Adult acquired flatfoot is a very common condition that affects the feet and ankles of adult males and females. In people with adult acquired flatfoot, the arch of the foot falls or collapses. It can be a painful, sometimes debilitating condition. However, a painful flatfoot can usually be helped with braces or orthotics and other non-surgical treatments.

Adult acquired flatfoot is different than flatfoot in children. Children will usually outgrow flatfoot on their own, often without treatment. In adults, flat feet usually remain permanently flat. Treatment usually addresses the symptoms rather than a cure.

Causes

Posterior tibial tendon dysfunction is the most common cause of AAFD. Often there is no specific event or injury that starts the problem. More commonly, the tendon is injured from “wear and tear” over time. Posterior tibial tendon dysfunction occurs more commonly in patients who are born with a flat foot or who develop the condition for other reasons. With a relatively flat arch, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder. Weight also plays a role in the progression of this disorder.

Injuries to the back of the foot and fractures of the bones in the foot can also cause flatfoot to develop.

Another cause of flatfoot is arthritis. Arthritis that attacks and inflames the cartilage in the joints of the foot can cause the foot to lose its arch and flatten.

In people with diabetes, a condition called Charcot foot may cause flatfoot to develop. This condition may also cause the foot to deform. People with diabetes often have less feeling in their feet or neuropathy, so they do not initially notice as their foot collapses. This can lead to a more severe flattening before diagnosis.

Symptoms

Depending on the cause of the flatfoot, a patient may experience one or more of the different symptoms below:

• Pain along the course of the posterior tibial tendon which lies on the inside of the foot and ankle. This can be associated with swelling on the inside of the ankle.
• Pain that is worse with activity. High intensity or impact activities, such as running, can be very difficult. Some patients can have difficulty walking or even standing for long periods of time.
• When the foot collapses, the heel bone may shift position and put pressure on the outside ankle bone (fibula). This can cause pain on the outside of the ankle. Arthritis in the heel also causes this same type of pain.
• Patients with an old injury or arthritis in the middle of the foot can have painful, bony bumps on the top and inside of the foot. These make shoe wear very difficult. Occasionally, the bony spurs are so large that they pinch the nerves which can result in numbness and tingling on the top of the foot and into the toes.
• Diabetics may only notice swelling or a large bump on the bottom of the foot. Because their sensation is affected, people with diabetes may not have any pain. The large bump can cause skin problems and an ulcer (a sore that does not heal) may develop if proper diabetic shoe wear is not used.

At certain stages of this disorder, pain may shift from the inside to the outside of the ankle as the heel shifts outward and structures are pinched on the outside of the ankle.

Diagnosis

The diagnosis of posterior tibial tendon dysfunction and AAFD usually is made from a combination of symptoms, physical exam and X-rays. Your foot and ankle orthopedic surgeon, Dr. Ishrat Khan, DHCC, Dubai will look at the location of the pain, shape of your foot, flexibility of the hindfoot joints, and how you walk to make the diagnosis and assess how advanced the problem is. 

Treatment

Treatment depends very much upon a patient’s symptoms, goals, severity of deformity, and the presence of arthritis. Some patients get better without surgery. Rest and immobilization, orthotics, braces, and physical therapy all may be appropriate.

With early-stage disease that involves pain along the tendon, immobilization with a boot for a period of time can relieve stress on the tendon and reduce the inflammation and pain. Once these symptoms have resolved, patients may transition to using an arch support or orthotic that supports the inside of the hindfoot.

If surgery is needed, a number of different procedures may be considered. Procedures may include ligament and muscle lengthening, removal of the inflamed tendon lining, tendon transfers, cutting and realigning bones, placement of implants to realign the foot, and joint fusions. In general, early stage disease usually can be treated with tendon and ligament procedures with the addition of osteotomies (cutting/shortening of bone) to realign the foot.

Later stage disease with either a rigidly fixed deformity or arthritis usually is treated with joint fusion procedures. Fusions involve removing the joint that connects two bones, so that they become fixed together. These procedures allow powerful correction of bad deformities, leading to increased stability and pain relief; however, they also lead to a stiffer foot and loss of motion.

