Achilles Injuries in the NFL

Jon Beason out for year with torn Achilles

Even the most conditioned athlete, with the support of numerous athletic trainers and coaches, can succumb to the devastating injury of Achilles ruptures. The worst part about this fact, is that the injury can eliminate most patients from returning to prior-injury function without adequate treatment.




The Achilles is the strongest tendon in the body, however the forces that are exerted by this structure exceed loads equal to tow trucks pulling on a stationary car for portions of a second during exercises. Many patients are seen in our office with various injuries to this area, and some with spontaneous ruptures. I had previous discussed how this can occur, and for the sake of sports injuries I will limit this discussion to when load exceeds the Young's modulus for the tendinous structures.


This bascially means that the tendon has more force than the inherent scaffolding is able to withstand. This leads to weakening of the collagen matrix and eventually can lead to ruptures. In partial and complete ruptures associated with exercise and impact sports, surgery is recommended to reduce the rate of re-rupture. But as you may have read, our Carolina Pro Bowl linebacker will be sidelined with this for the season, because it may take up to 12 months for full remodeling of the tendon to occur even with surgical repair.

We use a nonabsorbable suture method which contains a metallic wire filament called a "tightrope". This is never absorbed by the body, and is interwoven throughout the tendon to reapproximate it's tension prior to the rupture. The body then needs to augment this surgical repair by bridging the collagen matrix across the damaged portion of the tendon until full strength is achieved. I always tell patients that it will take 3 months to walk again, and a year to run again. This is by no means a minor injury.

Hopefully the Panthers have a good backup for their otherwise healthy linebacker this season !

How can diabetes deform my foot ?

Collapse of my foot and diabetes:



Charcot neuroarthropathy is a common cause of morbidity in persons with diabetes mellitus and sensory neuropathy. Although Charcot neuroarthropathy is a clinical diagnosis, recent advances in diagnostic imaging have eased the clinical challenge of deciphering infection from Charcot changes. Bone infections should be ruled out entirely before this can be said to be the diagnosis. Advances in surgical treatment have demonstrated new options for limb salvage.




There are several proposed mechanisms, but mainly it is most acceptable to believe that uncontrolled or difficult to control diabetic blood sugar levels lead to nerve damage which allows numbness to replace sensation. This allows bones to break naturally over time which go unnoticed by the individual, and the bones become inflamed and eventually break down and collapse with extensive fractures and swelling. This is a simplified description of the deforming process of Charcot foot.




Then and now.

In the recent past, the best treatments have been said to include below the knee amputations, and cumbersome braces which need to be consistently maintenenced and refurbished.

"Surgery on a diabetic is dangerous".




This was a common theme which precluded the possibility of reconstructive procedures to minimize deformity and were largely not based on evidence based medicine. Today it is known that in the vast majority of patients who develope these deformities, circulation is not compromised on a macrovascular level, but instead may be such in a microvascular setting. That means essentially that the small vessels may have glycosylated end products which impede wound healing. This usually is not on it's own a contraindication to reconstruction either, as the most common driving force for wound healing complications in this patient population may be more directly related to the abnormal bone prominences formed by the collapsing foot.

Today's current outlook on this disease process:




At FFLC, we treat all stages of this disease. Initially, we will order several important tests and imaging studies to assess the structural deformity and assess the body as a whole to come to the conclusion which is best for each patient. Newer external treatments such as multiplanar external fixation with either Achilles tenotomy or gastroc recessions, and immobilization have been a mainstay in the acute stages of the disease over the last 10 years. For chronic stable deformities, medial beaming techniques are utilized to realign the foot and ankle to a more straight position to offload centrally located ulcers.

A team approach is also essential for treatment of this complexity. Diabetes is a difficult clinical beast to slay, and whenever this systemic concern is not maintenced well, recurrence of Charcot (along with many other deletarious concerns) is likely. Usually reconstruction of the foot and ankle is performed on the presumption that multidisciplinary functions are well coordinated, such as endocrinology referral, infectious disease, vascular surgery, home health care nursing, physical therapy, and primary care are all significant parts of the entire process.

It literally takes an entire team of healthcare professionals to save a limb.

"TAKE YOUR VITAMINS" :

How vitamin D levels can impact even healthy active patients !

Low Vitamin D Linked to NFL Injuries.

Low levels of vitamin D can increase a professional athlete’s odds of injury, according to study findings by Summit Medical Group, a study of 89 players from the NFL’s New York Giants during their 2010 pre-season evaluations, 80 percent of the players were found to have insufficient levels of vitamin D. Findings also revealed that African American players and players who suffered muscle injuries had significantly lower levels. For the study they analyzed data on the number of players who had lost time due to muscle injuries. Vitamin D levels were then classified based on player race and time lost due to muscle injury.

