I have been advising my patients to exercise, keep active, and walk as long as they can in order to stay mobile and healthy. However, seniors often tell me activities that require prolonged walking is limited by ankle pain from arthritis. They often ask, “What is arthritis of the ankle?” How does it happen? What can I do about it?

Three Most Common Forms of Arthritis of the Ankle

• Osteoarthritis – is also known as degenerative arthritis. It is the most common form of arthritis in the ankle. It is usually a gradual, slow and progressive process of “wear and tear” to the cartilage in the ankle joint which eventually wears down to the bony joint surface. It is most often found in middle-aged and older people and in weight bearing joints such as the hip, knee and ankle.
• Rheumatoid Arthritis (RA) – is a form of inflammatory arthritis in which many joints of the body can be affected. It is very destructive to the cartilage, joint and tissues surrounding the joint. It can occur at any age and usually affects multiple joints.
• Post-Traumatic Arthritis- is a form of arthritis that can occur following a trauma or injury to the ankle. It is a form of osteoarthritis that is triggered years after a fracture or ligament injury. Those of you who know Jim Gouldsbury, Jr., a local letter carrier for the United State Postal Service, may know the effects of prolonged weight-bearing on injured limp. Jim suffered from an ankle injury several years ago and worked in a job that requires constant weight-bearing. He is now suffering from traumatic arthritis at a relatively young age.

Symptoms of Arthritis

• Pain - usually occurs gradually. However, a sudden onset can occur, especially associated with a sudden twist or fall. Pain is often worse in the morning and improves with movement. Changes in the weather or barometric pressure can cause pain associated with arthritis.
• Swelling – can swell after increase activity at the end of the day.
• Stiffness – is more noticeable in the morning and improves with movement. However, overuse can create more pain and swelling and lead to stiffness also.
• Weakness – from disuse associated with pain and can lead to occasional buckling of the ankle when walking or climbing steps.                 
• Loss of Function- is associated with pain, swelling, weakness and stiffness which limits walking, stair climbing etc.

Diagnosis

Your family physician will examine your ankle to determine if you have arthritis. In more advanced cases you may be referred to a specialist such as a podiatrist,  orthopaedic surgeon or rheumatologist for further examination and treatment. X-rays will show if the joint space between the bones in the ankle is getting narrow from wear and tear arthritis. If rheumatoid arthritis is suspected, blood tests and an MRI may be ordered. The diagnosis will determine if you problem if minor, moderate or severe.

Treatment

Conservative Treatment

In the early stages your treatment will be a conservative, nonsurgical approach, which may include; anti-inflammatory medication, orthopedic physical therapy, exercise, activity modifications, supplements, bracing, etc. You and your family physician, podiatrist, orthopedic surgeon or rheumatologist will decide which choices are best.

• Anti-inflammatory Medications: such as aspirin, acetaminophen or ibuprofen to reduce pain and swelling in the joint. 
• Orthopedic Physical Therapy: such as heat, cold, ultrasound, electrical stimulation, joint mobilization, range of motion exercises, strengthening exercises, partial weight bearing aerobic exercises.
• Activity Modifications: such as eat well and lose weight, doubles tennis instead of singles, sitting or lying leg exercises instead of standing, walk instead of run, soft bed treadmill instead of hard surfaces, avoid squatting, kneeling, and bending.
• Supportive Devices: such as ankle sleeves, light bracing, orthothics (inserts), use good running shoes for exercise and walking, use good quality supportive shoes for work/dress.

Conservative But More Aggressive Treatment

• Corticosteroids: stronger anti-inflammatory medications than those above which are injected directly into the ankle joint.
• Viscosupplementation: a type of synthetic fluid, injected into the ankle joint and designed to imitate the joint fluid of the ankle to promoted healing and mobility.
• Glucosamine and Chondroitin: supplements taken orally to control the pain of osteoarthritis and promote healing.
• Rheumatoid Medications: specifically designed  for RA

Surgical Treatment

When conservative measures no longer succeed in controlling pain and deformity, improving strength and function then more aggressive treatment may be necessary.

• Arthroscopic Surgery: uses a scope to clean and repair damaged tissues inside the ankle joint.
• Fusion Surgery: the ankle bones are surgically fused together to limit movement of painful joint.
• Total Ankle Replacement: replaces severely damage joint surfaces with metal and/or plastic.

SOURCES: Rothman Institute, Philadelphia, PA and American Academy of Orthopaedic Surgeons

Visit your doctor regularly and listen to your body.     

EVERY MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog

EVERY SUNDAY in "The Sunday Times" - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy in Scranton and Clarks Summit. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Mackarey's articles, visit our exercise forum!

