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    Got Foot Pain? Get Relief!

    Last updated 18 days ago

    Plantar Fasciitis (Fasciosis) / Heel Spur Syndrome

    Robert P. Nirschl M.D., M.S.

    Heel pain affects nearly 2 million Americans each year and up to 10% of the U.S. population over a lifetime. Plantar fasciitis is the most common cause of heel pain and the most common orthopaedic complaint relating to the foot that we see at Nirschl Orthopaedic Center. The plantar fascia is a large ligament/tendinous structure that runs along the bottom of the foot.  It attaches to the heel bone (calcaneus) and the base of the toes (ball of the foot).  The plantar fascia helps support the bottom and arch of the foot.

    Pain in the heel is due degeneration in the tendon and inflammation of surrounding tissue.  As you step down, the irritated tissue pulls on the bone causing pain. The condition called Plantar Fasciosis, can become chronic lasting months or years.

    The irritated plantar fascia tissue becomes degenerated and unhealthy if it is repeatedly overstretched. (If stress happens over a long period of time, the heel bone responds by laying down more bone where the plantar fascia attaches to the heel, thus creating a heel spur).  It is commonly believed that these spurs point downward because stepping on it feels like stepping on a tack.  The spur actually runs parallel along the bottom of the foot, pointing toward the toes. Typically, the heel spur itself does not cause pain, but reflects a long standing chronic bone reaction to the stretching tension of the plantar fascia on the bone.

    What causes undue stress on the plantar fascia?

    • Foot structure- an arch that is either too high or too low (e.g. flat feet)
    • Excessive pronation, the feet roll inward too much when you walk
    • Heavy use – either an occupation that requires long hours of standing and heavy lifting, or participation in sports that require a lot of leg and foot movement, or being overweight
    • Ill-fitting shoes with poor arch support
    • Tight calf and hamstrings muscles – causes a tug of war over the ankle and foot joints. Note – prolonged periods in high heels or using heel lifts in shoes can cause tight calf muscles.

    The heel pain is usually due to a combination of several causes listed above.  Therefore it takes a combination of exercises, control of overuse by bracing and other treatments to affect a solution.  An experienced doctor or physical therapist can evaluate you to determine what your problem areas are and what treatment is appropriate.

    Pain may develop slowly, over time, or suddenly after intense activity: It is usually worse:

    ·       In the morning when you take your first steps

    ·       After standing or sitting for a long time

    ·       When climbing stairs

    ·       After intense activity

    What can you do?

    • Give your feet a break. Cut back on activities that make your foot hurt
    • Apply ice to the painful area. Do this at least twice a day for 10 - 15 minutes, more often in the first couple of days. Keeping tennis balls or a water bottle in the freezer and using them to perform a foot massage by rubbing your foot over the ball or bottle is a convenient technique
    • Take an over-the-counter anti-inflammatory  pain reliever such as Advil, Motrin, or Aleve
    • Do foot, heel, and calf stretching exercises several times a day.
    • Pick shoes with good arch support and a cushioned sole
    • Try heel cups shoe inserts. Use them in both shoes, even if only one foot hurts. *This is a short term fix as prolonged use of heel cups will make the calf muscles tighter*
    • Wear a night splint while sleeping to help stretch the foot/fascia
    • Try Physical Therapy
    • Count’R-Force arch brace is often helpful

    We have also found the use of the Count‘R-Force arch brace relieves stress on the plantar fascia by spreading the tension away from the plantar fascia attachment with resultant decrease in pain. www.countrforce.com

    Even with the correct exercises, some people have abnormal foot mechanics or abnormal structural alignment that continues to place too much stress on the tissues.  These problems can be present for several years before pain occurs, but will continue to cause discomfort if not corrected.  Prescription orthotics (custom molded inserts that fit into your shoes) may be required to correct these structural problems

    If you are dealing with plantar fasciitis or other orthopaedic injury, please give us a call to schedule an appointment. Nirschl Orthopaedic Center is a leader in sports medicine and rehabilitation. Schedule an appointment with an orthopedic doctor today by calling our Arlington, VA location at 703-525-2200. For more information on rotator cuff injuries, tennis elbow and other orthopaedic conditions, visit our website

     

    OVERUSE INJURIES GENERAL CONCEPTS By Robert P. Nirschl M.D., M.S.

