I am Dr. Nick Casscells. I am an orthopedist at MedStar Georgetown University Hospital. I specialize in
the foot and ankle. We see patients of all kinds for foot and ankle injuries
and different deformities. And, the problems of the foot and ankle are vast. They can be trauma that
recently occurred. They can be old trauma. They can be deformities that you're born with. They can be
pain that comes up into the foot and ankle that we don't know why it came up. And, all these patients
are different ages, different sizes, and from different backgrounds. Despite growing up in
an orthopedic family, I went into medical school with an open mind exploring all the different
facets that medicine has to offer. But I did land on orthopedics, in the end, mostly because I fell
in love with the different problems the patients have, the immediacy of being able to treat many of
those problems with surgery, and actually fixing a problem as opposed to treating a chronic illness.
So, orthopedics really fascinated me in the different ways that we treat the very complicated
problems that patients have. There are orthopedic advancements occurring all the time, many of which
are things that we do in the OR but many of which are the things that we do outside of the OR. There are
advancements in therapy. There are advancements in medication that are preventing surgeries. And
then within the surgical field, there are always new and exciting devices that we are using that
are allowing patients to bear weight sooner, get back to their activities faster, and speeding up
recovery in a way that has really revolutionized the way we treat patients with injuries.
When I look at a patient, I don't just look at their foot or the ankle. But I like to treat
them as a patient as a whole. And so certainly, we explore the problems and solutions of the
foot and ankle. But also, we make sure that the solutions and treatments that we offer fit into
the person and what they need in particular. And sometimes, that's surgery, but often, it's not. And
trying to get the patient back to whatever it is that they want to do. The most satisfaction
I get is the individual patient, taking a patient that is having a bad problem, a patient that has
had a bad problem for a long time, and finally being able to help them get through it to a
point where they can return to do the things they love. And sometimes, these follow-ups that
they have aren't just weeks but they're months. And for a patient to finally be able to return
to an activity that they hadn't been able to do in years is really quite satisfying.
So the foot and ankle has a very complex anatomy. Probably the most important part
of it is the ankle which is consisted of three bones: the fibula, the talus, and the tibia. And the
talus articulates between the medial side of the tibia and the fibula and works in a fulcrum like
fashion to allow the ankle to move up and down. And, it's really one of the most important joints
in the body for weight bearing. The foot underneath becomes a little bit more complicated with several
different joints. We can basically break it down into the hindfoot, the midfoot, and the forefoot.
The midfoot has several bones and joints that construct the arch of the foot and is generally
a much more rigid structure to allow a person to generate force, particularly when running, sprinting,
etc., any of these kinds of explosive activities. And lastly, we come to the forefoot which is mainly the
toes and the bones, the metatarsals just behind the toes, that have to have a lot of flexibility
in order to accommodate uneven ground, in very flexible situations to be able to spring off of
the forefoot to accelerate, or quickly slow down, and do all the athletic activities that we like
our entire bodies to perform for. Foot and ankle surgery can be quite complex, specifically because
there are so many joints in each of these areas within the foot and ankle. The joints have very
complex motions, particularly in the hindfoot. The subtalar joint is a joint that's off axis with
the rest of the body at two separate 45 degree angles, and it's it's complex movement can make
fixing problems in it quite challenging. Other parts of the foot and ankle that require specific
attention to and complicated surgery include the ankle joint itself, which is a big enough joint
that we can put a camera in and do arthroscopy in to address many of those problems which
allows us to minimally invasively correct several different pathologies that often afflict the ankle.
The best way to know if you need surgery for your foot and ankle problem is that you have
pain despite failing multiple conservative non-operative modalities of treatment. There
are many non-operative modalities of treatment that can solve a lot of foot and ankle problems.
These include immobilization in a boot or brace. They include injections, physical therapy,
as well as custom orthotics. If we've tried all of the conservative and non-operative techniques and
still the pain persists, often surgery can be the right answer. We use surgery as a last resort, but
often, an important tool to be able to get you back to the activities that you love doing. And whether
that be tennis or basketball or any sort of walking or golf that you love to do, we want to get
you back on the court or back on the field or back to whatever your previous level of function was.
