Search for tag: "foot and ankle"

Interviewer: Maybe you have a bit of a bump on your foot, maybe it's painful, maybe it's just a little irritating, can't quite fit into the shoes that you used to wear. Is it a bunion, and what exactly is a bunion?

We're here with Dr. Devon Nixon, an orthopedic surgeon at the University of Utah Health, and he has an emphasis in lower extremity, foot, and ankle medicine.

Now, Dr. Nixon, what exactly is a bunion?

Dr. Nixon: Possibly one of the most common things that I see in practice. A bunion is more than just a bump that's forming on the outside of your big toe. What's actually happening is it's a complex change three-dimensionally in the alignment of the toe.

And sometimes it happens at a young age, so we see patients in their teenage to young adult years. And then sometimes it's acquired over time. So people in their fourth, fifth, and sixth decades of life begin to notice it gradually increasing. But it's not just a bump that's forming.

Interviewer: So what is it that causes a bunion?

Dr. Nixon: That's a great question and one that we don't have easy answers for. Probably the biggest component is genetic. We don't quite understand the genetics behind bunions, but they occur very commonly in families.

Historically, we used to put a lot of emphasis on people wearing tight shoes over the course of their lifetime. And that may or may not play a role. But my personal take is that it's not as big of a role as maybe we once put on it, that these are developing from factors that are somewhat patient-specific but largely outside of patients' control.

Interviewer: Since we understand that bunions have a genetic component to them, is there a particular population that is impacted more so you see it more commonly with?

Dr. Nixon: Certainly, bunions are more common in women than in men. They do occur in men, but certainly the heavy proportion is in favor of women.

And not all patients will have a strong family history, meaning that their mother or their grandmother, or other family members have had bunions, but certainly you hear that commonly.

But this is what we would describe in medicine is multifactorial. So there are many layers to this. Some of it is genetic, some of it is possibly shoe wear, but again, my take is that that's probably not as big of an emphasis as maybe it once was.

Interviewer: And for people that have, say, a bump on their foot, how do they know that it's a bunion and not, say, anything else that could be going on?

Dr. Nixon: I mean, certainly the easiest way to help make that distinction or determination is to come in and see someone with an orthopedic surgical focus on foot and ankle issues to help you better understand exactly what's happening.

Certainly, growths can form in your feet. But a bunion is really feeling like there's this strong bony contribution or strong bone prominence that's forming on the inside of the big toe, out by the joint. And at the same time, the big toe may be starting to drift towards the second and third toes.

So if those kinds of things are happening in concert, that's typically how a bunion looks and feels. There's a bump that's forming on the inside, but again, that's because the three-dimensional alignment of the toe is changing and not just growth that's happening at the bone level.

Interviewer: So what are some of the potential impacts that it can make on the foot on your day-to-day life if it's not treated?

Dr. Nixon: Certainly, bunions are a funny thing because they don't always bother all patients that have them. And so just because it may be a smaller "bunion" does not necessarily mean that it may not be symptomatic. So you don't necessarily have to wait until it's crossing over or underneath your second and third toes before you need to seek treatment.

The challenge is that we don't have a lot of in between options for treatment. So plenty of people try modifying their shoes to widen them so that they're more comfortable. They add some of these over-the-counter gel inserts that slide between the big toe and the second toe. And that certainly can make shoe wear and walking much more comfortable for people.

Unfortunately, doing those things does not change what we would describe as the natural history of a bunion, which is that it may slowly progress over time. And that's true for all forms of bunions.

Now, it doesn't mean that if it's progressing that it's going to be bothersome to you, but after those things no longer work, like modifying your shoes, adding in a toe spacer, if you continue to have pain and you're feeling like the bunion is limiting your quality of life, then that may be a reasonable time to start talking about what are the surgical options.

Now, bunions are extremely common. I see them many times in each clinic. Not all of them need surgery. But if you feel like you are at a position where modifying your shoes and adding some of these toe spacers is not the answer for you, then there are very reasonable things to think about from a surgical perspective, and many patients do really well from them.

Interviewer: So maybe you or a loved one has a bony protrusion on your foot. It's maybe painful, maybe not. It's a bunion. How exactly does one treat a bunion and what kind of results can one expect from the treatment options?

We're here with Dr. Devon Nixon. He is an orthopedic surgeon at University of Utah Health, with an emphasis on lower extremity, foot, and ankle medicine.

Now, Dr. Nixon, before we kind of go into treatments, let's just start real basic. What is a bunion exactly?

Dr. Nixon: A bunion is an interesting thing that we see really commonly in clinic. It's more than just a bump that's forming on the inside part of the big toe. What's actually happening is there's a complex three-dimensional change that's occurring where one portion of the toe is beginning to move towards the inside, which then drives the big toe part towards the second and third toe. And it may begin to even cross over under those second and third toes.

Interviewer: And is there any way to, say, prevent them?

Dr. Nixon: I wish there was a way to prevent them. They're very common, and certainly not everyone with a bunion needs surgery. And so there are plenty of things to do to try to make them more comfortable, like modifying your shoes or adding a toe spacer. But unfortunately, those options don't necessarily change the long-term progression, which is that the bunion may slowly increase over time.

Interviewer: So let's go back a little bit with that. When you're talking about treatments, you said it's not necessarily surgery. If we're not doing surgery, what are the other options available, and what are you actually treating with those?

Dr. Nixon: Like most things in my practice and in most orthopedic practices, there are nonsurgical and surgical treatments. And the nonsurgical things that many patients choose to do are to add some modifications to their shoes. So they get them in wider forms to help reduce some of the irritation on the inside part of the big toe, which, for many patients, is one of their biggest pain drivers.