    Last updated 1 month ago

    Sports injuries are classified as either an overuse or an acute injury. Most sports injuries are a result of overuse and they occur when the body has been pushed too hard, too fast or too long. Pain and swelling are the first indications of overuse injury, and, as is the case for acute injury, “PRICEM” is the rule of thumb for general treatment.

    Protect the injury or it may easily become an acute injury.  Don’t play through the pain. Stop the activity causing discomfort and rest. Put ice on the injured area as soon as possible, but be cautious about direct application that might cause “ice burn”. Compression reduces the swelling. Use an elastic bandage around the injury. Spandex clothing, a neoprene sleeve, or an elastic stocking may serve the same purpose and might also offer some limited measure of support and protection. Elevate the injury above the level of your heart and continue to do so even during sleep.

    It is important to let an overuse injury completely heal before subjecting the injured area to additional stress or abuse. Playing hurt has the same effect as ripping a wound open repeatedly before it can heal. It not only won’t heal, but it may result in a very serious or even irreversible problem. It is also important to reduce the irritative chemical inflammation to aid in the healing process. Compression, ice and elevation are all associated with that component, but medication may be needed as well. Frequently, aspirin or ibuprofen (Motrin, Aleve, Advil, etc.) in therapeutic dosages are effective, but cortisone or some other prescription drug may be necessary. Aspirin at that dosage may cause an upset stomach so buffered aspirin is recommended. Aspirin is not recommended for children because of the risk of Reye’s syndrome. It can also retard blood clotting (helpful to prevent strokes and heart attacks) but should not be taken 10 days in advance of surgery.

    Ice is effective in reducing the pain and swelling in an injured area when inflammation is present. Subsequent treatment with heat will facilitate healing by increasing blood flow to the region for removal of excess liquid and toxins that are a by-product of the injury, as well as enhancing nutrition and oxygenation. It is even possible to create a pumping effect with alternate heat (30 minutes) and cold (5-10 minutes) applications. Massage can also be used to aid circulation to the injured area. But care should be taken not to irritate or abuse the injury, and extreme caution should be used with a mechanical massager.

    The best way to prevent sports injuries is to follow a good warm-up and conditioning program. A regular exercise program with weights and resistance equipment will help structural development that can better withstand the physical stress that will be encountered during sports.  Stretching before and after sports activity will better prepare those muscles and tendons for future use. Some of the more common soft tissue injuries that result from overuse are:

    Sprains: A sprain is an injury to a ligament, a firm band of tissue that supports the joints. Three types of sprains can occur: Grade 1- the ligament is stretched; Grade 2- some of the fibers are torn; Grade 3 – the ligament is totally torn. Sprains are usually the result of twisting trauma, and most commonly occur in the ankle and/or knee joint.

    Strains: A strain is an injury to a muscle-tendon unit. Like sprains, strains can be classified according to severity – stretched, a partial tear, or a complete tear. Strains may occur when muscles lack strength and flexibility. Deficient warm-up or exposure to extreme cold or unusually stressful activity are additional important factors. Strains in the hamstrings and groin adductors (rear and inner muscles of the upper leg) are common, but strains in muscles of the shoulder girdle are becoming recognized as an important contributing factor to shoulder tendinitis as well as primary injury. Strains are always accompanied by weakness.

    Tendinitis/Tendinosis: Tendinosis is a degeneration or injury of a tendon and is generally caused by repetitive trauma. Tendinosis is common in tennis and other sports and repetitive use occupations. Tendinosis, rather than tendinitis, is the correct term as we now know that inflammatory cells are not present in the injured tendons. The most commonly affected tendons are the Achilles tendon, tendons at the knee (runner’s knee), tendons of the posterior tibial muscles-tendon attachment (shin splints), and tendons of the elbow (tennis elbow) and shoulder (rotator cuff tendinosis). Treatment may include medication for pain control, physical therapy to heal, and control of overuse with counter-force bracing. As a last resort, surgery may be an option. Practicing proper sports techniques will also go a long way in preventing tendinosis.

