Death by Ankle Sprain

A recent and unfortunate death is being highlighted due to the inability of medical officials to capture a life threatening condition. A 29 year old woman was in and out the Emergency room for several days complaining of leg pain. The patient originally suffered from an ankle sprain but the pain continued to persist and worsen. Appropriate tests were done with no definitive answers found to suggest a problem. The patient refused to leave the hospital. She was arrested for trespassing. Fifteen minutes after being incarcerated, the woman was found dead in her jail cell. What went wrong?

An autopsy revealed the young woman died of a pulmonary embolism, a blood clot in the lungs. The woman’s leg pain was likely due to blood clots in the legs also known as deep vein thrombosis (DVT) that eventually traveled to her lungs and resulted in her death. Blood clots are uncommon and complicate less than 1% of foot and ankle injuries. The risk factors are trauma, recent surgery, prolonged inactivity, hospitalization, smoking, obesity, and birth control. Pain or discomfort in the calf is typically the preceding symptom through many DVTs can be silent. Many patients who are at high risk are typically treated prophylactically with blooding thinning medication such as aspirin or heparin.

When a patient complains of such leg pain, it is the standard of care to screen for a DVT. Though hospital records are still being reviewed, Medicare and Medicaid reviewers have not found a deficiency in the patient’s care. So why did she die? Could it have been prevented? I was not there and I can only speculate the course of events but some reports are describing the patient as having drug seeking behaviors. The patient was known to be homeless, combative and uncooperative with healthcare professionals during her hospital visit. Once the appropriate tests were performed and were negative, her continued complaints were disregarded and many assumed she was falsifying her symptoms. The emergency room is well known to drug seekers and it is a daily, hourly occurrence to encounter a patient who’s complaints cannot be supported by medical reasoning. It is often very difficult and challenging to identify those patients with serious and legitimate complaints and those who have ulterior motives.

For this young lady, it is hard to speculate if further evaluation and persistence of medical health care workers in diagnosing her leg pain would have ultimately saved her life. By protocol, they did their job, they could not find a problem and diagnosed her with a muscle strain/cramping. It was not necessarily a misdiagnosis because they tested her for DVTs but did not find enough clinical evidence to diagnose her. Could an intervention have saved her life… maybe? This is the grey are of medicine and there wasn’t one big thing that was missed. Is there fault? I don’t know if one person can be blamed. It’s an unfortunate loss and when caught, a DVT can be treated and pulmonary embolisms can be avoided.

My Toes are Always Cold!

When a patients comes to my office complaining of cold or numb toes there a three things that instantly pop into my head; diabetes, vascular disease, or Raynaud’s phenomenon. Now before you get all excited and start self diagnosing, many people just have cold feet because it is cold! We may think it is a new problem or it has gotten worse, but we must also take note that the temperature is dropping, our floors are colder and it has been months since our feet have seen this weather. Still, persistent coldness, numbness, or pain is not normal.

Why do diabetics have cold feet? Diabetes cause many changes in your body over time. One such change happens in the nerves. The elevated sugar levels in the blood damage the nerves and inhibit their ability to function properly. This is called peripheral neuropathy. Neuropathy can affect the foot in two ways. First it changes our perception of sensations and eventually progresses to loss of sensation. Most patients describe the process as burning and tingling that eventually leads to numbness, but I have heard many different descriptions. Just yesterday a gentlemen with neuropathy said, “It felt like was standing in ice cold water and my toes eventually froze with no feeling.” Secondly, neuropathy changes the way nerves reacts to stimuli. The nerves in the feet do not communicate well with the rest of the body. For example when we are warm the blood vessels dilate, this explains why we get rosy cheeks. But with diabetes the nerves in the foot don’t always get the message and the vessels stay constricted and less warm blood is getting the toes.

Are cold feet a sign of vascular disease? Our body produces heat in many different ways but a major facilitator to maintain body temperature is our blood. Blood vessels enlarge when we are warm and get smaller when we are cold. It is more important to keep our organs at a certain temperature than our hands, so our body naturally adjusts blood flow to facilitate the demands. With vascular disease, our vessels are damaged or clogged and either blood is not traveling where it needs to be fast enough or it is has trouble getting back to the heart to get re-warmed and refilled with oxygen. In the most simplistic terms: less blood moving means less warmth moving through our hands and feet.

