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

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.

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.

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

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.

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