Another thing is they can add over-the-counter gel inserts that slide between the big toe and the second toe to help push the toe a little bit out of the way to make it more comfortable.

And those are all driven based on symptoms. So the choice of whether or not to move forward with surgery is a patient-driven choice. It's certainly not one that I will make for them. My goal is to help them have the information they need to make the right choice.

But the options after modifying your shoes and adding an insert, there's not a lot of in-between. So, unfortunately, the conversation may then move towards, "What are my surgical options?" which are to help get the toes straighter and to help remove the bump.

Interviewer: So let's move on to those surgical options. As an orthopedic surgeon, any time a patient hears the word "surgery," there's a little bit of anxiety. There's a little bit of weighing the risks and benefits. Kind of walk us through the surgery. Not necessarily the nuts and bolts of everything, but as a patient, is this an outpatient procedure? How long can I expect to recover, etc.?

Dr. Nixon: Absolutely. I mean, I'm a surgeon, but I'm extremely sensitive to the fact that no one wants to go through surgery. And my job will never be to sell anyone on the surgery. It's the patient coming in to tell me that this is what they think is the best option for them. They feel like they've tried these other things.

And then the different technical options for surgery vary from patient to patient. So it's driven by a lot of factors, some of them clinical, some of them on the X-ray, some of them very patient-specific.

But largely, what we're doing is we're trying to correct the bunion by straining the big toe. And you can do that by either cutting the bone and shifting it. We call that an osteotomy.

You can fuse certain joints around the big toe. So one of them is fusing a joint closer to the middle of the foot, and we call that a Lapidus procedure.

And then another procedure is, depending on the patient, if they have some arthritis that's developed, you can fuse the actual big toe joint itself.

But a lot of these decisions of what to do from a surgical perspective are not uniform to everyone. So that's a conversation that we all have in clinic. If patients feel like they're at a surgical level, I look at the X-rays, I talk to them, get a good history, understand their activity level, what are their goals, and if there's any arthritis present, and then we talk about, "What are these varying treatment options?"

Interviewer: So a surgery like this, how long can someone expect to be undergoing treatment? How long does the procedure last and how long is recovery?

Dr. Nixon: Yeah. The surgery is an outpatient procedure. You go home the same day. The main goal is that . . . Depending on which type of surgery to do, it doesn't really change the fact that for the first four to six weeks, we're going to be keeping you off of your foot in terms of full weight out at the big toe.

If we're cutting the bone, doing what we described as an osteotomy, we need that bone to heal. And if we're trying to get joints to fuse, then we need those bones to heal together too. And so there is a form of protected weight-bearing, which can be challenging if it's your right foot because it's going to limit your driving.

But the first two weeks, you have sutures in. They get removed at two weeks. And then between Weeks 2 to 6, you're kind of protecting your foot, and then usually get X-rays around the six-week mark. Depending on the type of surgery you had, we may begin to advance your weight-bearing so that you're putting more full weight on the big toe.

Interviewer: Now, is there much physical therapy or anything involved with this particular procedure?

Dr. Nixon: Physical therapy is certainly a very reasonable thing to consider. And for some patients, they think that it's helped them considerably. Some of that depends on the type of surgery and the surgeon's specific decision-making. Not all bunions need physical therapy afterwards, but certainly plenty of patients that I operate on benefit greatly from physical therapy.

Interviewer: And what is the success rate for a procedure like this?

Dr. Nixon: It depends a little bit on the operation you do. So one of the things that we're trying to address if you have both a bunion and arthritis, if you have the big toe joint fused, and if that goes on to fusion, which can occur in about 90% or so of patients, then those are some of our happiest patients. They do quite well. They can remain very active.

The downsides to a fusion are that it does limit the motion in the big toe. So getting back into high heels is challenging. Getting back into certain types of activities, like certain yoga poses, the toe just won't let you do that. So that is one of the downsides, but it certainly is a very powerful and successful operation.

If we are preserving the joint and we are cutting the bones, then patient satisfaction is usually in the 80% to 90% range. Patients do quite well from those operations.

Whichever one you choose, they do require some level of recovery. And I would be lying to you if I said that it's a fast recovery. Some patients recover faster than others, but the first couple of weeks, there's going to be some swelling involved, so it's really important to keep it elevated. But as you begin to progress your recovery, you'll begin to get that swelling down and hopefully be able to quickly transition back into regular shoes, as we allow you to, once we get X-rays that confirm that everything has healed up well.

Interviewer: What is something that you as a surgeon would tell to give that last bit of kind of confidence to someone who's considering bunion surgery?

Dr. Nixon: I think what's really important is that the decision-making is all by the patient. My job or any of my partners' jobs is just to make sure that you have the right information to make the decision.

And at the end of the day, patients can get a lot of good pain relief and a lot of satisfaction and a lot of improvement from having their bunion corrected, whichever method you choose.

And like most things in life and in medicine, they all have some form of a pro and con weighing, a pro and con assessment, but whichever one you choose, patients do quite well from these operations. There is a recovery involved, but ultimately, patients do quite well.

Many kids, especially athletes, will complain that their feet hurt at some time. Heel pain is especially common and especially during growth spurts.

Heel pain in athletes who are growing actually has a name. It's called calcaneal apophysitis, otherwise known as Sever's disease. It is most common between the ages of 9 and 14 and is seen in athletes who do a lot of running and jumping. My teenage soccer player has this and actually so do several of his teammates, or the teammates of my younger son who will probably end up having this also. Basically, what it is, is inflammation of the growth plate of the heel bone. The bones, muscles, and tendons in that area all grow at different rates during puberty. And when they're out of sync, the muscles and tendons pull too hard on the growth plate and that causes the inflammation.

