Tuesday, October 8, 2013

Julio Jones' foot injury

There are reports that Julio Jones has sustained a season ending foot injury while playing last night in the Atlanta Falcons' 30-28 loss to the New York Jets.  According to reports, Jones continued to play through the injury.  Jones had a 5th metatarsal fracture in 2011 - the same foot that was injured last night.  A specific diagnosis has not been reported yet, as Jones is seeking a second opinion, but there has been speculation that the injury is a Lisfranc ligament tear.

What is the Lisfranc ligament and how is it injured? 


The Lisfranc ligament is a strong ligament in the midfoot that helps to stabilize the foot.  As pictured in the image above, it is attached from the medial cuneiform to the 2nd metatarsal base.  When this ligament is disrupted, there will be a displacement of the bones.  This displacement can lead to instability of the foot as well as degenerative joint changes (arthritis) in the future.  The ligament can be disrupted from a direct or indirect force on the foot.  An example of a direct force on the foot would be a heavy object dropping on the foot.  An indirect force on the ligament would be from a rotational force on the foot while the foot was pointed downwards.  

How is a Lisfranc injury diagnosed and treated?  

A Lisfranc injury is diagnosed clinically with the help of imaging studies such as x-rays and MRIs.  Lisfranc injuries can vary in severity - from a mild sprain to a tear in the ligament to fractured bones.  X-rays reveal if there is any displacement of the bones.  If there is no displacement but pain when pushing or stressing the Lisfranc ligament.  In these cases, an MRI may reveal a mild sprain of the ligament.  In these cases, the patient is casted and immobilized with a cast for about 6 weeks before progressing to a walking boot.  If x-rays show a displacement of the bones and/or fracture(s) of the midfoot, surgery is indicated in athletes, as even a small displacement of the bones can lead to long term disability and pain.  Surgery is done to realign the ligament and reduce any associated fractures that may be present in the foot.  Recovery after surgery requires 6 weeks in a non-weightbearing cast before transition to a walking boot for 2 weeks.  Typically an athlete will require a few months of rehab before returning to their sport depending on the severity of the injury.  

Does Julio Jones have a Lisfranc injury? 

With the limited information that we do know - it is possible that Julio Jones may have a Lisfranc injury.  Seeing as he was able to play through the injury is encouraging as it likely means it is a fairly mild injury.  However - he was able to play through a foot fracture in the past so his pain tolerance may be more than most.  With a average timeline of 3 to 4 months for return, it fits the timeline of him missing the rest of the season - which is what early reports indicate.  If he does have a Lisfranc injury, it is important to have the bones realigned if they are displaced to maintain stability of the bones in the midfoot.  Once they are realigned and the ligament is healed there should be minimal to no residual problems for him in the future.  It is possible that he may have a new fracture in his 5th metatarsal as well.  With a surgically repaired 5th metatarsal Jones fracture, a screw is often used to fix it.  The screw can occasionally serve as a stress riser and put the bone at risk for a stress fracture.  In fact, a CT scan is a clue that the problem is likely boney rather than involving soft tissues (like a Lisfranc ligament) unless the Lisfranc ligament tear had an associated fracture.

Update: Julio Jones does indeed have a fracture in the area of his previous injury and is scheduled to have surgery on Monday October 14th, 2013.  The procedure is likely to remove the previous hardware, clean up the fracture, and fix it again with screws and/or plates.  A period of 6-8 weeks immobilization is needed to allow for healing of this fracture.  Due to the lack of blood supply to the Jones fracture site, it may take longer.

Follow me on Twitter @sydneyyau




Monday, September 30, 2013

Why Matt Kemp is out for the playoffs

Matt Kemp, who is an outfielder for the Los Angeles Dodgers, will be unable to help the his team in the post season this year due to an MRI showing swelling in one of the major weightbearing bones in Matt Kemp’s ankle, the talus.  Kemp initially injured his ankle in a play at the plate against the Washington Nationals on July 21st.  After missing 52 games on the disabled list, he returned to play on September 16th.  However, he was held out of Saturday’s game due to soreness in his ankle.  This prompted an MRI that revealed swelling in the talus, taking Kemp out of the lineup in the post season. 

What does swelling in the ankle (talus) mean?

