Mucoid Cysts in the Toes

Sometimes a small cyst or ganglion will form on the toes at the joint just behind the toe nail. If punctured a thick gelatinous fluid escapes. These are technically tiny toe ganglions but in this location they are more correctly knows as a mucoid cyst. They are frequently treated by a "puncture" and the injection of a bit of cortisone. Unfortunately they often recur. A more permanent correction involves the removal of a little bone.

Solving this problem will require a "hammertoe" surgery that can be done in the office with local anesthesia or the surgery center under local anesthesia with a bit of sedation. A surgical shoe will need to be worn for a week or two followed by a tennis shoe for another week or so.

This is a fluid filled cyst that balloons out from the underlying joint (much like the inner tube of a bicycle tire can squeeze out between the cracks of an old tire). Sometimes these pesky little things will go away by puncturing the cyst with a needle (of course, after anesthetizing the toe first!) and injecting a drop or tow of cortisone. Most of the time they come back after this kind of I&D (incision and drainage) and they need to be removed surgically. Even surgery can fail if you are not aggressive and take the entire cyst, down to the bone.

Lisfranc injury ends NFL season potentially

Matt Schaub of the NFL's Houston Texans, sustained a midfoot sprain to the right foot, notably called a "Lisfranc" injury in last week's game. This is considered a "significant injury" which has the potential to end his season in 2011.







Why is that?








Most players require lateral movement and the ability to jump and stop suddenly after sprinting. These are all functions that the midfoot complex will play a significant role in accomplishing. The injury itself is a complicated one, with numerous variations that each have a significant prognosis in longterm funcion. This injury may have a pure ligamentous tear, or even a fracture component with the ligament tear. With this, some orthopedic literature has condoned the possibility that with regards to athletes, surgery may be indicated in more cases to realign the foot and promote more stability longterm. Other studies have shown that if the alignment is maintained with the bones of the midfoot, a cast or walking boot may be sufficient for a minimum of 6 weeks followed by progressive weight bearing.


Classification
There are three classifications for the fracture:

1) Homolateral: All 5 metatarsals are displaced in the same direction. Lateral displacement may also suggest cuboidal fracture
2) Isolated: 1 or 2 metatarsals are displaced from the others
3) Divergent: metatarsals are displaced in a sagittal or coronal plane. May also involve intercuneiform area and a navicular fracture.

Treatment
Treatment options include operative or non-operative treatment. If the dislocation is less than 2 mm, the fracture can be managed with casting for 6 weeks. The patient's injured limb cannot bear weight during this period. For operative treatment, screws +/- k-wire will be used for internal fixation of the fracture after closed or more likely open reduction. Again, the patient's injured limb should not bear weight for approximately 6–12 weeks. The screws/k-wires are usually removed later, sometimes before weight bearing.

At FFLC, we find this injury to be a relatively underdiagnosed entity, and have had to treat numerous late onset arthrosis, as well as acute injury patients with this mechanism of injury. If you are on the field, and you twist your foot and it remains painful, it is not a straightfoward injury and should be followed by a foot and ankle surgeon.

Even with that being said, the possibility of late onset arthrosis and deformity can ensue without proper diagnosis, and in the NFL the players are fortunate to have medical professionals there to diagnose them right at the time of injury.

Is MRI really being overutilized?

So often in this litigious society, practitioners are being scrutinized by lawyers for malpractice. This includes lacking diagnostic information to either support or negate a diagnosis. That is why wounds are cultured without looking "infected" and why radiographs are done even after soft tissue surgery. So often are practitioners forced to practice "defensive medicine" that the costs for health care are going to rise simply because of these examinations. Without these tests to "confirm" a diagnosis, surgery may not be authorized by an insurance company, or if someone is injured on the job or as part of a traffic accident, the extent of damage may be overlooked.

This is in my opinion, that these tests need to be done. MRI should be ordered to confirm or negate osteomyelitis in the presence of diabetic foot wounds. Also with severe ankle sprains to rule out underling ligamentous damage or cartilage lesions. Without the tests, even in the presence of clinically suspicious findings, there will always be a malpractice lawyer who will ask you, "why didn't you get the test, Dr?"

In the case of MRI, there are few to no real risks, as there are no radiation exposures for this exam. Also, for patients that are not able to have this test (ie. pacemaker,etc) it is usually determined by CT scan for whatever the reason for the advanced imaging. In other words, these tests are available and although not entirely necessary, they are invaluable to not only diagnose with more certainty, but also allow for surgical planning and provide further means to demonstrate pathology leading towards surgical intervention in the case of malpractice depositions.

The coutnter argument is that over-utilization of MRI is expensive and wasteful, according to researchers. For example, the information needed to diagnose knee OA can be obtained using x-ray. While an x-ray can cost less than $150, the cost of an MRI is about $2,500.
Medical imaging accounts for 10 to 15% of Medicare payments to physicians. Ten years ago, medical imaging accounted for less than 5%. The cost of medical imaging is expected to continue soaring at an annual rate of at least 20%. Suffice to say, it's an expensive business.

And sometimes, MRI findings may be overly sensitive, leading to incorrect diagnosis, or over diagnosis of tendon pathology.

