Thursday, December 15, 2011

Roethlisberger Suffers High Ankle Sprain

Ben Roethlisberger and the high ankle sprain

Last week in the football game between the Pittsburgh Steelers and the Cleveland Browns, Ben Roethlisberger the quarterback for the Steelers was tackled in such a way that he suffered an injury to his ankle. Using slow motion analysis of video online, it can be seen that “Big Ben” was planting his left foot trying to escape tacklers when he was hit from behind and from the left essentially trapping his left foot on the ground with the inside of the foot against the ground. His left knee then hits the ground and creates a rotational base as he was hit from the right by another opponent. The top of the left shoe can be seen clearly as he falls on his left side effectively making the lower part of his foot and leg point 180 degrees from normal (or backwards).

Amazingly he walked off the field and returned and completed the game later. Reports of his injury over the past week include that he has a grade 1 high ankle sprain. He is in a walking cast boot and may compete against the 49ers on Monday night.

Big Ben’s injury differs from the usual ankle sprain because of the mechanism of injury. Normally ankle sprains are on the outside (lateral aspect) of the ankle and involve tearing of the lower ankle ligaments. Big Ben’s injury involves the ligaments that hold the leg bones together. The term ankle sprain can be used to indicate anything from a minor injury or an actual tearing of the ligaments.

From my analysis of the injury from one perspective of video on the internet it appears to me that it is amazing that the ankle was not dislocated at the time of injury and that it is likely that the ligament was ruptured or torn. In normal adults, ligament healing will usually take about three weeks and will need protection during this time. I would anticipate a significant amount of pain would be present if an individual were to try to weight bearing without significant support of the ankle before it is healed.

Big Ben is getting the best of care by getting an immediate X-ray and then an MRI. Many times normal ankle sprains will require both of these studies as well. Support and protection are requirement for normal healing of ankle sprains as well.

So, the take home point is:

1. Don’t attempt to walk off ankle sprains

2. Start Rest Ice Compression and Elevation

3. Get professional help and imaging

For more information see

Wednesday, November 23, 2011

Ray Lewis may watch from the sidelines on Turkey Day

Ray Lewis missed playing against Cincinnati last week due to a toe injury.  This is the first game he has watched from the sidelines since 2007.  There is a less than 50 percent chance that he will play against the Bengals on Thanksgiving.  He may be out up to 4 weeks. 

Please visit our website if you would like to learn more about Sports Injuries.

November is Foot Health Awareness Month!!

November is foot health awareness month as it relates to issues that affect diabetes and foot health by

the US Department of health and human services. This department recognizes the need for diabetics

to be aware that foot health is an integral part of their medical care. Two separate studies have

indicated that amputations may be decreased and healthcare costs may be decreased by regular visits

to podiatrist’s office by diabetics. This is something that I have personally observed over the years.

If patients understand they are diabetic and they need special care for their feet, we can help them

remain ambulatory and decrease their risk for amputations and ulcers. In the past, when Medicare

did not cover the cost of special diabetic shoes for diabetics at risk, I personally witnessed many

unnecessary ulcerations and amputations because of ill-fitting shoes. As a result of the Medicare shoe

program for at risk diabetics, I have seen the number of ulcers drastically reduced over the past 10

years. For the ulcerations and infections that do happen, the new materials and treatments for wound

care have allowed us to heal diabetic ulcerations that were previously untreatable.

The most important point that I have for diabetics is that regular visits to a podiatrist’s office are an

investment in your future which can eliminate and prevent ulcerations and amputations. Even at the

very beginning of the progressive disease of diabetes, even when you feel nothing is wrong with you, a

visit to a podiatrist office can help make you aware of problems that you may not understand presently.

At that first visit, your feet can be examined and evaluated for foot deformities, circulatory problems

and neurological problem. Common problems as hammer toes and bunions can be evaluated and

treated conservatively with a variety of shoes and appliances. The mechanics of your walking will be

evaluated and the structural integrity of your feet can be reviewed. The range of motion of your lower

extremity can be evaluated. Many problems in these areas can be addressed with special supports and


For diabetics, circulation, the amount of blood going into and leaving your feet, is a very important to

be evaluated. Using the latest technologically advanced noninvasive testing, the amount of blood flow

to and from the foot can measured and problem areas can be identified. This is important because

decreased blood flow can be associated with changes in healing, ulcerations and limb threatening issues.

Being able to identify and treat problems with circulation in diabetics can help prevent or treat many of

these problems.

Sometimes patients will come to office and say “I feel like I have a sock wadded up on the bottom of

my foot” or “I feel like my feet just don’t belong to me anymore.” These and other symptoms such

as numbness, tingling or other changes in sensation may be the beginning of the disease known as

neuropathy. Often this disease is associated with diabetes and is major cause of difficulties for patients.

Several times a year patients will come to the office with an infection in their feet from foreign bodies

that they didn’t realize they had stepped on because they could not feel it. At our office all patients are

screened for neuropathy with special attention placed on diabetics. It is important for diabetics to have

their neuropathy recognized early and have medical and accommodative treatment performed. This can

help prevent some of the more tragic complications of diabetes.

For more information please see our web site at or call out office at 239-

Wednesday, August 31, 2011

Back to School Sports Injury Prevention Tips

By Dr. Dalia Krakowsky, Podiatrist, Marshfield Clinic Minocqua and Park Falls Centers

The fall time for our community’s children typically means back to books and homework. For many of them it also means back to fall sports. Many return to strenuous sports such as football, cross-country running, and basketball after a summer of relaxing. This can predispose them to injury. This can further be exacerbated by a child’s level of physical maturity and degree of athletic ability.

Proper training and conditioning can help prevent injury as well as help improve coordination and overall physical performance. There are several methods one can help avoid injury.