So what can your child do to help once the pain has started? Well, to be honest, the pain will improve most once your child is done with their growth spurt. Also, it's best to stop any activities that cause pain. But, of course, we know that's not going to happen, especially if your child is on a competitive or a school athletic team.

So other things that help include having an ice pack in a towel and icing the heel for 15 minutes every one to two hours during flare-ups. Have your child take an anti-inflammatory pain medicine, like ibuprofen or naproxen. But be sure to check with your child's pediatrician on dosing. Gel heel cups and shoes with good support are also helpful. They help put less pressure and less stress on the heel. Your child's pediatrician can also give you exercises that can help with stretching and which can help with the pain and help keep the condition from getting too bad.

If the pain continues, your child may be referred to a physical therapist. And if all else fails, then your child will be put into a walking boot and referred to an orthopedic specialist for management of severe cases. Eventually, Sever's disease gets better, but not really until your child has stopped growing and that growth plate closes. Until then, manage the pain and follow the advice your child's doctor gives them.

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Producer Mitch has been training for his very first 5k. After several months of improvement and finally reaching his goal of running a full five kilometers, he hit a major set back. He caught his toe on a bad patch of sidewalk and badly rolled his ankle. As if the loud crunch wasn't bad enough, It immediately became quite swollen and turned black and blue overnight.

According to sports medicine specialist, Dr. Christopher Gee, sprained ankles are quite common in sports like running. They can take a while to heal and can be a major setback to any athlete at any level.

One way to prevent a rolled ankle is to improve a person's proprioception. Proprioception is the body's ability to sense where it is in space. It's the sense that allows you to put your hand behind your head and still know how many fingers you're holding up.

When running, your foot gives the same type of feedback. The nerves in your foot send signals about the angle of the terrain, how far the foot is turning, where your leg is in space. In the best-case scenario, as your ankle starts to twist too far, your brain should sense what's happening and quickly use your leg muscles to straighten out the joint before the injury.

There are exercises available that can help improve a person's proprioception by retraining the nerves and neural pathways in your feet. These exercises can include standing on one foot or doing activities while on a wobble board. Diagnosing an Ankle Injury

When a patient comes to Dr. Gee with a sprained ankle he diagnoses the severity and treatment through a three-part process.

First, Dr. Gee will get a history of the patient as well as a description of the event that caused the injury. It's important for the physician to know what kind of athlete the patient is. An injury in a new runner may have a different cause, treatment, or outcome than a seasoned runner. Additionally, the physician will ask a series of questions about what they heard and felt during the injury, which could clue them into the severity of the sprain

Next comes a series of x-rays of the injured joint. Fractures in any joint can be serious. They can require casting or surgery if severe enough. As such, it's important to rule out any breaks early in the treatment of a sprain.

Finally, the orthopedic physician will conduct an exam on the joint itself. An x-ray doesn't tell the whole story of an ankle sprain. There can be significant swelling and tearing of ligaments that won't show up on imaging. The doctor will assess how severe the bruising and swelling of the ankle is. Then they will press on joint lines to test for tearing and rotate the joint to check for functionality. This part of the process can be uncomfortable for the patient, but it's a crucial step to diagnosis Treatment and Recovery after Rolling Your Ankle

After a sprained ankle, it can take weeks to get back to even walking around normally. It can take longer to get back to full activity, like running.

"The biggest thing to do is to get the fluid out and the swelling down," says Dr. Gee.

Inflammation in the joint is the first thing to treat. There is likely a lot of swelling and bruising with a sprained ankle, and the inflammatory response causes a majority of the pain and irritation. The swelling can be brought down by staying off of it, icing it, elevating it, and compressing the area with an ace bandage. This should be done for the first week or two after the injury.

Once the inflammation starts to come down, the second phase of recovery is working on motion exercises with the affected joint. Try moving your toes back and forth or "drawing the alphabet" by moving your toes around at the ankle. Short walks and spending time standing can also be helpful.

The final step of recovery is to gradually return to full activity. For runners, this may mean short jogging sessions at a slower speed. It's important to listen to your body and not push yourself too hard too early. Exerting beyond what your body can handle could lead to further injury and a longer recovery. Keep in mind, it can take 6-8 weeks after a sprain to get back to normal.

"It will get better," says Dr. Gee, "it just takes time."

The first 3-4 weeks of healing will be the hardest. Listen to your body and only do what feels comfortable. If the joint begins swelling, clicking, or causing pain, slow down. Odds and Ends

The Who Cares About Men's Health 5K is on June 20. We encourage anyone who wants to join this virtual race and show support for Mitch as he gets closer to his goal of going from couch to 5K. The virtual race can be completed any way you'd like, whether it be running, biking, walking, skipping, whatever you can do to get in your physical activity that day.

We have received a handful of messages from listeners about testosterone therapy in response to Episode 22: "Will Testosterone Cure Everything?" The questions asked were quite specific and would require a professional's opinion. We will be bringing in a urologist in to help answer these questions in a future episode. Just Going to Leave This Here

On this episode's Just Going to Leave This Here, Troy is overcoming his serious sports withdrawals by getting into space science and rocket launches. Scot urges listeners to stay vigilant on their efforts to stop the spread of COVID-19. Talk to Us

If you have any questions, comments, or thoughts, email us at hello@thescoperadio.com.

Announcer: Need reliable and wellness information? Don't listen to the guy in the cube next to you, get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question. On The Scope.

