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Treating Mortons Neuroma

Overview

intermetatarsal neuromaA neuroma is an often painful enlargement of one of your body?s nerves. Morton?s neuroma is the name used to describe nerve enlargement in your foot, particularly enlargement of one of the nerves traveling to your toes in your forefoot. Morton?s neuromas most commonly develop in one of your intermetatarsal nerves, one of many nerve branches within your foot that originated in your spine. Morton?s neuroma is more likely to affect women than men.

Causes

Various factors have been implicated in the precipitation of Morton’s neuroma. Morton’s neuroma is known to develop as a result of chronic nerve stress and irritation, particularly with excessive toe dorsiflexion. Poorly fitting and constricting shoes (ie, small toe box) or shoes with heel lifts often contribute to Morton’s neuroma. Women who wear high-heeled shoes for a number of years or men who are required to wear constrictive shoe gear are at risk. A biomechanical theory of causation involves the mechanics of the foot and ankle. For instance, individuals with tight gastrocnemius-soleus muscles or who excessively pronate the foot may compensate by dorsiflexion of the metatarsals subsequently irritating of the interdigital nerve. Certain activities carry increased risk of excessive toe dorsiflexion, such as prolonged walking, running, squatting, and demi-pointe position in ballet.

Symptoms

If you have a Morton?s neuroma, you may have one or more of these symptoms where the nerve damage is occurring, Tingling, burning, or numbness, pain, a feeling that something is inside the ball of the foot or a feeling that there?s something in the shoe or a sock is bunched up. The progression of a Morton?s neuroma often follows the following pattern. The symptoms begin gradually. At first they occur only occasionally, when wearing narrow-toed shoes or performing certain aggravating activities. The symptoms may go away temporarily by removing the shoe, massaging the foot, or by avoiding aggravating shoes or activities. Over time the symptoms progressively worsen and may persist for several days or weeks. The symptoms become more intense as the neuroma enlarges and the temporary changes in the nerve become permanent.

Diagnosis

You should visit a doctor or podiatrist (foot doctor) if you have pain or tingling that does not stop. Your health care provider will examine your feet and will apply pressure on the spaces between the bones of the toes to determine the location of the foot pain. The doctor may order X-rays to rule out other conditions associated with foot pain, such as a stress fracture or arthritis. X-rays alone will not show whether or not a neuroma is present, so an ultrasound scan or magnetic resonance imaging (MRI) test may be done to confirm the diagnosis. A diagnostic procedure called an electromyography is sometimes used to rule out nerve conditions that may cause symptoms like those of associated with Morton?s neuroma.

Non Surgical Treatment

Symptoms of a Morton’s neuroma can completely resolve with simple treatments, such as resting the foot, better-fitting shoes, anti-inflammation medications, and ice packs. More rapid relief of symptoms can follow a local cortisone injection. Symptoms can progressively worsen with time. For those with persistent symptoms, the swollen nerve tissue is removed with a surgical operation.

Surgical Treatment

For severe or persistent pain, you may need surgery to remove the neuroma. Once the nerve is gone, you permanently lose feeling in the affected area. One alternative to surgery is to undergo neurolysis injections. These use chemical agents to block pain signals. Another alternative is to take a prescription pain reliever that alleviates nerve pain.

Prevention

While Morton?s Neuroma has been an ongoing topic of clinical investigation, the condition is in some cases difficult to either treat or prevent. Experimental efforts involving the injection of muscle or bone with chemicals such as alcohol, as well as suturing, and covering affected areas with silicone caps have been attempted, with varying success.

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Achilles Tendon Rupture Thomas Test

Overview
Achilles Tendon
The Achilles tendon, or calcaneal tendon, is a large ropelike band of fibrous tissue in the back of the ankle that connects the powerful calf muscles to the heel bone (calcaneus). Sometimes called the heel cord, it is the largest tendon in the human body. When the calf muscles contract, the Achilles tendon is tightened, pulling the heel. This allows you to point your foot and stand on tiptoe. It is vital to such activities as walking, running, and jumping. A complete tear through the tendon, which usually occurs about 2 inches above the heel bone, is called an Achilles tendon rupture.

Causes
Often the individual will feel or hear a pop or a snap when the injury occurs. There is immediate swelling and severe pain in the back of the heel, below the calf where it ruptures. Pain is usually severe enough that it is difficult or impossible to walk or take a step. The individual will not be able to push off or go on their toes.

Symptoms
Typically patients present with sudden onset of pain and swelling in the achilles region, often accompanied by a audible snap during forceful dorsiflexion of the foot. A classic example is that of an unfit ‘weekend warrior’ playing squash. If complete a defect may be felt and the patient will have only minimal plantar flexion against resistance.

Diagnosis
On physical examination the area will appear swollen and ecchymotic, which may inhibit the examiners ability to detect a palpable defect. The patient will be unable to perform a single heel raise. To detect the presence of a complete rupture the Thompson test can be performed. The test is done by placing the patient prone on the examination table with the knee flexed to 90?, which allows gravity and the resting tension of the triceps surae to increase the dorsiflexion at the ankle. The calf muscle is squeezed by the examiner and a lack of planar flexion is noted in positive cases. It is important to note that active plantar flexion may still be present in the face of a complete rupture due to the secondary flexor muscles of the foot. It has been reported that up to 25% of patients may initially be missed in the emergency department due to presence of active plantar flexion and swelling over the Achilles tendon, which makes palpation of a defect difficult.

Non Surgical Treatment
Non-surgical treatment of Achilles tendon rupture is usually reserved for patients who are relatively sedentary or may be at higher risk for complications with surgical intervention (due to other associated medical problems). This involves a period of immobilization, followed by range of motion and strengthening exercises; unfortunately, it is associated with a higher risk of re-rupture of the tendon, and possibly a less optimal functional outcome.
Achilles Tendon

Surgical Treatment
Some surgeons feel an early surgical repair of the tendon is beneficial. The surgical option was long thought to offer a significantly smaller risk of re-rupture compared to traditional non-operative management (5% vs 15%). Of course, surgery imposes higher relative risks of perioperative mortality and morbidity e.g. infection including MRSA, bleeding, deep vein thrombosis, lingering anesthesia effects, etc.

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