Posterior Ankle Endoscopy or Arthroscopy

Posterior ankle endoscopy/arthroscopy is a technique used to look at and treat problems in the back of the ankle. The ankle joint is the joint between the lower leg bones (tibia and fibula) and the ankle bone (talus). The joint below the ankle joint is called the subtalar joint; it lies between the ankle bone and the heel bone (calcaneus). The talus has a boney prominence in the back next to the flexor halluces longus (FHL) tendon. This is the tendon that moves the big toe downward toward the floor.


X-ray of ankle from the side

The bony posterior prominence might be the cause of ankle pain in some people if it is large (salled a trigonal process) or it is not completely fused with the talar bone (called an os trigonum).

Pain may also occur if the FHL tendon gets irritated. This can happen if the tendon doesn’t fit well because the tunnel is too tight or the tendon is too big, or if the tendon is inflamed and swollen (called tenosynovitis).

An ankle sprain may cause a tear of the posterior or ankle ligaments. The torn pieces can flip inside the joint and get pinched between the joint surfaces, causing pain. This problem is called posterior soft tissue impingement.

The Achilles tendon attaches to the back of the heel bone. It can get pinched by a prominent piece of bone at the top of the heel (called a Haglund’s deformity). This can lead to wear of the Achilles tendon and calcium deposits in the tendon (called insertional Achilles tendonitis).


Patients typically experience pain in the back of the ankle. The precise location of the pain may differ depending on the cause. The pain from Achilles tendonitis is typically at the surface in back of the heel. This pain often increases when wearing closed shoes and improves with shoes that have open heels (e.g. clogs).

The pain from an os trigonum, an FHL problem or posterior soft tissue impingement tends to be deeper. It typically increases with downward motion of the ankle (pointing the toes). Soccer players and ballet dancers tend to be at higher risk for these problems.


The FHL tendon and part of the FHL muscle seen running beside the os trigonum.

With the patient lying face-down or on the side, the orthopaedic foot and ankle surgeon makes incisions at the back of the ankle. Typically two incisions are made on either side of the Achilles

tendon. An arthroscope (a tube- shaped device with a camera at the tip) is inserted and allows the surgeon to see the area. Fatty tissue at the back of the ankle is removed to create a workspace. The FHL tendon is identified and the blood vessels and nerves are protected.

A small part of the posterior ankle capsule might need to be removed in order to enter the ankle joint. A device that “stretches” the ankle joint is often used to help with visualization.

The problem causing the pain is identified and treated accordingly using various small instruments:

  • The os trigonum is freed from the surrounding soft tissues then removed.
  • The FHL tenosynovitis is cleaned up using a shaver and the tunnel is released if necessary.
  • The torn ligaments causing posterior soft tissue impingement are cleaned up with the shaver.
  • The Haglund’s deformity is removed using a burr.

NOTE: You should avoid a posterior ankle endoscopy or arthroscopy if you have Infection in the skin or soft tissue of the posterior ankle area. You should discuss all of your medical conditions with your surgeon before you have this procedure.


The post-operative dressing is usually a splint or bulky soft dressing. A post-op shoe or boot may be added for protection. Weight bearing may be restricted depending on the surgery that is done. Always ask your surgeon about postoperative weight bearing. Foot elevation is encouraged in the first 48 hours after the procedure. The stitches are removed in 10 to 14 days and more aggressive exercises can be started thereafter. Early motion of the ankle and foot joints is typically recommended. Formal physical therapy may be ordered. A night splint to keep the ankle at 90 Degrees may be used to prevent tightening of the posterior ankle soft tissue.


Injury to blood vessels and nerves is uncommon but remains a complication of this procedure. Other complications include numbness on the bottom of the foot, very sensitive skin on the outside part of the foot, Achilles tendon tightness, chronic pain syndrome, infection, and the formation of a cyst at the incision site.


What are the advantages of arthroscopic surgery over open surgery?
Arthroscopic surgery for posterior ankle and subtalar joint problems is much less invasive and produces less scar tissue in most cases. The magnification of the arthroscope and the nature of arthroscopy often allow for the evaluation of the tissues and pathologic problems in a more natural state with less injury to the surrounding tissues. This may provide advantages over traditional open surgery.

What are the usual tests done before this procedure?
An X-ray can diagnose an os trigonum or enlarged trigonal process and can reveal other bony problems. MRI can be beneficial in evaluating soft tissues such as ligaments and tendons. In some cases, MRI can provide a better understanding of the problem.

When is the surgery indicated?

Surgery should be considered after three months or more of conservative treatment has failed. Nonsurgical approaches include rest, anti-inflammatory medications, a cast or walking boot for a short period of time, physical therapy and local steroid injection.