One of the most important ways to avoid sport related injuries in all activities is to properly warm up. Warming up helps to loosen muscles and prepare for an athletic activity. This includes proper stretching (but not overstretching), whether it be passive or dynamic as well as a light cardiovascular warm up.

Other ways to help avoid injuries is proper training prior to competition, which is typically sport specific and well managed by team coaches and trainers. Training typically includes cardiovascular fitness, strengthening and conditioning, stretching and improving flexibility, coordination and agility improvements as well as other sport specific modalities.

Despite proper warming up and training, a child still may unfortunately incur an injury during athletics. Injuries are commonly seen as a result of overuse, and are often seen as the sport season progresses. Common injuries include:

1.Ankle sprains: This can involve either a partial tear or stretching of ankle ligaments. Symptoms may include ankle pain, swelling and bruising. Treatment typically involves a period of rest, icing, and either protective weight-bearing with a boot or a period of non-weight-bearing. It may take several weeks and often months for complete healing to occur. Once symptoms improve it is important to restore balance, coordination and strength in order to help prevent recurrence.

1.Shin splints: This can occur due to improper training, increase in acceleration during athletics, or overtraining. It can also be seen in sports where running on an incline or with quick acceleration is performed. Symptoms typically include pain to the front of the leg with activity, alleviated with rest. Treatment predominantly includes rest, possible use of physical therapy modalities and anti-inflammatory measures. Prevention of recurrence typically includes slower progression through the specific sport, conditioning and possible use of orthotics.

1.Heel pain: This can be a result of inflammation of the plantar fascia (the ligament that attaches to the bottom of the heel bone), inflammation of the heel cord as it attaches to the back of the heel bone, or inflammation of the growth plate located at the back of the heel bone. Symptoms typically include pain and possible swelling. Treatment is catered to the level of discomfort, and can include icing, resting, use of heel cushions and orthotics.

1.Stress Fractures/Fractures: Fractures due to overuse are less commonly seen in younger people, as their bones are often more flexible. As a child matures, they are more predisposed to stress fractures due to overuse. Symptoms typically consist of pain and often associated swelling. There can be bruising as well. Often advanced imaging such as an MRI or a bone scan is needed to further evaluate a fracture if it is not easily seen on an X-ray. Treatment depends on level of injury and can involve rest, protective weight-bearing in a boot, non-weight-bearing in a cast or surgery to repair the injury.

If your child complains of pain, or has symptoms of unusual swelling, contact a health care provider to immediate care in order to prevent worsening of the situation. Early detection of a specific injury and early treatment means your child can most likely return to their sport or activity in a timely fashion.

Tuesday, August 16, 2011

Check out these shoes!!!!

NBA All Star John Starks and founder of Ektio shoes talk about the new high-top basketball shoe that potentially can prevent ankle sprains.

Monday, August 8, 2011

Giants Prince Amukamara out indefinitely

Amukamara fractured his fifth metatarsal and will undergo surgery.  It is his very first broken bone and surgery he has ever had!  To read the whole article click here.

Lawsuit pending against toning shoes

The new fad of toning shoes might not be the best option for most of the general public.  To read the entire article regarding the lawsuit click here.

Lions rookie Nick Fairley has foot surgery

Lions cant catch a break!!!  Nick Fairley was injured in practice last Monday and underwent surgery a few days later.  He will have to miss a big portion of training camp and it is unsure if he will be ready by the start of the regular season.  To read the entire article click here.

Thursday, July 21, 2011

Aretha Franklin Breaks Toe over Jimmy Choos

The Doctors at Gulfcoast Foot and Ankle can take care of your fractures no matter how they happen! 

Click here to read story about Aretha Franklin.

Thursday, July 7, 2011

Kobe Bryant has Platelet Surgery on his Knee

The Doctors at Gulfcoast Foot and Ankle may not be able to do platelet surgery on knees but if you are having problems below the knee then platelet surgery might be right for you and we have the Doctors that can help!

Click here for the rest of the article.

Monday, June 27, 2011

Florida Gators Austin Maddox pitching in orthotics

Maddox suffered a sprained foot in the NCAA regionals a little over 3 weeks ago.  He is pitching tonight in the 1st of 3 games in the College World Series with a taped arch and custom made orthotics.

To learn a little more about his injury click here.

Wednesday, June 1, 2011

Have Smelly Feet?

Foot odor can occasionally happen.  But for some its always there.  Click here to reveal the reasons for smelly feet and ways to get rid of them.  You will be amazed that food, alcohol and adrenal stress can all change the smell of your feet.  There are many ways to help foot odor in this article......even one that usually treats wrinkles!

Plantar Fasciitis and Sports

Below is a link to an article all about Plantar Fasciitis.  Its affects many people each year and can be very debilitating to athletes.  Scott Podsednik, Chris Burgess and Tim Duncan are just a few athletes spoken about in this article that have had this keep them from playing.

Click here to read the full article

Monday, May 2, 2011

With diabetes, save a leg, save a life

Each year in the U.S. diabetes results in the amputation of about 65,700 legs or feet. About 85% of those began with a diabetic foot ulcer. And for Dr. David Schwegman, the mission to educate people about the issue is personal.
His father, a diabetic, had a foot ulcer that resulted in the amputation of his left leg, which contributed to his death, his son said.

"He became a statistic," Schwegman said. "He was one of the 50% of people that died within five years after having an amputation."

Diabetic foot ulcers, or DFUs, are usually located on the ball of the foot, the bottom of the big toe or sides of the feet. They can be a result of neuropathy, or nerve damage which leads to a loss of feeling.

Although prevention is key, simply not treating an ulcer can lead to infection, particularly in the bone, and eventual loss of a limb.

"If you have a DFU that leads to a major amputation, your risk of death in five years is greater is higher than that of breast cancer and prostate cancer combined," Schwegman said.

"This is a very, very serious health problem that has very serious risks if not dealt with properly and quickly," the doctor said. "In order to do that, we really need to get the word out to both the patients and the physicians."

