Drinking Enough Water?

Hydration is a primary key to performance in sports, especially in the case of high endurance requiring activity like running, playing basketball, soccer, or tennis. We see a number of patients who are coming in with chronic aching legs and "charlie horse" variety of symptoms at night. These patients are not typically reporting any specific injury, but they are stating in general that sleep is difficult, and "locking" or "knotting" in the muscles is noted. These typically lead to immediate need to discontinue current activity, and keep area extended to prevent flexion locking while actively experiencing the cramping sensations.

If you've ever had muscle spasms or muscle cramps, you know they can be extremely painful. In some cases, a muscle may spasm so forcefully that it results in a bruise on the skin. Most muscle spasms and cramps are involuntary contractions of a muscle. A serious muscle spasm doesn't release on its own and requires manual stretching to help relax and lengthen the shortened muscle. Spasms and cramps can be mild or extremely painful. While they can happen to any skeletal muscle, they are most common in the legs and feet and muscles that cross two joints (the calf muscle, for example). Cramps can involve part of a muscle or all the muscles in a group. The most commonly affected muscle groups are:


•Back of lower leg / calf (gastrocnemius).

•Back of thigh (hamstrings).

•Front of thigh (quadriceps).

•Feet, hands, arms, abdomen

Muscle cramps range in intensity from a slight twitch or tic to severe pain. A cramped muscle can feel rock-hard and last a few seconds to several minutes or longer. It is not uncommon for cramps to ease up and then return several times before they go away entirely.



What Causes Muscle Cramps

The exact cause of muscle cramps is still unknown, but the theories most commonly cited include:

•Altered neuromuscular control

•Dehydration

•Electrolyte depletion

•Poor conditioning

•Muscle fatigue

•Doing a new activity

Other factors that have been associated with muscle cramps include exercising in extreme heat. The belief is that muscle cramps are more common during exercise in the heat because sweat contains fluids as well as electrolyte (salt, potassium, magnesium and calcium). When these nutrients fall to certain levels, the incidence of muscle spasms increases. Because athletes are more likely to get cramps in the preseason, near the end of (or the night after) intense or prolonged exercise, some feel that a lack of conditioning results in cramps.



Research Supports Altered Neuromuscular Control as the Cause of Cramps

While all these theories are being studied, researchers are finding more evidence that the "altered neuromuscular control" hypothesis is the principal pathophysiological mechanism the leads to exercise-associated muscle cramping (EAMC). Altered neuromuscular control is often related to muscle fatigue and results in a disruption of muscle coordination and control.

According to a review of the literature conducted by Martin Schwellnus from the University of Cape Town, the evidence supporting both the "electrolyte depletion" and "dehydration" hypotheses as the cause of muscle cramps is not convincing. He reviewed the available literature supporting these theories and found mostly anecdotal clinical observations and one small case-control study with only 10 subjects. He also found another four clinical prospective cohort studies that clearly did not support the "electrolyte depletion" and "dehydration" hypotheses as the cause of muscle cramps. In his review, Schwellnus concludes that the "electrolyte depletion" and "dehydration" hypotheses do not offer plausible pathophysiological mechanisms with supporting scientific evidence that could adequately explain the clinical presentation and management of exercise-associated muscle cramping.

"Scientific evidence for the "altered neuromuscular control" hypothesis is based on evidence from research studies in human models of muscle cramping, epidemiological studies in cramping athletes, and animal experimental data. Whilst it is clear that further evidence to support the "altered neuromuscular control" hypothesis is also required, research data are accumulating that support this as the principal pathophysiological mechanism for the aetiology of exercise-associated muscle cramping (EAMC)."

Treating Muscle Cramps

Cramps usually go away on their own without treatment, but these tips appears to help speed the healing process:

•Stop the activity that caused the cramp.

•Gently stretch and massage the cramping muscle.

•Hold the joint in a stretched position until the cramp stops.

