Center for Orthopedic and Sports Injuries

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Footwear and Achilles Tendon Injuries

Achilles tendon injuries and footwear are related in three ways: correctly fitting footwear can be a major factor in preventing Achilles tendon injuries, recovering from Achilles tendon injuries, and preventing the re-occurrence of Achilles tendon injuries. Unfortunately, the reverse is just as true: incorrect footwear can increase the likelihood of Achilles tendon injuries, delay recovery, and increase the chance of a re-occurrence

An Achilles tendon injury is usually a sign that footwear changes should be made.  Better fitting shoes and sports shoes often make a huge difference to the Achilles tendons.  A good fit means a lot more than just the right shoe size and width; it means the correct arch, cushioning, firmness, height, and heel height.  Keep shoes that fit well, get rid of old worn out shoes and shoes that do not have a good fit.


Achilles Tendon il-shoes

Achilles Tendon Shoe and Sports Shoe Guidelines

In addition to the right shoe size and width for a snug fit, the following factors are of particular importance to the Achilles tendon:

Good Arch Support

Flat feet (feet with low arches) and high arched feet are each associated with a higher likelihood of Achilles tendon injuries.  The shoe’s arch support should match the foot’s arch.  Feet with low, normal, and high arches all benefits from adequate arch support, either built into the shoe or inserted.

Bend at the Balls of the Feet

Shoes should bend at the same place your foot bends.  Your foot bends at the balls of your feet, so your shoes should bend just underneath the balls of your feet.  If the shoes bend anywhere else, they are not providing adequate support for the foot, so can strain the Achilles tendon.  Some shoes, sandals, flip-flops, and moccasins bend everywhere, so do not provide adequate support.

Heel Cushioning

Cushioning is too soft if the heel sinks lower than the front of the foot. Too little cushioning overly strains and stretches the Achilles tendon.  The heel of most running shoes is slightly cushioned, which is fine.

Heel Height

  • Low Heel Height is Bad.  Too little heel height overly strains and stretches the Achilles tendon.  If the heel sinks lower than the forefoot, the heel height is too low.  Racing flats, heelless spikes, flip-flops, moccasins, and shoes with heel heights lower than 1/2″ – 5/8″ (12-15 mm) have too little heel heights.
  • High Heel Height is Bad.  The greater a shoe’s heel height, the less stretching the Achilles tendon does with each stride and the smaller the calf muscles’ range of motion.  Too short a range of motion promotes calf muscle shortening, disproportionate weakness in the parts of the calf muscle that are not stretched with each step, and possibly a general weakening of the calf muscle.  Frequent wearing of high heels reduces the length of the Achilles tendon, which can lead to later injury.   High heels are the worst; some boots are almost as bad.
  • Good Heel Heights.  The heel of most running shoes and most men’s dress shoes is slightly elevated, which is fine.
  • Why High Heels are Bad but Temporary Heel Lifts/Pads are Good.  On the one hand:  long term wearing of high heels or use of heel lifts/pads induces shortening of the gastrocnemius (calf) muscle, reduces its range of motion, and increases Achilles tendon stiffness.  On the other hand: short term temporary use of heel lifts/pads can help Achilles tendon injury recovery by temporarily reducing the range of motion to reduce strain on the Achilles tendon during the initial injury recovery process.  As progress is made with injury recovery, the temporary heel lifts/pads should be reduced and then eliminated to allow full range of motion for the calf muscle and avoid Achilles tendon stiffness.


  • Pronation.  Pronation is the foot’s contact with the ground as you run.  Normal pronation is: the outside of the heel making initial contact, the foot rolling inward a bit (approximately 15%), complete contact with the ground, and then an even push off by the front of the foot.  Most people have normal pronation.  Gait analysis can be tricky, so if it is performed by non-professionals may result in a misdiagnosis of over or under pronation.  If you suspect that you have pronation problems, check with a doctor to be certain
  • Pronation Problems.  Of the people with pronation problem, most over pronate and only a few under pronate.  Typically, people with flat feet (fallen arches) are more likely of over pronate, while those with high arches are more likely to under pronate.
    • Over pronation is also known as excess pronation or hyper-mobile feet.  In over pronation the foot rolls inward more than a bit, and most of the push off is done by the big and second toe.
      • Over pronation can lead to Achilles tendon injuries, but the reverse can also be true: tight or short Achilles tendons can cause over pronation. If the pronation is caused by something other than tight or short Achilles tendons, then a motion control shoe will probably be helpful. If Achilles tendon tightness is causing the pronation, then motion control shoes are probably not appropriate.  Check with a physician to be certain.
      • Anti-pronation (also known as motion control) shoes prevent excessive pronation by being harder to twist than normal.  This decreases the amount of muscle activity around the ankle, subtalar joint (just below the ankle), and Achilles tendon.  The overall anti-pronation quality of a shoe can be tested by holding it with one hand at the widest point and one hand at the heel, and then twisting the shoe as though the ankle were leaning inward. The more difficult it is to twist, the more anti-pronation the shoe.
    • Under pronation is also known as supination.  In under pronation the foot rolls inward less than a bit.  Under pronation can be visible on your running shoes: the outer edges wear out sooner.   Shoes designed for supination appear to be rare.

Barefoot Running and Achlles Tendons

Barefoot Running has generated a lot of interest, but research suggests that it neither increases nor decreases the likelihood of an Achilles tendon injury.  For some people, running barefoot, or using barefoot-like shoes, is the correct footwear.

Achilles Tendon Braces, Casts, Etc.

A temporary brace may be required to immobilize the foot after a severe Achilles tendon injury, such as an Achilles tendon rupture. The braces used to steady the Achilles tendon, range from wrap devices that provide a little support to immobilization devices that prevent the Achilles tendon from flexing or pointing.  Some sports shoes, such as hockey skates and ski boots, have some of the immobilisation characteristics of braces, which may help athletes in those sports avoid, or recover faster from, Achilles tendon injury.  Consult a doctor prior to considering any brace or cast.

Achilles Tendon Orthotic Guidelines

Some people have such unique feet or biomechanics, that custom build individualized shoes (orthotics) are required.  Consult with a doctor to be certain.  Orthotics can be both very beneficial and very expensive.  Orthotics should be full length (rather than ending at the arch), and made of flexible (rather than hard material). Full length is important because 70% of the time that a foot is on the ground during a stride, the weight is on the forefoot. People with Achilles tendon concerns should discuss orthotic features relating to: cushioning, heel height, degree of arch support, and anti-pronation with their physician. Working with a doctor is important because orthotics often require expert readjustment before they are completely effective.





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Shoulder dislocation

The shoulder is the most mobile and least stable joint in the body. Its ability to move in many directions makes it prone to dislocation, and in younger people, sports injuries are a common reason. Throwing or reaching for a ball puts the shoulder at risk because there is little that stabilizes the shoulder joint.