How much time it will take an athlete or ballet dancer to return to play or performance after this procedure?

It usually takes eight to 12 weeks for a ballet dancer to return to performing after posterior ankle arthroscopy and os trigonum excision, but this time certainly can vary. Always check with your surgeon about the anticipated timeline for recovery. Some swelling and discomfort can continue for several months after surgery.


SOURCE: American Orthopaedic Foot & Ankle Society

Cartiva – Cartilage Implant

A new solution for painful arthritis of the big toe

ONS orthopaedic foot surgeons Dr. Michael Clain and Dr. Sean Peden, are among the few in the country using a new synthetic cartilage implant to treat painful arthritis in the joint of the big toe (metatarsophalangeal or MTP joint).  The implant is composed of a bio-compatible, slippery organic polymer that functions similarly to natural cartilage. Patients who undergo this implant surgery experience reduced pain, functional improvement and improved range of motion in a much shorter period of time than with traditional procedures such as fusion surgery.

While fusing the joints in the big toe is a common and useful procedure to alleviate the rubbing of bone on bone that results from arthritis, it can inhibit the foot’s natural motion. With the new synthetic cartilage, the big toe is able to bend and bear weight similarly to a non-arthritic toe.

If one of our surgeons determines that this product will benefit you, the same day surgical procedure takes about 30 to 60 minutes. Your surgeon will make a two-inch incision along the top of the toe and remove a piece of the bone to make a space for the implant. The implant does not require glue or cement to stay in place.

Patients typically will be able to put weight on their toe immediately following surgery. Your surgeon will give you toe mobility exercises to help regain movement of your toe.  The synthetic cartilage is designed to last a lifetime, so ideally patients will not need to undergo a replacement procedure in the future. It was FDA approved for use in United States in July 2016, but the device has a long track record in Canada and Europe.

Synthetic cartilage implants may not be the right treatment for everyone, but the device certainly expands the options available for patients for relief of pain and return of function.  It is important to discuss your individual condition with your physician to understand the benefits and risks and any post operative limitations you may experience during the recovery process.  You can learn more about the synthetic cartilage implant by clicking on the brochure to the right.

2nd MTP Instability and Synovitis

2nd MTP instability and synovitis is the weakness and inflammation of the joint capsule of the 2nd metatarsophalangeal joint, which is located at the base of the toe where the long foot bone (metatarsal) meets the toe (phalanx).

Its cause may be genetics or any of a number of pre-existing conditions, including hallux valgus (a bunion), a long second metatarsal bone, and sometimes injury to the ligaments, such as a small tear to the plantar (underside) capsule of the 2nd joint.


Symptoms of this condition include pain and swelling at the base of the toe or under the 2nd toe near the ball of the foot, that worsens with activity or weight bearing, Deviation or curling up of the 2nd toe, either toward or away from the big toe, can also occur. Left untreated, it can lead to formation of a hammer or claw toe, where the toe will curl up and not straighten or lie flat. In severe cases the 2nd toe will cross over the big toe.


Diagnosis of 2nd MTP instability and synovitis is made through the evaluation of a patient’s symptoms and examination of the affected area. X-rays may show the deformity, meaning the deviation of the toe either up/down or left/right. The x-ray may also give clues as to the cause, such as hallux valgus (a bunion), a congenitally long 2nd metatarsal, or a very high arch (cavus foot). If the cause of the pain remains unclear, an MRI can be helpful for a definitive diagnosis as well as to rule out other causes of pain, such as a pinched nerve in the foot (neuroma) or a stress fracture. The MRI will often show mild changes, including increased fluid and ligament tears in and around the 2nd metatarsophalangeal joint.


Often, the pain and swelling will subside with time using conservative treatments, such as
• Rest
• Activity modification – avoiding strenuous high impact sports or very tight shoes
• Taping the toe down or two the adjacent toe. Small straps and braces available online can mimic the taping.
• Certain orthotics or shoe inserts can help take the pressure off the painful area.
• Over the counter medicines such as ibuprofen (Advil/Motrin) or naproxen (Alleve) can help control symptoms by reducing inflammation throughout the body and blocking pain, however, they will not correct the condition.
• Injections can be helpful in controlling symptoms and pinpointing the source of pain. However, they are not a long term solution as repeated use can weaken the ligaments.


Surgery to correct the problem is recommended if conservative treatment fails to relieve pain to a satisfactory level. A surgical procedure would typically involve a combination of corrections depending on the structure and shape of the foot, such as ligament repair, shortening or lengthening the toe bones, shortening the metatarsal bone, and correction of other problems such as a bunion, toe straightening or a neuroma.