That's where the Save a Leg, Save a Life Foundation , or SALSAL, comes in. On Saturday, Schwegman, along with the Atlanta chapter of the national group, are offering free foot screenings as part of the American Diabetes Association's Health Expo.

You can find an expo near you by visiting the American Diabetes Association's calendar for 2011. Diabetics can be screened for cuts, blisters, discoloration of feet, and any signs of bacteria or infections, conditions that can lead to foot ulcers.

Right now, 18.8 million adults and children in the U.S. have diabetes. The Centers for Disease Control and Prevention estimates that 7 million people have undiagnosed diabetes and 79 million are prediabetic.

Diabetics need to know that treating the ulcer early is the best way to get it healed.

"If we're not treating them aggressively, the chances that they heal is actually very, very low," Schwegman said.

An important part of the evaluation of a person with a diabetic foot ulcer is a thorough vascular exam, since diabetics have a higher risk of having peripheral arterial disease. The condition results when circulation to the legs and feet is blocked or narrowed by calcifications. The poor blood flow can cause pain and discoloration in the feet- an increase in a red color, a dusky bluish color or sometimes the toes turn black and result in amputation.

Dr. Desmond Bell, a wound care specialist and founder of SALSAL, recommends going straight to a podiatrist or wound care specialist if a cut, sore or wound does not heal in a week or two. Those with a history of diabetic foot ulcers should see a specialist immediately.

Bell said several newer treatments are available to treat these wounds. None are a "silver bullet" for every single wound.

SALSAL hopes to educate both physicians and the general public about them in order to prevent unnecessary amputations. Of the thousands of products available, only these three have evidence that they have increased wound healing rates:

-Advanced skin cell substitutes include Dermagraft and Apligraf. These are similar in that they are derived from neonatal foreskins.

-A growth factor gel, Regranex.

Hyperbaric oxygen therapy can also heal wounds and treat infections.

Most exciting, Bell said, is peripheral revascularization, in which cardiologists and others, go into the groin similar to an angioplasty for the heart. Through this new procedure, doctors can open up blockages in the leg and restore blood flow.

"It requires lots of doctors often times and it requires a motivated patient," Schwegman said. "By saving their leg, it really does save their life."

Tuesday, April 5, 2011

Bunions more common in women

New research has found that an increase in the severity of bunions not only increased foot pain and impaired mobility, but also affected people's general health and quality of life.
Bunion deformity was found in 36% of the study sample. It occurred more frequently in women and older individuals. The study also found that pain in other parts of the body beyond the foot was associated with increased bunion severity.
Associate Professor Hylton Menz of La Trobe University in Melbourne, Australia, and colleagues at the Arthritis Research UK Primary Care Centre, Keele University examined the prevalence of and factors associated with hallux valgus – bunions.
The Medical Research Council funded study assessed the severity of deformity on general and foot-specific Health Related Quality of Life (HRQOL) of 2,831 people aged 56 years or older in North Staffordshire.
The research team established five severity grades of hallux valgus, corresponding to the angle of deformity - from 0, 15, 30, 45, and 60 degrees.
Results showed that the impact of increasing hallux valgus severity on HRQOL is independent of age, sex, education, body mass index, and pain in other parts of the body.
They also revealed that impact of bunion extends beyond pain and physical function to affect general health, vitality, social function, and mental health.
"Our findings indicate that hallux valgus is a significant and disabling musculoskeletal condition that affects overall quality of life," concluded Associate Professor Menz.
"Interventions to correct or slow the progression of the deformity offer patients beneficial outcomes beyond merely localised pain relief."
Hallux valgus is a common foot condition that is caused when the big toe bends in towards the smaller toes. It develops over time and is accompanied by a painful soft tissue and bony protrusion, known as a bunion.
As the deformity progresses the lateral displacement of the hallux (big toe) begins to interfere with normal alignment and function of the smaller toes, leading to further deformities such as hammer toe or claw toe, altered weight-bearing patterns, and the development of corns and calluses.
Family history, wearing high-heeled shoes or shoes that are too narrow, and flat footedness have all been suggested to contribute to the development of bunions.
Details of this UK population-based study appear in the March issue of Arthritis Care & Research, a journal published by Wiley-Blackwell on behalf of the American College of Rheumatology (ACR).