Shoulder dislocation facts

  • The shoulder joints are the most commonly dislocated joints in the body.
  • Approximately 25% of shoulder dislocations have associated fractures.
  • Closed reduction, without the need for surgery, is the most common initial treatment. Medications may be required for sedation to help relax the muscles surrounding the shoulder and facilitate the reduction.
  • Immobilization with a sling is important to decrease the risk of a repeat dislocation. First dislocations are immobilized in an external rotation position. Recurrent dislocations may be immobilized in a regular sling.
  • Early follow-up is important to decide when to begin allowing shoulder motion.
  • Total time of immobilization varies, and balance needs to exist between shoulder stability and loss of motion and function from prolonged immobilization.
  • Recurrent shoulder dislocations may be an indication for surgery to repair and tighten torn tissues.
  • Uncomplicated rehabilitation and healing will allow return to normal function in 12-16 weeks.


What is dislocation of the shoulder? What causes a shoulder dislocation?

The shoulder joint is the most mobile joint in the body and allows the arm to move in many directions. This ability to move makes the joint inherently unstable and also makes the shoulder the most often dislocated joint in the body.

In the shoulder joint, the head of the humerus (upper arm bone) sits in the glenoid fossa, an extension of the scapula, or shoulder blade. Because the glenoid fossa (fossa = shallow depression) is so shallow, other structures within and surrounding the shoulder joint are needed to maintain its stability. Within the joint, the labrum (a fibrous ring of cartilage) extends from the glenoid fossa and provides a deeper receptacle for the humeral head. The capsule tissue that surrounds the joint also helps maintain stability. The rotator cuff muscles and the tendons that move the shoulder provide a significant amount of protection and stability for the shoulder joint.

Dislocations of the shoulder occur when the head of the humerus is forcibly removed from its socket in the glenoid fossa. It’s possible to dislocate the shoulder in many different directions, and a dislocated shoulder is described by the location where the humeral head ends up after it has been dislocated. Ninety-five percent or more of shoulder dislocations are anterior dislocations, meaning that the humeral head has been moved to a position in front of the joint. Posterior dislocations are those in which the humeral head has moved backward toward the shoulder blade. Other rare types of dislocations include luxatio erecta, an inferior dislocation below the joint, and intrathoracic, in which the humeral head gets stuck between the ribs.

Picture of the shoulder joint

Picture of the shoulder joint

Dislocations in younger people tend to arise from trauma and are often associated with sports (football, basketball, and volleyball) or falls. Older patients are prone to dislocations because of gradual weakening of the ligaments and cartilage that supports the shoulder. Even in these cases, however, there still needs to be some force applied to the shoulder joint to make it dislocate.

Anterior dislocations often occur when the shoulder is in a vulnerable position. A common example is when the arm is held over the head with the elbow bent, and a force is applied that pushes the elbow backward and levers the humeral head out of the glenoid fossa. This scenario can occur with throwing a ball or hitting a volleyball. Anterior dislocations also occur during falls on an outstretched hand. An anterior dislocation involves external rotation of the shoulder; that is, the shoulder rotates away from the body.

Posterior dislocations are uncommon and are often associated with specific injuries like lightning strikes, electrical injuries, and seizures. On occasion, this type of dislocation can occur with minimal injury in the elderly, and because X-rays may not easily show a posterior dislocation, the diagnosis is often missed should the patient present for evaluation of shoulder pain and/or decreased range of motion of the shoulder joint.

A shoulder separation is a totally different injury and does not involve the gleno-humeral shoulder joint. Instead, the acromio-clavicular joint is involved. This is where the clavicle (collarbone) and acromion (part of the shoulder blade) come together in the front of the shoulder. A direct blow laterally, often from falling directly onto the outside part of the shoulder, damages the joint, the cartilage inside, and the numerous ligaments that maintain stability. While there may be pain and swelling at the end of the collarbone, the patient usually is able to somewhat move the shoulder itself.

What are risk factors for a dislocated shoulder?

Shoulder dislocations tend to occur in two age groups:

  • Most frequently, the shoulder dislocates in younger adults due to a sporting injury.
  • The second most common age group affected is the elderly patient who falls. As the body ages, the collagen fibers that are the building blocks of tendons, cartilage, and the labrum begin to break down and lose the tight-knit appearance that provides strength to the structures. With age, a reduced amount of trauma (usually a fall on an outstretched hand) is required to dislocate the shoulder.

What types of doctors treat a dislocated shoulder?

Patients with shoulder dislocations are often treated in an emergency department. Emergency specialists are trained to diagnose a shoulder dislocation and to reduce the joint. They are also trained in different methods of sedation.

Orthopedic doctors often provide follow-up care for patients with shoulder dislocations. They are the providers who would also decide whether surgery is required, either for the acute injury or after follow-up to stabilize the shoulder and prevent further dislocations.

Primary-care providers, sports-medicine physicians, certified athletic trainers, and physical therapists all may have a role in caring for the patient during their initial treatment and recovery.


What are the symptoms and signs of a dislocated shoulder?

Dislocations hurt. When the humerus is forcibly pulled out of the socket, cartilage, muscle, and other tissues are stretched and torn. Shoulder dislocations present with significant pain, and the patient will often refuse to move the arm in any direction. The muscles that surround the shoulder joint tend to go into spasm, making any movements very painful. Usually, with anterior dislocations, the arm is held slightly away from the body, and the patient tries to relieve the pain by supporting the weight of the injured arm with the other hand. Often, the shoulder appears squared off since the humeral head has been moved out its normal place in the glenoid fossa. Sometimes, it may be seen or felt as a bulge in front of the shoulder joint.

As with other bony injuries, the pain may provoke systemic symptoms of nausea and vomiting, sweating, lightheadedness, and weakness. These occur because of the stimulation of the vagus nerve, which blocks the adrenaline response in the body. Occasionally, this may cause the patient to faint or pass out (vasovagal syncope).


How do physicians diagnose dislocated shoulders?

When a patient presents with a shoulder dislocation, pain control and joint relocation are primary considerations. However, it is still important for the health-care professional to take a careful history to understand the mechanism of injury and the circumstances surrounding it. It will also be important to know if this is the first shoulder dislocation or whether the joint has been previously injured. In addition, questions may be asked about medications, allergies, time of the last meal, and past medical history to prepare for a potential anesthetic administration to help relocate, or reduce, the shoulder dislocation.

Physical examination of the shoulder will begin with inspection. In an anterior dislocation, the shoulder appears to look “squared off,” with a loss of the normal rounded appearance of the shoulder caused by the deltoid muscle. In thinner patients, the humeral head may be palpated or felt in front of the joint. Posterior dislocations may be difficult to assess just by looking at the shoulder joint.

Pain and muscle spasm accompany dislocated joints, and a shoulder dislocation is no different. When the joint is disrupted, the muscles surrounding it are stretched and go into spasm. The patient will experience significant pain and will often resist the smallest movement of any part of the arm. The health-care professional may feel for pulses in the wrist and elbow, as well as test for sensation to assess the blood and nerve supply to the arm. One place where sensation is tested is the lateral or outside part of the shoulder, also called the deltoid badge area. Numbness may signal damage to the arteries and nerves when the shoulder is dislocated. The brachial plexus, the axillary artery, and axillary nerve are located in the armpit and are relatively unprotected.

Plain X-rays may be taken to confirm the diagnosis of shoulder dislocation and to make certain there are no broken bones associated with the dislocation. Two common fractures are the Hill-Sachs deformity, a compression fracture of the humeral head, and a Bankart lesion, a chip fracture of the glenoid fossa. While these may be present, they do not hinder the relocation of the shoulder. Other fractures of the humerus and scapula may make shoulder reduction more difficult.