It was presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Annual Meeting in San Diego on Sunday July 10, 2011.

Symptoms and Health Risks of Vitamin D Deficiency

Symptoms of bone pain and muscle weakness can mean you have a vitamin D deficiency. However, for many people, the symptoms are subtle. Yet even without symptoms, too little vitamin D can pose health risks. Low blood levels of the vitamin have been associated with the following:

1, Increased risk of death from cardiovascular disease
2. Cognitive impairment in older adults
3. Severe asthma in children
4. Some forms of cancer


Vitamin D is manufactured in the human body when bare skin is exposed to sunlight. Your body needs vitamin D to absorb calcium, a mineral essential to bone structure, muscle function and cardiovascular health. According to the Linus Pauling Institute at Oregon State University, vitamin D deficiency can cause muscle weakness and pain and low bone-mineral density in both adults and children. Studies have revealed a correlation between the incidence of traumatic injuries and vitamin D status.
Research suggests that vitamin D could play a role in the prevention and treatment of a number of different conditions, including type1 and type 2 diabetes, hypertension, glucose intolerance, and multiple sclerosis.

New research has connected vitamin-D deficiency to an increased risk of muscle injuries in athletes.

Researchers looked at 89 football players from a single NFL team and conducted lab tests of vitamin D levels in the spring of 2010. The mean age of the players was 25.The team gave the researchers data to allow them to determine which players had lost time because of muscle injuries.The results showed that 27 players had deficient levels of the sunshine vitamin, and 45 more had levels consistent with insufficiency. Only 17 players had levels within normal limits. Sixteen players had suffered a muscle injury—and the mean vitamin-D level of the injured players was 19.9 nh/mL, a deficient value.


Causes of Vitamin D Deficiency

Vitamin D deficiency can occur for a number of reasons:

IF

1. You don't consume the recommended levels of the vitamin over time. This is likely if you follow a strict vegetarian diet, because most of the natural sources are animal-based, including fish and fish oils, egg yolks, cheese, and beef liver.
2. Your exposure to sunlight is limited. Because the body makes vitamin D when your skin is exposed to sunlight, you may be at risk of deficiency if you are homebound, live in northern latitudes, wear long robes or head coverings for religious reasons, or have an occupation that prevents sun exposure.
3. You have dark skin. The pigment melanin reduces the skin's ability to make vitamin D in response to sunlight exposure. Some studies show that older adults with darker skin are at high risk of vitamin D deficiency.
4. Your kidneys cannot convert vitamin D to its active form. As people age their kidneys are less able to convert vitamin D to its active form, thus increasing their risk of vitamin D deficiency.
5. Your digestive tract cannot adequately absorb vitamin D. Certain medical problems, including Crohn's disease, cystic fibrosis, and celiac disease, can affect your intestine's ability to absorb vitamin D from the food you eat.
6. You are obese. Vitamin D is extracted from the blood by fat cells, altering its release into the circulation. People with a body mass index of 30 or greater often have low blood levels of vitamin D


Treatment for Vitamin D Deficiency

Treatment for vitamin D deficiency involves getting more vitamin D -- through diet, supplements, and/or through spending more time in the sun. Although there is no consensus on vitamin D levels required for optimal health -- and it likely differs depending on age and health conditions -- a concentration of less than 20 nanograms per milliliter is generally considered inadequate, requiring treatment.
Simple blood test can be obtained to determine if serum concentrations are within the acceptable normal limit, and those who are found to be deficient or on the lower end of normal with muscle aches, recurrent stress fractures, or other symptoms will be placed on some form of supplementary treatment protocol.
Guidelines from the Institute of Medicine call for increasing the recommended dietary allowance (RDA) of vitamin D to 600 international units (IU) for everyone aged 1-70, and raising it to 800 IU for adults older than 70 to optimize bone health. If you don't spend much time in the sun or always are careful to cover your skin, as sunscreen inhibits vitamin D production, you should speak to your doctor about taking a vitamin D supplement, particularly if you have other risk factors for vitamin D deficiency as mentioned earlier.

Many foods and drinks have fortified vitamin D as well, and also many doctor's offices are offering supplementations or at least recomendations for such in their offices.

Important News for Your Toddlers

As many kids become old enough to start walking on their own, many new challenges await the fledgling parents. Their children will want to approach and inspect everything they see, and often times they will not pay attention to where they are going leading to considerable bumps and bruising. But what if this leads to more serious injuries?

Occasionally at the FFLC, we will be consulted by our peers to treat atypical injuries arising from "freak accidents". Sometimes this occurs at a friend's house, other times it happens during the 4 seconds you are not able to see the child. Regardless gettting an accurate history about the injury is key to determine the treatment required for each injury and often times this is not possible. Sometimes the pattern or location of the injury may give the missing information some element of certainty.