Monday, March 21, 2011

American Diabetes Association ALERT! DAY

Americans are urged to “Join the Million Challenge” on American Diabetes Association Alert DaySM by taking the Diabetes Risk Test and finding out if they are at risk for developing type 2 diabetes
Tuesday, March 22, 2011 is the 23rd annual American Diabetes Association Alert Day, a one-day, “wake-up” call  asking Americans to “Join the Million Challenge” by taking the Diabetes Risk Test and find out if they are at risk for developing type 2 diabetes and if they are at high risk, to speak with their health care provider.
At the end of 2010, the American Diabetes Association surpassed their goal of inspiring one million Americans to join the American Diabetes Association’s movement to Stop Diabetes®.  To continue this momentum, the Association is asking the public to “Join the Million Challenge” by rallying one million people to take the Diabetes Risk Test and find out if they are at risk for developing type 2 diabetes, beginning on Diabetes Alert Day on March 22, 2011 and ending April 22, 2011.
Diabetes is a devastating disease that affects nearly 26 million Americans including. A quarter of those affected by diabetes are not aware that they have the disease.  If current trends continue, one in three American adults will have diabetes by 2050. In addition, approximately 79 million, or one in three American adults have prediabetes, which means that their blood glucose (sugar) is higher than normal but is not high enough to be classified as diabetes.  Without intervention, individuals with prediabetes are at a much higher risk for developing type 2 diabetes.  Seeking to change the future of diabetes, the American Diabetes Association is using Diabetes Alert Day to help identify the undiagnosed and those at risk for type 2 diabetes by educating people about diabetes risk factors and warning signs.
Unfortunately, people with type 2 diabetes can live for years without realizing that they have this serious disease. While some people with diabetes exhibit noticeable symptoms (such as frequent urination, blurred vision and excessive thirst), most people diagnosed with type 2 diabetes do not experience these overt warning signs at the time that they develop the disease.  Often, type 2 diabetes only becomes evident when people develop one or more of its serious complications, such as heart disease, stroke, kidney disease, eye damage or nerve damage, which can lead to amputation.
2011 Diabetes Alert Day
“Studies have shown that type 2 diabetes can be prevented or delayed by losing just 7% of body weight (15 pounds if you weigh 200) through regular physical activity (30 minutes a day, five days a week) and healthy eating,” said Gina Perales Hethcock, Director of Communications and Hispanic Initiatives for the North Texas office. “The American Diabetes Association hopes that this American Diabetes Association Alert Day will encourage people to ‘Join the Million Challenge.’ By understanding your risk, you can take the necessary steps to help prevent the onset of type 2 diabetes.”
To help people determine their risk for type 2 diabetes, the American Diabetes Association provides the Diabetes Risk Test, which entails answering simple questions about weight, age, family history and other potential risk factors for diabetes. People at high risk are encouraged to speak with their health care providers.  You can “Join the Million Challenge” by getting your free Diabetes Risk Test (English or Spanish) at, 1-800-DIABETES (1-800-342-2383) or text JOIN to 69866 (Standard data and message rates apply).  Although Diabetes Alert Day is a one-day event, the Diabetes Risk Test is available year round.
The Association is also encouraging the public to help spread the word about Diabetes Alert Day by sending out messages on Facebook and Twitter.  You can download a Diabetes Alert Day application to post on your Facebook page or you can tweet about the importance of understanding one’s risk for type 2 diabetes and provide a link to the Diabetes Risk Test at
The primary risk factors for type 2 diabetes are being overweight, sedentary, over the age of 45 and having a family history of diabetes.  African Americans, Hispanics/Latinos, Native Americans, Asian Americans and Pacific Islanders are at increased risk, as are women who have had babies weighing more than nine pounds at birth.

Laser is new tool in targeting toenail fungus

'Diabetes belt' emerges in Southeast U.S.

Individuals who live in one of several Southern states are significantly more likely to receive a positive HbA1c test for diabetes, as a new study from the Centers for Disease Control and Prevention has identified what officials are calling the "diabetes belt" of the U.S.

The belt stretches from Pennsylvania in the Northeast to Texas in the Southwest and includes all the states in between. The rate of diabetes in these states is 11 percent, compared to a national rate of 8 percent.

The researchers said that obesity and sedentary lifestyles were most likely the causes of this discrepancy. Nearly 33 percent of people from these states are obese, while the national average is 26 percent. More than 30 percent are largely sedentary, compared to a national rate of 24.8.

Identifying areas where prevalence of the disease is highest could allow public health officials to direct their resources more efficiently and hopefully contain diabetes, the researchers said.

"Identifying a diabetes belt by counties allows community leaders to identify regions most in need of efforts to prevent type 2 diabetes and to manage existing cases of the disease," said Lawrence E. Barker, who led the study. "Although many risk factors for type 2 diabetes can't be changed, others can."

Wednesday, March 9, 2011

Why Does My Big Toe Joint Hurt Part 3

Well folks, its official....I had my first pain free run in months!  I was about a mile into my run yesterday and I thought to myself, "Wow my toe doesnt hurt a bit!"  I ran 3 10 minute miles and my toe is not sore at all today.  Other parts of my body...well that is a different story.  Dr. Gordon is truly special and has helped me a lot.  I am a firm believer of orthotics now.  Also I have noticed that when I walk up stairs the cracking and popping in my knees has decreased dramatically!  Im only 30 so that is a GREAT thing.

Today I developed blisters on my heels from my stupid dress shoes.  I put my orthotics in them but I didnt take the shoe inserts out.  I think that may be the trick.  My shoes were rubbing too high on my heels. toe still doesnt hurt so that is a big plus.  Its all trial and error.  Who knows maybe I will get my husband to dish out some cash for better dress shoes that my orthotics fit nicely in.  Its a medical necessity right????!!!!

Paramedic took severed foot from car crash victim... to use it to train her dog

By Daily Mail Reporter

Last updated at 11:19 PM on 8th March 2011

A former paramedic who admitted to taking a man's severed foot from the scene of a crash is now being sued for going 'beyond the bounds of decency'.

Cynthia Economou, a former fire-fighter-paramedic from Florida, admitted to taking Karl Lambert's foot in September 2008 to use as a training aid for her body recovery dog.

But now Mr Lambert is seeking unspecified damages in a lawsuit issued last week.

Enlarge Sued: Cynthia Economu is now being sued for taking a foot she found in a car wreck in 2008. She said the foot was used to train her cadaver dog

The lawsuit lists the taking of the foot as: 'Outrageous and went beyond the bounds of decency...was odious and utterly intolerable in a civilized society.'

Economou was originally sentenced to six months probation in 2009 for second-degree petty theft.

At the time, she told a court the foot was unusable when she found it at the crash scene an hour after Mr Lambert was airlifted to hospital.

She said: 'It was an unrecognisable mass of flesh.

'It wasn't a clean cut. You couldn't even recognise it as a foot....If I had thought it was somehow re attachable and usable, I would have gone to my commander.'

The lawsuit, however, contends that Economou: 'Removed the leg rather than delivering it to the hospital where it could have been reattached.'

At the time of her 2009 arrest, police records show the foot was valued at less than $100.

At the time it was alleged that Economu brought the amputated foot to a fire station before a family member brought it home to use for training her cadaver dog.

Body recovery or 'cadaver' rescue dogs help search teams find dead bodies in murder or disaster recovery situations.

