Peripheral Neuropathy

What is peripheral neuropathy?

Peripheral neuropathy describes damage to the peripheral nervous system, the vast communications network that transmits information from the brain and spinal cord (the central nervous system) to every other part of the body. Peripheral nerves also send sensory information back to the brain and spinal cord, such as a message that the feet are cold or a finger is burned. Damage to the peripheral nervous system interferes with these vital connections. Like static on a telephone line, peripheral neuropathy distorts and sometimes interrupts messages between the brain and the rest of the body.

Because every peripheral nerve has a highly specialized function in a specific part of the body, a wide array of symptoms can occur when nerves are damaged. Some people may experience temporary numbness, tingling, and pricking sensations (paresthesia), sensitivity to touch, or muscle weakness. Others may suffer more extreme symptoms, including burning pain (especially at night), muscle wasting, paralysis, or organ or gland dysfunction. People may become unable to digest food easily, maintain safe levels of blood pressure, sweat normally, or experience normal sexual function. In the most extreme cases, breathing may become difficult or organ failure may occur.
Some forms of neuropathy involve damage to only one nerve and are called mononeuropathies. More often though, multiple nerves affecting all limbs are affected-called polyneuropathy. Occasionally, two or more isolated nerves in separate areas of the body are affected-called mononeuritis multiplex.
In acute neuropathies, such as Guillain-Barré syndrome, symptoms appear suddenly, progress rapidly, and resolve slowly as damaged nerves heal. In chronic forms, symptoms begin subtly and progress slowly. Some people may have periods of relief followed by relapse. Others may reach a plateau stage where symptoms stay the same for many months or years. Some chronic neuropathies worsen over time, but very few forms prove fatal unless complicated by other diseases. Occasionally the neuropathy is a symptom of another disorder.

In the most common forms of polyneuropathy, the nerve fibers (individual cells that make up the nerve) most distant from the brain and the spinal cord malfunction first. Pain and other symptoms often appear symmetrically, for example, in both feet followed by a gradual progression up both legs. Next, the fingers, hands, and arms may become affected, and symptoms can progress into the central part of the body. Many people with diabetic neuropathy experience this pattern of ascending nerve damage.
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What are the symptoms of peripheral nerve damage?
Symptoms are related to the type of affected nerve and may be seen over a period of days, weeks, or years. Muscle weakness is the most common symptom of motor nerve damage. Other symptoms may include painful cramps and fasciculations (uncontrolled muscle twitching visible under the skin), muscle loss, bone degeneration, and changes in the skin, hair, and nails. These more general degenerative changes also can result from sensory or autonomic nerve fiber loss.
Sensory nerve damage causes a more complex range of symptoms because sensory nerves have a wider, more highly specialized range of functions. Larger sensory fibers enclosed in myelin (a fatty protein that coats and insulates many nerves) register vibration, light touch, and position sense. Damage to large sensory fibers lessens the ability to feel vibrations and touch, resulting in a general sense of numbness, especially in the hands and feet. People may feel as if they are wearing gloves and stockings even when they are not. Many patients cannot recognize by touch alone the shapes of small objects or distinguish between different shapes. This damage to sensory fibers may contribute to the loss of reflexes (as can motor nerve damage). Loss of position sense often makes people unable to coordinate complex movements like walking or fastening buttons, or to maintain their balance when their eyes are shut. Neuropathic pain is difficult to control and can seriously affect emotional well-being and overall quality of life. Neuropathic pain is often worse at night, seriously disrupting sleep and adding to the emotional burden of sensory nerve damage.
Smaller sensory fibers without myelin sheaths transmit pain and temperature sensations. Damage to these fibers can interfere with the ability to feel pain or changes in temperature. People may fail to sense that they have been injured from a cut or that a wound is becoming infected. Others may not detect pains that warn of impending heart attack or other acute conditions. (Loss of pain sensation is a particularly serious problem for people with diabetes, contributing to the high rate of lower limb amputations among this population.) Pain receptors in the skin can also become oversensitized, so that people may feel severe pain (allodynia) from stimuli that are normally painless (for example, some may experience pain from bed sheets draped lightly over the body).
Symptoms of autonomic nerve damage are diverse and depend upon which organs or glands are affected. Autonomic nerve dysfunction can become life threatening and may require emergency medical care in cases when breathing becomes impaired or when the heart begins beating irregularly. Common symptoms of autonomic nerve damage include an inability to sweat normally, which may lead to heat intolerance; a loss of bladder control, which may cause infection or incontinence; and an inability to control muscles that expand or contract blood vessels to maintain safe blood pressure levels. A loss of control over blood pressure can cause dizziness, lightheadedness, or even fainting when a person moves suddenly from a seated to a standing position (a condition known as postural or orthostatic hypotension).
Gastrointestinal symptoms frequently accompany autonomic neuropathy. Nerves controlling intestinal muscle contractions often malfunction, leading to diarrhea, constipation, or incontinence. Many people also have problems eating or swallowing if certain autonomic nerves are affected.
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What causes peripheral neuropathy?

