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Ankle Sprain - Podiatrist Torrance, Redondo Beach, Palos Verdes, California
Dr. Robert Anavian discusses the symptoms, causes and treatments for Sprain Ankle.
Ankle Sprains in the Runner
Ankle sprains are one of the most common joint injuries runners experience. The injury can occur when one rolls over a rock, lands off a curb, or steps in a small hole or crack in the road. Usually the sprain is only mild, but on occasion it may seriously injure the ligaments or tendons surrounding the ankle joint. Management of this injury relies on early and accurate diagnosis, as well as an aggressive rehabilitation program directed toward reducing acute symptoms, maintaining ankle stability, and returning the runner to pre-injury functional level.
General Anatomy of the Ankle
The ankle is comprised of three main bones: the talus (from the foot), the fibula and tibia (from the lower leg). The three bones together form a mortise (on the top of the talus), as well as two joint areas (on the inside and outside of the ankle), sometimes called the gutters. The ankle is surrounded by a capsule, as well as tissue (the synovium) that feed it blood and oxygen.
Some of the more important structures that hold the ankle together are the ankle ligaments.
Most ankle sprains involving the ligaments are weight bearing injuries. When a runner's foot rolls outward (supinates) and the front of the foot points downwards as he or she lands on the ground, lateral ankle sprain can be a result. It is usually this situation that causes injury to the anterior talo-fibular ligament. However, when the foot rolls inwards (pronates) and the forefoot turns outward (abducts), the ankle is subject to an injury involving the deltoid ligament that supports the inside of the ankle. This can occur when another runner steps on the back of the ankle, as at the beginning of a race, or when a runner trips and falls on the runner in front of him.
When assessing an ankle sprain, your podiatrist will want to know the mechanism of injury and history of previous ankle sprains. Where the foot was located at the time of injury, popping sensations, whether the runner can put weight on the ankle are all important questions needing an answer. If past ankle sprains are part of the history, for example, a new acute ankle sprain can have a significant impact.
The physical examination should confirm the suspected diagnosis, based on the history of the injury. One looks for any obvious deformities of the ankle or foot, black and blue discoloration, swelling, or disruption of the skin. When crackling, extreme swelling and tenderness are present, together with a limited range of motion, one may suspect a fracture of the ankle. A feeling of disruption on either the inside or the outside of the ankle may indicate a rupture of one of the ankle ligaments.
To check for ankle instability, the runner should be evaluated while weight bearing. Manual muscle testing is also valuable when checking for ankle instability. One of the more critical tests that a runner should be able to perform before allowing resumption of activity is a single toe raise test. If the runner is unable to do this, one might suspect ligamentous injury or ankle instability.
X-rays help rule out fractures, fleck fractures inside the ankle joint, loose bodies, and/or degenerative joint disease (arthritis). Stress X-rays are taken when ligamentous rupture or ankle instability is suspected. When a stress test is taken of your ankle, don't be surprised if the same test is performed on the other ankle. This is done to compare the two ankles, particularly in cases of ligamentous laxity (loose ligaments).
In the past, more commonly, ankle arthrography has been used. This involves injecting a dye into the ankle joint as it is X-rayed. This helps determine if a rupture of a ligament or tear of the ankle capsule has occurred. However, this procedure does involve some discomfort during the injection process, and, on rare occasions, an allergy to the dye occurs.
Other diagnostic tests include computerized tomography (CT Scan) to discover injuries of the bone, and magnetic resonance imaging (MRI) to isolate and diagnose specific soft tissue injuries (ligaments, tendons, and capsule). The MRI is very specific, and gives a clear-cut view of these important structures.
Treatment of an acute ankle injury usually begins with an aggressive physical therapy program that controls early pain and inflammation, protects the ankle joint while in motion, re-strengthens the muscles, and re-educates the sensory receptors to achieve complete functional return to running activity.
