Harlan Selesnick, M.D
 
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Lower Leg

JOCK Doc's Lower Leg Questions

Question
I have had pain in the ball of my foot for 5 months ;pain gets worse with long days on feet. I have had 2 x-rays, MRI and bone scan. I've been referred to a doctor in Baltimore. My local orthopedic surgeon doesn't see cause for pain but said there is fluid in great toe joint. Should I be walking on it and what could this be? Leon

Answer
There are several possible causes for pain on the ball of the foot in a dancer. These include tendonitis, stress fracture of the 1st metatarsal head, stress fracture of the small sesamoid bone(s), sesamoiditis, bunion, metatarsalgia, neuroma, and hallux rigidis. Not all these conditions will show on a bone scan or MRI. Since you are not getting better I recommend you see an orthopedic foot specialist in your area that is familiar with dancers feet. The Jock Doc


Question
In December of 1998 I suffered a tibial plateau fracture in my right leg. It was not severe enough to warrant a cast or surgery, so my doctor prescribed rest and then a rigorous several months of PT. I improved quickly at first in some ways, but it took me a long time to regain quad strength and any flexibility. During the summer of '99, I was still in a lot of pain and discomfort and soon discovered that I had an inflamed plica and fat pad. In November of '99 I had arthroscopic surgery to 'clean up' my knee, which included a smoothing of the underside of my patella. Since then I have had more PT and am now working out on my own. I just spoke to my doctor last week to keep him posted on my progress and he said that the discomfort and moderate effusion I have is normal. He also said that while I will continue to improve past this point, my fracture was the kind that may never allow my knee to feel 'normal' again. He said I am not to try running until the summer and that I may never be comfortable as a runner again. I have had a lot of trouble getting through daily activities at times b/c of pain and a 'tugging' sensation in my knee, but I do push myself to work out nonetheless. I am about to begin using a trampoline to further my strength and hopefully regain more balance and flexibility in my 'bad' knee. It is tough for me to find more info. on my injury, being that most tib. plateau fractures I've read about have been far more severe than mine. Any more info. or advice on this topic would be very helpful. Thank you! Tiffany

Answer
Tibial plateau fractures involve the articular surface of the joint and if they are out of place can lead to arthritis , pain and swelling. It appears that your fracture was in place but yet you have not returned to near normal function. It also appears that you had roughening of the kneecap surface (chondramalacia) that can result in a slower rehab from arthroscopic surgery. I agree that continued pain-free rehab and strengthening will likely help to decrease symptoms. As long as you are improving then I do not believe more needs to be done at this time. If you plateau and are still not satisfied with the result then you may want to get a second opinion. The Jock Doc


Question
I have an important concern regarding a post sost surgical complication on the tibia and fibia bones. there is an infection 4 days after surgery and the recommended procedure is intravenous antibiotics for six weeks, one half an hour a day. What does the actually mean in terms of healing? Is there really a danger here. Please respond. I'm in a panic here. Thank You. Karen

Answer
An infection in the bone can be a serious condition and requires aggressive treatment. I believe that your doctors are doing the right thing. An infection such as this requires IV antibiotics for about 6 weeks and occasionally requires surgical drainage. It is important you listen to your physicians. The Jock Doc


Question
I am a 38 year old athletic female. In June 1999, I suffered a tib/fib and medial malleollus fractures from a soccer slide tackle. I had a metal IM nail and 6 screws inserted. Recently, due to continued excruciating pain in my knee, I had the two screws removed from underneath my knee. An arthroscopy revealed no further knee problems. Removing the screws seems to have resolved my pain and I hope for complete recovery. What are the chances of playing soccer again without suffering devastating injuries the next time someone crashed into my leg. Is the steel rod strong enough to not bend upon impact? Will the rod deteriorate over time? Are the tib/fib more likely to break since they have been fractured before? Or should I be ""smart"" and not play soccer again? I would appreciate your suggestions or response! Aloha. Simone