(Gouty Arthritis)Gouty Arthritis

Gout is a disease in which the defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet. Elevated uric acid in the blood stream commonly leads to sudden episodes of acute inflammatory joint pain, stiffness and swelling. The most commonly affected area is the joint at the base of the big toe but it can affect other joints and soft tissues around the foot, hands, wrists, and knees.

Uric acid is a breakdown product of certain proteins and is typically excreted through urine. When levels are high the uric acid can crystallize, forming a small solid material that deposits in and around joints. However, many people have elevated uric acid and never get gout in their entire life. Other people have a “normal” uric acid level but develop gout.


Diet is commonly blamed for gout. While diet can be an important factor, in many cases it is irrelevant. Based on research, diet is the cause of gout in less than 12% of cases. However, there is some evidence to suggest that being overweight can increase chances of developing this condition. Age, gender, genetics, medical conditions, and certain medications are all considered risk factors. In some cases trauma or surgery can precipitate gout or trigger a gout flare up. Sometimes, there is no clear cause for an attack.


• Gout usually presents itself in the middle of the night with swelling, tenderness, redness and sharp pain.
• Attacks can last a few days or a few months.


The best way to diagnose gout is to aspirate (draw up with a needle) fluid from an affected joint. Unfortunately, this is a painful procedure and not always possible, especially in the small joints of the foot. With or without blood tests to indicate uric acid levels, you doctor will assess of several factors that indicate gout, including:

• Family and medical history.
• Age and gender. Older males are most commonly affected by gout. It is rare in children or teenagers, barring a medical condition.
• X-rays tend to be normal.
• Blood tests


Often gout flares up once and goes away forever. The treatment is rest, increased fluids, and medications and/or corticosteroids. These treatments reduce the inflammation caused by gout crystals.
A patient’s age, level of pain and risk factors will determine which medications and dosage will be prescribed. Patients usually feel relief within 24 hours if treatment is started when symptoms first appear.

If the pain from the initial attack disappears before the patient has seen a doctor, he or she should seek medical attention anyway, as a buildup of uric acid in the blood can still harm joints.


If gout recurs or is chronic, the patient should consult with medical doctor or foot specialist. Left untreated, chronic gout can lead to joint, tendon and other tissue damage and the formation of deposits of uric acid in the tissues, known as tophi.

Recurrent gout is treated non-surgically and most often controlled with medications that lower uric acid levels and prevent attacks. Activity modification, dietary changes and adjustment to certain medications can help reduce the buildup of uric acid in the blood. In these rare cases, surgery is necessary. Otherwise, the treatment is activity modifications, dietary changes, and medication adjustments to reduce the buildup of uric acid in the blood.


The link between certain foods and gout is unclear. Some studies point to alcohol, fructose sweetened drinks, meats, and seafood, while others come up with the opposite results. In some cases, too much activity in a short period of time and dehydration can lead to a gout flare up.

There is some good evidence that coffee, vitamin C, dairy products, and cherries can reduce the risk of gout. Also, regular physical exercise seems to diminish the risk.

Wide-Awake Hand & Wrist Surgery

One of the most significant advances in hand and wrist surgery has been the advent of wide-awake surgery.

Wide-awake surgery allows patients to be completely awake during surgery by using only local anesthesia and eliminating the need for sedation or a general anesthetic. While it may sound gruesome to be fully conscious when you go under a surgeon’s knife, the benefits to patients are many.  This technique improves surgical outcomes and the patient experience because it eliminates the need for traditional pre-operative testing, and fasting on the day of surgery. Patients are able to stay alert and interact with their surgeon about the procedure and post-operative plan without the residual grogginess associated with sedation.

What is Wide-Awake Surgery?

In the past, patients undergoing hand and wrist surgery would have a tourniquet applied around the upper arm and inflated during surgery to keep blood out of the surgical area.  In most cases, patients would require sedation or general anesthesia to tolerate the pain caused by the tourniquet.  In wide-awake surgery, the only medication administered to the patient is a local anesthetic mixed with epinephrine that is injected in the surgical site.  The way it is injected, in combination with the epinephrine, allows for a bloodless operative field.  This eliminates the need for a painful tourniquet and the sedation needed to endure the discomfort.

The Benefits of Wide-Awake Surgery

The most significant benefit of wide-awake surgery is its ability to improve surgical outcomes.  This is because certain procedures such as trigger finger release and tendon repairs, can be tested during surgery with an awake, comfortable patient using voluntary, active motion.  Typically, a patient would need to be awakened to groggily perform the tests and then re-sedated during surgery, or the patient would remain sedated and the surgeon would test the success of the procedure using passive motion, which can produce inferior results.