On an MRI after an ankle sprain injury, swelling in the talus typically will mean that there is some cartilage damage in the bone, called an osteochondral lesion.  When an ankle is sprained, a number of different structures can be injured.  In addition to the ligaments and tendons around the ankle being torn, occasionally a small piece of cartilage can chip off of the talus bone.  This cartilage damage is usually not readily seen on x-rays, but will often show up on MRI as bone swelling.  A CT scan may be useful in determining the size of the lesion. 

How did this happen? 

When there is an ankle sprain, many structures in the area can also be injured as well.  In addition to ligaments tearing, the peroneal tendons (tendons on the outside of the ankle) can stretch and tear as well.  Additionally, the ligament may tear off bone at its attachment site.  Depending on the severity of the sprain, the cartilage may chip off if there was any impact in the area.  According to reports, Matt Kemp's previous MRIs did not show any swelling of the bone.  Therefore, this injury may have been a result of a loose, or unstable ankle.  If the ligaments do not heal correctly, they may become loose.  Ligaments are strong structures that help to prevent unwanted motion.  When they are too loose, however, the ligaments may not be able to hold joints in place and there may be excess and unwanted motion at the joint.  Over time, there may be rubbing of the bone due to these loose ligaments which may cause cartilage damage or bone swelling in the ankle bone.  I suspect that the ligaments may be a little loose, causing a little movement in the ankle while Matt Kemp was playing.  This small movement may have been enough to cause irritation of the ankle and possibly a cartilaginous injury.   

What is the treatment of an osteochondral lesion?

Treatment of an osteochondral lesion depends on the location and severity of the lesion.  Lesions on the inside, or medial aspect, of the talus are usually deeper and more stable.  Lesions on the outside, or lateral aspect, of the talus are usually shallower and wafer shaped – making them less stable.  Osteochondral lesions can be classified as compression or bruising of the bone (stage 1), partially detached (stage 2), completely detached but non-displaced (stage 3), or completely detached and displaced in the ankle joint (stage 4).  Stage 1, 2, and lateral stage 3 lesions are best treated conservatively with a period of immobilization that includes a non-weightbearing below knee cast for six weeks.   If pain persists after this period of immobilization, surgery may be indicated.  Medial stage 3 and stage 4 lesions are best treated with surgery.  

What are the surgical options for osteochondral lesions?

There are a number of procedures that can be done depending on the size and depth of the lesion. Before surgery, the size and depth of the lesion should be determined with a CT scan to help with planning the appropriate procedure.

Microfracture surgery

Cartilage in general has a poor blood supply and it has poor healing potential.  Microfracture surgery involves drilling holes into the lesion to stimulate blood flow in the area and promote the formation of fibrocartilage.  This procedure is fairly minimally invasive as it is often done through a scope.  This procedure has good outcomes for smaller lesions.

Cartilage graft (OATS procedure) 

A cartilage graft can be placed in the area of the osteochondral defect to effectively replace damaged cartilage.  This method is usually reserved for lesions of about 1 cm in diameter.  In this procedure, the osteochondral lesion is punched out and replaced with a cartilage graft of identical size from a donor.  For the best results, a graft is taken from the similar bone in which the osteochondral defect is present as to recreate the anatomic contour of the joint as best as possible.  This is best done with a cadaver bone that matches the affected ankle.  Cadaver bones should be used within 14 days of it being harvested and should be fresh, not frozen.  Frozen grafts will deteriorate cartilage cells and reduce the ability of the graft to successfully incorporate into the host.

Stem cells

Mesenchymal stem cells make up about 2-3 % of all blood cells in bone marrow and they have the ability to differentiate into different types of cell types if placed in the right environment.  They also have the ability to stimulate new blood vessel growth, which is important in developing avascular tissue such as cartilage.  Stem cells can be separated from bone marrow that is harvested from the body and either injected into the ankle joint or placed over the osteochondral lesion itself in a gel form with a scaffold graft.  The stem cells will then differentiate into cartilage due to the growth factors and signals that are present in the environment in which they were placed.  

What should Matt Kemp do?

