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In Motion Winter 2011

Plantar Fasciitis

So your heel hurts when you first get out of bed in the morning and every time you sit down for a while, and then start walking? Chances are you have plantar fasciitis.

The problem typically isn't in the diagnosis but how to get rid of that pestering pain.

What is it?

Plantar fasciitis is a localized degeneration and irritation of the thick fibrous tissue that connects your heel to the base of your toes and makes up the majority of your arch in your foot. You are not alone if you have it, nearly 15% of people will be affected by it during their lifetime. That’s about 2 million per year.

What causes it?

The trauma that causes the pain is usually linked to increased, repetitive stress to the plantar fascia. This causes microtears to occur at the area under increased load, right at the inside aspect of the bottom of the heel. It can be due to an increase or change in exercise volume or intensity, walking or working out in different/new shoes or a new surface, or a combination. People with tight calves and hamstrings, and those that are overweight, seem to be more prone to plantar fasciitis.

How is it diagnosed?

A good thorough history and physical exam should solidify the diagnosis. A set of x-rays may show a bone or heel spur right where the plantar fascia attaches to the heel. This is an area of increased stress typically due to the tightness of the plantar fascia and shouldn’t change the management.

What helps?

The approach to treating plantar fasciitis is multifaceted and individualized and can be guided by your physician and physical therapist team. Recovery is dependent on how long you have suffered….the longer you have had it, typically the longer it will take to get better.

Supportive shoes can make a big difference. Flat shoes, such as flip flops, have been implicated in the onset of plantar fasciitis. Make sure you have the right type of shoes for your feet. If you are unsure, a good running shoe store or your therapist may offer guidance. Heel cups can lessen the pain with each step, and over the counter arch supports can help support the arch and relieve some of the pressure on the plantar fascia attachment. Some people need custom orthotics, but technology has made some of the over the counter brands nearly as effective and comfortable, and they are a cheaper option.

Many people benefit from multiple stretches to loosen up the fascia, Achilles tendon, calf (especially the soleus muscle), and hamstring. Localized icing and over the counter pain medications, including anti-inflammatories, can provide some pain relief.If the pain is significantly worse with those first few steps out of bed in the morning a night splint that keeps the plantar fascia from tightening overnight can be very helpful. If that doesn’t work, other options include taping, bracing, injections, or shock wave treatments, and for the severely recalcitrant cases, potential surgery.

Plantar fasciitis treatment requires patience. Unfortunately, there are no quick fixes, but with dedication, you should be back up on your pain free feet soon.

Innovative Orthopaedic Procedure Ends Shoulder Pain

It was a perfect fall day in northwest Ohio, crisp and sunny. Sandy Nearhood and her granddaughter, Sara, were walking Sara’s 75-pound golden retriever, Sam. A local high school football game was under way at the field that adjoins the Nearhood’s property. The team made a big play, the crowd cheered, the band played, and “Sam got spooked,” Nearhood recalls. He gave a mighty jerk on the leash she was holding and took off running, dragging her along.

That big pull on his leash dislocated Nearhood’s shoulder.

The orthopaedic specialist on duty at the local ER put her shoulder back in place and sent her home with a sling. “I didn’t have any pain, but I could only use one arm to do things,” says Nearhood, a registered nurse. She was looking forward to the physical therapy that she expected would bring her arm back to normal.

Instead, therapy worsened her problem. Her shoulder became unstable, and she was unable to keep the joint properly in place. Strength and feeling in her arm were decreasing. “At that point, my doctor said he wanted to refer me to the best, so he sent me to Dr. John Brems at Euclid Hospital,” Nearhood says.

An MRI and other tests revealed not only a damaged deltoid (shoulder) muscle but also nerve damage and a major tear in the rotator cuff – the four muscles and tendons that stabilize the shoulder. John Brems, MD, who specializes in shoulder injuries, recommended a reverse shoulder replacement.

“Reverse shoulder replacement was developed for people with severe rotator cuff problems that cannot be repaired by the usual surgeries,” Dr. Brems says.

The normal shoulder is a ball and socket joint. The ball is the end of the humerus – the long bone from the elbow to the shoulder – and the socket in the scapula, the shoulder bone.“In this procedure, we use a prosthesis that reverses this anatomy – the socket is at the end of the humerus and the ball is on the scapula,” Dr. Brems explains. “This construction helps the deltoid muscle lift the arm.”

He has performed many of these procedures and believes it can make a major difference for the right patient. “It’s not a miracle cure, but in properly selected patients reverse shoulder replacement can provide pain relief and restore at least some use of their arm,” he says.

At the time of her surgery, Nearhood was unable to work, taking daily pain medication and spending her days in a recliner. After surgery, she was delighted to be almost pain-free and feel the strength returning to her arm as she recovered.

Today, Nearwood is happily working two jobs and is back to her numerous volunteer activities. “I have more strength and reach than even Dr. Brems expected,” she says with pride. As for Sam, the dog who caused it all, “I still love him dearly,” she says, “I just don’t walk him any more.”

Ask the Doctor: Herniated Disc

Q. How do I know if it’s a herniated disc or just a backache?

A. If your back is aching or throbbing, you may simply have a sprain or strain, especially if you’re young and otherwise healthy. But the older you get, the more likely your pain is caused by a herniated disc. That’s when one of the spongy discs in your spine gets damaged — or deteriorates with age — and bulges out of place or breaks open.

Herniated discs most often occur in the lower back. The pain may start like any other backache. But days or even weeks later, the pain may shift to the buttock or leg. Some people describe it as a shooting pain, numbness or burning. This “pinched nerve” feeling down the leg is called “sciatica.”

