Overview
The Achilles tendon is an important part of the leg. It is located just behind and above the heel. It joins the heel bone to the calf muscles. Its function is to help in bending the foot downwards at the ankle (this movement is called plantar flexion by doctors). If the Achilles tendon is torn, this is called an Achilles tendon rupture. The tear may be either partial or complete. In a partial tear, the tendon is partly torn but still joined to the calf muscle. With complete tears, the tendon is completely torn so that the connection between the calf muscles and the ankle bone is lost. Causes The causes of an Achilles tendon rupture are very similar to Achilles tendinitis. Causes include. Running uphill. Running on a hard surface. Quickly changing speeds from walking to running. Playing sports that cause you to quickly start and stop. Symptoms An Achilles tendon rupture is when the tendon that connects the heel bone to the calf muscle tears and the fibers separate. This happens mostly between the ages of 30 and 50, and usually is caused by sports. Symptoms of Achilles tendon rupture include the following. A pop or snap when the tendon tears. Severe pain in back of the ankle, making it nearly impossible to walk. Swelling and discoloration. Tenderness. Inability to rise on toes. A gap in the back of the ankle where the tendons are separated. Diagnosis A diagnosis can be made clinically, but an MRI or ultrasound scan can confirm it. On examination, the patient will present with reduced plantarflexion strength, a positive Thompson test and potentially, a palpable gap in the Achilles. The whole length of the tendon should be examined to check for injuries that can occur at the insertion and the musculotendinous junction. Non Surgical Treatment Treatment of the initial injury is with use of ice, elevation, and immobilization. If suspected you should contact your podiatrist or physician. Further treatment with continued immobilization, pain medication, or anti-inflammatory medications may be advised. If casted the foot is usually placed in a plantarflexed position to decrease the stretch on the tendon. As healing progresses the cast is changed to a more dorsiflexed position at the ankle. The casting processes can be up to 8 weeks or more. Surgical Treatment While it is possible to treat an Achilles tendon rupture without surgery, this is not ideal since the maximum strength of the muscle and tendon rarely returns. The reason is the ends of the tendon are ruptured in a very irregular manner, almost like the ends of a paint brush. As soon as the tendon ruptures, the calf muscle (gastrocnemius muscle) continues to pull on the tendon and the end of the ruptured tendon pulls back into the leg, which is called retraction. Once the tendon retracts, it is never possible to get sufficient strength back without surgery, because the muscle no longer functions at the correct biomechanical length and is now stretched out. There are patients for whom surgery cannot be performed, in particular, due to existing medical conditions that may add to potential for complications following surgery. For these patients, a specially designed boot that positions the foot correctly and takes the pressure and tension off the muscle and tendon is used. Most importantly, a cast is never used because it causes permanent shrinkage (atrophy) of the calf muscle. The special boot permits pressure on the foot with walking. The boot also has a hinge to permit movement of the ankle. Many studies of Achilles tendon ruptures have shown that this movement of the foot in the boot while walking is ideal for tendon healing. If surgery is not recommended, it is essential to obtain special tests to check that the ends of the tendon are lying next to each other so that healing can occur. The best test to do this is an ultrasound and not an MRI. Overview
Small or mild length leg discrepancies (LLD), i.e., below 3.0 cm, have been considered as enough to cause orthopaedic changes such as lumbar pain, stress fractures and osteoarthritis on lower limbs (LLLL) joints. In addition to the classification by its magnitude, discrepancies can also be categorized according to etiology, being structural when a difference is noted between bone structures' length or functional as a result of mechanical changes on the lower limb, and are found in 65% - 70% of the healthy population. Causes There are many causes of leg length discrepancy. Structural inequality is due to interference of normal bone growth of the lower extremity, which can occur from trauma or infection in a child. Functional inequality has many causes, including Poliomyelitis or other paralytic deformities can retard bone growth in children. Contracture of the Iliotibial band. Scoliosis or curvature of the spine. Fixed pelvic obliquity. Abduction or flexion contraction of the hip. Flexion contractures or other deformities of the knee. Foot deformities. Symptoms Often there are few or no symptoms prior to the age of 25-35. The most common symptom is chronic lower back pain, but also is frequently middle and upper back pain. Same-sided and repeated injury or pain to the hip, knee and/or ankle is also a hallmark of a long-standing untreated LLD. It is not uncommon to have buttock or radiating hip pain that is non-dermatomal (not from a disc) and tends to go away when lying down. Diagnosis A qualified musculoskeletal expert