The current treatment plan for Matt Kemp is immobilization in a non-weightbearing cast.  This likely means that the lesion is either a stage 1, 2, or lateral stage 3 lesion and likely to heal with conservative treatment.  It is very important to rest this injury because the talus bone does not have a great blood supply.  Any additional movement or pressure to the lesion may prevent the lesion from healing.  Over time, an untreated osteochondral lesion can lead to ankle arthritis.  Therefore it is not an injury that he should play through, as it can cause further damage to the ankle.  A CT scan would be useful in evaluating any cartilage or bone defect that may be present in the ankle.  Should he continue to have pain and/or swelling to the ankle after his period of immobilization, surgery may be indicated.  After immobilization, a period of rehab is needed.  Range of motion and strengthening exercises are done to help strengthen the ankle.  Assuming conservative treatment is successful, Matt Kemp should be back for spring training in 2014 with minimal residual effects from the ankle injury.

Monday, July 29, 2013

Albert Pujols' out for the season?

Albert Pujols has been suffering from plantar fasciitis for 6 or 7 years and reports indicate that he may have torn his plantar fascia last Friday.  He was placed on the disabled list and will be getting an MRI.  This MRI would reveal whether or not the fascia is torn.

I discussed Pujols' condition in an earlier blog post and it appears that the fascia may have degenerated enough causing a tear.  Tearing of the fascia may actually be beneficial for Pujols as the tension may be relieved from the ligament pulling at the heel bone.  However, a tear in the fascia is painful and requires time to heal.  A tear in the fascia may sideline him for the rest of the year.

Plantar fascia tear

The plantar fascia is a strong ligament on the bottom of the foot that helps to support the arch.  It attaches at the heel and fans out to attach to each of the toes.


A plantar fascia partial or full tear can occur in any of the bands, but the medial band (the band closest to the big toe) is the most common.  

Cortisone injections, which are commonly used to treat plantar fasciitis, can be the source of a plantar fascia tear, as they can often weaken the integrity of the plantar fascia.  Studies describing the incidence of a plantar fascia rupture after injection range from 2.4-22% (1-3).  Degeneration of the fascia may also play a role in a plantar fascia tear.  Patients suffering with plantar fasciitis for long periods of time eventually develop plantar fasciosis.  In this state, the plantar fascia thickens and develops scar tissue.  This thickening can cause a loss of integrity to the fascia, increasing its risk of rupture.  

Albert Pujols' case

In Pujols' case, he has been suffering from this problem on and off for 6 to 7 years and likely has plantar fasciosis.  If he had been treated with corticosteroids - as many athletes are - his risk of developing a partial tear may have increased as well.  Should Pujols have a partial tear in his fascia, he needs to be immobilized and the fascia needs to be supported.  Depending on the severity of the tear, he may be out 1 to 2 months recovering.

References:
1. Kim C, et al.  Incidence of plantar fascia ruptures following corticosteroid injection.  Foot Ankle Spec 2010; 3(6):335-7
2. Acevedo JI and Beskin JL.  Complications of plantar fascia rupture associated with corticosteroid injection.  Foot Ankle Int 1998; 19(2):91-7
3. Saxena A and Fullem B.  Plantar fascia ruptures in athletes.  Am J Sports Med 2004; 32(3):662-5





Thursday, July 25, 2013

Tim Hudson's unfortunate injury

Sydney K Yau, DPM.  Follow me on Twitter @sydneyyau

Atlanta Braves pitcher Tim Hudson sustained an ankle fracture last night while covering 1st base.  The runner, Eric Young Jr. of the New York Mets, inadvertently stepped on Hudson's lower leg trying to get to 1st base ahead of the throw.  Hudson was immediately in pain and fell to the ground.  See the injury here:


Hudson is to undergo surgery when the swelling subsides.

Explaining the injury

Looking at the replay, you can tell that Young Jr. lands on Hudson's lower leg and causes the lower leg to flatten and turn out.  Hudson likely has a tibia and fibula fracture above the ankle joint and possibly a syndesmotic injury.  The tibia and fibula are the leg bones of the body.  Together they connect the knee to the ankle and form the ankle joint.  They are held together near the ankle by a strong ligament called the syndesmotic ligament or interosseous membrane.  This ligament provides stability to the ankle and is important for many athletes.  Occasionally this ligament is sprained and is diagnosed as a "high ankle sprain".



This fracture is a result of direct impact so it does not follow any typical fracture patterns from ankle fractures sustained from indirect impact such as from twisting injuries.  Looking at the replay, it appears that Young Jr. lands above the ankle joint at the lower leg.  This is important as it does not appear that the fracture affects the ankle joint itself.  If the fracture was within the ankle joint, he is at risk for arthritis in the joint and this may delay his healing and affect his rehabilitation.  If the fracture, as I suspect, is above the ankle joint, the tibia and fibula can be realigned with surgery and there is less risk of arthritis in his joint.  If there is separation of the tibia and fibula on radiographs, this means that the syndesmosis is torn and needs to be repaired as well.