Anything we can do that minimizes the trauma that occurs during surgery that has at least as good
results as an open surgery, we think is worthwhile pursuing and performing. And so, for the ankle that
can be several things. But, one of the things we do with relative frequency is ankle arthroscopy
which is taking a camera looking into the ankle and then through a separate portal performing the
different types of procedures that needed to be done. Many at this time, it's repairing cartilage or
bone grafting or cleaning up different types of synovitic processes that occur intra-articularly.
So the most common foot and ankle conditions fall into three categories.
There's deformity, something you're either born with or has been progressing for some time.
There are sports related injuries. And then finally, trauma which tends to be broken bones, and these
often require the specialty of an orthopedic foot and ankle surgeon to be able to thoroughly
evaluate and decide whether or not an intervention is necessary, which could be anything from
simple physical therapy, boot brace immobilization, or something as complex as a surgical
intervention.
For most foot and ankle procedures, there is a short period of non-weight bearing after surgery.
This usually lasts about six weeks. After that, we usually have you start walking. But usually,
that walking is done in a boot or brace for the next four to six weeks. So to really be back into
a regular shoe after the vast majority of foot and ankle cases, it's about three months. That
being said, there are many smaller foot and ankle procedures where patients are walking right away,
perhaps in a hard-soled shoe or even a boot right off the bat. But many of the foot and
ankle procedures that we do, do require a period of non-weight bearing for the tissue and bones
to heal in the places that we've put them before we get you back to your activities.
The vast majority of foot and ankle procedures are outpatient
procedures that are performed at the hospital or the surgery center.
And, most people go home the same day without any sort of overnight stay in the hospital.
The vast majority of foot and ankle surgeries, most people are walking at the latest at six
weeks from the procedure. There are many procedures where we have patients walking sooner afterwards,
particularly forefoot cases like alex rigidus which is arthritis of the big toe or bunion
surgery where patients are essentially walking on their heel on their foot right away.
But for many of the cases that involve the midfoot and the hindfoot or the ankle joint itself,
people are off their foot for a period of four to six weeks before we get them walking in a boot.
Many types of surgery on the foot and ankle require the patient to be non-weight-bearing
after surgery, sometimes for as short a period as two weeks. But sometimes, even up to six weeks.
Even sometimes, 12 weeks. And this can be very difficult for patients. We're very used to
being able to walk on both of our limbs, but there are many devices that assist you that we can use
to help ameliorate that. The simple of which are crutches and a walker. But, probably the best way
is to use a knee scooter in which you put your knee of the injured or post-operative extremity
onto the scooter. It's got four wheels and hand brakes, sort of like a bicycle.
Often, some of them have a little basket and bell, as well. But, they allow you to zip around
pretty quickly and effectively after complex foot and ankle surgery that requires you to
be non-weight bearing for a certain period of time. And many patients get back to work
very quickly with one of these devices and can restore their activities of daily living.
Footwear can be very important in addressing different foot and ankle pathologies, and there
are many shoes that are designed for fashion and many shoes that are designed for comfort.
Many people have a foot that doesn't have restrictions on what kind of shoe where it
can wear, but some feet do have difficulties getting into certain kinds of shoes.
Many people have different foot deformities that also require the use of an orthotic that adjusts
the way that they walk on their foot in order to make their walk smoother and decrease pain
that they're getting in the foot. The most common of these deformities are an overly high arched
foot or a cavovarus foot, with the opposite being a flat foot or a planovalgus foot.
And, both of these conditions can be treated often with conservative therapy
like orthotics and physical therapy, but sometimes do need surgical correction to actually
take the deformity, and remove the deformity, and create a straight plantigrade foot.
Prompt foot and ankle care is very important, mostly to have an expert look at the foot injury
and be able to describe to you whether or not the injury or the deformity is one that progresses.
Many are progressive and will go on to be a worse problem if they aren't handled promptly,
but many are not. And so, you should consult your foot and ankle specialist to know
if yours is one that needs to be taken care of or that can be watched over time.
A bunion is a common foot and ankle problem where many of the patients think that there's a growth
on the inside of the foot. But, it's actually an often progressive deformity of the first joint
of the big toe, the MTP joint, where the first bone starts to swing inward and the second bone starts
to swing outward and that angle that can become sharper and sharper creates a bulge that sticks
out on the inside of the foot. Many of these are progressive and many of them often become
painful. And when they get like that, they can cause secondary problems of the lesser toes, the second
and the third toe particularly causing hammer toes or painful calluses on the bottom of the
foot. When these bunions develop to the severity, particularly the ones that are painful, they
often require surgery for correction which isn't just as simple as removing
the prominence because that's not the actual problem. We actually have to realign the bone so
that the toe goes straight and no longer has that acute angle sticking out on the inside of the foot.