Part II of II  

Introduction:

As most sports enthusiasts know, Aaron Rodgers, former Green Bay Packer quarterback and recent New York Jets QB (for just over a minute and half) suffered a season ending injury when he tore his Achilles tendon in the first game of the 2023/24 NFL season. Since then, I have been answering many questions from patients and sports fans about the nature of the Achilles Tendon rupture injury, recovery, and how to prevent it.

As the days continue to get shorter and temperatures begin a slow steady decline, athletes and exercise enthusiasts will work harder to warm-up and exercise during the winter months. A little caution and preparation are in order to avoid muscle/tendon strain, or worse yet, muscle/tendon tears, especially Achilles Tendon rupture. The Achilles tendon is one of the more common tendons torn.

This is the second of two columns on Achilles tendon rupture. Last week, I discussed the definition, sign and symptoms of the problem. This week will present examination, treatment and outcomes.

Achilles Tendon Rupture Exams and Tests:

A thorough history and physical exam is the first and best method to assess the extent of the injury and determine accurate diagnosis. While a complete tear is relatively easy to determine, a partial or incomplete tear is less clear. Ultrasound and MRI are valuable tests in these cases. X-rays are not usually used and will not show tendon damage.

Achilles Tendon Rupture Treatment:

Initial First Aide Treatment:

• Remember RICE!
  • Rest the involved tendon/ankle/heel. Pain is telling you NOT to move the tendon. Use crutches and limit weight bearing on the involved foot until you are seen by a medical professional.
  • Ice the tendon/ankle/heel. Control the swelling and spasm.
  • Compress the ankle/foot and control the swelling but do not wrap it too tightly.   
  • Elevate the ankle/foot to allow gravity to help control swelling.
• Medication: Depending on your tolerance and previous experience, choose an over-the-counter nonsteroidal anti-inflammatory drug for pain and inflammation such as ibuprofen. Discuss with your primary care physician and pharmacist.
• Note: If symptoms persist, see your primary care physician, podiatrist or orthopedic specialist to determine the extent of your injury. Do not delay too long to seek medical attention because early intervention will produce the best outcomes.

Early Treatment - Conservative:

• Protection – the torn tendon must be protected from further damage or stretching by using a heel lift to put the tendon on slack. In more involved cases, a removable walking cast/boot may be used for additional protection.
• Physical Therapy -  
  • Controlled Motion – gentle controlled motion to the ankle, foot and toes to control swelling and prevent stiffness is usually encouraged.
  • Modalities – such as ice, compression, ultrasound, massage, electrical stimulation may also be employed for pain and swelling.
  • Gradual Resistance Exercises – in the case of a partial tear, once healing begins, resistance exercises may be introduced gradually. These exercises will require the supervision of a physical therapist to emphasize resistance in a lengthening position (to be described under “prevention” later in this column).

Surgery:

Consultation with an orthopedic or podiatric surgeon will determine the best treatment option for you. When conservative measures fail and for tendons completely torn, surgical intervention is usually considered to be the best option with a lower incidence of re-rupture. Surgery involves reattaching the two torn ends. In some instances, a graft using another tendon is required. A cast or walking boot is used post-operatively for 6-8 weeks followed by physical therapy. 

Outcome:

Most people return to close to normal activity with proper management. In the competitive athlete or very active individual, surgery offers the best outcome for those with significant or complete tears, to withstand the rigors of sports. Also, an aggressive rehabilitation program will expedite the process and improve the outcome. Walking with full weight on the leg after surgery usually begins at 6 -8 weeks and often requires a heel lift to protect the tendon. Advanced exercises often begin at 12 weeks and running and jumping 5-6 months. While a small bump remains on the tendon at the site of surgery, the tendon is well healed at 6 months and re-injury does not usually occur.

Achilles Tendon Rupture Prevention:

Prevention of muscle and tendon tears is critical for healthy longevity in sports and activities. In addition to the Achilles tendon, the tendons of the quadriceps (knee) and rotator cuff (shoulder) are also vulnerable. A comprehensive prevention program includes: gradual introduction to new activities, good overall conditioning, sport specific training, pre-stretch warm-up, stretch, strengthening, proper shoes, clothing, and equipment for the sport and conditions. Also, utilizing interval training, eccentric exercise (lowering body weight slowly against gravity – Photo 1) and proprioceptive and agility drills are essential (Photos 2 & 3). 

In PHOTO 1a & 1b: Eccentric Lowering and Lengthening: for the Achillies tendon during exercise. Beginning on the ball of both feet (1a), bend the strong knee to shift the weight onto the weak leg (1b). Slowly lowering the ankle/heel to the ground over 5-6 seconds. Repeat.

