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Chat with a Foot&Ankle Specialist

Online Health Chat with Dr. Mark Berkowitz

October 5, 2011


Introduction

Cleveland_Clinic_Host: Proper foot care is not something most of us think about until problems literally put us out of step. Yet, foot and ankle problems are among the most common health ailments. Virtually everyone will experience some degree of foot and ankle problem during their lifetime.

The normal foot and ankle have 26 bones, 33 joints, and more than 100 muscles, tendons, and ligaments. The average person will walk the equivalent of four times around the world in his or her lifetime. So it’s hardly surprising that nearly three-quarters of Americans will eventually experience some type of foot problem. In athletes, these problems are even more common. Although some problems are inherited, many stem from a lifetime of accumulated abuse and neglect, such as wearing improper footwear or not seeking early medical attention.

Mark Berkowitz, MD, is an orthopaedic surgeon specializing in lower extremity trauma; all conditions of the foot and ankle, including arthritis, tendon, and ligament problems; all fractures of the lower extremity; and sports injuries of the foot and ankle. Dr. Berkowitz graduated from Case Western Reserve University School of Medicine and went on to complete his residency at Tripler Army Medical Center. He also completed a fellowship in Foot/Ankle/Lower Extremities Trauma at Florida Orthopaedic Institute.

To make an appointment with Dr. Berkowitz or any of the specialists in the Department of Orthopaedic Surgery at Cleveland Clinic, please call 866.275.7496. You can also visit us online at www.clevelandclinic.org/ortho.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Mark Berkowitz, Cleveland Clinic orthopaedic surgeon and lower extremity specialist. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Ankle Issues

japike43: I had a severely sprained ankle in mid-July and still have residual problems with it. It is very stiff and sore at times. Do you have any advice? Also, I have the beginnings of a bunion on my foot. What type of maintenance or control can I do with this to prevent surgery? Periodically, I have quite a bit of pain with it. Thanks.

Dr__Mark__Berkowitz: Severe ankle sprains frequently take three to six months to heal, so it is not uncommon for symptoms to persist longer than most people expect. The key is physical therapy to help re-strengthen the ankle and prevent re-injury. Completion of a formal ankle rehabilitation program gives you the best chance to get over these residual symptoms. If the symptoms persist despite completion of a three-month rehab protocol, then you have to ask if something else might be contributing. In those cases, I often obtain an MRI to evaluate the surrounding cartilage and tendons, which may also have been injured.

As for the bunion, initial treatment involves wearing shoes that are wide enough to accommodate the bunion. Brands such as Keen and Merrell and New Balance have a variety of styles that can provide greater room for the bunion. Specialized gel pads are also available to provide additional cushioning over the bump, but these pads only work when paired with a properly fitted shoe. If the symptoms persist despite these interventions, then surgery can be considered.

Chicago0319: Hello. I recently broke all the bones in my right ankle. I had surgery when plates and screws were put in. I'm still in a cast but am concerned about the future of my ankle. What precautions should I be taking?

Dr__Mark__Berkowitz: I'm sorry about your injury. But I think the real determining factor in terms of how you will do in the future is how well the ankle was put back together. My goal when fixing ankle fractures is perfect reduction because the ankle doesn't tolerate even small shifts very well. A classic study demonstrated that just 1 mm of displacement in the ankle increases the pressure on the joint by 42 percent. So if the surgery was done well, you have a great chance of getting back to your pre-injury function. The wild card is whether the cartilage was damaged. This can predispose you to arthritis, regardless of how well the fracture was fixed. In general though, if your fracture was put back together well, you've got a great chance.

sunsetorange: Can you refer me to a formal ankle rehab program that is on the "Web"? Thanks.

Dr__Mark__Berkowitz: Unfortunately, I'm not familiar with any rehab program on the Web. I'm sure if you search you can find some generic ankle exercises, but I think the role of a therapist is to identify each individual's specific needs and to create a program that addresses those needs.


Multiple Concerns

denali: I have a few questions. About a year ago, I was told that I had really bad arthritis in my ankle but there wasn't much they could do. Last week I was told that I have a peroneal tendon tear. Did the tear happen from the arthritis or from some injury? I also have really bad plantar fasciitis/heel spurs in my right foot. It is agonizing. I have had it for about 15 months. My foot is noticeably swollen. I cannot take anti-inflammatories nor can I get the cortisone injections. I am in a lot of pain and I have been told that there isn't anything else to be done. Can you offer any advice on either condition? Thank you

Dr__Mark__Berkowitz: It sounds like, unfortunately, you have a lot of different things going on. The key is to evaluate each condition and determine what is actually causing symptoms and what is bothering you the most. For instance, there may be arthritis in the ankle, but if it is the heel that is really bothering you, then that is where the attention should be paid.

In general, though, there are options for treating all of your stated conditions. Ankle arthritis can often be improved by wearing a special custom brace to limit motion at the joint. Surgical options include fusion or ankle replacement. A formal orthopaedic evaluation would be necessary to determine what treatments are best suited for your condition.