Bunion surgery is so common because, number one, bunions are so prevalent. The second problem is
they tend to be painful, particularly given certain types of shoe wear. There are many populations in
this world that don't wear shoes still today, and many of them have bunions. And most of them
to be honest, don't cause them a whole lot of problems. But when you put a bunion which
has widened the forefoot into a shoe that can't accommodate it, these often become very painful
and progressive. And, they can lead to secondary problems down the road which we try to prevent.
The two most common complications of bunion surgery are stiffness in the big toe after surgery,
and the second one is actually the recurrence of the bunion. Both of these complications, we
are very careful to avoid when performing bunion surgery by using techniques that
decrease the post-operative stiffness as well as rehabilitation techniques to keep the joint moving.
Secondarily, we also use many techniques in order to prevent the recurrence of the bunion
by fixing it in the right way. There are actually over a hundred described
different types of bunion operations, and we perform specific ones for specific bunions
in order to make sure that that bunion is not one that is going to come back in the future.
Physical therapy can be an important tool following many surgeries and bunion surgery
as well. In particular, we try to avoid stiffness after bunion surgery. And so when a patient is
beginning to get stiff or the patient doesn't seem to be getting their motion back quite the
way we would have wanted, physical therapy can be very helpful to get the big toe moving again like
it was before. Not every bunion surgery and not every surgery in the foot and ankle in general
requires physical therapy. Many do, particularly the ones surrounding sporting injuries and athletes.
But any anytime that there is an indication for physical therapy where we are concerned about
motion and regaining motion, physical therapy is a very valuable tool that we use. A common problem
people have is ankle sprains and repetitive ankle sprains. Now many ankle sprains can be treated
conservatively, and they do quite well. But some of them have lingering problems, and
particularly, patients who tend to sprain their ankle over and over again think that it's just
the way they're built. But actually, there are very good techniques for tightening up
the ligaments of the ankle so that you no longer continue to sprain the ankle over and over again.
The procedure is called a brostrum, and we tightened up the anterior lateral
ligaments of the ankle in order to rebuild it in a way that's much more stable. And people
can walk on uneven ground without having to fear rolling their ankle over and over again.
A lot of people have a problem in the back of their heel where their Achilles tendon plugs
in on the calcaneus in the back. They can develop a large spur here that can become quite painful,
particularly in the back of shoes. Many people think that this is a problem that they have to
deal with, But actually, that spur can be removed and the Achilles tendon reinserted into the bone
in a way that provides people with relief both in the shoes they wear
and throughout the activities that they do through the day and
taking away that chronic pain that they can't get rid of in the back.
Many patients have the problem of ankle arthritis where the cartilage breaks down in the ankle joint.
This is very unique compared to some of the other joints in the body like the knee or the hip
because ankle arthritis is often related to past injuries, particularly an old ankle fracture. Many
people have been told for their ankle arthritis that the only option is to fuse the ankle where
they lose the mobility but get the benefit of decreased pain. Newer techniques and newer
technologies have now developed ankle replacements which we do at MedStar Georgetown that can
preserve the motion of the ankle while also taking away the pain of severe ankle arthritis.
Many patients have a problem of a flat foot or a feet that turn outward. Over time, this can
become actually a painful deformity where people get pain on the inside of their foot and ankle.
And, many people think that they have to just live with this pain.
Formerly, surgeries were done that actually fused the hindfoot in order to correct the flatfoot
and restore the arch. But, this is a surgery that sacrificed motion in order to decrease pain. We
now do surgeries that actually move the bones into different positions to restore the arch
but keep the joints mobile. And so that people can keep their motion but have a corrected foot that
no longer has pain on the inside. And so, this flat foot correction is becoming more and more popular
among patients who want to keep their motion but want to have a straight and painless foot.
The foot and ankle care at MedStar Georgetown Hospital is unique because we follow the motto
of cura personalis, which is care for the whole person. And so while we are focused on
getting the foot better and back to its normal anatomy and normal function, we also focus on the
patient and getting them back to their regular activities in whatever it is they love to do.