Peripheral neuropathy may be either inherited or acquired. Causes of acquired peripheral neuropathy include physical injury (trauma) to a nerve, tumors, toxins, autoimmune responses, nutritional deficiencies, alcoholism, and vascular and metabolic disorders. Acquired peripheral neuropathies are grouped into three broad categories: those caused by systemic disease, those caused by trauma from external agents, and those caused by infections or autoimmune disorders affecting nerve tissue. One example of an acquired peripheral neuropathy is trigeminal neuralgia (also known as tic douloureux), in which damage to the trigeminal nerve (the large nerve of the head and face) causes episodic attacks of excruciating, lightning-like pain on one side of the face. In some cases, the cause is an earlier viral infection, pressure on the nerve from a tumor or swollen blood vessel, or, infrequently, multiple sclerosis. In many cases, however, a specific cause cannot be identified. Doctors usually refer to neuropathies with no known cause as idiopathic neuropathies.
Physical injury (trauma) is the most common cause of injury to a nerve. Injury or sudden trauma, such as from automobile accidents, falls, and sports-related activities, can cause nerves to be partially or completely severed, crushed, compressed, or stretched, sometimes so forcefully that they are partially or completely detached from the spinal cord. Less dramatic traumas also can cause serious nerve damage. Broken or dislocated bones can exert damaging pressure on neighboring nerves, and slipped disks between vertebrae can compress nerve fibers where they emerge from the spinal cord.
Systemic diseases — disorders that affect the entire body —often cause peripheral neuropathy. These disorders may include: Metabolic and endocrine disorders. Nerve tissues are highly vulnerable to damage from diseases that impair the body's ability to transform nutrients into energy, process waste products, or manufacture the substances that make up living tissue. Diabetes mellitus, characterized by chronically high blood glucose levels, is a leading cause of peripheral neuropathy in the United States. About 60 percent to 70 percent of people with diabetes have mild to severe forms of nervous system damage.
Kidney disorders can lead to abnormally high amounts of toxic substances in the blood that can severely damage nerve tissue. A majority of patients who require dialysis because of kidney failure develop polyneuropathy. Some liver diseases also lead to neuropathies as a result of chemical imbalances.
Hormonal imbalances can disturb normal metabolic processes and cause neuropathies. For example, an underproduction of thyroid hormones slows metabolism, leading to fluid retention and swollen tissues that can exert pressure on peripheral nerves. Overproduction of growth hormone can lead to acromegaly, a condition characterized by the abnormal enlargement of many parts of the skeleton, including the joints. Nerves running through these affected joints often become entrapped.
Vitamin deficiencies and alcoholism can cause widespread damage to nerve tissue. Vitamins E, B1, B6, B12, and niacin are essential to healthy nerve function. Thiamine deficiency, in particular, is common among people with alcoholism because they often also have poor dietary habits. Thiamine deficiency can cause a painful neuropathy of the extremities. Some researchers believe that excessive alcohol consumption may, in itself, contribute directly to nerve damage, a condition referred to as alcoholic neuropathy.
Vascular damage and blood diseases can decrease oxygen supply to the peripheral nerves and quickly lead to serious damage to or death of nerve tissues, much as a sudden lack of oxygen to the brain can cause a stroke. Diabetes frequently leads to blood vessel constriction. Various forms of vasculitis (blood vessel inflammation) frequently cause vessel walls to harden, thicken, and develop scar tissue, decreasing their diameter and impeding blood flow. This category of nerve damage, in which isolated nerves in different areas are damaged, is called mononeuropathy multiplex or multifocal mononeuropathy.
Connective tissue disorders and chronic inflammation can cause direct and indirect nerve damage. When the multiple layers of protective tissue surrounding nerves become inflamed, the inflammation can spread directly into nerve fibers. Chronic inflammation also leads to the progressive destruction of connective tissue, making nerve fibers more vulnerable to compression injuries and infections. Joints can become inflamed and swollen and entrap nerves, causing pain.