Fixing the injury

Surgery is needed to realign the tibia and fibula and possibly repair the syndesmotic ligament as well. The fracture will likely be reduced surgically and held together using plates and screws.  If the syndesmotic ligament is torn, screws are often placed across the ligament to repair the ligament.  The surgeon should check the alignment of the bones in all three planes and make sure the ankle joint is in anatomic position to reduce risk of arthritis in the future.  This is especially important should the fracture extend into the ankle joint.  The surgeon should also check to make sure adequate length is maintained of the bone to prevent shortening, causing a limb length discrepancy.  This is more of a risk if the fracture is in multiple pieces, which may be possible in this case.

Hudson's prognosis

I believe that Hudson is likely done for the season.  Recovery time for the bones to heal often will last 6 to 8 weeks.  After the bones heal, Hudson will need to rehab his ankle for at least a month or two to restrengthen his leg and redevelop stability in his ankle should the syndesmotic ligament be torn.  The biggest risk after surgery is arthritis in the ankle and instability of the ankle.  This can happen if the ankle is not well aligned after surgery.  Due to the healing times, I believe he will likely be unable to start pitching until after the current season ends.  However, as long as the fracture is reduced back into its correct anatomic position and bone is allowed to heal, I believe this shouldn't be a career ending injury for Hudson and he should be back pitching next season for the Atlanta Braves unless he chooses to retire.

Tuesday, July 23, 2013

Matt Kemp returns! (and injures himself again).

Matt Kemp of the Los Angeles Dodgers returned to the lineup 2 nights ago and had 3 hits, including a home run, to help the Dodgers to a 9-2 victory.  However, he was taken out of the game in the ninth inning on a play at home plate.



On the night of the injury, Dodger manager Don Mattingly said that the injury appears to be a sprain and that no x-rays were planned to be taken.  He did not anticipate that Kemp would need to go to the disabled list.  However, last night, Don Mattingly was less clear on this issue.  He said that Kemp would likely miss the 3 game series against the Blue Jays and that Kemp actually may head back to the disabled list for the 3rd time this season.

Ankle Sprains

The ankle has many ligaments that holds the joint together and makes it more stable.  They are slightly elastic but have a firm end point that can be reached to prevent abnormal motion from occurring in the joint.  An ankle sprain occurs when the force exerted on the ligaments exceeds its failure point.  The ligament can tear or rupture depending on the extent of the force that is applied to it.  If the bone is actually weaker than the ligament, a piece of bone can be avulsed off by the ligament.

Matt Kemp's injury
As seen in the gif above, Matt Kemp sustained an inversion type ankle sprain.  In this sprain, the ligaments that are affected are on the outside of the ankle.  There are 3 ligaments on the outside of the ankle that prevent excess inversion of the ankle.  These are the anterior talo-fibular ligament (ATFL), calcaneal-fibular ligament (CFL) and posterior talo-fibular ligament (PTFL).  When these ligaments get sprained, they can stretch or even tear.  Judging from his injury and the amount of inversion that the ankle went through, it is likely that the ligaments tore.

Matt Kemp's outlook? 

According to reports, no x-rays were planned.  This is confusing to me; especially since he was seen limping in the locker room afterwards.  If there is an avulsion fracture, this may take longer to heal and recuperate from.  The bone needs to heal to maintain stability of the ankle.  X-rays are inexpensive and very non-invasive and there is little to no harm to take x-rays to evaluate the ankle after an injury like this.

Having said this, if this is a a ligament sprain is fairly easy to treat but it requires time.  Athletes may take 2-6 weeks to recover from this depending on the severity of the sprain.  Treatment requires immobilization, bracing, and physical therapy.

During treatment of a sprain, it is important to immobilize the ankle so that the ligaments can heal in its natural, anatomic position.  If the ligaments heal in a stretched out position, the ankle sprain may result from an unstable ankle and may eventually lead to arthritis.

I think Matt Kemp will recover well from this injury but it may take at least 2-3 weeks for him to feel stable on his ankle.  If he has an avulsion fracture, this may take 6-8 weeks for him to come back.