Modalities that decrease pain and control swelling include icing, electrical nerve stimulation, ultrasound, and/or iontophoresis patches. Easy, mild motion, with the limits of pain and swelling, can actually reduce the effects of inflammation. A continued passive motion (CPM) machine can be very helpful in decreasing pain and swelling.
Resumption of running activity is usually dependent on the runner's limits of pain and motion, and is begun to tolerance. As the runner improves, diagonal running can be prescribed. It is important to protect the runner with braces such as air casts, ankle braces, etc., which help to allow motion at the ankle joint under weight bearing.
Home exercise programs are very helpful for the post-ankle sprain runner. Proprioception re-education is critical for both the acute as well as the chronic ankle sprain. It may involve using a simple tilt board or more sophisticated proprioceptive training and testing devices.
For the acute grade III lateral ankle sprain, or complete deltoid tear, complete immobilization is usually recommended for at least four weeks. Afterwards, a removable cast is used to restrict motion and allow for physical therapy. If the ankle does not respond and ankle instability is diagnosed, surgical intervention may be required.
Today, ankle arthroscopy a much less invasive procedure than other surgery, allows the ligament to be stabilized with tissue anchors. This eliminates an extended period of immobilization, joint stiffness and muscle atrophy. Post-operatively, this primary ligament repair is protected for approximately a two-to three-week period of time in either a cast or removable cast boot, with daily-continued passive motion, cold therapy, and controlled exercise.
At three weeks, a simple air cast or ankle brace is applied for an additional three weeks while therapy and rehabilitation is progressing. At six weeks, these devices are used only during running and other athletic activity as a safeguard. As the runner resumes strength and proprioceptive capabilities, the devices are discontinued.
When an acute or chronic ankle sprain is not treated, as unfortunately is all too often the case, repeated ankle sprains may occur. Because chronic ankle injuries do not show acute inflammation even when the ankle is weak and unstable, this may set the runner up for another ankle sprain when least suspected. A successive sprain may be more severe than the first, and cause an even more significant injury.
The most important point to keep in mind when talking about ankle injuries, then, is to prevent the condition from becoming chronic or recurrent.
So the next time you roll over that stone, or land in that small hole, make sure that your simple ankle sprain is just that: simple.
If you don't want to have a swollen ankle all the time while running, don't ignore early warning signs. If you have any doubts about its seriousness, have your podiatrist check your injury.
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Children’s Foot Problems - Podiatrist Torrance, Redondo Beach, Palos Verdes, CA
Dr. Robert Anavian discusses the symptoms, causes and treatments for Children’s Foot Problems.
Pediatric Foot Problems
Dr. Anavian has extensive experience and training in the care of children's foot problems. During his residency, Dr. Anavian was the Chief Resident for the Baja Project for Crippled Children and was responsible for running the Baja Projects clinics in Tijuana and Mexicali, Mexico. He received extensive training in pediatric surgery of the foot and ankle as well as conservative care of pediatric deformities and pathology. Since his residency he has become one of the Co-directors of the Baja Project for Crippled Children.
Our office has extensive experience in treating problems that children have with their feet. Whether your child was born with foot problems or has developed problems due to sports or dance, our office can help your child stay active and keep them participating in the activities they love. We treat many children and teenagers who are having trouble doing sports or dance because of problems with their feet. We have many dancers and ballerinas who have benefited from treatment. If your child is having problems doing the activities they like to do, please call for a consultation. Foot pain is never normal.
Dr. Anavian can help your child with the following problems:
• Dance injuries or pain (Ballet, Hip Hop, Jazz, Modern dance).
• Sports injuries or pain (Soccer, Basketball, Baseball, Football, etc.).
• Flat feet, High Arch feet.
• Child does not want to run or be active.
• In or Out toeing.
• Skin Conditions (Athletes foot, Warts, etc.).
• Nail problems.