They are trained to sniff out decaying of putrefied human remains in a range of climates, including freezing water.

Crash: This is the car crash where the foot was found by Miss Economu in 2008

Speaking to website TCpalm at the time she said: 'This is just so unbelievable, it’s like a dream I’m in.

'I can’t believe it’s happening.'Economou left her paramedic job after the incident came to light.

Mr Lambert had to have his leg amputated roughly five inches below the knee after the accident.

She was sentenced to six months probation, but was not formally convicted of the crime.

In 2007 Economou was named St Lucie County fire fighter of the year.

Monday, March 7, 2011

Yanks C Cervelli out indefinitely with broken foot

TAMPA, Fla. – New York Yankees backup catcher Francisco Cervelli will be in a protective boot for at least four weeks because of a broken left foot, and it's uncertain when he'll be able to play again.
Cervelli was hurt when he fouled a ball off his foot Wednesday against Houston, and the break is above the toes. Yankees manager Joe Girardi announced the extent of the injury before Friday night's game against Boston.
Test results will be reviewed by a foot specialist. It's not known how long it will take for Cervelli to complete a rehab program once the boot is removed.
"How long it would take after, if it was healed, you don't know," Girardi said.
Girardi said there are no current plans to use Jorge Posada, who is moving from catcher to designated hitter this season, behind the plate in spring training games.
"I can't tell you 100 percent, exactly, what's going to happen over the next four weeks," Girardi said. "I can't. Just like I wouldn't have predicted this, but right now I don't plan on having him really catch in a game. We'll see what the other guys can do."
Jesus Montero, Austin Romine and Gustavo Molina are the top contenders to back up starter Russell Martin, who had offseason surgery to repair a minor tear in his right knee.
"We still have plenty of guys here that could earn that spot," Girardi said. "Basically what it does, it eliminates a catcher from the opening day competition."
Cervelli does not have much luck in spring training. Last season he was sidelined with a concussion and in 2008 he broke his wrist in a collision at the plate.
"He's had a rough go at spring training," Girardi said. "I feel for him. You could see the disappointment when we walked over to tell him."
Montero played at Triple-A last season and Romine was in Double-A. Molina has 23 games of major league experience, including four with the Red Sox last season.
"When you look at Montero and Romine, the one thing they're lacking was the big league experience," Girardi said. "But, they're not lacking in talent. We're not sure, if it's one of the kids, how they're going to handle it, but we might find out."
NOTES: RHP Rafael Soriano, the former Tampa Bay closer who be the primary eighth-inning setup man for closer Mariano Rivera, threw 20 pitches during his first batting practice session. Bradley Suttle and Daniel Brewer put the ball in play in just three of 11 swings. "Probably as many swings and misses in a batting practice session as I've ever seen," Girardi said. Soriano could be ready for his first game action after one more BP outing.

Friday, February 25, 2011

Why Does My Big Toe Joint Hurt: Part 2

Well its been a little over a week wearing my orthotics.  I must say that the biggest challenge about wearing these is getting used to tennis shoes and socks....not the orthotics.  Living in Florida has put me in the bad habit of wearing thin, crappy flip-flops.  I took my first long walk with them in on Tuesday.  My toe was a little bit stiff at first but once I started walking it felt pretty darn good.  The bad part of my walk was the squeaking.  It was so loud it made me self conscious.  The good part of my walk is that my destination was the grocery store where I could pick up some baby powder.  As soon as I took my orthotics out and sprinkled baby powder in the bottom of my shoes the menacing noise disappeared.

Wednesday I had a softball game and I wanted to wear them but Im not to that point yet.  Not because they are not comfortable but because Im too superstitious!  I know that it is extremely silly but hopefully Dr. Gordon will understand. My toe really doesn't hurt as much as it used to so I am pretty excited that the orthotics are making a difference.  Tomorrow will be the big test....I am going to take a run in them.  Wish me luck!

Wednesday, February 16, 2011

Why Does My Big Toe Joint Hurt

As  I walked into Gulfcoast Foot and Ankle I was greeted by the familiar faces behind the desk.  I was not walking in as an employee that day, but for the first time as a patient.  For about 5 months now my big toe joint has hurt me pretty badly.  Why would I wait so long to see a podiatrist….especially when I work for one!?  Well I guess the main reason is sheer stupidity.  But in all honesty I just figured the pain would go away.  Well it did not so there I sat in the waiting room to see Dr. Gordon.  He was extremely surprised to see me thinking I stopped by to discuss marketing strategies or to go over the Student Scholar Athlete Awards we need to present….no Dr. G Im here as a patient.  I was placed in a chair and asked a few questions and he decided the best thing to do was some simple x-rays to see what was going on in that toe joint.  A lovely lady appeared in the room and whisked me away to the x-ray machine.  After a few minutes I was back in the chair studying my bones with Dr. Gordon.  Hallux Limitus, Dr. Gordon told me with no look of question or doubt in his face.  

Hallux Rigidus/Limitus involves the 1st metatarso-phalangeal joint.  This joint is located at the base of the big toe.  Hallux Rigidus/Limitus causes pain and stiffness in the big toe, and with time it becomes increasingly harder to bend the toe.  This is a progressive condition during which the toe's motion decreases as time goes on.  In the early stages, motion of the big toe is only limited, and at this point, the disorder is called Hallux Limitus.  As the problem advances, the big toe's motion gradually decreases until it becomes rigid or frozen.  At this point, the disorder is referred to as Hallux Rigidus.  As motion becomes progressively limited, pain increases, especially when the big toe is extended, or pushed up. 
Great…what now… was the only thing I could think.  Im trying to start running and this really was putting a damper on things!!  Dr. Gordon decided to cast me for orthotics.  My feet are flat I had this Hallux Limitus thing going on so it seemed like the best thing to do.  He had me lay on my back and lay on my stomach and took measurements of my feet.  Then he proceeded to put strips of wet plaster on my foot to make a mold.  He made quick work of the plaster and before I knew it he was taking these white molds off my feet that sort of resembled a thin version of a wooden shoe from Holland that looked just like my foot!  So off to the lab went my feet molds.
This morning a received the call that my orthotics were in!  I was so excited to see what they would feel like.  I packed up my sneakers and socks and headed to the office.  This was a special trip because I was going to the office today as both an employee AND a patient.  Dr. Gordon put the orthotics in my shoes and told me to give them a try.  My feet felt AMAZING!!!  Even after 1 minute of walking in them my feet felt so good.  The pain in my toe isn’t gone yet but Im sure it will take more than 2 minutes.  I was almost sad that I was only allowed to wear them for a couple of hours today.  But…Doctors orders!  I will let you know next week the progress that I am having since I will be wearing them a lot more then.

