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By Colorado Foot and Ankle
October 30, 2020
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Fall is officially here which means football season is underway! Football players can experience a wide range of foot and ankle injuries, ranging from turf toe to Lisfranc injuries, high ankle sprains to Achilles tendon ruptures. Let’s delve a little deeper into each of these injuries, including a look at their mechanism of injury and possible treatment options.

Turf toe refers to an injury to the ligaments surrounding the big toe joint. It often occurs from overextending the big toe during a “push off”
type motion, causing the ligaments to elongate or tear. This injury is especially common in football or soccer players due to the artificial turf
surface. Athletes may experience a popping sensation when the injury occurs or may feel stiffness and limited motion around the big toe. It is important to see a podiatrist if you experience any of these symptoms, and an x-ray will be performed to rule out any fractures or dislocations. Milder injuries to the joint can be treated with immobilization, compression, ice, and elevation. Athletic tape can also be utilized to stabilize the toe and minimize motion at the joint during the healing process. For more advanced injuries, a walking boot or cast may be necessary to eliminate all motion and allow the ligaments and damaged tissues to heal properly.

A Lisfranc injury refers to a strain in the midfoot, an area which is highly important in stabilizing the arch and the entirety of the foot. Lisfranc injuries range from purely ligamentous injuries to fractures in the midfoot bones. One common mechanism of injury in football players is a downwards force on a foot with toes flexed towards the ground. In essence, the toes buckle underneath the foot and there is strain or collapse at the midfoot level. It is not uncommon for players to experience immediate pain and swelling, with the inability to bear weight. Imaging is highly important in these injuries and may include x-rays, MRI, or CT scans. Treatment ranges from a walking boot or cast to surgical intervention. Recovery times can range from 4-6 weeks to several months for more complex fracture-dislocation injuries. Untreated injuries can lead to further instability and chronic pain.

High ankle sprains generally refer to an injury to the ligament complex above the ankle joint. This complex, referred to as the syndesmosis, is responsible for stabilizing the joint between the two long bones of the leg, the tibia, and the fibula. The mechanism of injury usually occurs from an external or outward rotation of the leg on a planted foot, especially when the foot and toes are pointing up (dorsiflexed) in relation to the ankle joint. Podiatrists can diagnose this injury by squeezing the two bones together at the lower leg, which will elicit pain. X-rays and MRIs can also aid in making this diagnosis. Conservative treatment options include immobilization in a walking boot, ice, compression, and elevation. In cases where the gapping between the two bones (referred to as the “diastasis”) is excessively wide, surgical treatment is indicated to stabilize the ankle joint. This can involve either screws or surgical anchors to support the two bones and decrease the gapping.

Achilles tendon ruptures are among the most common injuries to affect football players. A rupture refers to a complete tear of the calf tendon, either within the midsubstance of the tendon or, less commonly, when the tendon tears off the back of the heel bone. One possible mechanism of injury includes the forced planting of the foot on the ground with the majority of the player’s body weight pushing down. Any type of aggressive dorsiflexion of the ankle (when the foot and the toes pointing upwards at the ankle joint) can cause a “popping” sensation in the Achilles, which may be indicative of a partial or complete rupture of the Achilles tendon. If the tendon is torn, the patient will be unable to plantarflex (point their foot and their toes in a downward direction), and will likely be unable to bear weight on the affected extremity. Podiatrists will often feel a noticeable gap in the area of the tendon rupture on the back of the patient’s calf. Though clinical evaluation is often all that is needed to make the diagnosis, ultrasound or MRI imaging can be helpful in confirming a tendon rupture and informing the doctor of the gap that exists between the two torn tendon ends. TIn milder injuries, tendon ruptures can be treated conservatively with complete immobilization in a boot or cast. More often in the athletic population, surgical treatment and open repair of the tendon rupture is indicated, as this leads to a lesser chance of re-rupture. Surgical intervention includes an open end-to-end repair of the torn Achilles tendon, often using a heavy stitch (suture) material to reapproximate the tendon ends. It is important to note that these injuries have a long recovery period of rehabilitation and physical therapy, generally ranging from 9-12 months.