Interviewer: All right. Today's listeners question: "When I go walking, I feel great except for about after 3 miles, my left arch gets really sore. So bad usually, I have to turn around and head back. Usually gone by the next day, but I'd like to be able to walk more than just three miles. What can I do?"

Dr. Harold: That's a good question. I think, a lot of times, arch pain comes from a muscle that helps to support the arch. One thing you could do is to look in the mirror at home and stand flat on your feet barefoot and see if one foot has more of a collapsed arch than the other. That could be an indication that that muscle might be a little bit weak.

The other thing you can try is to stand on just the foot that hurts and do toe raises just on that foot. Do them repetitively, 10, 15 toe raises and see if that recreates the pain. If it does and the pain is coming from this muscle that helps to hold up your arch, then what's happening is that that muscle is getting a little fatigued as you hike. And then, after a while, it can no longer support the load and it causes pain. That's something that can be fixed with good arch supports when you hike, as well as some therapy to strengthen that muscle.

Other possibilities, some people can get foot pain and the arch that's unrelated to that muscle. It's more sometimes a burning pain they get in the arch with prolonged walking. Sometimes it's also related to either footwear or occasionally is related to socks as well in the shoe that cause some friction and some abrasion and some pain there. So maybe try and change the socks or the shoes around and see if one shoe is better than another.

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Dr. Gellner: Everyone wants pretty feet, but what if your child's toe gets all red and angry looking? The problem might be an ingrown toenail.

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kid Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: An ingrown toenail is a toenail that grows into the skin of the toe, and it's usually the big toe. It causes your child to have tenderness, redness, and swelling of the skin around the corner of the toenail on one of the big toes. Ingrown toenails are usually caused by tight shoes, which is very common with growing kids' feet, or improper cutting of the toenails.

They can take several weeks to heal, so how can you help your child during this time? First, soak your child's foot twice a day in warm water and antibacterial soap for 20 minutes. While the foot is soaking, massage the swollen part of the cuticle outward away from the nail. If your child's cuticle is just red and irritated, an antibiotic ointment is probably not needed.

But if the cuticle becomes swollen or oozes pus, put over-the-counter antibiotic ointment on the area where the pus is coming out three times a day for up to a week. The pain your child has is usually caused by the corner of the toenail rubbing against the raw cuticle. When to See Your Pediatrician

If the soaks and ointment don't help, it's time to see your child's pediatrician. Your child's pediatrician may need to cut the corner of the nail off or take more off of the nail than just the corner so that the irritated tissue can heal more easily.

Your pediatrician only needs to do this once in most cases. The main purpose of this is to help the nail grow over the nail cuticle rather than get stuck in it. Finally, weather permitting, of course, have your child wear sandals or go barefoot as much as possible to prevent pressure on the toenail until it heals. If your child must wear closed shoes, protect the ingrown toenail by taping a thin piece of gauze over the infected area.

Ingrown toenails can often be prevented. Again, the most common cause of ingrown toenails are those shoes, narrow shoes in particular. So make sure your child's shoes fit properly. Get rid of any pointed or tight shoes. After the cuticle has healed, cut the toenails straight across, leaving the corners visible. You can gently file them so that they're more rounded and don't poke.

Don't cut the nails too short. If your child has ingrown nails over and over, your pediatrician may refer you to a foot doctor called a podiatrist, who can better help manage recurrent nail problems.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: September 28, 2018
originally published: May 8, 2016

Dr. Jones: Old Chinese foot binding practices to make women hobble on little five-inch, deformed feet. You, five inch high heels for your pretty Christmas dress, awesome. This is Dr. Kirtly Jones from Obstetrics and Gynecology at The University of Utah Health Care and this is, "Women's Feet" on The Scope.

Announcer: Covering all aspects of woman's health this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Some years ago, I had the opportunity to visit a museum in Kuala Lumpur entitled, "Enduring Beauty." Wandering through the exhibit, I saw what I thought were tortuous practices of neck elongation, plates put in the lips and ears, Chinese foot binding, and others. The last room in the exhibit was enlightening, 19th-century corsets and contemporary girdles and high heels.

It's a good thing that most millennials have never worn a girdle if you don't count Spanx, but high heels? Over many years of my career as a gynecologist, I have been in a unique position to observe the damage that a life in high heels can do women's feet. Ladies, you know what I mean. Men and woman have been wearing elevated shoes for thousands of years. In ancient Egypt, they might have been a sign of class.

Shoes are made of tougher stuff and are more likely to survive for historical studies so we know about this. Those early elevated shoes were more platforms than heels, though. Men and women wore heels as part of fashion going back to the 1500s when shoes were made of two parts and heels were added. This was popularized by several royal women who weren't very tall who wanted to feel taller than their husband's mistresses.

So a person of social standing and wealth could be called well-heeled. And men may have worn heels as a practical matter to keep their boots in stirrups. Okay. Ao heels have been around for a long time and fashion comes and goes. But very high heels have been back since the late 1980s and '90s and there are consequences.

Recently, a study from the University of Alabama published in the "Journal of Foot and Ankle Injuries" stated, "In the US, emergency rooms treated 123,355 high heel-related injuries between 2002 and 2012." And it had doubled in the past 10 years. More than 19,000 of those injuries occurred in 2011 alone. Sprains and strains to the foot and ankle were the most common and most patients were in their 20s and 30s.

One in five of those accidents resulted in broken bones. And those are just the injuries that took women to the emergency room. Not the ones that hurt but women stayed home. So let's talk about an interesting study of South Korean flight attendants looking at ankle stability in a career spent in high heels. Students at a school for flight attendants, who have to wear heels all day long at school, had their balance tested.