Answer
Once your fracture has solidly healed you should be able to return to all sports normally. Usually the hardware is left in place as removing it may weaken the bone for up to 1 year. Although you are at slightly greater risk for a new injury with a rod and screws in place, I do not feel this should keep you out of sports after solid bone healing has occurred. I have several professional and collegiate athletes playing without limitations with rods in their tibias. The Jock Doc


Question
I need information on treatment for severe ' bone spurs' on maximal joint of ankle which seem to be causing problems with Gait; contracture of opposite leg; back problems; general loss of mobility over a period of five years in a 35 year old male. Joan

Answer
Bone spurs can be the result of repetitive trauma over many years or the result of an old fracture or sprain.. I recommend you see an orthopedic surgeon to determine the type, location, and significance of your spurs. Some spurs can be removed with the arthroscope. Other problems with associated arthritis may require more complex surgical treatments. The Jock Doc


Question
I have been told by my family doctor that I have severe arthritis in my left ankle. As a child, I had to wear special shoes because I had very weak ankles and there was a tendency for them to turn in. I was a teacher for 33 years and have been retired for over five years. My ankle has progressively gotten worse and I can barely walk. My bones in my ankle seem to move around. At times there is so much pain that I can't even take a step. I have been told that my x-rays show that the padding between the bones in my left ankle has deteriorated to the point that there is basically bone rubbing on bone. It seems that the three doctors (orthopedic surgeons), that I have been to, think that fusing the bones in my ankle is the only solution in order for me to receive relief. I would like an opinion from someone like you with a background in sports medicine. If surgery is a necessity, I would like some guarantee of being able to walk again without pain. Do you know of anyone that has had the same type of problem that I have and has had surgery? If so, could you refer me to them so that I might talk with them about their surgery to see if it was successful or not. Also, do you know of any surgeons that are specialists in operating on ankles in the Houston, San Antonio, Dallas, Austin or Corpus Christi areas? If so, please let me know. At present, every step I take hurts. I have to limp in order to walk, and due to me limping and giving to it, I am now having increased pain in my right hip and knee. I can't stand and put my full weight on my left leg. If there is a doctor that can perform such a surgery to correct this, so that I can again walk without pain, I would greatly appreciate you letting me know. Thanks so very much! Jane

Answer
I agree with your 3 opinions that an ankle fusion would likely give you the best results in terms of function and pain relief. Ankle replacements at this time do not appear to function well in active people and may loosen. Therefore, when your pain gets to the point as it has now where it is disabling and affecting your lifestyle the best treatment with the best chance of success is a fusion. There are different techniques of fusion, but they appear to have comparable results with a skilled surgeon. In the Houston area Dr. Walter Lowe and Dr. Bruce Moseley take care of many high level athletes and in Dallas Dr. Tarek Souryel also has much experience. I recommend you ask the physician you feel most comfortable with for the names of patients who have had the surgery. The Jock Doc


Question
I’m a 22-year-old college student. 2 months ago I broke dislocated my tibia and broke my fibia. 8 screws, one plate and a pin later (non-metal), my doctor says it is not healing (non-union). The Dr. recommends putting in a metal pin in and also using cartilage graphing technique that has not been done before. I don't like the idea of being the ‘experiment’, but if need be I would have to do it. I’ve been non-weight bearing for 8 weeks and would like to know what can I do to excel the healing? Can I take calcium pills or vitamins? I still put my leg up as much as possible but is there other things that I can do? What would you recommend? I'm desperate to try anything, your input would be very valuable. Harry

Answer
Non unions are defined as no evidence of healing for at least 6 months. However, with a fracture as severe as yours the doctor must feel you are at significant risk for the fracture not healing. Before having an experimental procedure I would recommend you get a second orthopedic opinion from a trauma specialist such as found at a university teaching center or a major trauma center in your area. As far as dietary supplements a well balanced diet with a multi vitamin should be sufficient. Calcium and other supplements have not yet been shown to make a difference in healing in healthy individuals. The Jock Doc


