Bone/Joint

Each step that we take applies a phenomenal load to the heel. Consider the fact that in a simple slow walk, the load applied to the heel can be more than twice our body weight. If we increase the speed of our walk, take bigger steps or jump, the load applied to the heel at heel strike is significantly increased. This load may be more than three times our body weight. And consider how many times this loading occurs in the course of a normal day. Step after step, over and over again. The ability of the heel to sustain these loads without developing heel pain is quite incredible.

The following is a list of links to pages on Myfootshop.com that discuss specific types of heel pain.

Plantar heel pain

Baxter's nerve entrapment - dull pain on the bottom of the heel.

Bursitis - dull achy pain on the bottom of the heel that increases with the duration of time spent on your feet.

Plantar fasciitis - sharp tearing pain on the bottom of the heel when first standing.

Heel spur syndrome - sharp plantar heel pain.

Tarsal tunnel syndrome - a nerve entrapment of the medial heel.

Posterior heel pain

Achilles tendonitis - sharp posterior heel pain when first starting to run.

Bursitis - dull achy posterior heel pain.

Calcaneal stress fractures - dull achy heel pain that increases with the duration of time on the heel.

Gout - although more common to the forefoot, gout can strike the back of the heel.

Haglund's Deformity - posterior heel exostosis.

Sever's disease - heel pain common to 8-12 y/o boys.

Other heel pain

          Sinus tarsi syndrome - pain found in the body of the heel.

Calcaneal fractures have a track record of being difficult to treat and have frustrated doctors for years. The calcaneus is much like an egg; an outer firm shell and soft on the inside. As a result, the calcaneus often shatters when broken. Calcaneal repair not only requires re-apposition of multiple fracture patterns, but also requires restoration of the subtalar joint. The subtalar joint is the interface between the calcaneus and talus and is a primary load bearing joint of the foot. In some cases, the calcaneal-cuboid joint may also be affected by an extensive fracture pattern.

Three classifications are used to describe calcaneal fractures. The Essex-Lopresti classification describes subtalar joint depression fractures (very severe fractures) in a bit more detail than the more commonly used Rowe classification. A third, and newer classification proposed by Sanders in 1993 uses CT scanning to determine the stage of calcaneal fracture. Plain x-rays and CT scans are often used to determine the extent and classification of calcaneal fractures.

The Essex-Lopresti Classification Of Calcaneal Fractures

Type A - Tongue type
Type B - Joint depression type

The Rowe Classification Of Calcaneal Fractures

Type 1a - Tuberosity fracture medial or lateral
Type 1b - Fracture of the sustentaculum tali
Type 1c - Fracture of the anterior process of the calcaneus
Type 2A - Beak fracture of the posterior calcaneus
Type 2b - Avulsion fracture involving the insertion of the tendo-Achillles
Type 3 - Oblique fracture not involving the subtalar joint
Type 4 - Body fracture involving the subtalar joint
Type 5 - Body fracture with subtalar joint depression and comminution

The Sanders Classification Of Calcaneal Fractures

Type I fractures are nondisplaced.
Type II are two-part or split fractures
Type III are three-part or split depression fractures.
Type IV were four-part or highly comminuted articular fractures.

Stress fractures of the calcaneus

Stress fractures of the calcaneus are the result of a sudden abrupt injury but can occur without a history of trauma. The most common injury seen our practice is a fall from a height of more than 6 feet. A stress fracture of the calcaneus is a condition that is often overlooked as a differential diagnosis of heel pain. Plantar fasciitis (also called heel spur syndrome) is so common that most health care providers will defer to plantar fasciitis as a primary diagnosis when evaluating heel pain. A good patient history, and particularly one that notes the onset and character of the pain, is very important when differentiating between plantar fasciitis and calcaneal stress fractures.

The diagnosis of calcaneal stress fractures can be difficult at times. Stress fractures, regardless of where they occur in the body, are different than what we would tend to think of when we discuss fractures. The appearance of a stress fracture on x-ray is not always evident. Quite often, the only x-ray findings that we'll see are those signs that show up towards the end of the healing process, sometimes as long as several months after the onset of the injury. We don't actually visualize the fracture, but rather we see the calcification that occurs in the late phases of the healing process. Should the symptoms of heel pain not respond to treatment for plantar fasciitis, or initial clinical findings seem suggestive of a stress fracture, there are several tools that can be used to help differentiate between calcaneal stress fractures and each of the other common conditions considered in treating heel pain. These tools include plain x-ray, bone scans, CT scanning and MRI.

