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July 04 2017

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Do Fallen Arches Require Surgery?

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Flat Foot

There are many different causes of and treatments for flat foot. The most important part of treatment is determining the exact flat foot type on an individual basis, and doing so early on. The main objective is to become educated on the potential problems, so that you can stop them before they start. Conservative treatment is often successful if initiated early. The old adage "a stitch in time saves nine" definitely applies to the human body, hopefully more figuratively than literally. Do not ignore what your common sense and your body are telling you. Yes, you can live without an arch, but never neglect a symptomatic foot. If you neglect your feet, they will make you pay with every literal step you take.

Causes

A Rigid Flat Foot may be congenital, where the arch never develops when growing. A Rigid Flat Foot can also be acquired due to disease processes involving inflammatory arthritis, neurological conditions such as Charcot neuro-arthropathy or trauma. A Flexible Flat Foot (fallen arches) may also be congenital where excessive pronation occurs for shock absorption. In some cases this condition may be the result of neurological disease or injury involving muscle weakness, hyper-mobile joints or ligament laxity. These conditions may allow for excessive pronation causing the arch to fall when weight bearing or during activity. Both of these foot types can result in posture mal-alignment involving the lower back, hips, knees and feet which may result in pain in those areas.

Symptoms

The majority of children and adults with flexible flatfeet never have symptoms. However, their toes may tend to point outward as they walk, a condition called out-toeing. A person who develops symptoms usually complains of tired, aching feet, especially after prolonged standing or walking. Symptoms of rigid flatfoot vary depending on the cause of the foot problem. Congenital vertical talus. The foot of a newborn with congenital vertical talus typically has a convex rocker-bottom shape. This is sometimes combined with an actual fold in the middle of the foot. The rare person who is diagnosed at an older age often has a "peg-leg" gait, poor balance and heavy calluses on the soles where the arch would normally be. If a child with congenital vertical talus has a genetic disorder, additional symptoms often are seen in other parts of the body. Tarsal coalition. Many people have no symptoms, and the condition is discovered only by chance when an X-ray of the foot is obtained for some other problem. When symptoms occur, there is usually foot pain that begins at the outside rear of the foot. The pain tends to spread upward to the outer ankle and to the outside portion of the lower leg. Symptoms usually start during a child's teenage years and are aggravated by playing sports or walking on uneven ground. In some cases, the condition is discovered when a child is evaluated for unusually frequent ankle sprains. Lateral subtalar dislocation. Because this often is caused by a traumatic, high-impact injury, the foot may be significantly swollen and deformed. There also may be an open wound with bruising and bleeding.

Diagnosis

If your child has flatfeet, his or her doctor will ask about any family history of flatfeet or inherited foot problems. In a person of any age, the doctor will ask about occupational and recreational activities, previous foot trauma or foot surgery and the type of shoes worn. The doctor will examine your shoes to check for signs of excessive wear. Worn shoes often provide valuable clues to gait problems and poor bone alignment. The doctor will ask you to walk barefoot to evaluate the arches of the feet, to check for out-toeing and to look for other signs of poor foot mechanics. The doctor will examine your feet for foot flexibility and range of motion and feel for any tenderness or bony abnormalities. Depending on the results of this physical examination, foot X-rays may be recommended. X-rays are always performed in a young child with rigid flatfeet and in an adult with acquired flatfeet due to trauma.

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Non Surgical Treatment

There are different modalities of treatment that are available to manage flat feet and fallen arches. The type of treatment that is chosen depends upon how severe the condition is and what symptoms the patients are experiencing. Below is a brief description of the available treatment modalities. In the event that the patient is experiencing swelling of the feet, rest and ice application is usually the initial treatment step. Oral anti-inflammatories may be offered which can help reduce inflammation as well as associated pain. Physical therapy has good outcomes and can include different exercises such as stretches and strengthening of the surrounding muscles. Changes in footwear and activity modification are also important when dealing with a painful flat (pronated) foot. These days, orthotic insoles are easily available either over the counter or through your Podiatrist which can effectively help maintain the arch of the foot and reduce the amount of stress placed on the foot. Podiatrists are able to prescribe a variety of different devices from prefabricated to customized and are trained to determine the most appropriate device for each individual. In order to offer the right kind of orthotic insole, podiatrists may perform a test called gait analysis. This involves asking the patient to walk and videoing the different movements that the foot of forms during the walking. Features such as over pronation can be easily seen on this and orthotic insoles can be prescribed to correct the specific abnormalities that are picked up on this analysis. Overall, orthotic treatment can result in a significant improvement in foot movement and reduction in foot discomfort.