Preventing Muscle Cramps

Until we learn the exact cause of muscle cramps, it will be difficult to say with any confidence how to prevent them. However, these tips are most recommended by experts and athletes alike:

•Improve fitness and avoid muscle fatigue

•Stretch regularly after exercise

•Warm up before exercise

•Stretch the calf muscle: In a standing lunge with both feet pointed forward, straighten the rear leg.

•Stretch the hamstring muscle: Sit with one leg folded in and the other straight out, foot upright and toes and ankle relaxed. Lean forward slightly, touch foot of straightened leg. (Repeat with opposite leg.)

•Stretch the quadriceps muscle: While standing, hold top of foot with opposite hand and gently pull heel toward buttocks. (Repeat with opposite leg.)

Most muscle cramps are not serious. If your muscle cramps are severe, frequent, constant or of concern, see your doctor.


Source http://sportsmedicine.about.com/od/legpainandinjuries/a/muscle_spasms.htm

The Mini Bunion

"I have a bunion on the outside of my foot"

This is more commonly called a bunionette, which is a small bunion occurring on the outside of the foot. They are also called tailor’s bunions, which likely stemmed from a shoemaker's peril in constructing fitting shoes for patients with extremely wide distal feet. Regular bunions affect the big toe, while a bunionette is a bunion on the pinky toes. A bunionette is a visible bump along the outside of the foot at the base of the little toe.During the development of a bunionette, the little toe is being pushed over towards the other toes. Over time, this causes the joint at the base of the little toe to protrude. Without treatment, bunions and bunionettes may progress to a completely dislocated toe with excessive widening of the angle between the fourth and fifth metatarsal bones. A painful callous, "Lister's" corn, or other abnormality may form at the site of the bunionette.Tailor’s bunions often happen to people who have feet which pronate excessively during their gait. These smaller bunions can also be a result of footwear that doesn’t fit properly. A more uncommon cause may be a genetic predisposition towards bunions which is passed from parents to offspring in a seemingly predictable pattern. A doctor will rule out other causes for the pain and swelling, such as arthritis or joint infection.Another cause, as the pseudonym “tailor’s bunion” implies, could be related to occupational or habitual pressure on the outside of the foot. The name comes from the fact that tailor’s were prone to these small, external bunions due to the position they kept their feet in while working, which may have caused pressure to the joint leading to bursal formation and eventual lateral capsule "wear and tear" leading to the medial pull of the toe towards the others.Though it is a possible cause, bunionettes are almost always caused by footwear. Ballet dancers are prone to bunionettes due to the tight ballet shoes.Bunionettes can be painful, especially when irritated by friction from footwear. A non-surgical treatment option for a bunionette involves buying shoes that allow more room for the toes. This may be coupled with various cushions and even arch supportive orthotics to reduce the abnormal pronation which may allow for more rapid progression of the deformity.Someone with tailor’s bunions may choose to go barefoot or wear sandals to stop this irritation. A shoe repair shop may be able to stretch shoes that are uncomfortable. In some cases, wearing footwear that doesn’t put pressure on the foot is the only treatment needed.Using nonsteroidal anti-inflammatory drugs (NSAIDS) may help relieve any pain or discomfort. Elevating the foot and applying ice to the affected area can give some relief. Any bunions occurring in children require medical attention.Using bunionette pads can help alleviate the pain. A bunionette pad cushions the affected area and stops friction from footwear. Bunionette pads are available at most drug stores. Moleskin or felt patches can be used to stop the bunionette from rubbing against the shoes.Tailor’s bunion surgery is an option if the bunionette is problematic. Bunion foot surgery should only be considered if the non-surgical bunion treatments fail to provide relief. The surgeon will order tailor’s bunion x ray to check the degree of damage to the foot. The surgeon will consider this and other factors to decide which procedure or procedures will be most effective to relieve your symptoms.