Cancers and benign tumors can infiltrate or exert damaging pressure on nerve fibers. Tumors also can arise directly from nerve tissue cells. Widespread polyneuropathy is often associated with the neurofibromatoses, genetic diseases in which multiple benign tumors grow on nerve tissue. Neuromas, benign masses of overgrown nerve tissue that can develop after any penetrating injury that severs nerve fibers, generate very intense pain signals and sometimes engulf neighboring nerves, leading to further damage and even greater pain. Neuroma formation can be one element of a more widespread neuropathic pain condition called complex regional pain syndrome or reflex sympathetic dystrophy syndrome, which can be caused by traumatic injuries or surgical trauma. Paraneoplastic syndromes, a group of rare degenerative disorders that are triggered by a person's immune system response to a cancerous tumor, also can indirectly cause widespread nerve damage.
Repetitive stress frequently leads to entrapment neuropathies, a special category of compression injury. Cumulative damage can result from repetitive, forceful, awkward activities that require flexing of any group of joints for prolonged periods. The resulting irritation may cause ligaments, tendons, and muscles to become inflamed and swollen, constricting the narrow passageways through which some nerves pass. These injuries become more frequent during pregnancy, probably because weight gain and fluid retention also constrict nerve passageways.
Toxins can also cause peripheral nerve damage. People who are exposed to heavy metals (arsenic, lead, mercury, thallium), industrial drugs, or environmental toxins frequently develop neuropathy. Certain anticancer drugs, anticonvulsants, antiviral agents, and antibiotics have side effects that can include peripheral nerve damage, thus limiting their long-term use.
Infections and autoimmune disorders can cause peripheral neuropathy. Viruses and bacteria that can attack nerve tissues include herpes varicella-zoster (shingles), Epstein-Barr virus, cytomegalovirus, and herpes simplex-members of the large family of human herpes viruses. These viruses severely damage sensory nerves, causing attacks of sharp, lightning-like pain. Postherpetic neuralgia often occurs after an attack of shingles and can be particularly painful.
The human immunodeficiency virus (HIV), which causes AIDS, also causes extensive damage to the central and peripheral nervous systems. The virus can cause several different forms of neuropathy, each strongly associated with a specific stage of active immunodeficiency disease. A rapidly progressive, painful polyneuropathy affecting the feet and hands is often the first clinically apparent sign of HIV infection.
Lyme disease, diphtheria, and leprosy are bacterial diseases characterized by extensive peripheral nerve damage. Diphtheria and leprosy are now rare in the United States, but Lyme disease is on the rise. It can cause a wide range of neuropathic disorders, including a rapidly developing, painful polyneuropathy, often within a few weeks after initial infection by a tick bite.
Viral and bacterial infections can also cause indirect nerve damage by provoking conditions referred to as autoimmune disorders, in which specialized cells and antibodies of the immune system attack the body's own tissues. These attacks typically cause destruction of the nerve's myelin sheath or axon (the long fiber that extends out from the main nerve cell body).
Some neuropathies are caused by inflammation resulting from immune system activities rather than from direct damage by infectious organisms. Inflammatory neuropathies can develop quickly or slowly, and chronic forms can exhibit a pattern of alternating remission and relapse. Acute inflammatory demyelinating neuropathy, better known as Guillain-Barré syndrome, can damage motor, sensory, and autonomic nerve fibers. Most people recover from this syndrome although severe cases can be life threatening. Chronic inflammatory demyelinating polyneuropathy (CIDP), generally less dangerous, usually damages sensory and motor nerves, leaving autonomic nerves intact. Multifocal motor neuropathy is a form of inflammatory neuropathy that affects motor nerves exclusively; it may be chronic or acute.
Inherited forms of peripheral neuropathy are caused by inborn mistakes in the genetic code or by new genetic mutations. Some genetic errors lead to mild neuropathies with symptoms that begin in early adulthood and result in little, if any, significant impairment. More severe hereditary neuropathies often appear in infancy or childhood.
The most common inherited neuropathies are a group of disorders collectively referred to as Charcot-Marie-Tooth disease. These neuropathies result from flaws in genes responsible for manufacturing neurons or the myelin sheath. Hallmarks of typical Charcot-Marie-Tooth disease include extreme weakening and wasting of muscles in the lower legs and feet, gait abnormalities, loss of tendon reflexes, and numbness in the lower limbs.
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How is peripheral neuropathy diagnosed?