This nails home another concept I have discussed on here on many occasions. We treat the patients, not the MRI findings. We need to understand the personality of the injury and how that injury is presenting itself in you, how your lifestyle or quality of life is affected, and whether or not the findings that we have identified on the MRI are in fact the competent producing cause of your discomfort — and then come up with an appropriate treatment plan that will likely involve a period of nonsurgical management— which, if unsuccessful perhaps might lead to an indicated surgical procedure, if your lifestyle changes and quality-of-life dictates that this is in fact an option.

Skin lesions on the foot

Example of a MRSA infection started as a "rug burn" with this gentleman rough housing with his dog.

Many patients know about how important sunblock is to avoid cancer from the sun. However, most primary care doctors and even some dermatologists may miss looking at skin on the foot. Numerous times each year, we play a role in the diagnosis of skin disorders from biopsies of lesions on the foot and leg. Each lesion that the skin creates will tell a small story as to the inner health of each patient. And even if a lesion is not painful, or is located somewhere you are not usually able to look at, it can be something quite problematic.

We condone the biopsy of any lesion that changes colors, bleeds, or looks different than other lesions on your body. This may include open lesions, pigmented lesions, blistering lesions, and even rashes. The skin only has several ways to show a clinician that something is wrong. That means that thousands of disease processes can only be shown by skin in less than 10 ways. That is a tough thing to diagnose without a definitive biopsy. Most dermatologists require yearly skin exams for anyone with a prior squamous or basal cell carcinoma. And melanoma should be checked for at least 2x yearly. Lesions of the foot and ankle are often found by a foot and ankle surgeon prior to most other specialists or general practitioners, and it is imperitive that a biopsy be performed.

Lesions like the above can actually be a multitude of pathologies being represented by a simple rash. In this case tinea pedis was the diagnosis initially. After 2 months of topical therapy it was later diagnosed with a biopsy as a squamous cell carcinoma (skin cancer).

This is a common presentation of a plantar wart. This is also important to send to a pathologist if they are excised as this may also have several other more aggressive variations of melanomas which can mimic this otherwise harmless viral skin infection.

Any lesion that you are unsure of should get checked by a doctor, whether that is your foot and ankle surgeon, general practitioner, or dermatologist or other specialist. No lesion is too small, or insignificant to investigate.

Wound Care at FFLC

Diabetic pressure wounds are prevalent on the feet of many neuropathic patients. Usually, if the arterial circulation is adequate, and the nutrition status is evaluated for protein intake, the final step is to offload the area. This is, in my experience, the most difficult part of wound care in our population. Everyone wants to remain active, and walking is a major component of this mentality. This picture is an example of a forefoot pressure ulceration, which is directly related to an equinus deformity combined with neuropathy in an insulin dependent diabetic female who has been to a wound care center for 2 years prior to my evaluation. After my initial screening protocol, which consists of taking an xray, listening to the arterial pulse with a hand held dopplar, and recording a HA1c value to determine longterm blood glucose control, I moved on to the physical examination of biomechanics. In her case, the main issue was not an underlying bone infection, or ill fitting shoes (as she had custom shoes with offloading soft insoles already placed). A definitive diagnosis of "gastroc equinus" was diagnosed.






After 2 weeks of continued debridements in the office the wound began to improve, but the central deepest portion was next to impossible to offload.










At this time, the patient was scheduled for an endoscopic gastroc recession, which is done with a 0.7 cm incision that heals in most cases after 7 days. This is a profound procedure which offloads the forefoot considerably, and in her case was the final step towards healing her wound. She also had a dermal skin graft application which also heavily increased the healing capacity of this particular wound.






There are many examples of how wound care can be performed by looking at the global picture in each patient. Sometimes the foot structure itself is the issue and requires reconstruction. Sometimes a bone infection is underlying, and excision of that portion of the bone is required, and even sometimes a leg needs more circulation requiring vascular interventions. Here at FFLC, we strive to be at the cutting edge of limb salvage, which may entail any number of procedures tailored to each individual patient. We work closely with the infectious disease and vascular surgeons to offer a team oriented approach to wound care. This allows rapid wound healing, and lowers the statistical possibility of deep seeded infections which can lead to amputations.

Each wound has a cause, and without a thorough examination, followed by extensive diagnostics and microbiologic cultures, many wounds will remain nonhealed. At FFLC, we offer comprehensive limb salvage efforts which transcend most private offices. We really do have the mindset of a wound care center. Weekly comprehensive debridements, Xrays on site, MRI and ABI testing nearby, and for the more complex wounds a reconstruction repitoire which may consist of internal and external fixation. We take limb salvage very seriously, and we all know that once a limb is lost, the statistics are not in a patient's favor for a 5 year lifespan afterwards in diabetic patients.

Navicular Fractures in Athletes

Numerous patients experience this sort of injury living an active lifestyle in Naples Florida.

Recently, Ben Roethlesberger of the Pittsburg Steelers also suffered a similar injury (although not confirmed by the Steelers), and he may need some time off his foot to sufficiently heal his injury. We see a number of patients who will have the vague symptoms of pain after activity in the medial aspect of the rearfoot area, which will not show anything on regular xrays. After 3 months, most doctors will refer to us for further workup. We usually will obtain more advanced study such as CT or MRI, and depending on what it shows, treatment ensues. This is one of the latest articles regarding this topic, which in short, demonstrates how a minimally displaced fracture may still require screw fixation in select cases to adequately relieve symptoms and ensure return to sporting activity in a reasonable timeline.