Since the body is 3-D and X-rays are 2-D, at least two X-rays are taken to be able to accurately assess where the humeral head is located — anteriorly (in front) or posteriorly (behind) in relationship to the glenoid. Extra X-ray views also better assess the bones, looking for fracture.

In certain circumstances, (often on the athletic field) if a health-care professional is present at the time of injury, an attempt may be made to reduce or relocate the shoulder immediately without X-rays being taken. Using manipulation described below, before the muscles have a chance to go into spasm, it is possible to relocate the shoulder. Imaging of the injured shoulder (X-ray or MRI) would then be considered at a later time.


What are home remedies for a dislocated shoulder?

When a shoulder injury occurs and there is concern about a fracture or dislocation, the patient likely needs to seek medical attention urgently.

Initial first aid at the scene may include

  • immobilizing the shoulder, perhaps by placing it into a sling,
  • applying ice packs to the affected area, and
  • not allowing the patient to have anything to eat or drink, in case sedation is required to reduce the shoulder. Vomiting may occur as a side effect of some of the medications used for sedation, and it is best to have an empty stomach to prevent complications.

It is also important to make certain that no other injury has occurred. If needed, it may be appropriate to call 911 and activate emergency medical services.

Some patients who have had previous shoulder dislocations and have unstable joints may be able to reduce their shoulder spontaneously when they feel it pop out of the joint.


What is the treatment for a dislocated shoulder?

The purpose of the initial treatment of a dislocated shoulder is to reduce the dislocation and return the humeral head to its normal place in the glenoid fossa. There are a variety of methods that may be used to achieve this goal. The decision as to which one to use depends upon the patient, the situation, and the experience of the clinician performing the reduction. Regardless of the technique used, the hope is to be able to efficiently reduce the dislocation with a minimum of anesthesia required. Most attempts at closed reductions are successful; that is, no incision or cut is made into the joint to assist in returning the bones to their normal position. The term “open reduction” refers to performing surgery to repair the dislocation. Methods for reduction of a shoulder dislocation are described below.

Scapular manipulation

The patient may be sitting up or lying prone. The health-care professional attempts to rotate the shoulder blade, dislodging the humeral head, and allowing spontaneous relocation. An assistant may be needed to help stabilize the arm.

External rotation (Hennepin maneuver)

With the patient lying flat or sitting up, the health-care professional flexes the elbow to 90 degrees and gradually rotates the shoulder outward (external rotation). Muscle spasm may be able to be overcome after five to 10 minutes of gentle pushing, allowing the shoulder to spontaneously relocate. The Milch technique adds gentle lifting of the arm above the head to achieve reduction.

Traction-counter traction

With the patient lying flat, a sheet is looped around the armpit. While the health-care professional pulls down on the arm, an assistant, located at the head of the bed, pulls on the sheet to apply counter traction. As the muscles relax, the humeral head is able to return to its normal position.

Stimson technique

With the patient lying prone (on their stomach), the injured arm is draped over the side of the cot and a weight is attached to it to gradually overcome muscle spasm and allow the shoulder joint to reduce.

Open reduction

In rare circumstances, the shoulder cannot be reduced using closed reduction techniques because a tendon, ligament, or piece of broken bone gets caught in the joint, preventing return of the humeral head into the glenoid. When closed reduction fails, it may be necessary for an orthopedic surgeon to perform an operation or open reduction.

Procedural medications

Depending upon the amount of pain and spasm present, medication may be needed to sedate and comfort the patient prior to and during the reduction procedure. These medications may also be given to relax the muscles to aid in the joint reduction.

Patients receiving intravenous medications need to have their vital signs monitored before, during, and after the shoulder relocation just as if they were in the operating room. In some circumstances (for example a patient with underlying lung or heart illnesses), the presence of an anesthesiologist or nurse anesthetist may be appropriate during the relocation. Health-care professionals use intravenous sedatives, narcotics, and muscle relaxants in combination for analgesia (to relieve pain), relax muscles, and help promote amnesia of the events. Common pain medications used include morphine, hydromorphone (Dilaudid), and fentanyl. Physicians may use midazolam (Versed), diazepam (Valium), or lorazepam (Ativan) as a muscle relaxant.

Instead of using narcotics, it is becoming more common to sedate the patient with anesthetics like ketamine or propofol to allow shoulder reduction.

Some health-care professionals may consider using intra-articular (intra = within + articular = joint) injections of lidocaine (Xylocaine) into the shoulder joint as local anesthesia to try to reduce the shoulder, instead of using intravenous sedation.


What happens after reduction of a shoulder dislocation?


Once the shoulder has been reduced, the health-care professional will want to reexamine the arm and make certain that no nerve or artery damage occurred during the reduction procedure. A post reduction X-ray is recommended to reassess the bones and insure that the shoulder is properly relocated.


Significant damage occurs to the joint with a shoulder dislocation. The labrum and joint capsule have to tear, and there may be associated injuries to the rotator cuff muscles. These are the structures that lend stability to the shoulder joint, and since they are injured, the shoulder is at great risk to dislocate again.

A sling or shoulder immobilizer may be used as a reminder not to use the arm and allow the muscles that surround the joint to relax and not have to support the bones against gravity.

For a patient who sustains their first shoulder dislocation, the clinician will often immobilize the shoulder in mild external rotation, meaning that the arm is placed in a special sling that supports the arm away from the body.

The physician may place repeated dislocations in a regular sling or immobilizer for comfort and support.

The length of time a sling is worn depends upon the individual patient. A balance must be reached between immobilizing the shoulder to prevent recurrent dislocation and losing range of motion if the shoulder has been kept still for too long.

Pain control

Once a clinician reduces a shoulder dislocation, much of the pain is resolved. Physicians may recommend ibuprofen (Advil, Motrin) as an anti-inflammatory medication and prescribe narcotic pain medications like codeine or hydrocodone for the short term.

Ice is an important component of pain control, helping to decrease the swelling associated with the injury.

Special situations/recurrent dislocations

In certain situations, it’s possible to reduce dislocations immediately. This is especially true in the sports medicine arena, where a health-care professional may reduce the dislocation on the field of play. This is a reasonable treatment alternative because the care provider was able to see the injury occur, examine the patient and come to the diagnosis, and then reduce the injury before muscles spasm sets in.

Many patients experience shoulder subluxation or partial dislocation. These are patients who have had previous dislocations and are aware that their shoulder has dislocated again and then spontaneously reduced. They may choose not to seek urgent or emergent care, but this situation should not be ignored. Once a shoulder dislocates, it becomes unstable and more prone to future dislocation and injury.


What is appropriate follow-up following a shoulder dislocation? How long is the recovery time for a dislocated shoulder?

Follow-up with a primary-care provider or orthopedic surgeon is advised after a shoulder dislocation. The decision as to when to begin range-of-motion exercises of the shoulder has to be individualized for each patient. In shoulder dislocations not associated with a fracture or other associated injury, younger patients may be kept immobilized for two to three weeks. In the elderly, this time frame may shrink to only a week because the risk of a frozen shoulder (a joint that becomes totally immobile) is markedly increased.

It may be necessary to get X-rays or a magnetic resonance imaging (MRI), depending upon the patient and the situation, to evaluate the extent of potential injury to the joint, including the bones, labrum, and cartilage.

