Hughston

Health 6262 Veterans Parkway P.O. Box 9517 ColumbusAler GA 31908-9517 t VOLUME 12, NUMBER 3 www.hughston.com SUMMER, 2000

Forefoot Deformities Fig. 1 Bunion Hallux valgus The forefoot can develop several deformities that can cause pain, functional problems, and deformities of other toes. Thick calluses form over points where the deformed area presses into the shoe, and they can ulcerate and become infected in severe cases. Proper treatment helps relieve the pressure points and your pain.

Great toe deformities The largest of these deformities is a bunion, which is a bulge of the bone at the base of the great toe (Fig. 1). It protrudes to the outside of the foot and presses against the shoe. This pressure causes inflammation in the skin over the bunion and severe pain. Often the great toe angles away from the bunion and presses against the small toes. This condition is The Hughston called hallux valgus and can cause Narrow toe box Foundation, Inc. ©2000 deformities in the small toes too. after Some people have a greater tendency than others to develop bunions and conditions most often affect the hallux valgus. Wearing shoes with second toe because it usually is the Inside This Issue: heels and narrow toe boxes is a major longest and is forced into the tip of  In-Toeing in Children cause of these deformities. Thus, the shoe. Hammer toe means that the women have 10 times the risk that toe contracts all of its joints and curls  Heel Pain men have for these problems. upward. The curling creates pressure  Lightning and Its Hazards on the tip of the toe, on the top of its Small toe deformities middle joint, and under the ball of the  Taking Care of Heel Pain The small toes generally can form foot. The pressure produces severe two types of deformities: hammer  Turf Toe pain at these points. Mallet toe causes and mallet contractures (Fig. 2). These just the tip of the toe to contract and Page 1 FOR A HEALTHIER LIFESTYLE the bone and can wear regular shoes, but you Fig. 2 Hammer toe adjusting the may have some soreness for several ligaments more months until the foot and toes (tissues that completely heal. connect two Forefoot deformities cause severe bones) of the pain or disability that may need to affected toe. be treated with surgery. Remember, Recovery to prevent deformities, ensure that takes time. you wear low-heeled, properly fitted To correct shoes that have wide toe boxes. Improperly fitted shoes the bunion can cause these lesser deformity, Stephen C. Hunter, M.D. toe deformities. the surgeon Columbus, Georgia removes the bulging Further reading: 1. American Orthopaedic Foot and Ankle Soci- portion of after ety. The adult foot. http://www.aofas.org/adult- the bone and foot.html To order a hard copy of the brochure, tightens the send a self-addressed, stamped envelope to: toe’s ligaments AOFAS, 1216 Pine Street, Suite 201, Seattle, WA 98101. Specify the name of the brochure. (Fig. 3). Mallet toe 2. American Academy of Orthopaedic Sur- Sometimes, he geons. Common foot problems. http://www. or she needs aaos.org/wordhtml/pat_educ/commfoot. The Hughston Foundation, Inc. ©2000 to realign htm For a hard copy, send a self-addressed, causes pressure on this area. Again, the midfoot bone (below the toe) to stamped envelope to: AAOS, 6300 North River Road, Rosemont, IL 60018-4262. Specify the wearing tight, short shoes adds to the correct more severe deformities. This name of the brochure. pressures that cause and aggravate procedure involves cutting the bone small toe deformities. and stabilizing it with pins and screws. The surgeon corrects small toe Nonoperative treatment deformities by cutting out bony Nonoperative treatment for these portions of conditions focuses on relieving the the affected Fig. 3 Midfoot realigned and pressure points. Wearing properly toe, loosening secured with a screw. fitted shoes with toe boxes that allow the ligaments, toes to move freely can alleviate and putting in much pressure. Your shoes should a temporary have heels that are no higher than pin to allow two inches and should have toe boxes the toe to heal that are no more than one-fourth straight. inch narrower than the widest part of To enable your forefoot. Special pads that you the foot to can purchase at the local pharmacy heal properly relieve pressure points on the ball of after surgery, the foot and on the toes. However, you must wear these devices do not correct the protective deformities. shoes and Operative treatment splints and use If you have extreme or disabling crutches while