Surgical Treatment

Acquired Flat Feet

Surgery is typically offered as a last resort in people with significant pain that is resistant to other therapies. The treatment of a rigid flatfoot depends on its cause. Congenital vertical talus. Your doctor may suggest a trial of serial casting. The foot is placed in a cast and the cast is changed frequently to reposition the foot gradually. However, this generally has a low success rate. Most people ultimately need surgery to correct the problem. Tarsal coalition. Treatment depends on your age, extent of bone fusion and severity of symptoms. For milder cases, your doctor may recommend nonsurgical treatment with shoe inserts, wrapping of the foot with supportive straps or temporarily immobilizing the foot in a cast. For more severe cases, surgery is necessary to relieve pain and improve the flexibility of the foot. Lateral subtalar dislocation. The goal is to move the dislocated bone back into place as soon as possible. If there is no open wound, the doctor may push the bone back into proper alignment without making an incision. Anesthesia is usually given before this treatment. Once this is accomplished, a short leg cast must be worn for about four weeks to help stabilize the joint permanently. About 15% to 20% of people with lateral subtalar dislocation must be treated with surgery to reposition the dislocated bone.

July 01 2017

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Leg Length Discrepancy Surgery Growth Plate

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Surgeries to lengthen a leg are generally only performed when there is a difference in leg length of greater than four centimeters. These types of surgeries can be more difficult and have more complications, such as infections, delayed healing, dislocations, and high blood pressure. In a several step process, bone lengthening surgeries involve cutting a bone in two in order to allow new bone growth to occur. After the bone is cut, a special apparatus is worn with pins that will pull the bone apart at approximately one millimeter per day. This causes osteogenesis, or new bone growth, in between the cut bone segments. A cast or brace may be required for several months after surgery to allow the new bone growth to harden and provide extra support.Leg Length Discrepancy

Causes

LLDs are very common. Sometimes the cause isn?t known. But the known causes of LLD in children include, injury or infection that slows growth of one leg bone. Injury to the growth plate (a soft part of a long bone that allows the bone to grow). Growth plate injury can slow bone growth in that leg. Fracture to a leg bone that causes overgrowth of the bone as it heals. A congenital (present at birth) problem (one whole side of the child?s body may be larger than the other side). Conditions that affect muscles and nerves, such as polio.

Symptoms

Many people walk around with LLD?s of up to 2 cm. and not even know it. However, discrepancies above 2 cm. becomes more noticeable, and a slight limp is present. But even up to 3 cm. a small lift compensates very well, and many patients are quite happy with this arrangement. Beyond 3 cm. however, the limp is quite pronounced, and medical care is often sought at that point. Walking with a short leg gait is not only unsightly, but increases energy expenditure during ambulation. It could also put more stress on the long leg, and causes functional scoliosis. Where the discrepancy is more severe, walking becomes grotesque or virtually impossible.

Diagnosis

On standing examination one iliac crest may be higher/lower than the other. However a physiotherapist, osteopath or chiropractor will examine the LLD in prone or supine position and measure it, confirming the diagnosis of structural (or functional) LLD. The LLD should be measured using bony fixed points. X-Ray should be taken in a standing position. The osteopath, physiotherapist or chiropractor will look at femoral head & acetabulum, knee joints, ankle joints.

Non Surgical Treatment

The treatment of LLD depends primarily on the diagnosed cause, the age of the patient, and the severity of the discrepancy. Non-operative treatment is usually the first step in management and, in many cases, LLD is mild or is predicted to lessen in the future, based on growth rate estimates in the two legs. In such cases, no treatment may be necessary or can be delayed until a later stage of physical maturity that allows for clearer prognostic approximation. For LLD of 2cm to 2.5cm, treatment may be as simple as insertion of a heel lift or other shoe insert that evens out leg lengths, so to speak. For more severe cases, heel lifts can affect patient comfort when walking, decrease ankle stability, and greatly increase the risk of sprains. For infants with congenital shortening of the limb, a prosthetic ? often a custom-fit splint made of polypropylene ? may be successful in treating more severe LLD without surgery. In many instances, however, a surgical operation is the best treatment for LLD.

Leg Length Discrepancy Insoles

shoe lift inserts

Surgical Treatment

The type of surgery depends on the type of problem. Outpatient procedures may be used to alter the growth of the limb. This is often done through small incisions. If an outpatient procedure is done, your child can continue with most regular activities. Other times, surgery may be very involved and require the use of an external device that is attached to the limb with pins and wires. This device may be left on for months to correct the deformity or lengthen the leg. If this type of surgery is required, your child will be making weekly visits to Cincinnati Children's.

June 28 2017

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What Causes Heel Pain

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Foot Pain

Heel pain is most often caused by plantar fasciitis, a condition that is sometimes also called heel spur syndrome when a spur is present. Heel pain may also be due to other causes, such as a stress fracture, tendonitis, arthritis, nerve irritation, or, rarely, a cyst. Because there are several potential causes, it is important to have heel pain properly diagnosed. A foot and ankle surgeon is able to distinguish between all the possibilities and determine the underlying source of your heel pain.What Is Plantar Fasciitis? Plantar fasciitis is an inflammation of the band of tissue (the plantar fascia) that extends from the heel to the toes. In this condition, the fascia first becomes irritated and then inflamed, resulting in heel pain.

