Donald E. Baxter

Painful Heel Syndrome: Results of Nonoperative Treatment

One hundred five patients (70% female and 30% male; average age, 48 years) with 132 symptomatic heels were treated according to a standard nonoperative protocol and then reviewed at an average follow-up of 29 months. The treatment protocol consisted of nonsteroidal anti-inflammatory medications, relative rest, viscoelastic polymer heel cushions, Achilles tendon stretching exercises, and, occasionally, injections. Obesity, lifestyle (athletic versus sedentary), sex, and presence or size of heel spur did not influence the treatment outcome. Ninety-four patients (89.5%) had resolution of heel pain within 10.9 months. Six patients (5.7%) continued to have significant pain, but did not elect to have operative treatment, and five patients (4.8%) elected to have surgical intervention. Despite attention to the outcome of surgical treatment for heel pain in the current literature, initial treatment for heel pain is nonoperative. The treatment protocol used in this study was successful for 89.5% of the patients.

Insertional Achilles tendinosis: Surgical treatment through a central tendon splitting approach

Twenty-two heels in 21 patients treated surgically for a primary diagnosis of insertional Achilles tendinosis were reviewed on the basis of preoperative and postoperative examinations, office records, and a comprehensive questionnaire administered to each subject. Each patient underwent surgical treatment using a midline-posterior skin incision combined with a central tendon splitting approach for debridement, retrocalcaneal bursectomy, and removal of the calcaneal bursal projection as necessary. The findings at surgery revealed involvement of the middle third of the insertion in 21 of 22 cases with only one patient manifesting isolated lateral involvement. Thirteen of 22 had an associated prominent calcaneal bursal projection and four of 22 a superficially inflamed bursa. Three patients required reinsertion of the tendo Achilles via drill holes and one underwent augmentation with a plantaris tendon. Operative findings and complications were reported. Eight male and 13 female patients underwent 22 procedures (one case bilaterally) with an average follow-up of 33 months. Preoperative symptoms include presence of symptoms over a range of three months to two years and pain associated with activities of daily living (17 of 22), limitation of regular activities (six of 22), and pain present at rest in six of 22. Postoperatively, 20 of 22 patients were able to return to work or routine activities by three months; only 13 of 22 were completely pain free. Only 13 of 22 also claimed that they were able to return to unlimited activities. Overall, there was an 82% (18 of 22) satisfaction rate with surgery and 77% (17 of 22) stated they would have the surgery again.

Heel pain syndrome: Electrodiagnostic support for nerve entrapment

A local entrapment neuropathy has been proposed as one of the etiologies of heel pain, but it has never been documented by electrodiagnostic studies. Primary symptoms in patients suspected of having a neurologic basis for their heel pain include neuritic medial heel pain and radiation either proximally or distally. On physical examination, all patients in our series had reproduction of their symptomatology with palpation over the proximal aspect of the abductor hallucis and/or the origin of the plantar fascia from the medial tubercle of the calcaneus. Twenty-seven patients (20 women and seven men; average age 49) with these clinical characteristics were examined by electromyography and motor/sensory/mixed nerve conduction studies. Bilateral heel signs and symptoms were present in 11 patients. Ten of the patients had a significant history of back pain with referral to the legs. In 23 of the 38 symptomatic heels, abnormalities were identified in the lateral and/or the medial plantar nerves. The number of abnormal values per heel ranged from one to four, with a mean of 2.1. The most common finding was involvement of the medial nerve (57%). Thirty percent of the heels had isolated findings in the lateral plantar nerve and 13% had abnormalities in both plantar nerves. Two patients had electrophysiologic evidence of active S1 radiculopathy, with ipsilateral evidence of plantar nerve entrapment suggesting a “double crush” syndrome. The results of this study support the presence of abnormalities of plantar nerve function in a selected group of patients with neuritic heel pain.

A Chevron-Akin Double Osteotomy for Correction of Hallux Valgus

Chevron osteotomy of the distal metatarsal combined with Akin osteotomy of the proximal phalanx is described for treatment of painful hallux valgus. Sixteen patients (24 feet) who underwent the Chevron-Akin osteotomy were retrospectively reviewed by questionnaire, physical examination, and comparison of preoperative and postoperative standing X-rays. After a mean follow-up of 29 months, there was 95% satisfaction with regard to pain relief and appearance of the foot. Good postoperative range of motion of the great toe was recorded subjectively and objectively. Mean improvement of the first intermetatarsal angle was 4.1 degrees (P = 0.05). The average preoperative hallux valgus angle was 27 degrees (range 13-40 degrees). Mean improvement with the double osteotomy was 14.3 degrees (P = 0.05). There was no significant shortening of the first ray with the double osteotomy. Degenerative changes of the first metatarsophalangeal joint were seen in two feet with intra-articular extension of the Akin osteotomy. One malunion occurred with shifting of the Chevron osteotomy after pin removal. The Chevron-Akin osteotomy compares favorably with the isolated distal Chevron osteotomy. In this series there was no compromise of joint motion, and a superior correction of the hallux valgus deformity was obtained.