Question
Is there any way to avoid achilles tendonitis? My daughter is a serious dancer and has been suffering from this every few months for the past 3 years. In the past, she has gotten better in a week's time if she stays totally off the foot (crutches) but this is no longer feasible for her. Her last incident took a month to heal. Does she need to get off the foot as soon as she feels pain or can she continue to dance without causing further damage to herself? She has been told to ice it every time she dances but complains that that only makes her feel stiff and worse. A recent MRI showed no damage or inflammation to the tendon...is it possible that it is not tendonitis, but instead related to her growing years? Alice

Answer
Dancers make up a very special group of sports medicine patients. It is very common to have foot and ankle problems. It is also likely that your daughter may not just have achilles tendonitis. There is a condition commonly seen in dancers known as Os trigonum syndrome. This is commonly exacerbated en pointe is actually a tendonitis of the toe and ankle flexors. I recommend you get another opinion from an orthopedist with experience with dancers to determine what exactly your daughter has and what can be done to prevent further symptoms. The Jock Doc


Question
My dad read an article in USA Weekend, June 4-6, 1999 about new surgical procedures. It mentioned a new procedure called "microfracture" performed on skater Scott Hamilton where tiny holes are poked into damaged cartilage to cause new cells to form. My dad has a lot of difficulty with his ankles and was looking for more information on this new technique, yet we cannot find anything. Do you perform this and/or what is your opinion of it? He has had a hip replacement in the past. Janet

Answer
Microfracture techniques for small localized areas of articular cartilage loss have been performed for quite a few years. The principle is to create small holes in the end of the bone with a pick or awl that allow a blood supply to the locally involved defect. This allows a fibrocartilage to grow which decreases wear and pain. The patient must stay non weight bearing with crutches for at least 8 weeks. Other techniques for localized articular cartilage defects include transfer of cartilage and bone plugs from non weight bearing areas (mosaicplasty) and cartilage re-growth techniques (cartisal). Your fathers problem sounds like a more diffuse type of arthritis and likely would not benefit from these techniques. I recommend you see an orthopedist in your area to determine when can be done to help your dad. The Jock Doc


Question
I am 58 years old and have been jogging about 3.5 miles mostly every other day for about 17 years. Over this period, I have had my share of the usual runner injuries. I currently have what feels like a knot in the calf muscle of my right leg, about 9 inches above my ankle, on the inside/rear of the calf. I first encountered this about a month ago and it was painful enough to curtail my running for a couple of weeks. During that time, I walked briskly. I tried running again, and it started to hurt after about 2 miles, so I stopped and walked. I gave it another week and started again - It seemed to be ok. About 2 weeks later, the pain (charlie horse?) came back with enough pain to make me even stop walking fast. I could feel a slight ""bump"" (or swelling) on that part of the calf and applied an ice pack for about 15-20 minutes without any success. I have done no exercise (except short 1-2 mile walks) because I now feel some pain and "tightness" in my calf whenever I walk. This has been going on for the past 2 weeks. William

Answer
I recommend you see an orthopedic surgeon to determine whether you have a partial tear of your medial (inside) gastrox (calf muscle) or a microfracture of the tibia (stress fracture). It is important that this be diagnosed accurately so you can properly treated and return to running quickly. The Jock Doc


Question
My son suffered a level 9 compound tib-fib fx while playing football 9/98. He rehabilitated for 9 months. He is in prep school, to be recruited for basketball. He wants the rod removed in the Spring. What is his rehab time going to be?? How long will he be out of commission? C. Dill

Answer
Tibia fractures are complex injuries. The timing of rod removal depends on several factors such as is the fracture healed, is the rod painful, how long has the rod been in, and the activity level of the patient after rod removal. I recommend you discuss this with your orthopedic surgeon because in some circumstances after rod removal the tibia is at risk of refracture and contact sports may be limited for up to 1 year. Not all tibial rods have to be removed. The Jock Doc


