Common Causes of Heel Pain

FOOT SPECIALIST DR. MARK YAKAVONIS, MD, MMS, AN ORTHOPEDIC SURGEON AT ONS, GETS TO THE BOTTOM OF THE QUESTION, WHY DOES MY HEEL HURT?

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 no wonder that heel pain is the 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, 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. Arthritis, wear and tear, or a build-up of uric acid in the small bones of the feet known as gout, 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. If left untreated, however, a sore heel will only worsen and can develop into chronic and more problematic conditions.

For that reason, it’s important to consult with a an orthopedic foot and ankle specialist to determine the underlying cause of pain in your heeL. If it lasts more than a few days, a medical consultation is particularly imperative if the pain  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.Foot picture

SOME COMMON CAUSES

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.

PAchilles Tendonain from behind the heel could indicate inflammation of the bursae and the Achilles tendon at the point where the tendon 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 X-ray 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 you experience pain that makes it difficult to walk or enjoy your everyday activities, schedule an appointment at ONS with one of our foot and ankle orthopedic specialists, Mark Yakavonis, MD or Michael Clain, MD by calling 203-863-1145 or request an appointment here.

07/10/2019

Your Aching Feet: Common Causes and Treatments for Foot Pain

PedenMD_BlogFoot massages are a great way to ease foot pain, but the relief won’t last long if an underlying condition is the cause of your discomfort. Orthopedic surgeon Sean Peden, MD, a foot and ankle specialist at ONS, will discuss common foot ailments including plantar fasciitis that result in pain in the heel and bottom of the foot and metatarsalgia, inflammation at the ball of the foot. The informative presentation will include evidence-based treatments including effective home remedies and non-surgical care. He will also highlight some the new technological advances in foot care, including developments in regenerative medicine that helps promote self-healing.

 

MRI versus the Stress Test: Which one do you need?

Mark Yakavonis, MD, MMS, is an orthopedic surgeon who specializes in foot and ankle surgery. Dr. Yakavonis has expertise in treating a variety of foot pain and deformity related conditions including Achilles tendonitis, ankle instability, cartilage injuries, bunions and hammer toes and keeps up to date with the latest breakthroughs in the field. Most recently, the unnecessary reliance on the MRI compared to conducting a simple stress test has caught his attention. The following is what he wants you to know:

Nowadays, orthopedic surgeons will frequently order Magnetic Resonance Imaging (MRI) studies for patients suffering from acute or chronic musculoskeletal injuries. Radiographs, also known as plain films, show a two dimensional projection or shadow of bone. It is useful for diagnosing obvious displaced fractures, but subtle findings are often missed.

The MRI is advanced technology that provides information in three dimensions about bone, tendon, muscle, ligament, fat, swelling, fluid, etc., but are unlike plain films, which just show bone. Basically, it shows us just about everything we need to know short of nerves and other subtle dynamic findings. It uses no radiation and is incredibly safe.

But in the setting of an ankle fracture – where either the fibula or tibia is broken near the ankle and our job as surgeons is to determine which ankles will be fine with a cast and which need a surgical correction – AN MRI IS OF NO ADDED BENEFIT. What I want to determine in this setting is whether the fracture is “stable.”

An unstable fracture will shift with time, even with a good cast, and certainly once a patient begins walking. Shifting is a very bad thing, especially in the ankle. It leads to abnormal pressures on the joint, cartilage wearing, degenerative changes, and stiffness, also known as post traumatic arthritis. In an active and healthy patient, that is unacceptable. A significantly better outcome is achieved with a one hour surgery to fix the fracture and restore anatomic alignment and stability.

The main problem with an MRI is that it is a static test. The images are taken with the patient lying flat on a table. There is no weight or force across the ankle joint. While an MRI can image the ligaments in the setting of an ankle fracture, these ligaments are always injured, but whether they are injured to the point of instability is indeterminable.

A simple test that costs very little and takes about 5 minutes is a stress radiograph. Using either gravity or the hands of a surgeon, a mild stress is placed across the ankle joint. If the joint widens or shifts I know that it will do the same in the future. The most up to date orthopedic literature supports stress x-rays are the best way to decide between surgical and non-surgical treatment, not MRIs.

The other problem with an MRI is cost and time. It is a 30-45 minute test and carries with it a significant cost. The burden of the cost is shared by the patient, the insurance company, and society as a whole. With the skyrocketing costs of healthcare in our country we should reject the notion of ordering tests when they should have no effect on our decision.

A 2014 article supports this from the Journal of Bone and Joint Surgery, the official scientific journal of the American Academy of Orthopaedic Surgeons.

07/10/2019

Ready for Spring Sports?

Golfer

Foot and ankle, hand and wrist injury prevention tips by orthopedics specialists

When: February 25, 2015 at 6:30 p.m.
Where: Noble Auditorium, Greenwich Hospital
Speakers: Mark Yakavonis, MD, MMS, Mark Vitale, MD, and Paddle and Tennis Professional Patrick Hirscht

If golf or racket sports are in your plans for the spring you will want to hear tips from fellowship trained orthopedic foot and ankle specialist Mark Yakavonis, MD, MMS and fellowship trained hand/wrist/elbow specialist Mark Vitale, MD, MPH who will discuss common injuries seen in golf and racket sports. Special guest and local tennis pro Patrick Hirscht will also speak. Learn about common injuries, and how to choose footwear, braces and exercises to prevent injury and play your best; whether it’s the foot, hand, wrist or elbow, they’re all at risk for injury when you’re active. Dr. Yakavonis and Dr. Vitale will discuss nonsurgical and surgical treatments, along with ailments particular to racket sports. You will have the opportunity to ask questions at the conclusion of the talk. The program is free and open to the public. Registration Requested. Call (203) 863-4277 or register online at www.greenhosp.org.