• Plain x-rays may be able to visualize a calcaneal stress fracture, but quite often due to the lack of disruption of the bone, plain films lack the ability to 'see' the fracture. As fractures heal, many times the healing process can be seen on plain x-ray films. The healing process will increase the amount of calcium surrounding the fracture. This increase in calcium is called bone callus. The formation of bone callus typically takes about 4-6 weeks to see on plain x-ray, therefore, periodic follow-up x-rays may aid in diagnosing a stress fracture of the heel. Additional finding may include radiolucency (darkening) of the x-ray in the early stages of fracture repair.
  

• A three phase technetium bone scan can help differentiate the location and degree of inflammation in the calcaneus thereby helping to diagnose a calcaneal stress fracture. Bone scans are tests that utilize a radioactive nucleotide injected into the patient to identify areas of inflammation. A scan is taken of the injured area three times over the course of three hours. Each of the scans show a different degree of inflammation based upon the increased blood flow to the inflamed area. In the case of a calcaneal fracture, a bone scan can help in many ways. First, the scan will locate the area of the fracture based upon the inflammation seen in fracture healing. Second, the bone scan will help to differentiate between many other potential problems of the heel such as plantar fasciitis. And lastly, a scan can help to determine the acuteness of the injury. For instance, we may see a questionable area on an x-ray but we will not be able to tell whether the suspected injury is old or new. The bone scan will help us in that a new injury will 'light up' on the scan due to its' current inflammation. An old injury on the other hand will not 'light up' on the scan due to its' lack of current inflammation.
  

• CT (computerized tomography) scanning is a test that performs a series of x-ray slices or cuts through the calcaneus. Computer software organizes these images in a way so that we can see a series or progression of change through the heel. CT scanning is particularly useful for defining contrast. Although not considered the best testing modality for calcaneal stress fractures (Sanders Stage I), CT scanning is the best tool for displaced calcaneal fractures (Sanders stage II-IV)
  

• MRI's are also helpful in differentiating calcaneal fractures from plantar fasciitis. MRI's can identify small areas of bone edema suggestive of a fracture. Often, due to the cost of an MRI, insurance companies will request a bone scan of the heel prior to approving a more costly MRI.

Treatment of calcaneal fractures

Non-displaced calcaneal fractures (Sanders Stage I) require a period of rest and partial to complete immobilization. Treatment options include hard casts or removable cam walkers. The duration of symptoms and time necessary for adequate healing varies with the age, nature of the fracture and general health status of the fracture. It is not unusual to find calcaneal fractures that are symptomatic up to 4-6 months post injury.

As previously mentioned, displaced calcaneal fractures (Sanders Stage II-IV) can be very difficult to manage. Closed reduction (manipulation of the fracture under anesthetic without surgery) can be successful in treating calcaneal fractures. The success of closed reduction depends upon the stage of calcaneal fracture. Open reduction, often called ORIF or open reduction with internal fixation, is what doctors use when closed reduction fails to reduce the fracture. Open reduction is not guaranteed to produce more successful outcomes compared to closed reduction.

The decision when to perform ORIF for calcaneal fractures varies. Some doctors prefer to act as soon after the injury as possible, while others prefer to wait 1-2 weeks following the injury using a fracture pillow to allow for the initial phase of inflammation to subside. Follow-up post reduction (whether close or open) varies but will include a period of non-weight bearing, splinting or casting to allow for fracture healing.

In severe cases of joint depression fractures (Sanders Stage 3 and 4) additional surgery may be required to fuse the subtalar joint. If the subtalar joint is significantly damaged in the injury, fusion of the subtalar joint is the only solution. Most doctors will stage these procedures, performing a subtalar fusion long after the immediate trauma of the injury. In severe cases of subtalar joint disruption where degenerative arthritis is inevitable, subtalar joint fusion may be advocated during ORIF of the calcaneal fracture.

The photos below show ORIF (open reduction with internal fixation) of a Sanders stage 4 fracture. Images 1 and 2 show the approach to the calcaneus, isolating the sural nerve in the lateral heel. Image 3 shows dissection of the subtalar joint. Image 4 shows the calcaneal cuboid joint. Images 5 and 6 show reduction of the fracture and partial fixation. Images 7 and 8 show closure and drain placement prior to placement in a compression splint.