will first take a medical history and conduct a physical exam. Other tests may include X-rays, MRI, or CT scan to diagnose the root cause. Non Surgical Treatment In some circumstances, the physician will recommend a non-surgical form of treatment. Non-surgical treatments include orthotics and prosthetics. Orthotics are a special type of lift placed in or on a shoe that can be used in the treatment of leg length discrepancies between two and six centimeters. In pediatric patients who have large discrepancies and are not good candidates for other treatment forms, prosthetics can be helpful. Surgical Treatment Epiphysiodesis is a surgical option designed to slow down the growth of the long leg over a period of months to years. It is only used in growing children. The operation involves a general anaesthetic. Small incisions are made around the knee near the growth plates of the thigh bone and the shin bone. The growth plates are prevented from growing by the use of small screws and plates (?8 - plates?). The screws are buried beneath the skin and are not visible. Stitches are buried beneath the skin and do not need to be removed. The child is normally in hospital for 2-3 days. The child can weight bear immediately and return back to normal activity within a few weeks. Long term follow up is required to monitor the effects of the surgery. The timing of the surgery is based on the amount of growth predicted for the child. Therefore, this procedure can under- and over-correct the difference in leg length. Occasionally the screws have to be removed to allow growth to continue. This procedure can be used on one half of the growth plate to correct deformity in a limb e.g. knock-knees or bow legs. This is known as hemiepiphysiodesis.
Overview
Many patients suffer from a ?collapsing arch? or ?flat foot? which can cause pain, instability and difficulty while walking. This condition is more commonly known as Posterior Tibial Tendon Dysfunction (PTTD). PTTD is a progressive flattening of the arch due to loss of function of the Posterior Tibial tendon. As the foot flattens, the tendon will stretch, become insufficient and lose its ability to function. This can have a direct effect on walking and posture, ultimately affecting the ankle, knee and hip. As the condition progresses, the joints in the hind foot may become arthritic and painful. Causes Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs. Symptoms Pain and swelling around the inside aspect of the ankle initially. Later, the arch of the foot may fall (foot becomes flat), this change leads to walking to become difficult and painful, as well as standing for long periods. As the flat foot becomes established, pain may progress to the outer part of the ankle. Eventually, arthritis may develop. Diagnosis Examination by your foot and ankle specialist can confirm the diagnosis for most patients. An ultrasound exam performed in the office setting can evaluate the status of the posterior tibial tendon, the tendon which is primarily responsible for supporting the arch structure of the foot. Non surgical Treatment Patients can be treated non-surgically with in-shoe devices and braces to hold their feet in the correct position. This can reduce pain and damage and assist with walking. Physical therapy is also given to improve muscle strength and help prevent injury to the foot. Surgery can be performed if the patient doesn?t find any relief. Surgical Treatment In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Your foot and ankle surgeon will determine the best approach for you.
Overview
Tendons do a lot of work. In fact, a great deal of what happens when you walk can be related to tendons tugging and pulling in appropriate ways in their proper places. With this in mind, it?s hardly surprising that on occasion, (probably because we too often forget to send them ?Thank you? cards), tendons may decide that they?ve had it. They may buck their responsibilities, shirk their work, and in all other ways cease to function properly. And that may mean bad news for you. Take the posterior tibial tendon: it runs from the bottom of the calf, goes right under that bump on the inside of the ankle (the medial malleolus) and ends up attaching itself to a bone on the inside of the middle of your foot (the navicular bone). It?s the main tendon that keeps the arch of your foot in place, and it helps a bunch in walking, too. Over time, though, we tend to put a lot of stress on this faithful tendon, especially if we?ve put on extra weight, or do a lot of activities that stress it out, walking, running, hiking, or climbing stairs. Sometimes athletes (who do a lot of that walking and running stuff) may put so much stress on the tendon that it tears suddenly. But for many of us, damage may take place gradually (i.e. the tendon stretches out) until the tendon tells us that it flat out quits. (It sometimes doesn?t even give two weeks notice.) In short, you may develop posterior tibial tendon dysfunction (PTTD). Causes Posterior tibial tendon dysfunction is the most common cause of acquired adult flatfoot deformity. There is often no specific event that starts the problem, such as a sudden tendon injury. More commonly, the tendon becomes injured from cumulative wear and tear. Posterior tibial tendon dysfunction occurs more commonly in patients who already have a flat foot for other reasons. As the arch