March 5th, 2010 › Foot and ankle surgery › Dr. Jeffrey Oster › no comments ›
Cam walkers. I’m sure you’ve seen them. Cam walkers are the removable
casts that are used as a step down cast following foot and ankle surgery. The real beauty of a cam walker is two fold. First, the rocker sole on the cam walker really does a great job in off-loading the forefoot. And I particularly like the air pump cam walkers that allow patients to pump air into the bladder of the walker. The air bladder does a great job in controlling edema and limited ‘bobble’ of the leg, ankle and foot inside the walker.
So what are the down sides to cam walkers? First, the heel in most cam walkers is very low. The lower the heel, the stronger the calf. By making the calf stronger, you have to then consider some of the ramifications of using a cam walkers. One common problem I see with use of a cam walker for more than 2-3 weeks is plantar fasciitis. Many folks will complain of plantar heel pain. Usually the plantar fasciitis will resolve in a matter of a few weeks upon the return to a regular shoe. The same holds true for Achilles tendonitis. Best to add a heel lift to the walker if you’re suspicious of either plantar fasciitis or Achilles tendonitis.
And using cam walkers for plantar fasciitis? To me, that just doesn’t make sense. One of the simple treatment tricks used for plantar fasciitis is the use of a simple heel lift.  Elevating the heel and doing some heel stretches go a long way in treating plantar fasciitis. So to put a new case of PF in a cam walker? Just doesn’t make sense in the least.
Other foot problems? I recently saw a case of posterior tibial tendon dysfunction (PTTD) as the result of using a cam walker. Again, you lower the heel, you increase the mechanical stress applied to the foot. And PTTD is directly tied to increased calf strenght.
The next worry up the leg with cam walkers is the knee. I’ve had patients who tear their medial meniscus as a result of using a cam walker. The jamming of the medial compartment of the knee likely has to do with the broad, flat surface of the cam walker. This broad , flat surface tends to throw folks into genu valgum, placing increased pressure on the medial compartment of the knee.
And lastly, lumbar pain. Walking with a cam walker is going to create two problems that can affect the lumbar spine. First is the leg length difference created by the walker. And second is the lifting that is necessary with the use of the walker.Â
Lifting of the leg? Let me explain. Walking is human motion that is designed to be efficient. With normal gait, the pelvis barely deviates from the transverse plane. By keeping the pelvis level, the spine is stable. Now let’s add in a cam walker. Lifting the leg with the walker forces gait to become less efficient and the lumbar spine becomes a pivot point. That places significant load on the lumbar discs. This increase in load can be pretty rough on a middle age to elderly patient.
And even after saying all these terrible things about cam walkers, I still use them regularly in practice. In one resect, they slow patients down a bit. In essence, they work a bit like a ball-and-chain. But they also have therapeutic value. But if you’re going to be wearing a cam walker for an extended period of time, just be sure to have a long talk with your doc and know what the warning signs are for knee and low back problems before they get out of hand.
Jeffrey A. Oster, DPM
The Chery Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: Achilles tendonitis, cam walker, heel pain, plantar fasciitis, PTTD, walking cast
March 4th, 2010 › Foot and ankle care › Dr. Jeffrey Oster › no comments ›
When we talk about the lateral column of the foot, we’re referring to the
bones of the outside, or lateral aspect of the foot. Inherent in any discussion of the lateral column is the concept of load bearing. The lateral column is the Rodney Dangerfield of the foot, it just gets no respect. The reason I say that is that the lateral column bears the brunt of load bearing during gait as the body passes over the foot. The majority of that load bearing is focused in a small segment of the foot referred to as the calcaneo-cuboid joint (CC joint). Let’s hone in on the CC joint and look at what may cause pain in the region of the calcaneo-cuboid joint, and differential diagnoses specific to that area.