    Bursitis: Bursitis is an overuse injury that results in the inflammation of bursa and is most common in areas near the elbow, shoulder, knee, heel and hip. Bursa are fluid-filled sacs found in regions where friction occurs. Their main function is to minimize friction between bones and tendons, tendons and ligaments or even bone and bone. The condition is frequently found in association with tendinosis. Players with injury to the knee bursa have excessive swelling due to accumulation of fluids in the bursa over and just below the knee cap. Other common bursitis areas include the shoulder, tip of the elbow, outer hip and under the Achilles tendon. The bursa sometimes must be drained or even removed before proper healing can take place. Cortisone is very effective in reducing the bursal inflammation, but other anti-inflammatory drugs maybe sufficient.

    Contusions: A contusion, or bruise, is an injury to soft tissue or bone in which the skin is not broken. A hard direct blow is the most common cause and a collection of blood (a hematoma) may form beneath the skin in the injured muscles, tendons or bone. Icing or some other form of cold application that will contract the blood capillaries will minimize the damage by preventing accumulation of blood and swelling.

    Conclusions

    It takes a long time for most players to admit to themselves that they are not indestructible, and they usually learn the hard way. Loss of flexibility and dehydration of tendons and ligaments with age make aggressive senior players more subject to injury but even the young are vulnerable. Much of this can be avoided by maintaining good strength and flexibility programs, practicing good pre- and post- work out preparation, becoming well informed about injury potential, and by simply using good judgment and control of abuse by using functional counter-force bracing. Following those principles, young people and should be able to continue active sports through their senior years. The enjoyment of that endeavor should result in maintained good health and physical conditioning that will enhance and extend your quality of life.  

    If you are dealing with an orthopaedic injury, please give us a call to schedule an appointment. Nirschl Orthopaedic Center is a leader in sports medicine and rehabilitation. Schedule an appointment with an orthopedic doctor today by calling our Arlington, VA location at (703) 525-2200. For more information on tennis injuries and other orthopaedic conditions, visit our website at www.nirschl.com.

    Diagnosing and treating Shoulder Dislocations By Derek Ochiai, MD

    Last updated 2 months ago

    Shoulder dislocations are common injuries.  Several factors, including age, the side of the dislocation, and the preferred sports/activity level of the patient, help to determine optimal treatment.

    What is a shoulder dislocation?

    The shoulder has been described as a ball-and-socket joint, but it is really a “ball-and-saucer” joint.  Unlike the hip joint, where the hip socket bone securely encompasses the head of the hip, the shoulder socket is relatively flat.  The upside of this flatness is that the shoulder joint has much more flexibility than a hip joint (I demonstrate this by telling patients that it is much easier to put your arm over your head than your leg!).  However, this increased flexibility comes at the cost of decreased bony stability.  Therefore, the shoulder relies on the soft tissue constraints around the shoulder for stability.  With a trauma, these soft tissue constraints can tear when the shoulder dislocates, and lead to chronic shoulder instability.

    What tissue tears with a shoulder dislocation?

    When a shoulder sustains an anterior dislocation (the most common type), the humeral head (ball of the shoulder) rotates out of the glenoid (shoulder socket) in the front of the shoulder.  This most frequently tears the anterior labrum, this rims around the shoulder socket, “deepening the dish” of the socket.  Also, the anterior inferior glenohumeral ligament (AIGHL) attaches to the front of the labrum, and tears along with the labrum.  This spectrum of injury is called a Bankart tear.

    Figure 1.  Clear tear of the anterior inferior labrum (Bankart tear).

    How do I know I dislocated my shoulder?