Should you require additional information or would like to make an appointment with our Consultant Orthopedic Surgeon Dr. Ishrat Khan OR Physical Therapists,  Anil Daniel,  OR Hadel Radwan  please call us or e-mail us at info@westminsterclinic.ae

Reference:

• oxfordhealth.nhs.uk
• clevelandclinic.org
• yourphysio.org.uk
• Mayoclinic.org
• footcaremd.org
• The National Center for Biotechnology Information -NCBI

Disclaimer: All contents on this site are for general information and in no circumstances information be substituted for professional advice from the relevant healthcare professional, Writer does not take responsibility of any damage done by the misuse or use of the information.

Your spine is made of 24 moveable bones called vertebrae. The lumbar (lower back) section of the spine bears most of the weight of the body. There are 5 lumbar vertebrae numbered L1 to L5. The vertebrae are separated by cushiony discs, which act as shock absorbers preventing the vertebrae from rubbing together. The outer ring of the disc is called the annulus. It has fibrous bands that attach between the bodies of each vertebra. Each disc has a gel-filled center called the nucleus.

A herniated disc occurs when the gel-like center of a disc ruptures through a weak area in the tough outer wall, similar to the filling being squeezed out of a jelly doughnut. Back or leg pain, numbness or tingling may result when the disc material touches or compresses a spinal nerve. Treatment with rest, pain medication, spinal injections, and physical therapy is the first step to recovery. Most people improve in 6 weeks and return to normal activity. If symptoms continue, surgery may be recommended.

Causes

A herniated disk is most often the result of natural, age-related wear and tear on the spine. This process is called disk degeneration.

In children and young adults, disks have high water content. As people age, the water content in the disks decreases and the disks become less flexible.

The disks begin to shrink and the spaces between the vertebrae get narrower. This normal aging process makes the disks more prone to herniation. A traumatic event, such as a fall, can also cause a herniated disk.

Risk Factors

Certain factors may increase your risk of a herniated disk. These include:

Gender. Men between the ages of 20 and 50 are most likely to have a herniated disk.

Improper lifting. Using your back muscles instead of your legs to lift heavy objects can cause a herniated disk. Twisting while you lift can also make your back vulnerable. Lifting with your legs, not your back, may protect your spine.

Weight. Being overweight puts added stress on the disks in your lower back.

Repetitive activities that strain your spine. Many jobs are physically demanding. Some require constant lifting, pulling, bending, or twisting. Using safe lifting and movement techniques can help protect your back.

Frequent driving. Staying seated for long periods, plus the vibration from the car engine, can put pressure on your spine and disks.

Sedentary lifestyle. Regular exercise is important in preventing many medical conditions, including a herniated disk.

Smoking. It is believed that smoking lessens the oxygen supply to the disk and causes more rapid degeneration.

Symptoms

In most cases, low back pain is the first symptom of a herniated disk. This pain may last for a few days, then improve. Other symptoms may include:

• Sciatica. This is a sharp, often shooting pain that extends from the buttock down the back of one leg. It is caused by pressure on the spinal nerve.
• Numbness or a tingling sensation in the leg and/or foot
• Weakness in the leg and/or foot
• Loss of bladder or bowel control. This is extremely rare and may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed. It  requires immediate medical attention.

Diagnosis

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor at westminster ortho med clinic, DHCC, Dubai will perform a physical examination. The exam may include the following tests:

• Neurological examination. A neurological examination will help your doctor determine if you have any muscle weakness or loss of sensation. During the exam, he or she will:
  • Check muscle strength in your lower leg by assessing how you walk on both your heels and toes. Muscle strength in other parts of your body may also be tested.
  • Detect loss of sensation by checking whether you can feel a light touch on your leg and foot.
  • Test your reflexes at the knee and ankle. These may sometimes be absent if there is a compressed nerve root in your spine.
• Straight leg raise (SLR) test. This test is a very accurate predictor of a disk herniation in patients under the age of 35. During the test, you lie on your back and your doctor carefully lifts your affected leg. Your knee stays straight. If you feel pain down your leg and below the knee, it is a strong indication that you have a herniated disk.

