Transcription:
Father and Daughter and Foot and Ankle

Cheryl Martin (Host): There is a wide variety of foot and ankle symptoms. And it's common for physical therapy to be the first treatment. Hello, I'm Cheryl Martin. I have a Bone to Fix With You. Today, a father and daughter experts are teaming up to break down the pathology of some of the top foot and ankle conditions. And talk about the role physical therapy, PT plays in treating them. With me are Dr. Marc Lipton, a podiatrist and foot and ankle surgeon. And his daughter, Mollye Blaxberg, a physical therapist, both are with the Centers for Advanced Orthopedics. It's great to have both of you on.

Dr. Marc Lipton: Thank you.

Mollye Blaxberg: Thank you.

Cheryl Martin (Host): First, let's go down the list of some common foot and ankle conditions with you Dr. Lipton, briefly explaining each one and Mollye, the PT treatment. So let's begin with planter fasciitis.

Dr. Marc Lipton: You got it right. That's right. Plantar fasciitis is probably the most common thing I see in the office. people often refer to it as heal pain or heal spur, but what it really is a chronic inflammation of the ligament on the bottom of the foot called the plantar fascia. The patient usually has pain. Mostly when getting outta bed in the morning feels really uncomfortable. They walk around a little bit, it eases up some, and as the day goes on, the pain gets worse. And we often treat this in the office with a combination of stretching icing anti-inflammatories, maybe orthotics in the shoes.

We send the patient home with some homework. Home stretches things that they can do at home. Maybe a prescription for some anti-inflammatory medication, maybe a device in their shoe, and some instructions on appropriate shoes and other types of things like insoles or heel cups that they can use. And hopefully with a little bit of that home care, they get better, but not everyone does every once in a. We have someone who's sort of resistant to therapy and after four or six weeks, not any better.

And one of the things that will suggest to them that may be helpful beyond like a cortisone injection or anything invasive is physical therapy. And. A lot of that is because they're not adequately doing their homework, like doing their home stretches as we've recommended. They're really tight. And what they do at home is not adequate enough to Stretch their plantar fascia and their Achilles tendon. And then we send them up to physical therapy and they're really helpful with helping to manage their care from that point on. And I'll hand it over to Mollye and let her.

Cheryl Martin (Host): And that's where Mollye comes in.

Dr. Marc Lipton: Exactly.

Mollye Blaxberg: Yeah. So, a lot of the things that we work on in outpatient, physical therapy for plantar fasciitis would be things. Stretching and massage and just kind of guiding the patient through different exercises and helping to progress those exercises. Not only giving them homework, which is something that, Dr. Lipton mentioned, that's gonna be important. But also working on progressing those exercises so that they can get back to the things that went they want to be doing whether that be walking or running or doing different sports and things like that. And the manual therapy is definitely something that we might focus on and working on soft tissue work to address the tight calf muscle and the plantar fascia on the base of the foot.

Cheryl Martin (Host): Now at this point, do you give them something to work on at home? Are they coming into the office for sessions with you?

Mollye Blaxberg: Absolutely. So it would be both. So they would be coming in for 1, 2, 3 sessions a week, and then I would be giving them exercises that they should be working on at home as well.

Cheryl Martin (Host): Great. Now what about Achilles tendonitis and ruptures, Dr. Lipton?

Dr. Marc Lipton: Well, Achilles tend deny is Not this similar from P fascitis in a lot of the symptoms, it's the location that's a little bit different. Achilles tendonitis is also an acute or chronic inflammation of the Achilles tendon, either from overuse or from an injury. And we find that I see them in the office initially diagnose them, get them started on treatment. We use anti-inflammatories. We may put them in some sort of a mobilizing device, such as a boot. We give them a period of time to rest. We may start them on some gentle exercises at home.

And most people will improve with a little bit of time, but some people don't, some people have a chronically tight Achilles tendon. Some people are not good about doing their home exercise. Sort of like me. But they do seem to do very well with physical therapy. Ruptures are a different story. Acute Achilles tendon ruptures sometimes are treated surgically and sometimes treated non-surgically and there are different reasons why we do serves around some people and we don't on other people.

