Ankle Pain: Tarsal Tunnel Syndrome

At the Centeno-Schultz Clinic we acknowledge that there are many causes of ankle pain.

Ortho 2.o discusses the key concepts in evaluating  the ankle:  Stabilization, Articulation, Neurological and Alignment.

Tarsal tunnel syndrome (TTS)  is an entrapment of the tibial nerve  on the medial side of the ankle and is characterized by numbness and pain in the toes and sole of the foot.

The tibial nerve, artery and tendons of the flexors travel as a bundle through the tarsal tunnel.  the tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.  In the tarsal tunnel the tibial nerve divides into three different segment:. calcaneal, medial and lateral. 

Anything that creates pressure in the Tarsal Tunnel can cause TTS. Common causes include cysts, bone spurs, varicose veins, ganglia, inflammation of tendons or swelling from trauma.

Symptoms include burning pain, tingling or numbness typically worse after prolonged standing.

Tarsal tunnel syndrome is diagnosed by clinical examination and based on findings such as area of sensory disturbance and positive Tinel sign over the tarsal tunnel.

Ultrasound imaging is utilized at the Centeno-Schultz Clinic for both diagnostic evaluations and therapeutic injections of prolotherapy and platelet derived growth factors.  Below is short axis  ultrasound image of the tarsal tunnel and tibial nerve.

Legend:  Abdh:  abductor hallucis muscle,

curved arrow:  tibial nerve,

fhl: flexor hallucis  longus tendon,

ST: sustentaculum tali,

straight open arrows:  flexor digitorum longus tendon,

void arrowhead:  tibial artery,

white arrow heads:  posterior tibial veins.

Ankle Sprains: Calcaneal Fibular Ligament

An ankle sprain, more commonly called “rolling your ankle,” is a stretch or tear in one or more ankle ligaments. It most commonly involves the anterior talofibular ligament and the calcaneal fibular ligament.  The former has been discussed in a previous blog.

At the Centeno-Schultz Clinic stability is a key concept in the treatment of orthopedic injuries.  Stability is one of  many critical concepts discussed in Ortho 2.0.  Joint instability can lead to injury, acceleration of cartilage and meniscus degeneration and an alternation in bio mechanics.

The calcaneal fibular ligament  is a narrow cord that connects the distal tip of fibula with posterior and lateral aspect of the calcaneus.

Inversion sprain is the most common injury whereby the  ankle is inverted and ligament are stretched or torn.

The  primary function of the calcaneal fibular ligament is to stablize sub-talar joint and limit inversion.

At the Centeno-Schultz Clinic the talar tilt test is  to evaluate talar instability.  The talar tilt test is defined as the angle produced by the tibial plafond and the dome of the talus in response to forceful inversion of the hindfoot.

The calcaneus and talus are grasped as a unit and tilted into inversion. The tibia is held stable with the ankle in neutral dorsiflexion.

Risk factors for an ankle sprain include:  weak muscles/tendons, weak or lax ligaments and poor ankle flexibility.

Anterior Talofibular Ligament: Ankle Stability

At the Centeno-Schultz Clinic stability is a key concept in the treatment of orthopedic injuries.  Stability is one of  many critical concepts discussed in Ortho 2.0.  Joint instability can lead to injury, acceleration of cartilage and meniscus degeneration and an alternation in bio mechanics.

The anterior talofibular ligament (ATF)  is a key lateral ligament in the  ankle.  Ligaments are dense fibrous tissue that connect one bone to another.  Treatment options for ligament laxity include prolotherapy, platelet derived growth factors and autologous stem cell therapy.

The anterior talofibular ligament has the following characteristics:

It connects anterior fibula to neck of talus.

In dorsiflexion, its fibers are oriented 75 deg to the floor

In plantar flexion, its fibers approach vertical orientation.

The ATF ligament prevents the foot from sliding forward in relation to the shin

It is the weakest of the ankle ligaments and it’s because of this it is the one that is most commonly injured.

The  anterior drawer and talar tilt tests are common tests used at the Centeno-Schultz Clinic to evaluate lateral ligament laxity.

Below is an ultrasound image of the ATF.  F=fibula and T=Talus.  The arrows identify the  anterior talofibular ligament.

Use of Stem Cells in the Treatment of Non-union Bone Fractures

At the Centeno-Schultz Clinic we acknowledge that most bone fractures heal without difficulty. Unfortunately some do not.

Fractures that demonstrate motion of the bony ends and incomplete healing more than 6 months after injury are called non-union fractures.  Of the estimated 6 million bone fractures in the United States each year, approximately 10% will develop slow (delayed union) or incomplete healing (non-union).

Conservative treatments are limited and include the use of bone simulators.

Surgical options include bone grafting and or removal of existing hardware and rebreatking the the fracture with insertion of new plates and screws.  This is a significant surgery and involves extensive rehabilitation.

Stem cells are an alternative to non-union surgery.  We recently published our results.  6 patients with chronic non-union fractures were treated with treatment intervention at an average of 8.75 months post fracture.  Autologous, culture expanded stem cells were injected into the fracture through a needle utilizing intermittent x-ray.

Centeno-Schultz Clinic  continues to publish it’s clinical work in the peer-reviewed medical literature.  This clearly separates us from the majority of clinics using stem cells to treat orthopedic injuries.  Here is a link to our  publicationsthat are  indexed in the National Library of Medicine.