Are cold feet a disease in itself? Actually, there is a disease that causes cold, numb feet! Raynaud’s disease is a condition in which your body over-reacts to cold stimuli. As I mentioned before, our blood vessels get smaller when we are cold. They can also get small when we are stressed or excited so our heart and brain get the most blood in demanding situations. With Raynaud’s our body blows the situation out of proportion and the vessels go into vasospasms. The toe(s) and or finger(s) will turn white due to the lack of blood flow, and then purple due to the increase in venous blood flow, finally when the toe is re-warmed it will turn red due to the return of blood flow. More often Raynaud’s occurs with other conditions such as Lupus, rheumatoid arthritis, or many other systemic diseases.

I cannot count the number of times I have heard the complaint about having cold feet. We have all had them and know the pure agony of freezing toes. Occasional coldness with changes in weather is normal. Struggling every day with cold feet is not normal.

Losing Weight Workouts without Foot Pain

The optimistic visions of the New Year are contagious. Lofty goals are being set and we all aim high in January. Still, many of us hold back. We paddle through a long list of excuses on why this year is not the year. Weight can be a huge aggravator for foot pain. Losing weight helps foot pain, but how do you lose weight when you can barely walk without pain?

In a survey done by the American Podiatric Medical Association, 72 percent of Americans says they do not exercise because of foot pain. First, foot pain is not an excuse and will not be accepted as one in my office! If you are having foot pain that is keeping you from healthy activities then something is wrong and you need to be treated. There are a variety of reasons that you may be having foot pain. Common conditions like plantar fasciitis require treatments such as cortisone injections, physical therapy, and night splints. Occasionally surgery is needed but this is a last resort.

The first thing to evaluate is your shoes. Not just the shoes you exercise in but all of your shoes. Most of us wear bad shoes or none at all. Whether it is dress codes or personal style, we do not give our feet enough room or support. We also love to kick the shoes off. Yes, walking barefoot around your house can be very bad for your feet! Some of us need extra support all of the time. Your shoes should be wide enough, long enough and have support in the arch area. Some athletes have trended towards the minimalist shoes or barefoot running. Is it ok? For some people, yes it is ok, but this is not for everyone and is only for the elite athlete with impeccable foot structure. Very few of us have the foot type that can bare the abuse.

Next is to evaluate the type of activities you are doing. Some sports or work outs have a higher impact on your feet than others. Swimming and biking have very low impact on the feet and are great alternatives if you are struggling with your feet. Other activities put a greater demand on your feet such as running on a treadmill or blacktop. You must also evaluate the consistency of high impact activities. Alternating between low and high impact activities will keep you doing what you love but also keep you on your feet!

It is that time of year to be optimistic. You will cure your foot pain, get back to the gym and lose the weight! First find the source of the pain, seek treatment, and stay focused. It is easy to find excuses and the foot is an easy target. Don’t let your feet get the best of you. 72 percent is an unreasonable amount of Americans struggling with foot pain.

Losing Weight Workouts without Foot Pain

The optimistic visions of the New Year are contagious. Lofty goals are being set and we all aim high in January. Still, many of us hold back. We paddle through a long list of excuses on why this year is not the year. Weight can be a huge aggravator for foot pain. Losing weight helps foot pain, but how do you lose weight when you can barely walk without pain?

In a survey done by the American Podiatric Medical Association, 72 percent of Americans says they do not exercise because of foot pain. First, foot pain is not an excuse and will not be accepted as one in my office! If you are having foot pain that is keeping you from healthy activities then something is wrong and you need to be treated. There are a variety of reasons that you may be having foot pain. Common conditions like plantar fasciitis require treatments such as cortisone injections, physical therapy, and night splints. Occasionally surgery is needed but this is a last resort.

The first thing to evaluate is your shoes. Not just the shoes you exercise in but all of your shoes. Most of us wear bad shoes or none at all. Whether it is dress codes or personal style, we do not give our feet enough room or support. We also love to kick the shoes off. Yes, walking barefoot around your house can be very bad for your feet! Some of us need extra support all of the time. Your shoes should be wide enough, long enough and have support in the arch area. Some athletes have trended towards the minimalist shoes or barefoot running. Is it ok? For some people, yes it is ok, but this is not for everyone and is only for the elite athlete with impeccable foot structure. Very few of us have the foot type that can bare the abuse.

Next is to evaluate the type of activities you are doing. Some sports or work outs have a higher impact on your feet than others. Swimming and biking have very low impact on the feet and are great alternatives if you are struggling with your feet. Other activities put a greater demand on your feet such as running on a treadmill or blacktop. You must also evaluate the consistency of high impact activities. Alternating between low and high impact activities will keep you doing what you love but also keep you on your feet!

It is that time of year to be optimistic. You will cure your foot pain, get back to the gym and lose the weight! First find the source of the pain, seek treatment, and stay focused. It is easy to find excuses and the foot is an easy target. Don’t let your feet get the best of you. 72 percent is an unreasonable amount of Americans struggling with foot pain.