Published in: Journal of Foot & Ankle Surgery, March/April, 2000
Amol Saxena, DPM


22 Navicular Stress Fractures sustained during athletic activity were retrospectively reviewed for return to activity time and the appearance of fracture pattern on Computerized Tomography. Average follow-up was 36.5 months. There were 10 females and nine males, with the average patient age being 27.2 years. Three patients sustained bilateral injuries at separate times.

Nine patients underwent open reduction, internal fixation (some with bone grafting); this group’s average return to activity (RTA) was 3.1 +1.2 months (range = 1.5-5 mos). Thirteen patients treated conservatively had an average return to activity of 4.3 +2.8months (range = 2 –13 months). The difference between the two groups’ RTA was significant (P=.02). Eleven patients utilized Pulsed Electromagnetic Fields and had an average RTA of 4.2 +3.4 months with three patients also having surgery. (The latter three patients had the fastest RTA at 3.0 months.) Two conservatively treated fractures that eventually took five and eight months to RTA, respectively, re-fractured during the treatment process.

Retrospective review showed CT fracture patterns in the frontal plane classified as: Dorsal cortical break (Type I), fracture propagation into the navicular body (Type II), and fracture propagation into another cortex (Type III). This is proposed as a classification system and is to include modifiers "A" (Avascular Necrosis of a portion of the navicular),"C" (Cystic changes of the fracture), and "S" (sclerosis of the margins of the fracture), the latter of which was most common in our series, particularly in continually symptomatic patients. Type I fractures were more likely to receive conservative treatment (P = .02) and Type III fractures took significantly longer to heal than Types I and II, (P values .001 and .01, respectively.) Type I and II injuries had an average RTA of 3.0 and 3.6 months, respectively. Type III injuries had an average RTA of 6.8 months. Based on our findings we recommend surgery for patients with these modifiers, particularly with Type II and III injuries.

Conservative treatment may be prolonged, and requires at least 6 weeks of non-weight bearing in a below knee cast/boot to be successful.

Achilles Injuries in the NFL

Jon Beason out for year with torn Achilles

Even the most conditioned athlete, with the support of numerous athletic trainers and coaches, can succumb to the devastating injury of Achilles ruptures. The worst part about this fact, is that the injury can eliminate most patients from returning to prior-injury function without adequate treatment.




The Achilles is the strongest tendon in the body, however the forces that are exerted by this structure exceed loads equal to tow trucks pulling on a stationary car for portions of a second during exercises. Many patients are seen in our office with various injuries to this area, and some with spontaneous ruptures. I had previous discussed how this can occur, and for the sake of sports injuries I will limit this discussion to when load exceeds the Young's modulus for the tendinous structures.


This bascially means that the tendon has more force than the inherent scaffolding is able to withstand. This leads to weakening of the collagen matrix and eventually can lead to ruptures. In partial and complete ruptures associated with exercise and impact sports, surgery is recommended to reduce the rate of re-rupture. But as you may have read, our Carolina Pro Bowl linebacker will be sidelined with this for the season, because it may take up to 12 months for full remodeling of the tendon to occur even with surgical repair.

We use a nonabsorbable suture method which contains a metallic wire filament called a "tightrope". This is never absorbed by the body, and is interwoven throughout the tendon to reapproximate it's tension prior to the rupture. The body then needs to augment this surgical repair by bridging the collagen matrix across the damaged portion of the tendon until full strength is achieved. I always tell patients that it will take 3 months to walk again, and a year to run again. This is by no means a minor injury.

Hopefully the Panthers have a good backup for their otherwise healthy linebacker this season !

How can diabetes deform my foot ?

Collapse of my foot and diabetes:



Charcot neuroarthropathy is a common cause of morbidity in persons with diabetes mellitus and sensory neuropathy. Although Charcot neuroarthropathy is a clinical diagnosis, recent advances in diagnostic imaging have eased the clinical challenge of deciphering infection from Charcot changes. Bone infections should be ruled out entirely before this can be said to be the diagnosis. Advances in surgical treatment have demonstrated new options for limb salvage.




There are several proposed mechanisms, but mainly it is most acceptable to believe that uncontrolled or difficult to control diabetic blood sugar levels lead to nerve damage which allows numbness to replace sensation. This allows bones to break naturally over time which go unnoticed by the individual, and the bones become inflamed and eventually break down and collapse with extensive fractures and swelling. This is a simplified description of the deforming process of Charcot foot.




Then and now.

In the recent past, the best treatments have been said to include below the knee amputations, and cumbersome braces which need to be consistently maintenenced and refurbished.

"Surgery on a diabetic is dangerous".




This was a common theme which precluded the possibility of reconstructive procedures to minimize deformity and were largely not based on evidence based medicine. Today it is known that in the vast majority of patients who develope these deformities, circulation is not compromised on a macrovascular level, but instead may be such in a microvascular setting. That means essentially that the small vessels may have glycosylated end products which impede wound healing. This usually is not on it's own a contraindication to reconstruction either, as the most common driving force for wound healing complications in this patient population may be more directly related to the abnormal bone prominences formed by the collapsing foot.