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Diabetic Foot Care - Podiatrist Torrance, Redondo Beach, Palos Verdes, CA
Dr. Robert Anavian discusses the symptoms, causes and treatments for Diabetic Feet.
Tips for the Diabetic Patient
Ulcerations, infections and gangrene are the most common foot and ankle problems that the patient with diabetes must face. As a result, thousands of diabetic patients require amputations each year. Foot infections are the most common reason for hospitalization of diabetic patients. Ulcerations of the feet may take months or even years to heal. It takes 20 times more energy to heal a wound than to maintain a health foot.
There are two major causes of foot problems in diabetes:
1. Nerve Damage (neuropathy): This causes loss of feeling in the foot, which normally protects the foot from injury. The protective sensations of sharp/dull, hot /cold, pressure and vibration become altered or lost completely. Furthermore, nerve damage causes toe deformities, collapse of the arch, and dry skin. These problems may result in foot ulcers and infections, which may progress rapidly to gangrene and amputation. However: Daily foot care and regular visits to the podiatrist can prevent ulcerations and infections.
2. Loss of circulation (angiopathy): Poor circulation may be difficult to treat. If circulation is poor gangrene and amputation may be unavoidable. Cigarette smoking should be avoided. Smoking can significantly reduce the circulation to the feet significantly. There are certain medications available for improving circulation (Trental) and by-pass surgery may be necessary to improve circulation to the feet. Chelation therapy is an alternative form of treatment for circulatory problems that is not well recognized by the medical community at large. Daily foot care and regular visits to the podiatrist can often prevent or delay the need for amputation.
Do the Following to Protect Your Feet
1. Examine Your Feet Daily
• Use your eyes and hands, or have a family member help.
• Check between your toes.
• Use a mirror to observe the bottom of your feet.
• Look for these Danger Signs:
Swelling (especially new, increased or involving one foot)
Redness (may be a sign of a pressure sore or infection)
Blisters (may be a sign of rubbing or pressure sore)
Cuts or Scratches or Bleeding (may become infected)
Nail Problems (may rub on skin, cause ulceration or become infected)
Maceration, Drainage (between toes)
If you observe any of these danger signs, call your podiatrist at once.
2. Examine Your Shoes Daily
Check the insides of your shoes, using your hands, for:
Irregularities (rough areas, seams)
Foreign Objects (stones, tacks)
3. Daily Washing and Foot Care
• Wash your feet daily.
• Avoid water that is too hot or too cold. Use lukewarm water.
• Dry off the feet after washing, especially between the toes.
• If your skin is dry, use a small amount of lubricant on the skin.
• Use lambs wool (Not cotton) between the toes to keep these areas dry.
4. Fitting Shoes and Socks
• Make sure that the shoes and socks are not to tight
• The toe box of the shoe should have extra room and be made of a soft upper material that can breath
• New shoes should be removed after 5-10 minutes to check for redness, which could be a sign of too much pressure: if there is redness, do not wear the shoe. If there is no redness, check again after each half hour during the first day of use.
• Rotate your shoes
• Ask your podiatrist about therapeutic (prescription) footwear, which is a covered benefit for diabetic patients in many insurance plans.
• Tell your shoe salesman that you have diabetes.
5. Medical Care
• See your podiatrist on a regular basis
• Ask your primary care doctor to check your feet on every visit.
• Call your doctor if you observe any of the above danger signs.
Do Not Do These Dangerous Acts
• Do Not Walk Barefoot - Sharp objects or rough surfaces can cause cuts, blisters, and other injuries.
• Do Not Use Heat on the Feet - Heat can cause a serious burn, especially if the patient has neuropathy.
• Do Not Apply a Heating Pad to the Feet
• Do Not Soak Your Feet in Hot Water
• Do Not Use Chemicals or Sharp Instruments to Trim Calluses - This could cause cuts and blisters that may become infected.
• Do Not Cut Nails into the Corners - cut nails straight across.
• Do Not Smoke - smoking reduces the circulation to your feet.
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