Peroneal tendon injuries can occur from injuries or wear and tear, but it is important to realize that MRI is not perfect in detecting peroneal tendon injuries. Sometimes, MRI will suggest a tear where none exists. Other times, MRI will miss tears that are there. Again, the key is correlating your symptoms and exam findings to the studies.

Plantar fascial pain is frustrating but can be improved by a dedicated plantar fascia stretching program. The key is stretching the toes and ankle back at the same time beginning first thing in the morning and repeating at least once an hour. This keeps it from getting tight. Newer ultrasound treatments are also available but are not routinely paid for by insurance. Surgery is a last resort, as the results have not been 100 percent positive. Other keys include not going barefoot and getting gel heel pads and good supportive shoes.


Plantar Fasciitis

mrsprez: A practice in my area offers ultrasound as a treatment for plantar fasciitis. Is this a successful treatment? How would you attempt to correct this condition?

Dr__Mark__Berkowitz: Reports of ultrasound treatment for plantar fasciitis are encouraging. There are different types of ultrasound, however. High-intensity ultrasound requires a degree of anesthesia but has achieved some promising results in the treatment of plantar fasciitis. Low-intensity ultrasound I don't believe has quite as much evidence supporting its effectiveness. I am a big proponent of trying these nonsurgical treatment options. However, the reality is that many patients are hesitant to proceed because insurances don't seem to want to pay for it.

Personally, I employ a dedicated stretching program along with cushioned gel heel pads and supportive shoes for a period of three to six months. That has been shown to provide relief in 90 percent of patients. If that fails, ultrasound and/or steroid injections can be tried. If symptoms persist, surgery can be considered, but the results have not been as predictable as we would like.


Achilles Injuries

CherBH: What would you say is the typical length of recovery for surgical repair of an Achilles tendon? I am 4 months post-op and it seems to me that there is a wide variation in recovery times. While I realize that individual conditions/circumstances affect the outcome, I have seen it vary anywhere from six months to two years or more. Also, are there any new/ongoing developments in research for non-surgical treatment of chronic insertional Achilles tendinitis?

Dr__Mark__Berkowitz: It depends how you define "recovery." I tell patients that recovery occurs in stages, but that overall, a year is required to get back to normal activities. At four months, I would expect that you are walking in a regular shoe but really just beginning the long process of re-strengthening the calf muscle. This is the longest part of the rehab process; but it is critical because, without getting the strength back, you will continue to limp and have decreased endurance and function. It doesn't sound like you are really "behind." Rather, I think you are just toward the beginning of a slow process.

Chronic insertional Achilles tendinosis remains a frequently stubborn condition to treat. Whereas some new treatment for mid-substance Achilles wear and tear, such as platelet-rich plasma injections and specific therapy regimens, have been recently reported. I am not aware of new treatments for wear and tear at the attachment to the heel bone. For recalcitrant cases, surgery remains a frequently effective option to diminish pain and improve function.


Peroneal Tendonitis

eriepa: I have had issues with peroneal tendonitis in my right foot, and now I believe I'm suffering the same issue in my left foot. I am overweight and know this is probably one of the main reasons for this problem, but I wonder if there is any type of pain management I could be doing - stretches, orthotics, etc. - so I can hopefully manage the condition and begin a workout program.

Dr__Mark__Berkowitz: The question is: why are you getting inflammation of the peroneal tendons? One common cause is malalignment of the ankle, specifically where the ankle turns in. This occurs most frequently in people with high arches who walk on the sides of their feet. This greatly stresses the peroneal tendons and predisposes them to irritation. In these cases, orthotic shoe inserts can help correct this malalignment and, in turn, make the peroneals feel better. An orthopaedic surgeon would be able to tell if you have this subtle malalignment.

I would also recommend a low-impact exercise program that emphasizes aquatic exercise, which will not stress the peroneals. This will allow you to begin exercising right away.


Injections

Bella: I have been suffering from planters fasciitis for months and am currently in physical therapy. How many cortisone shots would you recommend? I am a 51-year-old female.

Dr__Mark__Berkowitz: I don't encourage cortisone injections. They have side effects, including weakening of the plantar fascia, and may increase the risk of rupture. Personally, I am only willing to inject a patient once, and that is if the standard stretching and padding have not helped over six months. When I do use an injection, I will place the patient in a protective boot for a month or so to prevent a rupture.


Surgery

susankoons: Is there a way to treat a painful bone spur without surgery? And if not, does the Achilles have to be detached to remove the spur?

Dr__Mark__Berkowitz: Certainly there are non-operative treatments for bone spurs and wear and tear at the attachment of the Achilles. But honestly, this area often resists nonsurgical treatment and not infrequently may require surgery.

There are different techniques for surgical treatment. One technique is to come in from the side and remove the spur without detaching the tendon. The problem with this is that I think you have to detach the tendon to fully remove the spur. Also, frequently there is wear and tear in the tendon that needs to be removed as well, and you can't do that without detaching the tendon.