The most common ankle sprain occurs on the outside or lateral aspect of the ankle. The lateral ankle is supported by a group of three ligaments called the lateral collateral ligaments. The anterior ligament is the ligament that is most often injured in lateral ankle sprains. This ligament is called the anterior talo-fibular ligament (ATF). Isolated ATF sprains make up more than 75% of all ankle sprains. The ATF is a relatively small ligament that runs from the anterior aspect of the fibular forward to attach to the talus. The calcaneal fibular ligament (CF) is the second most commonly injured ligament of the lateral ankle. The CF is rarely injured as an isolated injury. The CF is usually injured in conjunction with the ATF. The CF runs from the fibula to the heel bone (calcaneus). The final ligament of the three lateral collateral ligaments is the posterior talo-fibular ligament (PTF). The PTF runs from the fibula back to the talus. The PTF is rarely injured in a lateral ankle sprains.

Lateral ankle sprains are graded by the location of the injury and the amount of damage to each of the ligaments. Typically we speak about a grade I, II or III ankle sprains. A grade I sprain is an injury that results in a stretch of the ATF ligament. Grade II is a partial rupture of the ATF and stretch injury of the CF ligament. Grade III is a complete rupture of both the ATF and CF ligaments. All ankle sprains result in an injury of the ATF ligament. Only a grade III affects the PTF and even in a grade III, the injury sustained by the PTF ligament is minimal.

Medial ankle sprains do occur but are far less common than lateral ankle sprains. The medial ankle is supported by a heavy ligament called the deltoid ligament. The deltoid ligament actually consists of five interwoven ligaments that create a broad fan of ligamentous tissue supporting the medial ankle. When an injury does occur to the medial ankle, stress applied to the deltoid ligament is often transferred to the distal tibia resulting in a fracture of the medial ankle.

The term high ankle sprain describes an injury to the anterior inferior tibial-fibular ligament (in pink in the image to the left). The anterior distal tibial-fibular ligament is also known as the Tillaux-Chaput ligament. The anterior inferior tibial-fibular ligament is the most distal ligament of the lower leg and maintains the contact of the fibula and tibia. Disruption of the anterior inferior tibial fibular ligament results in widening or what's called diastasis of the distal tibial-fibular articulation. Diastasis of the distal tibial-fibular articulation results in ankle instability and progressive arthritis of the ankle if left untreated.

Treatment of ankle sprains

Lateral ankle sprains

There are two steps described in the treatment of lateral ankle sprains.   The first step is the management of the acute injury. This step includes management of pain and swelling along with preventive measures to control lateral ankle instability. The second step is the prevention of recurrent sprains.

Step 1 (acute injury treatment)

Following the ankle sprain, management of the acute injury is best summarized by the acronym RICE;

R- rest
I- ice
C- compression
E- elevation

Rest is an essential part of healing following an ankle sprain. Rest is represented by many different changes in your activities. Rest can be as simple as backing off of your normal activities all the way up to and including a hard cast and non-weight bearing status with crutches or a walker. What's best for your individual case? Following a sprain, give the ankle several days before getting back to any activity. Only bear weight to tolerance. If it hurts, back off and do less. Some weight bearing is good from the standpoint of breaking up scar tissue and gaining an early range of motion. Too much weight bearing leads to unnecessary swelling.

Ice is used to control swelling. Personally, I'm not a big fan of heat at any time during the healing of an ankle sprain. The more ice the better. Care should be taken not to injure the skin, particularly if a patient has a loss of sensation such as diabetic neuropathy.

Compression is also used to control swelling and to splint the lateral collateral ligaments in a corrected position. Compression can be accomplished with a number of different aids such as ace wraps or ankle supports.

And finally, elevation. Elevation is one more method that can be used to control swelling. Patients with ankle sprains usually recognize the advantages of elevation even weeks after the injury.

Step 2 (prevention of future sprains)

There's a lot that can be done to prevent a second or recurrent series of sprains. The means used to prevent recurrent ankle sprains really depend upon the patient and their activities. Issues such as work, athletic activities and social activities are all considerations in the prevention of future sprains.

As an example, patient A is involved in a unidirectional sport such as running. An ankle brace would be cumbersome and probably detract from the enjoyment of a run. For this patient we would use a lateral sole wedge to inhibit supination of the foot. A lateral sole wedge is designed to realign the center of gravity and place it back over the foot. A lateral sole wedge would be a great tool for the chronic ankle sprainer who is a runner or for use in street shoes. It's important to recognize that a lateral sole wedge in this case is not a simple arch support. Increasing the arch height would tend to move the center of gravity to a position where the ankle would be more prone to sprain.