pain, you may need surgery to correct continuing your daily the deformity and, thus, permanently Bone shaved, fragment removed, activities. In resolve the pressure problems. and an osteotomy performed to two to three Surgery involves shaving or cutting realign the metatarsal bone. months, you The Hughston Foundation, Inc. ©2000 Page 2 FOR A HEALTHIER LIFESTYLE Most children’s that requires special treatment. For Fig. 1 feet straighten example, it may occur if one or both naturally without parents had rotational deformity treatment. (twisting of the bones). In-toeing may Occasionally, occur in children with a condition they need casts, such as cerebral palsy. Therefore, orthoses, or the doctor will take a careful special shoes medical history as part of the child’s to correct the evaluation. Through the evaluation, condition. In rare an orthopaedist can determine what, cases, correction if any, treatment is necessary for in- does not occur toeing in a child. naturally or with nonoperative James Alfandre, M.D. treatment, so the Columbus, Georgia child may need surgery. Further reading Internal 1. Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. 4th ed. Phila- tibial torsion delphia, PA: Lippincott-Raven; 1996. and femoral 2. Wenger DR, Rang M, eds. The Art and anteversion Practice of Children’s Orthopaedics. New The Hughston Foundation, Inc. ©2000 are similar York, NY: Raven Press; 1993. conditions, In-Toeing in Children which are often called knock knees. The Hughston Foundation, Inc. ©2000 The former refers to twisting of Noticing that your child or the tibia (shin bone); the latter, grandchild’s feet turn in can cause to twisting of the femur (thigh Femoral alarm, prompting a visit to the bone) (Fig. 2). Each condition (thigh bone) pediatrician or orthopaedist. Such causes the foot to turn inward. anteversion a condition may become apparent Twisting of these bones is normal shortly after the child is born or when in a young child and typically the child begins to stand or walk. resolves as he or she grows. Often, the walking child seems to With internal tibial torsion, the be clumsy or to trip over his or her leg gradually straightens by age feet. One or a combination of three three; with femoral anteversion, processes most commonly cause by age eight. Pediatricians in-toeing: metatarsus adductus, and orthopaedists once used internal tibial torsion, and femoral special shoes, night splints, and anteversion. Fortunately, they rarely cables to “untwist” these bones. require treatment and usually get However, treatment does not better with time. change the natural course of the Internal Metatarsus adductus, often called conditions and, therefore, is not tibial pigeon toes, is the most common recommended. Straightening (shin bone) foot condition seen by orthopaedists of the legs with surgery is rarely torsion who treat children. It occurs when needed and is not performed the front of the foot is turned inward, until natural correction has facing the other foot (Fig. 1). Boys and stopped. girls are equally affected. Although Although in-toeing usually the cause is not known, some doctors results from one of these think it results from the child being conditions, it also may be due Fig. 2 The Hughston Foundation, Inc. ©2000 tightly packed in the mother’s womb. to a less common condition Page 3 FOR A HEALTHIER LIFESTYLE The Hughston phonophoresis help about half the Heel Pain Foundation, Inc. ©2000 people treated. New high-impulse ultrasound technology shows Heel pain is a common condition some promise in people who do in people of all ages and at a variety not get better with other types of of activity levels. Usually, “heel pain nonoperative treatment; these tools syndrome” involves an inflammation will be used more in the future. or irritation of the plantar fascia (Figure). The plantar fascia is the Operative treatment ligament (tissue connecting two If your symptoms do not improve bones) under the foot that supports with nonoperative treatment and they the arch. It originates from the Plantar continue for more than six months calcaneous (heel bone), spans the fascia to one year, you may need surgery. arch, and inserts into the toes. Most Surgery is usually performed on an commonly, an overuse injury involving outpatient basis (i.e., you spend less the arch causes the plantar fascia than 24 hours in the hospital). The to become inflamed with tiny tears doctor makes a three-inch incision where it attaches to the heel bone. that exposes the inner and middle The overuse injury