    This is usually not a subtle injury.  A shoulder dislocation can occur because of a fall or a high energy trauma.  If a patient already has loose joints, a dislocation can occur with more lower energy forces.  With a dislocation, the patient usually has a lot of pain in the shoulder, and they can only move the shoulder with great difficulty.  Typically, once it is dislocated, a patient needs to seek emergent medical treatment to relocate the shoulder.  Sometimes, the shoulder partially “pops out of socket”, and then quickly goes back into place.  In this setting, the shoulder may be sore/painful, but the patient still has some limited motion of the shoulder.

    I’ve heard of athletes having “separated shoulders” and get back on the field quickly.  Is this the same thing?

    No, shoulder separations are completely unrelated to shoulder dislocations.  A shoulder separation occurs when the clavicle (collarbone) and scapula (wingbone) separate from a trauma.  This is OUTSIDE the shoulder joint.  Typically, shoulder separations can heal rather quickly, and the patient is fine afterwards.

    What should I do if I dislocate my shoulder?

    First of all, go to the Emergency Room or to an orthopaedic surgeon and get the shoulder back into place.  Sometimes, the doctor will need to give you some pain medication in order to relax the shoulder enough to move it back into the joint.  X-rays should be taken, to make sure that there is no broken bone.

    After that, typically a patient is put into a sling.  The patient should follow-up with an orthopaedic surgeon.  The surgeon may put the patient into physical therapy, or they may order an MRI, to look for a Bankart tear and other associated injuries.

    Does this injury require surgery?

    That depends.  There is good research that has been done, showing that, if a patient is under the age of 20 when they sustain a shoulder dislocation, there is a 90% chance of additional shoulder dislocations (http://www.ncbi.nlm.nih.gov/pubmed/19218560).  Therefore, in young athletes, surgery is definitely reasonable to consider.  If a patient is over the age of 40 with a first shoulder dislocation, the chances of a recurrent dislocation are much smaller, and in this case many times physical therapy is preferable.

    If surgery is needed, what is done?

    In most cases, the preferred surgery is a Bankart repair, where the labrum is fixed down to the bone.  This surgery can be performed arthroscopically, without the need for an open incision.  This re-tightens the AIGHL, restoring ligament stability to the shoulder.  After surgery, the patient is immobilized in a sling for a while (depends of the extent of the surgery how long the patient is in a brace), and then physical therapy starts.

     

    Figure 2.  Bankart repair, with multiple suture anchors fixing the labrum back down to the bone of the glenoid.

    If you are dealing with a shoulder or orthopaedic injury, please give us a call to schedule an appointment. Nirschl Orthopaedic Center is a leader in sports medicine and rehabilitation. Schedule an appointment with an orthopedic doctor today by calling our Arlington, VA location at (703) 525-2200. For more information on rotator cuff injuries and other orthopaedic conditions, visit our website at www.nirschl.com.

    Derek Ochiai, MD, is a board certified orthopaedic surgeon, fellowship trained in Sports Medicine.

    Follow Dr. Ochiai on Twitter @DrDerekOchiai.

    What does "fixing a hip labral tear" really mean? By Derek Ochiai, MD

    Last updated 2 months ago

    Many times, patients come to my office, and tell me they have a labral tear in their hip on MRI.  Then, they ask me to fix it arthroscopically.  This blog talks about why the labrum is important in the hip and how different treatment options can vary in results.

    What is a labral tear?

    The labrum is a rim of cartilage that surrounds the hip joint.  A labral tear occurs when the labrum peels away from the socket (acetabulum), and becomes detached.  This is the type of tear that is most likely to cause hip functional issues.

    Figure 1.  Chronic, inflamed labral tear.

    The labrum is important!

    Initially, when hip arthroscopy as a field was in its infancy, it was actually debated whether or not hip labral tears actually caused pain for a patient.  As more experience was gained, the typical symptoms of a labral tear of the hip were known:  sit to stand pain, feelings of catching in the hip, pain with prolonged sitting, pain getting in and out of cars, and pain with twisting activities.  Early results showed improvement with debridement (trimming out) the torn labrum (success rate around 70%).  However, while taking out a torn labrum can “smooth out” the joint and eliminate catching, it does not restore normal labral function.