What about bi-directional sports like racquetball or tennis? An ankle brace is indicated for these sports. The side to side forces are just too great to be controlled by a lateral sole wedge or arch support. Stirrup braces are helpful in the acute phase of sprains to control edema, but aren't all that helpful in bi-directional sports in controlling torsion of the leg or inversion of the foot. Lace up ankle braces, particularly those that will lace into the shoe are very effective in preventing recurrent lateral ankle sprains. A number of new braces are available that are thinner and easier to use than a traditional lace up ankle brace.

Supination is a contributing factor to ankle sprains.  Supination is the tendency to roll to the outside of the foot.  The normal foot has a center of gravity that is aligned through the center of the ankle and the center of the foot.  The supinated foot has a center of gravity that is lateral of the normal midfoot position.  When the center of gravity is eccentric, this will contribute to lateral ankle sprains.  Supination can be controlled by placing a lateral sole wedge on the outside of the shoe or by using a lateral sole wedge insert.  Heel wedges may also be used to control supination.

Several physical therapy techniques are helpful during rehab following ankle sprains. Physical therapists will use proprioception exercises to re-educate the ligaments of the ankle. Proprioception is the sense of knowing where you are in space. The lateral collateral ligaments benefit from this re-education process. The concept is to try to make the ligaments more responsive to the next possible injury.

Proprioception exercises:
When able, stand in a doorway placing all your body weight on the injured ankle. Balance by holding on to the door. As you start to gain more balance, close your eyes. This isolates the ankle and forces it to be 're-educated'.

Some patients are prone to chronic sprains even after their first sprain. If a patient tends to have severe, recurrent sprains, surgical stabilization of the ankle is indicated. An unstable ankle will progressively lead to ankle arthritis. The importance of having an ankle stabilization performed is that stabilizing the ankle can prevent early arthritis and internal ankle injuries. Ankle stabilization is a surgical procedure that involves repair of the lateral collateral ligaments. The status of the lateral ligaments of the ankle can be assessed with x-rays using stress applied to the ankle or with MRI.

The most common procedure performed to stabilize the lateral ankle is called a Brostrom procedure. A Brostrom procedure recreates the ATF ligament through the use of bone anchors and adjacent soft tissue at the lateral ankle. Occasionally, in severe cases, a tendon transfer may be indicated to assist in stabilizing the lateral ankle. Tendon transfer procedures can be quite extensive and all require prolonged periods of immobilization. Tendon transfer procedure like the Christman Snook and Elmslie are used for patients who may fail correction with a Brostrom procedure. These patients would include athletes who will put unusual stress on the ankle.

The following images show the steps involved with a Brostrom lateral ankle stabilization surgery. Image 1 shows the approach to the lateral ankle. Image 2 shows the subcutaneous space and extensor retinaculum. Image three shows an attenuated but intact anterior talo-fibular ligament. Images 4 and 5 show repair of the ligament with non-absorbable suture (Ethibond) anchored to the fibula (to the right). Image 6 shows closure of the extensor retinaculum. And image 7 shows final skin closure prior to casting.

Another commonly overlooked aspect of lateral ankle surgery is the position of the heel bone (calcaneus). If the heel is in an inverted position, this throws the body's center of gravity to the side of the ankle making one prone to lateral ankle sprains. If the calcaneus is in a fixed, inverted position, then part of a lateral ankle stabilization procedure will include a Dwyer wedge osteotomy of the heel to bring the heel in a position back under the leg. A Dwyer procedure helps to prevent against re-injury. The following images show a Dwyer osteotomy of the heel. Images 2 and 3 show the open wedge created with a saw cut on the lateral aspect of the heel. Image 4 shows closure of the wedge and rotation of the heel into the corrected position. Image 5 shows fixation with 2, 6.5mm bone screws through the bottom of the heel.

An arthroscopic method of ankle stabilization is being developed. This technique is referred to as arthroscopic monopolar radiofrequency thermal stabilization. AMRTS employs a radiofrequency probe to shrink the lateral wall, or capsule, of the ankle joint. The lateral collateral ligaments are also treated with AMRTS. This technique is currently under investigation in shoulder surgery and holds promise as a minimally invasive alternative to traditional methods of lateral ankle stabilization.

