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Does Severs Disease Necessitate Surgery?

Overview

Pain in the heel of a child's foot, typically brought on by some form of injury or trauma, is sometimes Sever's Disease. The disease often mimics Achilles tendonitis, an inflammation of the tendon attached to the back of the heel. A tight Achilles tendon may contribute to Sever's Disease by pulling excessively on the growth plate of the heel bone. This condition is most common in younger children and is frequently seen in the active soccer, football or baseball player. Sport shoes with cleats are also known to aggravate the condition. Treatment includes calf muscle stretching exercises, heel cushions in the shoes, and/or anti-inflammatory medications. Consult your physician before taking any medications.

Causes

Having flatfeet or very pronated feet can make one prone to Sever's disease. But also patient?s that have a very high arch foot structure tend to have a very high shock and high impact heel strike. This also puts extra stress on the heel and apophysis.

Symptoms

The most prominent symptom of Sever's disease is heel pain which is usually aggravated by physical activity such as walking, running or jumping. The pain is localised to the posterior and plantar side of the heel over the calcaneal apophysis. Sometimes, the pain may be so severe that it may cause limping and interfere with physical performance in sports. External appearance of the heel is almost always normal, and signs of local disease such as edema, erythema (redness) are absent. The main diagnostic tool is pain on medial- lateral compression of the calcaneus in the area of growth plate, so called squeeze test. Foot radiographs are usually normal. Therefore the diagnosis of Sever's disease is primarily clinical.

Diagnosis

A doctor or other health professional such as a physiotherapist can diagnose Sever?s disease by asking the young person to describe their symptoms and by conducting a physical examination. In some instances, an x-ray may be necessary to rule out other causes of heel pain, such as heel fractures. Sever?s disease does not show on an x-ray because the damage is in the cartilage.

Non Surgical Treatment

Treatment is primarily directed towards reducing the amount of stress to the heel. Often a heel lift, is placed in the shoe to reduce the pull of the Achilles tendon on the apophysis. Gel or cushioned heel cups may also be helpful in reducing micro trauma to the heel. Orthotic control may also be indicated when a pathologic condition exists in the foot that may be contributing to the increased heel stress. Occasionally, it becomes necessary for adequate healing, to rest the area completely. This can be accomplished either by complete elimination of all strenuous activities, or by using a walking cast or crutches. Often simply reducing activity levels is adequate. Your physician will discuss the best treatment plan with you and your child.

Achilles Tendon Rupture Conservative Treatment Blogs

Overview
Achilles Tendinitis Achilles tendon rupture is when the achilles tendon breaks. The achilles is the most commonly injured tendon. Rupture can occur while performing actions requiring explosive acceleration, such as pushing off or jumping. The male to female ratio for Achilles tendon rupture varies between 7:1 and 4:1 across various studies.

Causes
Achilles tendon ruptures are most likely to occur in sports requiring sudden stretching, such as sprinting and racquet sports. Achilles tendon ruptures can happen to anyone, but are most likely to occur to middle age athletes who have not been training or who have been doing relatively little training. Common sporting activities related to Achilles tendon rupture include, badminton, tennis, squash. Less common sporting activities that can lead to Achilles tendon rupture include: TKD, soccer etc. Occasionally the sufferer may have a history of having had pain in the Achilles tendon in the past and was treated with steroid injection to around the tendon by a doctor. This can lead to weakening of the tendon predisposing it to complete rupture. Certain antibiotics taken by mouth or by intravenous route can weaken the Achilles tendon predisposing it to rupture. An example would be the quinolone group of antibiotics. An common example is Ciprofloxacin (or Ciprobay).

Symptoms
The pain from an Achilles tendon rupture is usually felt in the back of the lower leg, in the area 2 to 6 cm. above the Achilles tendon's attachment to the calcaneus. Individuals with an Achilles tendon rupture often describe a "pop" or similar feeling at the time of the injury. A "hole" or defect in the Achilles tendon can usually be felt under the skin in this area. A limp and inability to rise up on the toes of the affected foot are usually present. If the affected foot does not plantar flex when the calf muscles are squeezed an Achilles tendon rupture is very likely.

