Have you been seeing an increase in lateral ankle pain among baby boomers who have recently resumed regular exercising or sports activities? Sports medicine experts say the pain may be the result of old ankle sprains that haven’t healed properly and recommend checking the ankles of these patients for chronic instability. An estimated 25 percent of sports injuries involve the foot or ankle, according to the American College of Foot and Ankle Surgeons (ACFAS), and a majority of these result from incomplete rehabilitation of earlier injuries. Robert Duggan, DPM, says rigorous physical activity for these patients may cause persistent pain and swelling, and increase the risk for further damage to improperly healed ligaments. When it comes to diagnosis, Mark Dollard, DPM, says it is easy to identify the major classic injuries of torn ligaments and bone fracture with stress testing. However, he cautions that initial diagnostic tests may miss the hidden tears in the peroneal tendons, osteochondral joint cartilage defects in the ankle, joint capsule defects, associated sinus tarsi syndromes or nerve damage. One may not see these developing problems until “months later” via sophisticated MRI or CT scans, according to Dr. Dollard, the Scientific Chairman of the upcoming 2003 National Scientific Conference of the American Podiatric Medical Association. Amol Saxena, DPM, concurs, noting that “peroneal tendon tears are an overlooked cause of lateral ankle pain.” He says there are warning signs you can look for during the clinical exam. Dr. Saxena says you should be especially suspicious of a split or tear of a peroneal tendon if your patient has persistent pain and tenderness after a sprain, feels a “pop” on the outside of his or her ankle, and cannot stand on the tips of the toes. He says sometimes the injury is so severe that the tendon will produce a snapping over the lateral malleolus, which usually needs to be repaired surgically. One should obtain a MRI to confirm clinical suspicion of the injury, advises Dr. Saxena, who practices within the Department of Sports Medicine at the Palo Alto Medical Foundation in Palo Alto, Calif. Key Treatment Considerations Recent research from the ACFAS annual meeting revealed that more than 85 percent of athletes who had surgery to repair a torn peroneal tendon were able to return to full sporting activity within three months after the procedure. Dr. Saxena, a Fellow of the American Academy of Podiatric Sports Medicine, adds that these patients usually do spend six to eight weeks in a cast postoperatively and then undergo physical therapy. Generally, when it comes to treating ankle sprains, Dr. Dollard says the severity of the sprain determines the duration of immobilization needed for proper healing. He says patients with grade 1 sprains (which involve stretched ligaments) or grade 2 sprains (consisting of partially torn ligaments) should resume “functional weightbearing with stabilizing devices as soon as possible to prevent diminished recovery of the lateral ankle reflexes.” In order to attain the necessary stability of the ankle, Dr. Dollard says one can utilize a variety of recent bracing devices, including custom dynamic hinged ankle foot orthosis or static AFO braces. These devices help patients make the transition from non-weightbearing casts or boot devices to weightbearing rehabilitation options, emphasizes Dr. Dollard, the Founding AMPA Liaison to the President’s Council on Physical Fitness and Sports. What Preventive Action Can Athletes Take? Dr. Dollard says baby boomers also tend to forget that their musculoskeletal reflexes that protect posture and balance do become slower as they age. (He notes lateral ankle reflexes are the most vulnerable.) This tendency makes sprains an “inevitable consequence” of a hasty return to exercise or the playing field, according to Dr. Dollard. Before baby boomers begin any exercise program, Dr. Dollard recommends testing them for any ankle instability or lower extremity balance problems with the functional Trendelenberg Test. He says you should have the individual stand on one foot only with his or her arms outstretched to the side. Proceed to have the middle-aged athlete gently raise up onto his or her tiptoes and hold that position for 30 seconds. “Any gross failure to hold this position or to tilt the torso in compensation over the supporting limb heralds impending balance disaster,” says Dr. Dollard. If that happens, Dr. Dollard says all attempts at any competitive fitness or sports program should be put on hold. He says you should encourage these athletes to perform preconditioning exercises, such as weight training and plyometric drills, so they can re-stimulate muscle reflexes in their lower legs. Can Enzymatic Debridement Foster Improved VAC Results? By Brian McCurdy, Associate Editor When considering negative pressure therapy for a chronic wound, you ideally