Medial ankle sprains

Medial ankle sprains are diagnosed and treated in ways very similar to lateral ankle sprains. X-ray is not a reliable tool to diagnose a medial ankle sprain but should be used to rule out an ankle fracture. MRI can confirm the diagnosis medial ankle sprain. Treatment of a medial ankle sprain includes rest, ice, compression and elevation. In severe cases, casting in a non-weight bearing cast may be necessary. It's infrequent that the medial ankle ligaments need to be surgically repaired. In most severe medial ankle injuries, stress applied to the deltoid ligament will be transferred to the tibia resulting in a medial ankle fracture.

High ankle sprains

High ankle sprains are often diagnosed with x-ray. The diagnosis of a high ankle sprain is confirmed in three ways. First, widening of the ankle results with a complete rupture of the anterior inferior tibial-fibular ligament. Comparison views between the patient's good ankle and the injured and con confirm widening of the ankle surrounding the talus. The second diagnostic sign of a high ankle sprain is widening of the lower leg between the tibia and the fibula. And lastly, in severe high ankle sprains the anterior distal tibial-fibular ligament will avulse or pull away a small fragment of bone from the distal margin of the tibia. This fragment is called a Tillaux-Chaput fragment or Tillaux-Chaput fracture. High ankle sprains can also be diagnosed by MRI.

Treatment of high ankle sprains requires surgical re-apposition of the tibia and fibula. This can be accomplished by the use of a trans-syndesmotic screw (between the tibia and fibula) or with the use of an Arthrex TightRope. This procedure is performed in a hospital or surgery center on an out-patient basis. The procedure is performed under general anesthetic and take approximately 45 minutes to complete. Follow-up consists of 6 weeks non-weight bearing in a hard cast.

Sever's disease is much more common in boys than in girls. Most cases of Sever's disease are found in children who are moderately obese. Sever's disease can also occur in very active children. Sever's disease is common in periods when activities for these children increase such as twice daily football practices in the fall or at the onset of track season in the spring.

Treatment of Sever's Disease

The treatment of Sever's disease depends upon the severity of symptoms experienced by the patient. Most children can continue with activities, including sports and begin a simple program of stretching and heel elevation that will make a significant difference in heel pain due to Sever's disease. If stretches and heel elevation is unsuccessful in controlling the symptoms of Sever's disease, children should be removed from sports and placed on restricted activities.

• Mild Symptoms - Wear a 3/8 heel lift at all times (not just during physical activity). It is important to use a firm lift and not a soft heel pad. Calf stretches 6/day for 60 seconds each. Calf stretches are best accomplished by standing with the toes on the edge of a stretching block.

• Moderate Symptoms - Follow the directions for minor symptoms and decrease activity including elimination of any athletic activity. In addition to stretching by day, a night stretching splint can be worn while sleeping.  Use of an AirHeel during the day is helpful.

• Severe Symptoms - Follow the directions for mild and moderate symptoms. Children should be removed from sports activities such as football, basketball, soccer or gym class. A below knee walking cast with a heel lift or in severe cases, non-weight bearing fiberglass cast, may be indicated for 4-6 weeks. The cast should be applied in a mildly plantar flexed position. Cam Walkers should not be used for Sever's Disease unless they have a built in heel lift.

Two forms of myositis ossificans are recognized.  The first and more common form of myositis ossificans is caused by trauma to soft tissue.   Trauma often results in a hematoma.  If the hematoma is poorly reabsorbed by the body, the hematoma is progressively sequestered by the body.  The hematoma is slowly eliminated by the body and replaced by a calcium deposit.  As an example, a common example of muscular trauma in drug abusers is called drug abusers elbow.  Drug abusers elbow is calcification that forms in the biceps muscle when drugs are repeatedly injected into the muscle.  Traumatic myositis ossificans is most commonly found in the skeletal muscle of the arms and legs.

The second form of myositis ossificans is an inherited form of myositis ossificans known to be caused by an autosomal dominant gene.

Hypercalcemia is a known contributing factor to myositis ossificans.  Hypercalcemia may be due to excessive vitamin D intake, hyperparathyroidism, aluminum toxicity or parathyroid carcinoma.

The symptoms of myositis ossificans are often benign.  Myositis ossificans is often diagnoses with x-ray as an incidental finding when an x-ray is take for an unrelated musculo-skeletal problem.  When symptomatic, symptoms include focal pain and swelling.  Symptoms are often, but not always related to a traumatic incident.

Treatment of Myositis Ossificans

In many cases, treatment is limited and only necessary if the lesion becomes symptomatic.  Excision of the calcified mass is the treatment of choice.  It's important to recognize that in many cases, excision of the calcified mass may not be indicated.