Diagnosis
To diagnose an Achilles tendon injury, your health care provider will give you a thorough physical exam. He or she may want to see you walk or run to look for problems that might have contributed to your Achilles tendon injury.

Non Surgical Treatment
This condition should be diagnosed and treated as soon as possible, because prompt treatment probably improves recovery. You may need to be referred urgently to see a doctor in an orthopaedic department or accident and emergency department. Meanwhile, if a ruptured Achilles tendon is suspected, you should not put any weight on that foot, so do not walk on it at all.Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches. The decision of whether to proceed with surgery or non-surgical treatment is based on the severity of the rupture and the patient?s health status and activity level. Non-surgical treatment, which is generally associated with a higher rate of re-rupture, is selected for minor ruptures, less active patients, and those with medical conditions that prevent them from undergoing surgery. Non-surgical treatment involves use of a cast, walking boot, or brace to restrict motion and allow the torn tendon to heal. Achilles Tendon

Surgical Treatment
Operative treatment of Achilles tendon ruptures involves opening the skin and identifying the torn tendon. This is then sutured together to create a stable construct. This can be performed through a standard Achilles tendon repair technique or through a mini-incision technique (to read about the different types of techniques, look under ?Procedure? in Achilles Tendon Repair). By suturing the torn tendon ends together, they maintain continuity and can be mobilized more quickly. However, it is critical to understand that the return to normal activities must wait until adequate healing of the tendon has occurred. The potential advantages of an open repair of the Achilles tendon include, faster recovery, this means that patients will lose less strength. Early Range of Motion. They are able to move the ankle earlier so it is easier to regain motion. Lower Re-rupture Rate. The re-rupture rate may be significantly lower in operatively treated patients (2-5%) compared to patients treated non-operatively (8-15%). The main disadvantage of an open repair of the Achilles tendon rupture is the potential for a wound-healing problem which could lead to a deep infection that is difficult to eradicate, or a painful scar.

Leg Length Discrepancy

Overview

The bone is lengthened by surgically applying an external fixation device to the leg. The external fixator, a scaffold-like frame, is connected to the bone with wires, pins, or both. A small crack is made in the bone and the frame creates tension when the patient or family member turns its dial. This is done several times each day. The lengthening process begins approximately five to 10 days after surgery. The bone may lengthen 1 millimeter per day, or approximately 1 inch per month. Lengthening may be slower in a bone that was previously injured. It may also be slower if the leg was operated on before. Bones in patients with potential blood vessel abnormalities, such as cigarette smokers, may also need to be lengthened more slowly. The external fixator is worn until the bone is strong enough to support the patient safely. This usually takes about three months for each inch. Factors such as age, health, smoking and participation in rehabilitation can affect the amount of time needed.Leg Length Discrepancy

Causes

An anatomical short leg is due to several orthopedic or medical condition mechanisms. Often, one leg simply stops growing before the other one does and is called ?congenital?. We often see mother-daughters or father-sons who exhibit virtually the same degree of shortness on the same side. Often it is not known why this occurs, but it seems to account for approximately 25% of the population demonstrating a true LLD. Other causes of a true LLD include trauma or broken bones, surgical repair, joint replacement, radiation exposure, tumors or Legg-Calves-Perthes disease.

Symptoms

In addition to the distinctive walk of a person with leg length discrepancy, over time, other deformities may be noted, which help compensate for the condition. Toe walking on the short side to decrease the swaying during gait. The foot will supinate (high arch) on the shorter side. The foot will pronate (flattening of the arch) on the longer side. Excessive pronation leads to hypermobility and instability, resulting in metatarsus primus varus and associated unilateral juvenile hallux valgus (bunion) deformity.

Diagnosis

Asymmetry is a clue that a LLD is present. The center of gravity will shift to the short limb side and patients will try to compensate, displaying indications such as pelvic tilt, lumbar scoliosis, knee flexion, or unilateral foot pronation. Asking simple questions such as, "Do you favor one leg over the other?" or, "Do you find it uncomfortable to stand?" may also provide some valuable information. Performing a gait analysis will yield some clues as to how the patient compensates during ambulation. Using plantar pressure plates can indicate load pressure differences between the feet. It is helpful if the gait analysis can be video-recorded and played back in slow motion to catch the subtle aspects of movement.