By default, when we speak of calcaneo-cuboid pain, the first diagnosis that most folks think of is cuboid syndrome. Cuboid syndrome is described as a subluxation of the calcaneo-cuboid joint. In my experience, I’ve always questioned cuboid syndrome as the primary cause of CC joint pain. The literature describes how in cases of cuboid syndrome, the CC joint can be physically manipulated and supported with taping and Rx orthotics. But the scientist in me is suspect of this diagnosis. The reason I’m suspect is that in the literature there is no documentation of studies that quantify cuboid syndrome. For instance, there are no MRI studies that show evidence of CC joint subluxation. Nor are there any CT scans that have been used to quantify the amount of subluxation.  Hmmmm. How come. Does that mean that cuboid syndrome is a bit nebulous? Maybe indeed, subluxation of the CC joint does occur, but when making a diagnosis, it’s important to be open to what in medicine we call a differential diagnosis. A differential diagnosis is simply other diagnosis that need to be considered when trying to make a definative diagnosis. Let’s take a look at the differential diagnosis of cuboid syndrome.
One of the often over looked aspects of the cuboid is how the peroneus longus tendon affects the function of the cuboid. The peroneus longus tendon originates in the lateral calf and descends the leg posterior to the lateral malleolus (outside ankle bone). The peroneus longus then takes an abrupt turn at the lateral aspect of the cuboid to insert into the base of the first metatarsal (bottom of the foot). The primary function of the peroneus longus is to plantarflex the medial aspect of the foot. So how does the peroneus longus affect the cuboid? In several ways, actually.
First, the peroneus longus traverses the cuboid in a small groove called the peroneal groove. In cases of an inversion sprain of the ankle, the function of the peroneus longus is to inhibit the sprain. It does so by contracting to inhibit the inversion of the ankle. But in some cases, the force of the peroneus longus tendon, focused in the peroneal groove, will be so strong that the tendon actually damages the cuboid. When seen with an MRI, abrupt force from the peroneus longus causes a bone contusion. A bone contusion is a bruise in the bone. So our first differential diagnosis for cuboid syndrome should be a bone contusion of the cuboid.
Second, a common finding specific to the lateral cuboid is a small little accessory ossicle called the os peroneum. Think of the os peroneum as functioning much like your knee cap (patella). When a tendon changes direction, this section of the tendon is subject to wear and subsequent failure. An accessory ossicle is used to decrease this wear zone. Just as the patella facilitates the transfer of force around the anterior knee, the os peroneum facilitates the transfer of force around the lateral wall of the cuboid. It is fairly common to see an irritation of the interface between the accessory bone and the underlying bone. This process is called chondromalacia. Chondromalacia of the articular surface of the os peroneum and cuboid is common and may be caused by wear (osteoarthritis) or acute injury. So our second differential diagnosis is chondromalacia of the os peroneum.
Our third differential is a fracture of the os peroneum. Again, let’s consider
the case of an inversion sprain of the ankle. As the ankle starts to roll, the peroneal muscle senses the stretch and responds by contacting. This contraction of the PL will help to inhibit the inversion sprain. But in the presence of an os peroneum (present in approx. 15% of the general population), that os peroneum can actually fracture into two or more parts. These fractures rarely heal in entirety. The resulting problem is chronic pain at the CC joint. Hence our third differential diagnosis.
Our fourth consideration should be a stress fracture of the cuboid. Stress fractures of the cuboid a somewhat rare and are often referred to as a ‘nutcracker fracture’ of the cuboid. These fractures rarely show up on plain x-ray and are most commonly diagnosed with an MRI.
Each of the previously described injuries are specific to the cuboid and peroneus longus tendon. But as we move out and away from the CC joint, we need to consider a few other conditions that may be included in our differential diagnosis. Those conditions include a fracture of the 5th metatarsal base and a tear in the peroneal tendons.
So, is all lateral mid-foot pain cuboid syndrome? No. Not in the least. That’s why it’s so important to keep an open mind when it come to making a diagnosis of lateral column pain. Be sure when making your diagnosis to incorporate a good history of the problem, noting the onset of pain and the mechanism of injury, if an injury is described.
