first line of defense.  Usually, there will have to be a period of at least three months without intense physical activity to allow the knee pain to go away.  Following this period, it is essential to begin training slowly, so as not to re-aggravate the tibia. 

            If you know a young athlete that is suffering from heel or knee pain, know that this pain is not normal.  A doctor can evaluate the injury, and can tell if they are suffering from either Sever’s or Osgood-Schlatter disease.  Each of these conditions is treatable, and young people will grow out of these conditions.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

Runners’ Nightmares!

If you are an avid runner, chances are you have run into some kind of foot or lower extremity problems. Think about it: the action of running involves the repetitive pounding of the foot on surfaces and sends shock waves up your body.

It is important to understand that running too soon, running too fast, or running too long are the major causes of running injuries. The conditions you may experience are your body’s way of telling you to stop overworking it! 

What are some common running ailments?

Stiff Calves

Novice runners may experience tight and stiff calf muscles and is intimately associated with the Achilles tendon. This tendon comes from your calf muscles and joins the heel to your leg. If your body is not used to exercising the calf muscles and associated structures, you will definitely experience an ache on the back of your leg.

Runner’s Knee

Have you ever walked, climbed stairs, or ran and felt a grinding and grating in your knee joint accompanied by severe pain? If so, Runner’s Knee may be one cause! This ailment is caused by an unstable patella. (The patella is your kneecap).

Shin Splints

Running on hard surfaces such as asphalt or concrete may lead to the development of shin splints. Shin splints is that burning, irritating pain originating from the center of your lower leg. Without rest or treatment, shin splints may progress into stress fractures! 

What is the best way to treat running injuries?

Stiff Calves

Make sure that prior to starting your running routine that your calves experience a full, deep stretch. You can build up the area by rising on to your toes one foot at a time, holding that position for a count of five and then lowering it.

Runner’s Knee

The best way to alleviate this condition is to ease off of the physical activity for a week and work to strengthen the muscles around the knee. To improve muscle strength clench your thigh muscles as often as you can in sets of 5. It’s a simple way to work the muscles that connect to your patella.

Shin Splints

To reduce the occurrence of shin splints, it is advised to run on soft surfaces such as grass while wearing shoes with ample cushioning. You may have to hold off on running for an extended period of time.

Different injuries require different modes of treatment, but the tried-and-true methods always involve prevention and a good stretching regimen. Watch and pace yourself when exercising – do not overdo it! And of course, ALWAYS seek a podiatrist’s consult when evaluating the intensity of the injury and deciding on the best treatment option! 

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.flfootandankle.com