Monday, April 22, 2013

A.C.L. Reconstruction


Originally it was felt that the knee should be repaired surgically as soon as possible. Now, most orthopedic surgeons feel that the swelling should subside and the patient should work to improve range of motion with physiotherapy for 2-3 weeks. Once this is accomplished the patient can then proceed to an anterior cruciate ligament reconstruction. As stated earlier, surgery does not have to be performed on a sedentary older patient, but it is almost always recommended to a younger, active athlete that they should have anterior crucial tear repaired. With modern techniques it is performed as an outpatient – the patient is discharged from the hospital the same day. The patients will leave the hospital on crutches wearing a knee immobilizer for approximately 10 days while they are up and getting around. When the immobilizer comes off, the patient usually will use a passive motion machine that moves the knee through flexion and extension. Physical therapy is started immediately post-operatively. Treatment of a torn anterior crucial ligament in the older patient usually consists of physical therapy and exercise training as well as potentially brace-wear for some activities.

Surgical Treatment Options
There have been many options described for the surgical treatment of the anterior cruciate ligament. The most popular and currently recognized as the gold standard at this point is an operation where the middle one third of the patella tendon is used as a graft. It is virtually impossible to repair the ligament that is torn. The torn ACL is simply removed and the replaced with the patella tendon graft. Two thirds of the patella tendon is left behind and it will repair itself, not compromising the function of the knee. At each end of the patella tendon a bone block is also taken; one piece from the tibia, and the other from the patella (kneecap). These two bony blocks are inserted into holes that are drilled into the tibia and femur and held into place with screws, which provide stabilization of the ligament graft.
There are other tissues that can be used to substitute for the anterior crucial ligament. Most commonly the second choice are hamstring tendons which are weaved into a graft close to the size of the anterior crucial ligament. We have also used quadriceps tendon and allograft. An allograft is donated cadeaver tissue which is freeze dried until the time of usage upon which time it is thawed out and trimmed to size and used as an ACL substitute. The advantage of an allograft operation is that there is a smaller incision required, the rehab is shorter, and less painful. The disadvantage is that it is not quite as strong as a graft formed from the patient’s own tissue.

Thursday, April 18, 2013

O'Donohue's "Terrible Triad"

The anterior cruciate is the main factor causing resistance to the anterior displacement of the tibia on the femur. This is demonstrated when the orthopedic surgeon pulls the tibia forward on the femur performing a test of the anterior cruciate ligament. The tibia will displace much further forward than it should when the ACL is torn. The ligament is tight when the knee is in full extension and has the least amount of tension at approximately 45’ of flexion. Because there are different bands to the anterior cruciate ligament different areas of the anterior cruciate tighten at different angles of the knee.

Physical Examination
Examination immediately at the time of injury will reveal usually at least mild swelling of the knee, but not necessarily. The best test is called a Lachman Test where each of the examiner’s hands are placed just above and just below the knee joint. The lower bone is brought forward with the knee angled at approximately 15’ and the examiner assess the end point. Usually, there is a firm endpoint with an intact ACL when the tibia is pulled forward. When the ligament is torn that endpoint is no longer present. The examiner will also look for increased excursion of the tibia forward on the femur. A Drawer Test is when the knee is flexed to 90’. Essentially, the same test is performed. It is more difficult in an acute situation to perform this test because usually the athlete’s knee is too sore to allow the knee to bend to 90’. A Pivot Shift is a test where the knee is brought from an extended position into flexion. Usually the knee will show a slight and subtle shift as the tibia rotates on the femur and shifts back into proper position. It is actually subflexed in the full extended knee position and returns to its natural position as the knee is flexed. As it returns to its natural position there is a "pivot shift" which takes experience to detect.
Associated injuries are always assessed for at the same time. Joint line tenderness representing torn cartilage and tenderness over the lateral knee which may reflect tearing of the collateral ligaments. O’Donohue’s "terrible triad" injury involves not only the ACL, but also the medial meniscus and the medial collateral ligament. It is unfortunately fairly common.

Monday, April 15, 2013

Natural History of the Torn Anterior Cruciate Ligament

Natural History of the Torn Anterior Cruciate Ligament

If left untreated the laxity which is immediately present only becomes worse. The other structures of the knee try in vain to provide some stability to the knee. Over time and with more usage these other structures stretch out as well, resulting in increased instability and then associated meniscal (cartilage) tears. There is an incidence of approximately 1 in 3 patients who at the time of the anterior cruciate ligament tear will tear their cartilage as well. This progresses with time because in an untreated knee the knee is unstable and produces greater stress on the cartilage. Up to 80% of the knees will eventually develop a cartilage tear. The smooth Teflon lining of the knee which is known as articular cartilage is often damaged at the time of the ACL tear. If left untreated, this will again progressively wear at the knee, causing an increased rate of osteoarthritis development. The patients will alter their gait and will develop a rather specific quadriceps avoidance gait because when they contract their quads during normal walking its slides the tibia forward which is usually stopped by the anterior crucial ligament. The patient will naturally and unconsciously try to prevent this. All these problems mean that the knee will progress to late degenerative changes and osteoarthritis much earlier than in a normal knee. There is not good evidence that bracewear alone will decrease the rate of re-injury to the knee. However, in older and non-active patients there is definitely a role for non-operative treatment by simply modifying their activities and avoiding all situations where they may pivot and damage their knee further.