Fractures in the long bones of toddlers is somewhat common, however it may happen with subtle force.

Typical symptoms include pain, refusing to walk or bear weight and limping -bruising and deformity are absent. On clinical examination, there can be warmth and swelling over the fracture area, as well as pain on bending the foot upwards (dorsiflexion). The initial radiographical images may be inconspicuous (a faint oblique line) and often even completely normal. After 1-2 weeks however, callus formation develops. The condition can be mistaken for osteomyelitis, transient synovitis or even child abuse. Contrary to CAST fractures, non-accidental injury typically affect the upper two-thirds or midshaft of the tibia.

Other possible fractures in this area, occurring in the cuboid, calcaneus, and fibula, can be associated or can be mistaken for a toddler's fracture. In some cases, an internal oblique radiography and radionuclide imaging can add information to anterior-posterior and lateral views. However, since treatment can also be initiated in the absence of abnormalities, this appears to have little value in most cases. It could be useful in special cases such as children with fever, those without a clear trauma or those in which the diagnosis remains unclear. Recently, ultrasound has been suggested as a helpful diagnostic tool if one is able to distract the youth long enough to allow a clear still leg to be examined with the ultrasound probe.

Pathophysiology
The proposed mechanism involves shear stress and lack of displacement due to the periosteum that is relatively strong compared to the elastic bone in young children. Very little is known as to the extent of the fall itself, or rather the typical fall necessary to induce this fracture pattern, but one clinical finding is never ignored: proximal tibial fractures and rib bruising with restrained behavior or timid demeanor.

It has been postulated, that multiple fractures in the absence of proven abuse or neglect, may require genetic testing to rule out underlying bone metabolizing disorders as well as other inheritable diseases. Some papers with the intent on clinical guideline development have theorized that 4 or more fractures in a 12 month period in toddlers is considered pathologic, and further testing is indicated. Others suggest that if a family history or in children whereby the familial genetics are unknown, immediate testing should be undertaken to better diagnostically evaluate the patient.

Spontaneous Injuries

Naples, Florida remains one of the most active communities I have lived in, with patients ranging in age from 60-90 years old still playing tennis and golf. Many of these same patients are very healthy and walk multiple miles every day. In lieu of the very active lifestyle that our patients enjoy, we have noticed many of these patients experience various forms of tendonitis and in some cases spontaneous tendon ruptures. Even though this can seem intuitive that with wear and tear our tendons may break down over time, some points about this pathology are notable and should be reviewed to answer a key point in this discussion: "why would this happen?"

TIBIALIS ANTERIOR:



We have had several patients complain of sudden inability to lift up the foot at the ankle, and pain in the front of the ankle with increased swelling and soreness. Usually after 4 days this pain subsides but function of the ankle becomes less efficient and eventually one will notice toes are grasping at the floor and the inside of the foot remains lowered during the "swing phase" of walking. This is a partial foot drop.

On average, the area corresponding to 0.5 to 3.0 cm proximal to its bony insertion is the most frequently reported site of spontaneous rupture of tibialis anterior tendon. This region of avascularity also corresponded to the location of superior and inferior retinacula, which serve as pulleys for the ATT mechanism. The hypothesis is that the hypoxic state of the tissue in this critical zone and the chronic impingement by the retinacula render this region vulnerable to chronic degeneration and, eventually, to rupture. This hypothesis is also believed to pertain to the Achilles and posterior tibialis tendons with their corresponding anatomy and fascial impingements.

ACHILLES TENDON:






We see this spontaneous rupture very commonly in "weekend warrior" type individuals, who remain very active on Saturday but otherwise are not apt to consistent exercise. Usually this tendon will forcibly stretch while the individual is propulsing off the ground, leaving excessive force passing thru the tendon leading to the rupture. Although the Achilles tendon is the strongest and largest in the body, it also recieves the most force on a consistent basis, which may lead to degredation over time. Chronic pain in the tendon which seems to never fully resolve may actually be the bodys attempt to heal this area, when in actuality the chronic inflammation leads to weakening of the collagen bridges that give much of the tensile strength of this structure, and over time it becomes thickened and eventually may rupture.


POSTERIOR TIBIAL TENDON:





This tendon has a long history of slow, progressive weakening which leads to flatfoot deformity in adulthood. Usually the tendon is not likely to spontaneously rupture until a patient is in their forties. Being overweight is a major contributing factor to this tendon being problematic. Many patients are wrongly diagnosed initially with plantar fasciitis, and this heel pain leads to medial foot pain, and eventually ankle pain.


