By: Asher Cherian, DPM1 and Laura Sansosti, DPM, FACFAS2

1Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA

2Clinical Assistant Professor, Temple University School of Podiatric Medicine, Philadelphia, PA

Pain control is an essential aspect of providing comprehensive care to our patients. There may be profound implications when inadequately managed, especially in the postoperative setting (1). In the background of an opioid epidemic, clinicians and healthcare providers should consider alternative methods to control acute and chronic pain. A multimodal approach to pain management is essential to reducing opioid requirements, minimizing adverse events from opioids, and hopefully increasing patient satisfaction. 

Local Anesthetics

Short-acting and long-acting local anesthetics can be used in a variety of clinical applications to provide non-opioid-based pain management. Local anesthetics have a unique benefit with overall low risk compared to oral medications. Local anesthetics can be administered via subcutaneous injection or topical application. Injectable local anesthetics are often administered during in-office procedures and pre-and post-operatively in the operating room to decrease postoperative pain and oral medication requirements. A significant amount of utility is provided by a local anesthetic infiltrated into an area of pain. It can provide adequate analgesia for several hours to days depending on the type and amount of local used. Depending on the clinical application, the determination to use a short-acting versus long-acting local anesthetic should be made. A diagnostic nerve block can also be a versatile tool for addressing painful symptoms for patients with idiopathic pain to a particular foot or ankle region. A literature review by Griffioen et al in 2018 found that regional blocks provided superior pain relief compared to opioids following a lower extremity fracture (2). There is also evidence within the orthopedic literature pertaining to total hip arthroplasty (THA) and total knee arthroplasty (TKA) that demonstrate the effectiveness and benefits of postoperative regional anesthesia. A study by Marques et al in 2014 showed that infiltration of local anesthetic following THA and TKA shortened hospital stays, reduced opioid consumption, led to earlier mobilization, and reduced vomiting (3). The study also concluded that receiving local anesthetic infiltration lowered pain scores at rest compared to controls after 24 and 48 hours (3). Postoperative local anesthetic blocks have provided significant postoperative analgesia after foot and ankle surgery (4). Patients who receive a popliteal fossa block have better pain scores, a more prolonged analgesic effect, and decreased opioid requirements in the immediate postoperative period (5). The popliteal fossa block was also found to have better pain scores and reduced opioid requirements than the ankle block (5). 

NSAIDs

NSAIDs work by inhibiting cyclo-oxygenase (COX), diminishing post-injury hyperalgesia. Mild to moderate pain can typically be treated with an oral NSAID or acetaminophen. Studies performed by Pogatzki-Zahn et al (2014) and Nonaka et al (2016) demonstrate NSAIDs to be more effective in postoperative pain control compared to acetaminophen (6,7). While these may not be benign medications in terms of potential renal and GI side effects and platelet inhibition, the use of selective COX-2 inhibitors decreases that risk. They also note that the harmful side effects of acetaminophen are often underestimated in terms of possible liver damage (6,7). Some may also argue that NSAIDs are detrimental to the early phases of bone healing. However, more long-term data is needed. A study by Cozowicz et al in 2018 found that COX-2 inhibitors and NSAIDs were associated with the strongest individual effect in opioid dose reduction. NSAIDs have also been shown to reduce opioid requirements following ankle fracture surgery (8). Effective pain control is critical during the first two days following ankle fracture surgery because patients, on average, consume the most opioids during this time. A study by McDonald et al in 2018 found that the addition of the NSAID Ketorolac significantly reduced postoperative pain while concurrently reducing opioid requirements (9). They also found that patients experienced less pain during postoperative days one to two, and the addition of Ketorolac maintained 

minor discomfort for up to four days post-operatively. The patients in their study found greater patient satisfaction with their pain management, less hypersensitivity, and fewer paresthesias when treated with a multimodal pain regimen, including NSAIDs (9). 

           With increasingly strict regulations on narcotic prescriptions and high addiction potential, the multimodal approach to postoperative pain control is critical. Each patient is a unique case and requires thought to their co-morbidities, planned procedure, and anticipated postoperative pain to determine the optimal regimen to control their symptoms. It is imperative to discuss expectations with your patient, especially regarding postoperative pain. Opioid contracts are increasingly utilized and serve as a good starting point for this discussion. For patients who have chronic pain, referral to pain management pre- or post-operatively can also be considered. By not solely utilizing opioid-based medications, we can reduce opioid dependency and provide better outcomes for our patients.

References:

1. Carr DB, Goudas LC. Acute pain. The Lancet. 1999; 353(9169): 2051–2058. 

2. Griffioen MA, O'Brien G. Analgesics administered for pain during hospitalization following lower extremity fracture: A review of the literature. Journal of Trauma Nursing. 2018; 25(6): 360–365. 

