Dr ROBERT J MOORE III

Foot and Ankle Surgeon

Foot and Ankle Trauma / Sports Injuries

Ankle Fracture Treatment – After the Emergency Room

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Yesterday I ended my week at the surgery center with yet another patient who had a negative MRI examination for ligament and cartilage damage in their ankle. He had a history of ankle sprains and a minor ankle fracture that did not require surgery years before. In my younger days, I would have slapped him on the back at 6-8 weeks after his fracture and told him to go back to normal activities and exercise as tolerated.

Ankle Arthroscopic Procedure

Now I tell them that there is a high probability that they may have cartilage damage and to pay attention to stiffness in the morning and/or aching pain at night after heavy activity. My patient was one of those fortunate ones that did not ignore these symptoms and had an ankle arthroscopic procedure performed in his 40s instead of “getting by with ibuprofen for years” like my 60 year old patient who had her ankle fused earlier this year.

Ankle Fracture Treatment Without Surgery

About 25% of our practice are follow ups from the emergency room or second opinions. Open fractures (bone exiting the skin and exposed) require immediate surgical attention, but most closed ankle fractures are sent home with crutches, pain pills and referral to a specialist.

Surprisingly for most ankle fracture patients, surgical repair is a low percentage. Non-weight bearing for 6-8 weeks in a cast or cam walker is the standard of care for an ankle fracture that meets the standard of care for normal ankle function after healing. Serial x-rays to view progress every 3 weeks and then physical therapy once it is healed is usually all that is needed if the ‘ankle mortise’ is maintained in the normal anatomical position. Unless the patient has other health problems like diabetes or poor circulation, the bone heals without any type of weakness or scarring. In most cases, the bone is just as strong as before the fracture due to its unique properties and a rich, inherent vascular supply. Both the osteoid (living bone) and calcium phosphate (white, hard portion) completely remodel and replace the debris and ‘dead bone’ within the fracture line.

Ankle Fracture Treatment With Surgery – ORIF

As for surgery, there are different views and variables that make it necessary. It depends on the location, fracture separation distance, rotation, and soft tissue involvement. An MRI is the most common test performed to access all the aforementioned, but a CT (Computed Tomography) is the gold standard for comminuted (multiple fractures) fractures that involve and cross different joints. For the surgeon, this test will show the 3 dimensional positions of all the fracture fragments to best prepare for surgery and order the proper equipment.

From external fixation devices, traditional plates and screws, to simple K-wire pins, there are many ways to repair an ankle fracture. There are 3 bones in the ankle (Tibia, Fibula, and Talus) and fractures can involve one, two, or all three. Below is a simple, oblique fracture repair of the fibula.

Warning: Graphic material

Ankle Surgery Recovery

He was non-weight bearing for 6 weeks, then walking in a cam walker boot for 2 weeks. He was also fortunate enough to not have any ligament or cartilage damage and reported back to the clinic 3 months later that he was biking and running. Although, he still received my warning to pay attention to any of the aforementioned symptoms in the future….

If you have any questions, feel free to fill out the form below or email / phone number for a clinic or virtual visit.

Stay Healthy and One Step Ahead!

Heel Pain – The truth behind the Morning Misery

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Plantar Fasciitis Treatment

Over the last 20 years career, there have been major medical advancements in foot and ankle surgery.   But in one arena, few things have changed.

When my heel pain patients come to the office, they are not only frustrated, but those painful first few steps in the morning have them or their spouses putting everything aside in their lives to make an appointment.  Then sometimes cancelling….

Why?  Because sometimes it goes away.

Why? Because in reality, it is an injury.

Plantar fasciitis is simply the band or the simile we us “bow string” like  structure connecting the ball of your foot to the bottom of your heel (calcaneus bone).

So who cares, get to the point and where is my pill to make this all go away?  Because 75% of our patients are cured and avoid surgery with a little education.

The foot is a simple machine made up of 26 bones that essentially ‘lock and unlock’ when standing and walking.  This unlocking and dropping of the archway puts stress on the plantar fascia, unfortunately and must commonly where it connects to the bottom of the heel.   The “heel spur” in reality is a calcification where the ligament attaches, not something that grows out of the heel and is responsible for that sharp pain in  the morning.  Its the pulling or micro ‘tears’ on the bottom of the heel combined with your entire body weight that causes the pain.

Then there is the other enigma.  “After a few steps in the morning, it warms up and goes away”  Not to get too scientific or deep into neurology, but the theory is that this is a evolutionary response to survive, cover up the pain and keep moving – or in the past, to get away from predators when injured.  Repetitive pressure to the area can interrupt the pain signal to the brain temporarily.  But with a short rest or sleeping all night, the distraction is gone and that first step sends that lovely, uninterrupted pain signal telling its homo sapien host – “me still injured”.

It’s a confusing paradigm because for most patients who have the mild to moderate variety (not seriously torn or a stress fracture) feel if they keep moving, they have less pain.   But in reality, they are continuing to injure themselves by simply going to work or going out to get the mail.

We still give a mild cortisone injection that gives relief and has no side effects, but the main emphasis for this problem is to rest and hold the arch up when the essential weight bearing (like getting something to eat) is necessary.  But rest is still the top priority.  In professional sports, some players are using crutches to speed up recovery and healing time.

The good news for the rest of us is that enduring the pain and getting in to a better shoe with a higher heel (more weight on the ball of foot) or higher arch with ‘heel stabilizer’ like a running shoe can do the trick.

Arch supports can help as well, but for long term relief, orthotics are the holy grail.  The problem is that not all orthotics are created equal, especially the custom molded variety.  I have modified a traditional molding technique and better orthotic material that essentially cures 75% of my patients.  Polypropylene is a thermo-molded, thin material that is also flexible to withstand activities like jogging or even high impact sports.  Although we have several athletes using our device in their cleats and high top shoes, our female patients benefit the most since they can use these custom molded orthotics in their flats due their slim design.

Of course there is a surgery available for the remaining 25% of the patients who do not heal or have continued pain, but it’s becoming more and more rare.  The procedure is quick with a small incision, sutures removed 2 weeks, full weight bearing in 3 weeks.

If you have any questions, feel free to log on to our website https://mfaspecialists.com/, email us or call (281) 444-6300.

Stay healthy and One Step Ahead!

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