In PHOTO 2: Proprioceptive Training: for the Achillies tendon. Standing on a Bosu Ball while exercising the upper body (for example, biceps curls, shrugs, rows, lats) while maintaining balance on the ball.

PHOTO 3: Agility Drills: for the Achilles tendon involves stepping through a “gait ladder” in various patterns and at various speeds. 

MODEL: Kerry McGrath, student physical therapy aide at Mackarey Physical Therapy

Sources: MayoClinic.com;Christopher C Nannini, MD, Northwest Medical Center;Scott H Plantz, MD, Mount Sinai School of Medicine

EVERY MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog

EVERY SUNDAY in "The Sunday Times" - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor  in Health Sciences specializing in orthopedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSOM. For all of Dr. Mackarey's articles, visit our exercise forum!

Introduction

 As most sports enthusiasts know, Aaron Rodgers, former Green Bay Packer quarterback and recent New York Jets QB (for just over a minute and half) suffered a season ending injury when he tore his Achilles tendon in the first game of the 2023/24 NFL season. Since then, I have been answering many questions from many about the nature of the injury and how to prevent it.

As the days continue to get shorter and temperatures begin a slow steady decline, athletes and exercise enthusiasts will work harder to “fit in” a warm-up before running or other activities during the winter months. But, no matter how limited time is, skipping the warm-up is risky. This time of year, one can expect to feel a little cold and stiff, especially if you are over 40, and therefore a little caution and preparation are in order to avoid muscle/tendon strain, or worse yet, muscle/tendon tears. The more commonly torn tendon is the Achilles tendon . Prevention of muscle tears, including the Achilles tendon includes; gradual introduction to new activities, good overall conditioning, sport specific training, pre-stretch warm-up, stretch, strengthening, proper shoes, clothing, and equipment for the sport and conditions.

Tendon Injury and How It Occurs

A muscle contracts to move bones and joints in the body.  The tendon is the fibrous tissue that attaches muscle to bone. Great force is transmitted across a tendon which, in the lower body, can be more than 5 times your body weight. Often, a tendon can become inflamed, irritated, strained or partially torn from improper mechanics or overuse. Although infrequent, occasionally tendons can also snap or rupture. A tendon is more vulnerable to a rupture for several reasons such as a history of repeated injections of steroids into a tendon and use of medications such as corticosteroids and some antibiotics. Certain diseases such as gout, arthritis, diabetes or hyperparathyroidism can contribute to tendon tears. Also, age, obesity and gender are significant risk factors as middle-aged, overweight males are more susceptible to tendon tears. Poor conditioning, improper warm-up and cold temperatures may also contribute to the problem.  

Tendon rupture is very painful and debilitating and must not be left untreated. While conservative management is preferred, surgical management is usually required for complete tears. The purpose of this column is to present the signs, symptoms and management of Achilles tendon ruptures.

Achilles Tendon

The Achilles tendon (also called the calcaneal tendon), is a large, strong cordlike band of fibrous tissue in the back of the ankle. The tendon (also called the heel cord) connects the powerful calf muscle to the heel bone (also called the calcaneus). When the calf muscle contracts, (as when you walk on the ball of your foot), the Achilles tendon is tightened, tension is created at the heel and the foot points down like pushing a gas pedal or walking on tip of your toes. This motion is essential for activities such as walking, running, and jumping. A partial tear of the tendon would make these activities weak and painful, while a full tear through the tendon would render these activities impossible.      

With age, the Achilles tendon (and other tendons) gets weak, thin, and dehydrated, thus making it prone to inflammation, degeneration, partial tear or rupture. The middle-aged weekend warrior is at greatest risk. A full or complete tear (Achilles tendon rupture) usually occurs about 2 inches above the heel bone and is associated with a sudden burst of activity followed by a quick stop or a quick start or change in direction, as in tennis, racquet ball, and basketball.

In some instances, the tendon can be injured by a violent contraction of calf when you push off forcefully at the same time the knee is locked straight as in a sudden sprint. Other times, the tendon is injured when a sudden and unexpected force occurs as in a trip off a curb or sudden step into a hole or a quick attempt to break a fall.

Achilles Tendon Rupture Symptoms

• Pain – sudden and severe pain in the back of the ankle or calf that feels like being hit by a rock or gun shot.
• Pop – sometimes it is reported that a loud pop or snap is heard when the tendon tears.
• Divot Deformity – sometimes a depression or indentation in the tendon is seen or felt with a bulbous area above or below the tear.
• Black and Blue – it is common to have bleeding after tearing the muscle or tendon with black and blue color and bruising the night or day after the injury.
• Swelling – in addition to swelling in the tendon area of the tear, sometimes swelling will be prominent in the ankle and foot.
• Stiffness – loss of movement due to swelling and weakness.
• Weakness – inability to “push off” on the injured foot when walking or climbing steps.
• Loss of Function – difficulty with daily activities that require walking, ascending inclines, climbing stairs, or jumping.