Monday, July 15, 2013

Matt Kemp's PRP injection - will it work?

Over the last few years, many athletes have had PRP injections.  The most recent is Matt Kemp of the Los Angeles Dodgers, who had a PRP injection in his shoulder (A-C joint).  Other athletes such as Kobe Bryant, and Tiger Woods have also had this treatment for their injuries.

What is PRP? 

Platelet rich plasma, or PRP, is plasma from the blood which is concentrated in platelets.  Platelets help to signal many growth factors and and inflammatory cells to an injured area.  These cells help promote new blood vessels to form and remodel tissue.

How is it harvested and used? 

PRP can be harvested from your own body.  Blood is drawn out and spun in a centrifuge to help separate the platelets from the rest of the blood cells.  The platelet rich plasma is then injected into the problem area to stimulate an inflammatory and healing response.  After the injection, the area is immobilize to provide the area of injury the best environment to heal.


How effective is PRP? 

There are many studies on PRP, but the results are mixed.  There are few randomized prospective and blinded studies that study PRP, and those show mixed results as well.  However, studies do show that there appears to be some benefit in using it for chronic injuries and less benefit with acute injuries.

Will it work on Matt Kemp? 

Matt Kemp initially had an irritation in his shoulder in April and was treated with a steroid injection.  This appeared to help his problem but he began to have problems with his shoulder a few weeks ago.  MRI studies show that Matt Kemp has an irritation of his AC joint in his shoulder.  This injection may help provide an immune boost to the shoulder to allow the injured area to heal.  However, I'm not sure if the PRP injection will help him too much.  Although this problem appeared to start in April, the shoulder irritation that he is having now is fairly acute (a few weeks old) and there should already be some degree of inflammatory cells in the area.  A PRP injection simply would add more inflammatory cells into the area and hence may be redundant in this case.

Additionally, if Matt Kemp is looking to return to the field sooner, PRP will likely not speed up his recovery.  PRP is simply a modality that helps to recruit inflammatory and healing cells into the area of injury and this does not typically increase healing times at all.


References: 

1.  Weber SC, Kauffman JI, et al.  Platelet-rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: a prospective, randomized, double-blinded study.  Am J Sports Med 2013; 41(2):263-70
2.  Rha DW, Park GY, et al.  Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial.  Clin Rehabil 2013; 27(2):113-22
3.  Chahal J, Van Theil GS, et al.  The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis.  Arthroscopy 2012; 28(11):1718-27
4. Mishra AK, Skrepnik NV, et al.  Platelet-rich plasma significantly improves clinical outcomes in patients with chronic tennis elbow: a Double-Blind, prospective, multicenter, controlled trial of 230 patients.  Am J Sports Med 2013
5. Filardo G, Kon E, et al.  Platelet-rich plasma for the treatment of patellar tendinopathy: clinical and imaging findings at medium-term follow-up. Int Orthotp 2013
6. Martinelli N, Marinozzi A, et al.  Platelet-rich plasma injections for chronic plantar fasciitis.  Int Orthop 2013; 27(5):839-42


Thursday, July 11, 2013

Derek Jeter returns - why did it take so long?

Sydney Yau, DPM @sydneyyau on twitter

New York Yankees shortstop Derek Jeter broke his left ankle during the ALCS last October and has yet to return to play 9 months later.  The initial injury didn't seem too harmful but he wasn't able to get up from it.



Jeter had been nursing a bone bruise and had cortisone injections in the ankle prior to his injury.  This may account for why the ankle broke.  A bone bruise can actually be a developing stress fracture that may have weakened the bone.  Cortisone injections - although they provide pain relief and allow athletes to play in important games like the ALCS, may also further weaken the bone if done excessively.  Those two factors may have contributed to why Derek Jeter broke his ankle in the first place.

Ankle Fractures

There are several types of ankle fractures - some require surgery and others do not.  When there is a broken bone in the ankle, we look at the position of the bones and alignment of the ankle joint.  If the bones are angled, shortened, or out of anatomic position, surgery is often indicated to realign the bones. If there is a mal-alignment of the ankle joint, surgery is indicated to realign the bones so that the ankle joint can be realigned.  If the ankle is not fixed, the ankle may undergo arthritic changes from abnormal pressures.  Generally, ankle fractures heal fairly successfully after surgery.  The bones will take about 6-8 weeks to heel and most people will need about 1-2 months of rehab.  With that timeline, Jeter would have likely have been ready for spring training and opening day.  However he suffered a setback.