3. Marques EMR, Jones HE, Elvers KT, Pyke M, Blom AW, Beswick AD. Local anesthetic infiltration for perioperative pain control in total hip and knee replacement: Systematic review and Meta-analyses of short- and long-term effectiveness. BMC Musculoskeletal Disorders. 2014; 15(1). https://doi.org/10.1186/1471-2474-15-220.

4. Elliot R, Pearce CJ, Seifert C, Calder JD. A prospective, randomized trial is a continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery. Foot Ankle Int. 2010; 31(12):1043-1047. 

5. Schipper ON, Hunt KJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Ankle block vs. single-shot Popliteal Fossa Block as primary anesthesia for forefoot operative procedures: Prospective, randomized comparison. Foot Ankle Int. 2017; 38(11): 1188–1191. 

6. Pogatzki-Zahn E, Chandrasena C, Schug SA. Nonopioid analgesics for postoperative pain management. Current Opinion in Anaesthesiology. 2014; 27(5): 513–519. 

7. Nonaka T, Hara M, Miyamoto C, Sugita M, Yamamoto T. Comparison of the analgesic effect of intravenous acetaminophen with Flurbiprofen Axetil on post-breast surgery pain: A randomized controlled trial. Journal of Anesthesia. 2016; 30(3): 405–409. 

8. Cozowicz C, Poeran J, Zubizarreta N, Liu J, Weinstein SM, Pichler L, Mazumdar M, Memtsoudis SG. Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilization: A retrospective study of obstructive sleep apnea patients undergoing elective joint arthroplasty. British Journal of Anaesthesia. 2019; 122(1), 131–140. 

9. McDonald E, Daniel J, Nicholson K, Shakked R, Raikin S, Pedowitz D, Winters B. A prospective randomized study is evaluating the effect of perioperative NSAIDs on opioid consumption and pain management after ankle fracture surgery. Foot & Ankle Orthopaedics. 2018; 3(3). https://doi.org/10.1177/2473011418s00085. 

By Alicia Canzanese, DPM, ATC

DEFINING THE CORE  
There is a growing body of evidence to support the importance of core stability in the prevention, treatment, and rehabilitation of lower extremity injuries.  Active patients often tell me they either don’t do any core exercises or the only exercises they do are crunches. The core involves a whole lot more than what people picture as six-pack abs.  If you want a strong core, crunches should not be the only exercise.  Some argue you shouldn’t be doing them at all and should replace them with much more beneficial exercises.   

The core, defined as the lumbo-pelvic-hip complex, is the whole area between your diaphragm and your upper thighs. It involves the muscles of the abs such as the rectus abdominis, but also the sides (obliques and transverse abdominus); the back (rectus abdominis and multifidus); the pelvis (the gluteal muscles); and the hips (including the hip flexors, abductors, and adductors).  

To truly work the core, you need to put together a program of exercises that address all the major muscle groups.  Instead of doing 100 crunches, which are primarily working one muscle group, split it up and do 25 of each: planks, side planks, side lying leg raises, and bridges.   

Other beneficial targeted core exercises include:  Bird-Dog’s, Superman’s (trunk extensions), clamshells, and marches or leg extensions on a swiss ball.  Most of these exercises, if done properly with a stabilized lumbar spine position, can be much safer and more protective to the spine than simple crunches.   

There are a lot of complicated core exercises out there, remember to start with the basics, like a basic plank or a bridge to work multiple muscle groups so you are getting a lot more bang for your buck.   

WHY THE CORE IS IMPORTANT FOR LOWER EXTREMITY INJURIES 
Just like in the children’s song, all the bones in the body are connected.  Having a strong core (Hips/Abs/Back) is one important way to stabilize the entire limb to both prevent and treat injury.  In order to prevent “overuse” injuries, you have to evaluate the entire kinetic chain. In kinetic chain theory, motion or translation in any segment of the limb affects the entire limb.  It is important that we as podiatrists not just look at the pathomechanics from the bottom up, but also from the top down:   

• If there is excess tilt, rotation, or weakness at the level of the hip and pelvis then this can lead to uncontrolled joint displacements or unwanted accessory movements down the entire limb to the feet.
• Having weakness in the core not only can contribute to overuse injuries but can also increase your susceptibility to acute injuries such as sprains and strains.
• Picture this: if you are playing soccer and are cutting and changing direction, all your weight is on one leg. If your hips and glutes are weak and there is excess wobble at the hips, that motion is going to translate down to excess motion in your leg, which can lead to an increased risk of knee ligament injuries and ankle sprains.
• Research shows us that there is coupled motion between the core and the lower extremity muscles.  The muscles of the hip and pelvis have been shown to be activated before the initiation of lower extremity muscles can occur.  If muscles aren’t being activated properly and there is excess motion being passed down the limb, then the individual is more prone to knee, leg, ankle, and foot injuries.
  