Recognizing any of the above conditions and seeing a podiatrist quickly after an injury can minimize the risk of complications or delayed diagnoses. Ultimately, it is both the patient and the physician’s goal to return to the sport in an efficient but safe manner!

Outcomes in all of medicine, but especially wound care, go beyond the physical clinical presentation. Accordingly, the panelists discuss unique mental, social and emotional challenges wound care patients may face, and share their experiences and opinions on how best to provide support and care.


What mental, emotional or social challenges do you feel patients with chronic wounds may encounter in relationship to their condition? Why?


Chronic wounds can certainly be a large burden on patients due to the necessary complexity of care, says Jacob Fassman, DPM, FACFAS, CWS. He adds that transportation issues and financial burdens of frequent visits are also very impactful. Both Dr. Fassman and Kazu Suzuki, DPM, CWS identify possible patient embarrassment from malodorous wounds, or needing to ask for help from family and friends as sources of distress and isolation. Both doctors also agree that pain management needs pose a significant challenge for wound care patients.

“Having chronic pain for months or years, let alone undergoing an amputation, can be devastating to one’s mental health,” says Dr. Suzuki. 

Citing the work of Beattie and colleagues, Valerie Marmolejo, DPM, MS says a perceived lack of control and loss of self are significant aspects of the psychosocial health ramifications of a diabetic foot ulcer (DFU).1 For example, Fejfarová and Jirkovská note that weightbearing restrictions impact the patient’s ability to perform daily activities, including work-related activities.2 Dr. Marmolejo says this may have a negative impact on a patient’s attitude and self-confidence.1-6


How might these patient challenges pose further treatment challenges for the clinician?


“A key component in treating a patient with a chronic wound is to know that negative emotions will be involved,” says Dr. Marmolejo. 

The panelists agree that patients may express these negative emotions in a variety of different manifestations and behaviors. Patients may direct fear and anger at the provider, explains Dr. Marmolejo. She says it is important to understand the underlying reasons for these behaviors and still try to build a positive patient-provider relationship.

Patients with depression may not keep scheduled appointments, which challenges the provider to adequately and promptly address their condition, according to Dr. Suzuki. In addition to appropriate referrals to psychiatric professionals, Dr. Suzuki emphasizes awareness of pain management options. 

“I do my best to be proactive about pain counseling and management as there are many pharmacological interventions,” says Dr. Suzuki. 

For pain management, he notes that he would have patients start with acetaminophen around the clock (maximum 3,000 mg per day in divided doses) and use narcotic medication (such as tramadol, hydrocodone and oxycodone) for breakthrough pain. Dr. Suzuki says adjunctive pain medication options may include gabapentin, pregabalin (Lyrica®, Pfizer) and duloxetine (Cymbalta, Lilly). He adds that many of his patients also self-medicate with CBD supplements.

When it comes to pain control interventions, Dr. Fassman cautions providers to be aware of unwanted side effects such as somnolence, confusion or even addiction. 

Dr. Fassman adds that clinicians should carefully weigh and balance non-clinical issues such as transportation challenges and large or repetitive copays when formulating an appropriate treatment plan that still prioritizes positive outcomes.


What strategies have you employed to prevent or address psychosocial issues during wound treatment? 


“I try to be direct and concise with patients who have chronic wounds,” says Dr. Fassman. “I will utilize phrases such as ‘It is essential, Ms. Jones, that you keep your appointment with me next week,’ or ‘It is critical you control your blood sugars in order to heal the wound and prevent you from losing your foot.’” 

