Department of Orthopaedic Surgery

The Department of Orthopaedic Surgery offers services and programs through the following Divisions. Use these links to directly access all our Department sites.

Sports Medicine

Osteochondral Lesions

Overview

The plantar fascia is a thick layer of connective tissue that originates from the heel (calcaneus) and fans out to the underside of each toe. It provides support to the arch of the foot and serves as a shock absorber during activities that require extension of the toes (e.g., running, walking). As the toes extend, the plantar fascia tightens and elevates the arch of the foot.

Plantar fasciitis is a degenerative condition that results from repetitive stress that causes micro-tears in the fascia. If these tears occur frequently enough to overcome the body’s ability to heal itself, a chronic state of inflammation ensues. The hallmark symptom of plantar fasciitis is heel or arch pain in the sole of the foot. This pain is often worse at the beginning of the aggravating activity and lessens as the foot warms up. Most patients report increased pain when they first step out of bed in the morning.

Causes

Obesity, sudden weight gain, prolonged standing / weight-bearing, and overtraining in runners are common risk factors for plantar fasciitis as they all place increased, repetitive tensile forces on the plantar fascia.

Other risk factors include flat feet and reduced dorsiflexion (upward flexion of ankle) and tightness of the calf muscles. Heel spurs are found in 50% of patients with plantar fasciitis, although the mechanism with which they produce fascial damage is unclear. Systemic diseases such as diabetes mellitus and rheumatic disease have also been implicated as they lead to changes in the muscular and bony structure of the feet.

SYMPTOMS & DIAGNOSIS

Diagnosis of plantar fasciitis is made on the basis of the symptoms described above and physical examination by a clinician. Local tenderness experienced by the patient is best reproduced by the clinician with flexion of the toes and ankle upward and palpating the length of the fascia.

Plain x-rays should be undertaken to rule out the presence of heel spurs and other causes of inferior heel pain (e.g., calcaneal stress fracture, bone malformations). MRIs (magnetic resonance imaging) should be undertaken to rule out soft tissue disease in cases of intractable plantar fasciitis after conservative management.

Treatment

Different doctors will have different approaches to dealing with OCLs, and this also depends on exactly what your injury is.

Children


Children under the age of 16 may have some bone growth left in them. Bone growth means that the end of the bone, known as the physis, is still growing. The cells in the physis are dividing and canstill make normal hyaline cartilage. This means that children can often recover completely and heal their injury. In most cases, doctors will recommend waiting to see if this happens, and will only recommend more aggressive treatment if this doesn’t happen.

Adults


Once the physis at the affected joint has closed, unfortunately there is no longer a possibility for normal, natural healing. The only treatment for OCLs is surgery. A variety of surgical techniques exist, but these days, all of them are arthroscopic. This means that only small (usually – inch or so) incisions are made around the knee, to get a small camera and instruments into the affected area. Arthroscopy allows you to recover faster with less pain after surgery, and with less risk for infection of the surgical site.

Surgical techniques


Simple techniques: Simple surgery means that the surgeon will remove any fragments of cartilage and bone in the joint and smooth the surfaces. If possible, the surgeon may try to put the fragments back in place and reattach them with a small pin, but this is not always possible to do. If she cannot reattach the fragment, she may attempt to stimulate the bone to heal the injury. But as we mentioned above, the healing from the bone only makes fibro cartilage, and so this may wear out.

Complex techniques: Complex surgery means the surgeon will do more than just fix what’s hurt as much as possible. The surgeon will try to put something new into the joint to help it heal. There are currently two such techniques:

Osteochondral Grafting:


Osteochondral grafting involves taking a small piece of bone and cartilage from outside the affected area and placing it in the defect. The bone can come from yourself, in a place that won’t hurt as much as where the injury is right now, or it can come from a donor. Each of these options has different risks and benefits that you should discuss with your surgeon. The end result, however, is to get back a nice smooth joint surface with normal hyaline cartilage, which can last a long time.

Autologous Chondrocyte Implantation (ACI)


ACI is a newer technique, which involves taking some cartilage cells from you, and stimulating them to grow and make hyaline cartilage in a lab. They are then reimplanted into the defect, usually with a small piece of bone.

Newer techniques, usually variations on ACI, also exist, and you may discuss these with your surgeon. There are many options for dealing with OCLs, and we have only covered some of them here. Your surgeon will know about newer or more promising techniques as they emerge, so discuss what you want with him or her.

DIAGNOSIS

To diagnose SIS, a doctor will review your symptoms and perform a physical examine. An impingement test, which involves injecting a local anesthetic into the bursa, can help to confirm the diagnosis.

He or she may also request X-rays or a MRI (magnetic resonance imaging) of the shoulder. MRI can show fluid or inflammation in the bursa and rotator cuff. In some cases, partial tearing of the rotator cuff will be seen.

Treatment

As with other arthritic conditions, initial treatment of arthritis of the shoulder is nonsurgical and may involve physical therapy. In addition, some therapies you may try include:

Resting the shoulder.


A course of non-steroidal anti-inflammatory medications, such as Ibuprofen. Supervised physical therapy and/or home stretching and strengthening exercises. Injection of a local anesthetic and cortisone into the shoulder.

Surgical Treatment

If nonsurgical treatment does not reduce pain, there are surgical options. As with all surgeries, there are some risks and possible complications. Your orthopaedic surgeon will do all that is possible to minimize these risks.

Operations are usually only performed if non-surgical treatment has failed. The goal of surgery is to remove the impingement on the rotator cuff and bursa by creating more space between the humeral head and the acromion.

The most common surgical treatment is sub-acromial decompression. This may be performed by either arthroscopic (small incisions with cameras) or open techniques. In this procedure the portion of the acromion causing impingement is removed along with some of the bursa. The surgeon may also treat other conditions present in the shoulder at the same time, including repairs of any rotator cuff tears.