Added On: Wednesday, August 20, 2008

The Ankle: The Last Frontier in Replaceable Body Parts

Dr. John G. Kennedy, assistant professor of orthopedic surgery at Weill Medical College of Cornell University, is clinical director of the running clinic in the gait laboratory at the Hospital for Special Surgery in New York. He is a specialist in sports medicine of the lower limb.

Q. Is it possible to wear out your foot?

A. Yes. When you run, enormous pressure is placed on your ankle joint. If your feet are malaligned, either because you are a supinator (the foot has a high, rigid arch) or a pronator (the foot has a low or flat arch), more pressure is placed on one side of the ankle than the other. If you are physically active, this can eventually wear away the protective layer of cartilage. Unlike the knee or hip, when the ankle is damaged and painful arthritis develops, there is not a good medical solution.

Q. If arthritis of the ankle makes walking too painful, can the ankle be surgically replaced?

A. In the world of replaceable body parts, the ankle has been the last frontier. Granted, we do have ankle replacements. And they are excellent alternatives to ankle fusion, which is the traditional treatment in which the ankle, or talus, is fused to the tibia, or shin, to stop the arthritic movements. However, the replacement ankles are not where they should be technologically when compared with the knee and hip replacements currently available.

Total ankle replacement is certainly an area we are researching. We are currently investigating biological alternatives to traditional metal and polyethylene inserts. My colleague Dr. Jonathan Deland, chief of the foot and ankle service at the Hospital for Special Surgery, has been working on a revolutionary new total ankle design that will be anatomically similar to the ankle joint. Clinical trials are expected to start in one year.

Q. What is the biggest foot and ankle problem that specialists treat?

A. One of the biggest problems we see is ankle instability coming from ankle sprains. About half of all joint injuries occur to the ankle, and approximately 85 percent of these are sprains, which are ruptures of the ankle joint’s surrounding ligaments.

Approximately 46 percent of all athletes have had a significant ankle sprain; some have even suffered multiple sprains. Sprained ankles are the single biggest cause for time lost due to injury in the National Football League. Ankle sprains are a real problem not just for the elite athlete, but for the weekend warrior, too. In the United States, there are 10,000 admissions to the emergency department every day for ankle sprains.

Q. Is it possible to ignore an ankle sprain and get on with your life?

A. The traditional treatment for the sprained ankle, our mothers used to tell us, was that if you didn’t break your ankle, then stop the whining, put some ice on it, and you will be fine. We are now learning that that may not have been the best strategy because it actually leads to more problems.

However, when most ankle sprains are addressed early on with rest, ice and compression and follow-up physical therapy, you should never be bothered again. To ignore a sprain, you do so at your peril. Return to exercise without proper rehabilitation can increase your chances for reinjury, perhaps more severely. You can also develop an osteochondral lesion, which is a crack in the cartilage or bone that will require surgical attention.

Q. What steps do you recommend for healing an ankle sprain?

A. Most ankle sprains result from forced and excessive inversion, an inward rolling of the ankles. These sprains frequently occur when stepping on another player’s foot or when a runner steps into a rut. The ligaments on the outside portion of the ankle, and the muscles on the lateral portion of the leg that are responsible for limiting ankle inversion, are typically injured. The high incidence of recurrent sprains that we see is primarily due to the failure to successfully complete an adequate three-phase treatment program.

Phase 1: Immediate early treatment goals are minimizing soft tissue swelling and regaining range of motion. This is done by applying a compression bandage around the ankle and foot. Elevate the ankle higher than the heart. Apply an ice pack for 20 minutes to control internal bleeding and fluid accumulation. Apply ice every two hours while awake for the next 48 hours. When the foot is elevated, perform range-of-motion exercises by keeping your heel still and tracing the alphabet in capital letters with your big toe.

Phase 2: After 48 hours, the goals are to eliminate all swelling and pain, regain full range of motion and restrengthen the muscles that stabilize the ankle. Remove the compression wrap and immerse your ankle comfortably in a container of hot water (104 degrees Fahrenheit). Perform the air alphabet. Next, place your foot into a container filled with crushed ice and cold water. While keeping the heel of the injured foot on the bottom of the container, lift and rotate the foot up and out until it makes contact with the side of the container. Hold that position for eight seconds, relax for two seconds, and repeat.

Start the hot-water exercises and perform them in descending periods of five, four, three, two and one minute. Alternate each of them with one-minute intervals of cold bath exercises. Continue using the compression wrap until the ankle has no swelling and is pain free.

Phase 3: The goal is to restore range of motion and regain strength to the muscles stabilizing the ankle. You want to be able to stand and balance on the injured foot for 20 seconds without wobbling. Heel raises are excellent. Stand on the injured foot and slowly raise your heel off the ground, then slowly lower it. Repeat 10 times for three sets. Once you can stand and balance on the ball of the injured foot for 20 seconds and have regained full range of motion, begin a jogging program on a flat, smooth surface for up to 20 minutes. When finished, ice the ankle for 20 minutes. When you are able to run on a field or court in a large figure eight pattern at quarter speed, advance to half speed and then full speed. At that point, you can return to full activities.

Q. What if an ankle is still sore in the weeks after the original injury?

A. Our message for the weekend warrior is not to try to run through the pain of an ankle sprain. If you still have chronic pain after three months of your sprain and physical therapy, you may have a chronic tear of the ankle ligaments or an osteochondral defect, or crack in the cartilage or bone that may lead to a cyst on the ankle. This will be uncovered easily with an M.R.I., not typically an X-ray. Once a lesion is there, surgery is necessary. If it’s a small lesion, then microdrilling or micropicking of the surface of the bone helps stimulate the formation of fibrocartilage to replace the lost cartilage.

If the lesion is large, it has to be replaced with something akin to the cartilage that was there. We replace “like with like” by going to the knee and taking out a plug of thin articular cartilage and bone from the outside of the knee joint, where it won’t be missed, and place it in the ankle defect.

Q. Will stem cells eventually play a role in relieving ankle or foot pain?

A. I was once told that all the metal and plastic inserts we are using in orthopedic surgery would be laughed at in 20 years, similar to the way we look at wooden teeth now. This is because the goal of medicine is to regenerate ourselves. Tissue engineering and work with stem cells are actually giving us that opportunity.

In orthopedics, the problem with cartilage, the translucent rubbery material that covers and protects the ends of bone, is that it doesn’t want to regenerate. We can get bone to regenerate, but not cartilage in the same way. When cartilage is damaged, the body often attempts to repair it with weaker fibrocartilage, but this is not as durable as the original cartilage. However, we are now actively at work in the laboratory looking to use adult stem cells to repair damaged cartilage, restore surface geometry and function, eliminate pain and delay or prevent further joint destruction.

Research is also being carried out using small molecules that can be used as drugs to stimulate cellular signaling pathways to trigger local cartilage cells to turn on and create more cartilage. We are in the early stages with this exciting research, but as we gain a better understanding of the fundamental biology and the mechanics of the foot and ankle, I expect that we will be very advanced in the next 10 years.


Anonymous Mind Body Shop said...

If I accept you as you are, I will make you worse. However, if I treat you as though you are what you are capable of becoming, I help you become that.

8:51 AM  

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