Jeter's setback 

In April, it was reported that a new break was found in the ankle.  How could this be?  April would have been at least 5 months after his injury and the bone would have had plenty of time to heal.

Here are 3 reasons why it broke again:

1.  Certain types of cortisone injections used to help provide pain relief may stay in the body's system for several months and delay or impede the ability for bone to heal - especially early on in the healing process.

2.  As the bone heals after surgery, patients are often immobilized and non-weightbearing in a cast.  This immobilization can cause "disuse atrophy" of the bones - which is a weakening of the bone because there are no weightbearing forces put on it.  Bone is very dynamic and requires pressure for it to remodel and grow stronger.  Therefore if Jeter returned to heavy activity too soon, the bone might not have been able to sustain the pressure put on it initially.

3.  Screws and plates are used to fix ankle fractures and are necessary to hold the bones together as it heals.  However, once it heals, the hardware can cause increased stress in the bone called "stress risers".  If the bone is already weak, weightbearing activity may cause a fracture along one of the screws because the bone is weaker there.

What will he be like in his return? 

Reports indicate that Derek Jeter will be returning to the lineup tonight after doing a rehab assignment.  Broken bones heal well and we shouldn't see any residual problems in the long term.  However, in the short term, it may take him some time to get his quickness and agility back.  With a period of immobilization it takes time for the muscles to regain their strength and muscle memory.  Other than that broken bones that heal correctly generally do not give any long term problems.  I believe Jeter will return and be an effective Major League player.

Monday, July 8, 2013

Should Albert Pujols have foot surgery?

Sydney Yau, DPM @sydneyyau

Los Angeles Angels baseball player Albert Pujols has been suffering with plantar fasciitis on and off for 7 years.  It has recently prevented him from playing on the field as a first baseman, as he is limited to being a designated hitter.  It is bothering him so much that he is now considering surgery in the offseason to help his problem.  As reported by Bill Shaikin in the Los Angeles Times, Pujols may be considering surgery to help relieve him of this problem.




The question is: Should Pujols have foot surgery?

What is plantar fasciitis and what can cause it?

The plantar fascia is a strong ligament on the bottom of the foot that attaches to the heel bone (calcaneus) and fans towards the toes of the foot along the arch.  It consists of 3 main bands of tissue - the medial band along the inside of the arch, the central band along the center of the arch and the lateral band along the outside of the arch.  The plantar fascia is a strong and elastic ligament and is responsible for maintaining the arch during gait.  Plantar fasciitis occurs when the ligament becomes inflamed mainly from overuse.  The medial band is the one that is most often affected.  The plantar fascia can be overused from abnormal loads on the foot or from normal loads repetitively on a mechanically faulty foot.  Flat feet, for example, cause the plantar fascia to elongate when weight bearing, causing the ligament to pull at the heel bone.  This may cause micro-tears and scarring in the fascia causing pain.  Another cause of plantar fasciitis is a tight Achilles tendon.  The Achilles is the strongest tendon in the body and tends to tighten as we get older.  Since the Achilles also attaches to the heel bone, it indirectly pulls at the plantar fascia, causing it to tighten further.

How is plantar fasciitis treated? 

Plantar fasciitis improves with conservative treatment most of the time.  Physical therapy to help reduce inflammation in the heel and to help stretch the calf muscle aids in reducing the tension and pain in the fascia.  An orthotic, or custom insole, can help reduce strain along the fascia by supporting the arch.  Steroid injections can also help reduce inflammation, but that is often more of a band-aid solution as it does not address the underlying cause of the issue.  Steroid injections can also weaken the fascia if done too often.

Now, Pujols has had this issue on and off for 7 years and he has quality professional trainers and therapists at his disposal.  It was reported that he has recently tried orthotics to reduce strain on the fascia as well.  However, despite conservative treatments, he is still in pain and unable to play in the field.  Why?

Chronic plantar fasciosis 

When conservative treatment does not help it is thought that the problem has become a chronic problem and the acute phase of plantar fasciitis becomes plantar fasciosis.  Plantar fasciosis is a non-inflammatory problem.  The acute phase, or inflammatory phase, of plantar fasciitis lasts anywhere from 3 to 6 months.  During the acute phase, the body sends various inflammatory cells to the area of injury to help with healing.  After a period of time, the body stops responding to the area of injury if it does not appear to be working and the area may begin to degenerate.  Pujols reportedly has had this problem on and off for 7 years and likely has plantar fasciosis - not plantar fasciitis.

