Chronic Exertional Compartment Syndrome

Chronic Exertional Compartment Syndrome (CECS) is an unusual cause of pain in the legs of people who participate in physical activity. It is caused by too much swelling of the muscles in the leg during exercise. This causes a decrease in blood flow to the muscles, resulting in pain and sometimes numbness and weakness of the leg.

Symptoms

Patients with CECS notice a dull ache in the leg with activity. If ignored, the pain becomes so bad that the activity must be stopped. The pain begins at the same time during activity. The pain usually goes away with rest, but it takes some time. It is often easy for someone with this problem to point to the exact location where the pain is.

Sometimes there is numbness, cramping, or weakness in the leg. On rare occasions, the condition will cause shrinking of the muscles in the affected area.

Diagnosis

The diagnosis is confirmed by measuring pressure in the leg with a special device.

Treatments

Non-surgical treatment options include stretching, changing your activity level, and sometimes giving up the activities that cause CECS.

If these options don’t work or are unacceptable, surgery may be the best way of dealing with the issue. The surgery of choice is called a compartment release. Your foot and ankle orthopedic surgeon makes one large or two small incisions in the outer tissue of the muscle compartment so that it will decompress. This decompression relieves pressure and increases blood flow to the muscle. The skin is then closed over the muscle. Sometimes a small camera is used during surgery, which allows for smaller cuts to be made on the skin.

Recovery

After surgery, the leg is kept elevated for 3-5 days to limit pain and swelling. Knee and ankle joint motion is allowed immediately, as is walking and light activities. You can restart normal activities four weeks after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Other problems include injuries to the leg’s blood vessels or muscle nerves. Some patients may lose strength in the leg after the tissue covering the muscle is opened.

FAQs

Will I be able to return to my physical activities?

Most patients are able to return to their activities that the CECS was preventing them from doing.

Will the problem come back after surgery?

Generally the problem does not come back.

Cavus Foot

A cavus foot has a high arch. The cavus can range from being slightly high to severely deformed, causing you to walk on the outside of your foot. Surgery sometimes is needed to realign the foot.

While the cause of a high-arched foot it often unknown, a cavus could be caused by nerve disease, clubfoot, or injury. Treatment ranges from changes in shoes to surgeries, depending on the amount of deformity and related problems.

The main goals of cavus foot surgery are to reduce pain, improve function, and prevent further damage or injuries.

Diagnosis

Your foot and ankle orthopedic surgeon may recommend surgery if there is no relief with physical therapy, orthotics, changes in shoes, and/or changes in activity. Some patients also will experience tendon problems, ankle weakness, and foot fractures. These patients may require other procedures to address related problems.

If you have medical problems that make surgery unsafe such as any infections or blood vessel disease, cavus foot surgery may not be appropriate.

A patient with cavus foot.

Treatment

The surgical procedures involved with the correction of the cavus foot are varied and depend on the patient’s foot and ankle alignment and related problems. Typically, the foot is realigned by cutting and repositioning the bones (known as osteotomies). Repairing fractures, tightening ligaments, and transferring tendons also may be necessary. The goal is for the repaired foot to evenly distribute weight along both inside and outside edges. A variety of incisions may be needed to perform the procedures related to the correction of the cavus foot.