Causes

Near the inflamed plantar fascia attachment, but not in it, some extra bone may form, producing a small "spur". In fact, it is a shelf of bone, not a sharp spur. These "heel spurs" are commoner in people with plantar fascitis, but they can be found in people with no heel pain. The heel spur is caused by the same process as the heel pain, but the spur is not itself the cause of the pain.

Symptoms

The symptoms of plantar fasciitis include pain along the inside edge of the heel near the arch of the foot. The pain is worse when weight is placed on the foot especially after a long period of rest or inactivity. This is usually most pronounced in the morning when the foot is first placed on the floor. This symptom called first-step pain is typical of plantar fasciitis. Prolonged standing can also increase the painful symptoms. It may feel better after activity but most patients report increased pain by the end of the day. Pressing on this part of the heel causes tenderness. Pulling the toes back toward the face can be very painful.

Diagnosis

Your GP or podiatrist (a healthcare professional who specialises in foot care) may be able to diagnose the cause of your heel pain by asking about your symptoms and examining your heel and foot. You will usually only need further tests if you have additional symptoms that suggest the cause of your heel pain is not inflammation, such as numbness or a tingling sensation in your foot - this could be a sign of nerve damage in your feet and legs (peripheral neuropathy), your foot feels hot and you have a high temperature (fever) of 38C (100.4F) or above - these could be signs of a bone infection, you have stiffness and swelling in your heel - this could be a sign of arthritis. Possible further tests may include, blood tests, X-rays - where small doses of radiation are used to detect problems with your bones and tissues, a magnetic resonance imaging (MRI) scan or ultrasound scan, which are more detailed scans.

Non Surgical Treatment

Initial treatment consists of rest, use of heel cushions to elevate the heel (and take tension off the Achilles), stretching and applying ice to the area. You can ice and stretch the area simultaneously by filling a bucket with ice and cold water and placing the foot flexed with the toes upward so that the Achilles tendon region is bathed in the cold water for 10 to 15 minutes twice a day. The Achilles region can also become inflamed around the tendon, called paratendinosis. This condition can be treated with the ice bucket stretching, rest and physical therapy. Another area that is commonly subjected to problems is the attachment of the Achilles near or on the heel bone. The heel (calcaneus) itself can have an irregular shape to it, causing irritation to the Achilles as it twists over the region and inflames the bursa, a naturally occurring cushion. Shoes can often aggravate this condition. Sometimes over-stretching, such as the Achilles stretch with the knee bent, can irritate the tendon and cause a bursitis. Prescription foot orthoses can help reduce the torque of the Achilles tendon in these types of cases. Often, the Achilles tendon calcifies near its attachment due to constant torque and tension. Repetitive stress can cause this calcific spur to crack, creating a chronic inflammatory situation that can require surgery. All of these types of chronic Achilles tendinosis that require surgery are successfully treated in over 90 percent of the cases. As with most foot surgery, complete recovery can take up to a year. Though heel pain is common and can be chronic, it does not have to be your weakness (as was the case with the warrior Achilles from Greek mythology).

Surgical Treatment

It is rare to need an operation for heel pain. It would only be offered if all simpler treatments have failed and, in particular, you are a reasonable weight for your height and the stresses on your heel cannot be improved by modifying your activities or footwear. The aim of an operation is to release part of the plantar fascia from the heel bone and reduce the tension in it. Many surgeons would also explore and free the small nerves on the inner side of your heel as these are sometimes trapped by bands of tight tissue. This sort of surgery can be done through a cut about 3cm long on the inner side of your heel. Recently there has been a lot of interest in doing the operation by keyhole surgery, but this has not yet been proven to be effective and safe. Most people who have an operation are better afterwards, but it can take months to get the benefit of the operation and the wound can take a while to heal fully. Tingling or numbness on the side of the heel may occur after operation.

back of heel cushions

Prevention

Feet Pain

The following steps will help prevent plantar fasciitis or help keep the condition from getting worse if you already have it. The primary treatment is rest. Cold packs application to the area for 20 minutes several times a day or after activities give some relief. Over-the-counter pain medications can help manage the pain, consult your healthcare professional. Shoes should be well cushioned, especially in the midsole area, and should have the appropriate arch support. Some will benefit from an orthotic shoe insert, such as a rubber heel pad for cushioning. Orthotics should be used in both shoes, even if only one foot hurts. Going barefoot or wearing slipper puts stress on your feet. Put on supportive shoes as soon as you get out of bed. Calf stretches and stretches using a towel (place the towel under the ball of your feet and pull gently the towel toward you and hold a few seconds) several times a day, especially when first getting up in the morning. Stretching the Achilles tendon at the back of the heel is especially important before sports, but it is helpful for nonathletes as well. Increasing your exercise levels gradually. Staying at a healthy weight. Surgery is very rarely required.