Imaging Studies

Magnetic resonance imaging (MRI) scan. These studies provide clear images of the body’s soft tissues, including intervertebral disks. Your doctor may order an MRI scan to help confirm the diagnosis and to learn more about which spinal nerves are affected. If you are unable to tolerate an MRI, a computerized tomography (CT) scan, or a CT myelogram may be ordered instead.

Treatment

For the majority of patients, a herniated lumbar disk will slowly improve over a period of several days to weeks. Typically, most patients are free of symptoms by 3 to 4 months. However, some patients do experience episodes of pain during their recovery.

Nonsurgical Treatment

Initial treatment for a herniated disk is usually nonsurgical in nature. Treatment focuses on providing pain relief.

Nonsurgical treatment may include:

Rest. One to 2 days of bed rest will usually help relieve back and leg pain. Do not stay off your feet for longer, however. When you resume activity, try to do the following:

• Take rest breaks throughout the day, but avoid sitting for long periods.
• Make all your physical activity slow and controlled, especially bending forward and lifting.
• Change your daily activities to avoid movements that can cause further pain.

Nonsteroidal anti-inflammatory medications (NSAIDs). Medications such as ibuprofen or naproxen can help relieve pain. (Speak to your doctor before taking any medications).

Physical therapy. The goal of physical therapy is to help you return to full activity as soon as possible and prevent re-injury. Physical therapists, Hadel Radwan, OR Anil Daniel at our clinic in Dubai can instruct you on proper posture, lifting, and walking techniques, and they’ll work with you to strengthen your lower back, leg, and stomach muscles. They’ll also encourage you to stretch and increase the flexibility of your spine and legs. Exercise and strengthening exercises are key elements to your treatment and should become part of your life-long fitness.

Epidural steroid injection. An injection of a cortisone-like drug into the space around the nerve may provide short-term pain relief by reducing inflammation.

There is good evidence that epidural injections can successfully relieve pain in many patients who have not been helped by 6 weeks or more of other nonsurgical care.

Surgical Treatment

Only a small percentage of patients with lumbar disk herniation require surgery. Spine surgery is typically recommended only after a period of nonsurgical treatment has not relieved painful symptoms, or for patients who are experiencing the following symptoms:

• Muscle weakness
• Difficulty walking
• Loss of bladder or bowel control

Microdiskectomy. The most common procedure used to treat a single herniated disk is microdiskectomy. The procedure is done through a small incision at the level of the disk herniation and often involves the use of a microscope.

The herniated part of the disk is removed along with any additional fragments that are putting pressure on the spinal nerve.

A larger procedure may be required if there are disk herniations at more than one level.

Rehabilitation. Your doctor, Dr. Ishrat Khan, or a physical therapist, Hadel Radwan OR Anil Daniel may recommend a simple walking program (such as 30 minutes each day), along with specific exercises to help restore strength and flexibility to your back and legs.

To reduce the risk of repeat herniation, you may be prohibited from bending, lifting, and twisting for the first few weeks after surgery.

Recovery & prevention

Back pain affects 8 of 10 people at some time in their lives, and usually resolves within 6 weeks. A positive mental attitude, regular activity, and a prompt return to work are all very important elements of recovery. If your regular job cannot be done initially, it is in the patient’s best interest to return to some kind of modified (light or restricted) duty. Your physician can give prescriptions for such activity for limited periods of time.

The key to avoiding recurrence is prevention:

• Proper lifting techniques (see Self Care for Neck & Back Pain)
• Good posture during sitting, standing, moving, and sleeping
• Appropriate exercise program to strengthen weak abdominal muscles and prevent re-injury
• An ergonomic work area
• Healthy weight and lean body mass
• A positive attitude and stress management
• No smoking

References:

• https://orthoinfo.aaos.org/ – Orthoinfo
• https://www.physio.co.uk/what-we-treat/musculoskeletal/conditions/upper-back/thoracic-intervertebral-joint-disorders.php
• mayoclinic.org https://www.mayoclinic.org/

Disclaimer: All contents on this site are for general information and in no circumstances information be substituted for professional advice from the relevant healthcare professional, Writer does not take responsibility of any damage done by the misuse or use of the information.

