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Overview
Achilles Tendon
An Achilles tendon injury can affect both professional and amateur athletes. The Achilles tendon is one of the longer tendons in your body, stretching from the bones of your heel to your calf muscles. You can feel it, a springy band of tissue at the back of your ankle and above your heel. It allows you to extend your foot and point your toes to the floor. Unfortunately, it's a commonly injured tendon. Many Achilles tendon injuries are caused by tendinitis, in which the tendon becomes swollen and painful. In a severe Achilles tendon injury, too much force on the tendon can cause it to tear partially or rupture completely.

Causes
An Achilles tendon rupture is often caused by overstretching the tendon. This typically occurs during intense physical activity, such as running or playing basketball. Pushing off from the foot while the knee is straight, pivoting, jumping, and running are all movements that can overstretch the Achilles tendon and cause it to rupture. A rupture can also occur as the result of trauma that causes an over-stretching of the tendon, such as suddenly tripping or falling from a significant height. The Achilles tendon is particularly susceptible to injury if it is already weak. Therefore, individuals who have a history of tendinitis or tendinosis are more prone to a tendon rupture. Similarly, individuals who have arthritis and overcompensate for their joint pain by putting more stress on the Achilles tendon may also be more susceptible to an Achilles tendon rupture.

Symptoms
You may notice the symptoms come on suddenly during a sporting activity or injury. You might hear a snap or feel a sudden sharp pain when the tendon is torn. The sharp pain usually settles quickly, although there may be some aching at the back of the lower leg. After the injury, the usual symptoms are a flat-footed type of walk. You can walk and bear weight, but cannot push off the ground properly on the side where the tendon is ruptured. Inability to stand on tiptoe. If the tendon is completely torn, you may feel a gap just above the back of the heel. However, if there is bruising then the swelling may disguise the gap. If you suspect an Achilles tendon rupture, it is best to see a doctor urgently, because the tendon heals better if treated sooner rather than later. A person with a ruptured Achilles tendon may experience one or more of the following. Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf, often subsiding into a dull ache. A popping or snapping sensation. Swelling on the back of the leg between the heel and the calf. Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes.

Diagnosis
In order to diagnose Achilles tendon rupture a doctor or physiotherapist will give a full examination of the area and sometimes an X ray is performed in order to confirm the diagnosis. A doctor may also recommend an MRI or CT scan is used to rule out any further injury or complications.

Non Surgical Treatment
As debilitating as they can be, the good news is that minor to moderate Achilles tendon injuries should heal on their own. You just need to give them time. To speed the healing, you can try the following. Rest your leg. Avoid putting weight on your leg as best you can. You may need crutches. Ice your leg. To reduce pain and swelling, ice your injury for 20 to 30 minutes, every three to four hours for two to three days, or until the pain is gone. Compress your leg. Use an elastic bandage around the lower leg and ankle to keep down swelling. Elevate your leg. Prop you leg up on a pillow when you're sitting or lying down. Take anti-inflammatory painkillers. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin) and naproxen (Aleve) will help with pain and swelling. However, these drugs have side effects, such as an increased risk of bleeding and ulcers. They should be used only occasionally unless your health care provider says otherwise and should be taken with food. Check with your doctor before taking these if you have any allergies, medical problems or take any other medication. Use a heel lift. Your health care provider may recommend that you wear an insert in your shoe while you recover. It will help protect your Achilles tendon from further stretching. Practice stretching and strengthening exercises as recommended by your health care provider. Usually, these techniques will do the trick. But in severe cases of Achilles tendon injury, you may need a cast for six to 10 weeks or even surgery to repair the tendon or remove excess tissue.
Achilles Tendonitis

Surgical Treatment
The surgical repair of an acute or chronic rupture of the Achilles tendon typically occurs in an outpatient setting. This means the patient has surgery and goes home the same day. Numbing medicine is often placed into the leg around the nerves to help decrease pain after surgery. This is called a nerve block. Patients are then put to sleep and placed in a position that allows the surgeon access to the ruptured tendon. Repair of an acute rupture often takes somewhere between 30 minutes and one hour. Repair of a chronic rupture can take longer depending on the steps needed to fix the tendon.