June 27 2017

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Leg Length Discrepancy Symptoms

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If one scans the literature it readily becomes obvious that leg length discrepancy/asymmetry is a common finding. This fact has been a very controversial topic within chiropractic, and diagnostic rationales have been built around this very common finding.

The object of this column is to consider some of the causes of this discrepancy that the profession may have ignored or not been aware of.Leg Length Discrepancy

Causes

LLDs are very common. Sometimes the cause isn?t known. But the known causes of LLD in children include, injury or infection that slows growth of one leg bone. Injury to the growth plate (a soft part of a long bone that allows the bone to grow). Growth plate injury can slow bone growth in that leg. Fracture to a leg bone that causes overgrowth of the bone as it heals. A congenital (present at birth) problem (one whole side of the child?s body may be larger than the other side). Conditions that affect muscles and nerves, such as polio.

Symptoms

Patients with significant lower limb length discrepancies may walk with a limp, have the appearance of a curved spine (non-structural scoliosis), and experience back pain or fatigue. In addition, clothes may not fit right.

Diagnosis

Limb length discrepancy can be measured by a physician during a physical examination and through X-rays. Usually, the physician measures the level of the hips when the child is standing barefoot. A series of measured wooden blocks may be placed under the short leg until the hips are level. If the physician believes a more precise measurement is needed, he or she may use X-rays. In growing children, a physician may repeat the physical examination and X-rays every six months to a year to see if the limb length discrepancy has increased or remained unchanged. A limb length discrepancy may be detected on a screening examination for curvature of the spine (scoliosis). But limb length discrepancy does not cause scoliosis.

Non Surgical Treatment

Heel lifts Raise the heel on the shorter leg. It is applied either to the heel of the custom orthotic or to the inside of the shoe under the insole at the heel. Generally if the discrepancy is greater than 3/8 of an inch, the modification is applied externally on the footwear. Custom made orthotics help to provide proper support and alignment to the foot, controlling conditions such as over pronation. Orthopedic Footwear, properly fitted, to which a lift might be applied inside or out.

Leg Length Discrepancy

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Surgical Treatment

Lengthening is usually done by corticotomy and gradual distraction. This technique can result in lengthenings of 25% or more, but typically lengthening of 15%, or about 6 cm, is recommended. The limits of lengthening depend on patient tolerance, bony consolidation, maintenance of range of motion, and stability of the joints above and below the lengthened limb. Numerous fixation devices are available, such as the ring fixator with fine wires, monolateral fixator with half pins, or a hybrid frame. The choice of fixation device depends on the desired goal. A monolateral device is easier to apply and better tolerated by the patient. The disadvantages of monolateral fixation devices include the limitation of the degree of angular correction that can concurrently be obtained; the cantilever effect on the pins, which may result in angular deformity, especially when lengthening the femur in large patients; and the difficulty in making adjustments without placing new pins. Monolateral fixators appear to have a similar success rate as circular fixators, especially with more modest lengthenings (20%).

May 29 2017

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Mortons Neuroma Solutions

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interdigital neuromaA Morton's neuroma, or interdigital neuroma, is a painful condition which involves a nerve on the plantar aspect (bottom) of the foot. Occasionally a neuroma develops following a bruising injury to the sole of the foot, such as might be caused by jumping onto a rock or other objects, but in general, the origin of the condition is unknown.

Causes

Experts are not sure what exactly causes Morton's neuroma. It seems to develop as a result of irritation, pressure or injury to one of the digital nerves that lead to the toes, which triggers a body response, resulting in thickened nerve tissue (neuroma). Feet conditions/situations that can cause the bones to rub against a nerve include high-heeled shoes, especially those over 2 inches (5cm), or a pointed or tight toe box which squash the toes together. This is probably why the condition is much more common in females than in males. High-arched foot, people whose feet have high arches are much more likely to suffer from Morton's neuroma than others. Flat feet, the arch of the foot collapses. The entire sole of the foot comes into complete or near-complete contact with the ground. A bunion, a localized painful swelling at the base of the big toe, which enlarges the joint. Hammer toe, a deformity of the proximal interphalangeal joint of the second, third, or fourth toe causing it to be permanently bent. Some high-impact sporting activities including running, karate, and court sports. Any sport that places undue pressure on the feet. Injuries, an injury or other type of trauma to the foot may lead to a neuroma.