Specific Techniques

• Soft-tissue surgery: Cavus foot is caused in part by an over-pull of one of the lateral ankle muscles. A release of this tendon can be performed on the outside of the ankle. Additionally, a transfer of this tendon can be performed to help correct the deformity of the ankle joint. Often patients will have a tightness of their gastrocnemius muscle, one of the main muscles in the calf. This can increase the deformity or prevent a correction from working. It is addressed with a lengthening of a part of the calf muscle or Achilles tendon. This is often performed through one or more small cuts in the back of the leg/ankle. Finally, the plantar fascia may be tight. The plantar fascia is a cord-like structure that runs from the heel to the front part of the foot. Your surgeon may perform a partial or complete plantar fascia release.
• Dorsiflexion osteotomy of the first metatarsal: This procedure flattens out the arch.
• Calcaneal (heel bone) osteotomy: This procedure is performed to bring the heel bone back under the leg. This is needed if correcting the deformity in the front of the foot does not also correct the back of the foot or ankle. A calcaneal osteotomy can be performed several ways and often is held in place with one or more screws.
• Tendon transfers: Too much pull of certain muscles and tendons often is the cause of the deformity associated with a cavus foot. Moving one of these muscles or tendons may help the foot work better. In addition, patients with a cavus foot may have weakness moving the foot up, which is sometimes called a foot drop. In these cases, a tendon from the back of the ankle may be moved to the top of the foot to help improve strength.
• Bony surgery: Correcting the deformity of the foot may not be possible with soft tissue procedures alone. In these instances, one or more bone cuts (osteotomies) may be needed. Instead of a bone cut, your surgeon may perform a fusion (arthrodesis) procedure. A fusion removes the joint between two bones so they grow together over time. During a fusion the bones may be held in place with plates or screws.
• Joint fusion: Sometimes patients have a deformity that has caused damage to the joints. In these cases, soft tissue procedures or bone cuts may not be enough, and it may be necessary to eliminate the motion of the joint.
• Toe surgery: Clawed toes are a common problem in patients with cavus foot deformity. This can be treated with tendon surgery, fusion, or removal of part of the toe bones. Following surgery the toes may temporarily be held in place with pins.

Recovery

Recovery typically requires at least six weeks of non-weight bearing so the bones and other structures can heal. In many cases, an even longer period of protection or non-weight bearing is needed. Typically, the final results are not seen for approximately 6-12 months after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Particular complications associated with cavus foot surgery include incomplete correction of deformity, return of deformity, and incomplete healing of the bone.

FAQs

If I have cavus foot surgery, will my foot be totally normal?

Foot surgery is difficult, especially when large amounts of correction are needed. The ability to bring the foot into a new position may not be lasting, even if everything looks perfect in the operating room. The goal is to provide improved position and function of the foot and ankle. In some patients with very severe deformity, the goal is a foot that functions well in a brace.

The calcaneus is the heel bone. Fractures or breaks of the calcaneus commonly occur after a fall from a height or car accident. Treatment of these fractures may require surgery.

Calcaneus Fracture Surgery

The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. Restoration of normal alignment and contour is considered the best way to restore function and minimize pain.

Diagnosis

Surgery is recommended when a broken heel bone has lost its alignment and contour. Identification of the fracture typically is made after a physical examination by obtaining standard foot and ankle X-rays. The specific type, pattern and classification of the fracture is best made by obtaining a CT scan. Your surgeon may require both X-rays and a CT scan to determine if surgery is your best option.

Not all heel fractures require surgery. If the shape of the calcaneus is generally maintained, surgery may not be needed. Patients with diabetes may be at increased risk for infection or wound healing problems. Patients with poor blood flow may also have difficulty healing properly. Elderly individuals may have difficulty with surgical rehabilitation.

Heel surgery often is delayed due to the swelling that typically accompanies these injuries. It may be severe enough to delay surgery for weeks or preclude it altogether. Surgery can safely proceed when the skin at the surgical site at the lateral heel wrinkles, indicating the dangerous swelling has gone away.

Medications such as immuno-suppressants or steroids may slow healing and delay or preclude surgery. Smoking is considered harmful for wound and fracture healing and smokers should quit before any planned calcaneus surgery.

Treatment

The most common surgical techniques utilized to treat a broken heel bone involve cutting through the skin to place the bone back together and using plates and screws to hold the alignment until the bones heal. A classic “open” procedure involves an incision over the lateral aspect of the heel. The incision is likened to a hockey stick or large “L” where the overlying nerve and tendons are moved out of the way. The fracture fragments are restored to the best possible position and a plate and screws hold the fragments in place.