Tuesday, February 15, 2011

Jennifer Grey of DWTS has Foot Neuroma Removed

Jennifer Grey has undergone surgery to have a neuroma removed from her foot.
The 50-year-old Dirty Dancing actress and Dancing With The Stars champion, said that the growth got worse after her stint on the show, leaving her with no option but to have the surgery.
Writing on Twitter, she said, 'Hard to believe, but I just had my foot operated on so hopefully I can walk again. Gotta dance. Miss you all. I guess that's the price of doing business when you kick ass like that at my age... haha.
'I had a neuroma the size of a small city removed. I think I went down a shoe size on one foot. After Dancing With The Stars it just got worse and worse, so do whatcha gotta do.'
She added, 'Ain't no thang. Pain is just a feeling. Then it's gone.'
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Tuesday, February 8, 2011

Study finds increase in running-related injuries among children

The annual number of running-related injuries has increased 34% during a 14-year period, according to a study published in the Feb. 2011 issue of Clinical Pediatrics.
Investigators examined running-related injuries — primarily sprains and strains to the lower extremities — among children and adolescents aged 6 to 18 years, finding an estimated 225,344 cases treated in emergency departments throughout the United States from 1994 to 2007. The data was collected from the National Electronic Injury Surveillance System.
One-third of the injuries involved a fall, the investigators noted, and more than 50% of running-related injuries occurred at school. The injuries varied by age, however, with children aged 6 to 14 years being more likely to suffer injury as the result of a fall or while running at school. Adolescents 15 to 18 years of age were more likely to sustain injuries while running in the street or at a sports and recreation facility.
“Encouraging children and adolescents to run for exercise is a great way to ensure that they remain physically active,” investigator Lara McKenzie, PhD, stated in a press release. “However, the findings from our study show that formal, evidence-based and age-specific guidelines are needed for pediatric runners so that parents, coaches and physical education teachers can teach children the proper way to run in order to reduce the risk of injury.”
The authors noted that this is the first study to examine a nationally representative sample of running-related injuries treated in U.S. emergency departments, but added that further research is necessary to thoroughly understand pediatric running-related injuries and the role injury prevention can play in reducing them.
  • Mehl AJ, et al. Running-related injuries in school-age children and adolescents treated in emergency departments from 1994 through 2007. Clin Pediatr. 50(2);126-132. doi: 10.1177/0009922810384719.

Wednesday, February 2, 2011

Flat Feet Are Associated With Knee Pain and Cartilage Damage in Older Adults

Researchers assessed the cross-sectional relation of planus foot morphology to ipsilateral knee pain and compartment-specific knee cartilage damage in older adults. The study, of 1,900 adults in their 50s or older, found that those with the flattest feet were 31 percent more likely than other study participants to say they had knee pain on most days. And they were 43 percent more likely to show damage to the cartilage at the inside of the knee.

Dr. Gordon has always believed that bad knees can be caused or exacerbated by flat feet. In 1994 he was talking about a research project with the Chairperson of the Department of Orthopedics at the University of Washington to see if a well made orthotic device would prevent knee surgeries specifically joint replacement surgery. Regrettably he left Seattle before the project could get off the ground.



To assess the cross-sectional relation of planus foot morphology to ipsilateral knee pain and compartment-specific knee cartilage damage in older adults.


In the Framingham Studies, we adapted the Staheli Arch Index (SAI) to quantify standing foot morphology from pedobarographic recordings. We inquired about knee pain and read 1.5 Tesla MRIs using whole-organ magnetic resonance imaging scoring. Logistic regression compared the odds of knee pain among the most planus feet to the odds among all other feet, and estimated odds within categories of increasing SAI. Similar methods estimated the odds of cartilage damage in each knee compartment. Generalized estimating equations adjusted for age, sex, BMI, and non-independent observations.


Among 1903 participants (mean age 65± 9 years; 56% female), 22% of knees were painful most days. Cartilage damage was identified in 45% of medial TF, 27% of lateral TF, 58% of medial PF, and 42% of lateral PF compartments. Compared with other feet, the most planus feet had 1.3 (95% CI: 1.1, 1.6) times the odds of knee pain (p=0.009), and 1.4 (95% CI: 1.1, 1.8) times the odds of medial TF cartilage damage (p=0.002). Odds of pain (ptrend=0.05) and medial TF cartilage damage (ptrend=0.001) increased linearly across categories of increasing SAI. There was no association between foot morphology and cartilage damage in other knee compartments.


Planus foot morphology is associated with frequent knee pain and medial TF cartilage damage in older adults.

Tuesday, January 25, 2011

A Guide To Conservative Care For Adult Flatfoot

Author(s): Patrick DeHeer, DPM, FACFAS, and Jessica Taulman, DPM

In recent years, the management of adult flatfoot has shifted from early surgical treatment to more conservative options for this commonly seen condition. Accordingly, these authors discuss the evaluation of adult flatfoot and enumerate various conservative methods to consider as initial treatment.