Question
5 months ago I was hit by a car and suffered a badly broken leg (3 fractures of the tibia and 1 fibula fx). I was treated w/ open reduction and internal fixation. The nail that was placed has moved a bit causing the uppermost fracture to heal at a slightly crooked angle. I'm also concerned about a slow healing (non-union?) fracture below. At five months out I still have pain and walk with a crutch or a pronounced limp. My physician states that this is a good result. I went for a second opinion and was told it is a bad result "non-healing, non-union fx absolutely requiring another surgery" (reaming the bone, placement of a larger nail, and breaking my leg again to set it straight). A third consult produced yet another opinion; sonic bone stimulator for the slow healing fx. Possible surgery later to straighten the leg. At this point I don't know who to believe and/or which treatment is the best course of action. I know that you can't dispense medical advice w/out seeing my x-rays, but any direction you can give me would be greatly appreciated. How can I find out which course of tx is best for me? THANK YOU FOR YOUR TIME AND CONSIDERATION! Deb

Answer
The tibia can be a very slow healing bone when fractured. It is difficult stating which of the physicians you saw is correct without seeing the x-rays. However, a bone stimulator which although expensive is easy to use and has no side effects may be helpful in getting the fracture to heal. If this fails or the angulation of the fracture is too severe then you may require surgical treatment. If you are still unsure it may be helpful to contact a major university trauma center and get an opinion from their trauma specialist, who is likely to have extensive experience with difficult problems. The Jock Doc


Question
I would like to know What is done when you have Arthroscopy on a knee. How long is recovery? Do you have to stay off your feet completely or just minimum use? Will I be able to go to work next day? Would appreciate quick response before I have surgery. Thank you so much for your help. Maria

Answer
Arthroscopy of the knee is usually an outpatient procedure. The most common reason for knee arthroscopy is to remove or trim a torn piece of meniscal cartilage. Other common arthroscopic procedures include smoothing damaged articular cartilage (chondroplasty) or repairing a torn meniscus with sutures or absorbable arrows. Most arthroscopies require just a day or two on crutches. A rehab program is usually begun post op to regain normal motion and function. Usually one can return to work in a couple of days , but mostly sitting initially. The specifics of your knee surgery should be discussed with your surgeon as your problem might be different. The Jock Doc


Question
I am training for my first marathon and I'm experiencing pain in my foot that greatly limits my activity for one week after every run that is 16 miles or longer. The pain is in my in my right foot, about 1/2 inch in front of the ankle, on the top of the foot, just right of the center. I am flat footed, but I don't seem to over pronate. My left foot feels great. What is your advice? Nancy

Answer
It is possible that due to your increased training schedule you may have have sustained an overuse injury to your foot. The most common overuse injury would be a micro fracture of your foot known as a stress fracture. I recommend you see your orthopedic surgeon or foot specialist promptly to accurately diagnosis the injury. If it is a stress fracture it may require a period of rest from running. X-rays or an MRI may help make the correct diagnosis. Rapid treatment of foot injuries help prevent further injury and help in a more rapid return to running. The Jock Doc


Question
I am a 16 year old cross-country runner and just this afternoon I ran the mile. Before the mile I stretched and ran a warm-up. After the warm-up I ran the mile a few minutes later like I always do. So I ran the mile in 5:01. When I was done the back of both of my calf muscles hurt so badly I could barely walk. It hurts every time I stand up straight now. I came home and soaked in the bath tub (warm water). Then I put icy hot on them. Please tell me what's wrong. Thanks. Asa

Answer
There are several possible causes for your calf pain. It is possible that you strained your calf muscles resulting in pain and stiffness. It is also possible that you may have a form of shin splints such as a stress fracture or inflamed lining of the bone (periostitis). It may also be possible that you have an "exertional compartment syndrome" which is caused by pressure on the muscles from swelling. Each of these conditions are treated differently. It is important that you see your orthopedic surgeon to establish the correct diagnosis so you can not only get better quickly, but hopefully learn to prevent the injury from happening again. The Jock Doc

 
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