Symptoms

Symptoms associated with a neuroma include a dull burning sensation radiating towards the toes, a cramping feeling, or even a stinging, tingling sensation that can be described as being similar to an electric shock. It is often worse when wearing shoes with most people finding the pain disappears when removing their shoes.

Diagnosis

Podiatrists conduct a physical examination and may order imaging tests, such as x-ray or MRI scan to diagnose Morton's neuroma. Conservative treatment options include custom-fitted orthotics, medication, and/or alcohol injections designed to harden the nerve. However, most patients with Morton's neuroma need minor surgery.

Non Surgical Treatment

Simple treatments may be all that are needed for some people with a Morton's neuroma. They include the following. Footwear adjustments including avoidance of high-heeled and narrow shoes and having special orthotic pads and devices fitted into your shoes. Calf-stretching exercises may also be taught to help relieve the pressure on your foot. Steroid or local anaesthetic injections (or a combination of both) into the affected area of the foot may be needed if the simple footwear changes do not fully relieve symptoms. However, the footwear modification measures should still be continued. Sclerosant injections involve the injection of alcohol and local anaesthetic into the affected nerve under the guidance of an ultrasound scan. Some studies have shown this to be as effective as surgery.plantar neuroma

Surgical Treatment

Surgery to remove the neuroma may be recommended if more conservative treatment does not solve the problem. While surgery usually relieves or completely removes the symptoms, it often leaves a permanent numb feeling at the site of the neuroma.

Prevention

Women, particularly those who wear tight shoes, are at greatest risk for Morton?s neuroma. The best way to prevent the condition is to wear shoes with wide toe boxes. Tight, pointed shoes squeeze bones, ligaments, muscles and nerves. High heels may worsen the problem by shifting your weight forward. Over time, this combination can cause the nerves to swell and become painful.

June 23 2015

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Help For Hammertoes Treatment

HammertoeOverview

Hammer toes deformities can be painful and unsightly. These toe deformities can be the result of a muscle/tendon imbalance or often the end stage result of some systemic disease such as diabetes or arthritis, especially Rheumatoid arthritis. Hammertoe deformities are progressive and can be prevented.

Causes

Hammertoes are more commonly seen in women than men, due to the shoe styles women frequently wear: shoes with tight toe boxes and high heels. Genetics plays a role in some cases of hammertoes, as does trauma, infection, arthritis, and certain neurological and muscle disorders. But most cases of contracted toes are associated with various biomechanical abnormalities of the feet, such as flat feet and feet with abnormally high arches. These biomechanical abnormalities cause the muscles and tendons to be used excessively or improperly, which deforms the toes over time.

HammertoeSymptoms

Well-developed hammertoes are distinctive due to the abnormal bent shape of the toe. However, there are many other common symptoms. Some symptoms may be present before the toe becomes overly bent or fixed in the contracted position. Often, before the toe becomes permanently contracted, there will be pain or irritation over the top of the toe, particularly over the joint. The symptoms are pronounced while wearing shoes due to the top of the toe rubbing against the upper portion of the shoe. Often, there is a significant amount of friction between the toe and the shoe or between the toe and the toes on either side of it. The corns may be soft or hard, depending on their location and age. The affected toe may also appear red with irritated skin. In more severe cases, blisters or open sores may form. Those with diabetes should take extra care if they develop any of these symptoms, as they could lead to further complications.

Diagnosis

Your doctor is very likely to be able to diagnose your hammertoe simply by examining your foot. Even before that, he or she will probably ask about your family and personal medical history and evaluate your gait as you walk and the types of shoes you wear. You'll be asked about your symptoms, when they started and when they occur. You may also be asked to flex your toe so that your doctor can get an idea of your range of motion. He or she may order x-rays in order to better define your deformity.

Non Surgical Treatment

Apply a commercial, nonmedicated hammertoe pad around the bony prominence of the hammertoe. This will decrease pressure on the area. Wear a shoe with a deep toe box. If the hammertoe becomes inflamed and painful, apply ice packs several times a day to reduce swelling. Avoid heels more than two inches tall. A loose-fitting pair of shoes can also help protect the foot while reducing pressure on the affected toe, making walking a little easier until a visit to your podiatrist can be arranged. It is important to remember that, while this treatment will make the hammertoe feel better, it does not cure the condition. A trip to the podiatric physician?s office will be necessary to repair the toe to allow for normal foot function. Avoid wearing shoes that are too tight or narrow. Children should have their shoes properly fitted on a regular basis, as their hammertoes feet can often outgrow their shoes rapidly. See your podiatric physician if pain persists.