Some patients may be candidates for surgery to prevent future dislocations. The decision depends upon the extent of damage to the joint and the type of activities in which the patient participates. This decision is individualized for each patient.

Physical therapy is an important component to return the shoulder joint to normal function. Therapy may include exercises to strengthen the muscles that surround the shoulder and to maintain range of motion of the shoulder joint.

The total rehabilitation and recovery time from a shoulder dislocation is about 12-16 weeks.


What are potential complications of a shoulder dislocation?

Fractures of the bones that make up the shoulder joint are a possible complication of shoulder dislocations. Up to 25% of patients will have an associated fracture. Not included in these numbers are the Hill-Sachs deformity that may occur in up to 75% of anterior shoulder dislocations.

Nerve damage is a potential complication. Most often, the circumflex axillary nerve is injured. The first sign of injury is numbness in a small patch distribution on the outside of the upper arm. This nerve often recovers spontaneously in a few weeks, but this is an important complication for the health-care professional to recognize since damage to the nerve may cause weakness of the deltoid muscle that helps move the shoulder.

Older patients who dislocate their shoulder may have rotator cuff injuries. The diagnosis may be difficult to make initially, and often the health-care professional will make the diagnosis during a follow-up visit.

Rare complications of shoulder dislocations include tearing of the axillary artery, the main artery that supplies blood to the arm and brachial plexus injury, in which the nerve bundle that attaches the arm nerves to the spinal cord is damaged. Both of these structures are located in the axilla or armpit and are potentially damaged by the initial dislocation or by attempts to reduce the dislocation.


What is the prognosis of a shoulder dislocation?

The goal of shoulder dislocation treatment is to reduce the shoulder and then to strengthen the tissues surrounding the joint to prevent recurrent dislocations. Age is the major factor as to whether there will be another dislocation. The younger the patient, the more likely that another dislocation will occur.

  • If the first dislocation happens before age 20, there may be up to a 95% chance that there will be a second dislocation in the future.
  • With an age younger than 40, the risk of future dislocation is less than 50%.
  • With an age older than 40, this risk drops to 10%.


Is it possible to prevent a dislocated shoulder?

Accidents and injuries happen, and the first dislocated shoulder usually cannot be prevented. The risk of recurrent dislocations may be decreased by following the physical therapy care plan after that first dislocation to strengthen and stabilize the shoulder. This includes wearing the sling for the appropriate amount of time, committing to the rehabilitation program, and keeping the shoulder muscles strong.




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Ultrasound in the diagnosis of clinical orthopedics: The orthopedic stethoscope

Ultrasonography has advantages over other imaging modalities in terms of availability and comfort, safety, and diagnostic potential. Operating costs are low compared with both computed tomography (CT) and magnetic resonance imaging (MRI). The portable equipment is accessible at locations distant from medical centers. Importantly, ultrasonography is performed while patients lie in a comfortable position, without pain or claustrophobia.


Ultrasonography is a totally safe noninvasive imaging technique. In contrast to computed tomography (CT) and X-rays, it does not emit ionizing radiation. Unlike magnetic resonance imaging (MRI), it is safe for all patients, including those with cardiac pacemakers and metal implants, without any contraindications.

With its outstanding diagnostic benefits, notably high resolution and capability of real time assessment[1,2], orthopedic ultrasound is often referred to as the “orthopedic surgeon’s stethoscope”. Its high resolution enables detection of tendon tears, tiny calcifications, and foreign bodies. Calcification in soft tissue and destructive and reparative hypertrophic changes on bone surfaces are more readily apparent, and at an earlier stage, than with plain X-rays, CT or MRI. Ultrasonography thus enhances early detection of pathologies.

The real time capability of musculoskeletal sonography enables dynamic assessment of joint and tendon movements and stability[3], and detection of fracture union and reunion, structural abnormalities, infection, ligamentous injury[4], nerve compression and mechanical impingement between orthopedic hardware and soft tissue structures. Beyond diagnostics, real time capability is useful for guiding therapeutic interventions, such as cyst aspiration. The fact that ultrasound examinations may be easily repeated as often as necessary, makes this modality useful for monitoring treatment.

Due to its flexibility and precision in the selection of the point of examination and in the field of vision, musculoskeletal ultrasonography has spatial, as well as temporal benefits. The possibility of placing the sonographic probe at the point of maximal tenderness increases the likelihood of detecting abnormalities, and ensures clinical relevance of the examination. Sonography affords comparisons of targeted findings with those of the contralateral side, and also enables under “vision” biopsy or joint aspiration.

Of the many indications for musculoskeletal ultrasonography, the evaluation of soft tissue pathology is particularly common[5]. In addition, ultrasonography is useful for the detection of fluid collection, and for visualization of cartilage and bone surfaces. Color or power Doppler provides important physiological information, including that relating to the vascular system. The capability of ultrasonography in delineating structures according to their echo textures results in excellent pictorial representation. This imaging principle is based on physical changes in composition, as compared to imaging with MRI, which is based on changes in chemical composition.

This article reviews the contribution of sonography to the evaluation of the musculoskeletal system.


Ultrasonography is preferable to radiography for the early detection of calcification in soft tissue in the neck region. In the investigation of suspected soft tissue tumors, such as in acute swelling of sterno-cleido mastoideus, and in cases of congenital muscular torticollis, ultrasound can often distinguish between a true tumor mass and a hematoma or muscle rupture[6].

The appearance of an echogenic structure with acoustic shadowing in the region of tenderness may indicate a cervical rib[7] (Figures (Figures11 and and2).2). Fracture of the clavicle in the newborn[8] and congenital pseudoarthrosis of the clavicle can also be diagnosed with ultrasound[9].

Figure 1

Transverse imaging of the right neck region. Note the echogenic structure with acoustic shadow.

Figure 2

X-ray corresponding to Figure Figure1.1. Note the cervical rib.


At our medical center, the shoulder is one of the bodily areas for which musculoskeletal sonography is most requested[10]. Age-related degenerative changes and overuse syndrome with degenerative tears leads many patients to seek medical treatment for painful shoulder.

Suspicion of rotator cuff pathology is the most important indication for shoulder sonography. Musculoskeletal ultrasound enables early detection of changes in tendons, in bursae-rotator cuff and in cartilage, thus leading to adequate treatment. Tears can be seen, located, and measured[1113] (Figures (Figures3,3, ,44 and and5).5). Their full anatomical extent can be assessed. Calcification is more visible with ultrasound than with MRI (Figure (Figure6)6) and the capability of precise location enables assessment of treatment. Sonographic palpation and comparison with the other shoulder is easily performed.

Figure 3

Partial thickness tear of supraspinatus. Right and left shoulder. Note the narrowing of the tendon. Transverse sonogram. A 70-year old male who presents with bilateral shoulder pain and has a painful arc at clinical examination.

Figure 4

Transverse sonogram, supraspinatus right and left shoulder. Anechoic defect. Partial thickness tear, right. Left: Normal supraspinatus.

Figure 5

Massive full-thickness tear of supraspinatus. Left shoulder. Non visualization of tendon. This 81-year old female has severe shoulder pain that increases at night.