Friday, April 12, 2013


The anterior cruciate ligament is a thick band of tissue which has two major strands that extend from the lower leg bone (tibia) to the thigh bone (femur). This ligament is very important for maintaining stability of the knee. When it is injured or torn the patient feels the instability of the knee when they turn or pivot. This instability is particularly problematic when participating in pivoting sports such as soccer and football. The ligament sits just in front of its counterpart, the posterior cruciate ligament, directly in the middle of the knee joint.

Mechanism of Injury

Most anterior cruciate ligament tears occur during a sporting activity and usually in younger patients. When you consider the number of sport hours played, they are more common in women. There have been a variety of reasons proposed for this, such as muscle imbalance and slight variations in the anatomy of the knee joint in women compared to men. The most common sports are football and basketball in younger patients; skiing injuries predominate in older patients. It is, however, possible to injure the anterior cruciate doing a variety of activities. We’ve seen bilateral ACL tears in a weight lifter who was doing an incline bench and popped both his knees at the same time when bench-pressing 350 pounds. It can also be a work-related injury. Interestingly, most people would expect that it is due to contact, but this is not true. Mostly it is a non-contact deceleration where the athlete suddenly turns to the opposite side of the planted and injured knee. As the patient turns and pivots the ligament tears. In basketball it is usually a result of a hyperextension and internal rotation of the tibia on the femur, associated with deceleration.
Usually the patient will feel a sudden pop in their knee immediately in injury to the knee. Surprisingly, sometimes the knee will not get very swollen, although it certainly can. The injury is often missed because the physical examination requires some experience and training. It might actually be easily missed in the initial stages.

Monday, April 8, 2013



Plantar fascitis is a common foot problem in sports participants.  It starts as a dull intermittent pain in the heel which may progress to a sharp persistent pain.  Classically, it is worse in the morning with the first few steps or at the beginning of sporting activity.
The plantar fascia is a thick fibrous material on the bottom of the foot.  It is attached to the heel bone (calcaneus) and fans forward toward the toes.  It is responsible for maintaining the arch of the foot.
The problem usually occurs when part of this inflexible fascia is pulled away from the heel bone.  This causes an inflammation and thus pain.  Plantar fascia injuries may occur at the midsole or towards the toes.   Since it is difficult to rest the foot, a vicious cycle is set up with the situation aggravated with every step.  In severe cases, the heel is visibly swollen.   The problem progresses rapidly and treatment must be started as soon as possible.
As the fascia is pulled away from the bone, the body reacts by filling in the space with new bone.  This causes the classic "heel spur."  This heel spur itself is a secondary X-ray finding and is not the problem, but a result of the problem.

Predisposing Factors
  • Flat pronated feet
  • High arched rigid feet
  • Inappropriate or improper shoes
  • Toe running, hill running
  • Soft terrain (i.e. running in the sand)
  • Increasing age
  • Arch Supports - These are custom made from molds taken of your feet.
  • Rest - Use pain as your guide.  If your foot is too painful, bearing sports can be temporarily replaced by swimming and/or cycling to maintain cardiovascular fitness.  Weight training can be used to maintain leg strength.
  • Ice - Icing your heel (frozen peas) for 15 minutes several times a day will reduce inflammation.  You should also ice your heel after activity for 15 minutes.
A physician may on rare occasions prescribe anti-inflammatory pills.  These are important in reducing the inflammation in your foot.
The initial objective of physiotherapy (when needed) is to decrease the inflammation.  Later the small muscles of the foot will be strengthened to support the weakened plantar fascia.
A cortisone injection is usually quite beneficial if the above have not solved the problem.  It is a local injection and it is very safe in this area.
Surgery is occasionally required for plantar fascitis.  The tension on the plantar fascia is released, and the spur may be exercised.
Risks include skin breakdown, infection, slow healing, nerve or blood vessel damage, blood clots, and other complications.  Discuss these with our team prior to your surgery and make sure you understand them.