want to ensure the patient has a clean, viable, non-necrotic wound bed in order to maximize treatment results. However, when sharp debridement is not possible, what are your options? You may want to consider enzymatic debridement in this clinical scenario, according to the authors of an abstract that was recently presented at the Symposium On Advanced Wound Care. Dawn Walek, RN, Jeffrey A. Niezgoda, MD, and Kathleen Nelson, RN, tested the adjunctive combination of Panafil (Healthpoint) and Vacuum Assisted Closure (VAC) Therapy (KCI) on a 38-year-old female patient who had insulin-dependent diabetes and presented with a necrotizing soft tissue infection in her left foot. When sharp debridement failed to resolve a thick fibrinous and slough layer under the VAC sponge, the authors applied Panafil to facilitate better debridement. The combination worked and the patient went on to achieve complete wound healing, according to the authors. “The combined use of negative pressure therapy with a topical healing and enzymatic debridement agent can synergistically promote an optimal wound healing environment by enhancing granulation tissue while removing fibrinous debris,” conclude the authors. Assessing The Potential Impact “Ms. Walek and her group have very astutely put two potentially very useful modalities together and anecdotally found a synergy,” notes David G. Armstrong, DPM, the Director of Research and Education in the Department of Surgery, Podiatry Section at the Southern Arizona Veterans Affairs Medical Center. He points out that many investigators over the last few years have hinted at the promising potential of combining enzymatic debriding agents with VAC therapy. Dr. Armstrong, a member of the National Board of Directors of the American Diabetes Association, also notes there is evidence that suggests Panafil works as a metalloprotease inhibitor. “There is little question that the VAC works at least partially in the same way by removing potentially harmful, inflammatory protease-rich exudate,” says Dr. Armstrong. “The two most likely work in concert in that way as well as helping in wound healing.” Study Offers New Findings On Opioids For Neuropathy By Brian McCurdy, Associate Editor While concerns over ineffectiveness, side effects and addiction have previously thwarted the prescription of opioids for neuropathic pain, a new study says levorphanol provides comparable results to tricyclic antidepressants and the anticonvulsant medication gabapentin. According to the double-blind study, which was recently published in The New England Journal Of Medicine, an eight-week course of levorphanol provided significant improvement for patients with chronic neuropathic pain. Those who received a high-strength dosage of levorphanol (8.9 mg a day) achieved a 36 percent reduction in pain while the low-strength dosage group (2.7 mg a day) reported a 21 percent reduction in pain. When a patient’s neuropathy gets to a point where narcotics are required, John Giurini, DPM, says he refers the case to a neurologist. While he does not prescribe opiates or narcotics himself, Dr. Giurini says his experience with narcotics is in line with the study results and believes narcotics work for about 50 percent of patients with chronic neuropathic pain. However, Dr. Giurini, Chief of the Division of Podiatric Surgery at the Beth Israel Deaconess Medical Center in Boston, says the majority of cases of peripheral neuropathy he has seen respond “reasonably well” with tricyclic antidepressants or gabapentin plus a mild analgesic such as darvocet-N-100. What Are The Drawbacks? Although people taking high dosage of opioids reported more pain reduction than those on a lower dosage, there are a few drawbacks, according to the researchers. They noted that 22 of the 81 patients did not complete the eight-week course of levorphanol and that more patients in the high-strength dosage group dropped out of the study due to side effects ranging from restlessness and increased anger to depression. Dr. Giurini has noted side effects such as constipation, drowsiness and irritability but his main concern is addiction. “(Addiction) is a significant problem,” says Dr. Giurini, an Associate Clinical Professor of Surgery at the Harvard Medical School. “I have a hard time justifying placing patients on these medications because of addiction when little is gained in terms of pain relief.” Dr. Giurini also says the nature of neuropathic pain makes it difficult to evaluate studies of medications for this condition. He says neuropathic pain can come and go. “Most patients will go through short stretches of severe pain followed by long stretches of mild pain,” he explains. Clarification The clinical photo of the dog bite injury that appeared on page 34 of the May issue should have contained the credit: Photo courtesy of Warren Joseph, DPM.
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