Wide-awake surgery also requires fewer pre-operative demands on the patient, as there is no need for the battery of pre-operative tests such as blood work, chest x-rays or EKGs, that is usually required before surgery.  This saves the patient time, anxiety, discomfort, and expense.

Nor do patients need to fast prior to a wide-awake procedure.  This is particularly significant for patients with certain medical conditions, such as diabetes, where blood sugar control can be challenging.  Since patients can eat and drink up to the time of surgery, there is no disruption to regular medicines taken, or concern about drug interactions with anesthesia.

Wide-awake surgery benefits the patient further because they are clear-headed to discuss the surgery, the post-operative plan and expected course of recovery with their doctor during or immediately following the procedure.

Ankle Sprain

An ankle sprain occurs when the strong ligaments that support the ankle stretch beyond their limits and tear. Ankle sprains are common injuries that occur among people of all ages as a result of the foot rolling or twisting to one side.  Sprains range from mild to severe; depending upon how much damage there is to the tissues.

Most sprains are minor injuries that heal with rest and applying ice. However, if your ankle is very swollen and painful to walk on — or if you are having trouble putting weight on your ankle at all, be sure to see your doctor. In many cases x-rays should be done to rule out a fracture.  Without proper treatment and rehabilitation, a severe sprain can weaken your ankle—making it more likely that you will injure it again. Other ankle sprains can lead to persistent pain or disability if inappropriately treated. Repeated ankle sprains can lead to long-term problems, including chronic ankle pain, arthritis, and ongoing instability.




  • Pain
  • Bruising
  • Tenderness to the touch
  • Ankle instability
  • A “pop” sensation at the time of injury


Almost all ankle sprains can be treated without surgery. Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately.  Depending on the severity of the sprain, your physician may wrap the ankle in a bandage or a device for protection and support such as a boot or an air brace. Mild sprains usually resolve within two weeks, while severe injuries can take as long as 12 weeks to recover.

  • Phase 1:  rest,  ice, immobilize and elevate the ankle to reduce swelling
  • Phase 2:   restore range of motion, strength and flexibility.
  • Phase 3:   gradual return to activities

Adult Acquired Flatfoot

Posterior tibial tendon dysfunction, also known as adult acquired flatfoot, is a common cause of pain and flattening of the arch of the foot that occurs with age. The posterior tibial tendon is a large and very important tendon on the medial or inner side of the ankle. It supports the arch and inverts the foot. Tendonitis or dysfunction is caused by repetitive irritation that occurs with walking and weight bearing.  Left untreated, this condition can worsen over time, causing pain and deformity (a very flat foot).  It usually occurs in one foot, but it can develop in both feet. It is different from painless flexible flatfeet, often seen in adolescents and children, because the pain and condition worsens over time.


The underlying cause of adult acquired flatfoot disorder is uncertain. It has been linked to certain ankle injuries and genetics. The irritated tendon stretches and loses its elasticity and ability to function. As a result, the arch flattens further. Over time, this can affect the biomechanics of the ankle the joints, leading to degenerative changes of the cartilage, also known as arthritis.


• Pain in the ankle, hind foot, and arch that worsens with increased activity.
• Swelling or deformity of the ankle, particularly on the inner ankle.
• Difficulty with balance, walking, and jumping on one leg.


The diagnosis is typically made by the patient’s story and the physical exam. X-rays do not show the tendon, but if done while standings, x-rays can show the flattening of the arch. The location of the pain, the shape and flexibility of the foot all come into play when making a diagnosis and indicate how advanced the problem has become. MRI can confirm the degree of damage to the tendon and can help guide management.


Nonsurgical Treatment
Early treatment attempts to stop the cycle of tendon damage and arch flattening. Depending on the severity of the condition, rest, braces, and walking boot immobilization may be recommended. Non-steroidal, anti-inflammatory drugs and properly fitting shoes may help reduce pain as well.  Shoes with arch supports over the counter or custom orthotics (shoe inserts) help. Physical therapy exercises are also part of the treatment.

Surgical Treatment
Surgery will be considered if the disorder is severe and limits the patient’s daily activities.
However, surgery is rarely helpful in the early stages of the disease. In cases of severe muscle tightness, a muscle lengthening procedure is controversial but shown in some research to prevent progression. Tendon transfer with bone realignment is a surgical treatment that restores function and reduces pain, but the recovery is significant. Triple arthrodesis is a fusion procedure that is right for certain patients where the deformity is severe and has led to joint damage.  Recovery time from surgery depends on the specific procedure and the patient’s age and functional level.