Many patients will also experience atypical tendon ruptures just from their other comorbidities. Rheumatoid arthritis, and other autoimmune disorders will have a much higher rate of spontaneous tendon ruptures. Also many patients who have been on various antibiotic therapy may experience widespread tendonitis and sometimes ruptures. Many times longstanding tendonitis (especially of the achilles tendon) will lead to eventual rupture without proper treatment and immobilization.

Don't ignore pain in the foot and ankle, as it may be your body's way to warn you of a possible tendon rupture waiting to happen!!

Dr Timm

Do your feet put the 'odor' in 'odoriferous'??

There are many commercials which are on television about erectile dysfunction, and I feel that in our profession the equivalent to this topic as far as being embarrassing for many patients is the topic of foot odor. Many people suffer from this condition, and it is usually ignored as a medical problem. The truth is that it can lead to several medical condition which are seen very commonly in the office of a foot and ankle surgeon.

The medical term for this excessive sweating is "hyperhydrosis" and it literally means "excessive water" or if you read between the lines even further, could mean abundant moisture.

Complications of hyperhidrosis include:

Fungal nail infections. People who sweat profusely are prone to many types of fungal infections. That's because fungi thrive in warm, moist environments, such as sweaty shoes. That's also why you're more likely to get an infection in your toenail than in your fingernail. A nail infection usually begins as a white or yellow spot under the tip of your nail. As the fungal infection spreads deeper, your nail may discolor, thicken and develop crumbling edges. Sometimes your nail may separate from the nail bed, and the skin around it may become red and swollen. You may even detect a slight odor.
Bacterial infections and warts. Hyperhidrosis can contribute to bacterial infections, especially around hair follicles or between your toes. It's also associated with warts. When you have hyperhidrosis, warts may take a while to go away after treatment and they have a tendency to recur.
Social and emotional consequences. People with hyperhidrosis typically have excessive sweating of the soles and palms, which may produce clammy hands and unpleasant foot odor. As a result, they can experience significant psychological, social, educational and occupational consequences.
Other skin conditions. Certain skin conditions, such as eczema and skin rashes, occur more frequently in people with hyperhidrosis. It may be that excessive sweating exacerbates skin inflammation.


Treatment for this may range from simple shoe and sock changes, to topical over the counter therapy. And in some instances we need to prescribe a formal treatment from your local pharmacy. In most cases, we are able to control this nuisance and allow you to return to your life without being as self conscious about your feet.

Palliative care:
Essentially, one must cycle through white socks regularly, throwing away older socks that are worn or have an odor even after washing them.
Change shoe gear and if you are active you should have new shoes for your activity every few months. Some runners should change their shoe gear every 3 months, as the miles take a toll on the materials of the shoes you use anyhow.

More than just "foot pain"

In my profession, I have diagnosed numerous and varying disorders which are not typically something a primary care doctor would initially send a patient to a foot and ankle specialist for. I have screened numerous diabetic patients, and have found a substantially high number of patients with PAD, or peripheral arterial disease. Of these, many have needed vascular surgery intervention to prevent below knee amputations. Through this screening process, we have saved numerous patients from amputations of their legs.

To a greater extent, this disorder may lead to stroke, heart attacks, and even amputations from gangrene. I have had patients ask me why they need to go to the hospital for their rest pain, and thank me after the fact. Today I thought I would give some general guidelines to put to rest many of the confusions regarding this systemic and devastating pathologic process.

"Doctor, my foot hurts me at rest. I take ibuprofen and it doesn't help. I let my leg down and it feels a little better, but when I raise it up it hurts again. I can only walk for a block then I have to rest. My ingrown nail is turning black and I stubbed it 2 weeks ago."

These are just some of the various complaints that a patient may have before they know that they have significant PAD. Slow to heal wounds, and non healing wounds are commonplace in poor circulation sufferers. Pain at rest is usually significant, because it means the tissue is starving for oxygen, and if the blood vessels are too narrowed or closed to deliver, then pain will follow. Trivial injuries which lead to significant pain and color changes of the toes, from blue to black, will also indicate a serious vascular pathology which requires hospitalization. Each patient that we see gets a thorough vascular exam for their legs, and noninvasive dopplar studies are done every Friday at our office.

Pain with consist ant ambulation, "ie intermittant claudication" may need additional interventions from a vascular surgeon. Usually blood thinners, such as plavix or aspirin are needed, as well as a walking regimen lead by a physical therapist to get 30 minutes to 1 hour of daily walking to help open the small vessels and treat this are in order. We also offer MICROVAS therapy for small vessel disease, as this tends to simulate the activity level of walking for 30 minutes, and helps to increase the blood flow to the leg and foot. I always listen to the pulses with the dopplar if I can not feel them with my hands. This is usually the case with diabetic patients, as their vessels are more rigid and difficult to feel with hands and fingers alone.