In the first year, their balance was poor. Probably like mine in heels. The second year, the woman had developed significant strength in muscles and tendons that support the ankle side to side, less wobble and had better balance. But by the fourth year, women had worse balance because they lost strength support front to back. Wearing high heels all the time limits the flexion of the foot and ankle.

So what to do? If you wear heels just for special occasions, you aren't likely to do permanent structural damage of your feet and ankles, unless you fall over, which you are more likely to do. So take care. Walk arm-in-arm with your honey. Can you wear those foldable little flats until you get to the occasion while you're walking on the street? Don't catch your stilettos in ventilation grates and put your heels on when you get there.

If you need to wear heels for work, although I cannot see US companies requiring heels as part of business casual, but you want to and you wear them all the time. Take them off when they're under your desk. Flex your feet up and down and stretch your calves gently on the edge of stair steps. This is an exercise called heel lifts and heel drops. Give your feet and ankles a chance to normalize with exercise at night and weekends in bare feet or running shoes that are flat, well-fit, and supportive.

For those of you who can wear high heels gracefully, they do look lovely. So I've been conditioned, like every other American woman, to see beauty in style and high heels. I'm envious of ladies who can carry it off, but be practical even if your shoes aren't. Don't' run, watch for treacherous terrain that can grab your stilettos, and be careful what you drink at a party that might further affect your balance. Stay smart and stay safe.

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Dr. Miller: You sprained your ankle, could you have a fracture and what to do about it? I'm Dr. Tom Miller in here with Scope Radio.

Difference Between an Ankle Fracture and a Sprained Ankle

Dr. Miller: I'm here today with Dr. Alexej Barg and he is an orthopedic surgeon here at the University of Utah. He specializes in foot and ankle problems. Alexej, ankle sprains are very common and occur frequently among adolescents and kids who are playing sports. Under what circumstances should one go receive additional attention after spraining an ankle to make sure that they haven't fractured the ankle?

I think this is a typical concern that I see in my practice. People come in, they sprain their ankles and they want to know, "Well, could I have fractured the ankle?"

Most Common Sports Injuries

Dr. Barg: The ankle sprain is for sure the most common injury in the United States. This is actually also the most common sports injury. More than every 10th patient who is showing up in the emergency room is coming to the clinic because of the ankle sprain. Of course, you cannot just do in every patient without seeing this patient, just the routine radiograph assessment.

In the last case, there are some clinical studies addressing the efficacy or whether the radiograph need to be done or not. I don't think those guidelines are good. However, it's still in the hands of the treating surgeon or orthopedic surgeon whether the patient does need the radiographs or not. In my experience, if it's just a mild sprain, especially in the younger kids or teenager, there's definitely no need to do immediately radiographs.

Dr. Miller: What does a mild sprain look like to you?

What Is a Mild Ankle Sprain?

Dr. Barg: A mild sprain looks like for me, for example, it's always only on the lateral side. That means on the outside, not the inside. Usually, it's just mildly small and the patient still can go for weight bearing. [inaudible 00:01:53] sort of pain or maybe just a sore, not necessarily the pain. They don't have the swelling on the medial side, on the inner side. This is for me the mild sore.

If the patient does present with a swelling with some hematoma, that means some color change, on the medial and/or lateral side, there's definitely need to perform or to do the radiographs, the X-rays to exclude a bone fracture.

Dr. Miller: What about if right after the ankle is sprained that they cannot weight bear? Does that make a difference? I've heard that sometimes, if the person who sprains their ankle is not able to put weight on that foot for a period of time right after the injury, they should receive an X-ray.

Dr. Barg: Usually, right after the injury, almost everybody who has ankle sprains cannot bear weight. I would definitely wait a couple hours. Usually, those patients have some substantial pain relief within four to six hours after the injury, especially if they do elevate the foot, if you do the cooling of the injured ankle.

If they still experience a very severe pain after six hours so they cannot walk on it at all, there is definitely an indication or the need to do the radiographs. Another question is if the patient continues having pain two or three weeks after the injury, it doesn't matter whether it was a mild injury, they need an x-ray. They should go to the clinic and, first of all, the orthopedic surgeon should take a look at it.

It can be a foot and ankle surgeon, it can be also the guy or the colleague who is experienced in sports injuries and then, finally, we will decide whether this particular person needs radiographs or not.

Dr. Miller: Question for you, is the injury of an ankle sprain usually to the inside or the outside? Medial or lateral on the foot?

Dr. Barg: Most likely, it is on the lateral side. On the lateral side, we have actually three ligaments and especially the anterior ligament. That means that the ligament in the front. It's a very thin ligament and almost everybody of us has already injured this. Fortunately, they do heal very well and I would say only maybe five percent of those patients with the lateral ankle sprain, that means the sprain on the outside, they develop the chronic instability that needs to be treated.

That is different on the medial side. Fortunately, on the medial side, the injuries are definitely rare. They are not as often than on the lateral side. However, most likely, the patient with the severe sprain of the medial ligaments, that means on the inner side, they do develop later the chronic instability that needs to be treated surgically.

Dr. Miller: After an ankle sprain, we determine it's not a fracture. What are the sorts of things that a patient can do, a person can do to eliminate the discomfort, the swelling and then get back in the game, so to speak?

Dr. Barg: Usually, I divide the severity of ankle sprains in four grades. Like first grade is a very mild sprain, the fourth grade is definitely the severe sprain. The mild sprain, the patient with the mild sprain doesn't need a specific therapy. They can [below] the ankle if it's comfortable for them.

