My name is Rick Laughlin, and I work in orthopedic surgery.  I’m on the faculty of the medical school, and our practice is spread out throughout the city.  Most our hospital work is in Miami Valley Hospital downtown.

Just to give you a little bit of the history of the building, the medical school here’s been for around 30 years, and they used to have a practice planned out here in the building that’s become the new medical school.  That’s that white building, or some of you may have read the paper.  That’s White Hall.  That used to be a practice facility.  So, for a period of time, we didn’t have any place to see outpatients here on campus.  This building’s a product of about seven to eight years of planning, and we’ve had the advantage of learning what we learned from the old building of what worked and what didn’t.  I think the exciting thing about this building is we have merged together several departments so we can provide a lot of services.  The genesis of much of it was driven by the athletic training department.

The athletic trainers needed much more space so we were able to combine our rehab facilities and physical therapy with the athletic trainers’.  So, that’s on the first floor, and we think we’ll be able to provide a great service in rehab for the same people that are rehabbing the varsity athletes will be working on our patient population.  We think we can all learn quite a bit from each other.

We moved into the building last July.  As we’ve gotten in and figured out where everything is, we’re going to start some educational sessions that we could present to the community.  This is the first one of these presentations.  We hope to do this on a regular basis and provide educational material to the surrounding community.   I really appreciate you all coming out and welcome.  The presentation is a general presentation, and if any of you have any questions, certainly feel free to ask them along the way.  So, we’ll get started.

We’re going to talk about just a few things that are very common problems in the foot and ankle.  My practice focuses on foot and ankle reconstruction, and there’s a lot of problems.  I think when people think of foot and ankle problems, you easily focus on the toes.  Everybody knows about bunions and hammertoes and things like that, but there’s a lot of problems around the back part of the foot or around the ankle that oftentimes go undiagnosed.  They can be cause for a lot of problems and pain, and a lot of times, people just live with it.  There are things you can do for it that are better.

The things we’re going to talk about tonight are flatfoot (one of the more common problems), Achilles tendon problem, and also peroneal tendon problems.  These are all tendons that cross the ankle.  Oftentimes, a lot of problems in orthopedics and soft tissues start becoming symptomatic around middle age.  Usually around the time that we turn 40, 45, many of our tendons don’t repair themselves as well.  So, get wear and tear problems with some of the tendons, and I’m sure a lot of you have heard about the rotator cuff.  A lot of the arthritis-type problems start becoming more commonly presented at that time.  We’re going to go over some of the tendon problems of the foot.

In flatfoot, there’s a lot of different reasons why people have flatfoot.  Sometimes people are just born with it.  That’s just the way the structure of your bones are.  This is something that comes about quite commonly.  It’s really common in middle-aged women, probably easily 10-to-1, as far as women to men.  The posterior tibial tendon is a tendon that’s right on the inside of the foot.  It goes right around the inside of the ankle.  It’s on the big toe side of the foot, and what it does is helps support your arch.  So, when you walk and the heel hits the ground as you try and walk over your foot and push off, the posterior tibial tendon’s what stabilizes the back of your foot and allows the push off like that.  So, when that tendon fails, your arch starts to collapse.

You can see in the foot here, the foot starts going out to the side.  See, this is the normal foot.  This, you can see is a little bit out to the side, and you can see the lateral toe more.  It’s a physical exam sign, one of the things that we teach the medical students and residents.  That’s called “too many toes sign”.  That means when you look at it from the back, the foot is abducted, and you see all their lateral toes.  It should be more like this guy.  You can barely see the fifth toe.  When you go home tonight, you can look at your husband or your wife.  Look at them from the back and see if they have the right number of toes.

The typical history is oftentimes people may have long standing history of flatfeet.  They’re usually flexible though.  Some people have flatfeet where they’re real stiff, and no matter what you do, you can’t push them back under.  Oftentimes, these are flexible, and usually the pain, again, is on the inside of the ankle.  It’s not something that tends to get better.  Some things in the body have the ability to heal.  This particular tendon, when it fails, it typically doesn’t heal.  It continues to stretch out, and when it stretches out, it’s like a rope that’s got too much slack in it.  If the rope’s got a lot of slack it in, you pull it, and nothing happens.  That’s basically what happens to your foot, and it changes the way you walk.

