At Atlantis Orthopaedics, we specialize in the treatment of foot and ankle injuries, sports-related foot and ankle injuries, forefoot deformities, ligament and tendon dysfunctions, flatfoot, ankle arthroscopy, ankle replacement, fusion surgery, and trauma. Dr. Rommel Francisco treats patients from Jupiter, Palm Beach Gardens, West Palm Beach, Lake Worth Boynton Beach and Delray Beach, with two convenient locations in Palm Beach County.

Sprains/Instability

Ankle sprains and fractures are common types of foot and ankle injuries. Most everyone knows what a bone fracture is—a breakage of a bone. Fractures can range from small cracks to total separation of two or more pieces of the bone, or even one or more shattered bones. There are many types of fractures that your foot and ankle specialist can treat and repair, with surgical intervention if necessary.

Sprains are not as well understood by most people as fractures are. An ankle sprain is a very common injury. It accounts for about 40% of athletic injuries. So what exactly happens when we sprain our ankle? There are ligaments that help support our ankles when we walk, jump, run, etc., especially on uneven ground. When we “twist” our ankles these ligaments are stretched beyond their capability to do so. Sometimes they are stretched (mild sprain), partially torn (moderate sprain) or fully torn (severe sprain).

Most ankle sprains—mainly the mild type—heal uneventfully with an initial period of rest, ice, compression, and elevation (RICE). However there are many that do not fully heal, where the ligaments stay “loose.” Common symptoms are continued feelings of instability, pain and swelling. A common complaint is “my ankle feels weak.”

So how do we treat ankle sprains? In addition to RICE, one may try a brace or even a cast for a few weeks depending on how severe the sprain. After this initial period of immobilization, a physical therapy program is started. The purpose of physical therapy is to prevent recurrence of the injury or chronic instability of the ankle. Therapy helps to strengthen the ankle and “re-train” the ankle to keep itself stable.

Sometimes there are patients who despite physical therapy have continued problems of pain and instability. In these cases surgery may be indicated. Surgery entails taking the torn ligaments and “tightening” them up again. For most patients this is an outpatient procedure. Post-operatively, I treat my patients in a cast for six weeks followed by a 4 to 6-week course of physical therapy. Expect a return to normal activity in four to six months post operatively

Ankle arthritis

Just like the knee or hip, arthritis can exist in the ankle. Ankle arthritis usually results from some type of injury in the past, like a fracture or severe sprain. It is rare for arthritis to occur spontaneously in the ankle, unless there is a history of some type of inflammatory arthritis (i.e. rheumatoid arthritis).

Some typical symptoms may include pain and swelling, especially worse with activity or prolonged walking. Some of the ways we treat ankle arthritis are with non-steroidal anti-inflammatory drugs (NSAIDs), various types of braces, and activity modification. Cortisone injections are also commonly used. Unfortunately, we can never get rid of arthritis. The above mentioned treatment options attempt to keep the pain down to a manageable level. If they do not provide a reasonable amount of relief, then surgery may be indicated.

Arthroscopy of the ankle attempts to debride the joint. However, it does not change or remove the existing arthritis. Any pain relief from this surgery is usually temporary at best. The length of pain relief, if any, varies greatly. This surgery is best indicated for younger patients who are trying to avoid the bigger surgeries I will discuss below.

Ankle fusion is the most common surgery to treat arthritis. It is considered the gold standard. The ankle joint is formed primarily by the tibia and talus. It is the motion between these bones along with there arthritic surfaces that causes pain. Fusion surgery attempts to eliminate this motion by essentially turning these two bones into one. During this surgery we prepare the joints to make the body think there is a fracture. We hold these bones together using metal screws and/or plates. We then wait for the body to bring new healing bone across this joint to eliminate any possible motion. This process usually takes at least 6-8 weeks in most patients.

