Charcot Foot

What Is Charcot Foot?  

Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). The bones are weakened enough to fracture, and with continued walking, the foot eventually changes shape. As the disorder progresses, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance.

Charcot foot is a serious condition that can lead to severe deformity, disability and even amputation. Because of its seriousness, it is important that patients living with diabetes—a disease often associated with neuropathy—take preventive measures and seek immediate care if signs or symptoms appear.

Causes

Charcot foot develops as a result of neuropathy, which decreases sensation and the ability to feel temperature, pain or trauma. Because of diminished sensation, the patient may continue to walk—making the injury worse. People with neuropathy (especially those who have had it for a long time) are at risk for developing Charcot foot. In addition, neuropathic patients with a tight Achilles tendon have been shown to have a tendency to develop Charcot foot.

Symptoms

The symptoms of Charcot foot may include:

  • Warmth to the touch (the affected foot feels warmer than the other)

  • Redness in the foot

  • Swelling in the area

  • Pain or soreness
     

Diagnosis

Early diagnosis of Charcot foot is extremely important for successful treatment. To arrive at a diagnosis, the surgeon will examine the foot and ankle and ask about events that may have occurred prior to the symptoms. X-rays and other imaging studies and tests may be ordered. Once treatment begins, x-rays are taken periodically to aid in evaluating the status of the condition.

Nonsurgical Treatment

It is extremely important to follow the surgeon’s treatment plan for Charcot foot. Failure to do so can lead to the loss of a toe, foot, leg or life.

Nonsurgical treatment for Charcot foot consists of:

  • Immobilization. Because the foot and ankle are so fragile during the early stage of Charcot, they must be protected so the weakened bones can repair themselves. Complete nonweightbearing is necessary to keep the foot from further collapsing. The patient will not be able to walk on the affected foot until the surgeon determines it is safe to do so. During this period, the patient may be fitted with a cast, removable boot or brace and may be required to use crutches or a wheelchair. It may take the bones several months to heal, although it can take considerably longer in some patients.

  • Custom shoes and bracing. Shoes with special inserts may be needed after the bones have healed to enable the patient to return to daily activities—as well as help prevent recurrence of Charcot foot, development of ulcers and possibly amputation. In cases with significant deformity, bracing is also required.

  • Activity modification. A modification in activity level may be needed to avoid repetitive trauma to both feet. A patient with Charcot in one foot is more likely to develop it in the other foot, so measures must be taken to protect both feet.
     

When Is Surgery Needed?

In some cases, the Charcot deformity may become severe enough that surgery is necessary. The foot and ankle surgeon will determine the proper timing as well as the appropriate procedure for the individual case.

Preventive Care

The patient can play a vital role in preventing Charcot foot and its complications by following these measures:

  • Keeping blood sugar levels under control can help reduce the progression of nerve damage in the feet.

  • Get regular checkups from a foot and ankle surgeon.

  • Check both feet every day—and see a surgeon immediately if you notice signs of Charcot foot.

  • Be careful to avoid injury, such as bumping the foot or overdoing an exercise program.

  • Follow the surgeon’s instructions for long-term treatment to prevent recurrences, ulcers and amputation.

Chronic Ankle Instability

What Is Chronic Ankle Instability?  

Chronic ankle instability is a condition characterized by a recurring giving way of the outer (lateral) side of the ankle. This condition often develops after repeated ankle sprains. Usually, the giving way occurs while walking or doing other activities, but it can also happen when you’re just standing. Many athletes, as well as others, suffer from chronic ankle instability.

People with chronic ankle instability often complain of:

  • A repeated turning of the ankle, especially on uneven surfaces or when participating in sports

  • Persistent (chronic) discomfort and swelling

  • Pain or tenderness

  • The ankle feeling wobbly or unstable
     

Causes

Chronic ankle instability usually develops following an ankle sprain that has not adequately healed or was not rehabilitated completely. When you sprain your ankle, the connective tissues (ligaments) are stretched or torn. The ability to balance is often affected. Proper rehabilitation is needed to strengthen the muscles around the ankle and retrain the tissues within the ankle that affect balance. Failure to do so may result in repeated ankle sprains.

Repeated ankle sprains often cause—and perpetuate—chronic ankle instability. Each subsequent sprain leads to further weakening (or stretching) of the ligaments, resulting in greater instability and the likelihood of developing additional problems in the ankle.