Hallux Rigidus

Hallux rigidus is degenerative arthritis of the big toe joint (metatarsophalangeal or MTP joint). It is the most common arthritic condition of the foot. The condition occurs more often in females than males, and typically manifests between the ages of 30 and 60 years. Patients often feel pain on the top of the big toe when walking, standing or when they bend or push off their big toe.


While the true cause of Hallux rigidus has not been determined, there are a number of risk factors that can come into play such as an abnormally long or elevated first foot bone (metatarsal) or genetic shelix-phototructural abnormalities that interfere with the proper functioning relationship with the foot and big toe such as fallen arches or ankles with excessive pronation. A traumatic injury, such as a severely stubbed or broken toe creates susceptibility as well. In these situations, the protective articular cartilage around the joint becomes worn and damaged, causing the raw bone ends to rub together. A bone spur or overgrowth on top of the bone may develop, which can prevent the toe from bending properly.


  • Stiffness and inability to move the big toe up or down
  • Pain, inflammation and swelling around the toe joint
  • A boney protrusion similar to a bunion or bone spur, EXCEPT on top of the toe


In most cases, a physician can diagnose Hallux rigidus through examination and manipulation of the toe joint. X-rays may be needed to help determine the severity of the condition, and the size and location of bone spurs, if any are present. Hallux rigidus is easier to treat when caught in its early stages, before significant cartilage is lost.


Mild to moderate conditions usually can be treated non-surgically with:

  • Changes in footwear to decrease pressure on the joint, a larger toe box, or generally more comfortable shoes
  • Ice/heat packs or anti-inflammatory medicines such as ibuprofen
  • Cortisone injections to reduce inflammation in the joint

In some cases, one of the following surgical procedures may be necessary:

  • Cheilectomy: In some mild to moderate cases, creating more space for toe to move by removing the bone spur and/or shaving part of the foot bone will allow the toe to bend properly. This procedure can be combined with a microfracture to restore normal cartilage. Following the procedure, patients will have to wear an open-toed surgical sandal for 2-4 weeks, and the foot may remain swollen for several months. However, patients experience significant long-term pain relief.
  • Arthrodesis: If there is severe damage to the articular cartilage, arthrodesis is the most reliable way to reduce pain. The damaged cartilage is removed and the joint is held place with a plate, pins and screws. Over time, the bones will fuse together. As a result, this joint in the toe will not move, but patients typically walk better due to decreased pain, and the foot still moves. Patients are typically kept completely off of the foot anywhere from 1-3 weeks using crutches, a scooter, or a walker. The total recovery can take 3-6 months.


  • Arthroplasty: Certain patients are candidates for replacement surgery, which removes the joint surfaces and replaces them with an artificial joint. This procedure was very unsuccessful historically, with high revision and failure rates. Newer implants and techniques are available and could be a good option to discuss in detail with your surgeon. Successful arthroplasty can relieve pain and maintain motion in the toe joint.

Ankle Fracture

An ankle fracture, also known as a broken ankle, is most commonly caused by the ankle twisting or rolling from tripping, falling, or an impact from an accident. Two joints are involved in ankle fractures, the ankle joint where the tibia, fibula and talus meet, and the syndesmosis joint, the joint between the tibia and fibula.

Courtesy of the American Association of Orthopaedic Surgeons

Ankle fractures can range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces your ankle out of place. Some fractures may involve injuries to ankle ligaments that keep the ankle bones and joint in its normal position.


One or all of these symptoms may indicate an ankle fracture:

• Immediate and severe pain at the site of the fracture, which can extend from the foot to the knee.
• Swelling, which may occur along the length of the leg or be more localized at the ankle.
• Bruising and tenderness to the touch.
• Decreased ability to walk. It is possible to walk or bear weight upon the ankle with less severe fractures. Never rely on walking as a test of whether the ankle is fractured.
• Deformity or bones protruding through the skin, a condition known as an open ankle fracture. These types of ankle fractures require immediate treatment to avoid problems like infection.

Most patients with ankle fractures are treated in an emergency room or a doctor’s office. An X-ray of the damaged ankle may be taken to determine what the fracture looks like, which bones are broken, how separated or displaced the bones are, and to find out the condition of the bone itself. The X-ray will help determine the proper course of treatment. In some cases special x-rays called stress x-rays are needed.


Ankle Fracture
X-ray of an Ankle Fracture

You may not require surgery if your ankle and the broken bone is not out of place or just barely out of place. The type of treatment may also be based on where the bone is broken.