Jeffrey A. Oster, DPM
The Cherry Valley Foot and Ankle Center, Newark, Ohio
Ohio Valley Sports Medicine, Chillicothe, Ohio
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: calcaneo-cuboid joint, cuboid, cuboid fracture, cuboid syndrome, os peroneum, peroneus longus
March 1st, 2010 › Foot and ankle surgery › Dr. Jeffrey Oster › no comments ›
As a young doctor, the Hoffman, or what some doctors call a Hoffman-Clayton procedure seem so darned aggressive. I was often reluctant to recommend a Hoffman procedure due based upon the assumption that the procedure was a joint destructive procedure. Over the course of my career though, I’ve seen the Hoffman procedure make a significant difference in many patient’s lives. As a result, I do tend to recommend Hoffman procedure more now that I would have int he past.
The two primary indications for a Hoffman procedure are joint subluxation secondary to rheumatoid arthritis and fat pad atrophy. Both conditions result in severe pain on the plantar forefoot. Many patients present with focal areas of callus that result in severe pain. In the early stages of these forefoot problems, patients can be accommodated with a metatarsal pad, metatarsal bar on the shoe or the use of a forefoot rocker on the shoe. But I’ve tended to find that for active patients, these modifications are going to be limited in their efficacy. These modifications are best for those folks who lead a limited level of activity. And example of limited activity would be a person who ambulates with a walker.
A Hoffman procedure involves the resection of metatarsal heads 2-5. A Hoffman-Clayton procedure is a resection of the metatarsal heads and bases of the proximal phalanges. In my hands, I tend to stick with the Hoffman procedure, leaving the phalangeal bases intact.
A Hoffman procedure does need to be performed in a hospital setting with either a general anesthetic or local anesthetic with sedation. A Hoffman can be performed on an outpatient basis. Most patients return to a loose fitting shoe at about 3-4 weeks post-op.
Fat pad atrophy and rheumatoid forefoot deformities can be difficult to manage conservatively. Although conservative care is a must, when conservative care fails, don’t forget about that old school procedure, The Hoffman procedure.
Jeffrey A. Oster, DPM
The Cherry Valley Foot and Ankle Center
Newark, Ohio
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: capsulitis forefoot, fat pad atrophy, forefoot pain, rheumatoid arthritis deformities
March 1st, 2010 › Uncategorized › Dr. Jeffrey Oster › no comments ›
We’re finishing up a long winter here in Ohio. And that means that a lot of the patients I’m seeing have had cold weather exposure as a result of wrestling with mother nature.  Patients have been spending time outside shoveling and trying to clear out driveways and work areas. Subsequently, we’re seeing a number of different cold weather injuries. I thought it might be helpful to categorise these injuries. Let’s take a look at the terms pernio, frostnip, frostbite, trench foot, chillblains and immersion foot.
The type of cold injury that folks may sustain will vary with temperature and moisture. We typically think of frostbite as a cold, dry injury. Most cases of frostbite are caused by long exposure in sub zero weather. Frostbite is the term used when the fluid content within cells freezes. This freezing of the intracellular fluid actually results in dehydration of the cell and ultimately cell death. The longer the exposure, the deeper the cell damage.
Pernio and frostnip are two terms that are synonymous. Both describe
superficial skin damage due to cold exposure. We typically associate pernio and frostnip with a cold, damp environment. The difference between pernio/frostnip and frostbite is that the former can occur at temperature above freezing. Superficial cell death occurs that looks much like a burn. Superficial nerve damage may occur but usually resolves over the course of 12 months.
Trench foot and immersion foot are injuries that occur to the foot due to long exposure in a wet, cool environment. The difference between these two terms has to do with the temperature of the foot. With trench foot, we tend to think of a cooler environment, ie 35-50 degrees F. Immersion foot, on the other hand, describes injuries at warmer temperatures. Both trench foot and immersion foot result in skin damage and superficial nerve damage.
Chillblains describes residual, long lasting neurological defects caused by any of the cold/wet injuries described above. Chillblains symptoms include numbness of the feet and poor circulation.