Diagnosis

In evaluating and diagnosing your condition, the foot and ankle surgeon will ask you about any previous ankle injuries and instability. Then s/he will examine your ankle to check for tender areas, signs of swelling and instability of your ankle as shown in the illustration. X-rays or other imaging studies may be helpful in further evaluating the ankle.

 

Nonsurgical Treatment

Treatment for chronic ankle instability is based on the results of the examination and tests, as well as on the patient’s level of activity. Nonsurgical treatment may include:

  • Physical therapy. Physical therapy involves various treatments and exercises to strengthen the ankle, improve balance and range of motion and retrain your muscles. As you progress through rehabilitation, you may also receive training that relates specifically to your activities or sport.

  • Bracing. Some patients wear an ankle brace to gain support for the ankle and keep the ankle from turning. Bracing also helps prevent additional ankle sprains.

  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed to reduce pain and inflammation.

When Is Surgery Needed?

In some cases, the foot and ankle surgeon will recommend surgery based on the degree of instability or lack of response to nonsurgical approaches. Surgery usually involves repair or reconstruction of the damaged ligament(s). The surgeon will select the surgical procedure best suited for your case based on the severity of the instability and your activity level. The length of the recovery period will vary, depending on the procedure or procedures performed.


Talar Dome Lesion

Talar Dome Lesion

What is a Talar Dome Lesion?

The ankle joint is composed of the bottom of the tibia (shin) bone and the top of the talus (ankle) bone. The top of the talus is dome-shaped and is completely covered with cartilage—a tough, rubbery tissue that enables the ankle to move smoothly. A talar dome lesion is an injury to the cartilage and underlying bone of the talus within the ankle joint. It is also called an osteochondral defect (OCD) or osteochondral lesion of the talus (OLT). “Osteo” means bone and “chondral” refers to cartilage.

Talar dome lesions are usually caused by an injury, such as an ankle sprain. If the cartilage doesn’t heal properly following the injury, it softens and begins to break off. Sometimes a broken piece of the damaged cartilage and bone will “float” in the ankle.

Signs and Symptoms

Unless the injury is extensive, it may take months, a year, or even longer for symptoms to develop. The signs and symptoms of a talar dome lesion may include:

  • Chronic pain deep in the ankle—typically worse when bearing weight on the foot (especially during sports) and less when resting

  • An occasional “clicking” or “catching” feeling in the ankle when walking

  • A sensation of the ankle “locking” or “giving out”

  • Episodes of swelling of the ankle—occurring when bearing weight and subsiding when at rest

Diagnosis

A talar dome lesion can be difficult to diagnose, because the precise site of the pain can be hard to pinpoint. To diagnose this injury, the foot and ankle surgeon will question the patient about recent or previous injury and will examine the foot and ankle, moving the ankle joint to help determine if there is pain, clicking, or limitation of motion within that joint.

Sometimes the surgeon will inject the joint with an anesthetic (pain-relieving medication) to see if the pain goes away for a while, indicating that the pain is coming from inside the joint.

X-rays are taken, and often an MRI or other advanced imaging tests are ordered to further evaluate the lesion and extent of the injury.

Treatment: Non-Surgical Approaches

Treatment depends on the severity of the talar dome lesion. If the lesion is stable (without loose pieces of cartilage or bone), one or more of the following non-surgical treatment options may be considered:

  • Immobilization. Depending on the type of injury, the leg may be placed in a cast or cast boot to protect the talus. During this period of immobilization, non-weightbearing range-of-motion exercises may be recommended.

  • Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation.

  • Physical therapy. Range-of-motion and strengthening exercises are beneficial once the lesion is adequately healed. Physical therapy may also include techniques to reduce pain and swelling.

  • Ankle brace. Wearing an ankle brace may help protect the patient from re-injury if the ankle is unstable.

When is Surgery Needed?

If non-surgical treatment fails to relieve the symptoms of talar dome lesions, surgery may be necessary. Surgery may involve removal of the loose bone and cartilage fragments within the joint and establishing an environment for healing. A variety of surgical techniques is available to accomplish this. The surgeon will select the best procedure based on the specific case.

Complications of Talar Dome Lesions

Depending on the amount of damage to the cartilage in the ankle joint, arthritis may develop in the joint, resulting in chronic pain, swelling and limited joint motion. Treatment for these complications is best directed by a foot and ankle surgeon, and may include one or more of the following

  • Non-steroidal or steroidal anti-inflammatory medications

  • Physical therapy

  • Bracing

  • Surgical intervention

High Ankle Sprains

High Ankle Sprains: What’s the difference?