The third option is an ankle replacement. The obvious advantage of this procedure over a fusion is the preservation of ankle motion. However, an ankle replacement should in no way be compared to a knee replacement, which is one of the most successful operations in orthopedic surgery. The prostheses for this operation have undergone quite an evolution over the years. Some older implants have been removed from the market by the FDA due to concerns of loosening of the implants. The newer implants have most definitely improved upon the faults of previous products. However concerns about the longevity of these implants still exist, and there are no long-term studies to demonstrate longevity of the procedure.

Painful flatfoot

Posterior tibial tendonitis

Flat feet is a rather common occurrence within the general population. Even in patients without pain associated with their flat feet, I always recommend an orthotic, or an arch support. Wearing an orthotic can help to protect the foot from the development of future problems related to flat feet. One of these problems is posterior tibial tendonitis. The posterior tibial tendon lies on the inside of your ankle. It serves as an inverter (turns the foot in) of the foot. It also helps to support the arch of the foot. In someone with flatfeet, this tendon must work harder to support the arch. With time this tendon can become “worn down” and become inflamed. One may notice that over time their feet have become “flatter.” This occurs because the tendon has stopped doing its job in supporting the arch. It is important to note that posterior tibial tendonitis can occur in patients with normal arches, but much less commonly than patients with flat feet.

Some of the ways we treat posterior tibial tendonitis is with anti-inflammatory medicines (NSAIDs), a period of casting or bracing, and activity modification. Long term treatment of this condition involves use of an orthotic to help support the arch and give the tendon some rest. If these modalities fail, then surgery may be indicated.

Surgery for this condition can become very extensive. The type of procedure chosen depends on the degree of deformity as well as the presence of arthritis. If there is coexistent arthritis in any of the joints involved, then fusion surgery would be indicated (see section on having fusion surgery). Otherwise, surgery would essentially consist of two parts. The first part involves debridement or removal of the diseased posterior tibial tendon followed by transfer of another tendon in the foot (usually one of the tendons to the small toes) to help take its place. The second part involves actually cutting the heel bone (called an osteotomy), then shifting it over to help create a better arch. The osteotomy is held in place by a metal screw. Immediate post-operative recovery involves four to six weeks in a cast, followed by 4-6 weeks of physical therapy. Expect full recovery and return to activity by 4-6 months.

Forefoot deformities

Bunions / Hallux Valgus

The forefoot can develop painful deformities that can impair function and restrict mobility. These deformities can result from many causes including improper fitting of shoes and normal aging. Dr. Francisco can offer surgical and non-surgical treatment of these disabling conditions.

Contrary to what most people believe, bunions are not just a “bump” growing on the inside of your big toe. Bunions are actually an angular deformity of the foot that develops from an imbalance of the muscles and ligaments around the big toe. Bunions can develop for various reasons. It can result from poor shoe wear (i.e. high heels). Genetics can also play a role where often parents, grandparents, siblings have suffered from the same problem. Patients with neuromuscular disease can also develop them. In most cases we never really know what caused a bunion to develop.

Pain can develop from irritation of the “bump” from shoes rubbing on them and/or the change in alignment of the forefoot from what is “normal.” Patients often have trouble finding the right shoes that fit them and cause the least amount of discomfort.

Some of the ways to treat bunions include various toe spacers, night splints, and orthotics. Shoe wear modification is the most important aspect of non-operative treatment. If these do not provide any significant relief, then surgery may be indicated.

Before thinking about having surgery for your bunion, think about what bothers you the most about it. Is it the pain or the deformity? Are you looking to go back into high heels or narrow shoes? The best indication to have bunion surgery is pain. Having surgery mainly for cosmetic reasons can be disappointing in the end. Many bunions after surgical correction can come back to some degree, but in most patients this happens with very little pain, if any. Going back into high heels should not be part of your expectations.

There are four basic ways we treat bunions surgically. The first way is with soft tissue correction or realignment. Here we release the ligaments/tendons on one side of the toe and tighten them on the other side. The second way is by cutting the bone to help realign the toe. The third way utilizes both soft tissue and bony procedures to realign the toe. The last procedure involves fusion of the toe into a corrected position. This procedure is mainly reserved for those with associated arthritis.