Diagnosing peripheral neuropathy is often difficult because the symptoms are highly variable. A thorough neurological examination is usually required and involves taking an extensive patient history (including the patient’s symptoms, work environment, social habits, exposure to any toxins, history of alcoholism, risk of HIV or other infectious disease, and family history of neurological disease), performing tests that may identify the cause of the neuropathic disorder, and conducting tests to determine the extent and type of nerve damage.
A general physical examination and related tests may reveal the presence of a systemic disease causing nerve damage. Blood tests can detect diabetes, vitamin deficiencies, liver or kidney dysfunction, other metabolic disorders, and signs of abnormal immune system activity. An examination of cerebrospinal fluid that surrounds the brain and spinal cord can reveal abnormal antibodies associated with neuropathy. More specialized tests may reveal other blood or cardiovascular diseases, connective tissue disorders, or malignancies. Tests of muscle strength, as well as evidence of cramps or fasciculations, indicate motor fiber involvement. Evaluation of a patient’s ability to register vibration, light touch, body position, temperature, and pain reveals sensory nerve damage and may indicate whether small or large sensory nerve fibers are affected. Also punch biopsies may be used to count the number of fibers present and histologically diagnose small fiber neuropathy.

Based on the results of the neurological exam, physical exam, patient history, and any previous screening or testing, additional testing may be ordered to help determine the nature and extent of the neuropathy.
Computed tomography, or CT scan, is a noninvasive, painless process used to produce rapid, clear two-dimensional images of organs, bones, and tissues. X-rays are passed through the body at various angles and are detected by a computerized scanner. The data is processed and displayed as cross-sectional images, or "slices," of the internal structure of the body or organ. Neurological CT scans can detect bone and vascular irregularities, certain brain tumors and cysts, herniated disks, encephalitis, spinal stenosis (narrowing of the spinal canal), and other disorders.
Magnetic resonance imaging (MRI) can examine muscle quality and size, detect any fatty replacement of muscle tissue, and determine whether a nerve fiber has sustained compression damage. The MRI equipment creates a strong magnetic field around the body. Radio waves are then passed through the body to trigger a resonance signal that can be detected at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional "slice" of the scanned area.
Electromyography (EMG) involves inserting a fine needle into a muscle to compare the amount of electrical activity present when muscles are at rest and when they contract. EMG tests can help differentiate between muscle and nerve disorders.
Nerve conduction velocity (NCV) tests can precisely measure the degree of damage in larger nerve fibers, revealing whether symptoms are being caused by degeneration of the myelin sheath or the axon. During this test, a probe electrically stimulates a nerve fiber, which responds by generating its own electrical impulse. An electrode placed further along the nerve’s pathway measures the speed of impulse transmission along the axon. Slow transmission rates and impulse blockage tend to indicate damage to the myelin sheath, while a reduction in the strength of impulses is a sign of axonal degeneration.
Nerve biopsy involves removing and examining a sample of nerve tissue, most often from the lower leg. Although this test can provide valuable information about the degree of nerve damage, it is an invasive procedure that is difficult to perform and may itself cause neuropathic side effects. Many experts do not believe that a biopsy is always needed for diagnosis.
Skin biopsy is a test in which doctors remove a thin skin sample and examine nerve fiber endings. This test offers some unique advantages over NCV tests and nerve biopsy. Unlike NCV, it can reveal damage present in smaller fibers; in contrast to conventional nerve biopsy, skin biopsy is less invasive, has fewer side effects, and is easier to perform.
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What treatments are available?