Prevention
To help prevent an Achilles tendon injury, it is a good practice to perform stretching and warm-up exercises before any participating in any activities. Gradually increase the intensity and length of time of activity. Muscle conditioning may help to strengthen the muscles in the body.
Overview


The majority of people in the world actually have some degree of leg length discrepancy, up to 2cm. One study found that only around 1/4 of people have legs of equal lengths. LLD of greater than 2cm is relatively rare, however, and the greater the discrepancy, the greater the chances of having a clinical problem down the road. A limp generally begins when LLD exceeds 2cm and becomes extremely noticeable above 3cm. When patients with LLD develop an abnormal gait, one of the debilitating clinical features can be fatigue because of the relatively high amount of energy needed to walk in the new, inefficient way. Poliomyelitis, or polio, as it is more commonly known, used to account for around 1/3 of all cases of LLD, but due to the effectiveness of polio vaccines, it now represents a negligible cause of the condition. Functional LLD, described above, usually involves treatment focused on the hip, pelvis, and/or lower back, rather than the leg. If you have been diagnosed with functional LLD or pelvic obliquity, please ask your orthopaedic surgeon for more information about treatment of these conditions.Leg Length Discrepancy


Causes


Leg length discrepancies can be caused by: hip and knee replacements, lower limb injuries, bone diseases, neuromuscular issues and congenital problems. Although discrepancies of 2 cm or less are most common, discrepancies can be greater than 6 cm. People who have LLD tend to make up for the difference by over bending their longer leg or standing on the toes of their shorter leg. This compensation leads to an inefficient, up and down gait, which is quite tiring and over time can result in posture problems as well as pain in the back, hips, knees and ankles.


Symptoms


Back pain along with pain in the foot, knee, leg and hip on one side of the body are the main complaints. There may also be limping or head bop down on the short side or uneven arm swinging. The knee bend, hip or shoulder may be down on one side, and there may be uneven wear to the soles of shoes (usually more on the longer side).


Diagnosis


The doctor carefully examines the child. He or she checks to be sure the legs are actually different lengths. This is because problems with the hip (such as a loose joint) or back (scoliosis) can make the child appear to have one shorter leg, even though the legs are the same length. An X-ray of the child?s legs is taken. During the X-ray, a long ruler is put in the image so an accurate measurement of each leg bone can be taken. If an underlying cause of the discrepancy is suspected, tests are done to rule it out.


Non Surgical Treatment


Treatment for an LLD depends on the amount of difference and the cause, if known. The doctor will discuss treatment options carefully with you and your child before any decisions are made. It is important to note that treatment is planned with the child?s final height and leg lengths in mind, not the current leg lengths. Treatment is generally not needed if the child?s final LLD is predicted to be 2 centimeters or less at full height. However, the child should return to an orthopaedic doctor by age 10 for re-evaluation. Treatment is often recommended for LLDs predicted to be more than 2 centimeters at full height. If treatment is done, it usually doesn?t begin until the child starts walking. Possible treatment options include, A ?lift? in one shoe to level the child?s hips. This is often the only treatment needed for small discrepancies.


Leg Length Discrepancy Insoles


Surgical Treatment


Large leg length inequalities can be treated by staged lengthenings or by simultaneous ipsilateral femoral and tibial lengthenings. Additionally, lengthenings can be combined with appropriately timed epiphysiodesis in an effort to produce leg length equality. Staged lengthenings are often used for congenital deficiencies such as fibular hemimelia, in which 15 cm or more may be needed to produce leg length equality. We typically plan for the final lengthening to be completed by age 13 or 14 years, and allow at least 3 years between lengthenings. Lengthening of both the tibia and femur simultaneously requires aggressive therapy and treatment of soft tissue contractures. Curran et al[57] reported the need for surgical release of soft tissue contractures in 3 of 8 patients treated with simultaneous ipsilateral femoral and tibial lengthenings. Lengthening over an IM nail can be done in an effort to decrease the amount of time the fixator needs to be worn and to prevent angular malalignment. This technique requires that the patient be skeletally mature and it carries a higher risk of osteomyelitis (up to 15%). Additionally, if premature consolidation occurs, a repeat corticotomy is more difficult.