Adult flatfoot is a common problem we, as podiatrists, see every day. Without early identification of the problem, the flatfoot deformity can progress.

There has been a shift in protocol over the years from surgical treatment early on in the diagnosis of adult flatfoot to a more valiant attempt at conservative treatment. In 1997, Sferra and Rosenberg stated that “conservative management is a critical part of initial treatment of posterior tibial tendon insufficiency, especially in patients with advanced age, sedentary lifestyle and medical comorbidities that preclude surgical intervention.”

In order to provide adequate treatment, whether it is surgical or conservative, to a patient with flatfoot, it is important to evaluate the patient clinically and radiographically to determine the cause of his or her flatfoot deformity. During the physical exam, the patient should stand during the observation. The physician should look for asymmetrical swelling, abduction of the forefoot and pes planus.

One should perform the bilateral heel rise test. When the heels appear asymmetrical or there is not a complete heel rise, consider posterior tibial tendon dysfunction (PTTD). Also perform the single limb heel rise. Incomplete inversion of the heel on toe rise or difficulty performing this test should alert the practitioner to a problem with the posterior tibial tendon.

During a seated exam, palpation of the tendon is necessary to evaluate soft tissue swelling and tenderness along the course of the tendon. To test motor strength, the podiatric physician should have the patient invert the foot against resistance with the foot plantarflexed to keep the tibialis anterior from substituting.

Radiographic evaluation reveals lateral subluxation of the talonavicular joint, an increase in the talo-first metatarsal angle and an increase in the divergence of the talus and calcaneus on the AP view. The lateral view will demonstrate plantarflexion of the talus, a decrease in the lateral talocalcaneal angle and collapse of the longitudinal arch. As the deformity progresses, the subtalar and talonavicular joints narrow. Ankle radiographs show arthritis and talar tilt in a longstanding deformity.

After clinically and radiographically evaluating the patient with a flatfoot deformity, it is important to distinguish between a flexible and rigid deformity. One can do this by evaluating the range of motion of the subtalar joint and perform the Hubscher maneuver (“Jack’s test”). If the arch cannot be recreated and the subtalar joint motion is limited, one must suspect a tarsal coalition or rigid flatfoot.

After determining whether the flatfoot deformity is rigid or flexible, the clinician should further evaluate the flexible flatfoot to determine the level of involvement of the posterior tibial tendon (PTT). The PTT is often the culprit of flexible adult flatfoot. The tendon is located posterior to the axis of the tibiotalar joint and medial to the axis of the subtalar joint. It functions to plantarflex and invert the foot.

The PTT also creates a rigid lever during gait.

When it is not functioning properly, the tendon is unable to form the rigid lever needed for gait and the forward propulsion of the gastroc-soleus complex acts at the midfoot, thus causing midfoot collapse. The PTT is injured by a combination of vascular insufficiency and the mechanical pulley of the tendon along the medial malleolus.

A Primer On PTTD Classifications

Johnson and Strom developed a PTTD classification system, which was later modified by Myerson to include stage IV.

Stage I. Peritendinitis and tenosynovitis of the posterior tibial tendon present. The rearfoot remains mobile and the patient has pain medially. A single heel rise test reveals mild weakness to the posterior tibial tendon.

Stage II. The posterior tibial tendon is elongated and attenuated. The rearfoot remains mobile. However, the calcaneus is in valgus on stance. There is still pain medially. The patient is still able to perform the single heel rise test although it is weak. A positive “too many toes” sign is present.

Stage III. Degeneration of the posterior tibial tendon is evident. The rearfoot becomes fixed and less flexible, and the calcaneus remains in valgus on stance. The patient may have pain both medially and laterally due to impingement laterally. A positive “too many toes” sign is visible.

Stage IV. A valgus tilt to the talus in the ankle mortise and early degeneration of the ankle joint are present.

Conti and colleagues developed another common classification system.11 This classification system is based on MRI and evaluates the state of the posterior tibial tendon.

Type I tear. One or two fine longitudinal splits occur in the tendon without degeneration of the tendon.

Type II tears. This involves wider, longitudinal tendon splits and intramural degeneration. The tendon also may show a variable diameter on selected cuts where a bulbous section may be distal to an attenuated portion.

Type III tears. More diffuse swelling and uniform degeneration of the tendon are present. A few tendon strands may remain or the tendon may be replaced entirely with scar tissue.

Current Concepts In Conservative Treatment

Goals for conservative treatment of flexible flatfoot include eliminating clinical symptoms, improvement of rearfoot alignment and prevention of progressive deformity.

Treatment for flexible flatfoot generally begins with immobilization via a removable cast boot or below the knee cast for up to six to eight weeks. This decreases inflammation and prevents overuse for acute tenosynovitis. Steroid injection into the tendon sheath for tenosynovitis continues to be controversial due to the adverse effect of tendon rupture.

One may also utilize UCBL orthotics to stabilize the rearfoot. These are helpful in patients with a stage II deformity because the rearfoot is flexible and passively correctable in this stage. These orthotics limit the range of motion of the subtalar joint and forefoot abduction. Other orthotics may have a medial posting, like the Blake inverted orthotic, to decrease the strain on the posterior tibial tendon medially and push the foot into a more rectus position.

Changes in shoegear and shoegear modifications are often beneficial to patients with a flexible flatfoot deformity. An extra depth shoe is able to provide a long rigid medial counter, a soft leather upper, high toe boxes and soft soles to absorb some ground reactive forces during gait.

One can add a medial stabilizer to the shoe as well as a rocker bottom to assist in toe off. It is also possible to add a medial wedge inside the shoe to support the posterior tibial tendon.

The Baldwin Boot Brace (Bolt Systems) is able to provide edema control, stability of affected joints and soft tissue protection. This low-profile device controls and restricts subtalar joint motion. This boot is able to provide good control of tibial rotational forces and has anterior padding to protect the anterior lower leg. One can use the Baldwin Boot Brace for patients with stage III deformity and patients with a fixed deformity as it holds the deformity and protects soft tissues.