Season in full swing

Every year during when the weather is cold "up north" the weather stays nice here in Naples, and so the patient volume can triple secondary to seasonal residents seeking foot and ankle care in our center. This time seems hectic and many patients are trying to enjoy the time that they share between their northern homes and their vacation homes in this area. This can sometimes be hampered by injury, sickness, and even unforseen foot and ankle pain. At our center, we strive to reduce pains from tendonitis, relieve infections from insect bites and stingray punctures, and take care of any other short or long term concern which just will not succumb to the schedules of our patients during their vacations in Naples. We are constantly treating patients during their stay in our area and even if this is strictly temporary until they return North, we are able to guarantee excellent care by means of extensive training as well as by extensive experience.

Irregardless the size of the injury or extent of the infection, we will keep you safe until you can get home in time for the summer. With our electronic records system, we can even email records to a physician to fascilitate ease of transition from here to home. And we are glad to follow up with any concerns which may carry over from home to here as well. Keep that in mind as you walk the beachlines, or play tennis and golf and thing are just not feeling quite right. There is always enough time to get you at least on track towards enjoying the rest of your vacation if you are treated at FFLC.

New Years Resolutions

Every year around mid January and into February, we get an influx of patients who are very driven to lose weight secondary to overindulgent eating during the holiday season. This leads to a high degree of previously inactive individuals who are developing heel pain from their newly achieved activity level. This creates a formidable foe with regards to maintaining an exercise level consistant with weight loss goals.

At FFLC we strive to get you back out there running, and this is done via a variety of measures for treatment of heel pain, which consists of well conforming inserts for your shoes, as well as ultrasound guided examinations to pinpoint pathology and isolate sore bursal formations and fascia tears. We strive to keep this community active, and usually this can be managed without surgical interventions. We routinely perform physician guided physical therapy at out PT office and for difficult to resolve pain, we will utilize state of the art extracorporal shock wave therapy.

When you are not stretching your legs and heels appropriately, a night splint may be very useful to allow you to stretch out the fascia and reduce recurrence of painful heels. With xrays on site and experienced foot and ankle surgeons on your side, it is no wonder Naples continues to stay active, even when heel pain becomes part of the equation.

Mucoid Cysts in the Toes

Sometimes a small cyst or ganglion will form on the toes at the joint just behind the toe nail. If punctured a thick gelatinous fluid escapes. These are technically tiny toe ganglions but in this location they are more correctly knows as a mucoid cyst. They are frequently treated by a "puncture" and the injection of a bit of cortisone. Unfortunately they often recur. A more permanent correction involves the removal of a little bone.

Solving this problem will require a "hammertoe" surgery that can be done in the office with local anesthesia or the surgery center under local anesthesia with a bit of sedation. A surgical shoe will need to be worn for a week or two followed by a tennis shoe for another week or so.

This is a fluid filled cyst that balloons out from the underlying joint (much like the inner tube of a bicycle tire can squeeze out between the cracks of an old tire). Sometimes these pesky little things will go away by puncturing the cyst with a needle (of course, after anesthetizing the toe first!) and injecting a drop or tow of cortisone. Most of the time they come back after this kind of I&D (incision and drainage) and they need to be removed surgically. Even surgery can fail if you are not aggressive and take the entire cyst, down to the bone.

Lisfranc injury ends NFL season potentially

Matt Schaub of the NFL's Houston Texans, sustained a midfoot sprain to the right foot, notably called a "Lisfranc" injury in last week's game. This is considered a "significant injury" which has the potential to end his season in 2011.







Why is that?








Most players require lateral movement and the ability to jump and stop suddenly after sprinting. These are all functions that the midfoot complex will play a significant role in accomplishing. The injury itself is a complicated one, with numerous variations that each have a significant prognosis in longterm funcion. This injury may have a pure ligamentous tear, or even a fracture component with the ligament tear. With this, some orthopedic literature has condoned the possibility that with regards to athletes, surgery may be indicated in more cases to realign the foot and promote more stability longterm. Other studies have shown that if the alignment is maintained with the bones of the midfoot, a cast or walking boot may be sufficient for a minimum of 6 weeks followed by progressive weight bearing.


