Skier’s Thumb is a common injury, especially in active individuals. Skier’s thumb, also known as “gamekeeper’s thumb” involves an injury to the ligament on the inside of your thumb – the ulnar collateral ligament (UCL) of the metacarpophalangeal joint. This injury can involve a sprain – in which case the ligament stretches or partially tears – or a complete tear leading to significant pain, weakness and instability of the thumb. The injury occurs most commonly from an acute traumatic event leading to hyperextension of the thumb.

Causes and risk factors

• Trauma causing hyperextension of thumb
• Commonly related to falls, especially while holding something in the hand such as a ski pole
• Chronic instability may arise from repetitive injuries

Symptoms

• Pain, swelling, bruising along the thumb
• Weakness with pinching/gripping
• Instability to the thumb

Diagnosis and treatment

In most cases, x-rays are obtained to ensure there is no fracture to the thumb. Most of the time, the diagnosis can then be made clinically based on your exam and symptoms. Occasionally, advanced imaging such as an MRI will be obtained to evaluate the extent of the tear and help determine treatment options.

Treatment depends on the extent of injury to the ligament. In most cases, UCL injuries are treated nonsurgically with immobilization, often by casting and then transitioning to a removable brace. In general, it may take up to three months to fully recover and return to normal activity after a sprain/partial tear of the ulnar collateral ligament. Complete tears may be treated surgically or nonsurgically depending on the pattern of tear and patient goals. Left untreated, complete tears can lead to chronic pain, weakness and instability of the thumb.

A scaphoid fracture is a break in one of the small bones in the wrist. This small bone is one the carpal bones on the thumb side of the wrist. It is central to the mobility and stability in the wrist. This bone has a weak blood supply, so early, accurate diagnosis and treatment is important.

Causes and risk factors

• Most often occurs by landing on an outstretched hand
• Sport activities
• Automobile accident
• These fractures occur in people of all ages

Symptoms

• Pain and swelling on the thumb side of the wrist
• Severe pain when wrist or thumb is moved
• Loss of motion in the area
• Increased wrist pain after more than a day

Diagnosis and treatment

Your doctor will examine your wrist for any swelling, bruising, and loss of motion, as well as tenderness to the area. Generally an x-ray will be taken, although they are not always able to detect scaphoid fractures in the first few days, so at times additional imaging is required. Depending on the fracture location, pattern and displacement, your doctor will discuss treatment options with you. Many times scaphoid fractures can be treated non-operatively with prolonged casting, but often surgery is advised. Regardless of treatment, scaphoid fractures generally take several months to heal.

Ganglion cysts are the most common form of lump or mass in the hand. Cysts can appear in many locations in the upper extremity but are most common around the wrist and at the end of the finger adjacent to the nail.

Causes and risk factors

• Most common in younger people between the ages of 15-40
• Women are more often affected
• Common among gymnasts or athletes in sports that apply continuous pressure to the wrist
• Cysts on the finger joint are often associated with arthritis

Symptoms

• Visible lump, although some cysts remain hidden under the skin
• Pain due to pressure on the joint
• Large cysts can cause concern about appearance

Diagnosis and treatment

Ganglion cysts often don’t require surgery and may disappear or reduce in size with time. Initially treatment involves rest, bracing, activity modification and over the counter pain medication. Another non-operative treatment is called aspiration, where the skin around the cyst is anesthetized and the fluid inside is drained with a needle. If symptoms are not relieved by these methods, an orthopedic surgeon may offer a surgical procedure called excision.

Flexor tendons are the tendons on the palm side of the wrist and hand that enable you to bend or flex your fingers and wrist. Flexor tendon injuries are uncommon injuries that usually occur from a traumatic laceration to the palm side of the hand or finger, but can occasionally occur from a trauma without a cut or laceration. In most cases, flexor tendon injuries require surgical treatment to regain motion of the injured finger and maximize long term function.

Causes and risk factors

• A deep cut or laceration in the wrist, palm, or finger
• Closed, hyperextension injury to the finger
• Certain medical conditions, such as rheumatoid arthritis, may place patients at a higher risk of developing a flexor tendon injury

Symptoms

• Pain and swelling in the wrist/palm/hand
• Inability to flex (bend) a digit or one of the joints of a digit

Diagnosis and treatment

In most cases, the diagnosis is made clinically based off your physical examination findings. In rare cases, additional imaging such as MRI or ultrasound is used to confirm the diagnosis. If a flexor tendon is completely lacerated or ruptured, then surgery is generally advised to regain motion and maximize long term function. While overall outcomes with surgery are good, rehabilitation can be lengthy and requires dedicated hand therapy. Most patients will regain the ability to use the affected digit, but the motion may not return to normal. Occasionally patients develop significant scar tissue that can affect their function and may require additional surgery to release.

Distal radius fractures are one of the most common forms of fractures. The break occurs most commonly approximately one inch from the end of the distal radius.

Causes and risk factors

• Falling on an outstretched arm
• Osteoporosis may increase the risk of fracture
• Car accident or bike fall may generate enough force to cause a break

Symptoms

• Immediate pain
• Tenderness in the wrist
• Bruising
• Swelling
• Deformity the wrist

Diagnosis and treatment

Treatment will depend on the severity of the break, and most distal radius fractures are treated non-operatively. If the fracture is significantly displaced and/or unstable, your doctor may discuss surgical treatment with you. In many cases, treatment is patient dependent and varies based on age, activity level and functional goals. Regardless of treatment selected, distal radius fractures generally take 10 – 12 weeks to heal and require a period of immobilization followed by progressive increase in range of motion and activity.

What is posterior tibial tendonitis?

The posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. It holds up the arch and helps support the foot when walking. When the tendon becomes inflamed or torn, it may not be able to provide stability for the arch of the foot and result in flatfoot.