Figure 6

Ultrasound examination of calcification. A: Calcific tendinitis. Calcification in the supraspinatus tendon, longitudinal view. Note: Acoustic shadow behind the calcification. A 29-year old woman presents with a short history (3 d) of incapacitating shoulder

The presence of fluid around the biceps tendon or subdeltoid bursa may indicate a bursitis infection or tear (Figure (Figure7).7). Lesions associated with rotator cuff disease, such as long biceps tenosynovitis and sub-acromial deltoid bursitis, can be visualized by ultrasound.

Figure 7

Ultrasound examination of biceps tendon. A: Bicipital tendinitis. Transverse sonogram. The tendon is surrounded by fluid. This 33-year old woman presents with pain and local tenderness in the area of the bicipital groove; B: Longitudinal view with fluid

Ultrasound can detect fractures in the head and shaft of the humerus, especially the greater tuberosity (Figure (Figure8).8). Greater tuberosity fractures are characterized by sonography as cortical discontinuity, and may appear as a cortical gap or step-off (double line)[14]. They should be included in the differential diagnosis of every shoulder sonography examination, even in the absence of a clear history of trauma. Osteolytic lesions of the proximal humerus can also be detected in ultrasound (Figure (Figure99).

Figure 8

Fracture of greater tuberosity, left. Note the discontinuity of the bone. The right shoulder has normal appearance. Transverse sonogram.

Figure 9

Longitudinal sonogram. Swelling of soft tissue with severe irregularity of the cortex right humerus. Left biceps normal. X-ray of the right arm demonstrates the osteolytic lesion of the right humerus. A 75-year old man presents with swelling of the right

Since conventional radiography does not adequately diagnose symptoms of shoulder pain, a sonographic examination is recommended as part of the early diagnostic protocol[15,16]. Ultrasound is useful in detecting pathologies in the acromioclavicular joint, such as acromioclavicular joint arthritis and dislocation (Figure (Figure1010)[17], as well as septic arthritis of the sternoclavicular[18] and acromioclavicular joints[19].

Figure 10

Ultrasound examination of acromioclavicular joint. A: Left shoulder – A-C arthritis. Note the irregularity and narrowing of the acromioclavicular joint. Erosive changes at the articular surface of the joint. A 65-year old man with a long history of pain

The effectiveness of sonography has been demonstrated for the evaluation and diagnosis of Hill-Sachs lesions, which frequently follow anterior gleno-humeral dislocation of the shoulder[20]. Moreover, ultrasound can be used to assess sonographic images in hemiplegic shoulders of stroke patients[21].

Dynamic sonography enables direct visualization of the relationships between the acromion, humeral head, and intervening soft tissues during active shoulder motion, and can provide information on the potential intrinsic and extrinsic causes of shoulder impingement syndrome[22]. In cases of frozen shoulder, abnormal gliding and rotational movement are apparent, with the entire soft tissue moving as a single unit (deltoid, rotator cuff. and humeral head). The capability of ultrasound in detecting a full thickness tear is impressive. Drakeford et al[23] reported sensitivity of 92% and specificity of 95%. Ultrasound can also be used to detect tears of pectoral muscle (Figure (Figure1111).

Figure 11

Longitudinal sonogram. Demonstrates a large pectoralis tear left. A 23-year old soldier felt a pop when he was lifting a wounded friend.


Ultrasound is useful for examining proximal muscles acting on the shoulder and elbow. Muscle compartments are divided into flexor and extensor groups. Ultrasound can detect common tendon injuries, such as “tennis” and “golfer” elbow, in which swelling, thickening, and accumulation of fluid is apparent[24,25]. Musculoskeletal ultrasound is an effective imaging technique for the diagnosis of olecranon bursitis, especially its early manifestation. Sensitive detection of small fluid collection is possible (Figure (Figure12),12), as well as differentiation between soft tissue and bone lesion, and between septic and non septic elbow. Ultrasound examination allows detection of effusions, synovial proliferation, calcification, loose bodies, rheumatoid nodules, gout tophi, and septic processes (Figure (Figure1313)[26,27], as well as distal biceps tendon lesions (Figure (Figure1414).

Figure 12

Longitudinal sonogram, right elbow. Small amount of fluid posterior aspect. No erosive changes in the bone.

Figure 13

Longitudinal view, left elbow. Swelling and fluid of soft tissue. Reactive elbow joint effusion, corresponding to bursitis. Right elbow normal appearance. This 60-year old man had pain and swelling over the dorsal aspect of the left elbow, olecranon bursitis.

Figure 14

Right distal biceps tendon tear in the area of insertion. Proximal biceps look normal. This 62-year old man felt a severe sudden sharp pain in the distal humerus region after lifting a heavy suitcase.


Ultrasound examination of the flexor and extensor tendons and ligaments of the finger may reveal such pathologies as tendinopathy, tenosynovitis, ruptures, and neoplasia (Figure (Figure1515 ). Cystic or solid swelling palpable tumors and occult ganglion can be observed[2830]. Foreign bodies often remain undetected in penetrating wounds and lacerations, pathologies frequently treated in the emergency room. Sonography is useful in the localization and removal of soft tissue foreign bodies[31,32], and in the detection of greenstick fractures of the distal radius and ulna[33].

Figure 15

Ultrasound examination of flexor tendons synovitis. A: Left hand flexor tendon synovitis. Note the fluid around the tendon. No tear is demonstrated; B: Left hand flexor tendon synovitis. Note the hyper-vascularity with the vascular inflammation signs;

The sonographic examination of a patient with suspected traumatic Mallet finger is important for the differentiation between traumatic Mallet finger and flexion deformity due to rheumatoid arthritis or osteoarthritis[34].


Ultrasound can be helpful in differentiating synovial and teno-synovial pathology, and in examining pathological and morphostructural changes of the median nerve in carpal tunnel syndrome.


While, clinical examination of the knee joint is relatively easy, very small effusions and synovitic proliferations may be missed. Ultrasound can detect these, as well as fluid in the knee and in the area of the tendons (Figure (Figure16).16). Further, ultrasound is useful for assessing ligaments, and for diagnosing pathologies relating to anterior knee pain[3537].

Figure 16

Ultrasound examination of knee quadriceps. A: Left knee longitudinal view. Transducer on the anterior aspect of the knee. Note the fluid in the suprapatellar recess. Normal quadriceps tendon with its insertion to the patella; B: Similar transducer position

Dynamic sonographic examination, with stress tests (Figure (Figure17),17), can demonstrate instability and meniscal pathology (Figure (Figure1818)[38]. Synovial cysts, medial collateral ligaments, lateral collateral ligaments and tears of tendon can be assessed. Ultrasound is also used in diagnosis of patellar and quadriceps tears (Figure (Figure1919 ).

Figure 17

Left knee medial aspect. Ultrasound demonstrates medial collateral ligament. Joint space is normal. Neutral position. Joint space measures 0.656 cm. The same area under valgus stress, demonstrating joint space of 0.947 cm, pointing to medial collateral

Figure 18

Ultrasound examination of meniscus. A: Left knee medial aspect, longitudinal sonogram. Medial meniscus anterior horn. Note the triangle-shaped hyperechoic structure of the normal medial meniscus; B: Medial meniscus lesion. Note the cleft and irregularity

Figure 19

Ultrasound examination of patellar and quadriceps tears. A: Longitudinal ultrasound image obtained in the midline, demonstrating the anterior knee, quadriceps tendon with its insertion to the patella, suprapatellar recess, and the patella. No effusion

Sonographic examination of the knee has been proposed as a simple and reliable method for diagnosis of Osgood-Schlatter (Figure (Figure20)20) disease[39] and patella bipartite[40].