flattens, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder. Symptoms PTTD begins with a gradual stretching and loss of strength of the posterior tibial tendon which is the most important tendon supporting the arch of the human foot. Left untreated, this tendon will continue to lengthen and eventually rupture, leading to a progressive visible collapse of the arch of the foot. In the early stages, patients with PTTD will notice a pain and swelling along the inner ankle and arch. Many times, they are diagnosed with ?tendonitis? of the inner ankle. If the foot and ankle are not properly supported during this early phase, the posterior tibial tendon can rupture and devastating consequences will occur to the foot and ankle structure. The progressive adult acquired flatfoot deformity will cause the heel to roll inward in a ?valgus? or pronated direction while the forefoot will rotate outward causing a ?duckfooted? walking pattern. Eventually, significant arthritis can occur in the joints of the foot, the ankle and even the knee. Early diagnosis and treatment is critical so if you have noticed that one, or both, of your feet has become flatter in recent times come in and have it checked out. Diagnosis Perform a structural assessment of the foot and ankle. Check the ankle for alignment and position. When it comes to patients with severe PTTD, the deltoid has failed, causing an instability of the ankle and possible valgus of the ankle. This is a rare and difficult problem to address. However, if one misses it, it can lead to dire consequences and potential surgical failure. Check the heel alignment and position of the heel both loaded and during varus/valgus stress. Compare range of motion of the heel to the normal contralateral limb. Check alignment of the midtarsal joint for collapse and lateral deviation. Noting the level of lateral deviation in comparison to the contralateral limb is critical for surgical planning. Check midfoot alignment of the naviculocuneiform joints and metatarsocuneiform joints both for sag and hypermobility. Non surgical Treatment Nonoperative therapy for adult-acquired flatfoot is a reasonable treatment option that is likely to be beneficial for most patients. In this article, we describe the results of a retrospective cohort study that focused on nonoperative measures, including bracing, physical therapy, and anti-inflammatory medications, used to treat adult-acquired flatfoot in 64 consecutive patients. The results revealed the incidence of successful nonsurgical treatment to be 87.5% (56 of 64 patients), over the 27-month observation period. Overall, 78.12% of the patients with adult-acquired flatfoot were obese (body mass index [BMI] = 30), and 62.5% of the patients who failed nonsurgical therapy were obese; however, logistic regression failed to show that BMI was statistically significantly associated with the outcome of treatment. The use of any form of bracing was statistically significantly associated with successful nonsurgical treatment (fully adjusted OR = 19.8621, 95% CI 1.8774 to 210.134), whereas the presence of a split-tear of the tibialis posterior on magnetic resonance image scans was statistically significantly associated with failed nonsurgical treatment (fully adjusted OR = 0.016, 95% CI 0.0011 to 0.2347). The results of this investigation indicate that a systematic nonsurgical treatment approach to the treatment of the adult-acquired flatfoot deformity can be successful in most cases. Surgical Treatment In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Symptomatic flexible flatfoot conditions are common entities in both the adolescent and adult populations. Ligamentous laxity and equinus play a significant role in most adolescent deformities. Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult acquired flatfoot. One should consider surgical treatment for patients who have failed nonoperative therapy and have advancing symptoms and deformities that significantly interfere with the functional demands of daily life. Isolated Joint Fusion. This technique is used for well reducible flat foot by limiting motion at one or two joints that are usually arthritic. The Evans Anterior Calcaneal Osteotomy. This is indicated for late stage II adult acquired flatfoot and the flexible adolescent flatfoot. This procedure will address midtarsal instability, restore the medial longitudinal arch and reduce mild hind foot valgus. The Posterior Calcaneal Displacement Osteotomy (PCDO). This technique is indicated for late stage I and early stage II PTTD with reducible Calcaneal valgus. This is often combined with a tendon transfer. A PCDO is also indicated as an adjunctive procedure in the surgical reconstruction of the severe flexible adolescent flatfoot. Soft tissue procedure. On their own these are not very effective but in conjunction with an osseous procedure, soft tissue procedures can produce good outcome. Common ones are tendon and capsular repair, tendon lengthening and transfer procedures. Flat foot correction requires lengthy post operative period and a lot of patience. Your foot may need surgery but you might simply not have the time or endurance to go through the rehab phase of this type of surgery. We will discuss these and type of procedures necessary for your surgery in length before we go further with any type of intervention. |
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