• Elevation and ice to reduce painful swelling and decrease the risk of damage to the surrounding tissue.
• A splint, worn for several days, may be placed to support the broken ankle and allow room for swelling. If the damaged ankle is not displaced, the splint may be applied immediately without moving the broken ankle. However, if the bones are displaced and/or the ankle joint is dislocated, a closed reduction is performed while the splint is placed. This treatment involves setting the tibia and/or fibula bones and ankle joint to improve the position and pain at the ankle. This treatment may require some type of anesthesia.
• Rest and avoiding weight bearing upon the ankle is essential to healing correctly. Crutches, walkers and wheelchairs are usually recommended, depending on the severity and type of ankle fracture. In many cases, a patient will not be able to place any weight on the ankle for several days,
weeks or even months. Your physician will make this determination.
• A cast or fracture boot can be applied to a fractured ankle once the initial swelling goes down. These are most commonly used to treat fractures where one bone is minimally displaced and not requiring surgery. Both a cast and a boot can provide adequate immobilization and protection to the ankle. A cast cannot get wet or be removed without special tools. A boot can be removed for bathing and sleeping. The type of fracture and the physician’s judgment will determine the best type of immobilization. The cast or boot is worn until the fracture is fully healed, which usually takes two to three months.
• The need for surgery will largely depend on the appearance of the ankle joint on the X-ray and the specific type of fracture. Badly displaced fractures and fractures of both the tibia and fibula commonly need surgery. During this type of procedure, the bone fragments are first repositioned into their normal alignment and are held together with special screws and metal plates attached to the outer surface of the bone. In some cases, a screw or rod inside the bone may be used to keep the bone fragments together while they heal. Restoring alignment of the broken bone is essential to full recovery because ankle arthritis can occur if a fracture heals improperly. The best way to minimize the risk of arthritis is to restore the ankle to as close to normal as possible.

There are usually few complications from a broken ankle, although there is a higher risk among diabetic patients and those who smoke. Your orthopaedic surgeon may prescribe a program of rehabilitation and strengthening. Range-of-motion exercises are important, but keeping weight off the ankle is just as important.

Ankle fractures in children are more likely to involve the tibia and fibula, which typically involves the growth plates. Growth plate fractures in the ankle often require immediate attention because the long term consequences may include legs that grow crooked or of unequal length. A child who breaks an ankle should be checked regularly for up to two years to make sure that growth proceeds properly.

Accessory Navicular Syndrome

The accessory navicular is an extra bone or piece of cartilage that is located at the inner side of the foot just above the arch and is incorporated within the posterior tibial tendon.Accessory Navicular Syndrome

Many people are unaware they have this congenital condition because it causes no problems. However, some people develop Accessory Navicular Syndrome when the bone and/or posterior tibial tendon are aggravated as a result of trauma, chronic irritation from poor fitting footwear, or excessive activity or over use.

Many people with accessory navicular syndrome also have flat feet (fallen arches), which puts more strain on the posterior tibial tendon, causing inflammation or irritation to the accessory navicular.


Symptoms of this condition typically first appear in adolescence, when bones are maturing and cartilage is turning into bone. Some people don’t experience the following symptoms until adulthood:

• A visible bony prominence on the inner side of the foot, just above the arch (midfoot).
• Redness and swelling of the bony prominence.
• Vague pain or throbbing in the midfoot and arch, usually during or after a period of activity.


Diagnosis of Accessory Navicular Syndrome is made through evaluation of a patient’s symptoms and examination of the foot structure, muscle strength, joint motion and the way the patient walks. X-rays can confirm the diagnosis. In some cases, an MRI will be ordered to further evaluate the condition.


The following non-surgical treatments can relieve the symptoms of Accessory Navicular Syndrome.

• Immobilization with casting or removable walking boot allows the affected area to rest and alleviate the inflammation.
• Ice to reduce swelling.
• Oral non-steroidal anti-inflammatory drugs such as ibuprofen may be prescribed.
• In some cases, steroid injections may be used in combination with immobilization to reduce pain and inflammation.
• Physical therapy may be prescribed, including exercises and treatments to strengthen the muscles and decrease inflammation. The exercises may also help prevent recurrence of the symptoms.

Even after successful treatment, the symptoms of Accessory Navicular Syndrome sometimes recur. When this happens, nonsurgical approaches are usually repeated.

If nonsurgical treatment fails to relieve the symptoms, surgery may be appropriate. Surgery may involve removing the accessory bone, reshaping the area and repairing the posterior tibial tendon to improve its function. This extra bone is not needed for normal foot function.