can be caused by segments of the plantar fascia near the increased standing, change in activity heel bone. Next, he or she lengthens cushion level (i.e., new or more vigorous the plantar fascia. The doctor also the heel. exercise program), increased body may release the plantar nerve from Other weight, poorly supportive shoewear, tissues that put pressure on it if it is helpful or injury to the foot. A tight Achilles irritiated. tendon (the tissue that connects the treatments calf muscle to the heel bone) puts include Postoperative treatment stress on the plantar fascia and is often wearing After surgery, you wear a special associated with heel pain. Typically, a night shoe and begin walking as tolerated. the initial symptoms involve pain splint or By six weeks, you usually can wear under the heel during the first few fiberglass your own shoes. You have maximum steps in the morning or after sitting cast. A night splint positions the foot improvement by around three for a long time. As the symptoms at a 90° angle to the leg (like when months. Seventy-five percent of progress, pain can be present with standing), which prevents it from people significantly improve with every step and can become constant. pointing downward. This treatment, surgical treatment. In most people, plantar fasciitis which is applied when you rest Heel pain takes time to get better, goes away spontaneously or with rest. or sleep, improves symptoms in and you must wear supportive shoes, However, healing takes a long time. most people.3 Even when all other participate in special exercises, and A research study showed that healing nonoperative treatments have failed, a use other treatments. Fortunately, time averages eight months.1 walking fiberglass cast sometimes rests most people with plantar fasciitis get the plantar fascia enough to allow it to completely well without surgery. Nonoperative treatment heal properly. Usually, the cast is worn The initial steps in treating plantar at all times for three weeks. Leland C. McCluskey, M.D. fasciitis include participating in a heel An injection of steroids (a strong Columbus, Georgia cord stretching program (see “Taking anti-inflammatory medication) into Care of Heel Pain,” p. 6), wearing Further reading the heel relieves symptoms in about 1. Wolgin M, Cook C, Graham C, Mauldin supportive shoes, and avoiding going one third of people. However, this D. Conservative treatment of plantar heel barefoot. Often, taking a nonsteroidal treatment is not appropriate for pain: long-term follow-up. Foot Ankle Int. anti-inflammatory medication (such as everyone and cannot be administered 1994;15(3):97-102. aspirin or ibuprofen) is helpful. Using often. Frequent injection carries some 2. Gill L, Kiebzak G. Outcome of nonsurgical treatment for plantar fasciitis. Foot Ankle Int. over-the-counter or custom-fitted risk of weakening and rupturing the 1996;17(9):527-532. arch supports relieves some stress on plantar fascia. 3. Wapner KL, Sharkey PF. The use of night the arch and allows the plantar fascia Physical therapy tools such as splints for treatment of recalcitrant plantar to heal quicker. Heel lifts or pads can ultrasound, iontophoresis, and fasciitis. Foot Ankle. 1991;12(3):135-137. Page 4 FOR A HEALTHIER LIFESTYLE ATC CORNER Lightning and Its Hazards

Lightning is the most consistent and significant weather hazard that athletes encounter. According to the National Severe Storms Laboratory, 100 fatalities and between 400 and 500 injuries requiring medical treatment occur from lightning strikes each year in the general American population. Even though the probability of being struck is extremely low, the danger increases when a storm is in the area and proper safety precautions are not followed. The National Collegiate Athletic Association (NCAA) has developed guidelines for lightning safety. with the warning system in their areas. thunder. Every five seconds between Prevention and education are the key The second step in the prevention the flash and the bang equals one factors in these guidelines. Prevention plan involves evacuation of the mile. The NCAA recommends that at starts with having a plan of action. The athletes. This step must be planned 30 seconds (when the lightning is only first step in this plan is to designate in advance of an evacuation. During six miles away) the athletes need to a chain of command. One person evacuation, athletes are directed to be evacuated. Remember, lightning monitors an approaching storm and a location that offers protection from