It could be age, it could be activity related or other comorbidities such as diabetes or poor circulation, that would prevent them from having surgery. In those cases, it's really important that they have some guided physical therapy because not only do they have to be immobilized, but they have to be strengthened again. And we try to get them into physical therapy pretty quickly after we see them. And then we hand them off to the therapist and then they start doing what they do.

Cheryl Martin (Host): Talk about that guided PT.

Mollye Blaxberg: Mollye.

Yes. So one thing that Dr. Lipton mentioned is possibly having them be immobilized. So once you're immobilized in a boot or something like that, then usually your gate becomes not normal. So your walking might be affected by that. So one thing that we're gonna be working on is weaning you out of the boot and working on getting your gate mechanics back to normal and ways that we're gonna be doing that is working on improving your range of motion. Because when you are immobilized in that boot, then you are stuck in one position for a prolonged period of time. And you can lose your range of motion and lose strengths with that. So we work on getting those. Back so that you can walk normally again and guiding you on different exercises with how to restore that in a timely fashion and not just going from zero to a hundred on your own.

Cheryl Martin (Host): I saw someone just this past weekend with a boot on, as a result of an achillie's tendon. How long does a person usually have to wear that? Does it vary?

Dr. Marc Lipton: Well, if they have a tendonitis where we just have a chronic inflammation of the tendon, or maybe just a partial tear, we're only keeping them in the boot. Hopefully not more than four to six weeks. But if they have an acute rupture where the tendon has completely come apart, they need to be in that boot for an extended period of time, sometimes up to eight weeks. And that really does pose a lot of problems. Not only with losing muscle mass and mobility and extremity, but also just the mechanics of the way the boot works.

I mean, they're gonna sometimes come in and complain, oh, now my hip hurts. Now my back hurts. My shoulder hurts. I'm getting headaches, stuff like that because we've thrown their whole body mechanics out of the wack, and therapy is very effective in helping those other things as well.

Mollye Blaxberg: I was just gonna say, I'd like to add that like he was saying we're not only working on strengthening muscles of the foot and ankle, but we're also working on strengthening muscles of the entire leg because you're losing muscle strength in the entire leg when you're immobilized in a boot like that. Especially when it's for that period of time.

Cheryl Martin (Host): What about ankle sprains and strains?

Dr. Marc Lipton: Yeah. When I see an ankle injury, ankle sprains can come in any one of different flavors, multiple ligaments could be injured or maybe just a very mild ankle sprain. We just need to put them maybe in the brace and do a little home exercise and a range of motion and they get better maybe one two weeks or so, but a lot of the sprains that we do end up seeing in the office are more severe. Where you have partial tear or almost complete tearing of some of the ligaments around the ankle, and they need to be immobilized for a period of time.

And again, just like with the Achilles tendonitis and Achilles tender ruptures, they're in a boot for a period of time, they lose muscle mass and mobility, and we like to get them out of that boot. strengthened as soon as possible. So therapy is really important to the rehab of these more severe ankle sprains. We see a lot of athletes who come in and some of these sprains are almost worse than fractures because there's a lot of soft tissue damage. There could be nerve damage from the sprains. There's a lot of swelling and we really depend on therapy to get range of motion, strength, and mobility back as soon as possible.

Cheryl Martin (Host): Mollye, what about the PT there?

Mollye Blaxberg: Yeah. So like Dr. Lipton was saying the first kind of thing that we're gonna be working on is reducing the swelling. So we can focus on that in a number of different ways. We have different tools at the office that we can use for that, like vaso, pneumatic compression devices, and different icing techniques that we can assist the patient in learning about. And then work on restoring range of motion, because like we've said being in an immobilize or not moving your foot for a while, you're gonna lose that range of motion.

And then work on strengthening the foot, ankle, knee, and hip. And then kind pivot to working on balancing exercises and increasing stability in the ankle in order to get those patients back to their normal function so that they can return to their activities that they'd like to return to.

Cheryl Martin (Host): Now we just talked about ankle sprains. What about foot sprains and strains?