    The hip labrum has multiple functions.   It increases the depth of the socket (acetabulum) of the hip, giving it increased stability.  It also protects the articular cartilage (gliding cartilage) of the hip; the degeneration of this gliding cartilage it what leads to arthritis of the hip.  An optimal hip arthroscopy will restore normal hip labrum mechanics.

    Repairing a labral tear:

    As sports medicine surgeons, we are always striving for improvement in our patient’s function and pain levels.  Therefore, we transitioned from trimming out a torn hip labrum to hip labral repair.  Fortunately, we have been performing shoulder labral repairs for quite a while, and the techniques and implants for shoulder labral tear repair were transferred to the hip.  Soon, we were able to reproducibly repair a hip labrum, anchoring the labrum back down to the bone.

    Figure 2.  Labral repair arthroscopic picture.  The suture (surgical thread) is attached to the acetabular bone, and the labrum is tied down to the bone.

    Repairing the tear is not the end of the story:

    We now know that MOST labral tears of the hip, especially in younger patients, are caused by a bony mismatch of the hip.  The hip is supposed to be a round on round joint, and extra bone (that develops in a patient’s early teenage years) can cause increased pressure on the hip labrum, eventually causing a labral tear.  This condition is called FemoroAcetabular Impingement syndrome (FAI).  When labral repair was COMBINED with arthroscopically treating FAI, the results improved dramatically.

    What if the labral tear is not repairable?

    In my practice, the vast majority of labral tears can be repair, with suture to bone fixation.  In cases where the labrum is not repairable, then labral debridement is reasonable.  Depending on how I assess the stability of the hip joint at time of surgery, sometimes I do a labral reconstruction, where I used a tendon graft to reconstruct the labrum.

    Figure 3.  Arthroscopic picture of a labral reconstruction using a donated graft.  The type of fixation used is exactly the same as with labral repair.  Note the similarities with how this looks compared to Figure 2.

    Derek Ochiai, MD, is a board certified orthopaedic surgeon, specializing in arthroscopic Hip Preservation surgery at Nirschl Orthopaedic Center.

    Follow Dr. Ochiai on Twitter @DrDerekOchiai.

    Nirschl Orthopaedic Center is a leader in sports medicine and general orthopedic services. Schedule an appointment with an orthopaedic doctor today by calling our Arlington, VA location at (703) 525-2200. You can also visit our website to learn more about hip injuries and other orthopedic issues, as well as our services.

    Treatment of Tendinosis / Tendinitis By Derek Ochiai, MD

    Last updated 3 months ago

    What does elbow pain, shoulder pain, knee pain, lateral hip pain, ankle pain, and heel pain all have in common?  Answer:  These are common areas for tendon overuse injuries (tendinosis / tendonitis).  Pain in these areas can be functionally debilitating, affecting athletes and non-athletes alike.  This article reviews what tendinosis is and the possible treatments of this injury are.

    What is tendinosis?

    Tendinosis is an overuse, “wear and tear” of a tendon.  While the term “tendonitis” is still used interchangeably with tendinosis, in most cases, the term tendinosis is correct, since laboratory studies done at our institution by Dr. Robert Nirschl on tendon overuse show that there is little inflammation at the site of injury.  Tendons connect muscles to bones, and near the attachment site to the bones, some tendons have a poor blood supply.  This means that as a tendon is subjected to increasing stress (especially a quick increase in activity level), that tendon may get some fraying and partial tearing, and the blood supply is not robust enough to naturally heal the tendon.  This can create a cycle of chronic pain, where activities cause pain, and when the patient rests, the pain improves.  Then, because the underlying tendinosis has not healed, when the patient stresses the tendon again, the pain returns.

    What are the symptoms of tendinosis?