Usually, we can start with physical therapy pretty quickly and the physical therapy, the main of the physical therapy is the first main, is to decrease the local swelling. The second main is the so-called proper [inaudible 00:05:20] exercises. Proper [Inaudible 00:05:22] exercises would work meaning that the physical therapist can teach the patient how to better control the ankle.

Again, if the sprain is more severe, for example, when I have a feeling that all ligaments on the lateral side are torn or even those medial ligaments can be damaged, in those patients, I recommend immobilization in a boot, for example, six weeks with only partial weight bearing. During that time, we're just trying to give the ligaments the chance to heal, time to heal. Exactly.

Dr. Miller: What I'm hearing is if a person has an ankle sprain, number one, look to see if there's discoloration. So anything that looks like blood beneath the skin. By discoloration, you mean black and blue?

Dr. Barg: Yes, and I do mean exactly this.

When Do I Get an X-Ray?

Dr. Miller: You probably need an X-ray or should get an X-ray and seek attention for that. If you can't weight bear immediately after, that doesn't necessarily mean that you have a fracture, but if that persists beyond a day or 12 hours to a day, then you probably need an X-ray. Even if it's a mild sprain and you're still struggling with pain after a couple of weeks, then you need to seek attention for that and get radiographs to make sure you haven't had a fracture.

Dr. Barg: Yes, absolutely. Another specific situation in this patient group is, for example, again, 95 percent of this group do heal without any restriction in the long term. However, those five percent, they still have, for example, four, six months after the initial injury, they still have some pain in the ankle or especially the instability feeling. Specifically, when the patient tries to walk on an uneven surface. Those patients need to see the doctor to see whether they need to be treated or not for ankle instability.

updated: October 28, 2020
originally published: September 9, 2015

Dr. Miller: Painful feet, especially in the morning, could that be plantar fasciitis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm here with Alexej Barg. He's an orthopedic surgeon here at the University of Utah and we're going to talk about foot pain as it relates to plantar fasciitis. Alexej?

Dr. Barg: Yeah, the plantar fasciitis, I'm originally from Switzerland and in Switzerland we call it the folks disease. Almost everybody in the country did experience this type of disease at least once in his life. Dr. Miller: What is it?

Dr. Barg: Actually, many people do not really know what it is. And I really do believe that plantar fasciitis is not a diagnosis. It's like a headache. A headache is not a diagnosis, it is just a symptom. And I do strongly believe that plantar fasciitis is also just a symptom.

Dr. Miller: Then it has multiple causes?

Dr. Barg: Yeah. Dr. Miller: Is it just pain?

Dr. Barg: It is the pain, but then you should figure out what is causing this pain and this is the most important part to plan the treatment. And maybe let me tell you what are the typical causes for plantar fasciitis.

Dr. Miller: Could we, before we talk about the causes, let's talk about what the symptoms might be. So if someone comes to you, how will they present with their problem before you look for the causes?

Dr. Barg: So, first of all, everybody can come with a plantar fasciitis regarding age. There is no big difference between genders. It can be female patient. It can be male patient. Typically, the patient presents with heel pain localized across the heel but with some radiating pain along, for example, the arch of the foot. These are the typical symptoms of plantar fasciitis.

Dr. Miller: Is it more common in people with high arches or what we call flat feet?

Dr. Barg: Yeah, the patient's with the flat feet do usually present with those pains, but there are also some different, some other causes. For example, for plantar fasciitis another cause can be the tightness of the lower leg muscles, especially on the back of the lower leg.

Dr. Miller: The calf muscles?

Dr. Barg: The calf muscles, exactly. And the second kind of common reason for plantar fasciitis can be the problem with the Achilles tendon. That means the Achilles pain can actually radiate to the plantar fascia so the people do think that the plantar fasciitis . . .

Dr. Miller: So it's a referred pain almost?

Dr. Barg: Exactly. Dr. Miller: So the typical person with what we would call the typical symptoms of plantar fasciitis, they experience that when they are putting weight on their feet? When they first get up in the morning and walk across the room or do they have that pain even at rest when they're not weight-bearing?

Dr. Barg: So usually the patient presents with two types of pain during the day. First of all, early in the morning so they have some problems getting into their shoes. For example, to get out of the house to walk to the car and during the day they're getting better. However, if they are all day on their feet at the end of the day they usually experience the same pain after they are weight-bearing on their feet.

Dr. Miller: So it sounds like there are different causes. There must be different treatments.

Dr. Barg: Yes, there are. So, first of all if the patient has a flat foot deformity then you should try to correct the flat foot deformity. In most cases, there is no need for surgery. For example, you can prescribe custom-made shoe insoles with some medial arch support. Most commonly, I also recommend the physical therapy. The physical therapy helps to reduce the local pain. And when we speak, for example, with the patient with the tight calf muscles there are some very specific exercises you can prescribe to the patients to elongate or to strengthen the calf muscles which may help to get the pain relief.

Dr. Miller: Now, I've seen some of my patients with plantar fasciitis who've seen physicians or podiatrists who treat that using a ball they roll up and down their feet. I don't quite know what that's for.

Dr. Barg: It helps actually. It helps even better if you put this ball in the freezer or in the fridge because then it's cool. What is even more important is to try and strengthen the plantar fasciitis. And the doctors can show them in the clinic how to do that or the patient can go to the physical therapist and the physical therapist can teach the people how to do that. Very important those stretching exercises should be done at least 10 times a day.

Dr. Miller: So for the calf or the bottom of the foot?