Today's current outlook on this disease process:




At FFLC, we treat all stages of this disease. Initially, we will order several important tests and imaging studies to assess the structural deformity and assess the body as a whole to come to the conclusion which is best for each patient. Newer external treatments such as multiplanar external fixation with either Achilles tenotomy or gastroc recessions, and immobilization have been a mainstay in the acute stages of the disease over the last 10 years. For chronic stable deformities, medial beaming techniques are utilized to realign the foot and ankle to a more straight position to offload centrally located ulcers.

A team approach is also essential for treatment of this complexity. Diabetes is a difficult clinical beast to slay, and whenever this systemic concern is not maintenced well, recurrence of Charcot (along with many other deletarious concerns) is likely. Usually reconstruction of the foot and ankle is performed on the presumption that multidisciplinary functions are well coordinated, such as endocrinology referral, infectious disease, vascular surgery, home health care nursing, physical therapy, and primary care are all significant parts of the entire process.

It literally takes an entire team of healthcare professionals to save a limb.

"TAKE YOUR VITAMINS" :

How vitamin D levels can impact even healthy active patients !

Low Vitamin D Linked to NFL Injuries.

Low levels of vitamin D can increase a professional athlete’s odds of injury, according to study findings by Summit Medical Group, a study of 89 players from the NFL’s New York Giants during their 2010 pre-season evaluations, 80 percent of the players were found to have insufficient levels of vitamin D. Findings also revealed that African American players and players who suffered muscle injuries had significantly lower levels. For the study they analyzed data on the number of players who had lost time due to muscle injuries. Vitamin D levels were then classified based on player race and time lost due to muscle injury.

It was presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Annual Meeting in San Diego on Sunday July 10, 2011.

Symptoms and Health Risks of Vitamin D Deficiency

Symptoms of bone pain and muscle weakness can mean you have a vitamin D deficiency. However, for many people, the symptoms are subtle. Yet even without symptoms, too little vitamin D can pose health risks. Low blood levels of the vitamin have been associated with the following:

1, Increased risk of death from cardiovascular disease
2. Cognitive impairment in older adults
3. Severe asthma in children
4. Some forms of cancer


Vitamin D is manufactured in the human body when bare skin is exposed to sunlight. Your body needs vitamin D to absorb calcium, a mineral essential to bone structure, muscle function and cardiovascular health. According to the Linus Pauling Institute at Oregon State University, vitamin D deficiency can cause muscle weakness and pain and low bone-mineral density in both adults and children. Studies have revealed a correlation between the incidence of traumatic injuries and vitamin D status.
Research suggests that vitamin D could play a role in the prevention and treatment of a number of different conditions, including type1 and type 2 diabetes, hypertension, glucose intolerance, and multiple sclerosis.

New research has connected vitamin-D deficiency to an increased risk of muscle injuries in athletes.

Researchers looked at 89 football players from a single NFL team and conducted lab tests of vitamin D levels in the spring of 2010. The mean age of the players was 25.The team gave the researchers data to allow them to determine which players had lost time because of muscle injuries.The results showed that 27 players had deficient levels of the sunshine vitamin, and 45 more had levels consistent with insufficiency. Only 17 players had levels within normal limits. Sixteen players had suffered a muscle injury—and the mean vitamin-D level of the injured players was 19.9 nh/mL, a deficient value.


Causes of Vitamin D Deficiency

Vitamin D deficiency can occur for a number of reasons:

IF

1. You don't consume the recommended levels of the vitamin over time. This is likely if you follow a strict vegetarian diet, because most of the natural sources are animal-based, including fish and fish oils, egg yolks, cheese, and beef liver.
2. Your exposure to sunlight is limited. Because the body makes vitamin D when your skin is exposed to sunlight, you may be at risk of deficiency if you are homebound, live in northern latitudes, wear long robes or head coverings for religious reasons, or have an occupation that prevents sun exposure.
3. You have dark skin. The pigment melanin reduces the skin's ability to make vitamin D in response to sunlight exposure. Some studies show that older adults with darker skin are at high risk of vitamin D deficiency.
4. Your kidneys cannot convert vitamin D to its active form. As people age their kidneys are less able to convert vitamin D to its active form, thus increasing their risk of vitamin D deficiency.
5. Your digestive tract cannot adequately absorb vitamin D. Certain medical problems, including Crohn's disease, cystic fibrosis, and celiac disease, can affect your intestine's ability to absorb vitamin D from the food you eat.
6. You are obese. Vitamin D is extracted from the blood by fat cells, altering its release into the circulation. People with a body mass index of 30 or greater often have low blood levels of vitamin D


Treatment for Vitamin D Deficiency

Treatment for vitamin D deficiency involves getting more vitamin D -- through diet, supplements, and/or through spending more time in the sun. Although there is no consensus on vitamin D levels required for optimal health -- and it likely differs depending on age and health conditions -- a concentration of less than 20 nanograms per milliliter is generally considered inadequate, requiring treatment.
Simple blood test can be obtained to determine if serum concentrations are within the acceptable normal limit, and those who are found to be deficient or on the lower end of normal with muscle aches, recurrent stress fractures, or other symptoms will be placed on some form of supplementary treatment protocol.
Guidelines from the Institute of Medicine call for increasing the recommended dietary allowance (RDA) of vitamin D to 600 international units (IU) for everyone aged 1-70, and raising it to 800 IU for adults older than 70 to optimize bone health. If you don't spend much time in the sun or always are careful to cover your skin, as sunscreen inhibits vitamin D production, you should speak to your doctor about taking a vitamin D supplement, particularly if you have other risk factors for vitamin D deficiency as mentioned earlier.