No medical treatments now exist that can cure inherited peripheral neuropathy. However, there are therapies for many other forms. Any underlying condition is treated first, followed by symptomatic treatment. Peripheral nerves have the ability to regenerate, as long as the nerve cell itself has not been killed. Symptoms often can be controlled, and eliminating the causes of specific forms of neuropathy often can prevent new damage.
In general, adopting healthy habits-such as maintaining optimal weight, avoiding exposure to toxins, following a physician-supervised exercise program, eating a balanced diet, correcting vitamin deficiencies, and limiting or avoiding alcohol consumption-can reduce the physical and emotional effects of peripheral neuropathy. Active and passive forms of exercise can reduce cramps, improve muscle strength, and prevent muscle wasting in paralyzed limbs. Various dietary strategies can improve gastrointestinal symptoms. Timely treatment of injury can help prevent permanent damage. Quitting smoking is particularly important because smoking constricts the blood vessels that supply nutrients to the peripheral nerves and can worsen neuropathic symptoms. Self-care skills such as meticulous foot care and careful wound treatment in people with diabetes and others who have an impaired ability to feel pain can alleviate symptoms and improve quality of life. Such changes often create conditions that encourage nerve regeneration.
Systemic diseases frequently require more complex treatments. Strict control of blood glucose levels has been shown to reduce neuropathic symptoms and help people with diabetic neuropathy avoid further nerve damage. Inflammatory and autoimmune conditions leading to neuropathy can be controlled in several ways. Immunosuppressive drugs such as prednisone, cyclosporine, or azathioprine may be beneficial. Plasmapheresis-a procedure in which blood is removed, cleansed of immune system cells and antibodies, and then returned to the body-can limit inflammation or suppress immune system activity. High doses of immunoglobulins, proteins that function as antibodies, also can suppress abnormal immune system activity.
Neuropathic pain is often difficult to control. Mild pain may sometimes be alleviated by analgesics sold over the counter. Several classes of drugs have recently proved helpful to many patients suffering from more severe forms of chronic neuropathic pain. These include mexiletine, a drug developed to correct irregular heart rhythms (sometimes associated with severe side effects); several antiepileptic drugs, including gabapentin, phenytoin, and carbamazepine; and some classes of antidepressants, including tricyclics such as amitriptyline. Injections of local anesthetics such as lidocaine or topical patches containing lidocaine may relieve more intractable pain. In the most severe cases, doctors can surgically destroy nerves; however, the results are often temporary and the procedure can lead to complications.
Mechanical aids can help reduce pain and lessen the impact of physical disability. Hand or foot braces can compensate for muscle weakness or alleviate nerve compression. Orthopedic shoes can improve gait disturbances and help prevent foot injuries in people with a loss of pain sensation. If breathing becomes severely impaired, mechanical ventilation can provide essential life support.
Surgical intervention often can provide immediate relief from mononeuropathies caused by compression or entrapment injuries. Repair of a slipped disk can reduce pressure on nerves where they emerge from the spinal cord; the removal of benign or malignant tumors can also alleviate damaging pressure on nerves. Nerve entrapment often can be corrected by the surgical release of ligaments or tendons. I have advanced training in this field and am more than willing to diagnose, treat, and manage these peripheral nerve disorders.

Treatment Options for Neuromas

'Morton's neuroma' (also known as Morton's metatarsalgia, Morton's neuralgia, plantar neuroma and intermetatarsal neuroma') is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the third and fourth intermetatarsal spaces.
This problem is characterised by numbness and pain, relieved by removing footwear and is commonly described by my patients as "feeling like walking on a bunched up sock".




It's not really a neuroma. Adding the Greek suffix "-oma" to a word literally means "tumour". That's why we attach it to words referring to cancerous conditions like lymphomas and benign tumours like fibromas.
A neuroma is not really a tumour at all. It's actually a growth of scar tissue around a nerve, due to chronic irritation. Instead of our using the word "neuroma", the more proper name for the condition would be "perineural fibrosis", which literally translates to "scar tissue around the nerve".

What are my options for treatment at FFLC?

Here at our center we try to avoid any surgical excision by performing various treatments which are minimally invasive, safe, and proven to be effective.

We typically offer several options, one being serial injections of a sclerosing alcohol mixture to dull the painful lesion and ultimately reduce the frequency and severity of the pain experienced. This is a weekly event, which may take up to 10 injections (effectively treating the lesion within 3 months time and avoiding surgery). We have had great success with the injections, and the are very beneficial for patients who are otherwise not great surgical candidates (especially patients with other medical problems which carry higher risk for surgery). Occasionally we use our ultrasound device to pinpoint our injection more accurately, to thereby target the nerve lesion with improved results in more difficult cases.

Another option is cryosurgery. This is illustrated on our Youtube channel. This is a small "stab" incision which is placed between the digits which are on either side of the pain. Then we use the ultrasound machine to visualize the placement of the cryoprobe. Our assistants hold the probe still while it delivers subzero temperature at a pinpoint location which we can see on the small screen. It is done in the office, and with minimal risk. Patients do well with this modality, and leave without a stitch. They follow up with us weekly until the wound is closed, and they are relatively pain free from that time foward.

