May is National Bike Month and there are many ways you can become involved.

The city of Indianapolis has just recently completed the Cultural Trail. In addition Friday May 17th is bike to work day presented by IndyCog. I personally feel the city has done a tremendous job of making itself a more biking friendly center with great accessibility through an ever expanding network of trails. May is a great month to get out and enjoy the trails, whether you are a new cyclist or experienced rider, pavement or mountain biking.

In general, I tend to recommend cycling to my patients. It is an excellent cardiovascular workout, which is fun and can be done independently or with a group. There is also reduced force across many of the joints in the lower extremity and foot. You can do it indoors or out and enjoy a variety of scenery, which is much more pleasant than wiling the time away on a treadmill or elliptical machine. 

As you start pedaling, there are a couple foot related issues to consider to improve your performance and reduce the risk of injury. Generally speaking there are two cycling specific injuries which are most common and most annoying.

Forefoot numbness and /or pain is probably the most common chronic cycling related issue we treat. The foot, obviously, is the contact point with the cycling pedal, whether you are using a cleat or a platform pedal. However, most of these problems can be easily addressed. In a 2003 study, cycling shoes with carbon fiber soles/shank were shown to induce more stress under the forefoot. The concept is to create greater transfer of energy through the foot, but this can come at a cost. There are options including nylon in lieu of the carbon fiber and a wider toebox to help alleviate some of these symptoms. Pedals with a wider platform distribute the force better than smaller pedals. Regardless of the platform width, you may still get some discomfort if you cycle greater distances. The repetitive nature of cycling with the foot typically locked into one position can exacerbate these issues. Adjusting your foot position on a platform pedal or changing your cleat position can be a simple solution. You may need to experiment with this or consult a fitting specialist for anything but a minor adjustment can affect your cadence significantly. If you have access to a trailer or roller you may find it most convenient to experiment in this more controlled environment. There are several OTC inserts which are cycling specific which may also address mechanical issues which maybe causing the numbness. If these options fail to address your symptoms, it may be time to visit your friendly neighborhood podiatrist, who also happen to be biomechanical experts!

Biomechanical abnormalities, such as a shorter (or longer) limb, bunions, hammertoes, neuromas, etc can all contribute to the problem and can be addressed with an extra insole in the forefoot (up to 1/4 inch if you have enough volume in the shoe), adding washers/shims between the cleat and the shoe or moving the cleat back on the longer leg's shoe. One of the most common underlying problems is a condition known as: pre-dislocation syndrome, which affects the 2nd metatarsal phalangeal joint. This is the joint at the base of the 2nd toe. It is relatively common to have a longer 2nd toe or longer 2nd metatarsal bone behind the toe, which increases the pressure on this area. This can be further worsened by any mechanical instability or bunion deformity, transferring additional force and pressure across the area. The nature of cycling and the contact point of the foot on the bike pedal or cleat further stresses this area causing pain, swelling and sometimes progressive deformity of the toe. The good news is this can usually be alleviated by icing, NSAIDs, and ROM exercises. If this fails to successfully reduce the symptoms, a functional foot orthosis may be employed to redistribute the forces to a more biomechanically sound position. These can be specifically made to your cycling shoes, with minimal additional weight. Occasionally an injection or surgery may be needed for severe deformity. Specific modifications may be employed for any other structural changes in the foot and ankle and to a lesser extent the knee.  Foot orthoses with a forefoot extension can help control excessive internal leg rotation, which can cause knee pain (patello-femoral syndrome/chondromalacia). Keep in mind there are other factors which may contribute to these symptoms such as a seat positioned too low or high, and cycling with too high a gear, can also contribute to knee pain. 

Achilles tendon problems are not uncommon with cyclists, particularly those covering a lot of mileage. The covering of the Achilles, known as the paratenon, can become inflamed from the continuous friction and repetitive stresses. Physical therapy, staying in the saddle and using lower gears can help. Stretching and home exercises as well as a proper warm up period will also help reduce this chronic situation. This may unfortunately progress to tendinosis in which there is thickening and scarring of the tendon fibers, which is more likely fail conservative treatment. Sometime surgery is needed and is very helpful at this point.