Depending on the type of procedure performed, post operative recovery involves at least four to six weeks of protected weight bearing. Return to normal activity can be expected anywhere from three to six months, depending on the procedure chosen.

Heel pain

Plantar fasciitis

Heel pain can occur after prolonged periods of walking or strenuous exercise, especially on hard surfaces without shoes or with poor support. However, plantar fasciitis is more often a wear-and-tear-type injury.

Within the arches of our feet, there is a thick band of tissue called the plantar fascia. This tissue is attached to the bottom of our heels, which bears much of our body weight.

With time this tissue becomes chronically inflamed, leading to heel pain. One often under-recognized cause of plantar fasciitis is tight calves. As we move down the leg, our calf muscles become the Achilles tendon, which attaches to the heel bone, and continues into the foot as the plantar fascia. When our calves are chronically tight, it makes the Achilles tendon and plantar fascia more prone to injury or chronic inflammation.

Some of the more common symptoms may include pain under the heel after prolonged walking or standing. The pain may be especially worse upon awakening in the morning or after prolonged sitting.

The treatment of plantar fasciitis rarely involves surgery. However it is important to know that heel pain rarely completely “goes away.” With the treatments I discuss, our goal is to help minimize the pain to a level that does not interfere with our daily activities or our quality of life.

The mainstay of treatment is stretching of the calf or Achilles. This helps to keep the plantar fascia “loose” and less prone to inflammation. Stretching should be done at least two to three times a day.

Morton's Neuroma

Pain, tingling of the toes

Pain from a Morton’s neuroma usually occurs at the bottom of the foot between the toes. Most often this occurs between the 3rd and 4th toes (80-90%) and less often between the 2nd and 3rd toes (10-20%.) The nerve that is affected in this condition lies in the bottom of the foot just underneath the skin. This nerve can become irritated and inflamed. It can occur from excessive weight bearing on that part of the foot, but most of the time there is no clear cause. Symptoms associated with a neuroma include pain, swelling and tingling in the toes. These can often be made worse by extensive walking or exercise. Tight fitting shoes also tend to exacerbate the symptoms.

Initially treatment involves activity modification, anti-inflammatory medicines (NSAIDs and shoe wear modification (wider shoes). Another treatment option may include orthotics or metatarsal pads to help alleviate the pressure from the affected area while walking. Cortisone injections are also commonly used. In the office we inject the area around the nerve to help decrease any inflammation around it. The duration and amount of relief from an injection can vary. If an injection does not provide any significant relief, even for a short time, then the possibility of another diagnosis should be explored. It is important to note that repeated injections should be avoided. The cortisone can thin the skin and soft tissues if given multiple times, which would deplete the padding under your foot.

If all of the above treatment modalities fail to provide any significant relief, then surgery may be indicated. Surgery for a Morton’s neuroma involves excision or removal of the affected nerve. Recovery from this surgery involves mostly wound healing, which usually takes two to four weeks. For the first two weeks after surgery, a special sandal is worn to help protect the wound. At two weeks post operatively, the sutures are removed and sneakers can be worn. Because the nerve is being removed, expect some numbness in the toes in that part of the foot. This is an expected occurrence, with most patients more than happy to trade in the pain from a neuroma for numbness in the toes.

Ankle arthroscopy

Debridement of the joint

Arthroscopy of the ankle attempts to debride the joint. However, it does not change or remove the existing arthritis. Any pain relief from this surgery is usually temporary at best. The length of pain relief, if any, varies greatly. This surgery is best indicated for younger patients who are trying to avoid the bigger surgeries I will discuss below.