Ankle sprains are common injuries. In fact, they are one of the most common injuries encountered in the United States. But what is the difference between a common ankle sprain and a high ankle sprain? And why do athletes with a high ankle sprain seem to be out for a longer period of time? The reason lies in the anatomy of the ankle and the different ligaments injured in a common vs. high ankle sprain.

The ankle is made of three bones in the lower leg: the tibia, the fibula, and the talus. These bones act together to form the ankle joint, which typically sustains loads three times a person’s body weight with normal daily activity. The soft tissues that surround the ankle allow for its stability and motion. The ligaments, in particular, stabilize the ankle.


Diabetic Foot Ulcers


Diabetic Foot Ulcers:  The Facts

During their lifetime, 15 percent of people with diabetes will experience a foot ulcer and between 14 and 24 percent of those with a foot ulcer will require amputation. Diabetes is the leading cause of lower extremity amputations in the United States occurring among people with diabetes. Each year, more than 82,000 amputations are performed among people with diabetes.

After an amputation, the chance of another amputation within 3 to 5 years is as high as 50 percent. The 5 year mortality rate after amputation ranges from 39 to 68 percent.

Prevention and Treatment of Diabetes Foot Problems

According to the National Diabetes Education Program (NDEP), a partnership among the National Institutes of Health, the Centers for Disease Control and Prevention and over 200 organizations, including the American Podiatric Medical Association, comprehensive foot care programs can reduce amputation rates by 45% to 85%. A comprehensive foot care program would include:

  • Early identification of the high risk diabetic foot

  • Early diagnosis of foot problems

  • Early intervention to prevent further deterioration that may lead to amputation

  • Patient education for proper care of the foot and footwear

If you are  diabetic, call Annapolis Foot and Ankle Center for a diabetic foot exam.  Amputations CAN be avoided with proper preventative care.


Morton's Neuroma

Morton's Neuroma

If you sometimes feel that you are "walking on a marble," and you have persistent pain in the ball of your foot, you may have a condition called Morton's neuroma. A neuroma is a benign tumor of a nerve. Morton's neuroma is not actually a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes.

Definition

Morton's neuroma occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot.

Morton's neuroma most frequently develops between the third and fourth toes, usually in response to irritation, trauma or excessive pressure.

The incidence of Morton's neuroma is 8 to 10 times greater in women than in men.

Symptoms

  • Normally, there are no outward signs, such as a lump, because this is not really a tumor.

  • Burning pain in the ball of the foot that may radiate into the toes. The pain generally intensifies with activity or wearing shoes. Night pain is rare.

  • There may also be numbness in the toes, or an unpleasant feeling in the toes.

Runners may feel pain as they push off from the starting block. High-heeled shoes, which put the foot in a similar position to the push-off, can also aggravate the condition. Tight, narrow shoes also aggravate this condition by compressing the toe bones and pinching the nerve.

Diagnosis

During the examination, your physician will feel for a palpable mass or a "click" between the bones. He or she will put pressure on the spaces between the toe bones to try to replicate the pain and look for calluses or evidence of stress fractures in the bones that might be the cause of the pain. Range of motion tests will rule out arthritis or joint inflammations. X-rays may be required to rule out a stress fracture or arthritis of the joints that join the toes to the foot.

Treatment

Initial therapies are nonsurgical and relatively simple. They can involve one or more of the following treatments:

  • Changes in footwear. Avoid high heels or tight shoes, and wear wider shoes with lower heels and a soft sole. This enables the bones to spread out and may reduce pressure on the nerve, giving it time to heal.

  • Orthoses. Custom shoe inserts and pads also help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.

  • Injection. One or more injections of a corticosteroid medication can reduce the swelling and inflammation of the nerve, bringing some relief.

Several studies have shown that a combination of roomier, more comfortable shoes, nonsteroidal anti-inflammatory medication, custom foot orthoses and cortisone injections provide relief in over 80 percent of people with Morton's Neuroma. If conservative treatment does not relieve your symptoms, your podiatrist may discuss surgical treatment options with you. Surgery can resect a small portion of the nerve or release the tissue around the nerve, and generally involves a short recovery period.