Figure 20

Right knee Osgood-Schlatter disease. Note the severe irregularity of tibial tuberosity. This 14-year old football player has severe pain and swelling of the tibial tuberosity,

In medial collateral ligament (MCL) injury, the combination of sonographic findings with those from a real time sonography valgus stress test can support the clinical diagnosis of an MCL stretch or tear, and pinpoint the exact location of the isolated MCL injury, thus facilitating proper treatment[41].

Ultrasound can suggest an early diagnosis of osteoarthritis (Figure (Figure21)21) by demonstrating joint effusion, synovial thickening, bony changes, patello femoral changes, articular cartilage changes, peripheral tears and lesions of the tendon, and meniscal pathologies, such as meniscal cysts, and Baker cyst[42]. Pathologies can be detected by ultrasound at a stage in which plain radiographs still appear normal. Muscle and ligament pathology (Figures (Figures22,22, ,2323 and and24),24), and tumors of the tibial tuberosity can be diagnosed[43], as well as fractures of the patella (Figure (Figure2525)[44].

Figure 21

Osteoarthritis medial aspect, right knee. Medial joint space narrowing with osteophyte formation and thickening of the medial collateral ligament, measured 0.355 cm. Lateral joint with normal appearance measured 0.538 cm. A 75-year old woman with typical

Figure 22

Longitudinal sonogram of the thigh. A young basketball player presented with pain over the anterior aspect of the distal right femur. Note the irregularity with partial tear of the muscle. Left thigh: Normal appearance.

Figure 23

Ultrasound examination of patellar tendon. A: Longitudinal view. Anterior aspect. Ultrasound image shows the patellar tendon from its origin in the patella into the tibial tuberosity left knee; B: Infrapatellar tendinitis. Note fluid accumulation deep

Figure 24

Ultrasound examination of knee cartilage. A: Left knee. Flexion position. Anterior transverse view. Note trochlear cartilage of femur. The hyaline cartilage is a hypoechoic homogenous structure with sharp margins, overlying the bright hyperechoic line

Figure 25

Longitudinal view, right patella with fracture. Left patella normal.


Ultrasound can provide a dynamic assessment of muscle tear, or of an intermittent muscle hernia or tendon subluxation. As with other soft tissue lesions, ultrasonography is useful for the evaluation of underlying pathologies in patients presenting with achillodynia and ankle pain. The Achilles tendon is the tendon most commonly evaluated in the leg and may be associated with a wide range of pathologies, including tendonosis, tears, calcification, and inflammations (Figure (Figure2626)[45,46]. Haglund deformity may be related to Achilles tendon pathology. The dynamic nature of the ultrasound examination enables tendon movement and visualization from the origin to the insertion of a tendon, as is needed in the evaluation of the Achilles tendon. Diseases of the Achilles tendon include a broad spectrum of pathologies ranging from paratendonitis to complete tendon ruptures. Tendonitis appears as fusiform swelling with hypoechogenicity and, tears and gaps can be measured. Ultrasound examination can detect shrapnel lesions, and contribute to the planning of surgical correction of ruptures in the Achilles tendon[47].

Figure 26

Ultrasound examination of achilles tendon. A: Longitudinal view, left ankle posterior aspect. Complete tear of Achilles tendon with retraction. A 54-year old man felt a sudden sharp pain in the left Achilles tendon while running. Physical examination

Ultrasound is also useful for diagnosing such pathologies of the ankle as tendon and ligament ruptures, and inflammation of the tendon sheath (Figure (Figure2727)[4851]. Ankle sprain can demonstrate partial or complete tears. The most common torn ankle ligament is the anterior talofibular. Ligaments may appear hypoechoic with fluid, or discontinuous. Similarly, ultrasound allows the appearance of the calcaneo fibular and deltoid ligaments to be seen.

Figure 27

Ultrasound examination of tibialis anterior tendon. A: Anterior longitudinal view, ankle. Tibiotalar joint with normal appearance of tibialis anterior tendon; B: Left ankle, longitudinal view. Tear of tibialis anterior tendon. This 68-year old male suffered

The sonographic appearance of rough fragmentation with saw-teeth appearance is a specific sign which has demonstrated effectiveness in the evaluation of Sever’s disease[52].

Sonography can be effective in evaluating cases of tibial stress fractures[53]. Routine ultrasound examination includes the anterior tibial, posterior tibial, peroneal and Achilles tendon and the tibiotalar joint is evaluated for effusion or loose bodies.

Tendinitis is visualized in ultrasound as hypoechogenicity of the tendon with increased interfibrillar distance. Retro-calcaneal bursitis and cellulitis can be seen (Figures (Figures2828 and and29).29). Partial tears indicate intrasubstance defects extending toward one surface of the tendon. Tendon discontinuity may indicate the proximal and distal stumps of the tendon. Insertion tendinopathy is seen as a hypoechoic enlargement of the tendon with fluid in the area inserted in the bone. Ultrasound is helpful in evaluating any syndesmosis, as is needed in post traumatic anterior ankle pain and in detecting foreign bodies in the ankle (Figure (Figure3030).


Figure 28

Left ankle retro-calcaneal bursitis. Longitudinal view. Normal Achilles tendon. Note the large amount of fluid in the retro-calcaneal bursa.

Figure 29

Longitudinal view, distal right leg. Swelling of soft tissue with fluid. Note increased echogenicity and thickening of the subcutaneous fat in the inflamed region.

Figure 30

Ultrasound examination of left ankle. A: Longitudinal sonogram, left ankle, demonstrates a wooden foreign body; B: Transverse view, left ankle. Note the hypervascularity in the inflamed area; C: Corresponding X-ray of left ankle. Note the swelling on

Ultrasound is useful in the assessment of foot lesions such as plantar fasciitis, plantar fascial tears, fibromatosis, morton neuroma, Jones fractures, and fractures of sesamoids and the 5th metatarsal bone.


Only rarely can a small effusion of the hip joint be detected by clinical examination. Thus, ultrasound, with its effectiveness in detecting effusion and synovitis, is generally used in the early assessment of hip pathology. Detection of an effusion allows direct aspiration to decrease the pressure and to evaluate the fluid for possible septic arthritis. Prompt aspiration in suspected cases of septic arthritis obviates the need for lengthy workups, and guides further treatment. Further, ultrasound can be used to visualize fragmentation of the femoral head in “Perthes disease”, and to detect a slipped capital femoral epiphysis.


Clinical assessment of the newborn hip is routinely performed in the first days of life. Static and dynamic scanning by ultrasound enhances the rate of early detection of hip abnormalities[60]. Ultrasound follow-up is part of the routine management of hip dysplasia.


Assessment of the echogenic surface of bone and the acoustic shadow behind it can reveal abnormalities. Although sonography is not generally the examination of choice for the diagnosis of bone pathology, it should not be ignored, since significant pathologies, including fractures, bone erosions and lytic lesions, are occasionally detected.