One of the most common appreciable weaknesses I see in my practice, especially when evaluating novice and recreational runners/walkers, is gluteus medius or hip abductor weakness.  This can be seen on evaluation either with simply looking for the Trendelenburg sign; while observing increased hip displacement/wobble/dip during gait while viewing posteriorly; or with increased crossover with gait (foot crosses over the midline during strike).  This abnormal leg motion can lead to stress on the lateral leg muscles and structures such as the IT Band, leading to lateral knee pain; over activation of the peroneal tendons leading to tendonitis around the foot and ankle; and can contribute to many overuse and acute injuries of the lower extremity.   

DECREASE INJURY RISK BY UPDATING CORE EXCERCISES 
From a podiatrist’s standpoint, the best examples in the medical research for the importance of core stability with injuries are ankle sprains, chronic ankle instability, and medial tibial stress syndrome (more commonly referred to as shin splints).  In order to help decrease injury risk, core (and especially hip abduction) strengthening/stability exercises should be included in your weekly fitness routine.  Also, as practitioners, it is important to make sure that when our patients are doing physical therapy (either at home or with a therapist) that they are including core stability exercises as an important part of their rehabilitation both to treat their injury and to prevent reoccurrence.   

In conclusion, if you are not addressing it, or if you are only doing crunches, IT IS TIME TO UPDATE YOUR CORE PROGRAM!   

• Make sure your core exercises address the whole “lumbo-pelvic-hip” complex and not just the 6-Pack Abs.
• In order to help prevent lower extremity injuries and overuse conditions, you need to make sure your patients are addressing any core, and especially the hip, weakness.
• In patients who have sustained acute ankle sprains, make sure that core/hip exercises are included in their rehabilitation program.

In the world of sports medicine, core stability is becoming a very important factor for the overall health of the athlete as it is all about the kinetic chain. The importance of core stability is really just adding truth to the children’s song, “The foot bone’s connected to the leg bone, the leg bone’s connected to the thigh bone …” and so on! 

Written by Steven Chen, DPM

A Bunion, medically known as hallux abducto valgus, is an orthopedic structural deformity that causes the bone behind the big toe to protrude. There are several causes for a Bunion deformity; the most common cause is over-pronation of the foot. The foot rolling inward weakens the ligaments and muscles causing the 1st metatarsal to shift, creating an over-growth bony deformity on the medial side of foot. Other factors that can lead to the formation of Bunions include trauma, having flat feet, wearing high heel shoes, as well as some hereditary factors. 

A Bunionette, or Tailor’s Bunion, is a smaller deformity on the outside of the foot associated with the little toe. It can be painful, similar to the Bunion deformity, especially if it rubs against the side of the shoe and limits range of motion at the joint site.   

Both deformities can begin with symptoms of redness, pain, swelling, and even blisters. If left untreated or not managed properly, these deformities can lead to: limited range of motion in the affected joint and arthritis; increased pain in the area; and skin breakdown leading to the need for wound care. 
Individuals with medical conditions such as diabetes and poor circulation can easily get bone infections from a Bunion or Bunionette, which would require long-term IV antibiotic treatment to heal the wound. If the bone becomes too infected, it could lead to gangrene and the possible need for an amputation.   
There are several conservative treatments and management options for a Bunion as well as a Bunionette: 

• These can range from ice and elevation of the affected area to a short course of anti-inflammatory medications to alleviate inflammation in joint.
• Also, various padding can be used around the area to help alleviate the irritation.
• Orthotics can also help limit the excessive pronation of the feet to aid in reducing and preventing the progression of a Bunion and Bunionette.
• Appropriate footwear, such wider-fitting shoes, can also relieve some of the pain caused by a Bunion deformity.

But when a Bunion or Bunionette does not respond to conservative treatment, your Podiatrist may recommend surgery to correct them. The surgery would remove the prominent, irritating bone deformity and correct any misalignment of the joint involved in order to restore proper toe function. 

Written by By Paul LaFata, DPM

Originally shared in the May/June 2021 PPMA Newsletter

Helping Runners Pick the Right Shoes Can Prevent Running Injuries

We all know these patients. We see these patients often. They are the ones who need pointed in the right direction as what to look for in a proper walking/running shoe, and subsequently help to avoid the running injuries we see regularly in our practices. Noting that most runners have a good feel for their shoe-gear. It’s the new runners/weekend warriors that tend to need to be pointed in the right direction. 