Dr. Barg: It's for the bottom of the foot. It's hard to describe how to do that. So what you usually do is bend your knee and you put your foot on the contralateral. That means the other ankle and pull on your toes so you try to flex the foot. You try to bring the plantar fascia in tension. And then you go with your thumb over this fascia, which is actually quite painful. So therefore I do recommend to do it just one minute or two minutes, but it's better to do it 10 times a day. Dr. Miller: So it's self-massage?

Dr. Barg: Exactly.

Dr. Miller: So it's basically massage of the sole of the foot while the foot is flexed. And how effective are the treatments if done correctly?

Dr. Barg: It's very, very effective. I would say in 90 to 95% of all those patients with these very simple measures can get pain relief. And usually I'd like to see the patient maybe six or eight weeks after the initial treatment. Fortunately, the patient normally doesn't show up in my clinic then because that means they ignore the follow-up appointment because they are absolutely pain-free.

However, the patient that has remaining pain, if they are coming back, then I do recommend shockwave therapy, which is extremely effective in treating plantar fasciitis. However, I do not like to start with this therapy despite the fact that it's an effective therapy because this therapy is very painful. So you're using kind of ultrasound machine and it hammers on the insertion of the plantar fascia, which is painful, which induces inflammation and the inflammation induces in itself the self-repairing process for the plantar fasciitis.

Dr. Miller: So if it doesn't hurt it's not going to do you any good?

Dr. Barg: Exactly. Exactly.

Dr. Miller: Now, one final question. I've heard some people mention that they've had a bone spur and someone told them that was the cause of their plantar fasciitis. Could you comment on that?

Dr. Barg: In the meantime, we know exactly that the bone spur is not the cause of plantar fasciitis. Many patients coming to me say, "My family doctor told me to remove the bone spur." I would definitely not recommend to do it because if you do just remove the bone spur, first of all, you will not eliminate the pain, but you may weaken the plantar fascia and even rupture the plantar fascia while you do remove the spur, which can be a big problem for the patient.

Dr. Miller: So, basically, lots of people have bone spurs. That doesn't mean it's the cause of the problem.

Dr. Barg: Yeah. So when we take just 100 normal people off the street without any pain and do any radiographs of the feet, I'm pretty sure we would detect maybe 10 or even 20 people of these 100 asymptomatic people, meaning people without pain, and we will see in up to 20% some spurs of the heel bone.

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Dr. Miller: Who gets ankle arthritis and what to do about it. We're going to talk about that next on scope radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Alexej Barg. Alexej is a professor of orthopedic surgery here at the University of Utah. Alexej, who gets ankle arthritis?

Dr. Barg: This is a very particular problem. We don't know actually why that people do develop, for example, knee osteoarthritis or hip osteoarthritis, however, we know exactly who does develop the osteoarthritis of the ankle joint or the subtibiotalar joint.

Dr. Miller: That's really interesting. I mean, we are more commonly used to hearing about knee and hip arthritis, not so much about ankle arthritis.

Dr. Barg: The most common reason to develop ankle osteoarthritis is previous trauma. It can be the bony fracture, but it can be also the repetitive ligament sprain of the ankle joint.

Dr. Miller: Due to sports injuries typically? Or is this some line of work that would be a problem?

Dr. Barg: Both injuries can lead or can end up final in end-stage ankle osteoarthritis. And many people do speak about hip or knee osteoarthritis however the ankle osteoarthritis is a growing problem. Upcoming in Europe and in Europe right now every tenth patient who is coming to an outpatient clinic for an orthopedic problem is coming with a problem of ankle or the foot, including ankle osteoarthritis. So this is a growing problem. It should not be underestimated. There are some studies showing that the patient having end-stage ankle osteoarthritis have the same pain, the same disability in daily activities comparable to those patients having, for example, hip osteoarthritis.

Dr. Miller: So it's obviously painful. So again, what is it that causes this arthritis? What sorts of people are prone to develop ankle arthritis?

Dr. Barg: In the past decades, several studies have been published to figure out which are the risk factors to develop ankle osteoarthritis, especially posttraumatic ankle osteoarthritis. And I would say in my opinion there are two very important factors: the first is definitely the severity of the initial injury. For example, if you have a fracture of the lower leg including the tibiatalor joint surface, that means that those patients have also the cartilage lesion at the time of the initial injury. And the second significant risk factor is for sure the deformity because some people or the most people, more than the half of all patients with ankle osteoarthritis, have a concomitant lower leg deformity. That means they have uneven load distribution within the joint, which finally leads to end-stage disease.

Dr. Miller: So it sounds like fracture of the foot, fracture of the ankle can lead to ankle arthritis. Is that correct?

Dr. Barg: This is correct. This is absolutely correct. And . . .

Dr. Miller: So automotive accidents, industrial accidents can lead to arthritis.

Dr. Barg: Yes, absolutely correct. However, the bony fractures of course they are severe injuries and everybody is aware of it. However, I mentioned this before, also there are repetitive ankle sprains and ankle sprains are definitely the most common sports injury in this country but also worldwide. I would say if you have at least two or three ankle sprain a year that means you are at high risk to develop, sooner or later, ankle osteoarthritis.

Dr. Miller: And so does ankle arthritis develop at a younger age typically than we see hip and knee arthritis in the United States? I think in general we will see knee and hip arthritis at the age of 55 and above.

Dr. Barg: This is another challenging problem specifically in this patient group. You mention this correctly. The patient with knee or hip osteoarthritis, they are usually in their fifth or sixth life decade. Patients with end-stage ankle arthritis, they are much younger. So sometimes I even see patients that are 30, 35 years old and their ankle joint is really gone. That makes the treatment is this patient group specifically very challenging because whatever you plan to do in those patients they should usually last for many years. That means for another 50 or maybe even 60 years in the future.