Ultrasound can be used to detect subperiosteal collections of fluid in early osteomyelitis, as well as fractures[61], osteophyte, and bone tumors with bone damage. It provides excellent anatomical detail of the cortical surface of superficial bone. In cases of exostosis, it may be used to measure the thickness of the cartilage cap. The use of ultrasound for the diagnosis of fractures is gaining more and more interest. When ultrasound evaluation is targeted and combined with an orthopedic examination of the pathological area, precise demonstration of cortical disruption, soft tissue damage, and hematoma are possible. Knowledge of bone anatomy is essential for complete ultrasound evaluation of the musculoskeletal system.

Muscle pathologies such as rupture, calcification, myositis ossificans, hemorrhage can be also assessed by ultrasound.


During recent years, musculoskeletal ultrasound has become recognized as an effective imaging technique for the diagnosis and follow-up of patients with rheumatic diseases[6267]. While most commonly used in the assessment of soft tissue disease or detection of fluid collection, ultrasound can also be used to visualize other structures, such as cartilage and bone surfaces[62,68,69].


Ultrasound is an invaluable diagnostic technique in orthopedic practice. Technological developments in resolution quality have increased the diagnostic possibilities while improvements in picture quality have increased clinical applications.

Muscoskeletal sonography is safer and more informative than X-rays for evaluating soft tissues pathology. Compared with MRI, it is accessible to all patients, without contraindications, and provides real time dynamic assessment.

Musculoskeletal ultrasonography is indicated for evaluation of soft tissue damage, particularly in sports injuries. The most practical uses are the evaluation of tendon structures, dynamic examination in motion, and the assessment of articular structures and diseases. Bursal disease with synovitis can be easily detected. Ultrasound should be performed when investigating rotator cuff tears, inflammation, calcific tendinitis and impingement syndrome, frozen shoulder, tennis or golfer elbow, biceps muscle, and distal biceps tendon insertion. Other indications include carpal tunnel syndrome, cysts of the wrists, pathology of tendon of the hands, retained foreign bodies, joint effusion, diseases of the knee, meniscal cysts, Baker cyst, ligament and osteoarthritis changes, Osgood Schlatter, and patella bipartite. In the ankle, ultrasound can detect tibio talar effusion, pathology of tibialis anterior, posterior, peroneal tendons, Achilles tendon, plantar fasciitis, and Morton neuroma.

Musculoskeletal sonography should be performed by an experienced operator with extensive knowledge of anatomy. Investment in training is justified in light of the contribution of this technology to diagnostic and therapeutic orthopedics and its accessibility to patients due to safety, non- ionizing radiation, low operating costs, lack of contraindications, and availability in locations distant from medical centers.



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5 Simple Exercises to Eliminate Neck Pain

When it comes to neck pain, it is important to not just treat the site of the pain, but to identify and address the underlying cause.


Most of the time neck pain is caused by misaligned hips, spine, and shoulders, along with a head that is stuck in the forward position due to lack of movement. As a result, the muscles of the neck and upper back tense up, which can lead to neck pain and stiffness.


Fixing the Whole Unit

This series of exercises is intended to be done in sequence and is designed to reposition the head and load-bearing joints to alleviate neck pain and stiffness. Some of the exercises might not seem to have anything to do with your neck, but they really do have everything to do with it.


All of the load-bearing joints of your body (shoulders, hips, knees, and ankles) work together as a unit. If you have neck pain, and you truly want it to go away for good, you need to get your entire body back in line, not just your neck.


As always, use your own best judgment, and if an exercise causes pain or discomfort, discontinue it immediately and go on to the next exercise.


Exercise #1: Static Back

  1. Lie on the floor with your legs on a chair or ottoman, with both your knees and hips at ninety degrees.
  2. Place your arms on the floor at either 45 degrees or shoulder level with your palms up.


This exercise will place your head in the same plane as your shoulders, and allow the muscles of your neck and upper back to release. Stay here until your back settles into the floor, typically 5-10 min.


Exercise #2: Static Extension Position

  1. Start on all fours, with your wrists under your shoulders, and your knees under your hips.
  2. Walk your hands out in front of you about six inches, then shift your body forward so your shoulders stack right over your wrists. Your hips should now be about six inches in front of your knees.
  3. Keep your elbows locked out straight, and allow your shoulder blades to collapse together.
  4. Let your head hang. It is really important to allow your neck to release here.
  5. Relax your stomach, and allow your low back to arch.
  6. Hold for 2 minutes, and don’t let your elbows bend.


This exercise may seem counterintuitive, as it is allowing your head to come forward, which is what we are trying to correct. But by allowing your head to hang, and keeping your elbows locked out while your shoulder blades collapse together, you are literally unlocking your shoulder girdle, which is most likely stuck in a protracted (forward) position. You are also repositioning your spine and hips into extension, counteracting the constant flexion they experience when you sit.

This is a challenging exercise, and you will feel a lot of work going on in your shoulders, forearms, and wrists. Hang in there. It will be worth it when it is over.


Exercise #3: Static Wall

  1. Lie on the floor and scoot all the way into the wall with your legs straight up it.
  2. If you are stiff in your hamstrings, scoot back until your tailbone rests flat on the floor.
  3. Pull your toes back and tighten your thighs.
  4. It is important for your feet to be hip-width apart and pointing straight out from the wall.
  5. Hold this position for 3 minutes.

In this exercise, the muscles of your neck and upper back will continue to release as your thoracic back extends against the hard surface of the floor. By keeping your thighs tight and toes pulled back, this exercise will also engage the muscles of your lower leg without interference from imbalances in the upper body.


Exercise #4: Sitting Floor

  1. Sit on the floor with your back up against the wall and your feet hip-width apart.
  2. Pull your shoulder blades together and down, tighten your thighs, and pull your toes back. Be sure that your feet stay straight. Your head should be touching the wall.
  3. Hold for 3 minutes.

This exercise will activate the muscles of your shoulders and upper back that will help to keep your spine and shoulders in the right place.


Exercise #5: Frog

  1. Lie on the floor with your feet together and your knees apart.
  2. Have your palms up on the floor at 45 degrees to your body.
  3. Just hang out here and relax for 2 minutes. Your low back will naturally arch off the floor, and you should allow that to happen.

Frog not only feels great, but also releases the muscles of your groin and inner thighs. Breathe while you are in this position, and pay close attention to what is happening to your body. You will feel the muscles of your neck, jaw, and upper back relax if you let them. Try not to chew gum or text during this exercise. Just let your body settle and adjust.





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Fallen Arch

What Is It?

A fallen arch or flatfoot is known medically as pes planus. The foot loses the gently curving arch on the inner side of the sole, just in front of the heel. If this arch is flattened only when standing and returns when the foot is lifted off the ground, the condition is called flexible pes planus or flexible flatfoot. If the arch disappears in both foot positions — standing and elevated — the condition is called rigid pes planus or rigid flatfoot.

Fallen Arch

Flexible Flatfoot
Flexible flatfeet are considered normal in young children because babies are not born with a normal arch. The arch may not form fully until sometime between ages 7 and 10. Even in adulthood, 15% to 25% of people have flexible flatfeet. Most of these people never develop symptoms. In many adults who have had flexible flatfeet since childhood, the missing arch is an inherited condition related to a general looseness of ligaments. These people usually have extremely flexible, very mobile joints throughout the body, not only in the feet. Flatfeet also can develop during adulthood. Causes include joint disease, such as rheumatoid arthritis, and disorders of nerve function (neuropathy).

