Posterior Tibial Tendon Tear: MRI images

One of my patients recently tore his posterior tibial tendon, the most important ankle tendon for arch support. He is being worked up for surgery and I thought his MRI images may be helpful to some of you suffering from Posterior Tibial Tendon problems.

The 3 medial ankle tendons that go into the foot are: flexor hallucis longus  (FHL), flexor digitorum longus (FDL), and the posterior tibial tendon (PT). See the solid dark circles that make up the FHL and FDL. See the white area where the posterior tibial tendon should be.

The FHL and FDL are well visualized. The medial or inside ankle bone shows old bone chips from a fracture 20 years ago by the sensor.

As we get further into the foot with our imaging, the area of the posterior tibial tendon is more blown-out than the FHL or FDL. Good, solid, tendons should look dark, condense, and have sharp borders. The PT has none of this.

Further imaging into the foot shows the PT tendon non-compact and almost stretched.

This side view of the ankle shows a solid FDL tendon as it comes down into the foot, and an almost nonexistent Posterior Tibial Tendon. 

This is such an important tendon in the body that I am forced to send to the surgeons for repair. Hopefully, once the surgical part is done, I can begin the often 2 years of gradual rehabilitation for full strength.

Leg Pain in a Runner: Tibial Stress Fracture

Over the next week, I am going to talk a lot about stress fractures. This is a common one in the lower inside of the shin (tibia) seen in a runner increasing his mileage. 

This AP Tib/Fib Xray documented the new bone formation seen next to the marker in a long distance runner. This bone reaction is called periosteal reaction and signifies that the bone is trying to heal. The new bone formation should be the thickest nearest to the fracture.

Plantar Fasciitis: MRI views noting Inflammation not Tearing

Dr Rich Blake and the Center For Sports Medicine Singing Group (aka Richie and the Saints) from Saint Francis Memorial Hospital in San Francisco sing " I Want A Hippopotamus For Christmas" at this year's Christmas Bash. Since there are hardly anymore record stores, see if iTunes is selling it. 

This is a great MRI scan showing intense inflammation around the plantar fascia just in front of the heel bone. The pain was so severe the MRI was done to rule out a tear in the plantar fascia or a calcaneal (heel bone) stress fracture. With the MRI you can look at the plantar fascia in all 3 body planes to make sure you are not missing anything.

Here the MRI section is a little closer to the heel bone showing some greater inflammation settling under the heel (called bursitis). Again, no tear is noted but in both views the plantar fascia would be considered thicker than normal from scarring. The health care provider must treat the intense inflammation initially before actual work can begin on the thickened plantar fascia (this is where ART shines--Active Release Technique--not colored crayons and ceramic bowls).

Talus Injury and Initial MRI Followup Post Ankle Sprain

Top 100 Biomechanical Guidelines #25: Understand the 3 Measurements taken on a Standing AP Pelvic Xray

Standing AP Pelvis Xray with shoes and orthotic devices

     Look at: Heights at the Acetabulum, Sacral Base, Heights at the Iliac Crests

     As you review this xray, you will see that the the left hip at the acetabulum (hip joint) is higher than the right. This is the true leg length difference if the foot is in its neutral subtalar position (why it is best to take this xray with stable shoes and stable orthotic devices in the shoes). The symbol marked UPRIGHT means standing and is on the left side. The base of the spine where L5 vertebrae rests on the sacrum, also called the sacral base, drops to the right side. One of the last posts discuss how to measure sacral base unleveling. Many feel that getting a level sacral base is more important than correcting the hip height difference.The highest point on the iliac crest, not even seen on the left since it is higher than the right side, is a summation of the pelvic difference. When you look at many points of the pelvis, comparing right to left, you will see how the left is higher all around. However, one of the major problems we face is one of trying to take xrays only when crucial (due to the radiation). I would love to xray after very change I make, but I must be conservative due to the radiation exposure.

     Common Xray Findings Example:

• Hip Height at Acetabulum 10 mm short right (TRUE STRUCTURAL)
• Iliac Crest 17 mm short right (further pelvic and Sacro-Iliac joint collapse)
• Sacral Base 13 mm short right (amount spine needs for leveling)

With these findings, it is easy to start with 1/8th inch lift (3.3mm) for 2 weeks, another 1/8th inch for 2 weeks, and then 3rd 1/8th inch lift for the final 2 weeks. I start with tie-on shoes that take the full 3/8th of an inch. I would then have the patient wear this amount for two months to get use to them. Some time with a physical therapist to work out the predictable muscle soreness that will ensue would be great during this time. After the 2 months, if there is still limb dominance, still some symptoms, then I would go up another 1/8th to correct for the sacral base (the extra 3 mm the xrays showed). Of  course, many stop the correct at lower levels if the symptoms are resolved. Patients can fight you alot during lift therapy since they do want lifts. Who would?? It is important to stay focused, and the xrays really help in this regard. The xrays tell us what is the short side, and by how much. Treatment can be gradual, but complete correction of a short leg is usually obtainable.