Many foods and drinks have fortified vitamin D as well, and also many doctor's offices are offering supplementations or at least recomendations for such in their offices.

Important News for Your Toddlers

As many kids become old enough to start walking on their own, many new challenges await the fledgling parents. Their children will want to approach and inspect everything they see, and often times they will not pay attention to where they are going leading to considerable bumps and bruising. But what if this leads to more serious injuries?

Occasionally at the FFLC, we will be consulted by our peers to treat atypical injuries arising from "freak accidents". Sometimes this occurs at a friend's house, other times it happens during the 4 seconds you are not able to see the child. Regardless gettting an accurate history about the injury is key to determine the treatment required for each injury and often times this is not possible. Sometimes the pattern or location of the injury may give the missing information some element of certainty.

Fractures in the long bones of toddlers is somewhat common, however it may happen with subtle force.

Typical symptoms include pain, refusing to walk or bear weight and limping -bruising and deformity are absent. On clinical examination, there can be warmth and swelling over the fracture area, as well as pain on bending the foot upwards (dorsiflexion). The initial radiographical images may be inconspicuous (a faint oblique line) and often even completely normal. After 1-2 weeks however, callus formation develops. The condition can be mistaken for osteomyelitis, transient synovitis or even child abuse. Contrary to CAST fractures, non-accidental injury typically affect the upper two-thirds or midshaft of the tibia.

Other possible fractures in this area, occurring in the cuboid, calcaneus, and fibula, can be associated or can be mistaken for a toddler's fracture. In some cases, an internal oblique radiography and radionuclide imaging can add information to anterior-posterior and lateral views. However, since treatment can also be initiated in the absence of abnormalities, this appears to have little value in most cases. It could be useful in special cases such as children with fever, those without a clear trauma or those in which the diagnosis remains unclear. Recently, ultrasound has been suggested as a helpful diagnostic tool if one is able to distract the youth long enough to allow a clear still leg to be examined with the ultrasound probe.

Pathophysiology
The proposed mechanism involves shear stress and lack of displacement due to the periosteum that is relatively strong compared to the elastic bone in young children. Very little is known as to the extent of the fall itself, or rather the typical fall necessary to induce this fracture pattern, but one clinical finding is never ignored: proximal tibial fractures and rib bruising with restrained behavior or timid demeanor.

It has been postulated, that multiple fractures in the absence of proven abuse or neglect, may require genetic testing to rule out underlying bone metabolizing disorders as well as other inheritable diseases. Some papers with the intent on clinical guideline development have theorized that 4 or more fractures in a 12 month period in toddlers is considered pathologic, and further testing is indicated. Others suggest that if a family history or in children whereby the familial genetics are unknown, immediate testing should be undertaken to better diagnostically evaluate the patient.

Spontaneous Injuries

Naples, Florida remains one of the most active communities I have lived in, with patients ranging in age from 60-90 years old still playing tennis and golf. Many of these same patients are very healthy and walk multiple miles every day. In lieu of the very active lifestyle that our patients enjoy, we have noticed many of these patients experience various forms of tendonitis and in some cases spontaneous tendon ruptures. Even though this can seem intuitive that with wear and tear our tendons may break down over time, some points about this pathology are notable and should be reviewed to answer a key point in this discussion: "why would this happen?"

TIBIALIS ANTERIOR:



We have had several patients complain of sudden inability to lift up the foot at the ankle, and pain in the front of the ankle with increased swelling and soreness. Usually after 4 days this pain subsides but function of the ankle becomes less efficient and eventually one will notice toes are grasping at the floor and the inside of the foot remains lowered during the "swing phase" of walking. This is a partial foot drop.

On average, the area corresponding to 0.5 to 3.0 cm proximal to its bony insertion is the most frequently reported site of spontaneous rupture of tibialis anterior tendon. This region of avascularity also corresponded to the location of superior and inferior retinacula, which serve as pulleys for the ATT mechanism. The hypothesis is that the hypoxic state of the tissue in this critical zone and the chronic impingement by the retinacula render this region vulnerable to chronic degeneration and, eventually, to rupture. This hypothesis is also believed to pertain to the Achilles and posterior tibialis tendons with their corresponding anatomy and fascial impingements.

ACHILLES TENDON:






We see this spontaneous rupture very commonly in "weekend warrior" type individuals, who remain very active on Saturday but otherwise are not apt to consistent exercise. Usually this tendon will forcibly stretch while the individual is propulsing off the ground, leaving excessive force passing thru the tendon leading to the rupture. Although the Achilles tendon is the strongest and largest in the body, it also recieves the most force on a consistent basis, which may lead to degredation over time. Chronic pain in the tendon which seems to never fully resolve may actually be the bodys attempt to heal this area, when in actuality the chronic inflammation leads to weakening of the collagen bridges that give much of the tensile strength of this structure, and over time it becomes thickened and eventually may rupture.


POSTERIOR TIBIAL TENDON:





This tendon has a long history of slow, progressive weakening which leads to flatfoot deformity in adulthood. Usually the tendon is not likely to spontaneously rupture until a patient is in their forties. Being overweight is a major contributing factor to this tendon being problematic. Many patients are wrongly diagnosed initially with plantar fasciitis, and this heel pain leads to medial foot pain, and eventually ankle pain.