Non Surgical Treatment

Treatment for an LLD depends on the amount of difference and the cause, if known. The doctor will discuss treatment options carefully with you and your child before any decisions are made. It is important to note that treatment is planned with the child?s final height and leg lengths in mind, not the current leg lengths. Treatment is generally not needed if the child?s final LLD is predicted to be 2 centimeters or less at full height. However, the child should return to an orthopaedic doctor by age 10 for re-evaluation. Treatment is often recommended for LLDs predicted to be more than 2 centimeters at full height. If treatment is done, it usually doesn?t begin until the child starts walking. Possible treatment options include, A ?lift? in one shoe to level the child?s hips. This is often the only treatment needed for small discrepancies.

LLL Shoe Insoles

Surgical Treatment

Differences of an inch-and-a-half to two inches may require epiphysiodesis (adjusting the growth of the longer side) or acute shortening of the other side. Differences greater than 2.5 inches usually require a lengthening procedure. The short bone is cut and an external device is applied. Gradual lengthening is done over months to allow the muscles and nerves accommodate the new length.

Tibial Posterior Tendon Dysfunction Exercises

Overview
This condition is characterized by a progressive flattening or falling of the arch. It is often referred to as posterior tibial tendon dysfunction (PTTD) and is becoming a more commonly recognized foot problem. Since the condition develops over time, it is typically diagnosed in adulthood. It usually only develops in one foot although it can affect both. Since it is progressive, it is common for symptoms to worsen, especially when it is not treated early. The posterior tibial tendon attaches to the bones on the inside of your foot and is vital to the support structure within the foot. With PTTD, changes in the tendon impair its ability to function normally. The result is less support for the arch, which in turn causes it to fall or flatten. A flattening arch can cause the heel to shift out of alignment, the forefoot to rotate outward, the heel cord to tighten, and possible deformity of the foot. Common symptoms include pain along the inside of the ankle, swelling, an inward rolling of the ankle, pain that is worse with activity, and joint pain as arthritis sets in. Adult Acquired Flat Feet

Causes
There are multiple factors contributing to the development of this problem. Damage to the nerves, ligaments, and/or tendons of the foot can cause subluxation (partial dislocation) of the subtalar or talonavicular joints. Bone fracture is a possible cause. The resulting joint deformity from any of these problems can lead to adult-acquired flatfoot deformity. Dysfunction of the posterior tibial tendon has always been linked with adult-acquired flatfoot deformity (AAFD). The loss of active and passive pull of the tendon alters the normal biomechanics of the foot and ankle. The reasons for this can be many and varied as well. Diabetes, high blood pressure, and prolonged use of steroids are some of the more common causes of adult-acquired flatfoot deformity (AAFD) brought on by impairment of the posterior tibialis tendon. Overstretching or rupture of the tendon results in tendon and muscle imbalance in the foot leading to adult-acquired flatfoot deformity (AAFD). Rheumatoid arthritis is one of the more common causes. About half of all adults with this type of arthritis will develop adult flatfoot deformity over time. In such cases, the condition is gradual and progressive. Obesity has been linked with this condition. Loss of blood supply for any reason in the area of the posterior tibialis tendon is another factor. Other possible causes include bone fracture or dislocation, a torn or stretched tendon, or a neurologic condition causing weakness.

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 diagnosis of posterior tibial tendon dysfunction and AAFD is usually made from a combination of symptoms, physical exam and x-ray imaging. The location of pain, shape of the foot, flexibility of the hindfoot joints and gait all may help your physician make the diagnosis and also assess how advanced the problem is.