“It’s one of the most common symptoms of a herniated disc,” says Russell DeMicco, DO, a spine physician who sees patients at main campus, Lutheran Hospital and Solon Family Health and Surgery Center.

Only about a third of patients can identify how or when their disc was damaged — like when they lifted something heavy and felt a stabbing pain. Most patients never know.

For many, the pain subsides in a few weeks with over-the-counter pain relievers or anti-inflammatories and simple exercises. It’s best to avoid strict bed rest. Bed rest leads to weaker muscles, and you may end up feeling worse than if you’d kept moving normally.

If these treatments don’t lessen your pain in one to two weeks, call your doctor. The next step may be formal physical therapy or epidural injections. Surgery also is an option for long-term pain or if the pain is accompanied by muscle weakness, like a dropped foot. Most people don’t need surgery or even an MRI.

An MRI is only needed to prepare for injection or surgery or to rule out infection and other conditions — not to diagnose the back pain. Whether it’s a sprain, strain or herniated disc doesn’t really matter. They’re all treated the same initially.

While herniated discs may be as common in older adults as wrinkles and gray hair, the condition can affect patients of any age. Those most at risk are smokers, people who are overweight and people who do not exercise.

Understanding Knee Replacement

When damage from arthritis or injury produces knee pain while walking, climbing stairs or even resting – and medications, walking aids and activity modification don’t help – your doctor may recommend total knee replacement.

Thankfully, today there are more options than ever before, says Kenneth A. Greene, MD, a specialist in hip and knee reconstruction and revision who practices at Cleveland Clinic main campus and Medina General Hospital.

“You don’t have to wait and suffer in pain,” Dr. Greene says. “With advances in knee replacement surgery, knee replacements last longer. The latest in pain management – long-acting pain blocks and catheters – also help patients get back on their feet faster.”

Here, Dr. Greene answers some commonly asked questions about total knee replacements:

What is a knee replacement?

Knee replacement surgery replaces the damaged articular cartilage or gliding surface and any associated loss of bony structure or ligament support. The goal is to relieve knee pain and restore mobility.

The procedure itself is a resurfacing of the damaged knee, and relies on the patient’s muscles and ligaments for support and function. There are several different replacement knees (prostheses) that your surgeon can recommend – based on the amount of arthritis or wear on your joint.

What are the types of knee replacement surgeries?

Types of knee replacements include:

  • Total knee replacement
  • Partial knee replacement

These different prostheses can be made of cobalt chrome, titanium and plastic, and can be fixed to the bone with acrylic cement or can be press-fit, which allows bone to grow into the implant. Your orthopaedic surgeon will select the type of knee replacement that best suits your amount of arthritis bone loss, and quality of the ligaments supporting the knee.

How long does it take to recover from knee replacement surgery?

Most patients who undergo total knee surgery have dramatic improvement within weeks of the surgery. The pain caused by the damaged knee is relieved when a new gliding surface is constructed. Patients who have knee replacement surgery are standing and moving the joint the day after surgery. After about six weeks, most patients are walking comfortably with minimal support. After muscle strength is restored, patients who have knee replacement surgery can enjoy most activities (except running and jumping).

How long do total knee replacements last?

There are still misconceptions about knee replacement. Many patients believe a total knee replacement will only last 10 years. Yet, most joint registries show long-term success rates of about 95 percent at 15 years following surgery.

Understanding Osteoarthritis

“You are not as young as you used to be,” you tell yourself after another round of golf. The pain and stiffness in your joints has slowly gotten worse, and you wonder how long you will be able to continue to keep up with your golf partners.

If the pain goes away in a few days, you may have osteoarthritis – the gradual wearing away of the cartilage in your joints. Osteoarthritis is the most common form of arthritis, and it usually affects your weightbearing joints: your hips, knees, ankles and feet. In addition to pain and stiffness, the symptoms include tenderness, loss of flexibility and a grating sensation when you use the joint.

“Unfortunately, there are no cures for osteoarthritis, and it will gradually get worse,” says Michael C. Kolczun II, MD, an orthopaedic surgeon who practices at Lakewood. “However, it is possible to manage your arthritis, gain control over your symptoms and remain active.”

“First and foremost,” says Dr. Kolczun, “see your family doctor if you have swelling or stiffness in your joints, particularly if it lasts for two weeks or more. Your doctor may recommend medications, physical therapy and/or exercise programs to relieve your pain. For those with mild-to-moderate pain, over-the-counter medication can relieve pain and/or reduce inflammation. Your doctor also may recommend prescription medications, which may include anti-inflammatories, painkillers or cortisone shots.”

In addition, you may want to ask for a referral to a physical therapist to create an individual exercise program to strengthen the muscles around your joints, increase your range of motion and reduce pain.

“Try to avoid stressing your joints,” says Dr. Kolczun. “Find new ways or tools to help you. An occupational therapist can help develop solutions for everyday tasks.”

However, if your joint is severely damaged by arthritis or injury, and conservative treatments have not allowed you to return to your normal activities of daily living without pain, you may want to be referred to an orthopaedic specialist.

Should you need a joint replacement, there are many options available today. The most common joint replacements are for the hip and knee, but technology now allows implants to replace your – shoulder, elbow, finger or ankle joints. Other procedures, such as realigning bones or fusing them, are also options. Your surgeon will help determine the right option for you, based on the level of damage to your joint.

“Today, there are more ways than ever before to help people suffering from osteoarthritis resume an active, pain-free lifestyle,” Dr. Kolczun says.

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