    Typically, patients will describe a sharp pain with activities.  For instance, for lateral tennis elbow (tendinosis of a tendon that extends the wrist), patients may feel a sharp pain with lifting a gallon of milk or shaking someone’s hand.  For rotator cuff tendinosis, a patient may feel pain reaching to put on a seat belt, or trying to get the sugar out of the top shelf in the kitchen.  In more severe cases, there may also be a dull, baseline pain, even at rest.  Sometimes, this can affect sleep as well.  Uniformly, the activity that incited the tendinosis is affected, be it sports or dance or gardening or working on the computer.

    How is tendinosis treated?

    First, if the symptoms are mild and have been only present for a few days, doing a short period of relative rest, staying away from activities that inflame the area of pain, is reasonable.  If a patient can take over-the-counter anti-inflammatories such as ibuprofen or naproxen, then these medications can give some comfort with daily activities.  The tendinosis area can have a poor blood supply, but there is some blood supply, and sometimes mild wear and tear can heal on its own.  If the pain dissipates, then slowly ramp up activities to the desired level.

    If the pain is persistent, a patient should probably be examined by a sports medicine physician.  A physical examination and sometimes X-rays can usually confirm the diagnosis of tendinosis.  Some minimally invasive treatment options at that point could include the following: 

    Physical therapy - The primary goal of physical therapy is to “build up a new blood supply” to the area of tendinosis through exercise.  The body is adaptive and dynamic, and by carefully introducing exercise designed to stress the area of tendinosis in a controlled fashion, this can lead to a cure.  There are also physical modalities that can be used, to improve ultrasound, electrical stimulation, and iontophoresis (see article with co-authors Dr. Nirschl and myself).

    1.    Bracing.  “Counterforce” bracing is a concept where the stress at the area of tendinosis is dissipated and spread out over a broad surface area, decreasing the pain and improving function.  By itself, it is not a cure for tendinosis, but can make a patient/athlete more comfortable and active during treatment.

    2.    Medications.  NO MEDICATION CURES TENDINOSIS.  However, anti-inflammatories and Tylenol can decrease pain, and this can be useful for function and to improve the patient’s ability to do the physical therapy exercises, which can lead to a cure.

    3.    Cortisone injections.  Cortisone injections also do not cure tendinosis.  However, if someone is having an acute flare of pain, sometimes cortisone injections are necessary to calm down the pain enough to respond to physical therapy.

    What if the tendinosis pain persists?

    Many times, the above treatments are very effective for treatment, but sometimes tendinosis can be resistant to these treatments.  Typically, this is because the tendinosis tissue damage is more advanced, and the body cannot regenerate a strong enough blood supply to heal this tissue.  In these cases, WHEN MORE CONSERVATIVE TREATMENT OPTIONS FAIL, the following are further treatment options.

    1.     Platelet Rich Plasma (PRP) injections.  The patient has their own blood taken, and it is spun down with a centrifuge, to concentrate the body’s natural growth factors.  This growth factor laden fluid is then injected at the site of the tendinosis.  This can recruit healing cells to the area of tendinosis, to spur healing.

    2.    Tenex FAST procedure.  The FAST procedure uses both ultrasound to identify the precise areas of tendinosis and a needle probe delivering a specific frequency of high energy ultrasound to remove the tendinosis tissue.  In cases where the tendinosis is recalcitrant to healing, this has the benefit of removing that tissue.  The procedure is outpatient based, and usually recovery is within 4-6 weeks.  Here is a short video of a Tenex procedure done for Achilles’ tendinosis. 

    3.    Surgical resection and repair.  This is still the “Gold Standard” for treatment of tendinosis, that fails other more conservative treatments.  In this procedure, the area of tendinosis is directly visualized and removed.  The normal tendon that remains is stitched together.  Dr. Nirschl pioneered the procedure for Tennis Elbow (elbow tendinosis).  A paper co-authored by Dr. Nirschl and myself showed excellent results of surgical resection and repair of tennis elbow, even when it is on both the inside and outside of the elbow.

    Treatment of tendinosis can be challenging, and a “one size or treatment fits all” approach is not adequate for all patients.  However, with proper treatment, the overall success rate for treating tendinosis and getting patients back to their normal activities is very high.

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