A temporary bracing option for posterior tibial tendon tenosynovitis is a stirrup brace. This brace is not able to control motion in the sagittal plane but it is able to help unload the posterior tibial tendon by transferring plantarflexion to the Achilles tendon and relieves strain from plantarflexion from the posterior tibial tendon.

A short ankle-foot orthotic (AFO) is helpful for stage II PTTD. This is able to control and restrict the subtalar joint more than orthotics alone. Use a tall AFO in stage III cases because the rearfoot can no longer be passively corrected to neutral. This tall AFO is able to prevent pronation during push off. The AFO also stabilizes the mediolateral movement of the ankle and limits excursion of the posterior tibial tendon by preventing plantarflexion and pronation.

There are numerous types of AFOs that are options. One common AFO is the Arizona brace. This brace reduces rearfoot valgus and midfoot collapse. The Richie brace is another effective AFO, which clinicians can use to help address the early stages of posterior tibial tendon dysfunction.

The patellar tendon bearing brace is an option to consider for elderly patients. This redistributes weight to the patellar tendon, medial tibial flare and popliteal area.

Iontophoresis with dexamethasone is a physical therapy modality. While this option is not as commonly employed as bracing options, iontophoresis can provide effective relief of inflammation to the PTT. There are no documented risks of tendon rupture with this modality and one may use this as a substitute for the controversial steroid injections into the tendon sheath.

To further determine which treatment options are helpful for patients with various stages of flatfoot, see “Recommended Treatments For Different Flatfoot Stages” at top right.

Other Considerations In Managing Flatfoot

Stretching of the gastroc-soleus complex is also important to consider. A tight heel cord increases the levering upward on the calcaneus and increases tension on the plantar fascia and ligamtents. When a flatfoot deformity occurs, the Achilles tendon assumes a position lateral to the subtalar joint axis and the gastroc-soleus shortens over time. Thordarson demonstrated that the Achilles tendon has a threefold greater effect on the deformation of the arch than the PTT has on supporting the arch.

Equinus is an essential piece to the puzzle of adult flatfoot that one should treat in order to reduce the pain and deformity. Adding a heel lift to orthotics or bracing will also help eliminate the equinus component to the flatfoot deformity.

The peroneus brevis is another muscle that one should consider when evaluating adult flatfoot.

Mizel and colleagues evaluated 10 patients with loss of both the peroneal tendon and the posterior tibial tendon due to common peroneal nerve palsy.17 This study showed that after five years, there were no patients who developed a flatfoot deformity. The authors concluded that the posterior tibial tendon and the peroneus brevis provided the balance of the foot medially and laterally. Since these tendons were not functioning, neither provided unopposed force. With no unopposed force, a rearfoot valgus did not result. The authors determined from this result that dysfunction of the posterior tibial tendon alone was not enough to cause a flatfoot deformity.

Tarsal coalition can result in a rigid flatfoot that causes a static foot deformity. The talocalcaneal and calcaneonavicular joints are common joints involved in tarsal coalition. Accommodative orthotics are first line treatment for flatfoot caused by tarsal coalition.

Final Thoughts

Conservative treatment is often able to decrease pain and the progression of flatfoot deformity. Early detection and treatment of posterior tibial tendon dysfunction can keep the deformity from progressing to further stages in the adult flatfoot scheme. Therefore, it is important to do a thorough history and physical exam with radiographic studies. Surgical correction is indicated for both complete posterior tibial tendon rupture and progressive deformity of the foot.

Should tenosynovitis persist after an extended period of conservative treatment, one should consider surgical correction as well. It is important to evaluate the patient thoroughly to be certain that one has explored the proper treatment methods.

Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and is a Diplomate of the American Board of Podiatric Surgery. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis.

Dr. Taulman is a first-year resident at Westview Hospital in Indianapolis.

Sunday, January 9, 2011

Zsa Zsa Gabor's Lower Leg To Be Amputated

UPDATE: Doctors decided Monday to try an aggressive course of antibiotics in order to avoid having to amputate. They say they won't know until Tuesday, when she undergoes the second half of the treatment, if the meds are working.
Some more bad news for Zsa Zsa Gabor: After a New Year's celebration filled with champagne and caviar, the veteran diva returned to the hospital on Sunday to have the lower part of her right leg amputated.
The 93-year-old was rushed by ambulance to Ronald Reagan UCLA Medical Center after doctors ordered the surgery.
"She wanted to stay home and have a holiday. They wanted to do this before the holiday, but now the doctors have forced us," the actress's husband, Prince Frédéric von Anhalt, told People.
What exactly went so wrong?
Gabor, who has been in poor health since suffering complications from hip surgery over the summer, had recently developed a lesion on her swollen leg. The wound, which did not respond to treatment, had quickly grown from just over an inch to nearly a foot in length.
"Doctors had wanted to operate on it for several days," said Gabor's spokesman, John Blanchette, but the actress wanted to first spend New Year's at home with von Anhalt.
"Frédéric and Zsa Zsa asked if they could spend New Year's at home, and [they] shared champagne and caviar. The doctors came to the house [Sunday], and when they unwrapped the bandages, the wound had festered and they were afraid of gangrene developing, which would be life-threatening," Blanchette said.
She was then taken to the hospital and prepped for surgery in the early evening.
"It's a dangerous operation, but the upside is that, if successful, she will remain her same old feisty self for a few more years," Blanchette said.
The Hungarian actress has been confined to a wheelchair since a 2002 car accident. Three years later, in 2005, she suffered a stroke, and has since experienced more health problems.
Before this latest emergency, Gabor had fallen out of bed and broken several bones. She was sent home a month later this past August but two days later was rushed back and even read her last rites by a priest.

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