Mallet Finger

A Mallet Finger is a finger injury that occurs when the extensor tendon that straightens your finger is torn. The tendon can be damaged from a ball or other obMallet Fingerject striking the tip of the finger and forcibly bending it. The force of the blow may even pull off a piece of the bone with the tendon so the tip of the finger can no longer straighten.


With a Mallet Finger, the fingertip cannot straighten on its own: it droops. The finger may be painful, swollen and bruised, especially if the bone has torn from the tendon (avulsion). Occasionally, blood collects beneath the nail, causing the nail to become detached at the base of the nail.


In most cases, Mallet Finger injuries can be treated without surgery. Full-time splint immobilization with the tip of the finger in extension is essential to allow the ruptured end of the tendon to Mallet Finger Xrayheal. Not allowing the tip of the finger to bend at all during the immobilization period is the key to successful healing. Once the Mallet Finger has completely healed, your physician or hand therapist will recommend exercises to regain motion of the fingertip.


Here are examples of different splints that are used to treat mallet injuries. Your physician will determine the type of splint that is most appropriate for your injury.

Stax Splint


Stax Splint

The open part of the splint lies
on top of the finger, leaving the
fingernail exposed.


Custom Splint


Custom Made Splint

A custom made splint, with the
longer side covering the fingernail.


Alumafoam Splint

Alumafoam Splint

The metal part of this splint is on
top of the finger, covering the



Heel Pain

The foot has more than 30 different joints. If you consider the tons of stress your feet endure from walking and standing day in and day out, it’s a wonder everyone doesn’t suffer from some sort of heelpainheel pain, which is the most common problem affecting the foot and ankle.

Feet are physiologically designed to handle the pressure … to a point. Repeated pounding on a hard surface while running or participating in another sport, or wearing ill-fitting shoes that inflame the foot’s tissues can cause pain on the bottom of your heel or behind it, for instance. Arthritis from years of wear and tear, or possibly from gout, (a build-up of uric acid in the small bones of the feet), can also cause heel pain.

In most cases, heel pain can be relieved without surgery. Rest, stretching exercises and possibly anti-inflammatory medication can usually do the trick. Left untreated, however, a sore heel will only worsen and can develop into chronic and more problematic conditions.

Consult with a specialist to determine the underlying cause of pain in your heel if it lasts more than a few days,  if it intensifies when you put weight on the foot, if there are signs of infection or injury, such as swelling, discoloration or fever, or if your heel is warm to the touch.

Some Common CausesPlantar faciiatis

Pain centered under your heel could occur if you’ve bruised the heel pad by stepping on a hard object such as a rock, or from repetitive pounding on hard surfaces during sports. This pain usually goes away over time with rest.

If the pain beneath your heel is mild at first but then flares up when you take your first steps in the morning, you may have plantar fasciitis, which is inflammation of the tissue band (fascia) that connects the heel bone to the base of the toes. Plantar fasciitis is the most common condition causing heel pain. If plantar fasciitis is left untreated, a painful heel spur (calcium deposit) can develop where the fascia attaches to the heel bone.

Achilles TendonPain from behind the heel could indicate inflammation of the bursae or the Achilles tendon in the area of where goes into the heel bone. Achilles tendonitis and associated pain from retrocalaneal bursitis can build slowly over time, causing the skin to thicken, become red and/or swell. In some cases, a bump that feels warm to the touch can develop at the back of the heel. If pain increases with the start of an activity after a period of rest or if it is too painful to wear shoes, your physician may order an Xray to determine if a bone spur has developed.

Injuries to the nerves in the foot can also produce heel pain. Neuropathy, or nerve damage, and Tarsal Tunnel Syndrome, in which the large nerve in the back of the foot becomes pinched and inflamed, are the two most common nerve-related conditions.

If heel pain is making it increasingly difficult to walk or enjoy your everyday activities, schedule an appointment with  ONS foot and ankle specialists, Sean Peden, MD and Michael Clain, MD, by calling 203-869-1145 or request an appointment here.

Collarbone Fracture

Also known as a clavicle fracture, a collarbone fracture is fairly common and can happen to people at any age.

The collarbone (clavicle) lies between the shoulder blade (scapula) and the ribcage (sternum) which connects the arm to the body.

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Most collarbone fractures occur from a hard hit to the shoulder. A fall on an outstretched arm may also cause a fracture to the clavicle. Sometimes during birth, a baby’s collarbone can fracture as a result of passing through the birth canal.

Symptoms of a collarbone fracture

A clavicle fracture is extremely painful. Other symptoms include:

  • A sagging shoulder
  • Difficulty lifting the arm, accompanied by a grinding sensation
  • A bump or deformity over the break
  • Bruising, swelling or tenderness

Treatment for a collarbone fracture

Non-surgical treatments

A sling or a figure eight wrap is recommended to support the arm in a healing position and relieve pain.  Your physician may suggest pain medication such as acetaminophen.