Many patients will also experience atypical tendon ruptures just from their other comorbidities. Rheumatoid arthritis, and other autoimmune disorders will have a much higher rate of spontaneous tendon ruptures. Also many patients who have been on various antibiotic therapy may experience widespread tendonitis and sometimes ruptures. Many times longstanding tendonitis (especially of the achilles tendon) will lead to eventual rupture without proper treatment and immobilization.

Don't ignore pain in the foot and ankle, as it may be your body's way to warn you of a possible tendon rupture waiting to happen!!

Dr Timm

Do your feet put the 'odor' in 'odoriferous'??

There are many commercials which are on television about erectile dysfunction, and I feel that in our profession the equivalent to this topic as far as being embarrassing for many patients is the topic of foot odor. Many people suffer from this condition, and it is usually ignored as a medical problem. The truth is that it can lead to several medical condition which are seen very commonly in the office of a foot and ankle surgeon.

The medical term for this excessive sweating is "hyperhydrosis" and it literally means "excessive water" or if you read between the lines even further, could mean abundant moisture.

Complications of hyperhidrosis include:

Fungal nail infections. People who sweat profusely are prone to many types of fungal infections. That's because fungi thrive in warm, moist environments, such as sweaty shoes. That's also why you're more likely to get an infection in your toenail than in your fingernail. A nail infection usually begins as a white or yellow spot under the tip of your nail. As the fungal infection spreads deeper, your nail may discolor, thicken and develop crumbling edges. Sometimes your nail may separate from the nail bed, and the skin around it may become red and swollen. You may even detect a slight odor.
Bacterial infections and warts. Hyperhidrosis can contribute to bacterial infections, especially around hair follicles or between your toes. It's also associated with warts. When you have hyperhidrosis, warts may take a while to go away after treatment and they have a tendency to recur.
Social and emotional consequences. People with hyperhidrosis typically have excessive sweating of the soles and palms, which may produce clammy hands and unpleasant foot odor. As a result, they can experience significant psychological, social, educational and occupational consequences.
Other skin conditions. Certain skin conditions, such as eczema and skin rashes, occur more frequently in people with hyperhidrosis. It may be that excessive sweating exacerbates skin inflammation.


Treatment for this may range from simple shoe and sock changes, to topical over the counter therapy. And in some instances we need to prescribe a formal treatment from your local pharmacy. In most cases, we are able to control this nuisance and allow you to return to your life without being as self conscious about your feet.

Palliative care:
Essentially, one must cycle through white socks regularly, throwing away older socks that are worn or have an odor even after washing them.
Change shoe gear and if you are active you should have new shoes for your activity every few months. Some runners should change their shoe gear every 3 months, as the miles take a toll on the materials of the shoes you use anyhow.

More than just "foot pain"

In my profession, I have diagnosed numerous and varying disorders which are not typically something a primary care doctor would initially send a patient to a foot and ankle specialist for. I have screened numerous diabetic patients, and have found a substantially high number of patients with PAD, or peripheral arterial disease. Of these, many have needed vascular surgery intervention to prevent below knee amputations. Through this screening process, we have saved numerous patients from amputations of their legs.

To a greater extent, this disorder may lead to stroke, heart attacks, and even amputations from gangrene. I have had patients ask me why they need to go to the hospital for their rest pain, and thank me after the fact. Today I thought I would give some general guidelines to put to rest many of the confusions regarding this systemic and devastating pathologic process.

"Doctor, my foot hurts me at rest. I take ibuprofen and it doesn't help. I let my leg down and it feels a little better, but when I raise it up it hurts again. I can only walk for a block then I have to rest. My ingrown nail is turning black and I stubbed it 2 weeks ago."

These are just some of the various complaints that a patient may have before they know that they have significant PAD. Slow to heal wounds, and non healing wounds are commonplace in poor circulation sufferers. Pain at rest is usually significant, because it means the tissue is starving for oxygen, and if the blood vessels are too narrowed or closed to deliver, then pain will follow. Trivial injuries which lead to significant pain and color changes of the toes, from blue to black, will also indicate a serious vascular pathology which requires hospitalization. Each patient that we see gets a thorough vascular exam for their legs, and noninvasive dopplar studies are done every Friday at our office.

Pain with consist ant ambulation, "ie intermittant claudication" may need additional interventions from a vascular surgeon. Usually blood thinners, such as plavix or aspirin are needed, as well as a walking regimen lead by a physical therapist to get 30 minutes to 1 hour of daily walking to help open the small vessels and treat this are in order. We also offer MICROVAS therapy for small vessel disease, as this tends to simulate the activity level of walking for 30 minutes, and helps to increase the blood flow to the leg and foot. I always listen to the pulses with the dopplar if I can not feel them with my hands. This is usually the case with diabetic patients, as their vessels are more rigid and difficult to feel with hands and fingers alone.

Athletes Beware: Poor foot mechanics could cost you your edge in sports!

How is this possible?



The results conducted by the American Podiatric Medical Association concluded that a staggering 73 percent of people asked said that they are suffering from foot pain.

The question is: why has foot pain become one of the most common complaints in the examination room?