Ankle fusion is the most common surgery to treat arthritis. It is considered the gold standard. The ankle joint is formed primarily by the tibia and talus. It is the motion between these bones along with there arthritic surfaces that causes pain. Fusion surgery attempts to eliminate this motion by essentially turning these two bones into one. During this surgery we prepare the joints to make the body think there is a fracture. We hold these bones together using metal screws and/or plates. We then wait for the body to bring new healing bone across this joint to eliminate any possible motion. This process usually takes at least 6-8 weeks in most patients.

The third option is an ankle replacement. The obvious advantage of this procedure over a fusion is the preservation of ankle motion. However, an ankle replacement should in no way be compared to a knee replacement, which is one of the most successful operations in orthopedic surgery. The prostheses for this operation have undergone quite an evolution over the years. Some older implants have been removed from the market by the FDA due to concerns of loosening of the implants. The newer implants have most definitely improved upon the faults of previous products. However concerns about the longevity of these implants still exist, and there are no long-term studies to demonstrate longevity of the procedure.

Ankle replacement

Total ankle arthroplasty

In the event that ankle pain does not respond to conservative management treatments such as anti-inflamatory drugs, physical therapy, braces or pain medication, an ankle replacement procedure may be indicated. Ankle replacement is not recommended for patients with deformities of the bottom bone of the ankle joint.

Ankle fusion is the most common surgery to treat arthritis and is an alternative to ankle replacement. However, for those patients that do not wish to have the ankle fused, especially when proper function of the foot and ankle are critical such as in patients that have very active lives and engage in sports activities, ankle replacement therapy is a chioce that can be carefully considered.

The obvious advantage of this procedure over a fusion is the preservation of ankle motion. However, an ankle replacement should in no way be compared to a knee replacement, which is one of the most successful operations in orthopedic surgery. The prostheses for this operation have undergone quite an evolution over the years. Some older implants have been removed from the market by the FDA due to concerns of loosening of the implants. The newer implants have most definitely improved upon the faults of previous products. However concerns about the longevity of these implants still exist, and there are no long-term studies to demonstrate longevity of the procedure.

Orthopedic surgery at Atlantis Orthopaedics

Atlantis Orthopaedics has been providing orthopedic care to patients throughout Palm Beach County and the neighboring communities since 1992. Each of our board-certified and fellowship-trained orthopedic surgeons has their own area of specialty such as Joint Replacement, Shoulder, Sports Medicine, and Foot and Ankle. We combine physical therapy with our surgical and non-surgical treatments to ensure your full and timely recovery.

We recognize that each patient is unique. Therefore, our plan of care is always customized to meet the needs of each patient. Our offices are equipped with the latest technology in medical imaging and electronic health records. We also strive to make sure that our staff is skilled, well-trained, and caring.

Should you need orthopedic surgery, our specialist and staff will guide you through the process and make you feel at ease about your procedure. And knowing the our surgeons use the latest techniques and technologies to make your surgery successful will reasure you that your procedure will have the best possible outcome.

Our surgeons are on staff at JFK Medical Center, JFK Medical Center North Campus and Palms West Hospital.

In the area of shoulder care, Dr. Routman has been a pioneer in developing new shoulder replacements that provide better results, getting you back in the action with a full recovery.

Dr. Francisco’s extensive education and training allows him to treat complex problems of the foot and ankle, including ankle fusion and ankle replacement surgery if indicated.

Dr. Reiter performs state-of-the-art techniques in ACL reconstruction, meniscus repair, and cartilage regeneration of the knee including autologous chondrocyte implantation. He also performs Arthrosporic labral and rotator cuff repairs of the shoulder.

Dr. Ashberg’s training in hip preservation surgery allows him to provide minimally invasive treatment of the hip in this cutting edge, rapidly developing area of orthopaedic surgery. Dr. Ashberg performs arthroscopic treatment of conditions such as acetabular labral tears, femoracetabular impingement (FAI), and borderline dysplasia. Lastly, Dr. Ashberg also offers minimally invasive, robotic assisted, anterior hip replacement surgery, with an emphasis on rapid recovery, including out patient surgery as an option.