EVERY MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog Next Week: Achilles tendon Part II of II.

EVERY SUNDAY in "The Sunday Times" - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor  in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSOM. For all of Dr. Mackarey's articles, visit our exercise forum!

Ankle swelling is a common symptom that occurs when your body retains fluid in the lower legs, ankles and feet. Most people have experienced it at some point in their lives and it often resolves on its own with elevation and muscle movement. While it is usually benign and occurs on both sides of the body, in some instances immediate medical attention is required. The most common causes of ankle swelling are:

Prolonged Positions – you have probably noticed swelling in your ankles and feet after a long trip by plane or car. Some may also experience symptoms after a long day at work sitting or standing in one position for an extended period of time. It may be the most common cause of lower leg swelling and easiest to resolve.

Diet- excessive salt in your diet is associated with swelling in the lower legs, especially when associated with other risk factors for swelling such as organ function or obesity.

Varicose Veins – when the valves in the blood vessels which carry blood from the legs back to the heart are damaged, blood and fluid can collect in the lower legs. Prolonged standing or sitting without intermittent movement with worsen the condition.

Pregnancy – during pregnancy, the body retains more fluids than usual and most women experience some form of swelling in the lower legs, ankles and feet.

Medications – certain drugs can cause fluid retention in the lower legs such as: anti-inflammatory medications, steroids, diabetes medications, antidepressants and cardiac medications.

Blood Clots – blockages in the blood vessels of the lower leg can limit the movement of fluid from the legs back to the heart. It is often present in only one leg and associated with warmth, pain, and cramping. It is a serious condition and requires immediate medical attention.

Trauma/Infection – after a trauma or injury such as an ankle sprain, bruise or fracture, the damaged tissue leaks fluid surrounding the affected area. Also, when specific area of the lower leg can becomes infected, as in the case of a cut or splinter in the ankle or foot that has not healed properly, swelling occurs in the surrounding tissues. These situations are often associated with warmth, pain and limited to the side of the injury. Treatment to injured tissues and the infection is required.

Lymphedema – swelling in the lower leg can occur when there is a blockage in the lymphatic system is blocked or when lymph nodes are removed in surgery for cancer. Medications, massage, compression garments, and elevation, can address the symptoms.

Obesity – due to the excessive weight placed on the tissues of the legs, ankle and feet and adipose tissue in the abdomen compressing blood vessels, obesity is one of the most common causes of lower leg swelling. It also complicates all of the above conditions associated with swelling in the legs.

Diseases – such as those of the kidney, heart, and liver are associated with swelling in the lower legs.

Tips to Control Swelling in the Ankles and Feet

Change Positions – on a long plane ride or sitting all day at school or work – get up and walk around every 30-45 minutes. Set a timer on your phone to remind you.

Exercise – regular exercises keeps the muscles and blood vessels in you lower extremities healthier. Also, intermittent movement of the leg muscles throughout the day, even when sitting, serve to prevent swelling. Try ankle pumps and toe curls.

Elevation – when sitting or lying down, try elevating your ankles and feet on a pillow to allow gravity to assist fluid movement in your legs.

Low-Sodium Diet – read the labels on your food and you will be shocked by how much sodium is in most foods, especially canned soups and vegetables. But, there are low-sodium options and don’t add more salt to your food.

Weight Loss – maintaining a healthy BMI is the single best thing you can do, not only for lower leg swelling, but for your overall health and wellness.

Compression Socks – for most people, over-the-counter compression socks will adequately prevent fluid retention in the lower legs. For comfort, begin with the lightest compression possible. 12-15 or 15-20 mm of mercury is a good start and put them on as soon as you get up in the morning, before swelling begins.

When to See Your Physician about Lower Leg Swelling –

• If you have a history of kidney, liver or heart disease and notice an increase of leg swelling
• If the swelling in your leg or legs are associated with warmth, redness and pain
• If you are have increased swelling in your lower legs and are running a temperature
• If you are pregnant and have sudden or severe onset of swelling
• If you tried conservative management (elevation, frequent positional changes) without success
• If the swelling in you lower legs continues to get worse
• If you have lower leg swelling and notice shortness of breath

Visit your doctor regularly and listen to your body.

EVERY MONDAY –  Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog

EVERY SUNDAY in ”The Sunday Times - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Paul's articles, check out our exercise forum!