Surgical Treatment

Any surgery must be carefully considered and approached in a serious manner, as any procedure is serious for the patient. But in most cases the procedure is relatively straight forward. The surgery can be done using local anesthetic and does not require hospitalization. The patient goes home in a special post-operative shoe or a regular sandal, and in most cases can walk immediately. That's not to say that the patient is walking or functioning normally immediately after the procedure. The patient must take some time off work to rest the foot and allow it to heal.
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June 06 2015

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How Can I Tell If I'Ve Got Over-Pronation Of The Feet

Overview

Overpronation still continues to be misused and misunderstood. For example, there was a study that got a lot of recent mileage in the mainstream media and the blogosphere that claimed to show that foot pronation was not associated with injury risk. It was intriguing following comments on the study in mainstream media and in social media, especially the parroting of the press release without any critical appraisal. The study actually eliminated the ?overpronators? that were probably at high risk from the study then found that ?overpronation? was not a risk factor. What is more intriguing was that there was another study from around the same time that found the exact opposite. Clearly, the data on ?overpronation? and risk for injury in runners is mixed, so we need to rely on the more formal systematic reviews and meta-analyses of all the data. The most recent one of those concluded that ?overpronation? is just a small risk factor for running injury risk, but it is still statistically significant.Overpronation

Causes

Although there are many factors that can contribute to the development of these conditions, improper biomechanics of the body plays a large and detrimental role in the process. Of the many biomechanical elements involved, foot and ankle function perhaps contribute the most to these aches and pains.

Symptoms

Overpronation can negatively affect overall body alignment. The lowering of the longitudinal arch pulls the heel bone in, causing the leg, thigh bone and hip to rotate inwards, and an anterior tilt of the pelvis. Unnecessary strain to the ankles, knees, hips and back can result. Plantar fasciitis and inflammation, metatarsal pain, problems with the Achilles tendon, pain on the inside of the knee, and bursitis in the hip are just some of the conditions commonly associated with pronation.

Diagnosis

People who overpronate have flat feet or collapsed arches. You can tell whether you overpronate by wetting your feet and standing on a dry, flat surface. If your footprint looks complete, you probably overpronate. Another way to determine whether you have this condition is to simply look at your feet when you stand. If there is no arch on the innermost part of your sole, and it touches the floor, you likely overpronate. The only way to truly know for sure, however, is to be properly diagnosed by a foot and ankle specialist.Pronation

Non Surgical Treatment

If you overpronate, you should talk with a foot and ankle specialist, especially if symptoms have not developed yet. Questions you may want to ask your doctor include what are the best running shoes on the market? Where can I find those shoes? If over-the-counter orthotics don?t work, how long should I wait before contacting you for custom-made orthotics? On my next visit, what type of diagnostic testing should I expect? If I limit the amount of time I spend running, will my overpronation symptoms disappear? What additional treatment options can we try?

Surgical Treatment

Subtalar Arthroereisis. The ankle and hindfoot bones/midfoot bones around the joint are fused, locking the bones in place and preventing all joint motion. This may also be done in combination with fusion at other joints. This is a very aggressive option usually reserved for extreme cases where no joint flexibility is present and/or the patient has severe arthritic changes in the joint.

May 18 2015

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Therapy And Severs Disease

Overview

Sever?s disease is a condition occurring in pre-adolescents that causes pain, swelling and soreness in the heel bone, also known as the calcaneus. Sever?s disease causes pain on either side of and/or on the bottom of the heel. During a period of pre-adolescent development, the growing heel bone can be overused when the child is involved in a lot of running and jumping activities. Impact on the heel bone and repeated traction on the growing bone from the Achilles tendon can lead to swelling in the area.

Causes

There are many contributing factors that cause strain across the growth plate, making your child prone to developing Sever?s disease. These include repeated minor trauma to the growth plate from running or jumping sports, tight calf or hamstring muscles, rapid growth spurts can lead to the leg muscles becoming tight, increasing tension on the growth plate, tight Achilles tendon, the Achilles tendon attaches to the back of the heel adjacent to the growth plate, poor foot posture, may increase the strain on the growth plate, footwear with a very low heel pitch (eg soccer boots), unsupportive or unstable footwear with poor shock absorption at the heel, running or playing sport on hard surfaces.

Symptoms

Sever's disease causes pain and tenderness in the back and bottom of the heel when walking or standing, and the heel is painful when touched. It can occur in one or both feet.

Diagnosis

All medical diagnosis should be made by taking a full history, examining the patient then performing investigations. The problem usually occurs in boys who are going through or have just gone through a growth spurt; one or both heels may be affected. Initially the pain may be intermittent occurring only during or after exercise. As the problem gets worse, pain may be present most of the time. There may be swelling over the back of the heel and this area is painful if touched or knocked. On examination the patient often has flat feet, very tight legs muscles especially the gastrocnemius.