Bundle up. It’s cold outside.Â
Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: chillblains, cold weather injuries, frostbite, frostnip, immersion foot, pernio, trench foot
February 12th, 2010 › Foot and ankle surgery › Dr. Jeffrey Oster › no comments ›
I saw a fellow this morning for heel pain. Clinical and x-ray finding were consistent with plantar fasciitis, right heel. But there was a problem with that diagnosis. The problem was that we had performed an endoscopic plantar fasciotomy on the same foot 5 years ago. Had the plantar fasciitis returned? It sure did seem that way.
Plantar fasciotomy, regardless of the method used (open with medial approach, open plantar approach, endoscopic, etc) is a reliable, time tested method of caring for recalcitrant cases of plantar fasciitis. But can plantar fasciitis recur following surgery? And after a 5 years period of being pain free? It appears the answer is yes.
The scientist in me knows that things happen for a reason. So what would be the reason that plantar fasciitis would reoccur? I’d have to guess that the patient had changed. Think of it this way, when you treat plantar fasciitis with a surgical procedure, you’re treating a patient who weighs a certain amount, has a certain level of activity and has a certain tissue elasticity specific to their age. That can change. And in this case, I think that change in this specific patient is at the heart of why the plantar fasciitis recurred.
What can change and what are the dynamics that could contribute to the return of plantar fasciitis post surgery? Body weight, age and tissue elasticity are important factors. And an increase in the duration of time on the feet could also be a significant variable. Plantar fasciitis doesn’t reoccur without a reason. It comes back for a specific reason. And I’d assume that it’s a combination of one or more of the above.
I’m not aware of any articles in the literature regarding the return of plantar fasciitis following surgery. So quoting return rates would be just a guess. But for those considering a plantar fasciotomy, the procedure can still be a very good choice to treat heel pain.Â
Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: heel pain, heel spur, plantar fasciitis
February 8th, 2010 › Foot and ankle surgery, Pain managment › Dr. Jeffrey Oster › no comments ›
I just saw a young girl in the office today who was in for her first post-op visit following surgery performed 3 days ago. She’s a stoic young gal, but I think I could honestly say that this was her first time having elective surgery. Granted, she’s a mother of 2 children, but still, this is the first time that she’s been down and unable to help around the house.
The surgery was an excision of plantar fibromatosis. Inherent in this procedure is that fact that an incision on the bottom (plantar aspect) of the foot requires 3 weeks non-weight bearing. This young gal is on crutches and still trying to be a mom.
In light of these issues, there was still one more issue that I feel rises to the top of my list in managing her care. And that fact was that she was unwilling to move her foot. Her unwillingness was certainly due to her pain, but it was also due to the fact that she was scared. And interestingly, those two issues, pain and anxiety perform a terrible dance with each other. The reason that it’s so important to break-up that dance is that it’s the first step in breaking into the pain cycle. I was taught long ago that each part of the body has a certain rhythm. And pain locks that rhythm, creating more pain.Â
So how do you break through on this kind of pain and regain that rhythm? The first thing is touch. It was important for me to lay hands on this young gal. I begin with light touch. Reassuring touch so that she feels safe. The second key is to try to initiate motion. Simple, slight rhythmic motion. And once the patient is reassured that she can move, I move just a little more. The goal is to try to get the patient doing just a little bit of motion on her own before leaving the office. This particular patient left with instructions to begin range of motion exercises, writing the ABC’s using her ankle as a pivot point. And you know, by the time she left, she was moving pretty well.
Pain is a funny critter. There’s a number of ways to manage pain, but the best way is to build a sense of confidence in the patient. Sure, narcotics are necessary, but it’s also important for patients to gain psychological control of their pain. I try to put our patients at cause rather than being the effect of their pain.
Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: Pain managment, plantar fibormatosis, post-op painfoot and ankle surgery
February 6th, 2010 › Foot and ankle surgery › Dr. Jeffrey Oster › no comments ›
One of the tools I use to gauge how well I do my job is to listen to post-op patients and their comments regarding how well they’re doing with their recovery. For most patients, their surgical experience is a first time experience. This means that they have no previous surgical experience with  which they can compare. So it’s incumbent upon me to be a good counselor prior to surgery. My job is to help patients to understand what to expect during the post-0p course of their surgery. And my job is to help the patients define realistic expectations regarding their care.