Tibiotalocalcaneal Arthrodesis: Anatomic and Technical Considerations

In the first of this two-part cadaver investigation, we inserted a specially designed, pointed device (simulating a 12-mm nail) in an antegrade fashion in each of eight fresh-frozen cadaver tibial specimens; the tibial isthmus was used as a centralizing guide. The exit point was noted, and the specimen was dissected to identify the structures at risk. In all specimens, we found that the device placed the lateral plantar artery and nerve at risk (average minimal distance from device to structure, 0 mm) and that damage to the flexor hallucis brevis and plantar fascia occurred. In addition, in six of the eight specimens, the device skewered or skived the flexor hallucis longus tendon. We also noted that in each specimen the exit point was the sustentaculum tali, not the body of the calcaneus as expected. Thus, there was less calcaneal bone-to-rod interface for stability, and distal locking would be less effective in the lateral-to-medial direction because of the lack of medial bone stock. On the basis of the results of the first portion of the study, we investigated an alternative approach to retrograde tibial nailing to reduce the risk of injury to the plantar and medial structures of the foot. We performed a medial malleolar resection, medially displaced the talus, inserted the device in an antegrade fashion, and dissected the specimens to analyze the structures at risk. We found that malleolar resection and medial translation of the distal extremity an average of 9.3 mm (range, 7–11 mm) increased the average minimal distance from the tip of the device to the neurovascular bundle to 18.4 mm (range, 14–32 mm). We also found that there was no damage to the flexor hallucis longus and that all eight specimens demonstrated bony contact completely surrounding the nail device within the tuberosity portion of the calcaneus (assessed by postoperative radiographs). The results of this study suggest that malleolar resection and medial translation of the distal extremity before retrograde nailing of the tibia may reduce the risk of vital structure injury and enhance the rigidity of the fixation.

Nerve Disorders in Dancers

Dancers are required to perform at the extreme of physiologic and functional limits. Under such conditions, peripheral nerves are prone to compression. Entrapment neuropathies in dance can be related to the sciatic nerve or from a radiculopathy related to posture or a hyperlordosis. The most reproducible and reliable method of diagnosis is a careful history and clinical examination. This article reviews several nerve disorders encountered in dancers, including interdigital neuromas, tarsal tunnel syndrome, medial hallucal nerve compression, anterior tarsal tunnel syndrome, superficial and deep peroneal nerve entrapment, and sural nerve entrapment.

Clinical results of simultaneous adjacent interdigital neurectomy in the foot.

Fifteen patients (19 feet) who underwent simultaneous surgical excision of two primary interdigital neuromas in adjacent web spaces of the foot were studied retrospectively. There were 11 female patients (73%). The average age of the patients was 54.4 years. Other causes of multiple web space tenderness were excluded prior to surgical resection of both neuromas. At an average follow-up of 68.6 months (range, 32–113 months), 10 feet (53%) had complete resolution of symptoms and six feet (31%) had minimal residual symptoms. Three feet in two patients (16%) continued to have significant pain after surgery. One sequela of the procedure was dense sensory loss of the plantar aspect of the third metatarsal head to the tip of the third toe. There was also proximal dorsal sensory loss to the second, third, and fourth toes which was a function of the type of incision used. The sensory loss did not cause disability in the patients, but did cause some awkwardness with nail care. Resection of adjacent interdigital neuromas, although rarely indicated, can be expected to provide significant pain relief in 84% of patients, which is similar to results reported for resection of a single neuroma.

Posterior Tibial Tendon Tears in Young Competitive Athletes: Two Case Reports

Unlike the Achilles tendon, the posterior tibial tendon does not typically undergo acute rupture. We report two cases of posterior tibial tendon tears occurring in young, athletic individuals (<30 years old) that required operative intervention before the patients could return to competitive sports. We believe that these are the first two reports of posterior tibial tendon tears occurring in this population without the patient having a prior history of steroid injections in the tendon. The tears we observed and described at surgical exploration were chronic and degenerative in nature. We also comment on our approach to treatment of posterior tibial tendon injuries in the athletic population.

Compressive neuropathies of the foot and ankle

Subtle compressive neuropathies of the foot and ankle can cause weakness in the foot that affects athletic performance, especially in runners or jumpers. Detection of these syndromes requires a knowledge of the sensory distribution and anatomic course of the peripheral nerves in the foot and ankle. Most compressive neuropathies can be treated with standard conservative measures; however, if chronic pain causes significant disability, surgical treatment may be indicated.

Bunionectomies and related surgery in the elite female middle-distance and marathon runner

When contemplating bunion surgery in the elite athlete, serious consideration should be given to its effects on the overall function and biomechanics of the forefoot. Many surgical treatment options are available, but their use in the high performance athlete has not previously been reported in the literature. In this paper we report on the successful use of the chevron bunionectomy procedure and related surgery in two world class female middle-distance and marathon runners.