Vitamin D Deficiency: A Podiatrist View on the Crisis

http://www.dreamstime.com/free-stock-image-umbrellas-on-the-beach-rimagefree1019661-resi2565486

Wouldn't you just love to be there? Where ever it is!! Of course, I have been stuck in the coldest summer in 40 years in San Francisco, California, which makes my day dreaming even worse. The image of the umbrellas on the beach highlights our need to protect our skin and avoid sun exposure. We lather up the Sunscreen as dutiful health conscious individuals but one of the side effects is a sudden crisis in Vitamin D Deficiency. What is the big deal? Vitamin D is essential to move calcium into your bones. As a podiatrist, I see too many patients low on Vitamin D and developing stress fractures and joint problems. So, find out your Vitamin D level (read the link below) at your next blood test.

http://www.vitamindcouncil.org/health/deficiency/am-i-vitamin-d-deficient.shtml

http://www.drblakeshealingsole.com/2010/04/patient-footlight-1-followup-on-foot.html

Calf Cramps: Common Causes and Diagnosis Not To Miss

     Calf cramps are a very common problem seen in my practice. I have experienced severe nocturnal cramps after too much basketball, or too many miles, as have many of my patients. I eat a daily banana with my morning coffee as a preventative measure. I need to drink more as the articles below discuss since dehydration is a big factor. I am always slightly dehydrated and have a mental block about drinking more (one of my many mental blocks). I have always found good stretching right after your workout of any muscle that cramps, and then one more time before bed, can greatly diminish or eliminate these cramps. If you have disc disease in your low back, the associated nerve root can cause severe leg cramps (after you lie down) in the muscle groups involved. Finding the right position of your spine in bed, and sometimes getting a new bed or mattress, can be important. So, dehydration, low potassium or sodium, low carbohydrates, tight muscles, strenuous exercise with a buildup of lactic acid or other waste products, low back irritation, and poor circulation are truly the main causes of cramps, mild to severe. Before I present my story about Doug, please glance through these links below so you can see what is out there for the consumer and why I want to tell (and slightly brag) Doug's story.
http://www.sportsinjuryclinic.net/cybertherapist/back/backlowerleg/calfcramp.htm

http://www.dummies.com/how-to/content/nocturnal-leg-cramps-nighttime-calf-muscle-pain.html

http://www.associatedcontent.com/article/218563/calf_cramps_causes_and_solutions.html

http://www.associatedcontent.com/article/218563/calf_cramps_causes_and_solutions.html

http://www.associatedcontent.com/article/218563/calf_cramps_causes_and_solutions.html

http://www.crampshelp.com/nighttime.html

     Doug presented to my office for a 2 week followup appointment after fracturing his right 5th metatarsal and being placed in a removable cast. This is a routine procedure. After about 10 days in the cast, he no longer had any foot pain in the fracture area, but began to get calf cramping on the side of the fracture. The calf cramping steadily got worse over the 3 days before his normal followup visit. The night before his visit he could not sleep because of the pain caused by the cramping. Removing the cast did not help his symptoms, and stretching the muscles did not help. It is easily explained by some dehydration, some electrolyte imbalance (have another banana), some tightness developing in the cast in an already tight calf, and some restriction of the circulation from the velcro straps holding the cast on his leg. These are all common causes by themselves of cramping, and they are exaggerated when several co-exist together. I also thought Doug may have tweaked his low back with the cast, even though he had an Even-Up, which could have been a 5th factor. It could have been easy to have dismissed it, simply giving the typical advice of stretching, drinking, massage, but something was different that is hard to put into words.There is definitely a sixth sense that plays out here (and I believe in guardian angles also). Doug knew his body, and something was not making sense. Red Flags went up. Doug was concerned. I listened. We decided to rule out the one in ten thousand chance he had a blood clot in his leg. This is never mentioned in the articles above, because it is rare. He had none of the predisposing factors for blood clots, except the slight foot fracture.

http://www.stoptheclot.org/learn_more/blood_clot_symptoms__dvt.html

Doug went that day to get an ultrasound to rule out a one in ten thousand chance that he had a blood clot, AKA Deep Vein Thrombosis. He called me 8 and 1/2 hours later, first availbability of getting that test, that the test was positive and he was on his way to the ER to be started on blood thinners. What a day!! Boy, did I feel good after that call that we had not missed it. But, Doug and his family probably felt better, much, much better, especially when you read the stats.

To all the articles on leg cramps, I say add an asterick for this possibility (call it Doug's Law). To Doug, I am glad you listened to your body, and I am glad this blog/this story can hopefully help someone else. Golden Rule of Foot: Increasing Leg Cramps over several days should be worked up for DVT.