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Best Foot Forward

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LEXINGTON Balance. Stability. Mobility. Taken for granted and underappreciated, they are essential to most of our daily activities.

But what’s a common response when someone twists an ankle playing basketball or tripping on a curb? “Walk it off. It’s just a sprain.” That attitude, says Nicholas A. Viens, MD, is a potential problem for the long-term health and strength of feet and ankles.

Viens, who received his medical degree from the Duke University School of Medicine and completed a residency in Orthopedic Surgery at Duke University Medical Center, specializes in orthopedic services and sports medicine focusing on the foot and ankle. His professional interests involve foot and ankle athletic and traumatic injuries, ankle instability, foot and ankle arthritis and treatment of degenerative conditions of the foot and ankle, including total ankle replacement.

After completing his fellowship training in Orthopedic Surgery of the Foot and Ankle at The Steadman Clinic and Steadman Philippon Research Institute in Vail, Colo., Viens joined the Lexington Clinic Orthopedics – Sports Medicine Center in September 2013 as the foot and ankle specialist.

“We know that ankle instability can be a chronic, disabling problem,” Viens says. “We believe ankle instability is one of the most common reasons patients ultimately develop arthritis.

“We don’t like hearing, ‘It’s just a sprain.’ Ankle sprains are significant injuries, and downplaying them really can do a patient a disservice.”

Viens believes that aggressive treatment is essential to the recovery and long-term stability of the ankle. Treatment often begins by immobilizing the ankle in a neutral or dorsiflexed position that allows the ligaments to heal with appropriate tension, followed by functional rehabilitation with physical therapy focusing on balance, gait training, range of motion and strengthening of the peroneal tendons. It is important that patients keep up with their exercises.

“Just saying, ‘Oh, you’ll be fine. Walk it off, take some anti-inflammatories and use an ankle wrap’ … that frequently doesn’t work,” Viens says.

Neither does assuming that every ankle injury is truly an “ankle sprain.” An injury might have all the characteristics of a sprain but actually be something quite different or more complex. Better understanding of the ankle anatomy, the damage that can occur and higher quality diagnostic tools are helping identify the exact type and degree of injury much more quickly and accurately. That allows for more targeted, and hopefully more effective, treatments.

“It can be a little bit of a diagnostic challenge,” Viens says. “Patients are often told that they have an ankle sprain, but that’s sort of a wastebasket term for some. A lot of patients don’t really have a typical ‘sprain’ at all, referring to a tear of the lateral ankle ligaments. They sometimes have a fracture that they were told was a sprain. Sometimes they have a sprain with other problems, such as a cartilage injury or tendon tears – or all of these things together. That’s a common occurrence that I see in my clinic.”

While a course of immobilization and functional rehabilitation are often very effective, there are times when more complex treatments are called for. Patients with more severe cases, a history of frequent injuries or inadequate response to the appropriate rehabilitation can become surgical candidates.

“Sometimes we’re able to tighten up the ligaments that are still there but stretched out, and then start the patient in rehab after protecting the ligament repair for a time, “Viens said.

While the standard repairs are relatively widespread, there are nuances, including a growing trend to focus on anatomic repair. At the Steadman Clinic, Viens was mentored by Dr. Thomas O. Clanton who recently researched the quantitative anatomy of ankle ligaments in an effort to improve surgical techniques for problems such as these. Dr. Viens worked with Clanton and others to study anatomic ligament repair and reconstruction techniques that can be used when the standard repair has failed or is unlikely to be sufficient. For instance, their published research demonstrates that an anatomic tendon graft reconstruction closely approximated biomechanical properties of the normal ligament early on and supported their clinical experiences about the value of such procedures for certain patients.

Irreplaceable? Not Necessarily

Although Viens and others hope better and more aggressive treatments for ankle injuries will help patients avoid arthritic problems down the road, patients with ankle arthritis are another group he enjoys seeing in the office. “Many patients have been told ‘there’s not much they can do’ for ankle arthritis, which simply isn’t the case.” Shoe wear modifications, bracing, medications and injections can all play a very helpful role in caring for patients with ankle arthritis.

When those treatments no long help a patient’s pain, surgical options exist, depending on each specific patient’s problem and goals. “Ankle fusion can be a very effective treatment for a lot of patients,” Viens says. Ankle replacements don’t have as long a history as hip and knee replacements and they are certainly not as common or known about – even among orthopedic surgeons. But the impression that ankle replacements aren’t effective is slowly changing, says Viens.

“Many older ankle replacements had issues,” he says. “So suffice it to say a lot of orthopedic surgeons remember, or have heard stories about, the old one and think, ‘You can’t replace ankles. They don’t do well.’ That’s not necessarily accurate. With the newer generation implants, in the right patient population, ankle replacement can be a great surgery.”

Viens stresses that the relatively short history of the newer replacements means there are no long-term data, such as that which exist for hip and knee replacements, but says mid-term data suggest that ankle replacements are now more viable options than ever before.

That, more than anything, exemplifies the general path of modern foot and ankle care. Orthopedic surgeons are focused more than ever on reducing the severity and long-term impact of foot and ankle injuries. Through improved understanding of anatomy and injuries, advanced diagnostic tools and more aggressive treatments, Viens and his colleagues hope they are making significant strides toward that goal every day.