Non Surgical Treatment

Fortunately Severs? disease can be treated and prevented through a number of different techniques that have all proven highly effective. The heel will repair itself even without active treatment provided that the suffering foot is given a chance to heal. Typically Severs? disease will take 2-8 weeks, although in many cases it can take longer as the continuous growing of the bone can exacerbate the condition. Podiatrists have an important role in preventing Severs? disease in young athletes, and in treating the condition when it develops so children can get back on their feet as quickly as possible. Generally treatment involves stretching muscles running down to the heel to relieve tension and pain, these include the hamstrings and calf muscles, and these stretching exercises will need to be performed at least 2 or 3 times a day. RICE is a classic method of speeding up the recovery of self-healing injuries like Severs? disease. This involves Rest, the application of Ice to the injury, Compression, and finally Elevation to encourage repaid. These measures can be advised by a trained podiatrist, but it is then up to a child to carry on with regular RICE.

Recovery

The condition is normally self-limiting, and a return to normal activities is usually possible after a period of 2-3 months. In one study, all the patients treated with a physiotherapy programme (above) improved and could return to their sport of choice after two months of treatment. The condition may recur, although recurrence was uncommon, according to one study.

April 27 2015

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Genetic Leg Length Discrepancy

Overview

You may be surprised to learn that most people have one leg that's just a bit longer than the other, or one foot that may be slightly larger. But for children with significant limb length discrepancies, the size difference between limbs can be a serious problem. There are two types of limb length discrepancies. Congenital discrepancy is when babies are born with one leg longer than the other. In some cases both legs are normal, except that one is shorter than the other. In other cases one particular part of the leg is underdeveloped or is absent. Acquired discrepancy is when babies are normal at birth, but some kind of injury happens, such as a severe fracture. The bone growth in that limb slows, which results in a leg length discrepancy that worsens as the child continues to grow.Leg Length Discrepancy

Causes

The causes of LLD are many, including a previous injury, bone infection, bone diseases (dysplasias), inflammation (arthritis) and neurologic conditions. Previously broken bones may cause LLD by healing in a shortened position, especially if the bone was broken in many pieces (comminuted) or if skin and muscle tissue around the bone were severely injured and exposed (open fracture). Broken bones in children sometimes grow faster for several years after healing, causing the injured bone to become longer. Also, a break in a child?s bone through a growth center (located near the ends of the bone) may cause slower growth, resulting in a shorter extremity. Bone infections that occur in children while they are growing may cause a significant LLD, especially during infancy. Bone diseases may cause LLD, as well; examples are neurofibromatosis, multiple hereditary exostoses and Ollier disease. Inflammation of joints during growth may cause unequal extremity length. One example is juvenile rheumatoid arthritis. Osteoarthritis, the joint degeneration that occurs in adults, very rarely causes a significant LLD.

Symptoms

Patients with significant lower limb length discrepancies may walk with a limp, have the appearance of a curved spine (non-structural scoliosis), and experience back pain or fatigue. In addition, clothes may not fit right.

Diagnosis

Limb length discrepancy can be measured by a physician during a physical examination and through X-rays. Usually, the physician measures the level of the hips when the child is standing barefoot. A series of measured wooden blocks may be placed under the short leg until the hips are level. If the physician believes a more precise measurement is needed, he or she may use X-rays. In growing children, a physician may repeat the physical examination and X-rays every six months to a year to see if the limb length discrepancy has increased or remained unchanged. A limb length discrepancy may be detected on a screening examination for curvature of the spine (scoliosis). But limb length discrepancy does not cause scoliosis.

Non Surgical Treatment

The non-surgical intervention is mainly usedfor the functional and environmental types of leg length discrepancies. It is also applied to the mild category of limb length inequality. Non-surgical intervention consists of stretching the muscles of the lower extremity. This is individually different, whereby the M. Tensor Fascia latae, the adductors, the hamstring muscles, M. piriformis and M. Iliopsoas are stretched. In this non-surgical intervention belongs also the use of shoe lifts. These shoe lifts consists of either a shoe insert (up to 10-20mm of correction), or building up the sole of the shoe on the shorter leg (up to 30-60mm of correction). This lift therapy should be implemented gradually in small increments. Several studies have examined the treatment of low back pain patients with LLD with shoe lifts. Gofton obtained good results: the patients experienced major or complete pain relief that lasted upon follow-up ranging from 3 to 11 years. Helliwell also observed patients whereby 44% experienced complete pain relief, and 45% had moderate or substantial pain relief. Friberg found that 157 (of 211) patients with LBP, treated with shoe lifts, were symprom-free after a mean follow-up of 18 months.

Leg Length Discrepancy Insoles

Surgical Treatment

Surgery to shorten the longer leg. This is less involved than lengthening the shorter leg. Shortening may be done in one of two ways. Closing the growth plate of the long leg 2-3 years before growth ends (around age 11-13), letting the short leg catch up. This procedure is called an epiphysiodesis. Taking some bone from the longer leg once growth is complete to even out leg lengths. Surgery to lengthen the shorter leg. This surgery is more involved than surgery to shorten a leg. During this surgery, cuts are made in the leg bone. An external metal frame and bar are attached to the leg bone. This frame and bar slowly pull on the leg bone, lengthening it. The frame and bar must be worn constantly for months to years. When the frame and bar are removed, a leg cast is required for several months. This surgery requires careful and continued follow-up with the surgeon to be sure that healing is going well.