Corns 101

Corns have been the bane of your toes since the invention of closed toe shoes. People resort to all sorts of home remedies to try and relieve themselves of the little devils. The cure is really very simple…prevention.

Corns are those thick, often painful excrescences that pop up on the top joints of your toes after wearing shoes that are either too short or too narrow (or both). Toes like to lie flat inside of shoes for a comfortable walking experience. Style often dictates otherwise in the form of shoes that are too narrow, or in the case of ladies shoes, having a high heel that pushes the toes together and rubbing them at the top of the shoe. Over time, this cramping of the toes causes the tendons on the tops of the toes to shorten causing a contracture of the toe till it assumes the shape of a “hammer”. Thus the “hammertoe” is born. That round, thickened skin on the top of the toe joint is in fact the “corn”. Shaving off the corn or padding it only gives temporary relief. The cure comes in two forms.

First part of the cure would be prevention. The shape of the shoe must fit the shape of the foot. Corns and the contracted digits don’t occur with the wearing of just one pair of shoes for an evening. They occur over several years of shoe abuse to your toes. Many people feel they know the size of their feet and, and buy shoes without even trying them on. Fashion often dictates the shape of the shoes and height of the heels. Over years, this is the recipe for painful corns and hammertoes.

Second part of the cure if you fail to heed the advice of the above paragraph, would be correction. This involves the surgical correction of the digits with the removal of a small piece of bone that has come to form the corn as well as the lengthening of the tendon that caused the toe to hammer. The human body is an amazing thing. If the toes are continuously stuffed into shoes that are too small, the tendons contract and eventually stay that way. “Hammertoe” correction to relieve the pain of the corns is a simple outpatient procedure, but why not try and avoid the problem in the first place?

Ladies…I’m not saying that you can never wear fashionable, high heels shoes. All I am saying is that you should use sensibility in when and where you wear them.
Men also suffer from this painful malady. Though they may not be in high heels, men also fall victim to wearing shoes that are too narrow or too pointy for the shape of their feet.

So folks what do you say? Let’s just “shoe “ a little common sense when buying and wearing shoes. Save those high heeled and pointy shoes for the weekend.
Rob Kosofsky D.P.M.

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What is a HIGH Ankle Sprain?

We are glued to the TV watching the big game and there goes a key player. Out with a High Ankle Sprain!!! So….what is a high ankle sprain? Can you have a low ankle sprain? The Vikings have been struggling, and now that Adrian Peterson, their star running back, has a high ankle sprain, do they even have a chance? The answer is no, but Peterson will be just fine and back in the game soon.

A high ankle sprain is a tear in the syndesmotic ligament. This ligament lies between the tibia and fibula and connects the bones throughout the lower leg. A typical ankle sprain involves the ligaments that surround the ankle joint. As the name suggest, the Syndesmosis is above the ankle joint and thus a tear in this ligament is called a “high ankle sprain.” Syndesmotic tears occur more commonly with an ankle fracture but isolated syndesmotic tears are also reported. The typical mechanism of injury is external rotation of the foot on the tibia and fibula, as seen on the photo below, on the right.



Syndesmosis injuries are more common than classic ankle sprains. They frequently occur in collision sports or those sports that have rigid ankle immobilizing gear such as skiing. Nearly 74% of ankle injuries reported in hockey are syndesmotic sprains. In the general population syndesmotic sprains make up only 10-20% of all ankle sprains. Typically, the athlete will present with a sore sometimes sharp pain over their leg between the tibia and fibula. The pain is worse when bearing weight and often the athlete cannot bear any weight on the extremity. The diagnosis of a syndesmotic tear is not difficult on physical exam but further studies are performed to identify any associated injuries or the extent of the injury. It is standard to take x-rays and to examine for any fractures, typically seen in the fibula or tibia. Often, an MRI is also ordered to identify the extent of the tear. Very rarely, surgery to repair the torn ligament is necessary.

The degree of severity can vary greatly. Due to the high incidence of associated injuries, it is difficult to outline the recovery time. Multiple studies have been done to determine the average recovery time. This can range from as low as 1 week to as high as 6 months. Studies have consistently showed that stage I and II ankle sprains on average have a faster recovery time than a syndesmotic sprain.

If an isolated syndesmotic sprain is identified with no other associated injuries than recovery time is very short. I feel comfortable saying that Peterson will be back on the field with the rest of the Vikings to finish the season. Unfortunately, with or without and injured Peterson, I don’t see them making it to the play offs.