Rigid Flatfoot
Unlike a flexible flatfoot, a rigid flatfoot is often the result of a significant problem affecting the structure or alignment of the bones that make up the foot’s arch. Some common causes of rigid flatfeet include:

  • Congenital vertical talus — In this condition, there is no arch because the foot bones are not aligned properly. In some cases, there is a reverse curve (rocker-bottom foot, in which the shape is like the bottom rails of a rocking chair) in place of the normal arch. Congenital vertical talus is a rare condition present at birth. It often is associated with a genetic disorder, such as Down syndrome, or other congenital disorders. The cause is unknown in up to half of cases.
  • Tarsal coalition (peroneal spastic flatfoot) — In this inherited condition, two or more of the foot bones are fused together, interfering with the flexibility of the foot and eliminating the normal arch. A rare condition, it often affects several generations of the same family.
  • Lateral subtalar dislocation — Sometimes called an acquired flatfoot, it occurs in someone who originally had a normal foot arch. In a lateral subtalar dislocation, there is a dislocation of the talus bone, located within the arch of the foot. The dislocated talus bone slips out of place, drops downward and sideways and collapses the arch. It usually occurs suddenly because of a high-impact injury related to a fall from a height, a motor vehicle accident or participation in sports, and it may be associated with fractures or other injuries.


The majority of children and adults with flexible flatfeet never have symptoms. However, their toes may tend to point outward as they walk, a condition called out-toeing. A person who develops symptoms usually complains of tired, aching feet, especially after prolonged standing or walking.

Symptoms of rigid flatfoot vary depending on the cause of the foot problem:

  • Congenital vertical talus — The foot of a newborn with congenital vertical talus typically has a convex rocker-bottom shape. This is sometimes combined with an actual fold in the middle of the foot. The rare person who is diagnosed at an older age often has a “peg-leg” gait, poor balance and heavy calluses on the soles where the arch would normally be. If a child with congenital vertical talus has a genetic disorder, additional symptoms often are seen in other parts of the body.
  • Tarsal coalition — Many people have no symptoms, and the condition is discovered only by chance when an X-ray of the foot is obtained for some other problem. When symptoms occur, there is usually foot pain that begins at the outside rear of the foot. The pain tends to spread upward to the outer ankle and to the outside portion of the lower leg. Symptoms usually start during a child’s teenage years and are aggravated by playing sports or walking on uneven ground. In some cases, the condition is discovered when a child is evaluated for unusually frequent ankle sprains.
  • Lateral subtalar dislocation — Because this often is caused by a traumatic, high-impact injury, the foot may be significantly swollen and deformed. There also may be an open wound with bruising and bleeding.


If your child has flatfeet, his or her doctor will ask about any family history of flatfeet or inherited foot problems. In a person of any age, the doctor will ask about occupational and recreational activities, previous foot trauma or foot surgery and the type of shoes worn.

The doctor will examine your shoes to check for signs of excessive wear. Worn shoes often provide valuable clues to gait problems and poor bone alignment. The doctor will ask you to walk barefoot to evaluate the arches of the feet, to check for out-toeing and to look for other signs of poor foot mechanics.

The doctor will examine your feet for foot flexibility and range of motion and feel for any tenderness or bony abnormalities. Depending on the results of this physical examination, foot X-rays may be recommended.

X-rays are always performed in a young child with rigid flatfeet and in an adult with acquired flatfeet due to trauma.


Expected Duration

Although infants are usually born with flexible flatfeet, most develop normal arches sometime between ages 7 and 10. In the 15% to 20% of children whose flatfeet last into adulthood, the condition often is inherited and lifelong. However, it may not cause symptoms.

A rigid flatfoot is a long-term condition, unless it is corrected with surgery or other therapy.


Because most cases of flatfeet are inherited, the condition is usually impossible to prevent. Even when children with flexible flatfeet are treated with arch supports and corrective shoes, there is little evidence that these devices prevent the condition from lasting into adulthood.


For mild pain or aching, acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID), such as aspirin or ibuprofen (Advil, Motrin and others) may be effective.

Flexible Flatfoot
When there are no symptoms, treatment is not needed.

If a child older than age 3 develops symptoms, the doctor may prescribe a therapeutic shoe insert made from a mold of the child’s foot or a corrective shoe. As an alternative, some doctors recommend store-bought arch supports. These appear to work as well as more expensive treatments in many children. With any conservative, nonsurgical treatment, the goal is to relieve pain by supporting the arch and correcting any imbalance in the mechanics of the foot.

Surgery is typically offered as a last resort in people with significant pain that is resistant to other therapies.

Rigid Flatfoot
The treatment of a rigid flatfoot depends on its cause:

  • Congenital vertical talus — Your doctor may suggest a trial of serial casting. The foot is placed in a cast and the cast is changed frequently to reposition the foot gradually. However, this generally has a low success rate. Most people ultimately need surgery to correct the problem.
  • Tarsal coalition — Treatment depends on your age, extent of bone fusion and severity of symptoms. For milder cases, your doctor may recommend nonsurgical treatment with shoe inserts, wrapping of the foot with supportive straps or temporarily immobilizing the foot in a cast. For more severe cases, surgery is necessary to relieve pain and improve the flexibility of the foot.
  • Lateral subtalar dislocation — The goal is to move the dislocated bone back into place as soon as possible. If there is no open wound, the doctor may push the bone back into proper alignment without making an incision. Anesthesia is usually given before this treatment. Once this is accomplished, a short leg cast must be worn for about four weeks to help stabilize the joint permanently. About 15% to 20% of people with lateral subtalar dislocation must be treated with surgery to reposition the dislocated bone.

When To Call a Professional

Call your doctor for persistent or unexplained foot pain, whether or not you have flatfeet. This is particularly important if your foot pain makes it difficult for you to walk.

Call your pediatrician or family doctor if your child complains about foot pain or appears to be walking abnormally. Even if there are no foot symptoms, it is wise to check with your doctor periodically about your child’s foot development just to be sure that everything is progressing as expected.


Up to 20% of children with flexible flatfeet remain flatfooted as adults. However, most do not have any symptoms. If a child with flexible flatfeet begins to have foot pain, conservative treatment with shoe modifications can usually relieve the discomfort, although it may not correct the problem permanently.

For rigid flatfeet, the outlook depends on the cause of the problem:

  • Congenital vertical talus — Although surgery usually can correct poor alignment of foot bones, many children with congenital vertical talus have underlying disorders that cause muscle weakness or other problems that interfere with full recovery.
  • Tarsal coalition — When shoe modifications are not effective, casting may help. When surgery is necessary, the prognosis depends on many factors, including which bones are fused, the specific type of surgery and whether there is any arthritis in the foot joints.
  • Lateral subtalar dislocation — With proper treatment, most people recover without severe long-term complications or disability. In some cases, there is continuing stiffness in the area of the foot arch, but this does not necessarily cause pain or difficulty in walking. The risk of long-term problems is lowest in people who have at least three weeks of aggressive physical therapy after their casts are removed.





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Most common indications for HIL and ESWT

hil eswt