Balance Braces

Are you at risk for a fall?

• Over 14 million American adults aged 65 and older experience a fall each year
• Every 15 seconds, an older adult is seen in an emergency room for a fall-related injury
• In 2010, such falls resulted in direct costs to the US healthcare system of over $30 billion dollars
• More than 20,000 of those falls resulted in death


Establishing and maintaining proper balance is one of the keys to reducing the risk of falls. In fact, good balance can often counteract the effects of other risk factors such as diminished muscle strength, dizziness and environmental obstacles among others. Patients who are prescribed and rigorously follow a comprehensive balance training & exercise program will realize an outstanding degree of falls risk reduction.

The Moore Balance Brace is extremely effective in improving balance, when worn, and reducing the risk of falls. It is soft and easily fits into most shoes.

If you are experiencing balance problems or perhaps have had multiple falls, visit one of our physicians to be evaluated for a Balance Brace.

Platelet Rich Plasma

What Is Platelet-rich Plasma (PRP)?

Although blood is mainly a liquid (called plasma), it also contains small solid components (red

cells, white cells, and platelets.) The platelets are best known for their importance in clotting

blood. However, platelets also contain hundreds of proteins called growth factors which are very

important in the healing of injuries.

PRP is plasma with many more platelets than what is typically found in blood. The

concentration of platelets — and, thereby, the concentration of growth factors — can be 5 to 10

times greater (or richer) than usual.

To develop a PRP preparation, blood must first be drawn from a patient. The platelets are

separated from other blood cells and their concentration is increased during a process called

centrifugation. Then the increased concentration of platelets is combined with the remaining

blood.

How Does PRP Work?

Although it is not exactly clear how PRP works, laboratory studies have shown that the increased

concentration of growth factors in PRP can potentially speed up the healing process.  To speed

healing, the injury site is treated with the PRP preparation.

PRP can be carefully injected into the injured area. For example, in Achilles tendonitis, a

condition commonly seen in runners and tennis players, the heel cord can become swollen,

inflamed, and painful. A mixture of PRP and local anesthetic can be injected directly into this

inflamed tissue. Afterwards, the pain at the area of injection may actually increase for the first

week or two, and it may be several weeks before the patient feels a beneficial effect.

What Conditions are Treated with PRP? Is It Effective?

According to the research studies currently reported, PRP is most effective in the treatment of

chronic tendon injuries - such as chronic Achilles tendonitis is promising. Much of the publicity

PRP therapy has received has been about the treatment of acute sports injuries, such as

ligament and muscle injuries. PRP has been used to treat professional athletes with common

sports injuries.

In our practice we commonly use PRP in the treatment of:

  • Plantar fasciitis

  • Achilles tendonitis

  • Tendon injuries

  •  Arthritis

  •  Ankle ligament injuries

The risks associated with PRP are minimal: There may be increased pain at the injection site,

but the incidence of other problems — infection, tissue damage, nerve injuries — appears to be

no different from that associated with cortisone injections.

Subchondroplasty Procedure

Subchondroplasty® Procedure

The SCP® Procedure is a minimally-invasive surgery that targets and fills subchondral bone defects, often referred to as Bone Marrow Lesions (BML). These often-painful defects are in the spongy cancellous bone that underlies the cortical bone. The procedure is usually performed along with arthroscopy ("scoping") of the nearby joint, allowing your surgeon to visualize and treat findings inside the joint.

How Do I Know If the SCP® Procedure Is Right for Me?

You may have a defect in the bone adjacent to your joint called a chronic Bone Marrow Lesion (BML). Many surgeons believe that chronic BML will not heal without intervention.  BML can only be seen on MRI. Only your doctor can tell you if you have this condition.

Surgical Procedure Overview

During the procedure, your surgeon will use fluoroscopy (intraoperative X-ray) to place a small, drillable cannula in the area of the bone defect. Your surgeon will then deliver AccuFill® Bone Substitute Material (BSM), which is an engineered calcium phosphate mineral compound, into the defect, where it hardens with properties that mimic cancellous bone. During the healing process, the AccuFill® BSM is resorbed and is replaced with new bone.

What is AccuFill BSM?

AccuFill BSM is an engineered calcium phosphate mineral compound. It flows readily to fill the subchondral defect and hardens quickly into a biomimetic implant once injected. AccuFill BSM mimics the properties of cancellous bone and is replaced with new bone during the healing process.