Spelling out the ‘anatomy of a shoe’ may be in order, something I find has helped my patients considerably. Especially when presented with these common run-ning injuries that sometimes manifest from shoe-gear—most commonly hammertoes, advanced metatarsalgia, ingrown toenails with or without subungual contusion, or subungual contusion alone. 

One common condition is “Runners Toe,” one where patients have sought repeated treatment. This problem presents with subungual contusions, which may lead to lysis of the nail-plate separating from the nail-bed. The source of the problem with this condi-tion may result from anterior shearing in the shoe. Thus not allowing the heel counter of the shoe to control the heel. This sometimes results from the lacing pattern of the running shoe. 

Going Back to Biomechanics Lab
It is typical for runners to increase their shoe size by approximately one-half their normal size. This takes into consideration the increase in swelling, which can occur with long-distance running. It also can compen-sate for the anterior displacement forces in the shoe; but what are we doing, as podiatrists, to prevent the foot from sliding anteriorly when running?

Being familiar with the anatomy of a shoe can make a difference with our patients. This goes back to our days in biomechanics lab in podiatry school when we reviewed the components of a shoe: the last, the shank, the medial posting, the shock absorption, and heel counter. 

1. The “last” refers to the template of the shoe, or the model for which the shoe is constructed. The last could be board (firm), slip (flexible), or strobel constructed. Strobel is most commonly found in running shoes. The shape of the last can be straight, curved, or semi-curved.

• Straight-lasted shoes are typically more supportive, and a curved last is less supportive.
• Most running shoes are a combination of moderate support with some flex to them and use a semi-curved last.

2. Overall, the shoe is divided into three parts: upper, outsole, and midsole. The upper, is the outside tip of the shoe and is stitched to the sole. The outsole is the bottom rubber, while the midsole is the insert between the two. This insert built into the shoe offers stability, along with the manufacturer’s insert.

• Stock midsole cushioning is typically made of EVA or a manufacturer’s proprietary foam.
• Midsole support often has a stabilizing bar extending from the medial arch to the medial heel. Different vendors have their own names for these, but they all aid in support, and tend to be more effective in controlling pronators. Additional medial posting may be found in rearfoot-motion-controlling shoes.

3. A shoe’s heel counter is considered the back of the shoe.

4. The shank is a rigid insert typically placed on/in the bottom outsole to create rigidity to the shoe’s midsole, and places more stress distally, allowing toe flexion to occur.

Together these things contribute to the overall fit and the amount of stability a particular shoe can provide. Most of the major brands all carry variations of these components, which may cause an underlying problem if the shoe doesn’t fit properly.

Evaluating a Patient’s Shoe-Gear 
I find it remedial to discuss/evaluate shoe-gear with patients. I evaluate the last, insole, and support, showing them the components of the shoes that may correlate and/or contribute to their pathology. We discuss biomechanics in layman’s terms.

Most often I find that patients wear shoes that are too small. Yet I have patients who present with symp-toms identical to those who wear their shoes too small, but the shoe size is correct. Examples would be—a subungual contusion or proximal nail-fold paronychia with a normal appearing nail. Here is what I do for these patients—

1. I evaluate the patient’s shoes by taking out the insoles and showing them the “wear pattern” of their toes. If these shoes are the appropriate size yet the
toe-pattern force acts as though the shoe is small, it means the toe-wear pattern is pushing up to the edge of the insole. 

2. From here, if the shoe is the appropriate size, we discuss a shoe-lacing technique to prevent the foot from sliding in the shoe. This obviously isn’t for those patients who necessitate velcro closures.

3. The technique is called the “heel lock” and is very simple. It is an effective way to lock the rearfoot into the heel counter, and is as follows so you can consider passing this along to your patients:

• This lacing pattern/technique creates an extra pulley-like tension at the proximal laces.
• This prevents the heel from sliding forward in the shoe.
• It is effective in controlling the heel in a proper-fitting shoe. 

It may seem like a formidable task to take more time with patients, but it has been in offering this basic education on a shoe’s anatomy that has greatly bene-fited my patients. Remembering also that some patients will always need velcro closures!   

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PHOTOS:

Figure 1: Heel-lock lacing creates a loop by utilizing the top two holes. One of the holes is usually offset a bit posteriorly.

Figure 2: Tighten laces as this creates the heel lock and aids in preventing anterior shearing forces

Figure 3: Use the loop as a "Lacing Eyelet."