Dr. Miller: Typically patients with ankle arthritis will present with pain and, I suppose, immobility, some type of immobility in the ankle. So what then are the next steps? Obviously they make their way to you, they know about your practice. What do you advise them?

Dr. Barg: First of all, I take a very exact medical history. So I want to know exactly how long the patient had the pain. What type of injury, if they had an injury, what type of injury exactly they had? Usually, I collect all possible medical records from the past. And the second step is definitely the clinical assessment, the clinical investigation. I do see how good the movement of the ankle is. I want to also check the alignment. That means they ask whether the ankle joint is straight or not. I also check the stability. And then finally I go further with the imaging, which is an extremely important part.

Dr. Miller: X-rays, typically?

Dr. Barg: Yeah, I always stay with a weight-bearing radiograph. Weight-bearing if very important. Many patients come from the family doctors, for example, with some imaging, but this imaging is not useful. I call is accidental imaging. Because you see just a very small part of the ankle, not weight bearing. That means you still see some ankle osteoarthritis, however, because they are not weight-bearing radiographs, you cannot really assess for example the alignment of the ankle joint.

Dr. Miller: So you're going to do a more thorough radiographic examination based on weight-bearing than typically you would see in a standard practice. Okay.

Dr. Barg: Yes.

Dr. Miller: Then, moving on to treatment, there are obviously different types. You can fuse the ankle, but there are other aspects of that care as well, I gather.

Dr. Barg: In the literature, mostly two treatments are described for the end-stage ankle osteoarthritis. This is to fuse the ankle or to replace the ankle. That means to use an ankle prosthesis. An ankle prosthesis, especially in the last two decades, experienced a really great progress. Regarding the design of prosthesis, they are definitely some designs are more anatomical design, which may really mimic much better the normal anatomy and normal biomechanics of the ankle joint.

However, in my opinion, both treatment options are not perfect. And so, therefore, in my clinic, we always try to use the joint preserving procedure. That means a surgery where you try to correct the underlying deformity. And you don't have to fuse the ankle. You don't have to replace the ankle. That means the patient still has their own ankle.

Dr. Miller: For our listeners, fusing the ankle, what does that mean?

Dr. Barg: To fuse the ankles means that you can do it actually laparoscopically, that means minimally invasive. Or you can do an open procedure. You just remove the remaining cartilage, you stabilize the tibiatalar joint using different implements. It can be screws, it can be plates.

Dr. Miller: These are the large joints at the back of the ankle, I guess.

Dr. Barg: Yes. And this for many decades has been the gold standard procedure for end-stage ankle osteoarthritis. The problem is for those patients the ankle joint does not move. That means that the functionality of the ankle joint should be taken over by adjacent joints. For example, by the subtalar joint, which is the joint underneath. And that means sooner or later those patients will develop diminutive changes in their adjacent joints. That's the biggest problem following ankle fusion.

Dr. Miller: Similar problem to folks who have disc fusions in their back.

Dr. Barg: This is maybe a similar problem, yes. Absolutely.

Dr. Miller: Some of them develop arthritis above and below the fusion.

Dr. Barg: I agree with you.

Dr. Miller: So because the points of stress change.

Dr. Barg: I agree with you.

Dr. Miller: Interesting. Alexej, in your experience, rebuilding the ankle joint, how durable is that? How long-lasting is that surgery? How much relief will it give and how long can one expect that to be helpful?

Dr. Barg: These questions cannot be answered clearly with a certain number, like two years, five years, 10 years. In my experience, if you do the joint preserving procedure, approximately 20% of all patients still need a bigger surgery like ankle fusion or ankle replacement within 10 years after the surgery. Which maybe the first sign is not that encouraging number, however, I can just tell you that if you do a very exact selection for this procedure, the patients are very happy because they still have their own joint. They don't have any restrictions doing, for example, recreation or sports activity. And actually this number is very dependent on how severe the ankle osteoarthritis is. I do communicate this very often and very clearly with the patient and I tell him what his expectation should be in the particular case.

Dr. Miller: It sounds like you have a great knowledge of the prognosis of each of these procedures that would help your patients make a decision on what to do.

Dr. Barg: Yeah, most likely we can say and predict exactly whether the procedure will last for two years or five years or for the 10 years. And for two years, sometimes if the patient is, for example, a hard worker and has to work on the street and has to lift heavy weight, this patient will not profit immediately, for example, for ankle fusion or ankle replacement. He'll want to wait another two or five years until he's retired and then he's ready for another surgery. Those patients are very thankful that you can offer them the joint preserving procedure.

Dr. Miller: Are there other tips for people who might have ankle arthritis? How do they find their way to a particular orthopedic surgeon? Should they see a specialist? Should they see a generalist orthopedic surgeon or should they see someone else, like a sports medicine physician?

Dr. Barg: I would suggest if the patient has ankle osteoarthritis, it doesn't mean a late stage. If it's at the early stage or the end-stage, this is a very challenging problem with many concomitant problems, which can be overseen by a person who is not that experienced in this area. By concomitant problems, I'm speaking, for example, about a concomitant deformity, a concomitant instability and so forth. So I do really think that those patients should really be seen be a person who has experience in dealing with this problem and who can also offer a different treatment option. Because the treatment options in the beginning of ankle osteoarthritis are definitely different, for example, than for patients with end-stage ankle osteoarthritis.

Dr. Miller: So bottom line is if you have ankle pain, try to have that diagnosed earlier rather than later. And if you have ankle arthritis, find your way to an orthopedic specialist who specializes in lower extremity problems.

Dr. Barg: Yes, absolutely. I agree with you.

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