How is plantar fasciosis treated? 

Plantar fasciosis is treated by converting the chronic problem into an acute problem.  For the plantar fascia, this is done in a variety of methods.

Shockwave therapy 

Shockwave therapy has shown promising results in various studies (1-4).  Shockwave treatment involves a series of low-energy (or sometimes high-energy) waves that are applied to the plantar fascia.  This promotes new blood growth into the area and effectively changes the chronic problem into an acute problem.  

Platelet-rich plasma injection

Several authors have found positive results with platelet-rich plasma injections for plantar fasciosis (5, 6).  Platelet rich plasma is plasma that consists of many of the body's growth factors and inflammatory cells that are present in an acute phase of an injury.  The platelet rich plasma is derived from the patient's own blood and separated from the rest of the blood through a centrifuge.  Once the platelet rich plasma is isolated, it is injected into the plantar fascia and effectively creates a local acute inflammatory
response that will help heal the fascia.


Topaz micro-ablation 

Topaz is another method to create an acute injury in a chronically painful plantar fascia by poking small holes into the fascia through the skin with a special probe.  This special radiofrequency probe is able to stimulate the tissue and stimulate new blood flow and inflammatory cells to the plantar fascia.


Release of plantar fascia 

If all else fails, the last resort for plantar fasciosis is to surgically release the plantar fascia and has had good success rates as well (1, 9).  This can be done through small incisions with an endoscopic camera to visualize the fascia before it is cut.  Only part of the plantar fascia (medial band) is cut so that other portions of the ligament (central and lateral bands) can still support the arch.  However, by cutting the medial band of the fascia, the integrity of the fascia is weakened and it may lead to pain along the outside of the foot.

Conclusion - what should Albert do?

So should Albert Pujols have surgery?  If so - which surgery would be most successful?

Since Pujols has been suffering from this ailment on and off for 7 years, I believe he has plantar fasciosis which is a chronic, or non-inflammatory, problem.  Due to this, most conservative treatments (which focus on reducing inflammation) do not work as there are no inflammatory cells to reduce.  Therefore, the chronic problem needs to be changed back into an acute problem for the best results.  I think Albert Pujols would benefit from shockwave therapy, platelet-rich plasma, or topaz micro-ablation in the off season.  These methods do not affect the integrity of the arch and all have minimal side effects.  Releasing the fascia would also be effective, but the procedure is more invasive and requires compromising the integrity of the fascia.  I believe that releasing the fascia should be a last resort should the other procedures fail.  Pujols should have plenty of time to recover from any procedure he does in the off season and hopefully we'll see him out on the field more often next year and not solely as a designated hitter!



References:

1. Saxena A, Fournier M, Gerdesmeyer L, Golleitzer H.  Comparison between extracorporal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete.  Muscles Ligaments Tendons J. 2013, 21; 2(4): 312-316
2. Chuckpaiwong B, Berkson EM, Theodore GH.  Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors.  J Foot Ankle Surg.  2009; 48(2):148-55
3. Ogden JA, Alvarez RG, Marlow M.  Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis.  Foot Ankle Int. 2002; 23(4):301-8
4. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, Russlies M, Stienstra J, Scurran B, Fedder K, Diehl P, Lohrer H, Henne M, Gollwitzer H. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008;36(11):2100–9.
5.  Martinelli N, Marinozzi A, et al.  Platelet-rich plasma injections for chronic plantar fasciitis.  Int Orthop.  2013; 37(5):839-42
6. Regab EM, Othman AM.  Platelets rich plasma for treatment of chronic plantar fasciitis.  Arch Orthop Trauma Surg.  2012; 132(8): 1965-70
7. Weil L Jr, Glover JP, Weil LS Se.  A new minimally invasive technique for treating plantar fasciosis using bipolar radiofrequency: a prospective analysis.  Foot Ankle Spec. 2008; 1(1): 13-8
8. Sorensen MD, Hyer CF, Philbin TM.  Percutaneous bipolar radiofrequency microdebridement for recalcitrant proximal plantar fasciosis.  J Foot Ankle Surg. 2011; 50(2): 165-70
9.  Lundeen RP, Aziz S, Burks JB, Rose JM.  Endoscopic plantar fasciotomy: a retrospective analysis of results in 53 patients.  J Foot Ankle Surg 2000; 39(4): 208-17


Tuesday, June 25, 2013

Will Kobe Bryant ever be the same?