Non surgical Treatment
In the early stages, simple pre-fabricated orthotics can help improve the heel position to reduce the mechanical load which is contributing to the symptoms. In advanced stages or long term orthotic use, a plaster of paris or foam box cast can be taken and specific bespoke orthotics manufactured. If the condition develops further a AFO (ankle foot orthotic) may be necessary for greater control. In more advanced stages of symptomatic Adult Acquired flat feet, where the conservative methods of treatment have failed there are various forms of surgery available depending upon the root cause of the issue and severity. Acquired Flat Foot

Surgical Treatment
Surgical correction is dependent on the severity of symptoms and the stage of deformity. The goals of surgery are to create a more functional and stable foot. There are multiple procedures available to the surgeon and it may take several to correct a flatfoot deformity. Usually surgical treatment begins with removal of inflammatory tissue and repair of the posterior tibial tendon. A tendon transfer is performed if the posterior tibial muscle is weak or the tendon is badly damaged. The most commonly used tendon is the flexor digitorum longus tendon. This tendon flexes or moves the lesser toes downward. The flexor digitorum longus tendon is utilized due to its close proximity to the posterior tibial tendon and because there are minimal side effects with its loss. The remainder of the tendon is sutured to the flexor hallucis longus tendon that flexes the big toe so that little function is loss.

What Exactly Is Adult Aquired Flat Foot ?

Overview
Adult flatfoot may be due to multiple problems including a dysfunctional posterior tibial tendon (PTT), hypermobility and ligamentous laxity, or possibly a coalition that becomes symptomatic. For a vast majority of patients, posterior tibial tendon dysfunction (PTTD) is the cause of symptomatic flatfoot and is the main trigger of surgical reconstruction in flatfoot. The common presenting scenario for adult flatfoot is a case of unilateral flatfoot with pain. Patients will often confirm they ?always had flat feet? but have noticed increased pain and additional collapse in the past few months to years. They may also note increased swelling and a possible concern over one foot increasing in shoe size. After a comprehensive dermatologic, neurologic and vascular assessment, one should direct his or her attention to the musculoskeletal portion of the exam. It is key to examine the foot and leg as a whole in order to determine the proper procedure and consider each phase of the corrective surgery. Flat Feet

Causes
As the name suggests, adult-acquired flatfoot occurs once musculoskeletal maturity is reached, and it can present for a number of reasons, though one stands out among the others. While fractures, dislocations, tendon lacerations, and other such traumatic events do contribute to adult-acquired flatfoot as a significant lower extremity disorder, as mentioned above, damage to the posterior tibial tendon is most often at the heart of adult-acquired flatfoot. One study further elaborates on the matter by concluding that ?60% of patients [presenting with posterior tibial tendon damage and adult-acquired flatfoot] were obese or had diabetes mellitus, hypertension, previous surgery or trauma to the medial foot, or treatment with steroids?.

Symptoms
In many cases, adult flatfoot causes no pain or problems. In others, pain may be severe. Many people experience aching pain in the heel and arch and swelling along the inner side of the foot.

Diagnosis
Starting from the knee down, check for any bowing of the tibia. A tibial varum will cause increased medial stress on the foot and ankle. This is essential to consider in surgical planning. Check the gastrocnemius muscle and Achilles complex via a straight and bent knee check for equinus. If the range of motion improves to at least neutral with bent knee testing of the Achilles complex, one may consider a gastrocnemius recession. If the Achilles complex is still tight with bent knee testing, an Achilles lengthening may be necessary. Check the posterior tibial muscle along its entire course. Palpate the muscle and observe the tendon for strength with a plantarflexion and inversion stress test. Check the flexor muscles for strength in order to see if an adequate transfer tendon is available. Check the anterior tibial tendon for size and strength.

Non surgical Treatment
Initial treatment is based on the degree of deformity and flexibility at initial presentation. Conservative treatment includes orthotics or ankle foot orthoses (AFO) to support the posterior tibial tendon (PT) and the longitudinal arch, anti-inflammatories to help reduce pain and inflammation, activity modification which may include immobilization of the foot and physical therapy to help strengthen and rehabilitate the tendon. Adult Acquired Flat Feet

