Ankle/Foot

Ankle Sprains

Ankle sprains are one of the most common orthopedic injuries.  This can occur when the ankle rolls and the foot is forced inward leading to tearing of the ligaments on the outside of the ankle.  The severity of an ankle sprain determines the recovery time.  X-rays should often be obtained, especially if it is difficult to bear weight.  MRIs are rarely helpful unless conservative management fails, usually 6-8 weeks after the injury. 

Most ankle sprains can be treated without surgery.  Treatment consists of rest, ice, compression, and elevation.  Anti-inflammatory medications can help decrease pain, and a physical therapy exercise plan can expedite recovery and return to play.  In many acute ankle sprains, it is particularly important to prevent repeat sprains by wearing a boot or a brace. 

Multiple sprains can lead to chronic lateral ankle instability (CLAI).  This is when the ligaments are torn and fail to heal or restore stability to the ankle.  People often complain of spraining their ankle easily when walking on uneven surfaces, such as the grass or gravel.  Multiple sprains can also damage the cartilage within the ankle joint, leading to arthritic problems.  

Surgery is reserved for ankle sprains that fail to heal with conservative management.  In these cases, the ankle may be treated with minimally invasive arthroscopic surgery to evaluate and treat cartilage injuries inside the joint.  The damaged ligaments can be tightened and reinforced to restore stability and trust in the ankle.  

Achilles Tendinitis

This common condition is characterized by pain and swelling in the achilles tendon.  This happens in two places.  Insertional achilles tendinitis occurs at the interface between the achilles tendon and the heel bone. Non-insertional achilles tendinitis occurs about 3-5cm above the heel bone. 

People with achilles tendinitis have swelling and tenderness around the achilles tendon.  This problem should be evaluated by an orthopedic surgeon to differentiate it from achilles tendon rupture.  X-rays often reveal calcification in insertional achilles tendinitis.

Treatment of both types of achilles tendinitis involves rest, ice, anti-inflammatories, and a boot or shoe with a heel lift to decrease tension within the tendon.  After calming the symptoms, physical therapy may be started, and gradual return to activity is attempted.  

MRI is often helpful if conservative management fails to evaluate the tendon for surgical intervention or to help differentiate partial tears of the achilles with tendinitis.  

Foot and Ankle Osteoarthritis

This disorder is seen in many people as they age.  This is commonly associated with a loss of cartilage within the affected joint.  This problem leads to pain, swelling, and stiffness in the affected joints.  Most commonly, it is seen in the ankle joint, the midfoot, or in the big toe.  

Ankle arthritis 

Ankle arthritis is usually the result of previous trauma, such as a bad ankle fracture or multiple ankle sprains.  People with this problem can have severe pain, deformity or alignment issues, significant loss of motion, and sometimes grinding sounds or sensations when moving the ankle joint.  

Treatment of ankle arthritis starts with decreasing pain by limiting motion with a brace and taking anti-inflammatory medication.  Weight loss and activity modification is also attempted.  Injections of corticosteroid, platelet-rich plasma, or stem cells can sometime be helpful as well.  Operative treatment is reserved for patients that have failed these conservative measures.  In mild or moderate arthritis, arthroscopic debridement (cleaning out) of the ankle joint can be helpful.  If the arthritis is severe, the two surgical options are ankle fusion or ankle replacement.  Ankle replacement is preferred in older patients with arthritis with limited deformity who are not excessively active.  

Midfoot arthritis 

Midfoot arthritis can happen from old trauma or from loss of support from the ligaments and tendons of the foot.  This causes pain in the arch, swelling in the foot, and sometimes bone spurs.  Pain is exacerbated when walking barefoot or in flexible shoes.  

Treatment of midfoot arthritis consists of shoewear modification such as arch supports or carbon fiber shoe inserts.  Shoewear should be supportive as well.  Anti-inflammatory medications can help decrease pain and swelling.  Injections can help with pain control, but these generally only offer short-term relief.  If these fail, midfoot fusion surgery can help provide long-term pain improvement.  

Hallux Rigidus

Arthritis in the big toe, also known as hallux rigidus, is a common cause of pain, swelling, and stiffness in the big toe.  It is aggravated by excessive upward movement of the big toe joint, such as prolonged running or walking uphill.  Tenderness and swelling usually occur over the top of the joint, and a large bone spur can form as well.  This painful joint can also cause pain in other areas of the foot, as people try to avoid putting pressure on the great toe and put more weight towards the outside of the foot.  

X-rays will help identify arthritic changes within the joint to confirm the diagnosis.  Most cases can be treated by limiting toe motion with stiffer shoes or insoles, wearing roomier shoes to decrease irritation, and taking anti-inflammatory medications.  Injections can provide short-term relief, but repetitive injections are generally not recommended. 

Surgical treatment is considered when conservative measures have failed.  The main types of treatment are bone spur removal, fusion of the big toe joint, and joint replacement. 

Osteochondral Lesion of the Talus (OLT)

An osteochondral lesion of the talus (OLT) is an area of damaged cartilage and bone on the top of the deep ankle bone within the ankle (talus).  It is also known as osteochondritis dissecans (OCD) of the talus.  Sometimes, it can occur after a bad ankle sprain.  It can also occur with ankle instability or overload of the ankle due to malalignment.  Some OLTs are asymptomatic.  Others can present with significant pain, swelling, clicking, or catching of the ankle joint.  The pain generally is worse with higher levels of activity such as running or jumping. 

Plain X-rays can sometimes help diagnose the problem.  The most useful study to detect this problem is an MRI.  The MRI can show if the cartilage is intact (nondisplaced OLT) or has been displaced.  If a large cyst forms under the OLT, a CT scan can help evaluate the cyst size and bone quality. 

Some nondisplaced OLTs can be treated conservatively with cast immobilization and non-weightbearing.  Therapy and bracing are also useful to help prevent instability and repeat injury. If OLTs fail to improve or if they are displaced, surgery is indicated.  Often, this can be performed in a minimally invasive method using arthroscopy.  

Plantar Fasciitis

Plantar fasciitis is the most common cause of heel pain.  The pain is often the worst with the first steps out of bed in the morning.  The plantar fascia is a thick band of tissue in the sole of the foot.  With repetitive loading and a tight heel cord, microtearing can occur at the attachment of the plantar fascia on the heel bone.  Risk factors include obesity, excessive standing, contracture of the heel cord, increasing age, and change in activity level.  Almost all people with this problem can be treated non-operatively with therapy exercises, anti-inflammatories, change in shoewear, and activity modification.

X-rays can be obtained to help rule out other causes.  Although some people are worried about heel spurs, the presence of a heel spur on x-ray imaging study does not correlate with symptoms.  Many people with heel spurs have no symptoms, and many people with painful plantar fasciitis do not have a heel spur on x-ray. 

There are a few other problems that can cause heel pain, so it is important to be evaluated by an orthopedic surgeon to rule out some of the other less common causes.  MRI is initially not indicated, but it can be helpful to rule out other causes of heel pain after conservative management fails to improve symptoms.