Follow a couple simple steps and you can avoid most of the overuse injuries associated with cycling and enjoy a great season in the saddle. If you need our assistance with fit, shoes, or biomechanical analysis, we are just a phone call away and ready to help.

The big toe joint (1st Metatarsophalangeal joint) is very important in the gait cycle. The great toe is able to stabilize the arch in midstance and 'toe off' and this is critical for a functional gait and normal arch functioning.  When the bone behind the big toe (the 1st metatarsal) is elevated, such as is seen in flat feet, the range of motion of the great toe is decreased. An abnormal length of the first metatarsal bone can also cause a stiff big toe joint. The clinical name for this condition is Hallux Limitus.

I frequently see patients with Hallux Limitus in my clinic. Pain is usually what prompts them to get it checked out. Sometimes they also notice a bump on top of their big toe.  When I examine these individuals I usually encounter a decrease in the range of motion of the toe joint, pain as the toe is pushed upwards (dorsiflexed) and/or pain when pressure is applied to the joint. Often hallux limitus is associated with a flat foot structure and tight Achilles tendon. On x-ray I often see bone spurs around the joint (hence the bump) and a decrease in joint space indicating wearing down of the cartilage. Hallux Limitus is basically the 'wear and tear' type of arthritis that people commonly get in their knees or hips.

So how do we treat it?

Treatment depends on the severity of the condition. Conservative treatment may include anti-inflammatory medications, orthotics, steroid injection to the joint, stiff soled shoes etc.. In mild cases of hallux limitus, these conservative treatments can be effective in decreasing pain and even improving motion in the case of orthotics.  When the joint degeneration is at a more advanced stage then surgical treatment options are more appropriate. A Cheilectomy is a procedure where the spur we talked about earlier is removed and the joint is cleaned up so to speak. This has been a very effective procedure in my practice and often results in decreased pain and increased range of motion.  Patients are usually in a boot for 2-3 weeks and then return to regular shoes. Ambulation is allowed day one. If the joint is degenerated beyond the point where a Cheilectomy can help, then a 'joint destructive procedure' such as an implant of fusion is then required.  Fusion usually requires the use of screws and sometimes a plate and non-weightbearing (sometimes weightbearing on the heel is allowed) for 6-8 weeks following surgery.

A recent article published in the Journal of the American Podiatric Medical Association reveals a study in which 51 patients were evaluated.  All of the patients had medial knee osteoarthritis.  They were treated with custom made insoles with arch support and a 5.0 to 8.7 degree lateral wedge.  They were then evaluated for pain at rest, at night, after 30 minutes of walking and after 50 minutes of walking.  There was a significant reduction in pain and improvements in function and quality of life with use of the insoles.














Although here at Podiatry Associates we treat foot and ankle pain, we specialize in custom insoles.  We understand that the function of the foot is directly related to the knee, hip and back.  It has been estimated that 12% of the population over the age of 60 have knee osteoarthritis.  This results in significant limitations and health care costs.  10 times more of these patients have medial knee osteoarthritis than lateral knee osteoarthritis.  It is recommended that these patients be treated conservatively before considering surgery.  Treatments to reduce medial load are very important in these patients.  Previous studies using pre-fabricated lateral wedges did not show significant improvements.  Therefore, we are recommending custom insoles for these patients. 

Much of my after school hours and summers of my high school and undergraduate years were spent working construction for my father’s company. Specifically, I worked in concrete construction pouring and framing foundations. Obviously, in the world of concrete, an unstable foundation has disastrous ramifications. Now, as a foot and ankle specialist, I like to believe that I am still in the foundation business, and it still holds true that an unstable foundation has its consequences.

Lateral ankle instability is often the long term consequence of an acute ankle sprain or multiple ankle sprains. It often becomes a vicious cycle as ankle instability subsequently leads to redundant injury. As you may recall from Dr. Abdo’s description of high ankle sprains this past January, the ankle is the most frequently injured joint in athletic competition. Since lateral ankle sprains account for nearly 25% of all musculoskeletal injuries, it comes as no surprise that ensuing lateral ankle instability is relatively common as well.