The technique of “closed” reduction and percutaneous fixation can sometimes be utilized. Multiple small incisions are placed in critical areas around the heel. The broken fragments can be realigned with the help of X-rays. Screws are then placed through the skin to hold the position.

The size and location of the incision and the type of screws and plates used are based on skin quality and the surgeon’s judgment on how to best access and fix the broken fragments of bone.

Specific Technique

General anesthesia, used to put a patient to sleep during surgery, commonly is used along with a regional nerve block, which involves a local injection to help with pain control. The addition of a regional block can provide 12 to 24 hours of pain control after surgery. Surgery can be a same-day procedure or planned with a hospital stay.

A tourniquet is used to minimize bleeding and to ensure proper visualization of critical structures that are protected during the surgery. For the standard open approach, a hockey stick or “L” incision is made on the outside of the heel. The sural nerve and the peroneal tendons are moved out of the way and the skin is held back by placing wires in key positions. The bony fragments are then visualized. The general alignment of the heel is restored. The fragments are then placed into position.

All fragments are temporarily held in position with small removable wires. The wires are then removed, and a plate and screws are placed. The skin is then closed. Post-surgical dressings and a splint are applied.

Recovery

Expect a lengthy recovery after calcaneus fracture surgery. You will be given a splint or cast. You should not put weight on your foot for at least 6-8 weeks until there is sufficient healing of the fracture. The foot remains very stiff and some permanent loss of motion should be expected. Most patients have at least some residual pain despite complete healing.

Everyone who sustains a malaligned break of the calcaneus, particularly involving the joint, should expect to develop some arthritis despite having surgery. If arthritis pain and dysfunction of the foot become severe, then further surgery may be required. Heel bone fractures often are severe and can be life-changing.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Complications from treatments for displaced calcaneus fractures can be severe. The most common early complications are in skin healing and nerve stretch. Most wound healing complications can be treated with wound care. Occasionally further surgical treatment may be required. The development of a deep wound infection often requires surgery and antibiotics. Nearly all nerve stretch complications will resolve over time.

FAQs

Do the plates and screws need to be removed?

No, plates and screws do not need to be removed. If they are causing pain or irritation, your surgeon may consider removing them, but he or she will make sure there is enough fracture healing before proceeding.

Arthritis of the Foot and Ankle

The pain and stiffness you feel in your feet and ankles as you age could be arthritis. If left untreated, this nagging pain can get worse over time, eventually making it difficult to walk even short distances. Severe arthritis can restrict your mobility, but with proper treatment, you can minimize the pain and maximize your quality of life.

Arthritis is a broad term for a number of conditions that destroy the workings of a normal joint. Arthritis may occur in your back, neck, hips, knees, shoulders or hands, as well as your feet and ankles. Almost half of people in their 60s and 70s have arthritis of the foot and/or ankle, but not all of them have symptoms.

There are many different types of arthritis. The most common type, osteoarthritis, results from wear and tear to joint cartilage, the cushioning between joints that allows them to glide smoothly. The damage can cause inflammation, redness, swelling, and pain in the joint.

Also, a sudden and traumatic injury such as a broken bone, torn ligament, or moderate ankle sprain can cause the injured joint to become arthritic in the future. Sometimes a traumatic injury will result in arthritis in the injured joint even though the joint received proper medical care at the time of injury. This type of arthritis, called post-traumatic arthritis, is the most common type that affects the ankle.

Another less common type, rheumatoid arthritis, is an inflammatory condition caused by an irritation of the joint lining. Other types of inflammatory arthritis include gout, lupus, ankylosing spondylitis, and psoriatic arthritis.

Diagnosis

The foot has 26 bones and more than 30 joints. Tough bands of tissue called ligaments hold these together. The muscles, tendons, and ligaments work together with the many joints of the foot to control motion and weight bearing position. This smooth motion makes it possible for a person to walk well. When you get arthritis in the foot, you develop pain and limited motion so that you cannot walk as well.

Arthritis can develop in any of these joints but some are more commonly affected than others. A foot and ankle orthopedic surgeon can help you locate the source of your pain and determine the best course of treatment.