Plantar fascitis can be aggravated by all weight-bearing sports.  Repetitive foot landing, such as occurs in running and jogging, will aggravate the problem.  When the problem is severe the best sports are ones which are non-weight-bearing (i.e. swimming, cycling).  Go back into other sports slowly.  If you have a lot of pain either during the activity or following morning, you are doing too much.
It is possible for shoes to cause the problem.  You may need different or new shoes.  A knowledgeable salesperson can be invaluable.

The following exercises are designed to strengthen the small muscles of the foot to help support the damaged area.  If performed regularly, they will help prevent re-injury.
Towel Curls
Place a towel on the floor.  Curl the towel toward you, using only the toes of your injured foot.  Resistance can be increased with a weight on the end of the towel.  Repeat 20 times.
Shin Curls
Run your foot slowly up and down the shin of your other leg as you try to grab the shin with your toes.  Repeat 30 times.  A similar exercise can be done by curling your toes around a tin can.
Toe Grabs
Stand feet together.  Rotate your knees outward while attempting to grab the floor with your toes using the muscles of your foot.   Hold 10 seconds, then relax.  Repeat 20 times.

Lean against a wall with your back knee locked.  Press forward until a stretch is felt in your calf muscle.  Hold for 15 seconds.
Then bend your knee until a stretch is felt in your Achilles tendon.  Hold a further 15 seconds.  Repeat 3 times.  You should feel a pull in your muscle and tendon, but no pain.

Thursday, April 4, 2013

Ruotures of the Achilles Tendon

Version III

Rupture of the Achilles tendon is one of the most devastating injuries which the competitive and recreational athlete can suffer.   Overall it is not as common an injury as, for example, tendonitis of the elbow, but it is much more difficult to treat in the higher levels of competitive sports.   Although it is not entirely avoidable, there is much that can be done to reduce your chances of suffering such an injury.
First it is necessary to understand the anatomy of the area.  The tendocalcaneus (Achilles tendon) is the thickest and strongest tendon in the human body.  It is approximately 15 cm long and begins in the mid-aspect of the calf and extends distally (towards the foot) to its insertion on the heel bone (calcaneus).  It actually originates from three separate muscles which join together to form the strong muscular group which is responsible for pushing the foot downward to provide the push-off for propelling the body forward.  This is especially accentuated in sports such as squash where a rapid push-off is required.  It is obvious, therefore, that when this tendon ruptures it is a major injury.

The classic history of the injury is that it usually occurs in males, although it certainly occurs in females as well.  It most commonly affects people aged 30-50 but can cross all age groups.  Unfortunately, it can particularly affect athletes and will simply occur as they are pushing off to reach forward, although it has been known to occur when the athlete is simply in the ready position anticipating forward movement.  The classic story is that the athlete feels a sudden pain in or just below the calf and, due to the sudden nature of the pain and the sensation of a direct blow, turns around to see who hit him with the tennis ball.   The sudden pain stops play immediately and medical attention should be sought without delay.
The medical and surgical treatment is controversial at times.  This is mostly related to the fact that treatment is difficult and there is no one simple answer to the problem.  The leg can either be operated on or casted for a prolonged period of time, and there are proponents of both types of treatment.  However, with either treatment there is a long period of casting and immobilization of up to ten weeks with a long and arduous course of physiotherapy after the casting is over.  Surgical repair is most commonly advocated for the more distal (lower) injuries which are closer to the insertion on the calcaneus (heel bone).   Often at higher levels of competition it is a career-ending injury in spite of vigorous surgical or casting treatment.  Although the athlete is able to recover, they rarely attain the high level of sport which they were at prior to the injury.

It is obvious that the best thing to do with the injury is to avoid it in the first place.  This can be done very simply with stretching exercises prior to the workout.  All stretching exercises, whether they are done for the Achilles tendon or for any other muscle group in the body, should be done with the speed of a glacier; that is to say that they should not be rapid twisting motions or pumping motions up and down.  The affected area should be put on a stretch and then held for 15 seconds just below the feeling of discomfort.  The best way to determine exactly how much of a stretch should be put on a limb is strained but still comfortable.  The stretch should be held for 15 seconds and repeated several times prior to workout if the best results are to be obtained.  This also promotes flexibility as well as protecting the tendon from injury.
By far the best treatment of this injury is prevention itself and although the stretching exercises do take a few minutes of time, they are well worth the effort and should be part of every athletes warm-up to avoid this devastating injury.

Sunday, March 31, 2013

Treatment of Foot Problems Pt.3


A muscle imbalance or abnormal bone length can make one or more small toes buckle under, causing their joints to contract.  This in turn, causes the tendons to shorten.  Corns (build-ups of dead skin cells where shoes press and rub) often form on the contracted joint, and may become irritated and infected.
Flexible Hammertoes
When hammertoes are flexible, you can straighten the buckled joint with your hand.  Flexible hammertoes may progress to rigid hammertoes over time.  Corns, irritation, and pain are common symptoms.   Function is often limited as well.
Rigid Hammertoes
A rigid hammertoe is fixed; you can no longer straighten the buckled joint with your hand.  Corns, irritation, pain, and loss of function may be more severe for rigid hammertoes than for flexible ones.