Plantar fasciitis is one of the most common causes of heel pain. It involves inflammation of a thick band of tissue that runs across the bottom of your foot and connects your heel bone to your toes (plantar fascia).

Plantar fasciitis commonly causes stabbing pain that usually occurs with your first steps in the morning. As you get up and move, the pain normally decreases, but it might return after long periods of standing or when you stand up after sitting. Plantar fasciitis is more common in runners. People who are overweight and those who wear shoes with inadequate support also have an increased risk of plantar fasciitis.

Causes of Plantar Fasciitis

The plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body’s natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis.

Risk Factors

In most cases, plantar fasciitis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:

• Age. Plantar fasciitis is most common between the ages of 40 and 60.
• Certain types of exercise. Activities that place a lot of stress on your heel and attached tissue — such as long-distance running, ballet dancing and aerobic dance — can contribute to the onset of plantar fasciitis.
• Foot mechanics. Flat feet, a high arch or even an abnormal pattern of walking can affect the way weight is distributed when you’re standing and can put added stress on the plantar fascia.
• Obesity. Excess pounds put extra stress on your plantar fascia.
• Occupations that keep you on your feet. Factory workers, teachers and others who spend most of their work hours walking or standing on hard surfaces can damage the plantar fascia.

Symptoms

The most common symptoms of plantar fasciitis include:

• Pain on the bottom of the foot near the heel
• Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
• Greater pain after (not during) exercise or activity

Doctor Examination and Diagnosis

Plantar fasciitis is diagnosed based on your medical history and physical examination. During the exam, your Doctor/specialist at Westminster Ortho Med Clinic, Dubai will check for areas of tenderness in your foot. The location of your pain can help determine its cause. Your doctor will look for these signs:

• A high arch
• An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
• Pain that gets worse when you flex your foot and the doctor pushes on the plantar fascia. The pain improves when you point your toes down
• Limited “up” motion of your ankle.

Imaging tests

Usually no tests are necessary. Your doctor might suggest an X-ray or magnetic resonance imaging (MRI) to make sure another problem, such as a stress fracture, is not causing you pain.

Sometimes an X-ray shows a piece of bone sticking out (spur) from the heel bone. In the past, these bone spurs were often blamed for heel pain and removed surgically. But many people who have bone spurs on their heels have no heel pain.

Treatment:

Nonsurgical Treatment

More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods.

• Rest: Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics).

• Ice: Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day.

• Nonsteroidal anti-inflammatory medication. Anti-inflammatory drugs can reduce the pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor.

• Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.

• Calf stretch
  Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.

• Plantar fascia stretch
  This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.

• Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain.

• Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful. Soft heel pads can provide extra support.

• Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.

• Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, and medication to decrease inflammation around the plantar fascia.

• Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is tried before surgery is considered.

Surgical Treatment

Surgery is considered only after 12 months of aggressive nonsurgical treatment.

Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite a year of calf stretches.

Plantar fascia release. If you have a normal range of ankle motion and continued heel pain, your doctor may recommend a partial release procedure. During surgery, the plantar fascia ligament is partially cut to relieve tension in the tissue.

Recovery. Most patients have good results from surgery. However, because surgery can result in chronic pain and dissatisfaction, it is recommended only after all nonsurgical measures have been exhausted.

Should you require additional information or would like to make an appointment with our Consultant Orthopedic Surgeon Dr. Ishrat Khan OR Physical Therapists,  Anil Daniel,  OR Hadel Radwan ,DHCC, Dubai, please call us or e-mail us at info@westminsterclinic.ae

References:

• https://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/symptoms-causes/syc-20354846
• https://www.physio.co.uk/what-we-treat/musculoskeletal/conditions/upper-back/thoracic-intervertebral-joint-disorders.php
• https://orthoinfo.aaos.org/en/diseases–conditions/plantar-fasciitis-and-bone-spurs
• nhs.uk/https://www.nhs.uk/conditions/plantar-fasciitis/

Disclaimer: All contents on this site are for general information and in no circumstances information be substituted for professional advice from the relevant healthcare professional, Writer does not take responsibility of any damage done by the misuse or use of the information.