Surgical Treatment

Depending of the severity of the fracture, pins, plates and screws can be surgically implanted to hold the bone in place.  Some pain is common after surgery as it is part of the healing process. Medication for short term pain relief is usually prescribed.


Physical therapy will usually start with gentle exercise that will gradually incorporate strengthening. It will be a slow process, but in order to return to the activities you enjoy it is very important to follow a physical therapy plan.

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Shoulder Separation

shoulder separation
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A shoulder separation can result from a fall or severe trauma at the shoulder joint.   The injury affects the acromioclavicular joint, or AC joint, where the collarbone (clavicle) and the highest point of the shoulder blade (acromion) meet.

If a deformity is seen, the injury is easier to identify. However, if there is not a deformity, a diagnosis is based on the location of the pain and an X-ray.

Shoulder Separation Treatment

Nonsurgical Treatment

A sling, pain relieving medications, and cold packs can help to alleviate the pain of a shoulder separation. As a way to help keep the AC joint less mobile, a more complicated supporter may be used. Even if there is a major deformity due to the injury, most people go back to nearly having full function of their shoulder. In some cases, people will continue to have pain located in the AC joint even if the deformity is mild. The pain can be due to:

  • Contact between both ends of the joint when it is in motion
  • Arthritis
  • A piece of cushioning cartilage is injured between the bone and where the ends of the joint meet.

Surgical Treatment

Surgery is only considered if there is persistent pain and a severe deformity.

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Shoulder Dislocation

While the shoulder is the most mobile joint in the body, its range of motion unfortunately makes it easier to dislocate.

There are multiple kinds of dislocations. One is called a partial dislocation (subluxation) which is when the head of the upper arm bone (humerus) is not completely out of the socket (glenoid). A complete dislocation is when the humerus is all the way out of the socket. Both can be painful and cause instability in the shoulder.

Dislocated Shoulder
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Shoulder dislocation symptoms

  • Shoulder pain that can radiate down the arm
  • Swelling
  • Arm weakness
  • Bruising around the shoulder

In some cases ligaments or tendons in the shoulder can be torn and nerves can be damaged.

The shoulder can dislocate forward, backward, or even downward. A common dislocation happens when the shoulder slips (anterior instability). This happens when the humerus moves out of the joint forward and down at the same time which can occur from a throwing motion.

Diagnosis of shoulder dislocation

Typically, an X-ray can reveal the position of the dislocation.  In some cases, an MRI may be needed to determine if there is damage to the surrounding tissue.

Shoulder dislocation treatment

The doctor will have to place the humerus back into the joint socket in what is known as a “closed reduction.” The pain stops almost immediately when the shoulder joint is put back into place.

Once the joint is put back in place, ice should be used 3-4 times a day and the shoulder should be immobilized in a sling for several weeks. When the pain and swelling begin to go away, rehab exercises can help restore the shoulder’s range in motion and to regain muscle strength. If the condition becomes chronic, a brace can sometimes help, or surgery may be recommended to repair and tighten the torn or stretched ligaments that help hold the joint in its place.

Chronic Shoulder Instability

The most mobile joint in the body is the shoulder.  Chronic shoulder instability is typically the result of frequent shoulder dislocations, when the upper arm bone (humerus) is forced or slides from the shoulder socket.

Shoulder Anatomy

Shoulder Instability
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Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The head of the upper arm bone (glenoid) fits into a rounded socket. The rotator cuff is a combination of muscles and tendons that attach the glenoid to the shoulder blade. Finally, the biceps tendon is a muscle in front of the upper arm with two tendons that attach the bones to the shoulder socket.

Causes of chronic shoulder instability

Chronic shoulder instability can occur in people who tend to have laxity in their ligaments.  Repeated overhead motion from activities such as swimming, tennis, and volleyball can weaken shoulder ligaments over time, leading to instablity.  Certain occupations that require overhead motions, such as painting, can also cause chronic shoulder instability.

Symptoms of chronic shoulder instability

  • Pain
  • Repeated shoulder dislocations or the shoulder “giving out”
  • The sensation that the shoulder is loose, is hanging, or slips in and out of the joint

Diagnosis and treatment for Chronic Shoulder Instability

Your physician may order an X-ray to determine the shoulder’s placement and an MRI to identify any injuries to the tendons and ligaments around the shoulder joint.  Surgery is usually necessary to repair stretched or torn ligaments in order to keep the shoulder in place.