Surgical Treatment
In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Symptomatic flexible flatfoot conditions are common entities in both the adolescent and adult populations. Ligamentous laxity and equinus play a significant role in most adolescent deformities. Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult acquired flatfoot. One should consider surgical treatment for patients who have failed nonoperative therapy and have advancing symptoms and deformities that significantly interfere with the functional demands of daily life. Isolated Joint Fusion. This technique is used for well reducible flat foot by limiting motion at one or two joints that are usually arthritic. The Evans Anterior Calcaneal Osteotomy. This is indicated for late stage II adult acquired flatfoot and the flexible adolescent flatfoot. This procedure will address midtarsal instability, restore the medial longitudinal arch and reduce mild hind foot valgus. The Posterior Calcaneal Displacement Osteotomy (PCDO). This technique is indicated for late stage I and early stage II PTTD with reducible Calcaneal valgus. This is often combined with a tendon transfer. A PCDO is also indicated as an adjunctive procedure in the surgical reconstruction of the severe flexible adolescent flatfoot. Soft tissue procedure. On their own these are not very effective but in conjunction with an osseous procedure, soft tissue procedures can produce good outcome. Common ones are tendon and capsular repair, tendon lengthening and transfer procedures. Flat foot correction requires lengthy post operative period and a lot of patience. Your foot may need surgery but you might simply not have the time or endurance to go through the rehab phase of this type of surgery. We will discuss these and type of procedures necessary for your surgery in length before we go further with any type of intervention.

Tibial Posterior Tendon Dysfunction Exercises

Overview Adult acquired flatfoot deformity or posterior tibial tendon dysfunction is a gradual but progressive loss of ones arch. The posterior tibial muscle is a deep muscle in the back of the calf. It has a long tendon that extends from above the ankle and attaches into several sites around the arch of the foot. The muscle acts like a stirrup on the inside of the foot to help support the arch. The posterior tibial muscle stabilizes the arch and creates a rigid platform for walking and running. If the posterior tibial tendon becomes damaged or tears the arch loses its stability and as a result, collapses causing a flatfoot. Adult flatfoot deformity can occur in people of all ages and gender however, it occurs most commonly in sedentary middle aged to elderly females. There are several risk factors for posterior tibial tendon dysfunction that include: obesity, steroid use, systemic inflammatory diseases such as rheumatoid arthritis, trauma, being born with a low arch, and diabetes. It occurs most commonly in one foot however, it can occur in both feet especially in people with systemic diseases such as diabetes and rheumatoid arthritis. Flat Foot Causes There are a number of theories as to why the tendon becomes inflamed and stops working. It may be related to the poor blood supply within the tendon. Increasing age, inflammatory arthritis, diabetes and obesity have been found to be causes. Symptoms Many patients with this condition have no pain or symptoms. When problems do arise, the good news is that acquired flatfoot treatment is often very effective. Initially, it will be important to rest and avoid activities that worsen the pain. Diagnosis Although you can do the "wet test" at home, a thorough examination by a doctor will be needed to identify why the flatfoot developed. Possible causes include a congenital abnormality, a bone fracture or dislocation, a torn or stretched tendon, arthritis or neurologic weakness. For example, an inability to rise up on your toes while standing on the affected foot may indicate damage to the posterior tibial tendon (PTT), which supports the heel and forms the arch. If "too many toes" show on the outside of your foot when the doctor views you from the rear, your shinbone (tibia) may be sliding off the anklebone (talus), another indicator of damage to the PTT. Be sure to wear your regular shoes to the examination. An irregular wear pattern on the bottom of the shoe is another indicator of acquired adult flatfoot. Your physician may request X-rays to see how the bones of your feet are aligned. Muscle and tendon strength are tested by asking you to move the foot while the doctor holds it. Non surgical Treatment Non-surgical treatment consists of custom orthoses and or special bracing devices along with supportive measures aimed at reducing the symptoms. While non-surgical treatment helps the majority of patients with PTTD, progressive cases may require surgical treatment including soft tissue tendon transfers, osteotomies and lastly fusion. Acquired Flat Feet Surgical Treatment A new type of surgery has been developed in which surgeons can re-construct the flat foot deformity and also the deltoid ligament using a tendon called the peroneus longus. A person is able to function fully without use of the peroneus longus but they can also be taken from deceased donors if needed. The new surgery was performed on four men and one woman. An improved alignment of the ankle was still evident nine years later, and all had good mobility 8 to 10 years after the surgery. None had developed arthritis.