Dr. Marc Lipton: Some sprain injuries actually need surgery to stabilize the foot or the ankle because the amount of ligamentous disruption is so severe. It can cause chronic instability of the foot or ankle and require an extensive amount of rehabilitation afterward, but foot and ankle sprains again we sort of treat similarly with a period of IM mobilization and then the period of physical therapy afterward.

Cheryl Martin (Host): Anything you wanted to add to that Mollye?

Mollye Blaxberg: I think it's very similar in the way that we would treat an ankle sprain.

Dr. Marc Lipton: And there are times as well, if I can add where we may need the device for like a foot sprain and the most severe ones that I can think of the lisfranc injuries in the midfoot. And we hear a lot about that with football players and high performing athletes and these require long term stability. So even though we wanna get them out of the boot quickly, rehab quickly, they're gonna need some sort of long term stability. And that's where something like an orthotic in the shoe, a device made to fit the shape of their foot and provide some rigidity and stability would be very helpful. And we would do that in combination of weaning them out of the boot, rehabbing them in therapy, and getting something in their shoe to stabilize them, to keep them going.

Cheryl Martin (Host): Tell us what Peraneal tendonitis is, and how it's treated?

Dr. Marc Lipton: So Peraneal tendons are the two big tendons on the outer aspect of the ankle. We call it the lateral aspect of the ankle and they are two tendons that provide a lot of stability for the foot and ankle. There's the peraneous longest in the peraneous brevis. So the two major tendons that come around the outside of the ankle and one attaches into the fifth Metatarcal and crosses on the bottom of the foot and attaches into the first Metatarsal. And those are two of the primary stabilizers of the ankle. They can become injured in an ankle sprain injury.

They can become injured by chronic overuse over time. A lot of time, and the most common thing we see is a. Fraying of those tendons just from overuse in time. So the average, middle aged person who does a lot of walking or running or working out will experience pain on the outer aspect of the ankle or pain near the base of the fifth metatarsal, that little Nobby piece of bone that sits on the other aspect of the foot. And that is from those tendons wearing out. And that's very difficult to deal with. It takes a long time for the symptoms to go away.

We treat it with immobilization such as bracing or something in the shoe, like an orthotic, anti-inflammatories, even injection type therapy. We use PRP, platelet risk plasma to help stimulate healing. But we find that, hand in hand with these treatments, we need to go to therapy, to help with stabilizing the ankle by strengthening the muscles that go come around from the lower leg that turn into tendons around the ankle. And that helps to reduce the load on these tendons. Mollye. I know they have some specific techniques in physical therapy that they use for this particular problem.

Mollye Blaxberg: Yeah, absolutely. Another thing that I wanted to mention is when you're coming out of these, if you're bracing these patients or putting them in immobilizes, we can kind of wean them off of that by doing some Kinesio taping techniques to help give them some more stability without Inhibiting their range of motion as much. So that's definitely a technique that we'll use with some of these different tendonitis and other things that we will do are manual therapy techniques to address the trigger points that can develop because of all the inflammation that's going on.

So manual therapy can include things such as just massage and soft tissue work. And then we are also doing techniques like Grafton, which is an instrument assisted soft tissue technique and cupping, which is another technique that we'll do. And then another one that we also use is called dry needling. So we can do dry needling for some of these tight muscles that have trigger points and they can cause a lot of pain and dry needling can really help to reduce the trigger points and reduce the pain.

Cheryl Martin (Host): Okay now discuss post fracture and post-operative care.

Dr. Marc Lipton: Right. They both are pretty similar because both require an extended period of immobilization to affect healing. So and I'm talking about non-operative fracture care, because operative fracture care is a whole nother story, but with non-operative fracture, you require a prolonged period of immobilization. Either in a boot or a surgical shoe or postoperative shoe, or even a cast. And again, it's all very similar in that we don't do well when we don't use a portion of our body for a long period of time, the muscles atrophy, the joint stiffen, and we can get that bone to heal.

But what happens after the bone is healed? You come out of the cast or the boot, and you have the stiffen weak ankle or foot, and we need to get you strengthened back up. So you can go back to doing the activities you like to do. And that's again, where physical therapy is really important. Some of the surgeries that we do, we want to increase motion and I'll speak for myself with like bunionectomies or hammertoe repairs or tendon work. We need to first get the bone, if we cut and reposition bone, we need that bone to heal.