This is the most common area of symptoms in a neuroma.

We advise patients that no surgery or technique is perfect, and must let you know that a possiblity of recurrence, pain, numbness, and infection are unlikely but known complications. And we reserve open excision for patients with large bulbous neuromas which are either palpated easily in a clinical setting, or visualized well on advanced imaging such as MRI. The large lesions, as well as revisional surgeries may require more invasive surgery but this is not the majority of cases by any means.

When you have finished the treatment course for neuroma ablation/excision, you will feel a numb sensation between the toes which the lesion was found. This is the most common complication, but it is not a true complication. Especially when that area was previously painful and quite problematic while walking.

Arthrosurface and You

Great Toe - Product Overview
The Arthrosurface® HemiCAP® system is a surgical method for the treatment of localized cartilage lesions and defects in the major joints. This system is comprised of three elements; a three-dimensional mapping technology, a set of instruments to map and prepare the damaged area and a cobalt-chrome and titanium implant. The system precisely aligns the surface of the implant to the contours of the patient's articular cartilage surface, thus filling the defect and restoring a smooth and continuous articular surface. The HemiCAP® system has been developed so that it can be utilized via minimally disruptive surgical techniques.

The HemiCAP® Instrument Set enables the surgeon to accurately place the implant and precisely map the curves of the articular surface, in real-time, under direct or arthroscopic visualization, with no angle-induced errors or magnification errors that might exist with MRI, or X-ray imaging techniques.

The HemiCAP® system is intended to provide an effective interim means for managing pain and disability in the middle-aged patient until a total joint replacement treatment option becomes more necessary, and is part of a clinical treatment strategy to help avoid early-age-revision scenarios. The prosthetic may also provide a treatment option for the older patient who may not tolerate the morbidity of a total joint replacement procedure.
The HemiCAP® implants and instruments are designed to remove a minimal amount of bone stock, preserve functional structures and tissues, and allow for an uncomplicated removal in the event of revision. (Taken from the manufacturer's website)

As far as implants go, this utilizes very minimal bone ressection which makes is easier to fuse the joint down the road if the need arises with less need for bone graft and plating techniques. Ultimately this implant in the right patient will do well. If you are too active, young, have Gout, or have bad arterial circulation you are probably not a good candidate for this procedure. Regardless, if you are having joint pain in the first toe joint and other doctors have told you that fusion is your only option, it would not be detrimental to stop here and let us decide if this implant is a good "fit" for you.

LASERS and Nail Fungus

Nail fungus is a chronic condition which manifests as a thickening, yellow or brown discoloration highly associated with concurrent tinea pedis (athlete's foot). This condition has made recent news on account of new NON FDA approved treatments which are beginning to surface here in Naples. I often am asked about the new high tech treatment which is said to be painless and effective. This is LASER fungal ablation. I am highly skeptical about this treatment, as it is only shown to have efficacy in the short term. I am certain it is not covered by insurance, and I doubt it is a first line treatment modality as of yet in terms of standard of care. Regardless, I am glad to enlighten our readers on the topic, and perhaps we can gain a fundimental understanding about this treatment modality.

Noveon Laser
Nomir Medical Technologies in Waltham, MA is developing a laser called Noveon for treatment of nail fungus. Noveon is a type of laser already commonly used by doctors for treatments like cataract surgery, dental work and hair removal. Noveon beams two different wavelengths of near-infrared light at toenails to selectively take aim at and kill fungi.In the latest study, after four Neovon laser treatments, about half of the 39 toenails tested no longer had active nail infections. Six months after the initial treatment, about 76 percent of the patients had clear nail growth,.

Patholase Laser
Another company, Patholase, is already marketing the Patholase PinPointe FootLaser for treatment of fungal nails. Clinical trials released by the company report 88% cure of the fungal infection with one laser treatment. However, according to a March 19, 2009 article in the New York /Times, the company’s claim of FDA approval for this procedure is being questioned. We will keep track of how this progresses and update this page when we have new information.

Will this Treatment be covered by Insurance?

Laser treatment of nail and skin conditions is not covered by insurance plans as it is considered aesthetic. You can expect the cost to run between $600 and $1200.