Dr. Marmolejo relates that taking into account a patient’s psychosocial health is important and begins with a thorough assessment of a patient’s level of education, employment history, history of alcohol, tobacco and drug use, how the patient interacts with his or her social network, the patient’s knowledge and perception of how his or her comorbidities affect health, the patient’s goals of treatment and reasons for previous treatment successes and failures if applicable.1,2,5,7

Dr. Suzuki explains that he strives to be as empathetic and positive as possible during interactions with patients. He adds that close communications with primary care doctors and the patient’s family may also be helpful. Judicious use of antidepressant medications and help from psychiatry colleagues may also be worthwhile, maintains Dr. Suzuki.  


Do you have any interesting case examples from this population to share with readers? 


Dr. Suzuki shares a case of a woman in her mid-40s with chronic leg wounds over 10 years due to thalassemia (a genetic blood disorder that causes anemia), resulting in multiple hospital admissions. He notes the patient is clinically depressed and only presents for appointments every other week or so. He relates that he sees this in other patients that deal with chronic, lifelong diseases. While some of these patients manage reasonably well, Dr. Suzuki says others experience hopelessness and neglect their medical conditions.

Dr. Fassman relates seeing a recent patient with a chronic, plantar foot ulceration. As an attorney, the patient found it challenging to be able to offload appropriately as he had to be in court and meetings, etc. The patient unfortunately developed a limb-threatening infection, which required hospitalization a few days before a planned vacation out of the country. The patient adamantly expressed he was leaving for his trip “no matter what.” 

“I utilized phrases with him such as ‘You have a limb- and potential life-threatening situation if you take a long flight out of the country,’ and ‘It is essential you stay in the hospital where you will have the support and care necessary,’” emphasizes Dr. Fassman. While it took repeated efforts, Dr. Fassman notes the patient did eventually cancel his trip.

A frequent concern she hears from past students, residents and fellows, says Dr. Marmolejo, is how to discuss the situation with a patient when an amputation is required. Taking the potential negative aftermath out of this conversation is a talent honed with time, according to Dr. Marmolejo. 

“This conversation can be traumatic for the patient, causing a multitude of emotions, including aggressive and negative ones that may be provider-directed,” notes Dr. Marmolejo. “The provider must learn to give the patient grace, understanding and honesty, and not take the expressed emotions personally. Additionally, one must strive to understand the patient’s perspective and concerns in order to address him or her appropriately, building a relationship with the patient that facilitates the best functional outcome and quality of life.”  

Dr. Fassman is a Fellow of the American College of Foot and Ankle Surgeons, and a Certified Wound Care Specialist (CWS). A Diplomate of the American Board of Foot and Ankle Surgery, Dr. Fassman is in private practice in Colorado Springs, Colo.

Dr. Marmolejo is a clinical wound specialist with LifeNet Health and is a medical writer with Scriptum Medica. 

Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, CA. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles, CA. He can be reached at [email protected]


1. Beattie AM, Campbell R, Vedhara K. ‘Whatever I do it’s a lost cause.’ The emotional and behavioural experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study. Health Expect. 2014;17(3):429-439.

2. Fejfarová V, Jirkovská A, Dragomirecká E, et al. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus? J Diabetes Res. 2014:371938. DOI: 10.1155/2014/371938. Available at: Published March 25, 2014. Accessed April 13, 2020.

3. Vileikyte L, Rubin RR, Leventhal H. Psychological aspects of diabetic neuropathic foot complications: an overview. Diabetes Metab Res Rev. 2004;20 Suppl 1:S13-8.

4. Vileikyte L. Psychosocial and behavioral aspects of diabetic foot lesions. Curr Diab Rep. 2008;8(2):119-125.

5. Roukis TS, Stapleton JJ, Zgonis T. Addressing psychosocial aspects of care for patients with diabetes undergoing limb salvage surgery. Clin Podiatr Med Surg. 2007 Jul;24(3):601-610.