Classification
There are three classifications for the fracture:

1) Homolateral: All 5 metatarsals are displaced in the same direction. Lateral displacement may also suggest cuboidal fracture
2) Isolated: 1 or 2 metatarsals are displaced from the others
3) Divergent: metatarsals are displaced in a sagittal or coronal plane. May also involve intercuneiform area and a navicular fracture.

Treatment
Treatment options include operative or non-operative treatment. If the dislocation is less than 2 mm, the fracture can be managed with casting for 6 weeks. The patient's injured limb cannot bear weight during this period. For operative treatment, screws +/- k-wire will be used for internal fixation of the fracture after closed or more likely open reduction. Again, the patient's injured limb should not bear weight for approximately 6–12 weeks. The screws/k-wires are usually removed later, sometimes before weight bearing.

At FFLC, we find this injury to be a relatively underdiagnosed entity, and have had to treat numerous late onset arthrosis, as well as acute injury patients with this mechanism of injury. If you are on the field, and you twist your foot and it remains painful, it is not a straightfoward injury and should be followed by a foot and ankle surgeon.

Even with that being said, the possibility of late onset arthrosis and deformity can ensue without proper diagnosis, and in the NFL the players are fortunate to have medical professionals there to diagnose them right at the time of injury.

Is MRI really being overutilized?

So often in this litigious society, practitioners are being scrutinized by lawyers for malpractice. This includes lacking diagnostic information to either support or negate a diagnosis. That is why wounds are cultured without looking "infected" and why radiographs are done even after soft tissue surgery. So often are practitioners forced to practice "defensive medicine" that the costs for health care are going to rise simply because of these examinations. Without these tests to "confirm" a diagnosis, surgery may not be authorized by an insurance company, or if someone is injured on the job or as part of a traffic accident, the extent of damage may be overlooked.

This is in my opinion, that these tests need to be done. MRI should be ordered to confirm or negate osteomyelitis in the presence of diabetic foot wounds. Also with severe ankle sprains to rule out underling ligamentous damage or cartilage lesions. Without the tests, even in the presence of clinically suspicious findings, there will always be a malpractice lawyer who will ask you, "why didn't you get the test, Dr?"

In the case of MRI, there are few to no real risks, as there are no radiation exposures for this exam. Also, for patients that are not able to have this test (ie. pacemaker,etc) it is usually determined by CT scan for whatever the reason for the advanced imaging. In other words, these tests are available and although not entirely necessary, they are invaluable to not only diagnose with more certainty, but also allow for surgical planning and provide further means to demonstrate pathology leading towards surgical intervention in the case of malpractice depositions.

The coutnter argument is that over-utilization of MRI is expensive and wasteful, according to researchers. For example, the information needed to diagnose knee OA can be obtained using x-ray. While an x-ray can cost less than $150, the cost of an MRI is about $2,500.
Medical imaging accounts for 10 to 15% of Medicare payments to physicians. Ten years ago, medical imaging accounted for less than 5%. The cost of medical imaging is expected to continue soaring at an annual rate of at least 20%. Suffice to say, it's an expensive business.

And sometimes, MRI findings may be overly sensitive, leading to incorrect diagnosis, or over diagnosis of tendon pathology.

This nails home another concept I have discussed on here on many occasions. We treat the patients, not the MRI findings. We need to understand the personality of the injury and how that injury is presenting itself in you, how your lifestyle or quality of life is affected, and whether or not the findings that we have identified on the MRI are in fact the competent producing cause of your discomfort — and then come up with an appropriate treatment plan that will likely involve a period of nonsurgical management— which, if unsuccessful perhaps might lead to an indicated surgical procedure, if your lifestyle changes and quality-of-life dictates that this is in fact an option.