Recommendations
If this modality seems applicable to you, by all means feel free to explore it. I am certain that more cost effective measures should be taken first, and if traditional treatment fail, perhaps the pursuit of more advanced treatment should then be entertained. This is an off label use of LASER modality, and only time will tell if it is advantagious longterm or at all to utilize this costly treatment protocol.

Pesky Warts

What exactly are they?? How did I come to get them? What can I do to rid my skin of them??


These are the main questions that patients frequently ask me when I initially see them for these lesions. I plan to answer each one and give you some insight as to what sorts of treatment strategies are available at our center.


Verruca vulgaris, or verruca plantaris is an epidermal manifestation of a viral infection from particles of the human papilloma virus. This sounds rather deleterious, but truthfully this is a mild variation of viral substances which are in a family of pathogens that cause various wart like lesions in other areas of the body. To simplify, it is a virus that causes wart tissue proliferation. The virus produces it's own blood supply, and the tissue gets thick very quickly causing the characteristic black spots within. When we "scrape" the wart off, we can see pinpoint bleeding from the vessels created by the viral tissue.












The skin has lines which we see as "Fingerprints" and the skin on the bottom of our feet have them too. When viral particles integrate with the skin tissue, these lines disappear. This is another clue towards the diagnosis of verruca.

The reason some people are susceptible to contracting plantar warts is a controversial topic. Some researchers believe it is stress. Others believe a juvenile immune system, or immune compromised individual are more prone. I believe there are a multitude of reasons, but don't fret if you think you will spread them to everyone in your family, because chances are you will not. They are contagious, but only to those who have the inherent susceptibility to getting them.

Treatment is varied, and little scientific research has shown one method of wart removal to be superior to another. In my practice, I have seen warts spontaneously resolve, and I have seen multiple attempts of their removal including surgery fail. They are resilient at times, and at other times they are simple to cure. Some believe with younger patients, you can actually coax the wart to resolve by simply drawing a picture of the wart and crumbling the artwork into the trash.

At the Family Foot and Leg Center, we have an excellent track record in their eradication. We use a multitude of treatment modalities, including PlantarStat application, Cryofreeze technology which using subzero temperatures to remove the lesions, and simple surgical excision as major options. Duct tape has also been utilized as an occlusion material with our medications, to soften the tissue and some believe even elicit further immune response against the viral particles. Come in to see us and we will be happy to assist you in your need to remove those pesky warts.

Adult Acquired Flatfoot (AAF)

Why do some adults get flat feet when they weren't born with flat feet ?

Occassionally I will get questions which are profound, as they give me insight into what people want to know as a whole. So whenever I get a good question I will try and answer it on this blog. This information may answer many of your questions that you did not know you had at the time, and may make for some intelligent reading as well.

The adult acquired flatfoot (AAF) is a progressive, symptomatic (painful) deformity resulting from gradual stretch of the tibialis posterior tendon as well as the ligaments that support the arch of the foot.

Most flat feet are not painful, particularly those flat feet seen in children. In the adult acquired flatfoot, pain occurs because soft tissues (tendons and ligaments) have been torn. The deformity progresses or worsens because once the vital ligaments and posterior tibial tendon are lost, nothing can take their place to hold up the arch of the foot.

The painful, progressive adult acquired flatfoot affects women four times as frequently as men. It occurs in middle to older age people with a mean age of 60 years. Most people who develop the condition already have flat feet. A change occurs in one foot where the arch begins to flatten more than before, with pain and swelling developing on the inside of the ankle. Why this event occurs in some people (female more than male) and only in one foot remains poorly understood. Contributing factors increasing the risk of adult acquired flatfoot are diabetes, hypertension, and obesity.

The following scheme of events is thought to cause the adult acquired flatfoot:

1) A person with flat feet has greater load placed on the posterior tibial tendon which is the main tendon unit supporting up the arch of the foot.

2) Throughout life, aging leads to decreased strength of muscles, tendons and ligaments. The blood supply diminishes to tendons with aging as arteries narrow.

3) Heavier, obese patients have more weight on the arch and have greater narrowing of arteries due to atherosclerosis. In some people, the posterior tibial tendon finally gives out or tears. This is not a sudden event in most cases. Rather, it is a slow, gradual stretching followed by inflammation and degeneration of the tendon.