But in order to get the bone to heal the foot can't move. But we also want those joints to work really well afterwards. So it's really important that we work with physical therapy to help increase range of motion, help increase strength, and they are our partners, without them the patient does not have a successful outcome. So we are always referring to physical therapy afterwards. A lot of people wanna know, well, I just spent all this time off my feet. I'm at home. I'm not working. I can't go to therapy. I can't afford it.

Or I wanna do my therapy at home. I want to just maybe learn something from the internet and maybe do that at home. And we really want them to see the therapist because they can teach them how to do the exercises appropriately. They can teach them how to do what they need to do at home, and also provide them with the manual therapy they need to rehab them faster and get them back to doing what they need to do quicker. It really slows up the process when they try to do things on their own that may not be quite right.

And we can't really teach them at least from my end, when we see them in the office, we're, x-raying them. We are reassessing their wounds. There's a lot that we do, but there's not often enough time to sit down and teach them the different exercises. And that's when therapy becomes so important to our

Cheryl Martin (Host): So PT is vital, Mollye?

Mollye Blaxberg: Absolutely. I would have to agree. I'm a little biased, but I would agree. So when it comes to the post operative care, so surgical instances, something that's definitely important and something that we will work on is incision care and making sure that there's not a lot of scar tissue that develops with the incision and working on massaging that and mobilizing the scar tissue. And again, using different techniques. Like I had mentioned before, like Grafton and cupping and things like that, and that those vaso Nomatic compression devices in order to assist with the tissue healing.

And when it's not postoperative care, so when it's just a non surgical post-fracture care, then it's more of stuff we were talking about working on restoring gate mechanics and getting them they're walking back to normal and then kind of progressing that from there to say they wanna get back to running. So we're slowly progressing them from walking to running and making sure that they have the stability and the strength in order to safely do that. So they're not gonna, re-injure the.

Cheryl Martin (Host): Okay, one more condition. And I know about arthritis, but I think this is my first time delving into foot and ankle arthritis. I didn't realize that.

Dr. Marc Lipton: Yeah, well, anywhere two bones meet and form of joint, you're gonna get arthritis and so it stands to reason that you can get it in your hands. You can get it in your hip, your knees. And you can get it in your feet. Even the little tiny bones in your toes can become arthritic and We know with arthritis, you get stiff and mobilization is the key. The more you move, the less you lose. And that old saying is move it or lose it. And it's so true. If you lose your range of motion, you become very painful. It makes it difficult to walk and stand.

And again, PT very helpful to help maintain motion. And strength in the foot and ankle. And we often send people up there. People who have arthritic joints also have some gate issues and PT is very helpful with improving gate and stability and even balance people seem to, again, in an aging population, have difficulties with their balance and maintaining themselves in an upright position. And PT is very helpful in restoring that ability to maintain their balance and it helps to improve their gate and reduce the possibility of a fall or an injury.

Mollye Blaxberg: Yeah, absolutely. When you lose strength in your foot and ankle, then you lose that stability and regaining that balance is gonna be really important for, like you said, preventing injury, preventing falls and things of that nature. So we will work on all different types of balance exercises in order to make our patients feel more safe out in the community. So working on navigating different types of surfaces in the clinic, we can simulate all different types of environments in the clinic with the tools that we have there and working on having patients stand on varying surfaces, like foam and the floor and all sorts of things in order to strengthen those little stabilizing muscles of the ankle. And like I said, reducing the risk of falls out in the community.

Cheryl Martin (Host): This has been so informative. Thanks so much to both of you, a great father and daughter team in the same field for giving us an overview of the role PT plays in treating foot and ankle conditions. Dr. Marc Lipton and Molly Blaxberg. you can find out more about us online at MD bone doc. Dot com that's MD bone docs.com. We have eight PT locations for your convenience. Get the unique experience of doctor and physical therapy, working together in one place towards your recovery. That's all for today. I'm Cheryl Martin, and that was A Bone That's Fixed.