Achilles tendinopathy is a condition that causes pain, swelling and stiffness of the Achilles tendon that joins your heel bone to your calf muscles. It is thought to be caused by repeated tiny injuries to the Achilles tendon. These may occur for a number of reasons, including overuse of the tendon – for example, in runners. Treatment includes rest, ice packs, painkillers and special exercises to help to stretch and strengthen the Achilles tendon. For most people, the symptoms of Achilles tendinopathy usually clear within 3-6 months of starting treatment.

How common is Achilles Tendinopathy?

• It is one of the most common injuries in sport and can account for approx 6-17% of all
• Running injuries and up to 50% of injuries in elite athletes.
• However, it can also develop in 6% of nonathletic populations.
• It can predominantly affect male athletes aged 30-40 years. (NICE, 2010).

What are the signs and symptoms of Achilles Tendinopathy?

• Morning stiffness
• Tenderness over the Achilles tendon
• Pain on either exercise or after exercise

Many things can affect the load being put through the tendon. Age, gender, weight, diabetes, having tight or weak calf muscles, stiff joints of the ankle, knee or foot and over-exercising can all impact on your prevalence to placing increased stress on the tendon.

Initial treatment guidelines

Rest:
Acute injuries require rest. This may involve reducing the level of your normal training regime or functional activities. By continuing to exercise on a painful Achilles tendon will likely make it more chronic thus becoming more difficult to treat. It is advisable to avoid any high impact activities or sports until your pain subsides. By modifying your activity, this will help to reduce pain, allow any inflammation to settle and minimize stress placed on the tendon.

2. Ice
During the initial stages of injury, ice treatment can be useful in managing pain and swelling. Apply a pack of frozen peas or an ice pack wrapped in a damp cloth to the tendon. Always check the skin following ice application for any skin burns. Leave this on for no more than 10 minutes, repeat up to 4 times per day or after exercise. If symptoms continue to persist after several weeks, ice can be beneficial in minimizing further tendon damage. Apply ice following any physical activity.

3. Pain relief
Simple analgesics such as paracetamol or Non Steroidal Anti-Inflammatory (NSAIDs) can help relieve pain. Care should be taken with NSAIDS, you may need to limit use to no more than 14 days. Prolonged use of NSAIDs may impede tissue healing long term. Please consult your doctor regarding NSAIDs use.

4. Orthotics
The use of a heel pad can also help raise the heel therefore reducing the strain on the Achilles tendon. Further gait analysis and bespoke orthotics would be beneficial for chronic conditions. Healing time frames In acute injuries, symptoms can normally take 3 to 6 months to resolve. In more chronic cases, it may take longer.

5. Physiotherapy management

Depending on the severity and stage of the condition, physiotherapy treatment for patients with an Achilles tendinopathy is vital to hasten the healing process, to ensure an optimal outcome and reduced the likelihood of recurrence. Treatments may often involve:

• Soft Tissue techniques
• Electrotherapy
• Stretching programme
• Joint mobilisations
• Gait Analysis and Orthotics
• Taping
• Hydrotherapy
• An eccentric loading exercise training programme
• Prescribe a rehabilitation programme and return to activity plan
• Acupuncture
• Advice and education

6. Eccentric exercise programme

Eccentric loading involves lengthening the muscle fibres as contraction occurs. Research evidence suggests that an eccentric exercise approach aims to reduce tendon thickness and promotes tissue repair. Emphasis is placed on the lowering phase of the exercise to ensure that the tendon is loaded sufficiently (Alfredson & Cook, 2007). It is recommended that Eccentric Exercise Programmes are followed for a period of 12 weeks to promote optimum recovery.

It is also important to note that during an eccentric exercise programme, you may experience an increase in pain, for up to 8 weeks, but this will reduce as you continue with the exercises.

Reference

• Alfredson, H. and Cook, J. 2007. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine 41(4), 211-216.
• NICE, 2010. Achilles Tendinopathy. Clinical Knowledge Summaries. http://cks.nice.org.uk/achillestendinopathy#!topicsummary.
• nhs.uk
• www.versusarthritis.org/about-arthritis/conditions/foot-and-ankle-pain/