Dr. Stephen L. Barrett, DPM, FACFAS, Phoenix, is considered to be one of the world’s experts in the treatment and diagnosis of heel pain. Dr. Barrett is the first surgeon to introduce minimally invasive endoscopic surgery to the foot in addition to several other surgical techniques which he has invented.
Dr. Barrett is an accomplished physician certified in foot and ankle surgery by The American Board of Podiatric Surgery. He is the U.S. Patent holder for the development of two endoscopic surgical procedures: endoscopic plantar fasciotomy (EPF) and endoscopic decompression fasciotomy (EDIN). He has trained over 5,000 surgeons throughout the word in his surgical techniques. He is a contributing editor for The Journal of the American Podiatric Association and Practical Pain Management as well as serving on the board of Podiatry Today.
We were fortunate enough to take a few minutes of Dr. Barrett’s time to ask him about the diagnosis and treatment of common sports injuries to the foot and ankle.
Dr. Barrett, what is the most common sports injury you encounter in your practice?
DR. BARRETT: Easily it would be a sprained ankle.
What is the usual cause and treatment? What are some of the misconceptions people normally have about this kind of injury?
DR. BARRETT: Something they do in their sport causes their ankle to roll in. For example, in basketball, they may come down on somebody else’s foot or land on the inside of their foot. We call that an inversion ankle sprain. For a runner, a little hole in the sidewalk or that type of thing will cause the same effect.
The way to treat it if it’s mild is just with what we call RICE – Rest, Ice, Compression, and Elevation. If it’s a very mild injury, this regimen usually will resolve the inflammation and pain within a few days. If it’s a moderate sprain or strain, it could take longer to start to feel better. You can usually tell how bad it is by the amount of bruising and the amount of pain and swelling. If it’s more than just a mild ankle sprain, still very painful after a day or so with no change in pain, then they should get it evaluated. It is important to have x-rays taken and make sure there’s no fracture or any other type of injury.
Do you find that individuals will let something like an injury go for too long? In other words, they think that it’s minor but in reality it’s something that needs to be addressed?
DR. BARRETT: Everybody’s different, everybody has different pain tolerances and athletes are usually much tougher individuals than non-athletes. They try to get back to their program quicker than somebody who is not as hardcore of an athlete. But what happens occasionally is that, with an inversion ankle sprain, there are a few injuries that will not show up until the sprain itself has healed.
One such possible injury is called an osteochrondral lesion of the talus (ankle) bone. What that means is a little piece of the top of the ankle bone where there’s cartilage on top of it gets bumped or impacted, and it often times this won’t show up until maybe six weeks after the injury.
By that time, the sprain has healed but the area is still nagging them and the patient can’t figure out why, why is this still hurting after this period of time? Most sprains or strains are completely healed after six weeks, so pain that persists past that time is a red flag. There are two other injuries that are commonly associated with this type of problem. One is called Sinus Tarsi Syndrome. There’s a little hole between the ankle bone and the heel bone and there’s some little tiny nerves in that area that will get stretched and pulled with that type of injury.
These nerves can send pain signals back to the brain. It’s not truly the ankle joint that’s affected, it’s actually the joint below the ankle joint called the subtalar joint but it’s so close anatomically that most patients can’t figure it out. They just think “well, my ankle” because it’s literally maybe a centimeter or two centimeters from the ankle joint itself. So that’s another injury that’s very common. Usually six months down the line they’ll come in and say “you know, my foot just hurts on the outside top of it and I had this ankle injury or ankle pain six months ago, and it’s still bothering me… ”
The third condition is what we call a common peroneal nerve injury. If you go just below your knee to the outside of your leg you can feel a little bump. That’s the fibular head, or the top of the long, skinny bone of the leg. There’s a nerve that runs right around that area called the common peroneal nerve. It’s a very important nerve because it allows people to be able to bring their foot up. When that nerve gets injured, sometimes a person will develop what is commonly called a “drop foot.” They are almost paralyzed, so to speak, from not being able to bring their foot up.
That injury can sometimes be very latent, from months to even years where a patient will just have a nagging sensation or they may feel a little weakness. Sometimes the patients describe that they “feel like my foot is slapping on the floor”. Over time, the nerve damage, if left untreated, causes the nerve to degenerate, and then we have less options for helping the patient. If a few months after a strain, you are having trouble bending your toes towards your ankle, please see some one trained in peripheral nerve.
So, those are some of the things that you have to factor in with that particular injury.
Doctor, let’s talk a little bit about footwear for athletes like runners. How important is the right footwear for injury prevention for somebody who is active like a runner?
DR. BARRETT: It’s extremely important. There’s different biomechanics just like we have different genetics. Every foot is different. If you put a foot in the wrong shoe and you put enough mileage on it, you’re going to get some biomechanical breakdown. That’s pretty intuitive, I think, that everybody would agree with that. The shoe companies have become extremely sophisticated in what they’re trying to do with controlling people’s biomechanics.
The problem is that’s more of a generic type of blanket coverage, so to speak, and the shoe chosen may not actually take care of the user from a stress standpoint, number of cycles standpoint, or it may in fact be the wrong shoe for them entirely. You need to look at that from a biomechanical standpoint, what kind foot does this patient have and is that shoe that they’re wearing really suited for them?
One of the things that I always recommend is that if somebody has an unusual foot condition, have it evaluated by somebody who knows biomechanics. Then, instead of trying to have the shoe take care of the problem, have a custom orthotic made by somebody who understands your specific biomechanics. That orthotic can be transferred from shoe to shoe so it actually ends up saving you money in the long run.
Invariably, there are a lot of folks out there who will come in with a bag of 8 or 10 pairs of different shoes, and they’ll try to find a shoe that fixes their problem when in fact no shoe will fix their problem. They actually need more of a significant treatment.
To wrap this up, what do you feel is the most important consideration that one should make when choosing a podiatrist for treatment?
DR. BARRETT: Well, I think that there are a couple of things. Podiatry is a very interesting profession because it’s a young profession and it’s a highly specialized profession so there are people within the podiatric profession that specialize just in children, people who specialize just in biomechanics, people who specialize primarily in surgery, included very specific areas such as peripheral nerve surgery for the lower extremity. If the patient really knows what their problem is, they should do a little bit of research to find out if that particular doctor has a focus or an interest in that area.