Thus, when I do this surgery, I partially detach the tendon enough to remove the entire spur and whatever damaged tendon is present. But I then aggressively repair the tendon back to the bone, which greatly facilitates its healing. You still have to protect it for a few weeks after surgery, but it generally leads to good relief of pain and return of function.

JanieGee: Can a big toe hammertoe be corrected?

Dr__Mark__Berkowitz: Hammertoes usually affect the lesser toes but in certain situations can affect the great toe. In that case, it is referred to as a "clawed hallux." As with all toe deformities, initial treatment is nonsurgical and aimed at padding the dorsal prominence from shoe rubbing. If this is not effective enough, then yes, surgery can be performed to straighten out the great toe. This usually involves a fusion of the offending joint to hold it straight. This sacrifices motion at the joint but achieves correction of the deformity.


Medication

nancyhanks: Recent commercials on gout are having an impact on medications. Can we believe the hype when attacks have been only to great toe and subside with rest?

Dr__Mark__Berkowitz: Obviously, the commercials are intended to get you to spend your money on their medicine. The question is: how well controlled is your gout? If it is well controlled with diet alone, you probably do not need the medicine in the commercials. However, if you have frequent attacks despite diet changes, then medical treatment is indicated, not only because the attacks hurt, but also because over time arthritis can develop if the attacks are frequent.


Exercise/Rehabilitation

CherBH: Is it essential to participate in strengthening exercises under a licensed physical therapist post-op for full recovery or would basic stretching/strengthening exercises at home be sufficient?

Dr__Mark__Berkowitz: I think it depends on the needs of the patient. I try to be sensitive to the financial realities of physical therapy. It is definitely not free. Thus, I don't send patients to therapy until and unless I think they require it. I try to instruct them on exercises they can do at home. I actually think this is more effective as it allows for more frequent sessions. That being said, I often think it is beneficial to meet with a therapist once or twice to familiarize you with the exercises and get some of the equipment (i.e., rubber bands). Often, therapists will also give you a handout outlining a program to follow. I think these one or two sessions are worthwhile and then a transition to doing the exercises on your own can be done. Additionally, if you belong to a gym or health club or rec center, you may not need supervised therapy as much as someone who doesn't. Bottom line, I agree with you that it does not have to be supervised.

eriepa: I am also considering an exercise bike to get started in the house.

Dr__Mark__Berkowitz: That would be fine, but think about finding some water aerobics classes as well. The water makes all your joints feel good.


Shoes

jgskinner: I walk a lot, 4 to 7 miles a day, I often do this in shoes with limited support. I am worried about the effects this may have on my feet. Will inserts help. Is it necessary to buy walking shoes? Thank you!

Dr__Mark__Berkowitz: It all depends on your feet and your symptoms. If you are walking 4 to 7 miles a day without any problems, then your feet are obviously healthy and your shoes are adequate. I would only consider special inserts if you are having problems with your routine, i.e., pain. Same with the shoe issue. Obviously, walking shoes are designed for walking, whereas fashionable shoes are not. But if you are not having any problems, I don't see any urgency to change.

nancyhanks: Do 4-inch heels cause foot injuries?

Dr__Mark__Berkowitz: High heels increase pressure underneath the ball of the foot, increase the likelihood of bunions, increase the likelihood of Achilles tendon problems, increase the likelihood of ankle sprains, etc.

Overall, I don't think they are very good for the feet. That being said, if you are not having any problems with your feet, I don't see any problem or reason why you would have to stop wearing them.


General Questions

jgskinner: How do you feel about the barefoot movement, how much support does the foot really need?

Dr__Mark__Berkowitz: Intellectually, I'm intrigued by the barefoot running movement and enjoy reading about it. In reality, though, I don't think the majority of people are really appropriate for barefoot running. I think if you are light, thin, fit, and have healthy, non-problematic feet, then a very gradual transition to barefoot running is possible. But I think the risk of developing stress injuries to the foot is high for most patients who don't have the prototypical "runner's body." I think the key to running is finding out what your individual limits are and staying within those limits to garner the benefits of running without getting injured. Personally, as the owner of a "non-runner's body," for me that means running only a few days a week, short distances, with very supportive shoes. I think that if I were to try barefoot running, even judiciously, I'd put myself at risk for problems. Thus, I think everyone needs to perform an honest risk-assessment. If you are happy with your current running program, I'm not sure I would risk a change.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Mark Berkowitz is now over. Thank you again, Dr. Berkowitz, for taking the time to answer questions about foot and ankle problems.

Dr__Mark__Berkowitz: I'd like to thank everyone for their great questions. Please don't hesitate to come see me for a formal evaluation at the Cleveland Clinic Main Campus on Wednesdays, our Middleburg Heights office on Mondays, and Medina General Hospital on Tuesdays. Thanks again.


More Information

To make an appointment with Dr. Berkowitz or any of the specialists in the Department of Orthopaedic Surgery at Cleveland Clinic, please call 866.275.7496. You can also visit us online at www.clevelandclinic.org/ortho.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

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This chat occurred on 10/5/2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.