One of the best ways to assess whether I’ve done my job well is to listen to patients comments during their post-op care. Are their expectations regarding their ability to care for themselves in the first post-op week realistic? Or do they seem challenged in their ability to do so. If they understand their post-op obligations and limitations, then I feel like I’ve done a good job in coaching them through their surgery.
Another way that I look at this question is in regards to return to work. Is the patient on track to return to work in a realistic time frame? And do they agree that this was the time frame that we discussed leading up to their surgery? If so, then again, I feel like I did a good job.
And lastly, how effectively was their problem(s) solved? Are they pain free? 50-75% pain free? And was that the expectation going into the surgery? Does the patient agree with their progress?
Surgical expectations are at the heart of what’s called the art of medicine. As we move into this new era of medicine with computerized charting and high tech diagnostic tools, sure, we may be able to use these tools to diagnose better, but how well have we communicated with the patient regarding expectations. Are we some times using these new diagnostic techniques to build unrealistic expectations? Perhaps.
Each patient is unique in their make up. Part of my job is to assess that person and how their unique make up will affect the outcome of the surgery. For instance, how will their general health affect healing? What about their job and how it may influence post-op healing?Â
Each of these questions comes together on that last visit when the patient is to be discharged. In a way, it’s a bit of an exit interview. And it’s a great way to review how well the patient’s expectations and my expectations met (or didn’t meet) in the middle. For the most part, those expectations do seem to sync. And when they do, I can smile knowing I did my job well.
Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: surgical expectations
February 5th, 2010 › Pediatric foot and ankle care › Dr. Jeffrey Oster › no comments ›
Even after 25 years in practice, there’s still one thing that gets me excited,
and that’s making a really good diagnosis. In a way it’s a bit like being Sherlock Holmes who famously said in 1892 in, A Scandal in Bohemia, “You see but you do not observe. The distinction is clear.” You don’t have to be a rocket scientist to make a good diagnosis. You just need to observe. And observe  carefully.
This week I saw a 6 y/o who had fallen off of his coffee table at home. He presented to a rural hospital ER for x-rays that were read, “ankle free of injury, no fracture.” He and his mom presented to my Chillicothe office with the plain films and the report. But something wasn’t right. On the ER films the left navicular seemed irregular. The boy was active with no limp in his gait. But with palpation of the midfoot and range of motion with the heel locked, there was some mid-foot pain. On a hunch, I got x-rays of the asymptomatic foot. And what I observed was two strikingly different navicular(s). The right was well formed and the left was sclerotic (bright white) and thin.
The diagnosis was Kohler’s Disease. Kohler’s Disease, also known as aseptic necrosis of the navicular, is a relatively rare finding in children. In fact I can’t remember the last case that I have seen. Aseptic means free of infection. Necrosis means that the blood flow to the navicular had been cut off and the bone had died.Â
So what to do? Some advocate a non-weight bearing cast. If this particular child had been more symptomatic, I think I would have seriously considered that as an option. Mom suggested a rigid arch support and that was a good call. But until we see an increase in symptoms, I think we’re best to simply decrease activities; no basketball leagues, no traveling soccer.
Aseptic necrosis follows a fairly unpredictable path of 4 stages. First is early recognition usually due to pain. Second is decrease mineral content of the bone (that’s the avascular aspect). Third is collapse and fourth is a remodelling phase. Although these stages overlap, we could say that this child was in stage 3 and entering stage 4.Â
I don’t believe that it was Kohler’s Disease that caused the pain following the fall. It was the fall that seem to stir up the coals. The radiographic changes were not just a week old. So this stoic little kid had been putting up with this for months.
Observe what you see. How cool is that?
Jeffrey A. Oster, DPM
Dr. Oster cannot answer medical questions or provide medical care through this blog.
Tags: aseptic necrosis, kohlers disease, navicular