07/10/2019

The Fragile Feet: A Ballerina Story (Part I)

Ballerina
Ballerina in en pointe position

Dr. Yakavonis, MD, MMS, of ONS and Greenwich Hospital is an orthopedic surgeon specializing in foot and ankle surgery and treatments for adult foot conditions as well as youth sports injuries in field athletes, gymnasts and ballet dancers. He shares a two-part blog about conditions to be aware of for ballet dancers and gymnasts.

Ballet dancers feet are much like a musician’s handsthey earn a living with them. In addition to putting an amazing amount of stress on their feet, they also are often well below an ideal body weight – either because of the stress of an enormous amount of training or because of unrealistic expectations placed on them by the ballet community. This leads to several different and often unique foot and ankle conditions.

One fairly unique foot and ankle condition in ballet is caused by the en pointe position. In this position an enormous amount of strain is put on the dancer’s great toe, as it is essentially holding up the entire body weight through a small joint. The main flexor tendon of the toe, called the flexor hallicus longus – normally quite small, takes over the job of the largest tendon in the body, the Achilles. The flexor hallicus longus hypertrophies well in compensation for its new job, but unfortunately this tendon is forced through a tight tunnel in the back of the ankle. When it gets too large it will get pinched in the posterior ankle joint. Patients develop painful irritation of the bones and soft tissues in the posterior ankle. An extra bone in the posterior ankle called the os trigonum, which present in about 10% of all people, can be become very painful and irritated in many ballerinas. This constellation of problems is called posterior impingement of the ankle, and it is noticed by the patient as a vague deep pain in the posterior part of the ankle, in front of the Achilles, that is felt with plantarflexion, the position of pointing the foot and toes downward.

Ballet dancers suffer from numerous other problems of the foot & ankle, many of which are not unique. One of the less glamorous problems they deal with are corns, calluses, and blisters. These are necessary adaptations to allow a high level dancer to compete.

Similar to posterior impingement, which arises from dancers spending an inordinate amount of time and stress in an extreme position at the ankle, ballet dancers will develop anterior impingement at the ankle. This comes from repetitive forceful dorsiflexion – pulling the foot and toes upward, toward the shin. Landing from jumps and deep knee bends exacerbate this problem. Pain is felt in the anterior ankle.

Treatment for the above condition is customized to the patient. Often a minor activity modification, or period of rest, can dramatically improve the symptoms. Unfortunately, rest is not easy to come by in the competitive living of a gymnast. Many dancers will treat the symptoms with a combination of anti-inflammatory medications and occasional steroid injections in the region of maximal tenderness. Surgery is a last resort option for any ballerina – when symptoms persist for many months and are limiting, despite all other efforts. Surgery is typically very successful in these patients and can be done with arthroscopic or minimally invasive techniques.

The most common orthopaedic injury of all is also very common amongst ballet dancers: the lateral (traditional) ankle sprain. The mainstay of treatment for ankle sprains is rest, ice, compression, and elevation – mnemonic RICE. A short period of rest and immobilization (1-2 weeks) is followed by aggressive physical therapy, with strengthening of the muscles that stabilize the ankle. Recent research has pointed to improved short and long-term outcomes when early motion and weight bearing is initiated. There is promising early research on the role of stem cell injections – harvested from the patient’s own blood or bone marrow – in the setting of an acute ankle sprain. This is a technique we will offer for the highest level athletes and dancers in certain situations, understanding that the research data on this intervention is still in development.

… to be continued in the next segment, The Fragile Feet: A Gymnast Story (Part II)

Want to learn even more? Dr. Yakavonis will be giving a seminar on “Solutions for Foot and Ankle Pain: Beyond a Foot Massage.”  The program is free and open to the public. Registration Requested. Call (203) 863-4277 or register online at www.greenhosp.org.

07/10/2019

What do you do when you are diagnosed with an old (chronic) Achilles tendon rupture?

Mark Yakavonis, MD, MMS, is an orthopedic surgeon who specializes in foot and ankle surgery. Dr. Yakavonis has expertise in treating a variety of foot pain and deformity related conditions including Achilles tendonitis, ankle instability, cartilage injuries, bunions and hammer toes.  His practice will also focus on youth athlete sports injuries and the types of injuries seen in field athletes, gymnasts and ballet dancers.

Achilles tendon ruptures will often not be discovered for months after the injury. In the months between injury and showing up at the doctor’s office, the torn tendon develops scar tissue which decreased the quality and elasticity of the tissue. Because of this, directly repairing the torn tendon, as is done in an acute injury, becomes is less than ideal. In this situation, we will supplement the tendon repair with a tendon transfer. Essentially, we borrow a tendon that bends the big toe (there is another tendon that compensates when it is borrowed), reroute it, and reattach it to the heel bone. This does two very important things:

1. It supplements the strength of the torn Achilles, allowing a quicker and better recovery.

2. It provides improved blood supply to the Achilles repair, providing healing factors to the area of diseased tendon.

In summary, ruptures of the Achilles Foot_AnklePictendon are increasingly common in our aging yet increasingly active population. In cases where an Achilles rupture is missed or the rupture cannot be repaired directly under normal tension, adding the flexor hallicus longus tendon transfer allows for significantly improved results with a shorter recovery.

If you suffer from foot and ankle pain and would like to attend a free seminar, Dr. Yakavonis of ONS is an orthopedic surgeon specializing in foot and ankle surgery, and Greenwich Hospital will present Solutions for Foot & Ankle Pain: Beyond Foot Massage . He will present treatments and surgical techniques for bunions and other foot deformities. Learn more and register online here.

07/10/2019