Curled Fifth Toe
The little toe may curl inward underneath its neighbor so that the nail faces outward.  With this inherited problem, the fat pad on the bottom of the toe (normally used for walking) loses contact with the ground.  Corns and pain may result.

Plantar Calluses

Second Metatarsal Plantar Callus
When the second metatarsal bone is longer or lower than the others, it hits the ground first - and with more force than it is equipped to handle at every step.  As a result, the skin under this bone thickens.   Like a rock in your shoe, the callus causes irritation and pain.  The treatment for this is an osteotomy.  The second metatarsal bone is cut, and the end of the bone is then "lifted" and aligned with the other bones.

Heel Spurs
A heel spur is a bony overgrowth on your heel bone (see Plantar Fascitis).  It may be stimulated by muscles that pull from the heel bone along the bottom of the foot.  High-arched feet are especially apt to have too-tight muscles here.  Heel spurs may cause pain  when the foot bears weight.  They can be treated first with an injection, anti-inflammatory medication, as well as arch supports if indicated.  If this fails, they can then be treated with surgical excision and a plantar release.  The band of tight muscles is released to relieve the abnormal stress.  The bone spur is surgically removed.

When a nerve is pinched between two metatarsal bones (usually the third and forth metatarsals), enlargement of the nerve may occur.  Abnormal bone structure contributes to the cause, but too-tight shoes can aggravate the condition.  You may experience sharp pain in your toes that may become severe enough to keep you from walking.
Excision: A small portion of the nerve is removed.  As a result of this, a small area is usually permanently numbered, but this is preferable to pain.
Follow-up Care
You can usually bear weight right away, but you must return to have your dressing changed.  Keep your incision dry until the stitches are removed.

High-Arched Feet (Pes Cavus)
The shape of your foot often determines the kinds of foot problems you will have.  Your feet may have unusually high arches due to an imbalance of muscles and nerves, which is usually inherited.   Too high arches can cause various problems - tired or aching feet; and calluses.   High arches are not usually investigated with surgery but most often treated with arch supports.

Flat Feet (Pes Planus)
Flat feet can be hereditary and are caused by a muscle imbalance.  Feet with low, relaxed arches may bring on such problems as hammertoes and bunions; arch, foot, and leg fatigue; calf pain; and an overly tight heel cord (which makes the foot even flatter).  Loose joints move to freely, causing pain and instability.  Flat feet are also usually treated with arch supports.

Orthotics (also called orthoses or orthotic devices) are prescribed, custom0made arch supports.  They fit inside most shoes and "bring the floor up to your feet."
A podiatrist may prescribe them to help correct such problems as high arches and flat feet.  Also, following some foot surgeries, orthotics can help support the correction that was achieved.
To be fitted with orthotics, your podiatrist will first take an impression of your feet.  Your orthotics are then fashioned from leather, plastic, or other materials.  Their fit is checked at an office visit and adjustments can be made as you wear them.  Expect an initial "breaking-in" period; you may need to build up wearing time gradually (as you would with contact lenses).

Surgery Decision
If your bunions or hammertoes are bad enough, they may need surgical correction.  This is a gratifying operation that can provide both pain relief and improved appearance.
All surgery carries risks including stiffness, persistent pain and swelling, recurrence of problem, damage to nerves, hardware breakage, blood clots in the legs, anesthetic problems, inability to correct the problem, etc.  Make sure you understand the risks and alternatives prior to surgery.

Post-Operative Tips
Your recovery, like your foot problem and surgery, is as unique as you are.  In addition to the previous tips given on follow-up care for each surgery, here are some pointers that can help you recover quickly and without complications, and help get you back on your feet again.
Pain:  To help relive pain and reduce swelling in the first 24 to 48 hours after surgery, apply an ice pack to the affected area and elevate your foot above heart level, as recommended.  Pain is usually most severe the second and third days after surgery, and after you first begin to walk again.
Bathing:  You will need to keep your foot dry.  Getting the stitches wet can lead to infection, so be sure to keep your foot outside the shower or bath.
Weight-Bearing:  Bearing weight and walking can stimulate circulation and promote healing.  But overtaxing a healthy foot can detract from the results of your surgery.
Shoes:  Our team may give you a wide surgical shoe to wear on the affected foot.  A surgical shoe stabilizes and protects the foot as it heals.
Returning to Work: How soon you can return to work depends on the type of surgery you had and the activities you job requires.  You can generally return earlier to a desk job than to physical labor.   Consider beforehand how much time you can take off from work until you are back on your feet.