For many people, this problem can be caused by one of the following: the kinds of shoes they wear, what activities they participate in, or how their feet are formed. Wearing poorly-fitting shoes can turn minor problems into major ones. People who engage in athletic activities are another segment of the population that are mostly affected by foot pain. Factors such as fallen arches, overpronation, and poor support can all be contributing factors to lower extremity pain. Parents can also be the cause of foot-related problems, because genetics play a role how the foot was formed in the womb. This can enhance the likelihood that someone will suffer from an array of painful foot conditions.

The Mechanics of the Foot
Flat feet can cause abnormal rotation of the feet when walking or running. Our feet handle balance, stability, and bear the weight of the body. The parts of the foot that help to keep the foot in harmony with the body include the arch, heel, tarsals and meta-tarsals. The arch provides stability by the following structures: the tendons, ligaments, and muscles. Pain can result from raised arches or abnormally-low arches, which can cause the foot to rotate abnormally. With high arches, the body’s weight is abnormally emphasized on the outer edge of the foot (oversupination). Conversely, overpronation happens with fallen arches because the weight of the body is concentrated on the inside of the foot, causing the ankles to roll inward .

Serious Foot Issues May Occur with Flat Feet A quick way to see if fallen arches or high arches are an issue is to find a good area where a foot impression can be made, such as on concrete. Immerse on foot in cold water and then stamp your foot onto the dry surface. Then, lift the foot off the ground and see the impression that is left by the foot. A flat foot with overpronation will leave a complete mark where the entire foot has touched the ground. A high arch will leave just a part of the ball of the foot’s outside portion, and heel of the foot. Either of these arch conditions can cause painful bony growths in the heel because the foot has to deal with too much pressure in places it is not intended to handle.

Orthotics Provide Effective Relief for Therapy For Plantar Fasciitis
People suffering from fallen arches, heel spurs, or who need plantar fasciitis treatment can get relief by using the best orthotics available in their shoes. They offer the needed support to fix the weak structures in the foot, such as those that make up the arch. They also offer cushioning in areas where too much pressure occurs, such as in the heel or ball of the foot. Orthotics are available in an array of sizes and types and are made to keep up with anyone’s activity level.

Tough Heel Pain

Many patients are becoming even more active with age, and as this new generation of elderly patients become our community's senior citizens we are finding out more often that you are only as young as you feel. With this, there are different aches and pains, and they are more common and can be restricting towards maintaining this level of leisure. Above all other pains common to the foot and ankle, heel pain is by far the most common. Sometimes, we will be a 3rd and 4th opinion to attempt to remove this nuisance from our patient's feet. Most often heel pain is treated by cortisone injections, physical therapy, weight loss, and orthotics.

But what about the patients who have been there and done that?

There are few treatments that are more promising in the field of heel pain management with more potential than the

Extra Corporal Shockwave Therapy

for very tough heel pain. A good overview of the proposed mechanism for how this works involves using devices that generate pulses of high-pressure sound that travel through the skin and yeild natural repair from the tissues and increased blood flow networks to damaged tissues.

For reasons that are not fully understood, soft tissue and bone that are subjected to these pulses of high-pressure energy heal back stronger and without causing further damage to the tissues like repeated cortisone injections may do.

The FDA has approved the use of some ESWT machines for heel pain and tennis elbow. ESWT devices evolved from lithotripters (a.k.a. kidney stone shock wave machines). The discovery of the beneficial effects of ESWT came as German researchers were trying to determine what type of high-pressure pulses could be sent through the body to disintegrate kidney stones without causing harm to surrounding tissue. In laboratory animals and humans, it was discovered (with some surprise) that surrounding tissue would often heal back stronger and this applies well to our topic of heel pain.

Physical therapists use ultrasound machines that warm internal tissue by high frequency sound waves, but the ESWT machines send higher-energy pulses 2 or 3 times per second rather than continuous lower-energy waves. Electricity is not sent into the body. It may take as long as 5 months to see the full benefit of an ESWT treatment. The beneficial effect of the high-pressure waves may be from the growth of new blood vessels ("neovascularization") in small cavities that are created by the pulses. New blood vessels to an area of tissue would promote healing either directly or indirectly by providing additional growth factors to the area of concern by way of new vascular channels.

Some studies have even shown this therapy to be equivalent to a fasciotomy, which is an invasive procedure that involves an incision to sever the medial fibers of the fascia for reduced pressure and tension on the inferior heel bone. This means that you can get equivalent results without the complications of a minor procedure. We provide 2 variations of the ESWT, a high energy and a lower energy, and each has benefits that have been shown to work well on difficult heel pain. Either method will be beneficial to our patients, and if you are limping in the AM, or have trouble walking after a brief rest from activity because your heel is holding you back, you should consider a consultation with one of our doctors.

Fungus Amongs't Us

Nail fungus is a slow moving colonization of human keratin, which rarely causes life threatening issues, but may almost always cause some form of discomfort with shoegear, ambulatory compromise, or unsightly appearence to the feet.

Nail fungus attacks all people. But there are some people that have higher risk of getting nail fungus infection. Who are those people, and why the more risk?

In general this apply with people that have lowered immune system. This include people with circulatory system problem, diabetic people, late-aged people and patients with cancer and chemotherapy treatment, for instance. Also with age, comes the liklihood of increased fungal risk. Low immune systems may allow the fungus to spread easily. Usually, once it infects one toenail or nail, they will spread immediately to the other nails on the same feet or hand over many years.