can strike up to 10 miles from the informs the person in charge if he the storm by having at least three storm without previous lightning or she believes athletes need to be walls and a roof. Metal structures are strikes to warn you. evacuated from the playing field. The not considered adequate protection The lightning protection system is person in charge of making the final because the lightning can travel an electronic monitoring system. It decision about evacuation is usually along the metal and strike the people monitors energy from as far away as a certified athletic trainer (ATC), inside the structure. Trees also do 15 miles and evaluates the energy game official, or coach. The game not provide adequate protection. field for lightning. The system official and coach have duties during Lightning can strike a tree, travel automatically gives a signal to warn the game or practice that prevent down it, and strike the people seeking everyone in the area that lightning has them from adequately monitoring shelter under it. Many people have been detected. an approaching storm. Therefore, lost their lives because they thought To prevent a catastrophic event, having someone who is familiar with a tree offered a safe haven during a respond sensibly when lightning is lightning patterns serve as the storm storm. in the area. Gambling with lightning monitor is imperative. The ATC on Education about lightning is a is not a risk worth taking. If you are staff is the perfect choice. necessary part of the safety guidelines. not sure it is safe to be in the area, The storm monitor must also obtain Understanding lightning patterns evacuate immediately. a weather report before the game or can save your life. The two ways practice so that he or she is aware of to determine whether lightning is Bruce Getz, ATC, and any weather system that may affect close by are the flash-to-bang theory Kelli Bowermeister the area. Some areas have a severe and the lightning prediction system. Columbus, Georgia weather warning system through the The flash-to-bang theory consists National Weather Service. Storm of counting the seconds between monitors must familiarize themselves the lightning flash and the bang of Page 5 FOR A HEALTHIER LIFESTYLE Taking Care of Fig. 1 A. Sit with your legs straight in Heel Pain front of you. Wrap a towel Stretching around the ball Heel pain can be very of your foot and aggravating, especially when hold the loose taking those first steps in the ends in each morning. The key to decreasing hand. Pull the and possibly eliminating heel ends of the towel pain is to stretch your heel cord toward you until and plantar fascia. The heel cord you feel a gentle is the Achilles tendon, which stretch in the connects the gastrocnemius and back of your calf. soleus muscles in the calf to the The Hughston Foundation, Inc. ©2000 heel bone. The plantar fascia is B. Stand on an incline box with the a thick tissue that runs along the higher edge toward the wall. With bottom of your foot, connecting your heel on the floor and knee the heel bone to the toes and straight, lean toward the wall until maintaining the arch. you feel a gentle stretch in your calf. You can stretch your heel cords as shown in Figure 1A-C and your plantar fascia as shown in Figure 2. You can also stretch your plantar fascia by modifying the exercise shown in Figure 1C. Place a rolled towel under the toes of your back foot when doing the stretch; you will feel a gentle stretch along the bottom of your foot in addition to the back of your calf. Each stretch should be painfree and held for 30 seconds. Complete five repetitions of the stretches four to five times each day. When stretching in the standing position, keep your heels down and your toes pointed straight ahead or slightly inward. Always do standing stretches with your *Illustrations drawn without shoes on*. In addition to these shoes to better stretches, your doctor may demonstrate precise recommend that you wear a placement of heel and toes splint that maintains a gentle The Hughston Foundation, Inc. ©2000 stretch on your heel cords overnight. C. Stand about an arm’s length from a wall with one foot in front of the other. Bend the front knee and put your hands on the wall. Lean forward until Additional pain relievers you feel a gentle stretch in the calf of your back leg. Next, bring your back leg Treatments to add to your closer to the wall and bend both knees. Lean forward until you feel a gentle stretch stretching program include in the heel cord of your back leg.