Causes and risk factors

• Overuse from high-impact sports such as soccer or running
• Acute injury from a fall or motor vehicle accident
• More common in women
• More common in middle-age adults and older

Symptoms

• Pain and/or swelling in the inside of the foot and ankle
• Pain worsens with activity
• Sometimes pain is felt on the outside of the ankle if the foot has collapsed due to the heel bone shifting to a new position

Diagnosis and treatment

When diagnosed early most patients with posterior tibial tendonitis can be treated conservatively with rest, ice, anti-inflammatory medications (NSAIDS), orthotics, and/or physical therapy. Your orthopedic surgeon will examine your foot and ankle and look for swelling, a change of shape in the foot, flexibility, and range of motion. Sometimes x-ray is used to confirm the diagnosis. If conservative treatment does not work, surgery may be necessary. The type of surgery depends on where the tendonitis is located and how much tendon is damaged.

What is posterior tibial tendon dysfunction?

Posterior tibial tendon dysfunction is one of the most common problems of the foot and ankle. It occurs when the posterior tibial tendon becomes inflamed or torn. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in flatfoot.

Causes and risk factors

An acute injury, such as from a fall, can tear the posterior tibial tendon or cause it to become inflamed. The tendon can also tear due to overuse. For example, people who do high-impact sports, such as basketball, tennis, or soccer, may have tears of the tendon from repetitive use. Once the tendon becomes inflamed or torn, the arch will slowly fall (collapse) over time.

Posterior tibial tendon dysfunction is more common in women and in people older than 40 years of age. Additional risk factors include obesity, diabetes, and hypertension.

Symptoms

• Pain along the inside of the foot and ankle, where the tendon lies. This may or may not be associated with swelling in the area.
• Pain that is worse with activity. High-intensity or high-impact activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time.
• Pain on the outside of the ankle. When the foot collapses, the heel bone may shift to a new position outwards. This can put pressure on the outside ankle bone. The same type of pain is found in arthritis in the back of the foot.

Diagnosis and treatment

Most patients can be treated without surgery, using orthotics and braces. If orthotics and braces do not provide relief, surgery can be an effective way to help with the pain. Surgery might be as simple as removing the inflamed tissue or repairing a simple tear. However, more often than not, surgery is very involved, and many patients will notice some limitation in activity after surgery.

What is peroneal tendonitis?

The peroneal tendons run on the outside of the ankle and connect the lower leg muscles to the foot. These tendons allow the foot to turn outwards and provide stability to the ankle during weight bearing activities. Inflammation of these tendons causes pain and swelling on the back and outside of the ankle. Please refer to the graphic below for a visual of the ankle tendon anatomy.

Causes

• Overuse or rapid increase in training from activities such as running
• Improper footwear
• Recurrent ankle sprains can cause peroneal tendonitis

Risk factors

• Patients with a hindfoot varus posture (heel is slightly turned inwards)
• Patients with high arched feet are more likely to develop peroneal tendonitis
• Patients with tight calves are more likely to develop peroneal tendonitis

Peroneal tendon tear symptoms

• Back and outside ankle pain
• Pain with inversion (turning inward) of the foot
• Feeling of weakness with eversion (turning foot outwards)

Treatment

Most cases of peroneal tendinosis heal without surgery. Your orthopedic surgeon may recommend rest, ice, non-steroidal anti-inflammatory medication (NSAIDS), a walker boot, or physical therapy. New shoes or orthotics may be recommended when the patient resumes activities. If the peroneal tendon has torn and requires surgery, it may need to be cleaned out and repaired. In severe cases, the two tendons may need to be connected surgically to heal.

Neuroma

(Mortons) Neuroma is a benign tumor of the nerve, most commonly occurring between the third and fourth toes. It is the thickening of the nerve tissue as it passes under the ligament connecting the toe bones in the forefoot.

Causes and risk factors

• Irritation
• Trauma
• Excessive pressure on the area
• More likely to occur in women than men

Symptoms

• Usually no visible signs
• Burning in the ball of the foot
• Intensified pain with activity and wearing shoes
• Numbness in the toes

Diagnosis and treatment

Studies have shown that switching to a wider shoe can reduce pressure on the nerve and give it time to heal. Custom shoe inserts may also relieve irritation and reduce pain. If symptoms persist, your orthopedic surgeon may suggest an injection to reduce swelling and inflammation.

What are mallet, hammer or claw toes?

Mallet, hammer, and claw toes are toes that are bent into a deformed position. Most often these seemingly strange and painful looking changes affect the four smaller toes.

• A hammer toe is any of the second, third, or fourth toes that is bent at the middle joint, causing a deformity that looks like a hammer. Initially the toes can be corrected, but if left untreated, surgery is most often needed.
• Claw toe affects the four smaller toes all at once. Here, the bend occurs closer towards the foot at the joint where the toes actually connect to the foot itself. They continue to bend at each joint until the toes actually curl down towards the floor.
• In a mallet toe, the bend occurs at the last joint, on the end of the toe. It most often occurs in the second toe, but can happen in any of the other toes.

Causes and risk factors

• Shoes that do not fit properly (most often too small)
• Muscle imbalance
• Increased pressure on the toes
• Diabetes, rheumatoid arthritis, and stroke

Symptoms

• Pain in the toes and feet
• Corns or calluses on top of the deformed joint
• Difficulty finding comfortable shoes

Diagnosis and treatment

Conventional treatment can be as simple as a new pair of shoes, allowing more room for the toes. An orthopedic surgeon may also prescribe some toe exercises and stretches throughout the day to counteract the tightening joint, and an over-the-counter pain medicine. Your doctor may also recommend using straps, cushions, or corn pads to relieve pain and symptoms.