4) Once the posterior tibial tendon stretches, the ligaments of the arch stretch and tear. The bones of the arch then move out of position with body weight pressing down from above. The foot rotates inward at the ankle in a movement called pronation. The arch appears collapsed, and the heel bone is tilted to the inside. The deformity can progress until the foot literally dislocates outward from under the ankle joint.

Treatment varies based on the stage of the disease, and each patient is treated differently based on findings. Arthritis, age, comorbidities, and whether it's flexible or rigid greatly influence the the foot and ankle surgeon's modalities. Surgery and bracing are key elements to reconstruction and palliative symptom control.

In this section, I encourage readers to submit questions/comments/personal stories/etc and I will definetly respond on this forum. I enjoy informing people about their conditions and the reasons why we do what we do for them. I do not have all the answers, as nobody can say they do, but I will strive to report the latest information available and keep you up to date as I go through these many topics.

Smoking and Bone Healing

After joining the Family Foot and Leg Center here in Naples, Florida, I have met quite a number of younger adult patients who have no idea of the deletarious effects that smoking can have on overall healing. Although this is a circumstantial finding backed by significant amounts of statistical evidence, many younger patients still are not aware of this. I thought it would be beneficial to enlighten everyone about this common topic.

Why are bones affected by smoking?


Bones are nourished by blood much like the other organs and tissues in your body. Nutrients, minerals, and oxygen are all supplied to the bones via the blood stream. Smoking elevates the levels of nicotine in your blood and this causes the blood vessels to constrict. Nicotine constricts blood vessels approximately 25% of their normal diameter. Because of the constriction of the vessels, decreased levels of nutrients are supplied to the bones. It is thought that this is the reason for the effect on bone healing, as the impending need for more oxygen and nutrients during fracture and osteotomy healing are not met, causing prolonged union time.

Evidence Based Medicine Review

"Cigarette smoking is detrimental to bony healing," said Dr. Franklin Chen, an orthopaedics instructor at Northwestern University Medical School in Chicago, Illinois, and lead author of a report presented at the recent annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held in New Orleans, Louisiana.
He and his colleagues focused on the 13-month healing rates of 54 patients who underwent surgery to help correct a specific type of (often work-related) wrist injury called symptomatic ulnar impaction syndrome. Chen says "95% of nonsmokers healed compared to 68% of smokers; this difference is statistically significant. The mean time to healing was 5 months for nonsmokers and 7.2 months for smokers." Previous studies have shown similar slower healing rates among smokers who have undergone spine or ankle fusion surgeries.

So that being said, it is important to note that when I or any of the physicians at our office "lecture" to you about the cessation of smoking and it's direct impact on your healing potential, we are not just being mean. It's based on clinical evidence that is monumental for your optimal outcome. This can impact healing time in stress fractures and wound healing as well, so cessation is your best bet!!!

Here is a link to a recent news article discussing this topic as well:

http://www.msnbc.msn.com/id/9730345/

Heel Pain and Life

So many people suffer from this day ruining clinical entity loosely labeled "heel pain". I often wonder what the staggering statistics would reveal about how many people encounter this at some point in their lives, especially since many people who deal with this will not enter the doctor's office at all, or wait until it has been bothersome and worsening for a number of months. Some will find out they will get better on their own. The rest will limp into the chair and tell us that they feel their life is in shambles because they are constantly in pain.

Many patients who deal with heel pain are most likely going to be under the common diagnosis of "plantar fasciitis". There are many other conditions that reveal themselves by heel pain as well, and these can be diagnosed by exclusion most times in a clinical setting. On it's own, plantar fasciitis is a relatively easy condition to treat, and there are many options to treat this nonsurgically. I will describe some simple stretch routines as well as ways to relieve this prior to any physician intervention.















Foot/Toe Stretch:
 Sit on a chair and place your ankle over the opposite knee.
 Grip toes and gently pull them back towards the knee, while holding the ankle to prevent it from moving.
 Feel the stretch in the sole of the foot all the way to the heel.
 Hold the stretch for 30 seconds.
 Repeat three times for each foot

Sometimes you can simply ice the foot with a frozen water bottle and roll this along the bottom of the foot at the end of the day for 3 to 10 minutes. Some people found that even having their significant others give a simple foot massage can alleviate these symptoms significantly. Also over the counter ibuprofen or other medicine (NSAID) can be useful. If this persists for more than a four week period of time without any relief, one should come see us at the Family Foot and Leg Center, PA so that we can get you over this hurdle and let you live without pain in the foot.