Page 6 FOR A HEALTHIER LIFESTYLE wearing good-quality shoes, icing the painful area, and massaging Fig. 2 Sit with one the arch. Do not walk barefoot; leg over the walk in shoes with good heel and other. Pull your toes arch supports such as high-quality up, especially the big walking or running shoes. Keep toe, until you feel a pair of shoes next to your bed a stretch along the so you can put them on before bottom of your foot taking your first step. Your doctor (plantar fascia). may recommend that you wear an additional arch support or a heel cup in the shoes. The Hughston Icing your foot can help relieve Foundation, Inc. pain. Rub a frozen bottle of water ©2000 or an ice cup over the tender areas for five minutes two times each day (Fig. 3). Massage your foot by rolling a tennis, golf ball, or baseball along your sole and heel. This friction massage can help break up adhesions and stretch the plantar fascia. Do this for five minutes two times each day. If you are a runner or just started a walking or running program, evaluate your training for errors such as warming up improperly, increasing mileage too quickly, running hills excessively, running on surfaces that are too hard, or wearing broken down shoes. Fig. 3A Adjusting your training program Rub a frozen bottle of can help relieve your pain. While water over the tender recovering from heel pain, walk or areas for five minutes jog in a pool or crosstrain by biking two times each day. and swimming. These activities maintain your cardiovascular fitness without stressing your heel cord or plantar fascia. Fig. 3B Heel pain takes time to go away. Massage your foot by Be patient and remember that rolling a tennis ball, no treatment is a substitute for baseball, or golf ball STRETCHING! along your sole. Teri LaSalle, M.S., P.T., ATC Columbus, Georgia Further reading 1. Candelora P, Hunter S. Overuse foot inju- ries. In: Baker CL, ed. The Hughston Clinic Sports Medicine Book. Philadelphia, PA: Wil- liams & Wilkins; 1995: 603-618. 2. Cornwall M, McPoil T. Plantar fasciitis: etiology and treatment. J Orthop Sports Phys The Hughston Foundation, Inc. ©2000 Ther. 1999;29:756-760. Page 7 FOR A HEALTHIER LIFESTYLE The Hughston Foundation, Inc. ©2000 Editor Turf Toe George M. McCluskey III, M.D. Managing Editor Turf toe describes a sprain of the ball of the Elizabeth T. Harbison foot at the great toe. A sprain means that the Art Director Carolyn M. Capers, M.S.M.I., C.M.I. ligaments (tissues connecting two bones) are stretched or torn. This injury most commonly Editorial Board Thomas N. Bernard, Jr., M.D. affects football athletes playing on artificial turf Douglas T. Cannon, M.D. with “turf shoes.” When the athlete tries to stop Clark H. Cobb, M.D. quickly, the shoe grabs the turf. As the great toe William C. Etchison, M.S. Bruce A. Getz, ATC slides over the insole and hits the inside of the shoe, Ashley S. Holloway, M.S. it is sprained. Charles H. Keaton, FACHE, CEO The great toe can also be injured when it is forced to Teri LaSalle, M.S., P.T., ATC Leland C. McCluskey, M.D. extend more than it normally can. For example, turf Jill Yates, R.N., O.N.C. toe can occur when the athlete is standing on the balls of the feet and another athlete pushes him Suggested readings and classic or her forward, hyperextending the great toe. references for articles contained A doctor needs to examine the athlete who may have turf toe. Treatment consists of applying in this issue can be found on www. ice, heat, and tape or stiff-soled inserts in the shoe hughston.com to restrict movement of the great toe. The athlete must follow the prescribed treatment to alleviate this disabling condition and to return to Health Hint his or her normal level of function. Beating the Heat Bruce Getz, ATC, and Kelli Bowermeister of Columbus, Georgia 1. Take advantage of shade when you must be outside. 2. Wear loose, light-colored, The Hughston Health Alert is a quarterly publication of the Hughston Sports Medicine Founda- tion, Inc. The Foundation’s mission is to help people of all ages attain the highest possible standards of natural-fiber clothing. musculoskeletal health, fitness, and athletic prowess. Information in the Hughston Health Alert reflects 3. Change clothes when they the experience and training of physicians at The Hughston Clinic, P.C., of physical therapists and athletic become saturated with sweat trainers at Rehabilitation Services of Columbus, Inc., of physicians who trained as residents and fellows under the auspices of the Hughston Sports Medicine Foundation, Inc., and of research scientists and and are unable to absorb further. other professional staff at the Foundation. The information in the Hughston Health Alert is intended to 4. Drink cold water frequently supplement the advice of your personal physician and should not be relied on for the treatment of an individual’s specific medical problems. during activity; do not wait until Special written permission is required to reproduce, by any manner, in whole or in part, the mate- you are thirsty. For optimum rial herein contained. Send inquiries to Medical Writing, Hughston Sports Medicine Foundation, Inc., hydration, drink before, during, P.O. Box 9517, 6262 Veterans Parkway, Columbus GA 31908-9517 USA. Copyright 2000, Hughston Sports Medicine Foundation, Inc. ISSN# 1070-7778 and after exercise.

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