What is ankle instability and how do we treat and prevent its development? There are two types of instability, mechanical and functional. In order to properly explain each type, a basic understanding of the structures involved is necessary. The ankle is a complex arrangement of tendinous, ligamentous, and boney structures, but to obtain a relative understanding of mechanical and functional instability the lateral ankle ligaments are most important. Three ligaments compose the lateral collateral ligaments of the ankle; the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The ATFL is the weakest of the three ligaments but also the most important in regards to lateral ankle stability.

Mechanical instability is the actual rupture or stretching of the ligamentous structures, namely the anterior talofibular ligament. This is an objective, clinical finding. This is often determined by a test known as the anterior drawer test. The ability to manually anteriorly translate the ankle is a positive anterior drawer sign.

Functional instability is the subjective presentation of instability. It is the report that the ankle feels like it is going to give out. It is the recurrent instability in sporting activities or every day activities. Functional instability entails what foot and ankle specialists refer to as a proprioceptive defect. Proprioception is the neurological concept of sensing where ones ankle is in space. Functional and mechanical instability often go hand in hand and it is not uncommon to have a patient that embodies both aspects of lateral ankle instability. However, one may have functional instability and not mechanical instability.

Management of lateral ankle instability may occasionally involve surgical reconstruction, but typically always involves a functional rehabilitation program. In essence, the treatment of instability ought to begin with the first acute injury. Less than 10% of patients with an acute injury will ever need surgical stabilization at a later stage in life if initially treated appropriately. Functional rehabilitation or early controlled movement involves a close relationship between the foot and ankle specialist and their local physical therapist.

Lateral ankle instability is, unfortunately common and can have devastating long term consequences. However, a proper understanding of the lateral ankle can assure prompt, appropriate management. Ankle injuries,specifically lateral ankle sprains, will always be prevalent as our population remains active, but instability, on the other hand, does not have too. You have likely heard it said that when one part of the body suffers, the rest suffers as well. This could not be truer with the foot and ankle. When the foundation is not stable, the remaining structure soon collapses.

By now you have committed to your New Year's Resolution Dr. House had blogged about earlier this year and if you were not exercising regularly and have started a new walking or running routine you may be finding your feet are hurting despite getting a new pair of shoes. Dr. Glynn has already blogged about how to pick those running shoes and you have followed her recommendations so the shoe is not an issue, but despite that the outside of your foot and ankle is painful. You also read Dr. Abdo's blog on high ankle sprains and you have not had any direct trauma so it is not that and you read my earlier blog about plantar fasciitis and you may or may not have associated pain on the bottom of your foot. So what is going on?

There are 3 tendons that are on the side and top of your foot and they are responsible for bringing your foot up to help clear the ground and if you have resumed an exercise program or upped your activity they may not like all the extra stress. These 3 tendons are the Peroneal tendons. So what can be done? First it is good to know for sure that that is the problem and physical exam is important. We may check x-rays to look for a fracture and ultrasound to evaluate the tendon for inflammation or tear. Sometimes MRI is also necessary.

Once it is confirmed that you have PERONEAL TENDONITIS, what can you do about it? For any acute or new pain or trauma RICE is important. R is for Rest and that may be from the activity or with immobilization with an ankle brace or boot. I is for Ice. C is for Compression and E is for Elevate. This can help you get through the short term but you need to look at the biomechanics and getting into a custom molded orthotic to give your foot the biomechanical advantage and is important for long term treatment.

Now you may have done all this and still have pain. We do due surgery to clean up the tendon if there is a split and also stimulate the tendon with either topaz, radio colblation therapy, or with PRP, platelet rick protoplasm to help the body heal itself.

You may have to go to physical therapy before or after surgery.

It is important to continue with your custom molded orthotics from Podiatry Associates of IN to help keep your feet healthy, so you may reach your fitness goals.