If your foot and ankle orthopedic surgeon suspects you have arthritis, he or she will ask you to have a complete medical history and physical examination. X-rays and laboratory tests often can confirm the type and extent of the arthritis. Other tests such as a bone scan, CT scan, or MRI may be used to evaluate your condition.

The ankle is made up of three bones:

• the tibia (shin bone), which forms the inside, front, and back of the ankle
• the fibula, which forms the outside of the ankle
• the talus, a small bone that sits between the tibia and fibula and the heel bone

The ends of these bones are called malleoli. The tibia has a medial (inside) malleoli and a posterior malleoli. The fibula forms the lateral (outside) malleoli.

A broken ankle (ankle fracture) occurs when the malleoli are broken. These fractures are very common. Ankle fractures happen with twisting of the ankle, falls, car accidents, or other injury. One, two, or all three malleoli can be broken. Ankle fractures can be displaced (out of place) or non-displaced. Symptoms of an ankle fracture include pain especially with weight bearing, swelling, bruising, and problems with ankle motion. X-rays help determine if treatment from a foot and ankle orthopedic surgeon is needed.

Ankle Fracture Surgery

The main goal of ankle fracture surgery is to put the ankle joint back in place and to stabilize the bones to heal. Getting the ankle joint back in place helps to decrease the risk of developing arthritis of the ankle. Stabilizing the ankle with plates and screws may allow earlier motion.

Diagnosis

When the ankle fracture is unstable or in bad position, surgery is needed to repair the ankle. In some cases, the bones of the ankle may poke through the skin. These are called open ankle fractures and require surgery.

Ankle fracture surgery is not needed if the ankle is in position and stable despite the fracture. Surgery may be too risky when patients have a severe medical condition.

Treatment

Antibiotics are given shortly before the start of the surgery. Once the patient receives antibiotics and anesthesia, the surgery can safely begin. Incisions are made through the skin of the ankle where the bones are broken. The breaks in the bone are then repositioned and held in place with implants (screws and plates). After the ankle fracture is repaired, the patient’s leg is placed in either a protective splint, cast or boot. Some patients go home after surgery the same day while others may stay overnight in the hospital.

Specific Technique

Most ankle fracture surgery involves open reduction and internal fixation (ORIF). An incision is made over the ankle to see the fractured bones. Like a jigsaw puzzle, the pieces of the broken bones are placed back together (open reduction). The broken bones are then held together (internal fixation) in this correct position with metal plates and/or screws. This internal fixation provides stability so movement can begin shortly after surgery as the ankle fracture heals.

Left, a bimalleolar ankle fracture before surgery. Right, the ankle fracture after it has been fixed.

Recovery

Surgical treatment of ankle fractures allows patients to regain ankle function while the bones and joint heal. Immediately after surgery, your ankle will be immobilized for a few weeks. Once the wounds are healed, you will be fitted for either a cast or a boot. Many surgeons use a removable boot. The boot protects the ankle as it heals but can be removed to allow washing, wound checks, and icing.

Once the broken bones start to heal, you will be told when you can put weight on the ankle in your cast or boot. You are then allowed to wean out of the cast or boot. You can progress to normal activities once the bones are fully healed. Some patients may need physical therapy for their ankle to regain full movement and strength. While everyone is different, it may take up to a year after surgery for some patients to regain ankle function.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Potential long-term problems after ankle fracture surgery include ankle joint stiffness, weakness, and arthritis. Possible complications include infection and problems with healing. Factors that increase risks after ankle fracture surgery include diabetes, steroid use, and cigarette smoking.

FAQs

Will my ankle hardware (plate and/or screws) have to be removed at some point?

Plates and screws used to fix an ankle fracture are not removed if they are not causing problems. Most people do not have problems with the plate and screws. In rare cases, the plate and screws can cause some pain or irritation. When this happens, the hardware may be removed after the fracture is healed, about a year from the original surgery.