This is a cartoon from the back. Calf muscle, big band… your second muscle is back here… then it becomes a tendon right down here. There’s two muscles in your calf, gastrocnemius muscle and the soleus muscle, which then come down to form this Achilles tendon and inserts down into the heel bone.  Treatment once again, nonoperative: stretching, bracing, casting. In this case we never…I never like to have cortisone injections. Although cortisone is helpful in a lot of places in orthopedics, getting injections around the Achilles tendon always worries me. Higher risk for rupturing the tendon. There’s better ways to treat tendonitis in this area than getting shots there. Some people may have heard about these newer treatments. PRP, it’s all over the news, everybody’s heard about it ever since the Steelers won the Superbowl three years ago. Basically this is a concept where you have some blood taken, they spin it down to get down to the plasma and then inject that plasma into a body part. There’s not any great science now that it works. You’ll hear plenty of people say “Hey, I did it. Works great.” Science isn’t quite there yet but it’s certainly something that’s on horizon, we’re testing it to find if it is really something to consider. Shockwave, this ultrasound shockwave treatment, again, it’s a newer concept. It’s been shown to work sometimes with tendons of the elbow, maybe in the heel. Again, one of those things we are certainly looking into. Surgery for the Achilles tendon. Same rule always applies. It is only performed when there is a failure with conservative management. I’m going to briefly talk about this because this came [inaudible] day-long conference on tendonitis surgery but essentially  if you’re having he insertional Achilles pain which is directly where the tendon is inserting on to the heel bone, sometimes there’s a big spur or calcium build up down there. In order to get that out you got to peel the tendon off the bone, remove that spur and reattach the Achilles to the bone again. If, however, you gotten this tendonosis I mentioned earlier where this pain is directly in the Achilles and you can see this on MRIs and things, it’s a different sort of surgery we don’t want to go down to where it inserts itself onto the heel, in this case you have to actually excise or remove that thickened, scarred down piece of tendon and in order to strengthen it we do different kinds procedures such as tendon transfers. This is a little more involved surgery.

Plantar fasciitis. The most common problem you see if you see foot and ankle injuries in the office at all. Everybody calls this heel pain, or bone spurs or heel spurs but in general 99% of the time when somebody comes to the office with heel pain, it’s plantar fasciitis. I’m going to show you a picture again, another cartoon what this Plantar Fasciitis is but think of it as this thickened band of tissue that radiates from your heel all the way up toward your toes. The pain is not caused from the bone spur and nobody wants to believe me but that’s true. The pain is actually caused from the band of tissue that has these microscopic tears in it. You might have a spur, you might not have a spur, it doesn’t mean you don’t have Plantar Fasciitis. Plantar fascia does help to maintain the arch, if not the only thing that gives you an arch. Symptoms are classic. Pain when you first wake up in the morning or after prolonged sitting or after activities. You’re up, you’re running, you’re doing fine until you sit down for a coffee break or go to sleep at night then this plantar fascia crinkles up on itself, you go to stand up, you re-tear it, it hurts like crazy until it stretches out. That’s usually the typical presentation. So here’s a picture of this band. I can’t call it a tendon or a ligament; it’s really just a fascia or a band of tissue that runs along the bottom of your foot. There’s your heel bone, here’s this fascia, goes all the way up your toes and right there. I guarantee there’s people in this room that have this or have had it or knows people that have had it, that’s where it hurts you. It’s right there on the inside bottom of your heel, worst when you first get up in the morning.  Causes. There’s a million causes of Plantar Fasciitis. Sometimes we can say it’s from an overuse injury, sometimes it’s weight gain, sometimes it’s a new activity. The fact is most of the time we don’t even know what brought it on or what the causes were. Treatment. Almost always nonsurgical.  And I wrote it in big capital letters three times: stretch, stretch, stretch. How you stretch, doesn’t matter. If you stretch with a therapist, if you stretch at home, if you stretch with a fancy [inaudible], whatever you do stretching is the key. There’s other things that people will talk about. However you do it, stretching is the way to cure this problem. Orthotics, fancy way to stretch your foot while you’re in your shoes throughout the day. Night splints or just ways to stretch it throughout the night time. I do mention cortisone injections here.