Overview
Another common term for this condition is Posterior Tibial Tendon Dysfunction (PTTD). There is a cause-effect relationship between pronation, flatfoot deformity and subsequent tenosynovitis of the posterior tibial tendon. Mechanical irritation of the tendon may lead to synovitis, partial tearing and eventually full rupture of the tendon. Other structures, including ligaments and the plantar fascia, have also been shown to contribute to the arch collapsing. As the deformity progresses, these structures have been shown to attenuate and rupture as well. In later stages, subluxation of various joints lead to a valgus rearfoot and transverse plane deformity of the forefoot. These deformities can become fixed and irreducible as significant osteoarthritis sets in.
Adult Acquired Flat Feet

Causes
Adult acquired flatfoot is caused by inflammation and progressive weakening of the major tendon that it is responsible for supporting the arch of the foot. This condition will commonly be accompanied by swelling and pain on the inner portion of the foot and ankle. Adult acquired flatfoot is more common in women and overweight individuals. It can also be seen after an injury to the foot and ankle. If left untreated the problem may result in a vicious cycle, as the foot becomes flatter the tendon supporting the arch structure becomes weaker and more and more stretched out. As the tendon becomes weaker, the foot structure becomes progressively flatter. Early detection and treatment is key, as this condition can lead to chronic swelling and pain.

Symptoms
Symptoms are minor and may go unnoticed, Pain dominates, rather than deformity. Minor swelling may be visible along the course of the tendon. Pain and swelling along the course of the tendon. Visible decrease in arch height. Aduction of the forefoot on rearfoot. Subluxed tali and navicular joints. Deformation at this point is still flexible. Considerable deformity and weakness. Significant pain. Arthritic changes in the tarsal joints. Deformation at this point is rigid.

Diagnosis
First, both feet should be examined with the patient standing and the entire lower extremity visible. The foot should be inspected from above as well as from behind the patient, as valgus angulation of the hindfoot is best appreciated when the foot is viewed from behind. Johnson described the so-called more-toes sign: with more advanced deformity and abduction of the forefoot, more of the lateral toes become visible when the foot is viewed from behind. The single-limb heel-rise test is an excellent determinant of the function of the posterior tibial tendon. The patient is asked to attempt to rise onto the ball of one foot while the other foot is suspended off the floor. Under normal circumstances, the posterior tibial muscle, which inverts and stabilizes the hindfoot, is activated as the patient begins to rise onto the forefoot. The gastrocnemius-soleus muscle group then elevates the calcaneus, and the heel-rise is accomplished. With dysfunction of the posterior tibial tendon, however, inversion of the heel is weak, and either the heel remains in valgus or the patient is unable to rise onto the forefoot. If the patient can do a single-limb heel-rise, the limb may be stressed further by asking the patient to perform this maneuver repetitively.

Non surgical Treatment
Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities.
Adult Acquired Flat Feet

Surgical Treatment
In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Symptomatic flexible flatfoot conditions are common entities in both the adolescent and adult populations. Ligamentous laxity and equinus play a significant role in most adolescent deformities. Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult acquired flatfoot. One should consider surgical treatment for patients who have failed nonoperative therapy and have advancing symptoms and deformities that significantly interfere with the functional demands of daily life. Isolated Joint Fusion. This technique is used for well reducible flat foot by limiting motion at one or two joints that are usually arthritic. The Evans Anterior Calcaneal Osteotomy. This is indicated for late stage II adult acquired flatfoot and the flexible adolescent flatfoot. This procedure will address midtarsal instability, restore the medial longitudinal arch and reduce mild hind foot valgus. The Posterior Calcaneal Displacement Osteotomy (PCDO). This technique is indicated for late stage I and early stage II PTTD with reducible Calcaneal valgus. This is often combined with a tendon transfer. A PCDO is also indicated as an adjunctive procedure in the surgical reconstruction of the severe flexible adolescent flatfoot. Soft tissue procedure. On their own these are not very effective but in conjunction with an osseous procedure, soft tissue procedures can produce good outcome. Common ones are tendon and capsular repair, tendon lengthening and transfer procedures. Flat foot correction requires lengthy post operative period and a lot of patience. Your foot may need surgery but you might simply not have the time or endurance to go through the rehab phase of this type of surgery. We will discuss these and type of procedures necessary for your surgery in length before we go further with any type of intervention.