6. Kinmond K, McGee P, Gough S, Ashford R. ‘Loss of self’: a psychosocial study of the quality of life of adults with diabetic foot ulceration. J Tissue Viability. 2003;13(1):6-8, 10, 12 passim. Erratum in: J Tissue Viability. 2003;13(2):80. 

7. Iversen MM, Midthjell K, Tell GS, et al. The association between history of diabetic foot ulcer, perceived health and psychological distress: the Nord-Trøndelag Health Study. BMC Endocr Disord. 2009 Aug 25;9:18.


As you may already know two medications are repeatedly being mentioned when treating Covid-19. These medications called hydroxychlorquine (Plaquenil) and azythromycin (Z-pack) are being used in symptomatic patients. They are used for very sick patients who are in respiratory distress and require intubation, but are now being used more early in the infection treatment. Doctors are using cocktails of drugs, 2-3 medications simultaneously, to interrupt several infection processes. These vary widely and are not standardized. Colorado Foot and Ankle would like to educate our patients that these medication both are known to cause very small percentages of spontaneous tendon ruptures, usually in the lower extremity. The rates would be about one percent in previous studies. What we don’t know is if the two medications together increase the rates of injury but intuitively we are concerned. We do know that the risk of tendon injury does increase when using steroid (Prednisone, Medrol Dosepack) with an antibiotic like azythromycin so be aware. Some tips for our community, if you have had treatments with the above medications and have developed a sore region of you Foot or Ankle consider, Tendinopathy. Usually, we would see this as a spontaneous swelling in the foot or ankle, surprisingly, these do not always hurt. Rest, Ice, Compression, Elevation (RICE Regimen) generally helps. Don’t stop the medications for Covid-19 but consider an evaluation. We haven’t seen a rise in Tendinopathy that would reach statistical significance as of late April but if widespread use of hydroxychloroquine and azythromycin continue it will likely occur. Our thoughts for you and yours. Bryan Groth DPM

Side Notes:
Azythromycin is commonly confused with Erythromycin.
Medication induced Tendinopathy usually has noticeable swelling and inflammation before rupturing so early detection is very helpful.

April 13, 2020
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Early April 2020
Update on COVID-19
From the Doctors and staff of Colorado Foot and Ankle

  • We are constantly monitoring the status of the COVID-19 virus and its' impact on health care and our ability to safely provide evaluation, management, and treatment to our patients.
  • We have remained OPEN and continuously evaluate and update our safety standards.
  • We have already readjusted our schedules to ensure that our patients spend a minimal amount of time in our reception area. In addition, we have set up our schedule so that each patient is almost immediately taken from check-in and placed in an examination room. We feel this greatly reduces exposure to you and to others.
  • We feel that if you are in pain, or feel that without treatment, you might be in pain, that a visit is essential. We are fortunate as foot and ankle specialists that we can safely execute our jobs at a safe distance from our patients.
  • We do not want to see that ingrown painful nail turn into an infection, or that callus or blister, becoming an urgent event that requires hospitalization, as that will increase your risk to COVID-19 exposure.
  • We also have split our doctors and staff into two different teams with each team working together, on different days, to minimize risk.
  • Our addition of telemedicine has been a huge success with many patients being able to be evaluated, without leaving their home.
  • Again, please understand that although we remain open, if you are feeling ill, if you have been traveling recently, or if you feel like you might have signs of the COVID-19 virus (fever, dry cough, sore throat, difficulty breathing), please stay home and consult with your Primary Care Physician.
  • We will continue to keep you informed through these email bulletins as things evolve.


By Colorado Foot and Ankle
October 19, 2017
Category: Uncategorized
Tags: Untagged

There may be no part of your body that undergoes more wear and tear than your feet. Learning how to prevent problems can stop them before they start!

At our practice, we know healthy feet makes for a happier life. The goal of this blog is to inform our patients on how to keep their feet and ankles healthy for a lifetime. We’ll provide the tools you need to stay on your feet!

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