There are many kinds of treatment, ranging from mild to aggressive. Some used home-brewed remedies, or some use natural treatments, and some goes to the doctor. The latter option is the one that most people choose, because they want effective and safe treatment. But what they don’t know is that prescribed medicines can cause side-effects because of their toxic chemical ingredients. This can be hard for people with liver diseases, because nail fungus treatment can take 3 months or more.

At the Family Foot and Leg Center, we use a variety of topical therpy, and have had excellent success with the Coot Touch Nail Laser System. The success rate statistics of treatment is 60–80 percent. There is a 15% chance that it will reoccur. Because of this statistic, many doctors advise the use of anti-fungal solutions after treatment to prevent another infection.

Simple tips to prevent fungus infection:

Wear open footwear as much as possible.
Change socks immediately if it becomes damp or wearing absorbent socks is more preferable.
Don’t wear high top boots if not needed.
Treat fungus as early as you can to stop its spreading.

Big Toe Pain

Seemingly every year around this time we see numerous patients from all over the country with lingering pain and difficulty walking which can be caused by the great toe joint. Some patients may think that bunions are the only thing that can cause this pain, but truly this is only part of the story. Numbers of studies in recent years show the natural progression of arthritis in toe joints which do not seem to have any bunion characteristics, such as prominent bone on the inside of the foot and deviation of the great toe towards the lesser toes, and this can be related in most cases to a distant trauma which occured an unknown time ago.

We offer several pain management modalities to provide nonsurgical relief in this area, ranging from orthotics and cortisone injections, to the new Cold LASER therapy for recurrent pain which can reduce symptoms in chronic pain of arthritis significantly without medications.

Something as trivial as stubbing your toe, or landing abruptly and resultant pain in the bottom of the joint that seems to go away, may eventually return later on as a limitation in joint motion, and pain in the foot which is related to the adaptive and errosive side effects from "hallux rigidus". This is quite prevalent after age 50 and can effect men and women, and can be the major source of a significant amount of discomfort and limitation with walking.

At The Family Foot and Leg Center, we offer numerous conventional and proven treatment protocols for our patients to give you the best chance at pain free ambulation. If you have arthritic changes on a regular xray, and the deformity is not too severe, you may even qualify for the latest implant arthroplasty technique known as "joint resurfacing". This is a relatively advanced joint replacement which allows patients to walk immediately after the surgery, and there are no weight bearing restrictions with a very high success rate both in the short term and long term.

Not everyone is a candidate, but for those who are, you will experience immediate relief. After several weeks post operatively, your range of motion should be close to the other foot, and in most cases significantly increased from before the procedure is done. It is an outpatient procedure, and we have strict criteria prior to undergoing this advanced modality. We offer numerous other therapies for other conditions of the foot and ankle, and I urge you to check out our website regularly as changes are constantly bringing our current and future patients up to date on the latest in the care of your foot and ankle conditions.

Tennis Time and Common Injuries!

With season in full swing, we are seeing more patients with tennis on their minds, and with sports will often bring associated injuries. Here are some common guidelines before making an appointment at Family Foot and Leg Center to treat the typical tennis injuries that are encountered:

Calf and Achilles tendon injuries
The common underlying cause in both calf muscle and Achilles tendon injuries is a tight calf muscle-Achilles tendon unit. This muscle-tendon unit crosses both the knee and the ankle. You can tell your calf muscle-tendon complex is tight if you cannot raise the ball of your foot higher than the heel of that foot with the leg extended (straight). A sudden overload from pushing off your foot while your leg is fully extended is the usual cause of injury.
Achilles tendinitis involves inflammation of the Achilles tendon as a result of overuse. To treat Achilles tendinitis, decrease playing time, take NSAIDs, use heel lifts in your regular shoes, and diligently stretch the calf muscles with your leg held straight.

A ruptured Achilles tendon is more severe than tendinitis. You may feel a sudden snap in the lower leg, as if someone has kicked you in the back of the foot. This is not a particularly painful injury, and a player may be lulled into thinking that the injury is not as severe as it really is. After an Achilles tendon rupture, a player will be able to walk flat-footed, but will not be able to stand up on his or her toes on the affected side. Treatment can consist of casting or surgery, but surgery is recommended for most Achilles tendon ruptures, especially for athletes.
With tennis leg (a tear of the calf muscle on the inside of the leg) you may feel as if you have been shot in the upper calf by a pellet gun. This muscle tear can be quite uncom-fortable. It is important to stop playing immediately and treat the calf muscle with RICE. Tennis leg may take several weeks to resolve.

Ankle sprains

Sprains of the outer ligaments of the ankle are common in tennis. You can minimize the risk by selecting shoes that are specifically designed for tennis and that have substantial support built into the outer counter of the shoe. The most effective treatment for ankle sprains is the usual RICE for 24 to 36 hours, then walking with an appropriate support on the ankle. If the swelling, pain, and bruising are severe, see your physician. Even after the most minor sprain, some sort of stabilizing ankle support is recommended during play for 6 weeks.
Tennis toeTennis toe can occur as the toes are jammed against the toebox of the shoe during tennis's quick starts and stops. Tennis toe is a hemorrhage under the toenail that can be quite painful. Your physician will treat this by drilling a hole in the toenail and relieving the pressure. Prevent tennis toe by keeping your toenails cut short and wearing shoes that provide adequate toe space.