The injury

Laker nation held their breath as this happened:

After the injury, many believed that Kobe would be able to come back from this devastating injury - but can we expect this to be true?  Kobe is as dedicated an athlete as they come but can he play at an elite level after this injury?

In athletes, the Achilles tendon is one of the most important tendons in the body.  It attaches to the calf muscle and is mainly responsible for a basketball player's ability to drive and jump.  It generates a lot of power and quickness can be determined by the strength of the Achilles.  The Achilles tendon itself is one of the strongest in the body but because of its responsibility and use, it is commonly injured.  A complete rupture of the tendon, as seen in Kobe Bryant and David Beckham, is often found in a 'watershed' area of the Achilles tendon.  The watershed area is located approximately 2-6 cm above its insertion into the heel bone and it is an area with low vascularity or blood supply which predisposes the tendon to injury and rupture.  Overuse of the tendon may also predispose an athlete to rupture of the tendon, but sudden movements or a stress that the Achilles tendon can not handle can cause the tendon to tear.


Can Kobe return from this injury? 

There are several studies that describe return to normal activity in athletes but not many that involve elite athletes like Kobe Bryant.  In a recent journal article in the American Journal of Sports Medicine, the authors reviewed injury reports of 18 players in the National Basketball Association (NBA) who had an Achilles rupture which was surgically repaired.  The average age of the players was 29.7 years old and the average playing experience of the players was 7.6 years.  Of these 18 players, 7 did not return to play another NBA game, 11 played one additional season, and 8 returned for 2 or more seasons.  Players who returned were generally less effective and the average player efficiency rating  (PER) was reduced by 4.57 in the first season and 4.38 in the second season.

Although this is a small sample size, these numbers do not bode well for Kobe Bryant.  He is now 34 years old and has 16 years of NBA experience, which are both above average in the study.  As the body ages, the tendons tend to lose elasticity.  Therefore tendons are more fragile and cannot handle as much stress.  With Kobe Bryant's injury, the tendon will likely heal with residual scar tissue and chances are that he will not have as much power in that leg as before his injury.  This will likely affect his ability to drive and jump.  Therefore it will affect his ability to create his own shots, ability to get to the line, and his jump shots.


Will Kobe Bryant's tendon be as strong as before his injury?  

With the already weakened state of Kobe's tendon, can we expect his tendon to repair and become better than before the injury?  Most studies say that after surgical repair there is some residual weakness to the Achilles tendon.  A recent study reviewed 63 patients with an average follow up of 10.8 years after a surgically repaired Achilles tendon to assess muscle strength and muscle activity 10 years after surgical repair.  Muscle activity in the injured leg was found to be increased compared to the uninjured leg, suggesting that other muscles were compensating for a weak calf muscle and Achilles tendon even 10 years after an Achilles rupture.

Therefore, although Kobe Bryant has access to world class rehabilitation facilities, Kobe's injury will likely rob him of some strength in his Achilles.  Other muscles in the lower leg will likely help him to compensate for this loss strength and he may still be able to play at an effective level.  However, Kobe's game is driven by his Achilles.  His ability to drive and shoot jump shots require his Achilles to be healthy and strong.

Kobe's future

I believe that Kobe Bryant will return to play in the NBA.  However, I believe he will be a very different player.  He will likely have some residual weakness in his Achilles, which will rob him of some of his quickness.  Kobe is a very smart player though, and he will learn to adapt to his body.  He'll still be able to read defenses and make smart decisions with the ball and he'll learn to make jump shots with his repaired Achilles.  And if he returns, can someone tell Mike D'Antoni not to play him 38 minutes/game?

Resources: 

Amin NH, Old AB, Tabb LP, et al.  Performance outcomes after repair of complete Achilles tendon ruptures in National Basketball Association players.  Am J Sports Med; June 3, 2013 (Epub ahead of print)
Horstmann T, Lukas C, Merk J, et al.  Deficits 10 years after Achilles tendon repair.  Int J Sports Med 2012; 33(6): 474-9