I rarely would use a cortisone shot. If somebody comes in and they are just in a lot of pain and can’t even stand on it then the cortisone might help to decrease the inflammation and make it feel better but it’s not going to cure your problem and it hurts like crazy too so I don’t do a lot of those shots. Surgery is only indicated if you’ve had 6 to 12 months of failure of conservative management and that’s because this almost always goes away with the right stretching exercises. If you do operate it can be done either through an incision or through a scope again but basically we’re doing the ultimate stretch, you’re just releasing that band of tissue. Stress fractures. I’ve talked about this briefly earlier. I’m not going to go into it too much. It’s just an overuse injury to a bone. “Paperclip concept” that I’ve talked about earlier. It can occur in any bone in the leg. Fairly commonly seen in tibias, which is your leg bone. You might think that you just have shin splints and it’s going to go away but in fact it could be a stress fracture. In heel bone, calcaneus, that’s a big runner injury or somebody does a marathon and they just can’t stand on their heel the next day. Metatarsals, these are the probably the most common place for stress fractures in the foot. They are the bones that connect your back of your foot to your toes. Diagnosis. X-Rays are usually normal. You take a paperclip and you bend it a thousand times you get little cracks in there that don’t show up on an X ray. Next step is either an MRI scan or a bone scan and that’s the way we usually will diagnose this. Treatment. Easy – eliminate the stress. Stop the activity, so it’s either a cast, a walking boot or some sort of brace to take the stress off the area. If you’re having trouble getting these things to heal there are more aggressive treatments such as these bone stimulators and injections and extremely rare for a stress fracture not to heal. [inaudible] or it’s been there for months and months and months sometimes surgery, just like we treat any fracture, with plates and screws and whatever you need to fix the fracture. Last problem I’m going to talk about in this wearing down is arthritis of the big toe. Arthritis as most people know is losing the cartilage; you lose the Teflon coating against the bones. A very common place to get the arthritis in lower extremities is in the big toe. It’s not your toe, it’s where your toe is connecting to your foot. It’s called the metatarsal phalangeal joint. Extremely common place to have this. Very common in former athletes or runners. It’s an old turf toe injury or old runner injury. Your first MTPJ which stands for metatarsal phalangeal join, we’re going to call that big toe joint, takes on a lot of stress and it’s an area that is very common 20, 30, 40 years after the sport that that area gets arthritis. I just mentioned this wearing down of cartilage in the area.  Sometimes it’s a single injury. A lot of [inaudible] or up on their toes. Somebody can fall on the back of their heel, jam that big toe up and it hurts for that game or for that week and goes away until 20 years later. [inaudible] I can talk to that one on an experience. Symptoms: pain in the area, swelling, bony deformity, loss of motion. All these things go along with arthritis. Diagnosing this, usually X rays. [inaudible] across the room. Nonoperative treatment for arthritis in this area: changing your shoes, try orthotics, maybe cortisone injections and medications we’ve talked about. Operative treatment very common for somebody who has such bad arthritis that doesn’t go away on its own. Arthritis never goes away, it’s the symptoms we are trying to treat. If it’s mild, only a few bone spurs in the area, maybe you can do a simple surgery like “clean up surgery” where you remove the bone spur, get the toe moving a little bit. More often arthritis has gotten much more severe and in this joint particularly joint replacement, like people who’ve had the hip and knee replacement, simply don’t work.

There is just too much stress in this big toe joint. I’m a proponent in this area of joint orthotesis which is a fancy way of saying to fuse the bones together. If you fuse them together in the right position they don’t hurt, they don’t move and you can still get into all, just about any activity you did beforehand. Now we’re into acute injuries. This is no longer the chronic wear and tear. These are some things that a lot of people have seen, had or know about. Torn meniscus doesn’t have to be in an athlete of 20. This can be in 40, 50, 60 year old folks. 70 and 80 year olds. Meniscus is the shock absorber part in joint of knee. It’s between the femur and the tibia. You have two of them, one of them inside one in the outside. They are these two C shaped bands of tissue that are very important for protecting your knee but unfortunately don’t have a great blood supply so once it’s torn, most of the time it stays torn. Twisting injuries to the knee, hyperextension injuries to the knee. And once you’ve gotten a little bit older that cartilage is not as rubbery as it used to be, it gets little more stiff so sometimes it’s not even one injury it’s more of a repetitive wear and tear thing. You can get cartilage wear and tear as well. Symptoms: knee swells, catches, locks, sometimes feeling of instability or your knee giving out, loss of motion to the point where some people [inaudible] they can’t move it at all. Diagnosing this is usually by examining the patient and of course MRI scan is critical in diagnosing meniscus tear. Yeah, I saw that injury. That guy might have a little bit of a meniscus tear potentially. Treatment. Unlike overuse injuries this problem is usually a surgical problem. You can try nonoperative management therapy, injections,  [inaudible] Once it’s torn most of the time it doesn’t heal itself. Usually this is a surgery problem done nowadays through an arthroscope which is a camera, they put a camera into your knee, usually one other incision with their little tools and then go in and remove the torn section of cartilage.