April 18 2015

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Best Surgery For Flat Feet In Adults

Overview
Adult-acquired flatfoot (AAF) is the term used to describe the progressive deformity of the foot and ankle that, in its later stages, results in collapsed and badly deformed feet. Although the condition has been described and written about since the 1980s, AAF is not a widely used acronym within the O&P community-even though orthotists and pedorthists easily recognize the signs of the condition because they treat them on an almost daily basis. AAF is caused by a loss of the dynamic and static support structures of the medial longitudinal arch, resulting in an incrementally worsening planovalgus deformity associated with posterior tibial (PT) tendinitis. Over the past 30 years, researchers have attempted to understand and explain the gradual yet significant deterioration that can occur in foot structure, which ultimately leads to painful and debilitating conditions-a progression that is currently classified into four stages. What begins as a predisposition to flatfoot can progress to a collapsed arch, and then to the more severe posterior tibial tendon dysfunction (PTTD). Left untreated, the PT tendon can rupture, and the patient may then require a rigid AFO or an arthrodesis fixation surgery to stabilize the foot in order to remain capable of walking pain free. Flat feet

Causes
The posterior tibial tendon, which connects the bones inside the foot to the calf, is responsible for supporting the foot during movement and holding up the arch. Gradual stretching and tearing of the posterior tibial tendon can cause failure of the ligaments in the arch. Without support, the bones in the feet fall out of normal position, rolling the foot inward. The foot's arch will collapse completely over time, resulting in adult acquired flatfoot. The ligaments and tendons holding up the arch can lose elasticity and strength as a result of aging. Obesity, diabetes, and hypertension can increase the risk of developing this condition. Adult acquired flatfoot is seen more often in women than in men and in those 40 or older.

Symptoms
Often, this condition is only present in one foot, but it can affect both. Adult acquired flatfoot symptoms vary, but can swelling of the foot's inner side and aching heel and arch pain. Some patients experience no pain, but others may experience severe pain. Symptoms may increase during long periods of standing, resulting in fatigue. Symptoms may change over time as the condition worsens. The pain may move to the foot's outer side, and some patients may develop arthritis in the ankle and foot.

Diagnosis
The history and physical examination are probably the most important tools the physician uses to diagnose this problem. The wear pattern on your shoes can offer some helpful clues. Muscle testing helps identify any areas of weakness or muscle impairment. This should be done in both the weight bearing and nonweight bearing positions. A very effective test is the single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). X-rays are often used to study the position, shape, and alignment of the bones in the feet and ankles. Magnetic resonance (MR) imaging is the imaging modality of choice for evaluating the posterior tibial tendon and spring ligament complex.

Non surgical Treatment
Footwear has an important role, and patients should be encouraged to wear flat lace-up shoes, or even lace-up boots, which accommodate orthoses. Stage I patients may be able to manage with an off the shelf orthosis (such as an Orthaheel or Formthotics). They can try a laced canvas ankle brace before moving to a casted orthosis. The various casted, semirigid orthoses support the medial longitudinal arch of the foot and either hold the heel in a neutral alignment (stage I) or correct the outward bent heel to a neutral alignment (stage II). This approach is meant to serve several functions: to alleviate stress on the tibialis posterior; to make gait more efficient by holding the hindfoot fixed; and thirdly, to prevent progression of deformity. Devices available to do this are the orthosis of the University of California Biomechanics Laboratory, an ankle foot orthosis, or a removable boot. When this approach has been used, two thirds of patients have good to excellent results. Adult acquired flat foot

Surgical Treatment
Surgical treatment should be considered when all other conservative treatment has failed. Surgery options for flatfoot reconstruction depend on the severity of the flatfoot. Surgery for a flexible flatfoot deformity (flatfoot without arthritis to the foot joints) involves advancing the posterior tibial tendon under the arch to provide more support and decrease elongation of the tendon as well as addressing the hindfoot eversion with a osteotomy to the calcaneus (surgical cut in the heel bone). Additionally, the Achilles tendon may need to be lengthened because of the compensatory contracture of the Achilles tendon with flatfoot deformity. Flatfoot deformity with arthritic changes to the foot is considered a rigid flatfoot. Correction of a rigid flatfoot deformity usually involves surgical fusion of the hindfoot joints. This is a reconstructive procedure which allows the surgeon to re-position the foot into a normal position. Although the procedure should be considered for advanced PTTD, it has many complications and should be discussed at length with your doctor.
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