Oftentimes, people may have a bit of a flatfoot, and they may not have pain.  They may have what seems like a minor sprain (you step off a curb).  It’s like the straw that breaks the camel’s back, and then the tendon fails.  You get swelling around your ankle.  Your arch collapses.  Then, you’ll notice the asymmetric progression.  So, one foot gets more flat than the other.  As you get out of the shower, as you look down at your feet, one is more flat, and the toes go out to the side.

So, physical exam.  Again, we talked about this a little bit before.  See how it heels out to the side?  Usually, you’re tender right on the inside of the big toe side of the foot, right around your ankle.  The other thing that you find is commonly when we examine you, we ask you to raise up on your toes.  As you raise up on your toes, you should see your heel invert, and again, that’s testing the function of that tendon.  Usually, once you get a foot like this, if you notice when this person stands on their left foot, they can’t raise up on their toes independently.  That’s what that tendon does.  So, there’s the heel raise.  Again, you can see, as he goes up, his heels go in a little bit.

So, people who have that, you can see, have their toes to the side.  You can see the big toe on the other side.  So, when that tendon doesn’t work, you get chronic swelling around the ankle.  People notice that they’re weaker as far as with their push-off, and it’s usually an activity-related pain.

Usually all you need is an X-ray.  I think one thing that’s common (and I don’t mean to make this an economics talk) but I know many of you have to start watching how you spend your healthcare money.  This is not a condition that requires MRI.  To get a diagnosis, you just need a physical exam, and MRIs are ordered a lot for a lot of problems.  In the foot and ankle, there’s a few things where they’re helpful, but for the most part, usually, you don’t need an MRI to make a diagnosis.  So, MRIs are extremely helpful in the shoulders and knees and backs, but in foot, they’re not all the helpful in making a diagnosis.  So, if someone orders an MRI of your foot, ask them if you really need it that much, especially if you’re paying for it out of your health savings account.

So, what we look for on the X-ray, you just need an X-ray with you standing.  This is your tibia, here there’s your calcaneus. Then you’re looking at your medial arch.  These bones should all line up pretty well.  You can see on this side the difference is you’ve got a sag.  So, what your posterior tibial tendon does, it comes down here, and it attaches right here to the bone.  So, when it’s not working anymore, these bones start to sag.  Then, you get the deformity.

So, these are just some of the structures that give way to the posterior tibial tendon.  The spring ligament is a ligament on the bottom of the foot that helps support the arch.  Then, the deltoid ligament is the medial ligament of the ankle, and that helps keep the heels centered under the leg.  This is what you get abduction through the forefoot.  The hindfoot valgus, that refers to the angulation of the heel.  The medial side or the big to side is very mobile so you can move it up and down, wherever you want. One of the ways they describe it to the patient is you think of your foot as a three-legged stool. You have three legs.  Your heel is one.  Then, your big toe side is one.  The small toe side is the other.  When one of those legs give out, meaning the medial side, the three-legged stool stars leaning over to the side, and that’s what happens with your foot.

We divide it into stages so it’s a very simple classification.  Stage 1 means there’s no deformity.  It’s just the tendon.  It’s swollen, but your arch hasn’t collapsed yet.  This is where you want to catch people because a lot of times if you get them in some type of brace or arch support that protects the tendon, and then you do some physical therapy.  Over 50%, usually 60-70%, their symptoms will go away, and they may not need anything else done.  So, usually you don’t need surgery at this stage, and honestly, I rarely see people at this stage.  I think usually the just don’t get a diagnosis, and they haven’t noticed any deformities.  They’re either seeing family physician, taking some Motrin®, or doing the simpler thing so oftentimes they don’t see them at this stage.

Stage 2 is when you’re starting to get a deformity, but it’s flexible.  So, you could put a brace on those people, and you can push it back into the alignment it needs to be.  There are lots of different kinds of braces.  That’s just one type of brace.  We can make some of the braces cosmetic so they fit inside your shoe, but when you are wearing a braces, you’re going to have certain shoe restrictions.  These things don’t fit in any type of shoe.  You’re going to wear athletic shoe or walking shoe with it.

Again, for the pain and swelling or the acute phases, we usually help mobilize it with a brace.  Then, you get some type of physical therapy.  The hard thing to explain to people is you do that to take care of the symptoms, but the tendon typically doesn’t heel.  So, if the tendon gets stretched out, it’s not going heel and go back to its normal length and support your arch.  So, what you’re trying to accomplish with the brace is prevent the deformity from getting any worse and to take care of the symptoms or support your tendon enough so the pain goes away.  It won’t typically control your deformity.  When you put the brace on, you’re trying to prevent the tendon from elongating and the arch from collapsing more.